Novel approach using [18F]FTHA-PET and de novo synthesized VLDL for assessment of FFA metabolism in a rat model of diet induced NAFLD.

BACKGROUND AND AIMS: The worldwide prevalence of Non-alcoholic Fatty Liver Disease (NAFLD) raises concerns about associated risk factors, such as obesity and type 2 Diabetes Mellitus, for leading causes of disability and death. Besides Magnetic Resonance Imaging (MRI) and Spectroscopy (MRS), functional imaging with Positron Emission Tomography (PET) could contribute to a deeper understanding of the pathophysiology of NAFLD. Here we describe a novel approach using the PET tracer [18F]FTHA, which is an analog of long-chain free fatty acids (FFA) and is taken up by tissues to enter mitochondria or to be incorporated into complex lipids for further export as very-low-density lipoprotein (VLDL). METHODS: Male Sprague Dawley rats, after 6 weeks on a high-fat diet (HFD), were used as a model of diet induced NAFLD, while a standard diet (SD) served as a control group. Liver fat was estimated by MR spectroscopy at a 9.4 T system for phenotyping. To measure hepatic FFA uptake, rats underwent 60 min dynamic [18F]FTHA-PET scans after unrestricted access to food (HFD: n = 6; SD: n = 6) or overnight (≤16h) fasting (HFD: n = 6; SD: n = 5). FFA removal was assessed from incorporated 18F-residual in de novo synthesized VLDL out of plasma. RESULTS: MRS of the liver confirmed the presence of NAFLD (>5.6% fat). Under non-fasting conditions, hepatic [18F]FTHA uptake was significantly increased in NAFLD: SUVmean (p = 0.03) within [0; 60] min interval, SUVmean (p = 0.01) and SUVmax (p = 0.03) within [30; 60] min interval. SUVs for hepatic uptake under fasting conditions were not significantly different between the groups. Analysis of FFA removal demonstrated elevated values of 18F-residue in the VLDL plasma fraction of the healthy group compared to the NAFLD (p = 0.0569). CONCLUSION: Our novel approach for assessing FFA metabolism using [18F]FTHA demonstrated differences in the hepatic FFA uptake and FFA incorporation into VLDL between healthy and NAFLD rats. [18F]FTHA-PET could be used to study metabolic disturbances involved in the progression of NAFLD.

Rectal preparation significantly improves prostate imaging quality: Assessment of the PI-QUAL score with visual grading characteristics.

PURPOSE: To investigate the effects of a rectal preparation regimen, that consisted of a rectal cleansing enema and an endorectal gel filling protocol, on prostate imaging quality (PI-QUAL). METHODS: Multiparametric MRI (mpMRI) was performed in 150 consecutive patients divided into two groups of 75 patients. One group received a rectal preparation with a cleansing enema and endorectal gel filling (median age 65.3 years, median PSA level 6 ng/ml). The other patient group did not receive such a preparation (median age 64 years, median PSA level 6 ng/ml). Two uroradiologists independently rated general image quality and lesion visibility on diffusion-weighted imaging (DWI), T2-weighted (T2w), and dynamic contrast-enhanced (DCE) images using a five-point ordinal scale. In addition, two uroradiologists assigned PI-QUAL scores, using the dedicated scoring sheet. Data sets were compared using visual grading characteristics (VGC) and receiver operating characteristics (ROC)/ area under the curve (AUC) analysis. RESULTS: VGC revealed significantly better general image quality for DWI (AUC R1 0.708 (0.628-0.779 CI, p < 0.001; AUC R2 0.687 (0.606-0.760 CI, p < 0.001) and lesion visibility for both readers (AUC R1 0.729 (0.607-0.831 CI, p < 0.001); AUC R2 0.714 (0.590-0.818CI, p < 0.001) in the preparation group. For T2w imaging, rectal preparation resulted in significantly better lesion visibility for both readers (R1 0.663 (0.537-0.774 CI, p = 0.014; R2 0.663 (0.537-0.774 CI, p = 0.014)). Averaged PI-QUAL scores were significantly improved with rectal preparation (AUC R3/R4 0.667, CI 0.581-0.754, p < 0.001). CONCLUSION: Rectal preparation significantly improved prostate imaging quality (PI-QUAL) and lesion visibility. Hence, a rectal preparation regimen consisting of a rectal cleansing enema and an endorectal gel filling could be considered.

One view or two views for wide-angle tomosynthesis with synthetic mammography in the assessment setting?

