The diagnostic challenge of lack of choline level elevation on 1H-MR spectroscopy in grade II-III gliomas.

The accurate diagnosis of brain tumour is very important in modern neuro-oncology medicine. Magnetic resonance spectroscopy (MRS) is supposed to be a promising tool for detecting cancerous lesions. However, the interpretation of MRS data is complicated by the fact that not all cancerous lesions exhibit elevated choline (Cho) levels. The main goal of our study was to investigate the lack of Cho lesion /Cho ref elevation in the population of grade II-III gliomas. 89 cases of gliomas grade II and III were used for the retrospective analysis - glioma (astrocytoma or oligodendroglioma) grade II (74 out of 89 cases [83%]) and III (15 out of 89 cases [17%]) underwent conventional MRI extended by MRS before treatment. Histopathological diagnosis was obtained either by biopsy or surgical resection. Gliomas were classified to the group of no-choline elevation when the ratio of choline measured within the tumour (Cho lesion ) to choline from NABT (Cho ref ) were equal to or lower than 1. Significant differences were observed between ratios of Cho lesion /Cr lesion calculated for no-choline elevation and glial tumour groups as well as in the NAA lesion /Cr lesion ratio between the no-choline elevation group and glial tumour group. With consistent data concerning choline level elevation and slightly lower NAA value, the Cho lesion /NAA lesion ratio is significantly higher in the WHO II glial tumour group compared to the no-choline elevation cases ( p < 0.000). In the current study the results demonstrated possibility of lack of choline elevation in patients with grade II-III gliomas, so it is important to remember that the lack of elevated choline levels does not exclude neoplastic lesion.

Assessment of sodium (23Na) brain MRI at 3T - preliminary results.

Purpose: The purpose of this work was to establish a database of tissue sodium concentration (TSC) in the normal brain of healthy volunteers. Tissue sodium concentration can be used as a sensitive marker of tissue viability in stroke or radiation therapy monitoring. Material and methods: Thirty-seven volunteers were scanned with a 23Na protocol in the span of one year; within this group, 29 studies were of acceptable quality. The study was approved by the Local Bioethics Committee. Data were acquired during a single magnetic resonance (MR) scanner session. The single scanner session consisted of 23Na 3D radial gradient echo (GRE) acquisition, MPRage, SPACE-FLAIR, and Resolve-DTI. MPRage images were segmented to obtain masks of the grey matter (GM), white matter (WM), and cerebrospinal fluid (CSF), which were registered to the sodium image space for image analysis. Images were transformed into TSC maps - a signal calibration curve obtained from the reference phantom of known sodium concentration and known relaxation time. Results: The collected data were analysed in 2 different ways: volunteers were divided by sex and by age. No significant differences in TSC were found between sexes. In all comparisons there was a significant difference in TSC between younger and older volunteers. In healthy volunteers mean TSC were as follows: GM 33.21 ± 4.76 mmol/l, WM 28.41 ± 4.03 mmol/l and for CSF 41.3 ± 6.69 mmol/l. Conclusions: This preliminary work is a base for further work with sodium imaging in brain lesions. The entirety of the col-lected data will be useful in the future as a baseline brain TSC for comparison to values obtained from pathologies.

The use of MR perfusion parameters in differentiation between glioblastoma recurrence and radiation necrosis.

INTRODUCTION: This study focuses on the challenge of distinguishing between tumour recurrence and radiation necrosis in glioma treatment using magnetic resonance imaging (MRI). Currently, accurate differentiation is possible only through surgical biopsy, which is invasive and may cause additional damage. The study explores non-invasive methods using dynamic susceptibility contrast (DSC) MR perfusion with parameters like relative peak height (rPH) and relative percentage of signal-intensity recovery (rPSR). MATERIAL AND METHODS: Among retrospectively evaluated patients (multicentre study) with an initial diagnosis of the primary and secondary brain tumour, 47 met the inclusion criteria and were divided into two groups, the recurrent glioblastoma (GBM) WHO IV group and the radiation necrosis group, based on MRI of the brain. All patients enrolled into the recurrent GBM group had a second surgical intervention. RESULTS: Mean, minimum and maximum rPH values were significantly higher in the recurrent GBM group than in the radiation necrosis group ( p < 0.001), while rPSR values were lower in the recurrent GBM group than in the radiation necrosis group ( p = 0.011 and p = 0.012). DISCUSSION: This study investigates the use of MR perfusion curve characteristics to differentiate between radiation necrosis and glioblastoma recurrence in post-treatment brain tumours. MR perfusion shows promising potential for distinguishing between the two conditions, but it also has certain limitations. Despite challenges in finding a sufficient cohort size, the study demonstrates significant differences in MR perfusion parameters between radiation necrosis and GBM recurrence. CONCLUSIONS: The results demonstrate the potential usefulness of these DSC perfusion parameters in discriminating between glioblastoma recurrence and radiation necrosis.

