Breast MRI Image Quality – Numaris X Module Workbook

MRI Breast Image Quality MR Breast Image Quality | Numaris X Module Workbook Education & Workforce Solutions SIEMENS Your potential is calling. Healthineers MR Breast Image Quality | Numaris X Welcome A Message from Nanci Wozniak Welcome to your training experience with Education & Workforce Solutions. I want to personally thank you for choosing Siemens Healthineers. We are honored to have you as our partner and hope you will enjoy this course. Our teams strive to ensure your priorities and needs are met. We sincerely appreciate your hard work around what really matters - the human side of health care. You are our heroes. Thank you for being part of the Siemens Healthineers family and we look forward to our partnership with you. Nani llig Nanci Wozniak Vice President, Education & Workforce Solutions CX SV USA – Customer Service Organization Siemens Healthineers Clinical Training and Continuing Education Contact Information Customer Care Center - Clinical Application Support: Call 1-800-888-7436 PEPconnect https://pep.siemens-info.com/en-us 2 MR Breast Image Quality | Numaris X Contents Welcome.......................................................................................................2 Contents .......................................................................................................3 Course Description ........................................................................................4 MR Breast Image Quality ................................................................................5 Additional Resources ...................................................................................48 3 MR Breast Image Quality | Numaris X Course Description Course Overview: This course is designed to provide participants with a practical approach to methodically evaluating breast images using troubleshooting strategies and sources for image analysis. Upon completion of this course, you will be able to: • Identify common causes of IQ concerns in breast imaging • Practice strategic problem-solving approaches to IQ concerns • Utilize tools at our disposal to effectively evaluate IQ concerns • Create action plans that methodically illustrate cause/effect and potential resolution/escalation • Foster dialogue and exchange of best practices related to IQ excellence 4 MR Breast Image Quality | Numaris X MR Breast Image Quality SIEMENS Healthineers . Breast Image Quality Case Studies MR Image Quality (IQ) Workshop Numaris X HOOD05162003271102 Effective: 05/04/2022 Unrestricted © Siemens Healthineers, 2022 Notes 5 MR Breast Image Quality | Numaris X Overview SIEMENS. Healthineers ... Teams Tools & Features Explain Desktop View (e.g., panels) • Content Area • List of Participants • Chat Explain/Demo Features • Raise your hand • Show conversation • Show participants Live Remote Training Suggestions • Phone should have sufficient battery power • Stay on mute unless you need to speak • Raise “hand” to get instructors attention • Use “Show Conversation” to ask questions and see responses • Limit office interruptions 3 Unrestricted © Siemens Healthineers, 2022 Notes 6 MR Breast Image Quality | Numaris X Agenda SIEMENS . Healthineers ... Breast Imaging Challenges • Introduction • Positioning‐Related Artifacts • Fat Saturation Inhomogeneity (B0) Artifacts • Dielectric (B1) Artifacts • Additional Recommendations 4 Unrestricted © Siemens Healthineers, 2022 Notes 7 MR Breast Image Quality | Numaris X Objectives SIEMENS . Healthineers ... At this end of this module, you should be able to: • Identify common causes of IQ concerns in breast imaging • Practice strategic problem‐solving approaches to IQ concerns • Utilize tools at our disposal to effectively evaluate IQ concerns • Create action plans that methodically illustrate cause/effect and potential resolution/escalation. • Foster dialogue and exchange of best‐practices related to IQ excellence 5 Unrestricted © Siemens Healthineers, 2022 Notes 8 MR Breast Image Quality | Numaris X Siemens‐Healthineers Disclaimers SIEMENS . Healthineers ... Practice of Medicine: The information presented in this MR Image Quality Excellence workshop is for illustration only and is not intended to be relied upon by the reader for