OBJECTIVES: To evaluate the diagnostic performance in the assessment setting of three protocols: one-view wide-angle digital breast tomosynthesis (WA-DBT) with synthetic mammography (SM), two-view WA-DBT/SM, and two-view digital mammography (DM). METHODS: Included in this retrospective study were patients who underwent bilateral two-view DM and WA-DBT. SM were reconstructed from the WA-DBT data. The standard of reference was histology and/or 2 years follow-up. Included were 205 women with 179 lesions (89 malignant, 90 benign). Four blinded readers randomly evaluated images to assess density, lesion type, and level of suspicion according to BI-RADS. Three protocols were evaluated: two-view DM, one-view (mediolateral oblique) WA-DBT/SM, and two-view WA-DBT/SM. Detection rate, sensitivity, specificity, and accuracy were calculated and compared using multivariate analysis. Reading time was assessed. RESULTS: The detection rate was higher with two-view WA-DBT/SM (p = 0.063). Sensitivity was higher for two-view WA-DBT/SM compared to two-view DM (p = 0.001) and one-view WA-DBT/SM (p = 0.058). No significant differences in specificity were found. Accuracy was higher with both one-view WA-DBT/SM and two-view WA-DBT/SM compared to DM (p = 0.003 and > 0.001, respectively). Accuracy did not differ between one- and two-view WA-DBT/SM. Two-view WA-DBT/SM performed better for masses and asymmetries. Reading times were significantly longer when WA-DBT was evaluated. CONCLUSIONS: One-view and two-view WA-DBT/SM can achieve a higher diagnostic performance compared to two-view DM. The detection rate and sensitivity were highest with two-view WA-DBT/SM. Two-view WA-DBT/SM appears to be the most appropriate tool for the assessment of breast lesions. KEY POINTS: • Detection rate with two-view wide-angle digital breast tomosynthesis (WA-DBT) is significantly higher than with two-view digital mammography in the assessment setting. • Diagnostic accuracy of one-view and two-view WA-DBT with synthetic mammography (SM) in the assessment setting is higher than that of two-view digital mammography. • Compared to one-view WA-DBT with SM, two-view WA-DBT with SM seems to be the most appropriate tool for the assessment of breast lesions.

A Multicentric Comparison of Apparent Diffusion Coefficient Mapping and the Kaiser Score in the Assessment of Breast Lesions.

MATERIALS AND METHODS: In this multicentric study, individual patient data from 3 different centers were analyzed. Consecutive patients receiving standardized multiparametric breast magnetic resonance imaging for standard nonscreening indications were included. At each center, 2 experienced radiologists with more than 5 years of experience retrospectively interpreted the examinations in consensus and applied the KS to every histologically verified lesion. The corresponding mean ADC of each lesion was measured using a Wielema type 4 region of interest. According to established methods, the KS and ADC were combined, yielding the KS+ score. Diagnostic accuracy was evaluated by the area under the receiver operating characteristics curve (AUROC) and compared between the KS, ADC, and KS+ (DeLong test). Likewise, the potential to help avoid unnecessary biopsies was compared between the KS, ADC, and KS+ based on established high sensitivity thresholds (McNemar test). RESULTS: A total of 450 lesions in 414 patients (mean age, 51.5 years; interquartile range, 42-60.8 years) were included, with 219 lesions being malignant (48.7%; 95% confidence interval [CI], 44%-53.4%). The performance of the KS (AUROC, 0.915; CI, 0.886-0.939) was significantly better than that of the ADC (AUROC, 0.848; CI, 0.811-0.880; P < 0.001). The largest difference between these parameters was observed when assessing subcentimeter lesions (AUROC, 0.909 for KS; CI, 0.849-0.950 vs 0.811 for ADC; CI, 0.737-0.871; P = 0.02).The use of the KS+ (AUROC, 0.918; CI, 0.889-0.942) improved the performance slightly, but without any significant difference relative to a single KS or ADC reading (P = 0.64).When applying high sensitivity thresholds for avoiding unnecessary biopsies, the KS and ADC achieved equal sensitivity (97.7% for both; cutoff values, >4 for KS and ≤1.4 × 10-3 mm2/s for ADC). However, the rate of potentially avoidable biopsies was higher when using the KS (specificity: 65.4% for KS vs 32.9% for ADC; P < 0.0001). The KS was superior to the KS+ in avoiding unnecessary biopsies. CONCLUSIONS: Both the KS and ADC may be used to distinguish benign from malignant breast lesions. However, KS proved superior in this task including, most of all, when assessing small lesions less than 1 cm. Using the KS may avoid twice as many unnecessary biopsies, and the combination of both the KS and ADS does not improve diagnostic performance.

Non-Invasive Assessment of Hypoxia and Neovascularization with MRI for Identification of Aggressive Breast Cancer.