Contrast-Enhanced Mammography (CEM) Capability to Distinguish Molecular Breast Cancer Subtypes.

With breast cancer ranking first among the most common malignant neoplasms in the world, new techniques of early detection are in even more demand than before. Our awareness of tumors' biology is expanding and may be used to treat patients more efficiently. A link between radiology and pathology was searched for in our study, as well as the answer to the question of whether a tumor type can be seen on contrast-enhanced mammography and if such knowledge may serve as part of precision medicine.

Evaluation of 3T proton MR spectroscopy in the spinal cord - preliminary results.

Purpose: 1H-magnetic resonance spectroscopy (1H-MRS) is a non-invasive technique that provides information on tissue metabolism and biochemistry. Because of technical difficulties, this method is rarely used in spinal cord examination. The main goal of this study was to develop a routine protocol for MRS of intramedullary lesions. Material and methods: A 1H-MRS protocol was set on a group of healthy volunteers. Forty-eight spectra were acquired in total. Thirty of them were acquired in cervical spinal cord, and the remaining 18 spectra were acquired in the thoracic spinal cord. Results: In 1H-MRS of the spinal cord one of the most important problems is small voxel size. Mean voxel size in this study was 7 × 9 × 29 mm, which is much smaller than in brain examinations. Finally, almost 60% of spectra were of acceptable quality in volunteer examinations, which enabled the subsequent examinations. Conclusions: Challenges of spinal cord spectroscopy were discussed, and the ability of providing additional diagnostic information was proven.

The effectiveness of contrast-enhanced spectral mammography and magnetic resonance imaging in dense breasts.

PURPOSE: Breast cancer is the most common cause of death from neoplastic disease in women. Among all breast anatomy types, glandular type is the most problematic concerning evaluation. While digital mammography still remains the basic diagnostic tool, one must be aware of its limitations in dense breasts. Although magnetic resonance imaging (MRI) has greatly improved sensitivity, its specificity is low. Moreover, there are contraindications for MRI for some patients, so a substitute has been searched for. This study was performed to check if contrast-enhanced spectral mammography (CESM) can be a viable option for patients with dense breasts. MATERIAL AND METHODS: The study involved 121 patients with abnormalities detected on base-line diagnostic imaging (ultrasound or mammography). The patients had subsequent examinations, both CESM and MRI performed within a maximum 2-month time interval. The sensitivity and specificity of both methods in the whole group as well as in specific breast structure types were measured and compared. RESULTS: Contrast enhancement was visible in all 121 cases on MRI, while on CESM lack of enhancement was noted in 13 cases. All of those 13 lesions turned out to be benign. There were 40 (33%) benign and 81 (69%) malignant tumours. The analysed group included 53 (44%) glandular type breast patients, 39 (32%) mixed type, and 29 (23%) fatty type. Although MRI proved to be slightly more effective in dense breasts, both methods showed similar results in the whole study group. CONCLUSION: CESM can be used with confidence in patients with glandular breast type when MRI is not available or there are reported contraindications to MRI.

Analysis of background parenchymal enhancement (BPE) on contrast enhanced spectral mammography compared with magnetic resonance imaging.

OBJECTIVES: With the growing number of new breast cancer cases in women, new methods of imaging arise. Contrast enhanced spectral mammography (CESM) and magnetic resonance imaging (MRI) are comparable methods regarding sensitivity. The aim of this study is to check if analysis of background parenchymal enhancement on CESM can improve its usefulness. MATERIAL AND METHODS: A total of 64 patients with breast lesions found previously on ultrasound or mammography underwent MRI and CESM within less than one month. On MRI the contrast enhancement kinetics and visual BPE were evaluated. On CESM the enhancement of lesions was noted as well as a quantitative level of BPH. The gathered data was analysed in terms of patterns and relations. RESULTS: A total of 66 lesions were identified both on MRI and CESM, including 11 (17%) benign and 55 (83%) malignant lesions. Among malignant lesions 13 (20%) were assessed as intraductal and 42 (64%) as infiltrating carcinomas. The study showed correlation between the level of enhancement on CESM and the type of kinetic curve on MRI and lesion enhance-ment on CESM as well as confirmed the fact that the BPE is a destimulant in both methods of imaging. CONCLUSIONS: Evaluation of BPE level on CESM can help reading radiologists to define a lesion as malignant with higher probability than based only on the qualitative lesion enhancement level.

Quantitative Assessment of Contrast Enhancement on Contrast Enhancement Spectral Mammography (CESM) and Comparison With Qualitative Assessment.

