Department of Radiology

Center for Advanced Imaging

Magnetic Resonance Imaging Abdomen/Pelvis Breast Endorectal Functional MRI Head & Neck Magnetic Resonance Angiography Musculoskeletal Spine Patient Instructions

Patient Instructions:

To schedule a MRI scan please contact (304) 293-7521. Please contact the MRI personnel at (304) 293-7521 if you need specific instructions for a scheduled scan.

Breast MRI and MRI-guided Breast Biopsy

The role of MRI in the evaluation of the breast continues to evolve. MRI does not replace mammography but rather is an adjuvant imaging technique. Breast MRI should always be correlated with a recent mammogram.  Studies performed for cancer detection require intravenous gadolinium contrast.  Studies for silicone implant rupture use different imaging sequences and do not require contrast.

Which patient population will benefit most from breast MRI?

Figure 1. Screening MRI done for history of LCIS and negative mammograms reveals small spiculated mass in the superior aspect of the breast. “Second look” ultrasound demonstrated a 10mm irregular hypoechoic mass. Ultrasound-guided biopsy confirmed infiltrating lobular carcinoma.

Current indications for breast MRI include a number of situations ranging from evaluation of silicone implant integrity to follow-up after surgery and chemotherapy.  Breast MRI can be useful in two screening situations. One is for the evaluation of silicone implants for evidence of rupture. The second is for screening of high risk patients:  The utility of MRI has been shown in BRCA1 and BRCA2 patients; it may also be useful in other high risk situations such as when there is a family or personal history of breast cancer, histological diagnosis of LCIS or ADH, and patients treated with chest XRT for Hodgkin’s disease. (See Figure 1.) Screening with MRI is not appropriate for women of average risk.

MRI can be used in the evaluation of newly diagnosed breast cancer for extent of disease.  Some advocate MRI in all new breast cancer patients. MRI is particularly useful when the full extent of tumor is not easily depicted by mammography and ultrasound, such as with infiltrating lobular carcinoma or invasive cancer with extensive intraductal component (EIC), and in women with mammographically dense breasts.  Additional foci of cancer may be found in the ipsilateral or contralateral breast. A case demonstrating this scenario is shown in Figure 2.  Pectoralis and chest wall involvement can be accurately demonstrated. MRI is helpful for surgical planning; it may decrease the incidence of positive surgical margins. Other appropriate applications include:

Figure 2. This is a 78-year-old woman with palpable right subaureolar mass and negative mammogram. Prior to MRI, an ultrasound-guided biopsy revealed infiltrating ductal carcinoma. MRI was done to evaluate extent of disease because the patient had dense tissue on mammograms. The MRI image on the right demonstrates the known right breast mass. MRI also revealed a highly suspicious enhancing mass in the left breast, shown on the left.

1. before and after neoadjuvant chemotherapy to assess tumor response, shown in Figure 3.
2. to evaluate the extent of residual tumor when there are positive margins at lumpectomy,
3. to discover the occult primary tumor in patients presenting with metastases to axillary lymph nodes and normal mammogram
4. after lumpectomy to differentiate scar from recurrence
5. to evaluate problem mammograms upon radiologist recommendation.  This includes suspected abnormalities seen on only one mammographic view or obscured by dense breast tissue.

Figure 3. 55-year-old woman with newly-diagnosed right breast cancer. On the left, MRI done before neoadjuvant chemotherapy demonstrates a 36mm enhancing mass. Anterior extension is suggestive of DCIS. On the left, post-chemotherapy MRI reveals minimal residual soft tissue density without enhancement in previous location of mass. Lumpectomy revealed no residual tumor. The region colored red shows the area of the lesion where the contrast agent wahed out the most rapid indicating angiogenesis. The region colored green cleared the contrast agent more slowly. Normal blood vessels in the chest wall are also colored by red.

At WVU, Breast MRI studies are processed by CADstream, a computer-aided detection system designed specifically for breast MRI. This system helps to streamline and standardize the interpretation of breast MRI. CADstream automatically identifies all areas of the breast that demonstrate contrast enhancement above a specified threshold and generates kinetic curves for these areas. It can produce 3-dimensional images and determine the exact volume and location of lesions, assisting in surgical planning.
It is important to note that MRI does not replace mammography. While reported sensitivity for invasive cancer approaches 100%, MRI is less sensitive for DCIS and has relatively low specificity.  An important cause of false positive MRI is enhancement of normal glandular tissue in premenopausal women and women on hormone replacement therapy (HRT).  Performing breast MRI on days 7-14 of the menstrual cycle can minimize this problem.