The aim of this study was to investigate the potential of magnetic resonance imaging (MRI) for a non-invasive synergistic assessment of tumor microenvironment (TME) hypoxia and induced neovascularization for the identification of aggressive breast cancer. Fifty-three female patients with breast cancer underwent multiparametric breast MRI including quantitative blood-oxygen-level-dependent (qBOLD) imaging for hypoxia and vascular architecture mapping for neovascularization. Quantitative MRI biomarker maps of oxygen extraction fraction (OEF), metabolic rate of oxygen (MRO2), mitochondrial oxygen tension (mitoPO2), microvessel radius (VSI), microvessel density (MVD), and microvessel type indicator (MTI) were calculated. Histopathology was the standard of reference. Histopathological markers (vascular endothelial growth factor receptor 1 (FLT1), podoplanin, hypoxia-inducible factor 1-alpha (HIF-1alpha), carbonic anhydrase 9 (CA IX), vascular endothelial growth factor C (VEGF-C)) were used to confirm imaging biomarker findings. Univariate and multivariate regression analyses were performed to differentiate less aggressive luminal from aggressive non-luminal (HER2-positive, triple negative) malignancies and assess the interplay between hypoxia and neoangiogenesis markers. Aggressive non-luminal cancers (n = 40) presented with significantly higher MRO2 (i.e., oxygen consumption), lower mitoPO2 values (i.e., hypoxia), lower MTI, and higher MVD than less aggressive cancers (n = 13). Data suggest that a model derived from OEF, mitoPO2, and MVD can predict tumor proliferation rate. This novel MRI approach, which can be easily implemented in routine breast MRI exams, aids in the non-invasive identification of aggressive breast cancer.

Multimodality Imaging of Breast Parenchymal Density and Correlation with Risk Assessment.

Purpose of Review: Breast density, or the amount of fibroglandular tissue in the breast, has become a recognized and independent marker for breast cancer risk. Public awareness of breast density as a possible risk factor for breast cancer has resulted in legislation for risk stratification purposes in many US states. This review will provide a comprehensive overview of the currently available imaging modalities for qualitative and quantitative breast density assessment and the current evidence on breast density and breast cancer risk assessment. Recent Findings: To date, breast density assessment is mainly performed with mammography and to some extent with magnetic resonance imaging. Data indicate that computerized, quantitative techniques in comparison with subjective visual estimations are characterized by higher reproducibility and robustness. Summary: Breast density reduces the sensitivity of mammography due to a masking effect and is also a recognized independent risk factor for breast cancer. Standardized breast density assessment using automated volumetric quantitative methods has the potential to be used for risk prediction and stratification and in determining the best screening plan for each woman.

Development of a Non-invasive Assessment of Hypoxia and Neovascularization with Magnetic Resonance Imaging in Benign and Malignant Breast Tumors: Initial Results.

PURPOSE: To develop a novel magnetic resonance imaging (MRI) approach for the noninvasive assessment of hypoxia and neovascularization in breast tumors. PROCEDURES: In this IRB-approved prospective study, 20 patients with suspicious breast lesions (BI-RADS 4/5) underwent multiparametric breast MRI including quantitative BOLD (qBOLD) and vascular architecture mapping (VAM). Custom-made in-house MatLab software was used for qBOLD and VAM data postprocessing and calculation of quantitative MRI biomarker maps of oxygen extraction fraction (OEF), metabolic rate of oxygen (MRO2), and mitochondrial oxygen tension (mitoPO2) to measure tissue hypoxia and neovascularization including vascular architecture including microvessel radius (VSI), density (MVD), and type (MTI). Histopathology was used as standard of reference. Appropriate statistics were performed to assess and compare correlations between MRI biomarkers for hypoxia and neovascularization. RESULTS: qBOLD and VAM data with good quality were obtained from all patients with 13 invasive ductal carcinoma (IDC) and 7 benign breast tumors with a lesion diameter of at least 10 mm in all spatial directions. MRI biomarker maps of oxygen metabolism and neovascularization demonstrated intratumoral spatial heterogeneity with a broad range of biomarker values. Bulk tumor neovasculature consisted of draining venous microvasculature with slow flowing blood. High OEF and low mitoPO2 were associated with low MVD and vice versa. The heterogeneous pattern of MRO2 values showed spatial congruence with VSI. IDCs showed significantly higher MRO2 (P = 0.007), lower mitoPO2 (P = 0.021), higher MVD (P = 0.005), and lower (i.e., more pathologic) MTI (P = 0.001) compared with benign breast tumors. These results indicate that IDCs consume more oxygen and are more hypoxic and neovascularized than benign tumors. CONCLUSIONS: We developed a novel MRI approach for the noninvasive assessment of hypoxia and neovascularization in benign and malignant breast tumors that can be easily integrated in a diagnostic MRI protocol and provides insight into intratumoral heterogeneity.

Abbreviated MRI of the Breast: Does It Provide Value?

