Breast cancer: early- and late-fluorescence near-infrared imaging with indocyanine green--a preliminary study.

PURPOSE: To assess early- and late-fluorescence near-infrared imaging, corresponding to the vascular (early-fluorescence) and extravascular (late-fluorescence) phases of indocyanine green (ICG) enhancement, for breast cancer detection and benign versus malignant breast lesion differentiation. MATERIALS AND METHODS: The study was approved by the ethical review board; all participants provided written informed consent. Twenty women with 21 breast lesions were examined with near-infrared imaging before, during, and after intravenous injection of ICG. Absorption and fluorescence projection mammograms were recorded simultaneously on a prototype near-infrared imaging unit. Two blinded readers independently assessed the images and assigned visibility scores to lesions seen on the absorption and absorption-corrected fluorescence mammograms. Imaging results were compared with histopathologic findings. Lesion contrast and diameter on the fluorescence mammograms were measured, and Cohen κ, Mann-Whitney U, and Spearman ρ tests were conducted. RESULTS: The absorption-corrected fluorescence ratio mammograms showed high contrast (contrast value range, 0.25-0.64) between tumors and surrounding breast tissue. Malignant lesions were correctly defined in 11 (reader 1) and 12 (reader 2) of 13 cases, and benign lesions were correctly defined in six (reader 1) and five (reader 2) of eight cases with late-fluorescence imaging. Lesion visibility scores for malignant and benign lesions were significantly different on the fluorescence ratio mammograms (P = .003) but not on the absorption mammograms (P = .206). Mean sensitivity and specificity reached 92% ± 8 (standard error of mean) and 75% ± 16, respectively, for fluorescence ratio imaging compared with 100% ± 0 and 25% ± 16, respectively, for conventional mammography alone. CONCLUSION: Preliminary data suggest that early- and late-fluorescence ratio imaging after ICG administration can be used to distinguish malignant from benign breast lesions.

Time-gated fluorescence spectroscopy improves endoscopic detection of low-grade dysplasia in ulcerative colitis.

BACKGROUND: Dysplasia in ulcerative colitis is frequently missed with 4-quadrant biopsies. An experimental setup recording delayed fluorescence spectra simultaneously with white light endoscopy was recently developed. OBJECTIVE: We compared detection of invisible flat intraepithelial neoplasia with protoporphyrin IX fluorescence and standard 4-quadrant biopsies. DESIGN: Prospective, crossover design without randomization of the order of procedures. SETTING: Gastroenterology Department, Humboldt University, Charité, Berlin, Germany. PATIENTS: Forty-two patients with extensive ulcerative colitis of more than 10 years' duration were included. INTERVENTIONS: Colonoscopy with 4-quadrant biopsies and targeted biopsies of macroscopic lesions and time-gated fluorescence-guided colonoscopy were performed 2 weeks apart by 2 blinded endoscopists. Three independent pathologists examined the biopsy specimens. MAIN OUTCOME MEASUREMENTS: The primary outcome criterion was detection rate of invisible flat intraepithelial neoplasia. RESULTS: Invisible flat intraepithelial neoplasia was detected in 3 (7%) patients by white light 4-quadrant biopsies and in 10 (24%) patients by fluorescence-guided endoscopy (P = .02). The sensitivity and specificity for differentiating patients with and without dysplasia were 100% and 81%, respectively. Dysplastic and nondysplastic mucosa could be discriminated with a sensitivity and specificity of 73% and 81%, respectively. LIMITATIONS: The trial was not randomized. CONCLUSION: The detection rate of intraepithelial neoplasia in patients with ulcerative colitis can be improved by fluorescence-guided colonoscopy.

Late-fluorescence mammography assesses tumor capillary permeability and differentiates malignant from benign lesions.

