Clinical Significance of Background Parenchymal Enhancement in Breast Cancer Risk Stratification.

BACKGROUND: Background parenchymal enhancement (BPE) is an established breast cancer risk factor. However, the relationship between BPE levels and breast cancer risk stratification remains unclear. PURPOSE: To evaluate the clinical relationship between BPE levels and breast cancer risk with covariate adjustments for age, ethnicity, and hormonal status. STUDY TYPE: Retrospective. POPULATION: 954 screening breast MRI datasets representing 721 women divided into four cohorts: women with pathogenic germline breast cancer (BRCA) mutations (Group 1, N = 211), women with non-BRCA germline mutations (Group 2, N = 60), women without high-risk germline mutations but with a lifetime breast cancer risk of ≥20% using the Tyrer-Cuzick model (Group 3, N = 362), and women with <20% lifetime risk (Group 4, N = 88). FIELD STRENGTH/SEQUENCE: 3 T/axial non-fat-saturated T1, short tau inversion recovery, fat-saturated pre-contrast, and post-contrast T1-weighted images. ASSESSMENT: Data on age, body mass index, ethnicity, menopausal status, genetic predisposition, and hormonal therapy use were collected. BPE levels were evaluated by two breast fellowship-trained radiologists independently in accordance with BI-RADS, with a third breast fellowship-trained radiologist resolving any discordance. STATISTICAL TESTS: Propensity score matching (PSM) was utilized to adjust covariates, including age, ethnicity, menopausal status, hormonal treatments, and prior bilateral oophorectomy. The Mann-Whitney U test, chi-squared test, and univariate and multiple logistic regression analysis were performed, with an odds ratio (OR) and corresponding 95% confidence interval. Weighted Kappa statistic was used to assess inter-reader variation. A P value <0.05 indicated a significant result. RESULTS: In the assessment of BPE, there was substantial agreement between the two interpreting radiologists (κ = 0.74). Patient demographics were not significantly different between patient groups after PSM. The BPE of Group 1 was significantly lower than that of Group 4 and Group 3 among premenopausal women. In estimating the BPE level, the OR of gene mutations was 0.35. DATA CONCLUSION: Adjusting for potential confounders, the BPE level of premenopausal women with BRCA mutations was significantly lower than that of non-high-risk women. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY: Stage 3.

Quantitative assessment of background parenchymal enhancement is associated with lifetime breast cancer risk in screening MRI.

OBJECTIVES: To compare the quantitative background parenchymal enhancement (BPE) in women with different lifetime risks and BRCA mutation status of breast cancer using screening MRI. MATERIALS AND METHODS: This study included screening MRI of 535 women divided into three groups based on lifetime risk: nonhigh-risk women, high-risk women without BRCA mutation, and BRCA1/2 mutation carriers. Six quantitative BPE measurements, including percent enhancement (PE) and signal enhancement ratio (SER), were calculated on DCE-MRI after segmentation of the whole breast and fibroglandular tissue (FGT). The associations between lifetime risk factors and BPE were analyzed via linear regression analysis. We adjusted for risk factors influencing BPE using propensity score matching (PSM) and compared the BPE between different groups. A two-sided Mann-Whitney U-test was used to compare the BPE with a threshold of 0.1 for multiple testing issue-adjusted p values. RESULTS: Age, BMI, menopausal status, and FGT level were significantly correlated with quantitative BPE based on the univariate and multivariable linear regression analyses. After adjusting for age, BMI, menopausal status, hormonal treatment history, and FGT level using PSM, significant differences were observed between high-risk non-BRCA and BRCA groups in PEFGT (11.5 vs. 8.0%, adjusted p = 0.018) and SERFGT (7.2 vs. 9.3%, adjusted p = 0.066). CONCLUSION: Quantitative BPE varies in women with different lifetime breast cancer risks and BRCA mutation status. These differences may be due to the influence of multiple lifetime risk factors. Quantitative BPE differences remained between groups with and without BRCA mutations after adjusting for known risk factors associated with BPE. CLINICAL RELEVANCE STATEMENT: BRCA germline mutations may be associated with quantitative background parenchymal enhancement, excluding the effects of known confounding factors. This finding can provide potential insights into the cancer pathophysiological mechanisms behind lifetime risk models. KEY POINTS: Expanding understanding of breast cancer pathophysiology allows for improved risk stratification and optimized screening protocols. Quantitative BPE is significantly associated with lifetime risk factors and differs between BRCA mutation carriers and noncarriers. This research offers a possible understanding of the physiological mechanisms underlying quantitative BPE and BRCA germline mutations.

