Abstract
This guideline presents Part IV of the Canadian Association of Radiologists (CAR) Practice Guidelines on Breast Imaging and Intervention and addresses breast magnetic resonance imaging (MRI). As the most sensitive imaging modality for breast cancer detection, MRI plays an established and expanding role in screening, staging, problem-solving, and treatment monitoring. This guideline provides updated recommendations on indications, technical requirements, contrast administration, reporting standards, quality assurance, patient safety, and facility readiness for MRI-guided intervention. Emphasis is placed on bilateral imaging protocols, multimodality correlation, and integration within multidisciplinary breast care. This guideline is intended to be used alongside the other components of the CAR Breast Practice Guidelines series, which collectively replace the 2016 consolidated guidelines and reflecting current evidence and clinical practice in Canada. While defining best practices and minimum expectations, this guideline supports flexibility in application based on patient factors, available resources, and evolving knowledge, with clinical judgment remaining the responsibility of the supervising radiologist.
Preamble
The practice guidelines of the Canadian Association of Radiologists (CAR) are not rules, but are guidelines that attempt to define principles of practice that should generally produce radiological care. The radiologist and medical physicist may modify an existing practice guideline as determined by the individual patient and available resources. Adherence to CAR practice guidelines may not ensure a successful outcome in every situation. The practice guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The practice guidelines are not intended to establish a legal standard of care or conduct, and deviation from a practice guideline does not, in and of itself, indicate or imply that such medical practice is below an acceptable level of care. The ultimate judgment regarding the propriety of any specific procedure or course of conduct must be made by the physician and medical physicist in light of all circumstances presented by the individual situation.
Introduction
The
Together, these documents replace the previous 2016 consolidated guidelines to reflect the current evidence base and clinical landscape in Canadian breast imaging, and complement the recently published Breast Disease Imaging Referral Guidelines, which provide guidance on the most appropriate breast imaging test for a given indication or patient population. 5
These guidelines aim to provide radiologists, technologists, and other allied staff with a consensus-based approach to performing and interpreting breast imaging. These recommendations align with those published by the Canadian and American Cancer Societies, the National Comprehensive Cancer Network, and the American College of Radiology. While the guidelines serve as an educational tool and outline best practices and minimum requirements, the Working Group acknowledges that alternative actions may be appropriate depending on available resources, patient factors, technological advances, and evolving medical knowledge.
Ultimately, the supervising radiologist is responsible for determining the most appropriate examination or intervention for each patient.
Overview: Breast Magnetic Resonance Imaging (MRI)
Breast MRI is the most sensitive clinical imaging tool available for detecting breast cancer, whether used for problem-solving, screening, or staging patients. 6 These guidelines outline the current applications of breast MRI as well as the fundamental requirements for its use in clinical practice.
Appropriate indications for breast MRI can be reviewed in the Canadian Association of Radiologists Breast Disease Imaging Referral Guideline. 1
Technique
With few exceptions, patients should undergo standard mammography prior to breast MRI, and the mammography study and report should be available for review at the time of interpretation of the MRI. The prior mammograms should have been performed 6 months or less before the MRI examination.
In the diagnostic setting, MRI should be performed in a timely fashion according to the indication. 1 Radiologists should work with their technologists and equipment vendors to ensure that their protocols are as efficient as possible.
Basic Requirements
Additional Sequences
GRE T1 without fat saturation-for evaluation of fat, lymph nodes, and architecture of the breast and to see clip placed after previous image guided biopsy.
Silicone Saturation and STIR with water saturation sequences can be used to determine the integrity of breast implants.
Documentation
Image labeling should include a permanent identification label that contains:
The facility name and location
Examination date
Patient’s first and last name
Identification number and/or date of birth
The radiologist’s report of the MRI findings should be placed in the patient’s medical record. Retention of the breast MRI images should be consistent with the policies for retention of mammograms, in compliance with federal and provincial regulations, local health care facility procedures, and clinical need. Images of all important findings should be recorded in a retrievable and reviewable image storage format. Images should also include the skin and the chest wall.