Using scanning time-domain instrumentation we recorded fluorescence projection mammograms on few breast cancer patients prior, during and after infusion of indocyanine green (ICG), while monitoring arterial ICG concentration by transcutaneous pulse densitometry. Late-fluorescence mammograms recorded after ICG had been largely cleared from the blood by the liver, showed invasive carcinomas at high contrast over a rather homogeneous background, whereas benign lesions did not produce (focused) fluorescence contrast. During infusion, tissue concentration contrast and hence fluorescence contrast is determined by intravascular contributions, whereas late-fluorescence mammograms are dominated by contributions from protein-bound ICG extravasated into the interstitium, reflecting relative microvascular permeabilities of carcinomas and normal breast tissue. We simulated intravascular and extravascular contributions to ICG tissue concentration contrast within a two-compartment unidirectional pharmacokinetic model.

Investigation of detection limits for diffuse optical tomography systems: II. Analysis of slab and cup geometry for breast imaging.

Using a statistical (chi-square) test on simulated data and a realistic noise model derived from the system's hardware we study the performance of diffuse optical tomography systems for fluorescence imaging. We compare the predicted smallest size of detectable lesions at various positions in slab and cup geometry and model how detection sensitivity depends on breast compression and lesion fluorescence contrast. Our investigation shows that lesion detection is limited by relative noise in slab geometry and by absolute noise in cup geometry.

Nonlinear reconstruction of absorption and fluorescence contrast from measured diffuse transmittance and reflectance of a compressed-breast-simulating phantom.

We report on the nonlinear reconstruction of local absorption and fluorescence contrast in tissuelike scattering media from measured time-domain diffuse reflectance and transmittance of laser as well as laser-excited fluorescence radiation. Measurements were taken at selected source-detector offsets using slablike diffusely scattering and fluorescent phantoms containing fluorescent heterogeneities. Such measurements simulate in vivo data that would be obtained employing a scanning, time-domain fluorescence mammograph, where the breast is gently compressed between two parallel glass plates, and source and detector optical fibers scan synchronously at various source-detector offsets, allowing the recording of laser and fluorescence mammograms. The diffusion equations modeling the propagation of the laser and fluorescence radiation were solved in frequency domain by the finite element method simultaneously for several modulation frequencies using Fourier transformation and preprocessed experimental data. To reconstruct the concentration of the fluorescent contrast agent, the Born approximation including higher-order reconstructed photon densities at the excitation wavelength was used. Axial resolution was determined that can be achieved by various detection schemes. We show that remission measurements increase the depth resolution significantly.

Review of optical breast imaging and spectroscopy.

Diffuse optical imaging and spectroscopy of the female breast is an area of active research. We review the present status of this field and discuss the broad range of methodologies and applications. Starting with a brief overview on breast physiology, the remodeling of vasculature and extracellular matrix caused by solid tumors is highlighted that is relevant for contrast in optical imaging. Then, the various instrumental techniques and the related methods of data analysis and image generation are described and compared including multimodality instrumentation, fluorescence mammography, broadband spectroscopy, and diffuse correlation spectroscopy. We review the clinical results on functional properties of malignant and benign breast lesions compared to host tissue and discuss the various methods to improve contrast between healthy and diseased tissue, such as enhanced spectroscopic information, dynamic variations of functional properties, pharmacokinetics of extrinsic contrast agents, including the enhanced permeability and retention effect. We discuss research on monitoring neoadjuvant chemotherapy and on breast cancer risk assessment as potential clinical applications of optical breast imaging and spectroscopy. Moreover, we consider new experimental approaches, such as photoacoustic imaging and long-wavelength tissue spectroscopy.

Computational Model for Tumor Oxygenation Applied to Clinical Data on Breast Tumor Hemoglobin Concentrations Suggests Vascular Dilatation and Compression.