Prediction of an increase in oxygen requirement of SARS-CoV-2 pneumonia using three different scoring systems.

INTRODUCTION: In patients with severe coronavirus disease 2019 (COVID-19), respiratory failure is a major complication and its symptoms occur around one week after onset. The CURB-65, A-DROP and expanded CURB-65 tools are known to predict the risk of mortality in patients with community-acquired pneumonia. In this retrospective single-center retrospective study, we aimed to assess the correlations of the A-DROP, CURB-65, and expanded CURB-65 scores on admission with an increase in oxygen requirement in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia. METHODS: We retrospectively analyzed 207 patients who were hospitalized with SARS-CoV-2 pneumonia at the Self-Defense Forces Central Hospital in Tokyo, Japan. Performance of A-DROP, CURB-65, and the expanded CURB-65 scores were validated. In addition, we assessed whether there were any associations between an increase in oxygen requirement and known risk factors for critical illness in COVID-19, including elevation of liver enzymes and C-reactive protein (CRP), lymphocytopenia, high D-dimer levels and the chest computed tomography (CT) score. RESULTS: The areas under the curve for the ability of CURB-65, A-DROP, and the expanded CURB-65 scores to predict an increase in oxygen requirement were 0.6961, 0.6980 and 0.8327, respectively, and the differences between the three groups were statistically significant (p < 0.001). Comorbid cardiovascular disease, lymphocytopenia, elevated CRP, liver enzyme and D-dimer levels, and higher chest CT score were significantly associated with an increase in oxygen requirement CONCLUSIONS: The expanded CURB-65 score can be a better predictor of an increase in oxygen requirement in patients with SARS-CoV-2 pneumonia.

Comparison of COVID-19 disease between young and elderly patients: Hidden viral shedding of COVID-19.

OBJECTIVES: The symptoms of Coronavirus disease 2019 (COVID-19) vary among patients. The aim of this study was to investigate the clinical manifestation and disease duration in young versus elderly patients. METHODS: We retrospectively analyzed 187 patients (87 elderly and 100 young patients) with confirmed COVID-19. The clinical characteristics and chest computed tomography (CT) extent as defined by a score were compared between the two groups. RESULTS: The numbers of asymptomatic cases and severe cases were significantly higher in the elderly group (elderly group vs. young group; asymptomatic cases, 31 [35.6%] vs. 10 [10%], p < 0.0001; severe cases, 25 [28.7%] vs. 8 [8.0%], p = 0.0002). The proportion of asymptomatic patients and severe patients increased across the 10-year age groups. There was no significant difference in the total CT score and number of abnormal cases. A significant positive correlation between the disease duration and patient age was observed in asymptomatic patients (ρ = 0.4570, 95% CI 0.1198-0.6491, p = 0.0034). CONCLUSIONS: Although the extent of lung involvement did not have a significant difference between the young and elderly patients, elderly patients were more likely to have severe clinical manifestations. Elderly patients were also more likely to be asymptomatic and a source of COVID-19 viral shedding.

Cervical varicosities may predict placenta accreta in posterior placenta previa: a magnetic resonance imaging study.