MRI-guided Breast Biopsy

The ability to biopsy lesions identified only on MRI is crucial to the success of a breast MRI program.  WVU physicians use the Suros ATEC system, a vacuum-assisted device with proven accuracy in several clinical studies. Our 10 years of experience in performing thousands of stereotactic and ultrasound-guided biopsies has allowed for a smooth transition to the MRI-guided procedure.  The patient can expect to be treated with respect and care; a Venetian blind has been added between the control room and the MRI scanner room to ensure complete privacy.

Return to top

Endorectal Coils for Prostate,
Cervical and Colorectal MRI

With the endorectal coils high resolution, small field-of-view imaging is achieved for the prostate, cervix, and rectum. “Preoperative staging should be performed using the best method available,” said Dr. Stephany Swart, the board-certified radiologist with fellowship training in abdominal MRI who personally supervises all endorectal MRIs in the CAI at WVU. With this advancement in technology, much more accurate staging can be attained to optimize treatment planning. The endorectal coil is used in combination with the external torso array of coils. This approach provides both the sensitivity to acquire high-resolution images of the prostate, cervix, and rectum and the ability to image the entire pelvis. This method provides the necessary sensitivity to zoom in on the area of interest while the pelvic phased array (four external coils) allows a large enough field-of-view (FOV) to assess pelvic lymph nodes and pelvic bones for metastatic disease.

The patient preparation is similar for all endorectal examinations. No food or water may be ingested from midnight the night before until the procedure and the bowel must be cleansed. Conscious sedation before the procedure is used if needed. Immediately pre-MRI, glucagon is given to relax the bowel. MRI contrast is always administered. Every effort is made to keep the patient relaxed, and comfortable while minimizing the scan time. Scan times are between 45 and 60 minutes with the endorectal coil inserted for only the last 20 minutes. For each type of exam (prostate, cervix, or rectal), a different shape of coil is used to obtain optimal images for the specific anatomy.

MRI is advantageous for these studies as it does not use ionizing radiation and provides images in sagittal, coronal, axial, and/or oblique planes. Furthermore, MRI provides better soft tissue contrast than other radiological techniques.

Endorectal MRI of the prostate is indicated when the patient has an increasing PSA level and a negative biopsy. The improved spatial resolution will aid in obtaining a biopsy sample from the cancerous region. Prostate cancer has low signal intensity as compared to surrounding regions of healthy tissue. This decrease in signal intensity is due to differences in structure between cancerous and normal prostate tissue. The MRI can also help differentiate between intracapsular and extracapsular extension for staging and in evaluation of the periprostetic bed. Endorectal MRI of the prostate can also provide images for radiation therapy treatment planning. Recently, there has been a dramatic improvement in MRI assessment of prostate cancer. The most recent MRI studies have demonstrated staging accuracies consistently between 75% and 90% as a result of endorectal MRI and increased experience in prostate MRI interpretation.

Figure 4: Images of the rectum acquired using endorectal probes. On the left, an axial T2-weighted image demonstrates a left lateral rectal wall mass with central ulceration. Note that a 6mm follicle in the right ovary is resolved using the endorectal imaging probe. On the right, a T1-weighted post gadolinium image details the rectal adenocarcinoma infiltrating through the serosa and into the adjacent mesorectal tissues. Note the exquisite spatial resolution.

Endorectal MRI is primarily used to stage previously diagnosed rectal cancer or evaluate treatment. As shown in the Figure 4, the primary advantage is the visualization of the layers of the rectal wall and the depth of tumor penetration of the wall. In addition, for rectal cancers, enlargement of the perirectal lymph nodes indicates nodal metastases as enlargement of the perirectal lymph nodes is not usually caused by inflammation. The lymph node border contours and signal intensity may also indicate metastases.