MRI of the breast is the most sensitive test for breast cancer detection and outperforms conventional imaging with mammography, digital breast tomosynthesis, or ultrasound. However, the long scan time and relatively high costs limit its widespread use. Hence, it is currently only routinely implemented in the screening of women at an increased risk of breast cancer. To overcome these limitations, abbreviated dynamic contrast-enhanced (DCE)-MRI protocols have been introduced that substantially shorten image acquisition and interpretation time while maintaining a high diagnostic accuracy. Efforts to develop abbreviated MRI protocols reflect the increasing scrutiny of the disproportionate contribution of radiology to the rising overall healthcare expenditures. Healthcare policy makers are now focusing on curbing the use of advanced imaging examinations such as MRI while continuing to promote the quality and appropriateness of imaging. An important cornerstone of value-based healthcare defines value as the patient's outcome over costs. Therefore, the concept of a fast, abbreviated MRI exam is very appealing, given its high diagnostic accuracy coupled with the possibility of a marked reduction in the cost of an MRI examination. Given recent concerns about gadolinium-based contrast agents, unenhanced MRI techniques such as diffusion-weighted imaging (DWI) are also being investigated for breast cancer diagnosis. Although further larger prospective studies, standardized imaging protocol, and reproducibility studies are necessary, initial results with abbreviated MRI protocols suggest that it seems feasible to offer screening breast DCE-MRI to a broader population. This article aims to give an overview of abbreviated and fast breast MRI protocols, their utility for breast cancer detection, and their emerging role in the new value-based healthcare paradigm that has replaced the fee-for-service model. Level of Evidence: 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:e85-e100.

Impact of hybrid PET/MR technology on multiparametric imaging and treatment response assessment of cervix cancer.

BACKGROUND AND PURPOSE: Multimodal tissue characterization by combined MRI and PET has high clinical potential in the context of sub-target definition for dose painting and response assessment but its clinical exploration is yet limited. The aim of this study was to prove the potential and feasibility of hybrid PET/MRI to non-invasively measure tumor hypoxia, perfusion and microstructure at one stop in tumors of the uterine cervix during chemoradiotherapy. MATERIAL AND METHODS: Ten cervix cancer patients were subjected to simultaneous multiparametric PET/MRI with [18F]fluoromisonidazole ([18F]FMISO). Imaging was scheduled before, twice during and after chemoradiotherapy. Intra- and inter-time point analyses of the extracted parameters (i.e. ADC, Ktrans, ABrix, [18F]FMISO-tumor to background ratio (TBR)) were performed. The [18F]FMISO uptake- and ADC-spatio-temporal changes were assessed. RESULTS: Patient averaged ADC values increased from baseline to follow up (1.03 ±â€¯0.11/1.30 ±â€¯0.13 × 10-3 mm2/s), while the TBR decreased (1.73 ±â€¯0.24/1.36 ±â€¯0.19), Ktrans dropped over time (0.17 ±â€¯0.05/0.05 ±â€¯0.05 min-1); for all above p < 0.05. None of these parameters correlated significantly on a voxel-by-voxel basis. Low-ADC regions spatially varied over time. There was pronounced reduction of the [18F]FMISO-avid volumes during treatment. CONCLUSIONS: The suggested hybrid PET/MRI protocol to non-invasively investigate tumor hypoxia, perfusion and microstructure at one stop was feasible, revealing spatio-temporal response patterns that could be utilized for comprehensive sub-target definition for dose painting and response assessment.

MRI in the Assessment of BI-RADS® 4 lesions.

The American College of Radiology (ACR) Breast Imaging-Reporting and Data System (BI-RADS) lexicon, which is used ubiquitously to standardize reporting of breast magnetic resonance imaging (MRI), provides 7 BI-RADS assessment categories to indicate the level of suspicion of malignancy and guide further management. A BI-RADS category 4 assessment is assigned when an imaging abnormality does not fulfill the typical criteria for malignancy, but is suspicious enough to warrant a recommendation for biopsy. The BI-RADS category 4 assessment covers a wide range of probability of malignancy, from >2 to <95%. MRI is an essential noninvasive technique in breast imaging and the role of MRI in the assessment of ACR BI-RADS 4 lesions is manifold. In lesions classified as suspicious on imaging with mammography, digital breast tomosynthesis, and sonography, MRI can aid in the noninvasive differentiation of benign and malignant lesions and obviate unnecessary breast biopsies. When the suspicion of cancer is confirmed with MRI, concurrent staging of disease for treatment planning can be accomplished. This article will provide a comprehensive overview of the role of breast MRI in the assessment of ACR BI-RADS 4 lesions. In addition, we will discuss strategies to decrease false positives and avoid false negative results when reporting MRI of the breast.

Multiparametric [11C]Acetate positron emission tomography-magnetic resonance imaging in the assessment and staging of prostate cancer.