PURPOSE: The aim of this study was to prenatally predict placenta accreta in posterior placenta previa using magnetic resonance imaging (MRI). METHODS: This retrospective study was approved by the Institutional Review Board of our hospital. We identified 81 patients with singleton pregnancy who had undergone cesarean section due to posterior placenta previa at our hospital between January 2012 and December 2016. We calculated the sensitivity and specificity of several well-known findings, and of cervical varicosities quantified using magnetic resonance imaging, in predicting placenta accreta in posterior placenta previa. To quantify cervical varicosities, we calculated the A/B ratio, where "A" was the minimum distance from the most dorsal cervical varicosity to the deciduous placenta, and "B" was the minimum distance from the most dorsal cervical varicosity to the amniotic placenta. The appropriate cut-off value of the A/B ratio was determined using a receiver operating characteristic (ROC) curve. RESULTS: Three patients (3.7%) were diagnosed as having placenta accreta. The sensitivity and specificity of the well-known findings were 0 and 97.4%, respectively. Furthermore, the A/B ratio ranged from 0.02 to 0.79. ROC curve analysis revealed that the area under the combined placenta accreta and A/B ratio curve was 0.96. When the cutoff value of the A/B ratio was set 0.18, the sensitivity and specificity were 100 and 91%, respectively. CONCLUSION: It was difficult to diagnose placenta accreta in the posterior placenta previa using the well-known findings. The quantification of cervical varicosities could effectively predict placenta accreta.

Quantitative Predictors of Response to Neoadjuvant Chemotherapy on Dynamic Contrast-enhanced 3T Breast MRI.

OBJECTIVE: To assess whether changes in quantitative parameters on breast MRI better predict pathologic complete response (pCR) to neoadjuvant chemotherapy (NAC) in breast cancer than change in volume. METHODS: This IRB-approved retrospective study included women with newly diagnosed breast cancer who underwent 3T MRI before and during NAC from January 2013 to December 2019 and underwent surgery at our institution. Clinical data such as age, histologic diagnosis and grade, biomarker status, clinical stage, maximum index cancer dimension and volume, and surgical pathology (presence or absence of in-breast pCR) were collected. Quantitative parameters were calculated using software. Correlations between clinical features and MRI quantitative measures in pCR and non-pCR groups were assessed using univariate and multivariate logistic regression. RESULTS: A total of 182 women with a mean age of 52 years (range, 26-79 years) and 187 cancers were included. Approximately 45% (85/182) of women had pCR at surgery. Stepwise multivariate regression analysis showed statistical significance for changes in quantitative parameters (increase in time to peak and decreases in peak enhancement, wash out, and Kep [efflux rate constant]) for predicting pCR. These variables in combination predicted pCR with 81.2% accuracy and an area under the curve (AUC) of 0.878. The AUCs of change in index cancer volume and maximum dimension were 0.767 and 0.613, respectively. CONCLUSION: Absolute changes in quantitative MRI parameters between pre-NAC MRI and intra-NAC MRI could help predict pCR with excellent accuracy, which was greater than changes in index cancer volume and maximum dimension.

Usefulness of computed tomography for hospitalized adult patients with fever to investigate cause of fever: single-center, retrospective cohort study.

PURPOSE: To verify that physicians' presumptive diagnosis is the most significant factor for finding any signs related to the cause of fever on computed tomography (CT) images. MATERIALS AND METHODS: This single-center retrospective cohort study included patients (age ≥ 16 years) who underwent CT to investigate the cause of fever between January 1, 2014, and August 31, 2016. Patients who underwent surgical procedures were excluded. The primary outcome was the presence of suspicious CT findings related to the cause of fever. We performed univariate and multivariate logistic regression analyses, adjusted for CT contrast agent use, quick sequential organ failure assessment score > 1, and C-reactive protein level. RESULTS: We enrolled 171 patients, of which 57 had CT findings, and 114 did not. Multivariate logistic regression analyses demonstrated a significant difference for the presence of a presumptive diagnosis by the attending physician (odds ratio, 4.99; 95% confidence interval 2.31-10.76; p < 0.01), but not for other covariates, including C-reactive protein. CONCLUSIONS: In hospitalized patients with fever, an attending physicians' presumptive diagnosis is associated with the presence of fever-related CT findings. Improving the quality of the diagnostic assessment before the CT scan may lead to more appropriate CT imaging use.

T1ρ magnetic resonance imaging value as a potential marker to assess the severity of liver fibrosis: A pilot study.