instruction as to the practice of medicine. Any health care practitioner reading this information is reminded that they must use their own learning, training and expertise in dealing with their individual patients. This material does not substitute for that duty and is not intended by Siemens‐Healthineers Medical Systems to be used for any purpose in that regard. Outcomes (Achieved and Observed) Disclaimer: “The statements by the Siemens‐Healthineers’ customers described herein are based on results that were achieved in the customer's unique setting. Since there is no "typical" hospital and many variables exist (e.g., hospital size, case mix, level of IT adoption) there can be no guarantee that other customers will achieve the same results.” Metal Disclaimer: The MRI restrictions (if any) of the metal implant must be considered prior to the patient undergoing an MRI exam. MR imaging of patients with metallic implants brings specific risks. However, certain implants are approved by the governing regulatory bodies to be MR conditionally safe. For such implants, the previously mentioned warning may not be applicable. Please contact the implant manufacturer for the specific conditional information. The conditions for MR safety are the responsibility of the implant manufacturer, not of Siemens‐Healthineers. 6 Unrestricted © Siemens Healthineers, 2022 Notes 9 MR Breast Image Quality | Numaris X Siemens‐Healthineers Disclaimers (continued) SIEMENS . Healthineers ... Contrast Disclaimer: A licensed physician may choose to use FDA‐approved contrast agents in conjunction with an MRI exam, based on his/her medical opinion and discretion and in accordance with the instructions for use and indications for use supplied by the pharmaceutical manufacturer for the contrast agents. Competitor Disclaimer: Competition product descriptions, comparison and specifications contained in this document are based on interpretation of available data at the time this material was being prepared [April 2022] and may require independent verification. Specifications have been obtained from competition brochures, websites, and other independent published sources. 7 Unrestricted © Siemens Healthineers, 2022 Notes 10 MR Breast Image Quality | Numaris X SIEMENS ..... Healthineers .. Breast – IQ Case Studies Introduction 8 Unrestricted © Siemens Healthineers, 2022 Notes 11 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS . Healthineers ... Introduction In the evaluation of breast cancer, MR Breast Imaging has become an important problem‐solving tool as an adjunct to Mammography and Ultrasound. MR breast imaging may be ordered for high‐ risk groups, cancer of unknown primary, scar or recurrence, and ruptured implants. MR breast imaging can be susceptible to a variety of artifacts that may affect the image quality. The following artifacts are discussed in this module: • Positioning‐Related Artifacts • Fat Saturation Inhomogeneity (B0) Artifacts • Dielectric (B1) Artifacts • Other Artifacts 9 Unrestricted © Siemens Healthineers, 2022 Notes 12 MR Breast Image Quality | Numaris X SIEMENS ..... Healthineers .. Breast – IQ Case Studies Positioning and Related Artifacts 10 Unrestricted © Siemens Healthineers, 2022 Notes 13 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS . Healthineers ... Positioning Introduction Patient Positioning is very important in MR breast imaging. Improper positioning of the breasts in a dedicated breast coil causes inhomogeneous fat saturation as well as other artifacts. Checking the localizer images and repositioning as necessary, before any diagnostic imaging is key. Use the positioning techniques and suggestions provided, as well as paying meticulous attention to detail before imaging. By doing this, you can improve image quality and limit the need for repeated imaging studies. Goals of proper positioning include imaging the maximum area of breast tissue, minimizing skin folds, and achieving homogeneous fat suppression and non‐ deformed breast tissue. 11 Unrestricted © Siemens Healthineers, 2022 Notes 14 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS. Healthineers ... Positioning Guide Patient Positioning 1. Guide the patient into the coil and center the breasts over the medial coil or center bar. 2. Adjust headrest for comfort. 