We present a computational model for trans-vascular oxygen transport in synthetic tumor and host tissue blood vessel networks, aiming at qualitatively explaining published data of optical mammography, which were obtained from 87 breast cancer patients. The data generally show average hemoglobin concentration to be higher in tumors versus host tissue whereas average oxy-to total hemoglobin concentration (vascular segment RBC-volume-weighted blood oxygenation) can be above or below normal. Starting from a synthetic arterio-venous initial network the tumor vasculature was generated by processes involving cooption, angiogenesis, and vessel regression. Calculations of spatially resolved blood flow, hematocrit, oxy- and total hemoglobin concentrations, blood and tissue oxygenation were carried out for ninety tumor and associated normal vessel networks starting from various assumed geometries of feeding arteries and draining veins. Spatial heterogeneity in the extra-vascular partial oxygen pressure distribution can be related to various tumor compartments characterized by varying capillary densities and blood flow characteristics. The reported higher average hemoglobin concentration of tumors is explained by growth and dilatation of tumor blood vessels. Even assuming sixfold metabolic rate of oxygen consumption in tumorous versus host tissue, the predicted oxygen hemoglobin concentrations are above normal. Such tumors are likely associated with high tumor blood flow caused by high-caliber blood vessels crossing the tumor volume and hence oxygen supply exceeding oxygen demand. Tumor oxy- to total hemoglobin concentration below normal could only be achieved by reducing tumor vessel radii during growth by a randomly selected factor, simulating compression caused by intra-tumoral solid stress due to proliferation of cells and extracellular matrix. Since compression of blood vessels will impede chemotherapy we conclude that tumors with oxy- to total hemoglobin concentration below normal are less likely to respond to chemotherapy. Such behavior was recently reported for neo-adjuvant chemotherapy of locally advanced breast tumors.

Scanning time-domain optical mammography: detection and characterization of breast tumors in vivo.

Optical mammography is one of several new techniques for breast cancer detection and characterization presently under development for clinical use that provide information other than morphologic, in particular on the biochemical and metabolic state of normal and diseased tissue. In breast tissue, scattering of red to near infrared (NIR) light dominates absorption and NIR light may penetrate several centimeters through the breast. Optical mammography avoids the use of ionizing radiation and offers the power of diffuse optical spectroscopy. However, because of strong light scattering, spatial resolution of optical mammography is generally low. The paper reviews the results of a clinical study on scanning time-domain optical mammography comprising 154 patients carrying a total of 102 carcinomas validated by histology. Ninety two of these tumors were detected in optical mammograms retrospectively and for 87 of the detected tumors optical properties and tissue parameters were derived. In addition developments on instrumentation and data analysis are covered and possible improvements of optical mammography are briefly discussed.

Time-domain scanning optical mammography: II. Optical properties and tissue parameters of 87 carcinomas.

Within a clinical trial on scanning time-domain optical mammography reported on in a companion publication (part I), craniocaudal and mediolateral projection optical mammograms were recorded from 154 patients, suspected of having breast cancer. Here we report on in vivo optical properties of the subset of 87 histologically validated carcinomas which were visible in optical mammograms recorded at two or three near-infrared wavelengths. Tumour absorption and reduced scattering coefficients were derived from distributions of times of flight of photons recorded at the tumour site employing the model of diffraction of photon density waves by a spherical inhomogeneity, located in an otherwise homogeneous tissue slab. Effective tumour radii, taken from pathology, and tumour location along the compression direction, deduced from off-axis optical scans of the tumour region, were included in the analysis as prior knowledge, if available. On average, tumour absorption coefficients exceeded those of surrounding healthy breast tissue by a factor of about 2.5 (670 nm), whereas tumour reduced scattering coefficients were larger by about 20% (670 nm). From absorption coefficients at 670 nm and 785 nm total haemoglobin concentration and blood oxygen saturation were deduced for tumours and surrounding healthy breast tissue. Apart from a few outliers total haemoglobin concentration was observed to be systematically larger in tumours compared to healthy breast tissue. In contrast, blood oxygen saturation was found to be a poor discriminator for tumours and healthy breast tissue; both median values of blood oxygen saturation are the same within their statistical uncertainties. However, the ratio of total haemoglobin concentration over blood oxygen saturation further improves discrimination between tumours and healthy breast tissue. For 29 tumours detected in optical mammograms recorded at three wavelengths (670 nm, 785 nm, 843 nm or 884 nm), scatter power was derived from transport scattering coefficients. Scatter power of tumours tends to be larger than that of surrounding healthy breast tissue, yet the 95% confidence intervals of both medians overlap.

Reconstruction of optical properties of phantom and breast lesion in vivo from paraxial scanning data.

