B re a s t M R I m a g i n g :
Normal Anatomy
Sara C. Gavenonis, MD
KEYWORDS
 Breast MR imaging  Normal anatomy
 Structural anatomy  Functional anatomy
Breast cancer is one of the most common cancers
in American women, with the American Cancer
Society estimating more than 200,000 women
being newly diagnosed with breast cancer in
2010.1 As an adjunct to mammography, breast
magnetic resonance (MR) imaging has emerged
as a powerful and useful tool in the detection and
evaluation of breast cancer. Dynamic contrast-
enhanced breast MR has sensitivities reported as
approaching 100% for invasive breast cancer.2–4
Given this sensitivity, breast MR imaging is
increasingly being used in both screening and
diagnostic breast imaging applications. In 2007,
the American Cancer Society published guidelines
for the application of screening breast MR imaging
in women with an elevated risk of breast cancer,
either by family history–based calculation or
because of prior medical history.5 The use of
breast MR imaging in specific diagnostic scen-
arios such as evaluating the extent of disease in
a patient with breast cancer has also been
studied.6–11 As the applications of breast MR
imaging increase and are refined, an under-
standing of the normal anatomy of the breast on
MR imaging and the basic rationale behind the
imaging of this structure is invaluable. Only with
a strong foundation of knowledge of the “normal”
can pathology be recognized appropriately.
The goals of this article are as follows:
1. Review a basic protocol for breast MR imaging
2. Review normal structural anatomy of the breast
3. Review expected range of normal functional
anatomy of the breast, as seen on dynamic
contrast-enhanced images of the breast.
Funding: Not applicable.
The author has nothing to disclose.
Breast Imaging, Department of Radiology, Hospital of the University of Pennsylvania, 1 Silverstein, 3400 Spruce
Street, Philadelphia, PA 19104, USA
E-mail address: Sara.Gavenonis@uphs.upenn.edu
Magn Reson Imaging Clin N Am 19 (2011) 507–519
doi:10.1016/j.mric.2011.05.009
1064-9689/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved.
PROTOCOL: TECHNICAL CONSIDERATIONS
Breast MR imaging has the ability to depict both
structural and functional anatomy of the breast.
Breast MR imaging protocol uses a multiplanar
imaging approach as well as the use of intrave-
nous gadolinium to achieve the goals of anatomic
depiction. This discussion focuses on the protocol
currently used at the Hospital of the University of
Pennsylvania (HUP), with reference to general
principles of breast MR imaging techniques.
At present, the standard clinical protocol for
breast MR imaging at this institution is acquired
with a 1.5-T magnet with a dedicated bilateral
breast coil. A minimum field strength of 1.5 T is
recommended for optimal breast MR imaging. It
is important that there is good magnetic field
homogeneity across both breasts, to allow for
optimal in-plane image resolution and signal to
noise ratio per pixel. Also, this allows for optimal
fat suppression across both breasts.
The importance of patient positioning should be
emphasized. For breast MR imaging, the patient is
positioned prone with the breasts pendant. It is
essential that the technologist positioning the
patient is aware of the pitfalls sometimes associ-
ated with use of the breast coil and prone posi-
tioning. For example, lateral and axillary breast
tissue is often excluded from the coil, and this is
sometimes only apparent during localizer sequ-
ences (Fig. 1). This situation can lead to nonvisual-
ization or suboptimal evaluation of the excluded
portions of the breast. Such malpositioning may
limit the visualization of not only the structural
anatomy of those portions of the breast(s). It
mri.theclinics.com
508 Gavenonis
Fig. 1. Axial localizer sequence. The patient is posi-
tioned prone, with the breasts pendant in the dedi-
cated breast coil. Asterisks indicate tissue that is not
fully within the chambers of the coil. Stepoffs of tissue
between breast within and outside of the chamber
are seen (blue arrows), created by the patient’s weight
on the breast. On the left side, breast parenchyma is
in the region of this stepoff (red arrow), and the