3. Ensure the patient is not rotated on the coil, shoulders are even. 4. Elevate the hips with additional support as needed to provide a flat back this will alleviate some pressure from the sternum. 5. Arms down is typically preferred for comfort and to relax more breast tissue down into the coil. If the patient will not fit into the bore with arms down, arms can go above their head to provide more clearance. This in turn stretches out the upper portion of the breast tissue and additional coverage may need to be added. 6. Provide headphones and ask the patient to try not to help or move for the rest of the exam. 12 Unrestricted © Siemens Healthineers, 2022 Notes 15 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS. Healthineers ... Positioning Guide cont. Patient Positioning 7. Reaching in with your hands, pull the breast away from the middle to separate any breast tissue that could be folded in the sternal area. 8. Clear any abdominal tissue Reach under the patient's chest until you can touch the middle coil, then with a “swooping” motion pull downwards towards the feet. If the patient has a sheet under them, pull downward. By starting with the patient aiming towards the bottom of the coil initially and pushing themselves upwards into the coil helps to smooth out tissue. This technique may be difficult for some patients. 9. The bottom of the breast should be about an inch in front of the bottom side of the medial coil/base plate depending on coil design. 10. Check breast position from the lateral, medial, and top‐down positions. 11. Nipple should be in profile if possible. 12. Ensure no folds. 13. Repeat the positioning check with the other breast. Reference: MR Breast Positioning for Best Image Quality; Job Aid Effective Date: 13 04/29/2020 | HOOD05162003086671 Unrestricted © Siemens Healthineers, 2022 Notes 16 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers ... Positioning Guide Lateral Coil Element placement (depends on coil manufacturer) 1. The height of the coil should be adjusted so that the top is at where breast tissue falls away from the chest wall, start on the larger Breast first. 2. Match the coil height on the other side to ensure even signal and alignment of elements. 3. Holding the breast with nipple at profile, move the coil in just until the coil touches the fullest portion of the Breast. Do not compress. Additional hints For large breasts, there can be anterior puddling (compression of the anterior Breast tissue and flattening of the nipples against the coil). This causes contrast agent flow to be non‐uniform. Place a pad on the coil underneath the patient’s sternum and lifting the patient up so that the breasts hang freely. Using a sheet sling technique. A positioning video is available for the Sentinelle coil on their website. Head End 14 14 Reference: MR Breast Positioning for Best Image Quality; Job Aid Effective Date: 04/29/2020 | HOOD05162003086671 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 17 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS .. Healthineers ... Positioning Guide Link to Positioning Article E1 https://pubs.rsna.org/doi/full/10.1148/rg.341125193 Positioning in Breast MR Imaging to Optimize Image Quality1 Eren D. Yeh, MD Dianne Georgian-Smith, MD Improper positioning of the breasts in a dedicated breast coil causes Sughra Raza, MD inhomogeneous fat saturation as well as other artifacts that decrease Lisa Bussolari, RT(R) (MR) the sensitivity of breast magnetic resonance imaging. Improper Jacqueline Pawlisz-Hoff, RT(R) positioning can create artifacts that can obscure a malignancy or (M) (MR) cause it to be missed. Goals of proper positioning include imag- Robyn L. Birdwell, MD ing the maximum area of breast tissue, minimizing skin folds, and achieving homogeneous fat suppression and nondeformed breast RadioGraphics 2014; 34:E1-E17 parenchyma. Review of prior images gives the technologist an im- Published online 10.1148/rg.341125193 pression of what the positioning and imaging challenges may be in Content Codes: BR each patient before the patient enters the imaging unit. Checking MR OA the triplane localizer images and repositioning as necessary before "From the Division of Breast Imaging, Depart- ment of Radiology, Brigham