We report on the reconstruction of absorption and reduced scattering coefficients of breast tissue in vivo of a patient with mastopathic disease. Distributions of times of flight of photons through the compressed breast were recorded by paraxial scanning. From data measured at four different source-detector offsets optical properties were reconstructed within the linear Rytov approximation by a fast inverse Fourier space method. Low-pass filtering in Fourier space was employed to remove excessive noise from high spatial frequency components and to reduce the computational efforts by a factor of 3, typically. The mammograms displaying reconstructed absorption and reduced scattering coefficients were compared with projection mammograms either obtained by time-window analysis of experimental data or based on average absorption and reduced scattering coefficients which were derived from measured temporal point spread functions within a simple homogeneous model. All inhomogeneities which were visible in the projection mammograms and which could be associated with specific breast tissue compartments could be correlated with inhomogeneities in the reconstructed absorption coefficient. In particular, the mastopathic disease was detected in the reconstructed absorption mammogram. In order to assess reliability of optical properties reconstructed from data obtained by paraxial scanning, corresponding phantom experiments and reconstructions of phantom optical properties were carried out. Because of the limited angular range sampled by the in vivo and phantom measurements, considerable blurring of the absorption coefficient occurs along the compression direction, compromising longitudinal resolution.

Time-domain scanning optical mammography: I. Recording and assessment of mammograms of 154 patients.

Using a triple wavelength (670 nm, 785 nm, 843/884 nm) scanning laser-pulse mammograph we recorded craniocaudal and mediolateral projection optical mammograms of 154 patients, suspected of having breast cancer. From distributions of times of flight of photons recorded at typically 1000-2000 scan positions, optical mammograms were derived displaying (inverse) photon counts in selected time windows, absorption and reduced scattering coefficients or total haemoglobin concentration and blood oxygen saturation. Optical mammograms were analysed by comparing them with x-ray and MR mammograms, including results of histopathology, attributing a subjective visibility score to each tumour assessed. Out of 102 histologically confirmed tumours, 72 tumours were detected retrospectively in both optical projection mammograms, in addition 20 cases in one projection only, whereas 10 tumours were not detectable in any projection. Tumour contrast and contrast-to-noise ratios of mammograms of the same breast, but derived from measured DTOFs by various methods were quantitatively compared. On average, inverse photon counts in selected time windows, including total photon counts, provide highest tumour contrast and contrast-to-noise ratios. Based on the results of the present study we developed a multi-wavelength, multi-projection scanning time-domain optical mammograph with improved spectral and spatial (angular) sampling, that allows us to record entire mammograms simultaneously at various offsets between the transmitting fibre and receiving fibre bundle and provides first results for illustration.

Design of a constant adiabaticity pulse for selective population inversion.

A new adiabatic pulse for population inversion and the principles of its design are presented. The pulse shape is characterized by the combination of two constraints. (i) Adiabatic following of the central isochromat of the spectral region of interest occurs with constant, possibly small adiabaticity parameter; thereby, the center isochromat gets most efficiently inverted. (ii) Frequency and amplitude modulations obey the principle of offset-independent adiabaticity; thus, the inversion dynamics of the center isochromat is extended over the desired bandwidth. Selective population inversion can be achieved rather independently of spatial radio frequency field inhomogeneities and with significantly reduced peak RF amplitude in comparison with the well-known sech/tanh adiabatic pulse.

Quantification of optical properties of a breast tumor using random walk theory.

For the first time we use a random walk methodology based on time-dependent contrast functions to quantify the optical properties of breast tumors (invasive ductal carcinoma) of two patients. Previously this theoretical approach was successfully applied for analysis of embedded objects in several phantoms. Data analysis was performed on distributions of times of flight for photons transmitted through the breast which were recorded in vivo using a time-domain scanning mammograph at 670 and 785 nm. The size of the tumors, their optical properties, and those of the surrounding tissue were reconstructed at both wavelengths. The tumors showed increased absorption and scattering. From the absorption coefficients at both wavelengths blood oxygen saturation was estimated for the tumors and the surrounding tissue.

Concentration and oxygen saturation of haemoglobin of 50 breast tumours determined by time-domain optical mammography.

