Breast MRI is increasingly used as an adjunct to conventional imaging modalities, particularly in diagnostic problem cases, but also for pre-operative staging. It is an extremely sensitive technique, with relatively limited specificity. To avoid both, false-positive, but particularly false-negative diagnoses, it is imperative to be familiar with the varying MRI appearance of benign and malignant breast tumors. This review serves to give an overview of the different criteria that can be used for differential diagnostic purposes. Moreover, practical guidelines are given to help with the adequate management of enhancing lesions.