weight on this portion could theoretically obscure
structural anatomy as well as have an effect on the
vascular enhancement of this region (thereby
affecting the functional anatomy). Ideally, this patient
should be repositioned.
must be noted that the pressure from the patient’s
weight on the portions of the breast excluded from
the coil also alters the vascular flow dynamics of
those areas. Thus, the functional anatomy of those
portions of the breast is also not optimally evalu-
ated, which can lead to false-negative results
(Fig. 2).
Positioning is also of paramount importance
during MR imaging–guided breast interventional
procedures. Although this topic is beyond the
scope of this article, it is important to be aware
of the impact of positioning on the potential
success of any MR imaging–guided breast proce-
dure. Consideration should be given to physical
access to the target site and to the impact of
altering the enhancement dynamics to the target
site during such procedures.
The patient’s arms are variably positioned either
above the head or at the sides, depending on
patient mobility, patient comfort, and ability to
image or access the target region of the breast.
The patient’s peripheral intravenous access is
connected to the injector before imaging, to mini-
mize any subsequent patient motion.
Localizer sequences are first performed (Table 1).
In addition, patient positioning can also be assessed
on localizer sequences. If necessary, the patient
should be repositioned (see Fig. 1; Fig. 3).
At the author’s institution, sagittal plane imaging
is performed for all precontrast series and dynamic
enhanced series. A delayed axial postcontrast
series is also obtained for multiplanar reference
purposes, as well as for delayed enhancement
information. The ability to cross-reference between
planes is useful in establishing the 3-dimensional
characteristics of any finding. Sagittal image acqui-
sition is chosen at HUP to maximize the in-plane
spatial resolution of the images, thus optimizing
morphologic assessment of any findings. Axial
dynamic image acquisition is an alternative option,
and can provide excellent temporal resolution
(fewer total slices to image both breasts) and also
provides the ability to compare symmetry on the
same image. There are pros and cons to each
approach; one compromise solution is to obtain
dynamic enhanced series with isotropic voxels, so
that reconstruction in the imaging plane of choice
can occur with postprocessing. The essence of
any breast MR imaging technique with regard to
imaging plane is to ensure there is some capability
of multiplanar assessment and cross-referencing,
so that any enhancement can be properly assessed
in terms of 3-dimensional morphology.
The phase-encoding direction is chosen to mini-
mize artifact from cardiac pulsation. This direction
will vary based on the chosen imaging plane. For
example, the phase-encoding direction will be cra-
niocaudal in the sagittal imaging plane and trans-
verse in the axial imaging plane. Although in the
axial plane this results in some cardiac pulsation
artifact in the axillary regions, it is preferable to
obscuring the medial portions of the breasts (which
is what would occur if the phase-encoding direc-
tion were chosen in the orthogonal axis).
After localizer sequences, at HUP a sagittal T2-
weighted turbo spin-echo sequence is acquired
(see Table 1) with fat saturation (Fig. 4). The T2
signal intensity of an MR imaging finding has
been reported to be useful as an adjunct to
morphology and kinetic information.12 Although
there are many benign MR imaging findings that
have increased T2 signal, such as cysts and
fibroadenomas,12 it is important to remember
that malignant lesions can also have increased
T2 signal. One study reported that 30 of 480
cancers displayed increased T2 signal relative to
surrounding parenchyma on fat-suppressed T2-
weighted imaging.13 Increased T2 signal intensity
of a finding can thus support a benign assessment
if morphology and enhancement is otherwise also
benign, but the increased T2 signal intensity of
a lesion should not trump suspicious morphology
or enhancement kinetics.
 Normal Anatomy - Breast MRI 509