BACKGROUND/AIM: Contrast enhanced spectral mammography (CESM) is a novel method of breast cancer diagnosis. Benign lesions are enhanced after contrast injection on both CESM and breast magnetic resonance imaging (MRI). Kinetic curves on breast MRI facilitate differentiation between benign and malignant lesions, while on CESM there is no such possibility and we need to asses lesions based only on their level of enhancement and its patterns. The aim of this study was to compare two subjective assessments of enhancement level on CESM with numerical values measured using the region of interests (ROIs) and to categorize obtained enhancement level values. PATIENTS AND METHODS: Patients with suspicious findings on previously performed examinations were qualified for CESM. The qualitative assessment was based on the subjective classification of visible contrast enhancement as weak, medium or strong. The quantitative assessment was obtained by measurements of an average enhancement value and sigma value within the ellipsoidal shape ROI, inserted into the evaluated contrast enhancing lesion. RESULTS: The study group included 151 patients with total of 195 lesions diagnosed. It was verified how the classification based on the threshold values of %RS (percentage signal difference between enhancing lesion and background) and SDNR (signal-difference-to-noise Ratio) corresponds to a subjective assessment. CONCLUSION: Quantitative assessment of contrast enhancement on CESM is helpful in making decisions whether a lesion requires a biopsy. This can reduce the number of unnecessary biopsy procedures and reduce the cost of diagnostics.

Correlation Between Enhancement Intensity in Contrast Enhancement Spectral Mammography and Types of Kinetic Curves in Magnetic Resonance Imaging.

BACKGROUND Due to the decreased sensitivity of mammography in glandular breasts, new diagnostic modalities, like contrast-enhanced spectral mammography (CESM) and digital breast tomosynthesis (DBT) have been developed. The aim of this study was to compare qualitative enhancement levels on CESM with type of kinetic enhancement curves on MRI examination. MATERIAL AND METHODS Patients qualified for the CESM examination presented some diagnostic doubts - suspected multifocality, multicentricity, or having dense glandular breast tissue. The enhancement level on CESM was described as weak, medium, or strong. Enhancement on achieved MR images was assessed on the basis of enhancement kinetic curves. The level of enhancement on CESM was associated with enhancement curves type on MRI. All lesions detected on CESM and MRI were histopathologically verified. RESULTS The study involved 107 lesions diagnosed in 94 patients: 71 lesions (66%) appeared to be infiltrating on histopathological examination, 9 lesions (8%) were non-infiltrating cancers, and 27 lesions (25%) were benign. Data analysis revealed that lesions with wash-out curve on MRI most often presented strong enhancement on CESM, while in lesions with progressive enhancement curve, strong enhancement on CESM was the rarest. The relationship between enhancement level on CESM and curve type on contrast-enhanced MRI depends on the nature of the lesion. The type of MRI curve was found to be associated with enhancement level on CESM. CONCLUSIONS We compared subjective assessments of contrast enhancement on CESM with enhancement kinetic curves on MRI. The results showed that the level of enhancement on CESM and type of kinetic curves on MRI depends on the lesion type.

Correlation between quantitative assessment of contrast enhancement in contrast-enhanced spectral mammography (CESM) and histopathology-preliminary results.

OBJECTIVES: Contrast-enhanced spectral mammography (CESM) is a novel method for breast cancer detection. The aim of this study is to check if there is a possibility of quantitative assessment of contrast enhancement in CESM and if there is any correlation between quantitative assessment of contrast enhancement in CESM and histopathology. METHODS: A total of 167 female patients underwent CESM. All subjects previously had suspicious lesions found on mammography, breast ultrasound, or both. After imaging, the following parameters were evaluated: number of enhancing lesions in each breast and size and degree of enhancement of each lesion. Based on the collected data, the percentage signal difference between enhancing lesion and background (%RS) and signal-difference-to-noise ratio (SDNR) were measured for each lesion. RESULTS: The number of lesions detected in the study population was 195. Among all diagnosed lesions, 120 (62%) were assessed to be infiltrating cancers, 16 (8%) non-infiltrating cancers, and 59 (30%) were benign. Thirteen (7%) lesions did not enhance in CESM; all non-enhancing lesions were confirmed to be benign under histopathological examination. Analysis of enhancement indices showed that signal values within lesions and signal values within background ROIs (regions of interest) were similar in CC (craniocaudal) and MLO (mediolateral) projections. Mean %RS values were correlated with the type of enhancing lesion, infiltrating cancers having the highest values, benign lesions the lowest. CONCLUSIONS: This work has demonstrated a significant correlation between the degree of lesion enhancement in CESM and malignancy. Quantitative analysis of enhancement levels in CESM can distinguish between invasive cancers and benign or in situ lesions. KEY POINTS: • There is a possibility of quantitative assessment of contrast enhancement in CESM. • Correlation between quantitative assessment of contrast enhancement in CESM and histopathology was observed.