and Women's Hos- any diagnostic or interventional imaging is key. Using a fat satura- pital and Harvard Medical School, 75 Francis St, tion pad, changing the arm position, or "rolling" the patient may be RA Bldg, RA-014, Boston, MA 02115 (E.D.Y ., D.G.S ., S.R ., I.B ., R.L.B.); and Department of considered in difficult cases. Padding to support the patient in an Radiology, Dana-Farber Cancer Institute, Bos- oblique position, using angled sponges to increase breast compres- ton, Mass (J.P.H.). Recipient of a Cum Laude sion thickness, and raising the grid to access posterior lesions may award for an education exhibit at the 2010 RSNA Annual Meeting. Received September 6, be helpful in targeting difficult-to-access lesions for biopsy. Using 2012; revision requested October 19; final revi- the presented positioning techniques and suggestions, in addition to sion received May 10, 2013; accepted May 29. For this journal-based SA-CME activity, the strict attention to detail before imaging, will improve image quality, authors, editor, and reviewers have no financial decrease imaging time and suboptimal images, and limit the need relationships to disclose. Address correspon- dence to E.D.Y. (e-mail: eyeh@partners.org). for repeat imaging studies. ORSNA, 2014 . radiographics.rsna.org 15 Unrestricted © Siemens Healthineers, 2022 Notes 18 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers ... Positioning Related Artifacts – Case Study #1 Initial Observation: STUDY 240993 Poor Fat Saturation. Action Plan: Check the localizers for breast placement and skin folds. In this case the patient has an inferior fold. Reposition the patient. Or use Dixon which is not sensitive to positioning or skin folds. • Dixon can always be used in cases with challenging Fat Saturation Large Inferior Fold • Many use Dixon as their default protocol Reference: Innovations 2021 – Breast Image Quality: The Challenges and Solutions; 16 16 HOOD05162003067440 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 19 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers ... Positioning Related Artifacts – Case Study #2 Initial Observation: Poor Fat Saturation. Action Plan: Check the localizers for breast placement and skin folds. In this case the patient has a lateral fold. Reposition the patient. Inferior Fold Or use Dixon which is not sensitive to positioning or skin folds. Dixon can always be used in cases with challenging Fat Saturation. Many use Dixon as their default protocol. Lateral Folds Reference: Innovations 2021 – Breast Image Quality: The Challenges and Solutions; 17 17 HOOD05162003067440 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 20 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers ... Positioning Related Artifacts – Case Studies #3 & 4 R SPRINGO SPF51.6 Reference: Innovations 2021 – Breast Image Quality: The Challenges and Solutions; 18 18 HOOD05162003067440 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 21 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers ... Positioning Related Artifacts – Case Studies #5 & 6 ₱ 1.00 MF 1.00 29 77:30 PÕE 30 77130 TP O Reference: Innovations 2021 – Breast Image Quality: The Challenges and Solutions; 19 19 HOOD05162003067440 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 22 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers' ... Positioning Related Artifacts – Case Study #7 R TR 7.6 TE 3.5 TA 00.81*29 VV 250.0 TP O TP F3 SP R79.5 BW 365.0 SP H1.0 31 SL 6.0/9.0 SL 1.4i 3L8. BR8 FoV 500*500 A1/PFP/SFS FoV 300*300 'f12d1 / 20 384*512 1: BL8;BR8 *f13d1 /10 366p*416s Sag Tra Reference: Innovations 2021 – Breast Image Quality: The Challenges and Solutions; 20 20 HOOD05162003067440 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 23 MR Breast Image Quality | Numaris X SIEMENS ..... Healthineers .. Breast – IQ Case Studies Fat Sat Inhomogeneity (B0) Artifacts 21 Unrestricted © Siemens Healthineers, 2022 Notes 24 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers .. Fat Sat Inhomogeneity (B0) Artifacts – Case Study #8 Initial Observation: Fat Saturation failure around the nipples. Positioning is good. Action Plan: Some small local areas of Fat Saturation loss are due to patient anatomy and not positioning. These can be caused by small air tissue interfaces