Fig. 2. Altered vascular dynamics: positioning effect. Initial MR imaging study. In this patient, the superior aspect
of the breast parenchyma is not fully included in the coil, and the patient’s weight is on this excluded tissue.
There is a lesion (blue arrow) in this excluded tissue, which does not demonstrate enhancement on this MR
imaging study. (A) Sagittal T1-weighted image, no fat saturation (FS), pre-gadolinium (Gd) contrast. (B) Sagittal
T1-weighted image, with fat saturation, post contrast (second time point is representatively shown). On a subse-
quent MR imaging study, obtained with more optimal positioning, the indicated lesion demonstrated suspicious
morphology and enhancement. Subsequent biopsy demonstrated invasive ductal carcinoma. In this figure, the
positioning of the patient resulted in altered vascular dynamics of the suspicious lesion, as the lesion was
excluded from the coil and the patient’s weight was on this tissue. This case highlights the importance of posi-
tioning of the patient and its effect on vascular dynamics.

Subsequently, a sagittal T1-weighted series acquisition, false-positive areas can be seen on

without fat saturation is obtained (see Table 1)
(Figs. 5 and 6). This series provides a useful
overview of the architecture and fibroglandular
tissue distribution of the breast. When used in
conjunction with the subsequent fat-suppressed
T1-weighted series, this series is also useful in as-
sessing the fat content of any structure, which
becomes especially useful in the characterization
of fat necrosis or lymph nodes (Fig. 7).
A sagittal T1-weighted series with fat saturation
is then obtained (see Table 1) (Fig. 8). This series
highlights any areas of intrinsic T1 high intensity
that are not fat. For example, material in proteina-
ceous cysts and areas of hemorrhage are identi-
fied. This series also serves as the baseline mask
for subtraction after the postcontrast series are
obtained. Although theoretically fat saturation is
not essential for obtaining information from
subtraction series, such an approach also
assumes there is no patient motion. If there are
areas of intrinsic T1 hyperintensity and there is
patient motion during the dynamic series
the subtraction series. Therefore, to minimize the
potential effects of even small amounts of patient
motion on the diagnostic quality of the subtraction
series, fat saturation is used for this portion of the
breast MR imaging examination at the author’s
institution. In addition, the use of fat saturation
optimizes the dynamic range of the image, making
any true enhancement more conspicuous on the
postcontrast source images.
Intravenous injection of gadolinium contrast
agent is then administered with a power injector
(2 mL/s), followed by a 20-mL saline flush. At
HUP, MultiHance (gadobenate dimeglumine) 529
mg/mL (Bracco Diagnostics, Princeton, NJ, USA)
is used, dosed based on the patient’s weight, for
a dose of 0.1 mmol/kg. Consideration to recent
renal function laboratory tests is also given, as
patients with impaired renal function may not clear
the gadolinium dose optimally and thus be more
susceptible to nephrogenic systemic fibrosis.
Renal function is assessed by glomerular filtration
rate (GFR), with a full dose given for a GFR greater
 510
Gavenonis
Table 1
Breast MR imaging protocol at the author’s institution (1.5 T)

Imaging Series
Sagittal T1-Weighted GRE
Multiplanar Sagittal Sagittal T1- (pre- and 3 postcontrast Axial T1-
Parameter Localizer T2-Weighted Weighted GRE series at 90-s intervals) Weighted GRE
Concatenations — 2 2 1 1
TR (ms) 20.0 6530 9.76 14.6 8.13
TE (ms) 5.00 86 4.76 3.61 3.83
Fat saturation No Yes No Yes Yes
Flip angle 40 180 20 30 15
Field of view (mm) 400 240 240 240 320
Matrix 256 256  256 512  512 512  512 512  512
No. of sections 1 each plane 58 88 88 160
Slice thickness (mm) 10.0 3 2.9 2.9 1.5
Voxel size (mm) 3.1  1.6  10.0 1.3  0.9  3.0 0.7  0.5  2.9 0.7  0.5  2.9 0.9  0.6  1.5
Bandwidth (Hz/pixel) 180 129 180 280 200
Relative SNR 1.00 1.00 1.00 1.00 1.00
Imaging time (min:s) 0:12 3:57 1:37 1:24 (4) 1:42

Subtraction images generated using precontrast series as a mask (3 sets of sagittal subtraction series generated).
Abbreviations: GRE, gradient recalled echo; SNR, signal to noise ratio; TE, echo time; TR, repetition time.