BACKGROUND: The aim of this study was to evaluate whether MP [11C]Acetate PET-MRI enables an accurate differentiation of benign and malignant prostate tumors as well as local and distant staging. MATERIALS AND METHODS: Fifty-six consecutive patients fulfilling the following criteria were included in this IRB-approved prospective study: elevated PSA levels or suspicious findings at digital rectal examination or TRUS; and histopathological verification. All patients underwent MP [11C]Acetate PET-MRI of the prostate performed on separate scanners with PET/CT using [11C]Acetate and 3T MP MR imaging. Appropriate statistical tests were used to determine diagnostic accuracy, local and distant staging. RESULTS: MP imaging with two MRI parameters (T2w and DWI) achieved the highest sensitivity, specificity, and diagnostic accuracy of 95%, 68.8%, and 88%, with an AUC of 0.82 for primary PCa detection. Neither assessments with a single parameter (AUC, 0.54-0.79), nor different combinations with up to five parameters (AUC, 0.67-0.79) achieved equally good results. MP [11C]Acetate PET-MRI improved local staging with a sensitivity, specificity, and diagnostic accuracy of 100%, 96%, and 97% compared to MRI alone with 72.2%, 100%, and 95.5%. MP [11C]Acetate PET-MRI correctly detected osseous and liver metastases in five patients. CONCLUSIONS: MP [11C]Acetate PET-MRI merges morphologic with functional information, and allows insights into tumor biology. MP [11C]Acetate PET-MRI with two MRI-derived parameters (T2 and DWI) yields the highest diagnostic accuracy. The addition of more parameters does not improve diagnostic accuracy of primary PCa detection. MP [11C]Acetate PET-MRI facilitates improved local and distant staging, providing "one-stop" staging in patients with primary PCa, and therefore has the potential to improve therapy. PATIENT SUMMARY: In this report we investigated MP [11C]Acetate PET-MRI for detection, local and distant staging of prostate cancer. We demonstrate that MP [11C]Acetate PET-MRI with two MRI-derived parameters (T2 and DWI) achieves the best diagnostic accuracy for primary prostate cancer detection and that MP [11C]Acetate PET-MRI enables an improved local and distant staging.

Quantitative Assessment of Breast Parenchymal Uptake on 18F-FDG PET/CT: Correlation with Age, Background Parenchymal Enhancement, and Amount of Fibroglandular Tissue on MRI.

Background parenchymal enhancement (BPE), and the amount of fibroglandular tissue (FGT) assessed with MRI have been implicated as sensitive imaging biomarkers for breast cancer. The purpose of this study was to quantitatively assess breast parenchymal uptake (BPU) on 18F-FDG PET/CT as another valuable imaging biomarker and examine its correlation with BPE, FGT, and age. METHODS: This study included 129 patients with suspected breast cancer and normal imaging findings in one breast (BI-RADS 1), whose cases were retrospectively analyzed. All patients underwent prone 18F-FDG PET/CT and 3-T contrast-enhanced MRI of the breast. In all patients, interpreter 1 assessed BPU quantitatively using SUVmax Interpreters 1 and 2 assessed amount of FGT and BPE in the normal contralateral breast by subjective visual estimation, as recommended by BI-RADS. Interpreter 1 reassessed all cases and repeated the BPU measurements. Statistical tests were used to assess correlations between BPU, BPE, FGT, and age, as well as inter- and intrainterpreter agreement. RESULTS: BPU on 18F-FDG PET/CT varied among patients. The mean BPU SUVmax ± SD was 1.57 ± 0.6 for patients with minimal BPE, 1.93 ± 0.6 for mild BPE, 2.42 ± 0.5 for moderate BPE, and 1.45 ± 0.3 for marked BPE. There were significant (P < 0.001) moderate to strong correlations among BPU, BPE, and FGT. BPU directly correlated with both BPE and FGT on MRI. Patient age showed a moderate to strong indirect correlation with all 3 imaging-derived tissue biomarkers. The coefficient of variation for quantitative BPU measurements with SUVmax was 5.6%, indicating a high reproducibility. Interinterpreter and intrainterpreter agreement for BPE and FGT was almost perfect, with a κ-value of 0.860 and 0.822, respectively. CONCLUSION: The results of our study demonstrate that BPU varied among patients. BPU directly correlated with both BPE and FGT on MRI, and BPU measurements were highly reproducible. Patient age showed a strong inverse correlation with all 3 imaging-derived tissue biomarkers. These findings indicate that BPU may serve as a sensitive imaging biomarker for breast cancer prediction, prognosis, and risk assessment.

Multiparametric MR Imaging with High-Resolution Dynamic Contrast-enhanced and Diffusion-weighted Imaging at 7 T Improves the Assessment of Breast Tumors: A Feasibility Study.