PURPOSE: Assessment of liver fibrosis is essential for the management of liver disease. Although liver biopsy is the gold-standard modality for the diagnosis of liver fibrosis, it has some limitations. Thus, other methods are required to overcome the disadvantages of a liver biopsy. T1ρ magnetic resonance imaging (MRI) values are potential biomarkers for liver cirrhosis. This study aimed to assess the relationship between T1ρ MRI values and liver fibrosis severity by measuring the correlation between T1ρ values and shear wave elastography (SWE) values, which are routinely used for the diagnosis of liver fibrosis. METHODS: T1ρ imaging and SWE values were obtained from four healthy volunteers and 16 patients with chronic liver disease. The regions of interest on MR images were drawn and matched with those of the right liver lobe on SWE images. RESULTS: The mean T1ρ values of the right liver lobe correlated positively with the mean SWE values (Pearson's correlation coefficient: 0.783; p < 0.0001; 95 % confidence interval: 0.623-0.880). CONCLUSION: The mean T1ρ values of the right liver lobe may be correlated with the severity of liver fibrosis.

The composition of the human fecal microbiota might be significantly associated with fecal SCFA levels under hyperbaric conditions.

The fecal microbiota and short-chain fatty acids (SCFAs) play important roles in the human body. This study examined how hyperbaric conditions affect the fecal microbiota and fecal SCFAs. Fecal samples were obtained from 12 divers at three points during deep-diving training (before the diving training, at 2.1 MPa, and after decompression). At 2.1 MPa, the changes in the frequency of Clostridium cluster IV and fecal iso-valerate levels were positively correlated, and the changes in the frequencies of Bacteroides and Clostridium subcluster XIVa were inversely correlated. After decompression, positive correlations were detected between the changes in the frequency of Bifidobacterium and fecal n-valerate levels and between the changes in the fecal levels of iso-butyrate and iso-valerate. On the other hand, inverse correlations were detected between the changes in the frequency of Clostridium cluster IX and fecal iso-butyrate levels, between the changes in the frequency of Clostridium cluster IX and fecal iso-valerate levels, and between the changes in the frequencies of Bacteroides and Clostridium cluster IV plus subcluster XIVa. During the study period, the changes in fecal iso-butyrate and iso-valerate levels were positively correlated, and inverse correlations were seen between the changes in the frequency of Clostridium cluster IV and fecal propionate levels and between the changes in the frequencies of Prevotella and Clostridium subcluster XIVa. These findings suggest that hyperbaric conditions affect the fecal microbiota and fecal SCFA levels and that intestinal conditions reversibly deteriorate under hyperbaric conditions.

Correlation between 18F-FDG uptake on PET/MRI and the level of tumor-infiltrating lymphocytes (TILs) in triple-negative and HER2-positive breast cancer.

PURPOSE: The tumor microenvironment is related to the metabolism of cancer cells and local immune reactions. Previous studies have established TILs could be a significant prognostic factor, especially for triple-negative breast cancers (TNBC) and human epithelial growth factor receptor 2 (HER2)-positive breast cancers. We explore the association between metabolic information on PET/MRI with TILs in TNBC and HER2-positive breast cancer. METHOD: We retrospectively reviewed the cases of 55 women with triple-negative or HER2-positive invasive ductal carcinomas who had undergone 18F-FDG PET/MRI without neo-adjuvant treatment for pre-operative evaluation. FDG uptake was quantified as standardized uptake value (SUV) max. The existence of peritumoral edema on PET/MRI was also recorded. The TIL score of the breast cancers was defined histologically on the basis of the proportion of the area infiltrated by lymphocytes, and classified as low (<10 %), intermediate (10-50 %), and high (>50 %). The association between PET/MRI findings and TILs was assessed using Kruskal-Wallis test and Wilcoxon signed-rank test. RESULTS: There were 14 high TIL, 20 intermediate TIL and 21 low TIL lesions. Higher values of SUVmax were found in the high and intermediate TIL group as compared to the low TIL group (P = 0.013). On the other hand, the lesions with peritumoral edema in the low TIL group tended to show high SUVmax (P = 0.014). CONCLUSIONS: 18F-FDG uptake on PET/MRI correlated with TIL levels in patients with TNBC and HER2-positive breast cancer. This finding suggests that preoperative PET/MRI may be useful as a non-invasive tool for guiding the treatment plan.