causing local susceptibility. • Switch from SPAIR to Quick Fat Sat • Or use Dixon which is not sensitive to the areas of susceptibility 10cm: Reference: Innovations 2021 – Breast Image Quality: The Challenges and Solutions; 22 22 HOOD05162003067440 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 25 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers ... Fat Sat Inhomogeneity (B0) Artifacts – Fat Saturation Explanation SPAIR (Spectrally Attenuated Inversion Recovery) SPAIR Water Excitation Default sequence selection used for most breast imaging. Insensitive to B1 issues often seen on 3T systems. Sensitive to small local B0 areas where local shim is not optimal. Quick Fat Saturation Available option for standard breast VIBE based sequences. APPERErs Sensitive to B1 issues often seen on 3T systems. Insensitive to small local B0 areas where local shim is not optimal. Quick Fat Sat Dixon May be used in the case of small inhomogeneities around the nipples. IR 6.2 TE 2.5 SP F94.7 TA 01:32 SL 4.00.0 BW 480 0 ToV 340*340 A3 MINORMIDIS20 3000*4405 FL.4.BR4 *1302/10 23 23 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 26 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers ... Fat Sat Inhomogeneity (B0) Artifacts – Fat Saturation Explanation Water Excitation Normal SPAIR Water Excitation Good Fat Saturation. Certain advantages with conspicuity. Longer TE and imaging times. Water Excitation Fast Shorter TE and scan times. Built for speed and very fast acquisitions. APPERErs Sometimes incomplete Fat or Weak Fat Suppression. Quick Fat Sat Dixon Dixon Most robust technique with consistent fat removal. Will generate additional fat series that are not sent to PACS. Occasionally the fat and water series swap. IR 6.2 If this happens the series can be renamed, and manual TE 2.5 SP F94.7 TA 01:32 SL 4.00.0 BW 480 0 ToV 340*340 A3 MINORMIDIS20 3000*4405 subtractions can be created. FL.4.BR4 *1302/10 24 24 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 27 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers ... Fat Sat Inhomogeneity (B0) Artifacts – SPAIR Breast SPAIR Breast parameter was introduced with XA11A Improved Fat Saturation. Improved Silicone Suppression. 3T only. SPAIR SPAIR Breast 25 25 Reference: MR XA30 VILT; Module 5 Pulse Sequences: HRT Approved 7.29.2021; HOOD05162003208678 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 28 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers .. Fat Sat Inhomogeneity (B0) Artifacts – Case Study #9 Initial Observation: Poor Fat Saturation of right breast. Asymmetry seen on localizer. Action Plan: • Right to left asymmetry can be detrimental to shim • Asymmetry can be due to patient anatomy and implants TA 01:38 TP H17 Poor positioning is the primary cause of asymmetry BW 501.0 SP H60.9 • SL 1.21 A1/PFP/SFS FoV 340*340 Asymmetry can be right to left or in the Z direction as well C:BL8;BR8 376p*416s • f13d1 / 8 Tra • Sharp angles in Breast tissue can cause local Fat Saturation loss Reference: Innovations 2021 – Breast Image Quality: The Challenges and Solutions; 26 26 HOOD05162003067440 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 29 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers ... Fat Sat Inhomogeneity (B0) Artifacts – Case Study #10 Initial Observation: Poor Fat Saturation of left breast. Asymmetry seen on Localizer. Action Plan: • Have the patient position by placing themselves straight down on the coil and avoid rolling on to the coil from one side • Check both sides of the patient from each side of the table BVV 501 0 • Avoid sharp angles in the breast tissue‐move the patient in the 1/PFP! Z direction up or down L8 BRA f1301"18 • Make sure the patient is lying flat on the coil and is not oblique • Use localizers as a tool to assure good symmetry • Localize as often as needed until good symmetry is achieved • Or switch to Dixon strategy Reference: Innovations 2021 – Breast Image Quality: The Challenges and Solutions; 27 27 HOOD05162003067440 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 30 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers .. Fat Sat Inhomogeneity (B0) Artifacts – Case Study #11 Initial Observation: Poor Fat Saturation. Saline bag placed under breast. Action Plan: Saline and water bags