For cervical cancer patients, MRI can be used to assess tumor size, extension to the parametrium, vagina, pelvic sidewall, bladder wall, rectal wall, and lymph node involvement. Thus MRI is the preferred method for staging cervical cancer especially for the evaluation of low-stage disease. Also MRI can detect lymphadenopathy, which is not part of the Federation for Gynecology and Obstetrics (FIGO) staging system, but is important for patient prognosis and management. Studies have shown that the staging accuracy is higher for MRI than for CT. Furthermore, MRI is the best modality for treatment evaluation of radiochemotherapy. In addition, MRI is more cost effective and patient-friendly than the traditional evaluation with cystoscopy, barium enema, and intravenous urography.

Although not performed with the endorectal coils, MRI is also used to evaluate uterine fibroids to determine if the patient is a good candidate for uterine artery embolization, which is done at our institution by Dr. Patricia Stoltzfus.

This is an axial T2 projection of the female pelvis prior to uterine artery embolization demonstrating a large left broad based exophytic leiomyoma. This is a post uterine artery embolization axial T2 image of the same patient showing significant decrease in size with the patient reporting significant decrease in her symptoms.

Once the candidate is determined to be eligible and the procedure is performed, they are followed up with post embolization MRI to evaluate the response to therapy.

Return to top

Magnetic Resonance Angiography (MRA)

Three-dimensional contrast-enhanced angiography is acknowledged as an accurate noninvasive tool for almost all vascular territories. In the WVU Center for Advanced Imaging we can use the 3 Tesla scanner to even further improve the spatial resolution. In the body and peripheral vessels, three phases are usually collected: arterial, portal venous, and venous. In the CAI during the last year, significant advances in gradient improvement and scanner performance have resulted in improved temporal and spatial resolution in MRA. The CAI’s MRI technologists have worked tirelessly to improve their timing for an optimal injection. Their diligence is the primary reason that the full potential of the upgraded equipment has been realized. The MRA images in Figure 5 speak for themselves. These images were acquired using a 1.5T system. From the patient’s perspective, the exams are minimally invasive and time efficient, usually around 30 minutes for the scan.

Figure 5: Magnetic Resonance Angiography (MRA) of the abdomen (left), pelvis (center) and thighs, peripheral vessels (right).

Return to top

Head and Neck:

3TMRA - Circle of Willis

For MRA of the neck and head, the 3T MRI scanner provides outstanding images with extremely high spatial resolution, four times higher than the 1.5T systems. Indeed, the resolution of these small vessels can be achieved even without a contrast agent for the more delicate patients. MRA of the head can be used to screen for intracranial aneurysms which are not uncommon, occurring in 1-5% of the U.S. population, according to a recent review by Brisman, Song, and Newell that appeared in the August 2006 New England Journal of Medicine. MRA is recommended for people at an increased risk for intracranial aneurysms, those with a family history of aneurysm or polycystic kidney disease. MRA is the technique of choice as it has a sensitivity of 69-99% and a specificity of 100%. CT angiography is comparably sensitive and specific but is contraindicated for patients with impaired renal function because of the large dose of contrast agent that must be administered.

Return to top

Muscoskeletal: MRI of the Knee

Recent breakthroughs in orthopedics have led to cartilage repair by drilling, abrasion, microfracture, or debridement. Thus surgeons need to evaluate the articular cartilage of the knee pre-surgically and to follow the recovery process with noninvasive imaging. This need has spurred further developments in MRI of the knee. Dr. Andrew Mace, chief of WVU Musculoskeletal Radiology for over 20 years, and Dr. Thuan Nguyen, trained at Duke, are using the amplified signal from the 3T scanner to image the articular cartilage with impressive detail. Anatomic articular cartilage detail not seen in 1.5T MRI scans is attained in the same amount of time. Images from the WVU CAI 3T scanner are shown in Figure 6.

Figure 6: On the left, the coronal proton-density weighted-image acquired at 3T clearly delineates the meniscus and defines the joint space. On the right, an example of intricate cartilage malformations and disturbances are easily identified; significantly impacting the clinical management of the patient.

While conventional radiography provides adequate images for the assessment of joint space, the articular cartilage itself is not visible on an x-ray. Further, the appearance of joint space narrowing is not an accurate tool for determining the structural integrity of the cartilage. The multiplanar capabilities and superior soft tissue contrast allows direct visualization of the articular cartilage as shown in Figure 6. Chondral injury and the significant cartilaginous loss associated with degenerative arthrosis can thus be readily diagnosed.

With the advent of new techniques in orthopedic surgery, MRI now plays a much more prominent role in diagnosis and treatment of the knee. Patients can expect an easy, quick, pain-free evaluation of their condition.

