CME

JOURNAL OF MAGNETIC RESONANCE IMAGING 34:1212–1217 (2011)

Technical Note

Supine Breast MRI

Peter Siegler, PhD,1* Claire M.B. Holloway, MD, PhD,2 Petrina Causer, MD,3
Gilbert Thevathasan, BEng,4 and Donald B. Plewes, PhD1

DYNAMIC CONTRAST-ENHANCED (DCE) breast mag-

Purpose: To achieve high-quality unilateral supine
breast magnetic resonance imaging (MRI) as a step to netic resonance imaging (MRI) exhibits high sensitivity
facilitate image aiding of clinical applications, which with somewhat variable specificity (1). It provides an
are often performed in the supine position. Contrast- accurate assessment of the extent of disease and mul-
enhanced breast MRI is a powerful tool for the diagno- tifocal disease (2,3).
sis of cancer. However, prone patient positioning typi- Breast MRI is commonly performed in the prone
cally used for breast MRI hinders its use for image position with the breasts pendant into specialized coil
aiding. arrays (4,5). This prone positioning minimizes breast
Materials and Methods: A fixture and a flexible four-ele- motion due to respiration and reduces the potential
ment receive coil were designed for patient-specific shap- interference with the beating heart. In addition, the
ing and placement of the coil in close conformity to the coil coupling is improved.
supine breast. A 3D spoiled gradient sequence was modi- While prone breast MRI is well suited for diagnosis,
fied to incorporate compensation of respiratory motion. it is less suitable for use in combination with clinical
The entire setup was tested in volunteer experiments and applications such as surgery and ultrasound guided
in a pilot patient study.
biopsy where the patient is in supine position (6,7).
Results: The flexible coil design and the motion compen- Given the scale of tissue deformations that are
sation produced supine breast MR images of high diag- expected from a prone to supine geometry, achieving
nostic value. Variations in breast shape and in tissue accurate deformation to guide a breast intervention is
morphology within the breast were observed between a computationally challenging, time-consuming, and
supine and a diagnostic prone MRI of a patient.
subject to substantial errors.
Conclusion: The presented supine breast MRI achieved An alternative and more direct approach is the
an image quality comparable to diagnostic breast MRI. imaging of the patient in supine positioning. Alderlies-
Since supine positioning is common in many clinical ten et al (8) showed that this approach substantially
applications such as ultrasound-guided breast biopsy or alleviates the need for computationally complex regis-
breast-conserving surgery, the registration of the supine
tration methods while minimizing the potential for
images will aid these applications.
registration errors. However, the body-coil was used
Key Words: breast MRI; breast cancer; supine position- to acquire the supine images, which caused only sub-
ing; image aid optimal image quality.
J. Magn. Reson. Imaging 2011;34:1212–1217. In contrast to prone breast MRI where the breast is
V
C 2011 Wiley Periodicals, Inc.
essentially motionless, respiration causes breast
motion in the supine position (9). Unless efforts are
made for motion compensation, chest wall and breast
motion can degrade image quality.
Breath-holding is impractical for high spatial reso-
lution scans and dynamic breast MRI. Gating meth-
1
Sunnybrook Health Sciences Centre, Imaging Research, Toronto, ON, ods (10) can compensate for respiratory motion but
Canada. are not time-efficient. Alternatively, phase-encode
2
Sunnybrook Health Sciences Centre, Department of Surgery, Toronto, reordering methods (11,12) are time-efficient, but
ON, Canada.
3
larger motions can degrade the image quality. Techni-
Sunnybrook Health Sciences Centre, Department of Medical Imaging,
Toronto, ON, Canada. ques that combine reordering and gating were there-
4
Sentinelle Medical Inc., Toronto, ON, Canada. fore introduced (13,14), including the zonal motion-
Contract grant sponsor: Canadian Breast Cancer Research Alliance adapted acquisition and reordering technique
(CBCRA)/Alliance Canadienne pour la recherché sur le cancer du (ZMART) (15) for 3D imaging.
sein (ACRCS); Contract grant number: 17772.
In this work, an MRI apparatus for unilateral breast
*Address reprint requests to: P.S., Sunnybrook Health Sciences
Centre, Division of Imaging Research – S 605, 2075 Bayview Ave., To- MRI in the supine positioning was developed. For
ronto, Ontario M4N 3M5, Canada. E-mail: peter.siegler@hologic.com motion compensation, a 3D gradient echo sequence
Received May 23, 2010; Accepted March 9, 2011. was modified in accordance with ZMART.
DOI 10.1002/jmri.22605
View this article online at wileyonlinelibrary.com.