will cause severe shim issues and frequency selection and are not recommended. Reference: Innovations 2021 – Breast Image Quality: The Challenges and Solutions; 28 28 HOOD05162003067440 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 31 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers ... Fat Sat Inhomogeneity (B0) Artifacts – Case Study #12 Initial Observation: Poor Fat Saturation in superior breast region. Susceptibility artifact. Action Plan: Ensure patient is changed out of street clothes and all foreign objects removed. Inspect sheets or pillowcases for metal objects or Radio Frequency Identification (RFIDs). Reference: Innovations 2021 – Breast Image Quality: The Challenges and Solutions; 29 29 HOOD05162003067440 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 32 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers .. Fat Sat Inhomogeneity (B0) Artifacts – Case Study #13 Initial Observation: Poor Fat Saturation (not shown). Asymmetry seen on Localizer. R Action Plan: Some asymmetry is due to patient anatomy and 5 cm cannot be changed. F Dixon is recommended, if not the default, for difficult cases where no amount of positioning will make a m TP O difference in the homogeneity. (e.g., single TR 7.6 TE 3.5 SP F18.0 mastectomy) TA 00.81*12 SL 6.0/12.0 BW 250.0 FoV 500*500 p2 M/NORM DIS2D/MF SPLIT 384*512s | CG/RG Tra A1/PER Zoom 0.83 BL8;BR8 224 *f12d1 / 20 96 nz Reference: Innovations 2021 – Breast Image Quality: The Challenges and Solutions; 30 30 HOOD05162003067440 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 33 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers ... Fat Sat Inhomogeneity (B0) Artifacts – Case Study #14 Initial Observation: 4 IMA 57 / 104 LPH Patient has saline implants. The saline implants are suppressed instead of the fat. Action Plan: Deselect the parameter Assume Dominant Fat. If this is parameter is left on for large Saline implants, then the system assumes the Water peak is the Fat peak and suppresses it. Confirm Center Frequency and make sure it is centered on the Water peak to the right. Reference: Innovations 2021 – Breast Image Quality: The Challenges and Solutions; 31 31 HOOD05162003067440 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 34 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers ... Fat Sat Inhomogeneity (B0) Artifacts – Tips for Implants Tips for Fat Saturation when Implants are present: Assume Dominant Fat is saved by default on Numaris 4 software (B19, E11). Deselect this parameter if patient has large Saline implants and Water, is the largest peak. This parameter is not applicable to the XA platform as the Fat and Water are automatically differentiated. Select Assume Silicone if the patient has Silicone implants and Silicone is the largest peak. This parameter is still relevant for the XA platform. Confirm Frequency Adjustment should be checked for patients with implants. Make sure the Center Frequency is on Water, which is the peak furthest to the right. 32 32 Reference: MR Breast Imaging; HRT Approved: 1.15.2021 HOOD05162003157509 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 35 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers ... Fat Sat Inhomogeneity (B0) Artifacts – Case Study #15 Initial Observation: Poor Fat Saturation. Confirm Center Frequency shows poor resolution of peaks. Action Plan: Check the patient for foreign objects or clothing material. This patient was wearing a belt buckle. Reference: Innovations 2021 – Breast Image Quality: The Challenges and Solutions; 33 33 HOOD05162003067440 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 36 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers .. Fat Sat Inhomogeneity (B0) Artifacts – Shim Box Improving the Shim: A shim box can be placed over the Breasts only, so that the +LPH sides and back are not considered in the shim calculation. Do not exclude relevant tissue such as the Axilla. Saving the Field‐of‐View (FoV) elongated in the Phase Encoding direction, excluding any irrelevant tissue posteriorly, will also accomplish this without the need for adjusting the shim volume. R 10cm MF 1.00 TR 4751.3 TE 122.0 TA 01:21*2 BW 159.0 M/DIS2D CHER R 'tse2d1_21 / 150 y 1145; Reference: Innovations 2021 – Breast Image Quality: The Challenges