Return to top

Functional MRI

At WVU, we offer functional MRI (fMRI) as a clinical tool for patients preparing for neurosurgery. For this purpose, fMRI is used to identify brain regions involved in specific functions:  movement, sensation, and language, for example. Referrals for fMRI can be made through the CAI, please call (304) 293-6898. The procedure involves a brief examination of cognitive, motor, and behavioral functioning by the neuropsychologist and an MRI examination.

For the past 5 years, radiologists and neuroscientists at WVU’s CAI have been working to develop a program for functional MRI (fMRI). FMRI is most commonly used in neuroscience research aimed at understanding the neural bases of cognition, emotion, movement, and other human behaviors. At WVU, we have taken advantage of the CAI resources to offer fMRI as a clinical tool for patients preparing for neurosurgery. In this context, fMRI is used to identify cortical regions involved in specific functions:  movement, sensation, language, and other cognitive abilities. During the 5 years of development, we have studied more than 40 healthy individuals and approximately 70 patients preparing for neurosurgical intervention for brain tumors, epilepsy, and vascular malformations. Patients have come for this specialized research procedure from all over the region, including the southern reaches of West Virginia, Southern Pennsylvania/Pittsburgh, Ohio, and Maryland.  Beginning January 1, 2007, the procedure will become available to patients and physicians at large.

Figure 7: Dr. Michael Parsons, Ph.D. of Behavioral Medicine and Psychiatry trains a patient to perform a motor task before a functional MRI experiment. The display on the computer shows the left arrow that she will see as a prompt in the MRI scanner during the fMRI exam.

Referrals for fMRI can be made through the CAI. The procedure involves a brief examination of cognitive, motor, and behavioral functioning by the neuropsychologist. The patients are trained before the scan so they will understand what to do as shown in Figure 7. During the fMRI scan, subjects are asked to perform simple movement tasks involving the relevant body parts (e.g., hand, foot, mouth), perform language tasks (e.g., naming pictures, thinking of words, reading), or other cognitive tests. Patients must be able to tolerate the MRI environment, preferably without any sedation, and must be able to follow task instructions without excessive movement, distractibility or confusion. Once the scans are complete, an analysis of patient performance is completed. Brain images are produced which illustrate areas of functional activity as colorized areas superimposed on high resolution anatomical images.  In addition, a report describing the patient’s performance during scanning and the activation foci is produced along with the images.

The images produced by fMRI are useful for consideration of relative risk to skills and abilities from a neurosurgical procedure and can be used in the decision-making process prior to surgery. The fMRI team, who are available to consult with the neurosurgeon, interprets every fMRI performed at WVU. In addition, in cooperation with the BrainLab Inc., we have developed the capability to integrate fMRI images into surgical guidance software for navigation during neurosurgery. This service is available to all WVU neurosurgeons and may be available to other surgeons in the community. Consider fMRI for your patients who are in need of neurosurgery in or near eloquent cortex. It is also useful for identifying the dominant hemisphere for language and assisting in the determination of whether or not intraoperative language mapping may be necessary.

MRI ACCREDITATION

 The Center for Advanced Imaging has currently been awarded a three year term of   Accreditation in MRI for all of our existing scanners as a result of a recent survey by the American College of Radiology (ACR).
 The ACR is a national organization serving more than 32,000 diagnostic – interventional radiologists, radiation oncologists and nuclear medicine and medical physicists with programs focusing on the practice of medical imaging and radiation oncology and the delivery of comprehensive healthcare services. ACR accreditation is considered the benchmark of quality. The ACR’s rigorous evaluation gives assurance that both staff and equipment have met national standards for quality care.
Accreditation is awarded by the ACR to our MRI facility for the achievement of high practice standards after a voluntary evaluation of our practice. Evaluations are conducted by board certified physicians and medical physicists who are experts in MRI. They assess the qualifications of the personnel as well as the quality of equipment. The surveyors report their findings to the ACR’s Committee on Accreditation, which subsequently provides the practice with a comprehensive report.
The Center for Advanced Imaging has been providing MRI services since 1985. Our facility currently houses four MRI scanners that include three 1.5Tesla and one 3Tesla magnets that have been awarded the above accreditation. This accreditation is the result of our continuous commitment to provide the highest quality diagnostic imaging with care and compassion.

Return to top