V
C 2011 Wiley Periodicals, Inc. 1212
Supine Breast MRI 1213

Figure 1. a: Flexible supine breast coil with four elements used for unilateral supine breast MRI. The black fixture is bend-
able to adapt to the breast geometry. b: Fixture and coil during the positioning of the patient. c: During the examination the
fixture holds the coil above the breast, when the patient is lying supine on the standard patient bed of the MR scanner. In
order to achieve an optimal coil coupling to the desired breast tissue, the flexible imaging coil can be bent as shown in (d)
and (e) or tilted as shown in (f).

MATERIALS AND METHODS Respiratory Motion Compensation

Imaging Coil and Support Structure During the entire procedure, a pneumatic respiratory
All experiments were performed on a whole-body 1.5T belt was used to monitor the respiratory state of the
MR scanner (GE Signa Excite, Milwaukee, WI). To free-breathing patient. The breast images were acquired
achieve good signal-to-noise ratio (SNR), a unilateral with a fast 3D gradient echo sequence (SPGR), which is
four-element receive coil (size: 26
23 cm2) for frequently used for DCE breast MRI (16). To compen-
supine breast MR imaging was built on a flexible Tef- sate for the respiratory motion of the breast in the
lon sheet (Fig. 1a) using 6.35-mm wide copper tape. supine position, the fast 3D SPGR sequence was modi-
Coupling between coil loops was minimized by over- fied in accordance with ZMART (15), which is a combi-
lapping neighboring loops, decoupling capacitors, and nation of phase-encode reordering and gating.
low input-impedance preamplifiers. For phase-encode reordering, the actual respiration
A coil fixture was designed to support the coil state determines which position in the k-space plane
above the breast of the patient on the standard bed of the two phase-encoding directions (ky and kz) is
of the scanner (Fig. 1b,c). It can be lifted to allow acquired. If the respiration state is closer to expira-
convenient patient positioning on the patient bed tion, a position next to the k-space center is acquired.
(Fig. 1b). Once the patient is in position, the fixture As the displacement due to respiration increases, the
is lowered over the patient’s breast and the coil array acquired position is placed towards the periphery of
can be positioned above the breast via translation in k-space. For gating, the acquired data are rejected if
all three directions (Fig. 1c). A gimbaled joint (Loc- the displacement detected with the respiratory belt
Line system, Modular Hose, Lisle, IL) connects the lies above the chosen gating window (spin-conditioned
coil to the fixture and allows arbitrary rotation and gating (10)). Phase-encode reordering has no effect on
tilting of the coil above the patient’s breast (Fig. 1d– the scan time. Using gating, the scan time is pro-
f). An additional set of gimbaled joints permits the longed depending on the gating threshold.
modification of the coil array shape so that it can
conform as closely as possible to different breast geo-
metries. The coil has no contact with the breast. In
addition, an air gap with a minimal width of 1 cm is Human Scans
kept between the coil and the breast skin (confirmed All human supine breast MRI scans were conducted
visually). The coil adjustment ensures optimal cou- under a protocol approved by the Human Ethics
pling to the breast tissue, while allowing the breast Review Board. Images were acquired unilaterally
to remain in its native supine configuration that is using the previously described supine breast setup
expected in subsequent surgical or interventional and a fast 3D SPGR sequence with compensation for
procedures. respiratory motion in accordance with ZMART. A
1214 Siegler et al.

pneumatic respiratory belt was used to monitor the 50). Datasets were acquired without and with motion
respiratory state of the free-breathing subject. compensation using reordering only.
When using the supine position, the breast is usu-
ally flattened against the chest wall by gravity, so that
an oblique coronal slice orientation minimizes the Patient Study
number of necessary slice acquisitions and measure-
ment time. The frequency encoding direction was A supine breast MRI examination was performed on
always chosen in the left–right direction in order to the affected breast of a patient with previously diag-
avoid artifacts aliasing from the arm and the contra- nosed breast cancer after obtaining informed consent.
lateral breast. The imaging parameters for the fast 3D SPGR were:
oblique coronal slice orientation, frequency encoding
from left to right, TE ¼ 4.2 msec, TR ¼ 6.5 msec, flip
SNR Assessment of Supine Coil Array
angle ¼ 30 , FOV ¼ 200
200 mm2, Dz ¼ 2 mm and
To assess the supine coil array, its SNR performance matrix: 256
256
46. The first scan showed
was compared with that of a routinely used prone coil adequate motion compensation using only k-space
array in a volunteer. A set of MRI data was acquired reordering. As a consequence, no gating was neces-
as order to reconstruct 3D datasets of absolute coil sary during the examination. After the injection of a
array SNR using (17,18): contrast agent (CA; Gd-DTPA), the first scan was
repeated four times. Afterwards one scan was per-
pffiffiffiffiffiffiffiffiffiffiffiffiffi pffiffiffiffiffiffiffiffiffiffiffiffiffiffi
SNR ¼ 2pH p= bH Cb; ½1 formed with fat suppression achieved using chemi-
cally selective radiofrequency (RF) excitation and
where p are the scaled complex image data, b the spoiler gradients (19). This fat-suppressed scan
complex coil sensitivities, and C the receiver noise co- required a longer repetition time of TR ¼ 16.2 msec.
variance matrix. All datasets were viewed in 3D using a software pack-
After informed consent, the left breast of a human age (Aegis, Sentinelle Medical, Toronto, Canada),
volunteer was scanned in prone and supine configu- which allows quick display of 3D datasets from differ-
rations. For each configuration, a set of MRI data was ent points of view.
acquired with a fast 3D SPGR sequence including The fat-saturated supine images were compared to
image data (flip angle ¼ 30 , field of view [FOV] ¼ 190 diagnostic MR images (bilateral scan, fat saturated,