and Solutions; 34 34 HOOD05162003067440 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 37 MR Breast Image Quality | Numaris X SIEMENS ..... Healthineers .. Breast – IQ Case Studies Dielectric (B1) Artifacts 35 Unrestricted © Siemens Healthineers, 2022 Notes 38 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers* ** Dielectric (B1) Artifacts – Case Study #16 Initial Observation: Left to right shading. Fat Saturation and positioning are good. Action Plan: R Right‐to‐Left signal differences is generally related to B1 inhomogeneity. • More prevalent on 3T systems Dem • The problem is seen on sequences most sensitive to B1 issues (e.g., T1 and Inversion Recovery sequences) Use SPAIR which is insensitive to B1 inhomogeneity Use a combination of B1 and Prescan Normalize filters F • Prescan Normalize Normal is the only strength available when it’s combined with the B1 filter • Use Dixon combined with B1 and Prescan Normalize filters Reference: Innovations 2021 – Breast Image Quality: The Challenges and Solutions; 36 36 HOOD05162003067440 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 39 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers .. Dielectric (B1) Artifacts – Case Study #16 Prescan Normalize only Prescan Normalize and B1 Filter R 10cm 10cn F F SP F65.2 SL 1.71 SP F55.[ SL 1. Reference: Innovations 2021 – Breast Image Quality: The Challenges and Solutions; 37 37 HOOD05162003067440 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 40 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Dielectric (B1) Artifacts – Case Study #17 Healthineers ... SPAIR Quick Fat Sat 10ch F 1.00 MF 1.00 TR 3.9 TE 1.5 EUR 4.0 TA 01:35 TPIQUE 1.4 BW 651.0 SP HSG DITA 01:30 p2 MIND NORM SL2BVV 587.0 FoV 360-36002 MIND/NORM CLER RBR 384p*512s f13d1 / 10 Tra41/PFP/FS 288C:LBR; RBR 135 fl3d1 /10 Reference: Innovations 2021 – Breast Image Quality: The Challenges and Solutions; HOOD05162003067440 38 38 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 41 MR Breast Image Quality | Numaris X SIEMENS ..... Healthineers .. Breast – IQ Case Studies Additional Recommendations 39 Unrestricted © Siemens Healthineers, 2022 Notes 42 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers ... Additional Recommendations – Effect of Menstrual Cycle Effect of Menstrual Cycle on Contrast Enhancement: In premenopausal women, it is best to perform the MRI 7 to 10 Day 1 Tra days after the start of the cycle, with some organizations allowing up to 14 days after. The background enhancement of the normal fibro‐glandular breast tissue is low, allowing better visualization of abnormalities. Day 7 Reference: Breast MRI General Imaging WBT; HRT Approved 8.30.2016; 40 40 HOOD05162002433740 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 43 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers ... Additional Recommendations – Prescan Normalize Prescan Normalize Recommendations: Use Prescan Normalize Broad Range for images without fat suppression. • Prevents the Fat closest to the coil elements from appearing brighter than other Breast tissue Better signal intensity of chest wall 1.00 • Broad Range Normal Use Prescan Normalize Normal or Moderate for images with Fat Saturation. • Keeps tissue outside of the coil darker for a better Signal‐to‐Noise Ratio (SNR) impression • This is a radiologist preference with some preferring one or the other • The exact level of normalization is dependent 1.00 on the software version Moderate 41 41 Reference: MR Breast Imaging; HRT Approved: 1.15.2021 HOOD05162003157509 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 44 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers .. Additional Recommendations – Frequency Readout Direction The Frequency Readout direction can influence Fat Saturation: Eddy Currents can result from the rapidly changing gradients and can influence the field homogeneity. Try switching the Phase Encoding direction, which will also change the Readout direction if Phase Left‐to‐Right inhomogeneous Fat Saturation is always on the same side of most patients. Phase Right‐to‐Left 42 42 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 45 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers ... Additional Recommendations – Improved Image Quality Additional Parameter