Restoration of Dehiscent Pancreaticojejunostomy Causing a Major Postoperative Pancreatic Fistula by Reinsertion of a Pancreatic Duct Tube Using the Rendezvous Technique.

INTRODUCTION: A postoperative clinically relevant pancreatic fistula can cause severe sequelae. We aimed to describe our minimally invasive procedure (rendezvous technique) for the treatment of a pancreatic fistula resulting from pancreaticojejunal anastomosis dehiscence involving a dislodged main pancreatic duct tube. METHODS: In our rendezvous technique, a guidewire is advanced into the jejunal lumen from the access site of the drainage tube and is caught by a snare catheter, which is used to replace the dislodged main pancreatic duct tube. Then, the guidewire is passed from the access site of the drainage tube to the site of the dislodged main pancreatic duct tube. A sheath is inserted along the route of the dislodged main pancreatic duct tube and is placed across the pancreaticojejunal anastomosis over the guidewire. Another guidewire is advanced into the main pancreatic duct via the sheath, and a new main pancreatic duct tube is inserted into the main pancreatic duct over the second wire. This technique was performed in two patients with a pancreatic fistula. RESULTS: Our rendezvous technique was successfully performed in a 73-year-old man with an intractable clinically relevant pancreatic fistula and large discharge from the drain and a 74-year-old woman with a pancreatic fistula and fluid collection between the elevated jejunum and remnant pancreas. Discharge from the drain and fluid collection decreased after the procedure. CONCLUSION: Our rendezvous technique is an effective minimally invasive approach for a pancreatic fistula resulting from pancreaticojejunal anastomosis dehiscence.

Effects of hyperbaric conditions on fecal microbiota.

We aimed to determine whether the composition of the fecal microbiota changes under hyperbaric conditions. In this study, we collected fecal samples from 6 healthy divers at three points during deep diving training (before, 2.1 MPa, end). The frequency of Clostridium cluster XVIII tended to be increased after compression. The frequencies of Clostridium cluster IV and subcluster XIVa were inversely correlated with that of Bacteroides. The compositional changes in the fecal microbiota exhibited interindividual variability. These findings suggest that hyperbaric conditions affect the fecal microbiota.

The clinical impact of MRI screening for BRCA mutation carriers: the first report in Japan.

BACKGROUND: There is no consensus on the appropriate surveillance for high-risk women with breast cancer in Japan. We investigated their imaging features and pathological characteristics to build a proper surveillance system for asymptomatic high-risk individuals in the future. METHODS: We retrospectively reviewed 93 female (median age 43 years) BRCA1 and BRCA2 mutation carriers from our institutional clinical database from 2011 to 2017. The study population was composed of 112 breast cancers. Mammography and MRI were reviewed by examiners blinded to patients' clinical history. Final surgical or biopsy histopathology served as the reference standard in all the patients. RESULTS: Fifty-nine breast cancers met selection criteria; of these, 30 were BRCA1-associated tumors, and 29 were BRCA2-associated tumors. Invasive ductal carcinoma was the most prevalent type in both BRCA1 and BRCA2. There were statistically significant differences in phenotype, nuclear grade, and Ki-67 labeling index between BRCA1 and BRCA2 mutation carriers. Additionally, imaging findings on mammography and MRI were statistically different. Tumors in BRCA2 carriers demonstrated mammographic calcifications more frequently, while those in BRCA1 carriers demonstrated a mass or architectural distortion (P < 0.001). Enhancement pattern on MRI also significantly differed between the two subgroups (P = 0.006). The size of MRI-detected lesions was statistically smaller than the size of those detected by other modalities (P = 0.004). CONCLUSIONS: The imaging and histological characteristics of BRCA1/2 mutation carriers were consistent with other countries' studies. MRI-detected lesions were significantly smaller than lesions detected by non-MRI modality. All lesions in BRCA1 mutation carriers could be detected by MRI.

Does integrated shimming improve lesion detection in whole-body diffusion-weighted examinations of patients with breast cancer?