190 mm2, Dz ¼ 2 mm, TE ¼ 4.2 msec, TR ¼ 6.5 accelerated by parallel imaging with acceleration fac-
msec, matrix: 256
256
46, 1 NEX), coil sensitivity tor R ¼ 2, matrix size ¼ 288
224
84, FOV ¼ 190
data (TE ¼ 4.2 msec, TR ¼ 5.3 msec, matrix: 32
32
190
252 mm3, TE ¼ 3.6 msec, TR ¼ 7.2 msec).

46, 4 NEX), and noise samples (TE ¼ 4.2 msec, TR Since the diagnostic scan was performed in a prone
¼ 6.5 msec, matrix: 256
256
46, 1 NEX). position with sagittal slice orientation, the data were
In the first configuration, the volunteer was unilat- reformatted to obtain images with a coronal slice ori-
erally scanned in the prone position using a conven- entation for comparison with the supine images.
tional eight element High Density Breast Array coil To account for breast motion between the acquisi-
(GE Healthcare, UK), which had coils in a fixed geom- tions of the supine datasets, all supine 3D datasets
etry within the coil housing. Lateral plates were used were registered to match the first precontrast dataset
to stabilize the breast tissue during imaging. Because (20). The contrast enhancement was then depicted by
the scan was unilateral, only four coil elements were subtraction of the precontrast 3D dataset from the
used for imaging, which corresponds to the number of four postcontrast datasets. Regions of interest (ROIs)
elements of the supine coil array. All images were were chosen within the tumor and normal fibrogland-
acquired in a sagittal slice orientation with frequency ular tissue. The average signal inside each ROI was
encoding from anterior to posterior to avoid effects of computed for each subtracted dataset and plotted as
heart motion and to minimize scan time. function of time after the injection of the CA.
In the second configuration, the volunteer was in
the supine position using the supine imaging appara-
tus (oblique coronal slice orientation, frequency RESULTS
encoding from left to right). Breast motion caused by
respiration was compensated with ZMART (using SNR-scaled maps through the breast of the human
phase-encode reordering and 60% gating window) volunteer are shown in Fig. 2 for the conventional
based on the signal tracked by the respiratory belt. imaging coil (Fig. 2a–d) and the supine coil array (Fig.
2e–h). The SNR of the prone coil array was more ho-
Volunteer Study mogenous over the entire breast compared to the SNR
performance of the supine coil array. However, for the
After obtaining informed consent, unilateral breast supine coil array the SNR at all points within the
scans were acquired from a free-breathing volunteer breast was at least as high as for the conventional
using the supine breast apparatus and a fast 3D coil. Lower SNR values were measured in the tissue
spoiled gradient echo sequence (oblique coronal slice beneath the chest wall (right side in Fig. 2h). The
orientation, frequency encoding from left to right, TE imaging volume of the supine coil array included also
¼ 4.2 msec, TR ¼ 6.6 msec, flip angle ¼ 30 , FOV ¼ the breast tissue, which was drawn by gravity to the
180
180 mm2, Dz ¼ 2 mm and matrix: 256
256
side of the torso next to the arm (left side in Fig. 2h).
Supine Breast MRI 1215

Figure 2. SNR-scaled maps through the left breast of a human volunteer using two imaging configurations. a–d: Conven-
tional imaging coil, where data were acquired with prone positioning and with a sagittal slice orientation. Shown are (a) a lat-
eral slice, (b,c) two central slices, and (d) medial slice (spacing between the slices: 16 mm). e–h: Supine coil array, where the
subject was in the supine position with the coil array placed above the breast and an oblique coronal slice orientation. Shown
are (e) a slice near the nipple, (f,g) two slices with increasing distance from the nipple, and (h) a slice near the chest wall
(spacing between the slices: 14 mm). With the supine coil array the SNR over the entire breast volume was at least as good
as the one with the conventional imaging coil. However, the supine coil array showed clear spatial variations in the SNR fol-
lowing the coil profile. The SNR color scale is shown on the right side.