The report should include:
All pertinent observations, including assessment of parenchyma and background enhancement
Documentation/correlation with prior imaging studies and/or procedures
Areas of clinical or radiologic concern
Level of suspicion based on imaging findings
Specific recommendations for patient management
BI-RADS® classification
Facilities and Quality Assurance
Given the rising prevalence of MRI in the screening and diagnosis of breast cancer, it is imperative that facilities contemplating the establishment of breast MRI programs take comprehensive steps to ensure optimal patient care. Specifically, these facilities must possess not only the capability to perform breast MRI but also the proficiency to conduct MRI-guided biopsies. Therefore, any facility considering the acquisition of new MRI coils must ensure that these coils are compatible with and fully supportive of biopsy procedures, and that there is sufficient administrative capacity to launch a robust breast MRI program. Facilities that overlook this aspect risk compromising the quality of care provided to patients, potentially leading to delays in diagnosis and treatment.
Clinical Practice Recommendations
Breast MRI should be practiced in a facility with the capacity for mammography, ultrasound, and breast intervention, including MRI-guided biopsy.
Facilities are strongly discouraged from performing breast MRI without the capacity to perform breast MRI-guided biopsies. If MRI-guided biopsy is not offered by the facility, a defined relationship with a referral center offering MRI-guided biopsy is required.
The results of biopsies initiated based on MRI findings require radiologic-pathologic correlation regardless of where the biopsy is performed. They should also be tracked by the radiologist recommending the biopsy.
Emergency equipment, along with necessary medications, should be readily accessible to address any adverse reactions related to administered medications, including gadolinium-based contrast agents.
Staff at the facility must be trained in the proper use of this emergency equipment and medications, following the guidelines outlined in the ACR Manual on Contrast Media. 7
A breast MRI accreditation program is not currently available in Canada. The ACR has established an accreditation program for quality assurance of a breast MRI program that can serve as a guideline for a breast MRI practice. The criteria evaluated in the program include:
Establishment and maintenance by the facility of an outcomes audit program to follow-up positive interpretations and correlate histopathology with the imaging findings
Reporting that uses the BI-RADS® terminology and final assessment codes
Calculation of statistics for each radiologist and facility.
Personnel Requirements
Radiologist
Radiologists involved in the performance, supervision, and interpretation of magnetic resonance imaging must have a Fellowship or Certification in Diagnostic Radiology with the Royal College of Physicians and Surgeons of Canada and/or the Collège des médecins du Québec. Equivalent foreign radiologist qualifications are also acceptable if the radiologist is certified by a recognized certifying body and holds a valid provincial license.
Before interpreting or performing new imaging modalities and interventional techniques independently, radiologists should obtain additional clinical training under supervision, with proper documentation, which must comply with pertinent provincial/regional regulations. Continuing professional development must fulfill the Maintenance of Certification Program requirements of the Royal College of Physicians and Surgeons of Canada.
To ensure a safe MRI practice, the supervising radiologist should be familiar with the MRI safety literature including the ACR Manual on MRI Safety, 8 and policies of appropriate contrast and sedation use.
In addition, the interpreting radiologist should practice and possess knowledge of imaging and diagnosis of breast disease.
The radiologist should be CAR Mammography Accreditation Program (MAP) approved, reading a minimum of 1000 mammograms per year and meeting the CAR MAP CPD requirements.
The radiologist should also meet the ultrasound requirements set out by the American College of Radiology, of having overseen, performed, and interpreted 200 breast ultrasound examinations in the prior 36 months.
The radiologist should be reading at least 100 breast MRI annually to maintain competence.