Using a dual-wavelength (670 nm, 785 nm) time-domain scanning instrument we have recorded optical mammograms of 93 patients suspected of having breast cancer which was subsequently assessed histologically. Among 65 histologically confirmed carcinomas, 54 were detectable in at least one of two optical mammograms recorded of each tumour-bearing breast in craniocaudal and mediolateral projection. Optical mammograms were based on photon counts in selected time windows of measured distributions of times of flight of photons. Optical properties of 50 carcinomas investigated at both wavelengths were derived by modelling the breast as partially homogeneous infinite slab with an embedded spherical inhomogeneity representing the tumour and by calculating the diffraction of photon density waves. In selected cases, additional information about the location of the tumour along the compression direction was used that was obtained from scans at selected offsets between source and detector optical fibres. A correlation plot of haemoglobin concentration and blood oxygen saturation of tumours and healthy tissue shows good separation between both kinds of tissue. The majority of carcinomas exhibited increased total haemoglobin concentration compared to healthy tissue.

Cancer prevention in ulcerative colitis: long-term outcome following fluorescence-guided colonoscopy.

BACKGROUND: Patients with long-standing ulcerative colitis require repeated endoscopies for early detection of neoplasias, which, however, are frequently missed by standard colonoscopy. Fluorescence-guided colonoscopy is known to improve the detection rate but the long-term effects of fluorescence-guided colonoscopy are unknown. METHODS: Colitis patients with negative findings at index fluorescence-guided colonoscopy entered a prospective long-term study with conventional colonoscopies at 2-year intervals. Risk and time to progression were evaluated. The positive predictive value was assessed in patients with neoplasias at index fluorescence-guided colonoscopy who underwent immediate total colectomy. RESULTS: Thirty-one patients with negative fluorescence-guided colonoscopy were surveyed for a mean of 7.8 ± 0.9 years. Neoplasia was observed in only two of them (6%) after 7 and 8 years of follow-up, respectively. Neoplasia at index fluorescence-guided colonoscopy was observed in 10 patients. In all of them, multiple flat low-grade intraepithelial neoplasia was diagnosed. At immediate colectomy performed in eight of them, the diagnosis of flat low-grade intraepithelial neoplasia was confirmed, corresponding to a positive predictive value of 100%. However, synchronous more advanced neoplasia was detected in three of the eight patients (38%). All patients, those with and those without neoplasia, were alive at the end of the study. CONCLUSIONS: Fluorescence-guided colonoscopy misses, in contrast to standard colonoscopy, few, if any, patients with neoplasia. Most neoplasia-negative patients remain negative during prolonged follow-up. However, when low-grade dysplasia is diagnosed by fluorescence-guided colonoscopy, colectomy is recommended because more than a third of the patients harbor synchronous, more advanced neoplasia.

A multichannel time-domain scanning fluorescence mammograph: performance assessment and first in vivo results.

We present a scanning time-domain fluorescence mammograph capable to image the distribution of a fluorescent contrast agent within a female breast, slightly compressed between two parallel glass plates, with high sensitivity. Fluorescence of the contrast agent is excited using a near infrared picosecond diode laser module. Four additional picosecond diode lasers with emission wavelengths between 660 and 1066 nm allow to measure the intrinsic optical properties of the breast tissue. By synchronously moving a source fiber and seven detection fiber bundles across the breast, distributions of times of flight of photons are recorded simultaneously for selected source-detector combinations in transmission and reflection geometry either at the fluorescence wavelength or at the selected laser wavelengths. To evaluate the performance of the mammograph, we used breastlike rectangular phantoms comprising fluorescent and absorbing objects using the fluorescent dye Omocyanine as contrast agent excited at 735 nm. We compare two-dimensional imaging of the phantom based on transmission and reflection data. Furthermore, we developed an improved tomosynthesis algorithm which permits three-dimensional reconstruction of fluorescence and absorption properties of lesions with good spatial resolution. For illustration, we present fluorescence mammograms of one patient recorded 30 min after administration of the contrast agent indocyanine green showing the carcinoma at high contrast originating from fluorescence of the extravasated dye, excited at 780 nm.

Patient safety concept for multichannel transmit coils.