Without motion compensation, the respiratory to 190 seconds. When comparing the supine (Fig. 4a–
motion created typical streaking artifacts along the d) and the reformatted diagnostic images (Fig. 4e–j),
phase encode direction in the volunteer study (Fig. large differences in the orientation and the shape of
3a–d). These presented themselves as displaced fat the breast and the lesion were observed. Using the 3D
signal outside the breast and within the fibroglandu- image viewer, the supine data were presented as sur-
lar tissue. Motion compensation achieved with reor- face volumes and maximum intensity projections
dering only (Fig. 3e–h) was quite effective at reducing (MIPs) (Fig. 5a).
these artifacts. Even additional gating did not further The supine images showed some positional changes
improve the motion compensation. of the breast between the scans. The displacements
In the patient study, the tumor was clearly visible were mostly in the anterior/posterior direction and
in the supine breast MR images that were acquired could be successfully corrected using 3D image regis-
with fat saturation (Fig. 4a–d). However, the use of fat tration (20). By subtracting the registered supine
saturation increased the scan time from 88 seconds dataset the CA dynamics was clearly depicted. Within

Figure 3. Images of the volunteer with an oblique coronal slice orientation near the chest wall, near the nipple, and in an in-
termediate slice (spacing between slices: 16 mm). The intermediate slice is additionally shown with a hard window for better
visualization of motion artifacts. Without compensation for respiratory motion (a–d), artifacts occurred in the direction of the
in-plane phase-encoding ky (arrows). Motion compensation using reordering only (e–h) successfully prevented motion arti-
facts without increasing the required scan time of 85 seconds.
1216 Siegler et al.

Figure 4. Images of a patient taken in the supine position (a–d) and in the prone position (e–j), where the image data were
reformatted from a sagittal to a coronal slice orientation. The distance between two successive slices was 20 mm in both
sets. The orientation and shape of the breast as well as the position of the lesion (arrows) were fundamentally different in the
two datasets.

the tumor, the signal enhancement showed the typical For the diagnostic scan in prone positioning, the
rapid enhancement followed by a washout phase (solid coils were placed on both sides of each breast as close
line in Fig. 5c). In contrast, the normal fibroglandular as possible. The breast was therefore flattened in the
tissue underwent only minor signal enhancement after regions where it was touching the coil (see sides of
the CA injection (dashed line in Fig. 5c). breast in Fig. 4e–h). In addition, the breast was pend-
ant and extended by gravity. The whole breast geome-
try as well as the relative position of the lesion varied
between the supine and the prone setting (Fig. 4).
DISCUSSION
These variations will cause tumor localization errors
The arrangements of the supine and the prone coils are in the operating room if the prone MR images are
fundamentally different and influence the resulting used to aid clinical procedures.
SNR profiles (Fig. 2). The prone coil array achieved a ho-
mogenous SNR profile over the entire breast (Fig. 2a–d).
In contrast, the sensitivity and thus the SNR profile of
the supine coil array dropped with increasing distance
to the array (Fig. 2e–h). In order to cover the entire
breast, supine imaging coils should therefore always
have a larger volume of sensitivity than conventional
coil arrays used with prone positioning.
The coils were designed to closely conform to the
breast anatomy while not distorting the breast from
its native supine configuration. This is essential for
preserving imaging of diagnostic quality and high
SNR.
Further improvements in coil flexibility can be
achieved with a greater number of coils of smaller
size, which may further increase SNR. This will also
accommodate different breast sizes, the breast tail
and axilla, and thus ensure full coverage of the breast
with high coil sensitivity and SNR.
The k-space reordering alone successfully sup- Figure 5. a: Surface volume (top) and maximal projection
(bottom) of the fat saturated dataset allow a good visualization
pressed respiratory motion artifacts in supine breast
of the 3D volume of the supine breast. b,c: Contrast enhance-
MRI (Figs. 3, 4a–c). An addition of gating was not nec-
ment after CA injection. b: Subtraction image indicating ROIs
essary. Since k-space reordering without gating has within the tumor (solid arrow) and normal breast tissue
no effect on the scan time, the temporal resolution of (dashed arrow). c: Signal enhancement (difference between
supine breast MRI using k-space reordering for respi- images after CA injection and the image before injection)
ratory motion compensation is comparable with cur- inside the two ROIs indicated in (b). The solid line shows the
rent diagnostic breast MRI in the prone position. typical rapid enhancement of tumor with following washout.
Supine Breast MRI 1217

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