Fig. 3. Axial localizer sequence. The patient is posi-
tioned prone, with the breasts pendant in the dedi-
cated breast coil. With larger breast sizes, the
anterior portions of the breast may abut the inferior
aspect of the coil chamber (arrow).
than 45 mL/min/1.73 m2 and a half dose given
for GFR between 30 and 45 mL/min/1.73 m2.
GFR less than 30 mL/min/1.73 m2 is consid-
ered the threshold at HUP as a contraindication
for gadolinium administration. Thus, dynamic
Fig. 4. Sagittal T2-weighted image with fat satura-
tion. Fat appears dark while breast parenchyma
appears intermediate to bright. Representative struc-
tures are indicated. N, nipple; S, skin; V, vessels; F,
fat; P, breast parenchyma (fibroglandular tissue).
Normal Anatomy - Breast MRI 511
Fig. 5. Sagittal T1-weighted image without fat satura-
tion. Adipose tissue is of high signal intensity, and
breast fibroglandular elements appear relatively
intermediate to dark. Representative structures are
indicated. N, nipple; S, skin; V, vessels; F, fat; P, breast
parenchyma (fibroglandular tissue); C, Cooper’s liga-
ment; M, pectoralis muscles.
contrast-enhanced breast MR imaging cannot be
performed in patients with GFR in that range.
These rules are based on Food and Drug Adminis-
tration guidelines, which can be viewed at the Web
site (http://www.fda.gov).
Fig. 6. Sagittal T1-weighted image without fat satura-
tion, in a different case. This representative slice is
more medial than the image in Fig. 5 (note the ribs
are viewed more in cross section). S, skin; F, fat; P,
breast parenchyma (fibroglandular tissue); M, pector-
alis muscles; R, ribs; I, intercostal muscles.
512 Gavenonis

Fig. 7. Lymph node. (A) Sagittal T1-weighted image, no fat saturation. A crescentic structure with a T1-
hyperintense central hilum is seen (arrow). On this image without fat saturation, the fatty hilum of the lymph
node is hyperintense, and the relative signal intensity of the cortex is lower. (B) Sagittal T1-weighted image,
with fat saturation, no contrast. The signal from the fatty hilum of the lymph node is nulled, as is fat elsewhere
in the breast. On this image with fat saturation, the relative signal intensity of the cortex to the hilum is higher.
Also, the relative signal intensity of fibroglandular elements then becomes intermediate to bright, given that the
fat appears dark. F, fat; P, breast parenchyma (fibroglandular tissue).

Dynamic postcontrast T1-weighted series with
fat saturation are then obtained in the sagittal
plane, with 3 series obtained at 90-second intervals
(see Table 1) (Fig. 9). This timing is based on
studies indicating that optimal temporal resolution
is achieved when imaging occurs at 60- to 120-
second intervals after gadolinium injection.4,14–16
An axial delayed T1-weighted series with fat
saturation is then obtained (see Table 1) (Fig. 10).
This series permits a larger field of view to visualize
Fig. 8. Sagittal T1-weighted image, with fat satura-
tion. The relative signal intensity of fibroglandular
elements is intermediate to bright, given that the
fat appears dark (fat signal is nulled). F, fat; P, breast
parenchyma (fibroglandular tissue).
the axillary, pectoral, and intramammary regions,
which are important in evaluating for lymphade-
nopathy in cases of breast cancer. However,
many extramammary structures are also visual-
ized, though not optimally. It is important to assess
these structures as well: for example, the heart,
liver, and chest wall musculoskeletal structures,
and the anterior lung fields (see Fig. 10).
Subtraction images are generated using the
combination of the dynamic postcontrast sagittal
series and “subtracting” the baseline mask of the
precontrast sagittal T1-weighted series with fat
saturation (Figs. 11 and 12). These images are
often viewed as linked series so that the temporal
characteristics of the enhancement can be best
appreciated.
It can be helpful to use both the source precon-
trast and postcontrast images in addition to the
subtraction images in the interpretation of breast
MR imaging, as an important pitfall to avoid is
the absence of intravenous (IV) gadolinium. This
situation could occur secondary to a failure in the
IV line, a leak, or a contrast extravasation not
immediately detected. When no gadolinium is
actually administered IV but image acquisition
continues, there can be the appearance of minimal
background enhancement in the breast, but there
will also be no enhancement in the great vessels
and no contrast in the heart. It is important to avoid
this pitfall by assessing the expected locations of
contrast in the great vessels and heart, to ensure
that contrast has been administered appropriately
(see Fig. 9C). Otherwise, the study would be
deemed nondiagnostic.
 Normal Anatomy - Breast MRI 513