The responsibilities of the supervising and interpreting radiologist include:
Review and validation of the clinical indication for the examination
MRI protocol
Use and dose of contrast
Ensuring a physician is available when contrast is given
Interpretation of imaging, including review of pertinent prior breast imaging studies and clinicopathologic review
Provision of a report
Quality assurance of the imaging examination and interpretation
Medical Radiation Technologist
The technologist is primarily responsible for performing the MRI scans and maintaining the overall safety of patients, staff, and equipment within the MR environment. This includes careful screening and preparation of patients, ensuring patient comfort, adjustment of protocols (if required) to produce high quality, diagnostic scans, technical and quality evaluation of images and relevant quality assurance. MR technologists are also responsible for the MRI room safety and ensuring that no maintenance staff enters the room without direct supervision. All personnel must be screened and educated about MRI by the MR technologist. MR technologists, if adequately trained, could also perform intravenous gadolinium injections requested by the responsible radiologist. Continued education of MR technologists is encouraged by the Canadian Association of Medical Radiation Technologists (CAMRT) and should meet pertinent provincial regulations.
Medical Physicist
An MRI medical physicist should perform initial acceptance testing of the MRI system immediately following installation, and prior to any clinical scanning. The medical physicist is preferably someone on site, but they can also be contracted to perform the testing. The credentials of the medical physicist should include a college certification in MRI physics (or other related MRI technology). Furthermore, they should also be accredited by either the Canadian College of Physicists in Medicine (CCPM), or one of the affiliated professional engineering societies in Canada (ie, PEng) and shall have specific training and experience in MRI. Training and experience shall include detailed knowledge of the physics of MRI, system components and performance, safety procedures, acceptance testing, and quality control testing. Acceptance testing may be done by a team of medical physicists if at least one of the group members has the credentials and takes responsibility for signing the report.
Information Systems Specialist
An Information Systems Specialist (ISS) is required by facilities performing digital imaging. This individual must be either on site or available upon request. He/she must be trained and experienced in installation, maintenance, and quality control of information technology software and hardware. The required qualifications of this individual will depend highly on the type of facility and the type of equipment.
The ISS should possess any relevant qualifications required by federal/provincial/territorial regulations and statutes and should be certified according to a recognized standard such as that of the Society of Imaging Informatics in Medicine or the PACS Administrators Registry and Certification Association. Expertise should include computer and database basics, networking concepts (such as DICOM, HL7, RIS, and HIS), security systems, medical imaging terminology, positioning and viewing characteristics, imaging characteristics of various modalities for image acquisition, transmission and storage, and facility workflow. The ISS should also be knowledgeable about federal, provincial, territorial, and institutional privacy legislation and policies, such as the Personal Information Protection and Electronic Documents Act (PIPEDA).
Responsibilities include ensuring patient record confidentiality, understanding facility policies and procedures, and the importance and requirements of an information systems quality assurance program. They also include communicating any changes/upgrades to staff and the resulting operational impacts.
2025 Guideline Development Committee
Co-Chairs
Samantha Fienberg, MD, FRCPC
Carolyn Flegg, MD, FRCPC
Committee Members
Priscila Sacilotto Crivellaro, MD, FRCPC
Rachel Fleming, MD, FRCPC
Wade Koberstein, MD, FRCPC
Anat Kornecki, MD, FRCPC
Anisa Mnyusiwalla, MD, FRCPC
Saly Zahra, MD, FRCPC
Previous Guideline Development Committees
2016 Committee
Shiela Appavoo, MD, FRCPC (Chair)
Ann Aldis, MD, FRCPC
Petrina Causer, MD, FRCPC
Pavel Crystal, MD, FRCPC
Anat Kornecki, MD, FRCPC
Yolanda Mundt, MD, FRCPC
Jean Seely, MD, FRCPC
Nancy Wadden, MD, FRCPC
2012 Committee
Shiela Appavoo, MD, FRCPC (Chair)
Ann Aldis, MD, FRCPC
Petrina Causer, MD, FRCPC
Pavel Crystal, MD, FRCPC
Benoît Mesurolle, MD, FRCPC
Yolanda Mundt, MD, FRCPC
Neety Panu, MD, FRCPC
Jean Seely, MD, FRCPC
Nancy Wadden, MD, FRCPC
Footnotes
Acknowledgements
The Working Group would like to thank the CAR members and radiologists across the country who contributed their feedback and suggestions during the revision process of this guideline.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.