PURPOSE: To propose and illustrate a safety concept for multichannel transmit coils in MRI based on finite-differences time-domain (FDTD) simulations and validated by measurements. MATERIALS AND METHODS: FDTD simulations of specific absorption rate (SAR) distributions in a cylindrical agarose phantom were carried out for various radio frequency (RF) driving conditions of a four-element coil array. Additionally, maps of transmit amplitude, signal phase, and temperature rise following RF heating were measured by MRI. RESULTS: Quantitative agreement was achieved between simulated and measured field distributions, thus validating the numerical modeling. When applying the same RF power to each element of the coil array but systematically varying the RF phase between its elements, the maximum of the SAR distribution was found to vary by a factor of about 15. CONCLUSION: Our results demonstrate that current RF safety approaches are inadequate to deal with the new challenge of multichannel transmit coils. We propose a new concept based on a systematic investigation of the parameter space for RF phases and amplitudes. In this way the driving conditions generating the highest local SAR values per unit power can be identified and appropriately considered in the RF safety concept of a given MRI system.

Quantitative magnetic resonance spectroscopy: semi-parametric modeling and determination of uncertainties.

A semi-parametric approach for the quantitative analysis of magnetic resonance (MR) spectra is proposed and an uncertainty analysis is given. Single resonances are described by parametric models or by parametrized in vitro spectra and the baseline is determined nonparametrically by regularization. By viewing baseline estimation in a reproducing kernel Hilbert space, an explicit parametric solution for the baseline is derived. A Bayesian point of view is adopted to derive uncertainties, and the many parameters associated with the baseline solution are treated as nuisance parameters. The derived uncertainties formally reduce to Cramér-Rao lower bounds for the parametric part of the model in the case of a vanishing baseline. The proposed uncertainty calculation was applied to simulated and measured MR spectra and the results were compared to Cramér-Rao lower bounds derived after the nonparametrically estimated baselines were subtracted from the spectra. In particular, for high SNR and strong baseline contributions the proposed procedure yields a more appropriate characterization of the accuracy of parameter estimates than Crémer-Rao lower bounds, which tend to overestimate accuracy.

Association of human hippocampal neurochemistry, serotonin transporter genetic variation, and anxiety.

The impact of the serotonin transporter (5-HTT) gene-linked polymorphic region (5-HTTLPR) on anxiety-related behavior and related cerebral activation has facilitated the understanding of neurobiological mechanisms of anxiety. However, the influence of the 5-HTTLPR genotype on hippocampal neuronal development and neurochemistry, which is relevant to anxiety behavior, has not been investigated. In 38 healthy subjects, absolute concentrations of N-acetylaspartate (NAA) were measured as a main surrogate parameter for hippocampal neurochemistry on a 3-T scanner. A significantly lower hippocampal NAA concentration in s allele carriers was observed as compared to l/l genotype. Other metabolites (choline, creatine + phosphocreatine, glutamate) were unaffected by genotype. The hippocampal NAA concentration was negatively correlated with trait anxiety scores (STAI). Metabolites measured in the anterior cingulate cortex (reference region) were not associated with genotype. The results are in accordance with the recently reported relationship between hippocampal neuronal development and anxiety behavior in adult animals and show an association between human limbic neurochemistry and genetically driven serotonergic neurotransmission relevant to anxiety.

Dynamic NMR spectroscopy of hyperpolarized (129)Xe in human brain analyzed by an uptake model.

Hyperpolarized (129)Xe (HpXe) NMR not only holds promise for functional lung imaging, but for measurements of tissue perfusion as well. To investigate human brain perfusion, several time-series of (129)Xe MR spectra were recorded from one healthy volunteer after HpXe inhalation. The time-dependent amplitudes of the MR spectra were analyzed by using a compartment model for xenon uptake modified to account for the loss of (129)Xe polarization due to RF-excitation and for the breathhold technique used in the experiments. This analysis suggests that the resonances detected at 196.5 +/- 1 ppm and 193 +/- 1 ppm originate from HpXe dissolved in gray and white matter, respectively, and that T(1) relaxation times of HpXe are different in gray and white matter (T(1g) > T(1w)).