Fig. 9. (A) Sagittal T1-weighted image, with fat saturation, post gadolinium contrast, time point 1 (90 seconds
after contrast injection). F, fat; P, breast parenchyma (fibroglandular tissue). (B) Sagittal T1-weighted image,
with fat saturation, post gadolinium contrast, time point 2 (180 seconds after contrast injection). F, fat; P, breast
parenchyma (fibroglandular tissue). (C) Sagittal T1-weighted image, with fat saturation, post gadolinium
contrast, time point 3 (270 seconds after contrast injection). Note the subtle but observable change in contrast
in the heart as the time points progress and circulation of contrast agent occurs (H). F, fat; P, breast parenchyma
(fibroglandular tissue); H, heart.

NORMAL ANATOMY axilla. Blood vessels are present within the breast
Structural Normal Anatomy and the axilla (see Figs. 10 and 12). Lymph nodes
are routinely present in the axillary region (see
In gross anatomic terms, the perimeter of the adult
Figs. 7 and 10B), and occasionally also within
breast is skin at the anterior, medial, and inferior
the breast. A normal intramammary lymph node
aspects. Posteriorly, the chest wall is the boundary
will have the same morphology and MR imaging
of the breast (pectoralis major and pectoralis
signal characteristics as lymph nodes elsewhere,
minor with associated fascia, ribs, and intercostal
generally including an overall crescentic shape
muscles) (see Figs. 4–6). At the upper outer
and a fatty hilum (see Fig. 7).
boundary, breast tissue variably extends into the

Fig. 10. (A) Axial T1-weighted image, with fat saturation, post gadolinium contrast, delayed time point (approx-
imately 2 minutes after last subtraction image). F, fat; P, breast parenchyma (fibroglandular tissue); M, pectoralis
muscles; St, sternum; D, hepatic dome; H, heart; V, vessel, axillary. (B) Axial T1-weighted image, with fat satura-
tion, post gadolinium contrast, delayed time point (approximately 2 minutes after last subtraction image), more
superior slice than that shown in a. Ax LN and blue arrows, axillary lymph nodes; V and yellow arrows, vessels,
internal mammary; H, heart; L, lung; A, aorta.
514 Gavenonis
Fig. 11. Sagittal subtraction series. (A) Subtraction 1 5 Postcontrast time point 1 Precontrast 5 (9A 8). (B)
Subtraction 2 5 Postcontrast time point 2 Precontrast 5 (9B 8). (C) Subtraction 3 5 Postcontrast time point
2 Precontrast 5 (9C 8).
The mature female breast has glandular compo-
nents (ducts and lobules), fibrous supporting
elements (Cooper’s ligaments), and surrounding
adipose tissue (see Figs. 4–6). The fibroglandular
elements of the breast are organized into
segments, with approximately 10 to 20 segments
Fig. 12. Internal mammary vessels, sagittal subtrac-
tion series. A representative image from a second
time-point subtraction series is shown to demonstrate
the prominence of the internal mammary vessels on
these images (V). Given that branches of the internal
mammary vessels can sometimes take a tortuous intra-
mammary course, a pitfall to avoid when viewing
a single image in a single plane is mistaking the
appearance of a vessel en face (or seen obliquely) as
a discrete lesion. Cross-referencing between axial
(Fig. 10B) and sagittal planes, and scrolling through
sequential slices can clarify the finding as vascular,
thus avoiding this pitfall.
in each breast. Each segment is arrayed about
a major lactiferous duct. The major ducts form
from tributaries within each segment called duct-
ules, each of which has associated lobules. A
terminal ductule with its associated lobules is
termed a terminal ductule-lobular unit or TDLU.
The TDLU is the site where many breast cancers
arise.17
Normal anatomic components of the breast can
be visualized and distinguished on MR imaging by
assessing signal intensity. On T1-weighted imaging
without fat saturation, adipose tissue is of high
signal intensity and breast fibroglandular elements
appear relatively intermediate to dark (see Figs. 5
and 6). The presence of fat can be confirmed by as-
sessing the same region on T1-weighted images
with fat saturation, where adipose signal would be
expected to be nulled (see Fig. 7). In T1-weighted
images with fat saturation, the relative signal inten-
sity of fibroglandular elements then becomes inter-
mediate to bright, given that the fat appears dark
(see Fig. 7B). Similarly, on T2-weighted series
with fat saturation, fat appears dark while breast
parenchyma appears intermediate to bright (see
Fig. 4).
On T1-weighted fat saturated images, intrinsi-
cally T1-hyperintense material such as proteina-
ceous fluid in ducts is highlighted. Moreover, on
T2-weighted fat saturated images intrinsically T2-
hyperintense material or lesions, such as fibroade-
nomas or simple cysts, are accentuated.
Functional Normal Anatomy
There is wide variation of normality in fibroglandu-
lar composition of the breast, and in mammog-
raphy the breast density percentage is classified
and reported as per BI-RADS (Breast Imaging
 Normal Anatomy - Breast MRI 515