PURPOSE: To ascertain whether multiparametric magnetic resonance (MR) imaging of the breast in combination with dynamic contrast material-enhanced (DCE) imaging and diffusion-weighted imaging (DWI) at 7 T is feasible and improves diagnostic accuracy. MATERIALS AND METHODS: From December 2011 to December 2013, 40 patients with suspicious breast lesions were included in this institutional review board-approved prospective study. Before bilateral multiparametric MR imaging of the breast at 7 T, all patients gave written informed consent. Lesions were classified according to Breast Imaging Reporting and Data System (BI-RADS) and assessed for apparent diffusion coefficient (ADC) values by two readers independently. For combined analysis of DCE MR imaging and DWI, the BI-RADS-adapted reading algorithm, which adapted ADC thresholds to the BI-RADS assessment category, was used. Diagnostic values of multiparametric, DCE MR imaging, and DWI were calculated. Receiver operating characteristic curve analysis was performed. Image quality and interreader agreement were assessed. Histopathologic results were used as the highest standard. RESULTS: There were 29 malignant and 17 benign lesions (range, 6-95 mm; mean, 23.3 mm). Multiparametric MR imaging yielded a sensitivity of 100% (29 of 29 lesions), a specificity of 88.2% (16 of 18 lesions), and an area under the curve of 0.941, which was greater than for DCE MR imaging (P = .003), which had a sensitivity of 100% (29 of 29 lesions), a specificity of 53.2% (nine of 17 lesions), and an area under the curve of 0.765. DWI had a sensitivity of 93.1% (27 of 29 lesions), a specificity of 88.2% (15 of 17 lesions), and an area under the curve of 0.907. Multiparametric MR imaging at 7 T of the breast eliminated all false-negative findings and reduced false-positive findings, from eight false-positive findings with DCE MR imaging to two false-positive findings. Thus, if used clinically, 7-T multiparametric MR imaging may have potentially obviated unnecessary breast biopsies in six of eight lesions (P = .031). Multiparametric MR imaging demonstrated either excellent or good image quality and interreader agreement (κ = 0.89-1.00). CONCLUSION: The clinical use of 7-T multiparametric MR imaging is feasible, provides good or excellent image quality, and has the potential to improve diagnostic accuracy.

Introduction of an automated user-independent quantitative volumetric magnetic resonance imaging breast density measurement system using the Dixon sequence: comparison with mammographic breast density assessment.

OBJECTIVES: The purposes of this study were to introduce and assess an automated user-independent quantitative volumetric (AUQV) breast density (BD) measurement system on the basis of magnetic resonance imaging (MRI) using the Dixon technique as well as to compare it with qualitative and quantitative mammographic (MG) BD measurements. MATERIALS AND METHODS: Forty-three women with normal mammogram results (Breast Imaging Reporting and Data System 1) were included in this institutional review board-approved prospective study. All participants were subjected to BD assessment with MRI using the following sequence with the Dixon technique (echo time/echo time, 6 milliseconds/2.45 milliseconds/2.67 milliseconds; 1-mm isotropic; 3 minutes 38 seconds). To test the reproducibility, a second MRI after patient repositioning was performed. The AUQV magnetic resonance (MR) BD measurement system automatically calculated percentage (%) BD. The qualitative BD assessment was performed using the American College of Radiology Breast Imaging Reporting and Data System BD categories. Quantitative BD was estimated semiautomatically using the thresholding technique Cumulus4. Appropriate statistical tests were used to assess the agreement between the AUQV MR measurements and to compare them with qualitative and quantitative MG BD estimations. RESULTS: The AUQV MR BD measurements were successfully performed in all 43 women. There was a nearly perfect agreement of AUQV MR BD measurements between the 2 MR examinations for % BD (P < 0.001; intraclass correlation coefficient, 0.998) with no significant differences (P = 0.384). The AUQV MR BD measurements were significantly lower than quantitative and qualitative MG BD assessment (P < 0.001). CONCLUSIONS: The AUQV MR BD measurement system allows a fully automated, user-independent, robust, reproducible, as well as radiation- and compression-free volumetric quantitative BD assessment through different levels of BD. The AUQV MR BD measurements were significantly lower than the currently used qualitative and quantitative MG-based approaches, implying that the current assessment might overestimate breast density with MG.

Adjunct ultrasonography for breast cancer screening in women at average risk: a systematic review.

BACKGROUND: Screening with mammography has the ability to detect breast cancer at an early stage but misses some cancers. Supporters of adjunct ultrasonography to the screening regimen argue that it might be a safe and inexpensive approach to reduce the false-negative rates of screening. Critics are concerned that adjunct ultrasonography will also increase the rate of false-positive findings and can lead to unnecessary biopsies and treatments in women at average risk. AIMS: The purpose of this review was to systematically assess the comparative benefits and harms of mammography with adjunct breast ultrasonography and mammography only in breast cancer screening. METHODS: We searched multiple electronic databases and the Cochrane Breast Cancer Group's Specialised Register (from 1995 to February 2012). To detect ongoing or unpublished studies, we searched trial registries and multiple sources of grey literature. Two researchers independently reviewed all abstracts and full-text articles against pre-defined eligibility criteria. We dually rated the risk of bias of studies and the strength of evidence based on established guidance. RESULTS: We did not detect any controlled studies that provide evidence for (or against) the use of adjunct ultrasonography for screening in women at average risk for breast cancer. Extrapolations of results from women at elevated risk for breast cancer indicate that the false-positive rates in women at average risk who were recalled because of positive ultrasonographies will exceed 98%. In women with dense or very dense breast tissue, the evidence regarding the use of adjunct ultrasonography is not conclusive. CONCLUSIONS: No methodologically sound evidence is available justifying the routine use of ultrasonography as an adjunct screening tool in women at average risk for breast cancer. IMPLICATIONS FOR PRACTICE: Clinicians should not use ultrasonography as a screening tool for breast cancer screening on a routine basis. The use should be limited to women with dense breasts for whom the accuracy of mammography is low, or for diagnostic purposes.