Recommendations for VIBE: Use Out‐of‐Phase TE (2.46ms at 1.5T, 1.23ms at 3T) for better Fat Saturation. • Use minimum for 3T if 1.23ms is not possible Asymmetric Echo Off will improve Resolution sharpness • May need to increase Bandwidth to get desired TE • Use Weak instead of Strong if needed • Use Asymmetric Echo Weak for Dixon at 3T in order to get TEs 1.23 In Phase and 2.46 Phase and Slice Partial Fourier Off for improved Resolution. Perform Sagittal VIBE bilaterally to acquire both breasts in half of the scan time as acquiring separately (increases acceleration in slice direction, CAIPIRINHA 3 for example). Use Slab‐Selective Phase Encoding (PE) when scanning Sagittal bilaterally to eliminate aliasing artifacts in the Phase Encoding direction, further reducing scan time with Phase Oversampling ~30%. Out‐of‐Phase 43 43 Reference: Siemens Breast MR Protocol Optimization Guide for customers_B17 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 46 MR Breast Image Quality | Numaris X Breast IQ & Artifacts SIEMENS ..... Healthineers ... Additional Recommendations – Improved Image Quality Additional Parameter Recommendations for VIBE: Use Out‐of‐Phase TE (2.46ms at 1.5T, 1.23ms at 3T) for better Fat Saturation. • Use minimum for 3T if 1.23ms is not possible Asymmetric Echo Off will improve Resolution sharpness • May need to increase Bandwidth to get desired TE Partial Fourier 6/8 Phase, 6/8 Slice, • Use Weak instead of Strong if needed • Use Asymmetric Echo Weak for Dixon at 3T in order to get TEs 1.23 Asymmetric Echo = On and 2.46 Phase and Slice Partial Fourier Off for improved Resolution. Perform Sagittal VIBE bilaterally to acquire both breasts in half of the scan time as acquiring separately (increases acceleration in slice direction, CAIPIRINHA 3 for example). Use Slab‐Selective Phase Encoding (PE) when scanning Sagittal bilaterally to eliminate aliasing artifacts in the Phase Encoding Partial Fourier = Off direction, further reducing scan time with Phase Oversampling ~30%. Asymmetric Echo = Off 44 44 Reference: Breast MRI General Imaging WBT; HRT Approved 8.30.2016; HOOD05162002433740 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 47 MR Breast Image Quality | Numaris X Additional Resources Job Aids MR Breast Positioning for Best Image Quality https://pep.siemens-info.com/en-us/mr-breast-positioning-for-best-image-quality Sentinelle Manual Breast Biopsy Workflow https://pep.siemens-info.com/en-us/sentinelle-manual-breast-biopsy-workflow Silicone Implant Breast MRI Step by Step https://pep.siemens-info.com/en-us/silicone-implant-breast-mri-step-by-step Video Breast Dot Engine https://pep.siemens-info.com/en-us/dotengine-breast 48 MR Breast Image Quality | Numaris X On account of certain regional limitations of sales rights and service availability, we cannot guarantee that all products included in this brochure are available through the Siemens sales organization worldwide. Availability and packaging may vary by country and is subject to change without prior notice. Some/All of the features and products described herein may not be available in the United States. The information in this document contains general technical descriptions of specifications and options as well as standard and optional features which do not Local Contact Information always have to be present in Siemens Medical Solutions USA, individual cases. Inc. 40 Liberty Blvd. Malvern, PA 19355-9998 Siemens reserves the right to modify the design, packaging, specifications USA and options described herein without Telephone: +1-888-826-9702 siemens.com/healthcare prior notice. Please contact your local Siemens sales representative for the most current information. Legal Manufacturer Imaging & Therapy Systems Note: Any technical data contained in Magnetic Resonance this document may vary within Henkestr. 127 defined tolerances. Original images DE-91052 Erlangen always lose a certain amount of Germany detail when reproduced. Telephone: +49 9191 18-0 siemens.com/healthcare Siemens Healthcare Headquarters Siemens Healthcare GmbH Healthcare Sector Henkestr. 127 91052 Erlangen Germany Phone: +49 9131 84-0 siemens.com/healthcare Published by Siemens Healthcare GmbH · HOOD05162003271102 Printed in USA · 00001 · ©Siemens Healthcare GmbH, 2022 49