Fig. 13. Minimal background enhancement. Precontrast images without fat saturation demonstrate a large
amount of fibroglandular tissue. (A) Axial localizer. P, breast parenchyma (fibroglandular tissue). (B) Sagittal
T1-weighted image, no fat saturation. F, fat; P, breast parenchyma (fibroglandular tissue).

Fig. 14. Minimal background enhancement. Sagittal source images, T1-weighted with fat saturation, demon-
strate minimal background enhancement of the breast parenchyma. Fat appears dark, and breast parenchyma
(fibroglandular tissue) appears as intermediate to bright signal. (A) Precontrast. (B) Postcontrast time point 1
(90 seconds after injection). (C) Postcontrast time point 2 (180 seconds after injection). (D) Postcontrast time point
3 (270 seconds after injection).

Fig. 15. Minimal background enhancement. Sagittal subtraction images highlight the minimal background
enhancement of the breast parenchyma. (A) Subtraction 1 5 14B 14A. (B) Subtraction 2 5 14C 14A. (C) Subtrac-
tion 3 5 14D 14A.
516 Gavenonis
Fig. 16. Mild background enhancement of the breast
parenchyma is demonstrated on this representative
sagittal subtraction image (representative third time
point).
Reporting and Data System).18 It must be noted
that there is also a variable functional anatomy of
the fibroglandular tissue, which manifests as
enhancement on postcontrast images. This
component of the enhancement pattern is termed
background enhancement, and has been classi-
fied as none/minimal, mild, moderate, and
marked.19
It is of paramount importance to note the
distinction between fibroglandular density and
background enhancement. For example, depend-
ing on the hormonal status of the patient or other
factors such as prior radiation treatment, a breast
that appears extremely dense on mammography
can theoretically have minimal to mild background
Fig. 17. Moderate background enhancement is demonstrated in this patient, on serial sagittal subtraction
images. Note that the enhancement pattern is persistent, and the background enhancement has a relatively
confluent appearance globally. (A) Subtraction 1. (B) Subtraction 2. (C) Subtraction 3.
enhancement (Figs. 13–15). Also, depending on
the context, a patient can have marked back-
ground enhancement that is normal physiologic
enhancement. Correlation with the clinical context
and the patient’s menstrual cycle is important in
the interpretation of these studies.
Examples of background parenchymal enhan-
cement can be seen in Figs. 16–19.
Background enhancement varies not only
between individuals (see Figs. 17 and 18) but
can also vary as a function of when a patient is
imaged during her menstrual cycle.20 Having the
background enhancement of both breasts is
useful for comparison of symmetry. Bilateral
studies may raise the theoretical potential for false
positives in the breast contralateral to the one of
interest, but the potential benefit of being able to
compare breast background enhancement is
often invaluable. Thus the author prefers to obtain
bilateral studies as per routine at HUP, rather than
unilateral studies.
Enhancement Kinetics
At HUP, dynamic postcontrast images are ob-
tained at 90-second intervals for 3 time points after
injection (see Fig. 9). This action permits the eval-
uation of the enhancement kinetics of any focal
findings.
Initial enhancement can be assessed by
comparing the precontrast and the first postcon-
trast series, and is described as rapid, interme-
diate, or slow.21–23 Lesions that have relatively
higher vascularity (for example, malignant lesions
with associated neoangiogenesis) would be ex-
pected to have a rapid rate of initial enhancement.
The second and third postcontrast series can be
used to assess if the pattern of enhancement is
gradually increasing (Type 1, persistent), stabi-
lizing (Type 2, plateau), or decreasing (Type 3,
 Normal Anatomy - Breast MRI 517