Mammography in combination with breast ultrasonography versus mammography for breast cancer screening in women at average risk.

BACKGROUND: Breast cancer is the most common malignant disease diagnosed in women worldwide. Screening with mammography has the ability to detect breast cancer at an early stage. The diagnostic accuracy of mammography screening largely depends on the radiographic density of the imaged breasts. In radiographically dense breasts, non-calcified breast cancers are more likely to be missed than in fatty breasts. As a consequence, some cancers are not detected by mammography screening. Supporters of adjunct ultrasonography to the screening regimen for breast cancer argue that it might be a safe and inexpensive approach to reduce the false negative rates of the screening process. Critics, however, are concerned that performing supplemental ultrasonography on women at average risk will also increase the rate of false positive findings and can lead to unnecessary biopsies and treatments. OBJECTIVES: To assess the comparative effectiveness and safety of mammography in combination with breast ultrasonography versus mammography for breast cancer screening for women at average risk of breast cancer. SEARCH METHODS: We searched the Cochrane Breast Cancer Group's Specialised Register, MEDLINE (via OvidSP) and EMBASE up until February 2012.To detect ongoing or unpublished studies, we searched the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and the National Cancer Institute's clinical trial database until June 2012. In addition, we conducted grey literature searches using the following sources: OpenGrey; National Institute of Health RePORTER; Health Services Research Projects in Progress (HSRPROJ); Hayes, Inc. Health Technology Assessment; The New York Academy of Medicine's Grey Literature Index and Conference Papers Index. SELECTION CRITERIA: For efficacy, we considered randomised controlled trials (RCTs), with either individual or cluster randomisation, and prospective, controlled non-randomised studies with a low risk of bias and a sample size of at least 500 participants.In addition to studies eligible for efficacy, we considered any controlled, non-randomised study with a low risk of bias and a study size of at least 500 participants for the assessment of harms.Our population of interest were women between the ages of 40 and 75 years who were at average risk for breast cancer. DATA COLLECTION AND ANALYSIS: Two review authors screened abstracts and full-text publications against the inclusion criteria. None of the studies met our inclusion criteria. MAIN RESULTS: Our review did not detect any controlled studies on the use of adjunct ultrasonography for screening in women at average risk for breast cancer. One ongoing randomised controlled trial was identified (J-START, Japan). AUTHORS' CONCLUSIONS: Presently, there is no methodologically sound evidence available justifying the routine use of ultrasonography as an adjunct screening tool in women at average risk for breast cancer.

Teleradiology with uncompressed digital mammograms: clinical assessment.

PURPOSE: The purpose of our study was to demonstrate the feasibility of sending uncompressed digital mammograms in a teleradiologic setting without loss of information by comparing image quality, lesion detection, and BI-RADS assessment. MATERIALS AND METHODS: CDMAM phantoms were sent bidirectionally to two hospitals via the network. For the clinical aspect of the study, 200 patients were selected based on the BI-RAD system: 50% BI-RADS I and II; and 50% BI-RADS IV and V. Two hundred digital mammograms (800 views) were sent to two different institutions via a teleradiology network. Three readers evaluated those 200 mammography studies at institution 1 where the images originated, and in the two other institutions (institutions 2 and 3) where the images were sent. The readers assessed image quality, lesion detection, and BI-RADS classification. RESULTS: Automatic readout showed that CDMAM image quality was identical before and after transmission. The image quality of the 200 studies (total 600 mammograms) was rated as very good or good in 90-97% before and after transmission. Depending on the institution and the reader, only 2.5-9.5% of all studies were rated as poor. The congruence of the readers with respect to the final BI-RADS assessment ranged from 90% and 91% at institution 1 vs. institution 2, and from 86% to 92% at institution 1 vs. institution 3. The agreement was even higher for conformity of content (BI-RADS I or II and BI-RADS IV or V). Reader agreement in the three different institutions with regard to the detection of masses and calcifications, as well as BI-RADS classification, was very good (κ: 0.775-0.884). Results for interreader agreement were similar. CONCLUSION: Uncompressed digital mammograms can be transmitted to different institutions with different workstations, without loss of information. The transmission process does not significantly influence image quality, lesion detection, or BI-RADS rating.

A combined high temporal and high spatial resolution 3 Tesla MR imaging protocol for the assessment of breast lesions: initial results.

