Should Breast MRI Be Ordered With Contrast?

Yes, breast MRI should always be ordered with intravenous contrast—there is no role for breast MRI without contrast in clinical practice. 1

Why Contrast Is Essential

Breast MRI relies fundamentally on detecting abnormal vascularity and enhancement patterns to identify malignancy. The technique works by:

Detecting increased angiogenic activity through gadolinium-based contrast enhancement, which is the primary mechanism for identifying breast cancer on MRI 2, 3
Achieving sensitivity >98% for invasive malignancy when contrast is used, compared to mammography's 86-91% sensitivity 1, 4, 5
Providing functional information about tissue perfusion and enhancement kinetics that cannot be obtained without contrast 4, 6

The ACR Appropriateness Criteria explicitly state:

"There is no role for MRI of the breast without contrast" in evaluating palpable breast masses 1
"There is no evidence to support MRI breast without contrast" in the initial evaluation of women presenting with breast findings 1
Non-contrast MRI cannot differentiate between benign and malignant lesions or characterize breast pathology 1

Annual screening with contrast MRI is recommended for women with ≥20% lifetime breast cancer risk, including BRCA1/2 carriers starting at age 25-29 1
MRI sensitivity (77-94%) significantly exceeds mammography (33-59%) in high-risk populations 1

Assessing extent of known malignancy before surgery, where contrast-enhanced MRI detects additional disease missed by mammography in 93-100% of cases 1, 7
Problem-solving for equivocal findings when mammography and ultrasound are inconclusive, though ultrasound should be performed first 1, 7
Evaluating dense breast tissue where mammographic sensitivity is limited 1

Annual MRI with contrast for women with personal history of breast cancer and dense breasts, or diagnosed before age 50 1
Higher cancer detection rates (odds ratio 1.7) compared to mammography alone, though with increased biopsy rates 1

0.1 mmol/kg body weight (0.1 mL/kg of gadobutrol) administered as intravenous bolus 8
Power injector delivery at approximately 2 mL/second for diagnostic imaging 8
Immediate post-contrast imaging with sequential acquisition to assess enhancement kinetics 8

Screen for renal impairment before contrast administration due to nephrogenic systemic fibrosis risk in patients with GFR <30 mL/min/1.73m² 8
Contraindicated in patients with history of severe hypersensitivity reactions to gadolinium-based contrast 8
Not approved for intrathecal use 8

Never order breast MRI without contrast—it provides no diagnostic value and wastes resources 1
Do not use MRI as first-line imaging for palpable masses in women ≥40 years; start with diagnostic mammography and ultrasound 1, 7
Avoid MRI in initial workup of palpable masses—it has no role before conventional imaging is completed 1
Do not perform breast MRI during days 1-6 or 22-28 of menstrual cycle in premenopausal women due to hormonal effects on background enhancement 1, 4, 5
Ensure proper technique: dedicated breast coil, experienced radiologists, and MRI-guided biopsy capability are essential for accurate interpretation 1