Fig. 18. Moderate background enhancement, in a different patient to the one shown in Fig. 17. This patient had
multiple prior MR imaging examinations, and this pattern of enhancement had been stable compared with prior
studies. Note that while the background enhancement is still classified as “moderate,” the morphology of the
background enhancement is distinct from the patient in Fig. 17. (A) Subtraction 1. (B) Subtraction 2. (C) Subtrac-
tion 3.

Fig. 19. Marked background enhancement. Note that the enhancement pattern is persistent. (A) Subtraction 1.
(B) Subtraction 2. (C) Subtraction 3.

Fig. 20. Multiple fibroadenomas. This patient had a history of prior surgical excision of multiple fibroadenomas.
MR imaging examination demonstrated multiple round and oval circumscribed masses, which were T2-
hyperintense and which demonstrated persistent enhancement. The findings appeared stable compared with
prior MR imaging examinations. The MR characteristics of the findings, in combination with the patient’s history
and the stability, are all in keeping with benignity. FA, fibroadenomas. (A) Subtraction 1. (B) Subtraction 2. (C)
Subtraction 3. (D) Sagittal T2-weighted image with fat saturation.
518 Gavenonis
Fig. 21. Invasive ductal carcinoma (IDC). (A) Subtraction 1. A representative image from the first sagittal subtrac-
tion series demonstrates rapid and heterogeneous enhancement of this irregular mass, which was biopsy-proven
malignancy. (B, C) Subtraction 2 and subtraction 3. There are components of the mass that demonstrate washout
kinetics.
washout). Many benign lesions (such as fibroade-
nomas) demonstrate persistent enhancement
(Fig. 20).22,23 In general, washout enhancement is
the most suspicious for malignancy (Fig. 21),22,23
noting that malignant lesion enhancement kinetics
can be variable.
It is also important to bear in mind that
normal background enhancement is expected
to have persistent enhancement (see Figs. 17
and 19).
SUMMARY
Dynamic contrast-enhanced breast MR imaging
has emerged as a useful tool in different clinical
scenarios. Structural and functional anatomy of
breast parenchyma and any focal breast findings
can be assessed using breast MR imaging, which
also has the benefit of being a multiplanar study. It
is important to integrate structural anatomy with
functional anatomy in the interpretation of breast
MR imaging and to interpret breast MR imaging
in the clinical context of the patient, as well as in
conjunction with other breast imaging modalities
such as mammography and ultrasonography.
Dynamic contrast-enhanced MR imaging is
a powerful tool in assessing the breast, and a firm
understanding of the normal anatomy of the breast
provides a foundation on which to detect pathology.
The “normal anatomy of the breast” actually
encompasses a wide range of normal, both within
large patient populations and for an individual
patient whose “normal breast anatomy” may vary
monthly and across her lifetime. Looking forward,
the information breast MR imaging provides about
this “normal” anatomy may also be useful in risk
assessment and in obtaining imaging biomarkers
of functional breast physiology.
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