PURPOSE: To develop a 3.0 Tesla breast imaging protocol that combines high temporal and spatial resolution three-dimensional MR sequences for quantitative time course and morphologic analysis of breast lesions. MATERIALS AND METHODS: Thirty-four patients were included in the study (age range, 31-82; mean age, 54.3). The study protocol was approved by the Institutional Review Board and written informed consent was obtained from all patients. The magnetic resonance imaging protocol included: a coronal T1-weighted volume-interpolated-breathhold-examination sequence, focused on high temporal resolution for optimal assessment of the contrast-enhancement behavior of lesions (SI 1.7 mm isotropic; TA 3.45 minutes for 17 measurements); a coronal T1-weighted turbo fast-low-angle-shot-three-dimensional sequence, with water-excitation and fat suppression, focused on high spatial resolution for morphologic analysis (SI 1 mm isotropic; TA 2 minutes); and a repeated coronal volume-interpolated-breathhold-examination sequence for detection of washout. Lesion size and morphology were assessed. Region-of-interests for suspicious areas were manually drawn and evaluated for contrast-enhancement behavior by plotting intensity courses against time. Sensitivity and specificity with a 95% confidence interval and the negative predictive value and positive predictive value were calculated. Diagnostic accuracy was assessed. The histopathological diagnoses were used as a standard of reference. RESULTS: Fifty-five lesions were detected in 34 patients. All malignant breast lesions were identified correctly. There were 5 false-positive lesions. The sensitivity of contrast-enhanced magnetic resonance imaging of the breast at 3 T was 100%, with a 95% confidence interval (CI) of 90.6% to 100%. The specificity was 72.2%, with a 95% CI of 49.1% to 87.5%. The positive predictive value was 0.88 and the negative predictive value was 1. Diagnostic accuracy was 91% with a 95% CI of 80.4% to 96.1%. CONCLUSION: Our prospective study demonstrates that the presented 3 Tesla MR imaging protocol, comprising both high temporal and high spatial resolution, enables accurate detection and assessment of breast lesions.

MRI assessment of cervical cancer for adaptive radiotherapy.

PURPOSE: To assess the importance of the information obtained from MRI for adaptive cervix cancer radiotherapy. PATIENTS AND METHODS: 49 patients with cervix cancer, treated by external-beam radiotherapy (EBRT) and MRI-assisted high-dose-rate brachytherapy +/- concomitant cisplatin, underwent MRI at diagnosis and at the time of brachytherapy fractions. 190 MRI examinations were performed. Pretreatment scans were correlated with clinical examination (CE) findings. Measurements in 3-D of the tumor extension and also of the distance from the tumor to the pelvic side wall were performed using both MRI and CE. The tumor volume regression induced initially by EBRT and the subsequent regression after each brachytherapy fraction were assessed. RESULTS: MRI and CE showed 92% agreement in overall parametrial staging and 73% agreement in terms of vaginal involvement. There was, however, disagreement in parametrial side (right/left) classification in 25% of the parametria examined. These were patients with unilateral displacement of the cervix and contralateral invasion of the parametrium. The mean tumor volume on the pretreatment MRI scan (GTVD) was 61 cm(3). At the time of the four brachytherapy fractions the mean was 16 cm(3), 10 cm(3), 9 cm(3), and 8 cm(3), defined as the GTVBT plus the gray zones in the parametria. CONCLUSION: CE and MRI findings agree well in terms of overall staging. The clinical assessment of side-specific parametrial invasion improved when having access to the additional knowledge obtained from MRI. The greatest decrease in tumor volume occurs during EBRT, whereas tumor regression between the first and subsequent brachytherapy fractions is minor.

Hypertrophy of the breast: a problem of beauty or health?

BACKGROUND: Despite the complex health burden for women with breast hypertrophy, medical directors of health insurance companies are not convinced that this procedure is of medical benefit for patients. Therefore, coverage of cost by the health insurance companies is no longer guaranteed. The purpose of this study is to evaluate the influence of breast weight on the physical and psychological morbidity of women and to prove the medical necessity of reduction mammaplasty. METHODS: We performed a cohort study of 50 women with various breast sizes, a mean age of 28 years (range 20-40 years), and a body mass index (BMI) <25. Breast weight was measured, the spine was investigated by magnetic resonance imaging (MRI), and a spine score of clinical symptoms was assessed. The Beck Depression Inventory (BDI) was used to evaluate psychological impairment. Pathological findings have been correlated with breast weight, and the risk of developing a morphological or psychological disorder independence of the breast weight was calculated. RESULTS: The incidence of degenerative spine disorders and the extent of depressive symptoms are correlated with increasing breast weight. CONCLUSIONS: The data show that high breast weight has a negative influence on the physical and psychological morbidity of women. This objective evidence in support of the medical necessity of reduction mammaplasty should guide managed care organizations' methods for determining coverage for reduction mammaplasty.