What are the guidelines for ordering a breast MRI for an adult female patient with a suspicious breast finding or high risk of breast cancer?

How to Order a Breast MRI

Order breast MRI for women with ≥20% lifetime breast cancer risk, BRCA mutations, prior chest radiation ≥10 Gy before age 30, or personal history of breast cancer diagnosed before age 50—not for average-risk women or routine problem-solving. 1, 2

Clear Indications for Ordering Breast MRI

High-Risk Screening (Annual MRI Starting Age 25-30)

• BRCA1/2 mutation carriers (lifetime risk 45-85%) should begin annual MRI at age 25-30 alongside annual mammography 2, 3
• Calculated lifetime risk ≥20% using Tyrer-Cuzick, BRCAPRO, or Claus models warrants annual MRI starting at age 30 1, 2
• Prior chest radiation ≥10 Gy before age 30 (e.g., Hodgkin lymphoma survivors) requires annual MRI beginning at age 25 or 8 years post-radiation, whichever is later 1, 2
• Personal history of breast cancer diagnosed before age 50 qualifies for annual MRI surveillance regardless of breast density 2, 3
• Lobular carcinoma in situ (LCIS) patients should be considered for annual MRI, particularly with additional risk factors 1

Diagnostic Indications

• Extent of disease assessment in newly diagnosed breast cancer to evaluate tumor size and detect additional ipsilateral or contralateral disease 4
• Neoadjuvant therapy monitoring to assess treatment response 4
• Occult primary tumor when axillary metastases are present without identifiable breast lesion 4
• Paget's disease evaluation when clinical suspicion exists 4

When NOT to Order Breast MRI

• Average-risk women have no evidence supporting MRI screening 1
• Problem-solving for equivocal mammographic findings rarely identifies occult cancer (only 7% cancer detection rate) and should be used judiciously 5
• Routine evaluation of palpable masses when mammography/ultrasound are adequate—MRI can be falsely negative and should not delay biopsy of suspicious clinical findings 6, 5
• Detection of microcalcifications—MRI cannot visualize these, making mammography essential 1, 7

Technical Requirements for the Order

The ordering facility must meet specific quality standards 3:

• Dedicated breast coil with high-field magnet
• Dynamic contrast-enhanced (DCE) protocol capability
• MRI-guided biopsy availability on-site
• Radiologists experienced in breast MRI interpretation

Practical Ordering Algorithm

Step 1: Risk Stratification

• Calculate lifetime risk using validated models (Tyrer-Cuzick, BRCAPRO, Claus) for women with family history 1, 2
• Identify genetic mutations through testing or documented family mutations 1
• Review radiation exposure history for cumulative dose and age at exposure 1, 2

Step 2: Age-Appropriate Timing

• Age 25-30: Start for BRCA carriers, radiation history patients 2, 3
• Age 30: Start for ≥20% lifetime risk based on family history models 1, 2
• Any age: Order for diagnostic indications (staging, neoadjuvant monitoring) 4

Step 3: Scheduling Considerations

• Premenopausal women: Schedule on days 7-14 of menstrual cycle to minimize background parenchymal enhancement 8
• Postmenopausal women: No timing restrictions 8
• Verify no contraindications: claustrophobia, implantable devices, gadolinium allergy, renal dysfunction 8

Common Pitfalls to Avoid

• Do not delay biopsy of suspicious mammographic (BI-RADS 4-5) or palpable findings to obtain MRI—11 of 14 cancers in problem-solving MRI studies were already identified on conventional imaging 5
• Do not use MRI as first-line for palpable masses—ultrasound or fine-needle aspiration should be initial diagnostic tests 6
• Expect higher false-positive rates (recall rate 15.1%, biopsy rate 11.8%) and counsel patients accordingly 3
• Do not order for women under 25 unless BRCA mutation or radiation history present 2, 3
• Recognize MRI limitations: cannot detect microcalcifications, can miss cancers (false-negative rate exists), and requires correlation with mammography/ultrasound findings 1, 7, 5

Alternative When MRI Unavailable

• Whole breast ultrasound can be considered for high-risk women with MRI contraindications, though it detects fewer cancers (0.3-7.7 per 1,000) with higher false-positive rates 2
• Contrast-enhanced mammography is an alternative with incremental cancer detection rates of 6.6-13 per 1,000 2
• Molecular breast imaging is NOT recommended for any high-risk screening population 2, 3