PURPOSE: To evaluate the feasibility of proposed integrated slice-by-slice shimming (iShim) for whole-body diffusion weighted imaging (WB-DWI) in comparison to conventional 3D shim in patients with breast cancer. MATERIALS AND METHODS: Retrospective analysis of 116 consecutive patients (116 lesions) who underwent whole-body PET/MR using iShim (iShim group) were performed and compared with historical control of 103 patients (105 lesions) using 3D Shim (3D Shim group). RESULTS: As compared with dynamic contrast-enhanced (DCE) breast MRI, the apparent diffusion coefficient (ADC) value could not be determined for 15 (14%) of the 105 lesions of the 3D shim group and for 10 (9%) of the 116 lesions on iShim group. The intergroup difference failed to reach statistical significance (P = 0.1843). On the other hand, there was a significant difference in the frequencies of PET-positive and DWI-negative lesions between the 3D shim and iShim group (8.6% vs. 1.7%, respectively, P = 0.01942). CONCLUSION: In regard to detectability of breast cancers by DWI, iShim may allow improved detectability as compared to conventional 3D shim.

Simultaneous whole-body and breast 18F-FDG PET/MRI examinations in patients with breast cancer: a comparison of apparent diffusion coefficients and maximum standardized uptake values.

PURPOSE: To compare standardized uptake value (SUV) and apparent diffusion coefficient (ADC) values acquired using a PET/MRI scanner in breast cancer patients. MATERIALS AND METHODS: Whole-body PET/MRI and breast PET/MRI were performed in 108 consecutive patients. Ninety-four patients who had a total of 100 breast cancers were analyzed. SUVmax and ADCmean acquired using breast PET/MRI were compared with pathologic prognostic factors. RESULTS: All the lesions were visually detectable using PET and diffusion-weighted imaging (DWI) on breast PET/MRI; however, lesions were visually undetectable on whole-body DWI in 13 patients (13%) or on whole-body PET in 7 patients (7%). An analysis of ADCmean and SUVmax demonstrated a statistically significant correlation between whole-body imaging and breast imaging (rho = 0.613, p < 0.001 and rho = 0.928, p < 0.001, respectively). In a univariate analysis, SUVmax was significantly correlated with HER2 status (p < 0.001), Ki-67 (p = 0.014), tumor size (p = 0.0177), and nuclear grade (p = 0.0448). In multiple regression analysis, only tumor size (p = 0.00701) was shown to independently influence SUVmax. CONCLUSION: Prone breast imaging was more sensitive than whole-body PET/MRI for detection of breast cancers. Both SUVmax and ADCmean showed limited correlation with pathologic prognostic factors.

Marginal sinus placenta previa is a different entity in placenta previa: A retrospective study using magnetic resonance imaging.

OBJECTIVE: The current definition of placenta previa does not include whether the placental edge is parenchyma or marginal sinus defined as placenta previa in which the placental marginal sinus just reached the internal os and/or in which the placental parenchyma might be located at > 2 cm from internal os. MATERIALS AND METHODS: Cases with placenta previa were identified through the review of magnetic resonance imaging (MRI) from among 210 cases at our institution between 2007 and 2016. The clinical outcomes of patients with marginal sinus placenta previa (Group A) were compared with patients with low-lying placenta and marginal placenta (Group B) and patients with partial placenta and total placenta previa (Group C), respectively. This study was a retrospective analysis. RESULTS: Twenty-seven (12.7%) cases were included in Group A. The patients in Group B and Group C were 72 and 108 cases, respectively. First, Group A more frequently underwent emergency cesarean section than Group B (p = 0.02). There was no statistical significance with other maternal history, post-or pre-operative hemorrhage, and/or additional treatment for hemorrhage between the two groups. Additionally, Group A delivered at a later gestational age (p < 0.01); were less frequently complicated with antenatal bleeding (p < 0.01); underwent emergency cesarean section (p < 0.01), allogenic blood transfusion (p < 0.01), and uterine artery embolization (p < 0.01) for postpartum hemorrhage less often; and had less perioperative hemorrhage (p < 0.01) than Group C. CONCLUSIONS: Marginal sinus placenta previa may be a mild type of placenta previa. This new classification could be useful in the management of placenta previa.