Intensity and Pattern of Enhancement on CESM: Prognostic Significance and its Relation to Expression of Podoplanin in Tumor Stroma - A Preliminary Report.

BACKGROUND/AIM: It is possible that the degree of enhancement on contrast-enhanced spectral mammography (CESM), a new diagnostic method, might provide prognostic information for breast cancer patients. Therefore, in a group of 82 breast cancer patients, we analyzed the prognostic significance of degree and pattern of enhancement on CESM as well as its relation to: (a) breast cancer immunophenotype (based on ER/PR/HER2 status) (b) podoplanin expression in cancer stroma (lymphatic vessel density plus podoplanin-positivity of cancer-associated fibroblasts), and (c) other histological parameters. MATERIALS AND METHODS: For each tumor the intensity of enhancement on CESM was qualitatively assessed as strong or weak/medium, while the pattern - as homogenous and heterogenous. RESULTS: Herein we report, for the first time, that strong and heterogenous enhancement on CESM was related to unfavorable disease-free survival of breast cancer patients (p=0.005). Moreover, the strong enhancement was more frequent in large and node-positive tumors (pT>1, pN>0) (p=0.002), as well as in carcinomas with podoplanin-sparse stroma (p=0.008). CONCLUSION: Intensity and pattern of enhancement on CESM might provide (together with the results of other diagnostic imaging methods) not only the confirmation of presence or absence of tumor, but also prognostic information.

Degree of Enhancement on Contrast Enhanced Spectral Mammography (CESM) and Lesion Type on Mammography (MG): Comparison Based on Histological Results.

BACKGROUND Contrast enhanced spectral mammography (CESM) is a new method of breast cancer diagnosis in which an iodinated contrast agent is injected and dual-energy mammography is obtained in multiple views of the breasts. The aim of this study was to compare the degree of enhancement on CESM with lesion characteristics on mammography (MG) and lesion histology in women with suspicious breast lesions. MATERIAL AND METHODS The degree of enhancement on CESM (absent, weak, medium, or strong) was compared to lesion characteristics on MG (mass, mass with microcalcifications, or microcalcifications alone) and histology (infiltrating carcinoma, intraductal carcinoma, or benign) to compare sensitivity of the two modalities and to establish correlations that might improve diagnostic accuracy. RESULTS Among 225 lesions identified with CESM and MG, histological evaluation revealed 143 carcinomas (127 infiltrating, 16 intraductal) and 82 benign lesions. This is the largest cohort investigated with CESM to date. The sensitivity of CESM was higher than that of MG (100% and 90%, respectively, p=0.010). Medium or strong enhancement on CESM and the presence of a mass on MG was the most likely indictor of malignancy (55.1% p=0.002). Among benign lesions, 60% presented as enhancement on CESM (were false-positive), and most frequently as medium or weak enhancement, together with a mass on MG (53%, p=0.047). Unfortunately, the study did not find combinations of MG findings and CESM enhancement patterns that would be helpful in defining false-positive lesions. We observed systematic overestimation of maximum lesion diameter on CESM compared to histology (mean difference: 2.29 mm). CONCLUSIONS Strong or medium enhancement on CESM and mass or mass with microcalcifications on MG were strong indicators of malignant transformation. However, we found no combination of MG and CESM characteristics helpful in defining false-positive lesions.

Comparison of the Mammography, Contrast-Enhanced Spectral Mammography and Ultrasonography in a Group of 116 patients.

Mammography (MG) is the gold-standard in breast cancer detection - the only method documented to reduce breast cancer mortality. Breast ultrasound (US) has been shown to increase sensitivity to breast cancers in screening women with dense breasts. Contrast-enhanced spectral mammography (CESM) is a novel technique intensively developed in the last few years. The goal of this study was to compare the sensitivity, specificity and accuracy of MG, US and CESM in detecting malignant breast lesions. The study included 116 patients. All patients were symptomatic and underwent MG, US and CESM. A radiologist with 20 years of experience in US and MG breast imaging and 1 year of experience in CESM reviewed images acquired in each of the three modalities separately, within an interval of 14-30 days. All identified lesions were confirmed at core biopsy. BI-RADS classifications on US, MG and CESM were compared to histopathology. MG, CESM and US were compared among 116 patients with 137 lesions encountered. Sensitivity of CESM was 100%, significantly higher than that of MG (90%, p<0.004) or US (92%, p<0.01). CESM accuracy was 78%, also higher than MG (69%, p<0.004) and US (70%, p=0.03). There was no statistically significant difference between AUCs for CESM and US (both 0.83). The AUCs of both US and CESM, however, were significantly larger than that of MG (p<0.0004 for each). CESM permitted better detection of malignant lesions than both MG and US, read individually. CESM found lesion enhancement in some benign lesions, as well, yielding a rate of false-positive diagnoses similar to that of MG and US.

Post-Irradiation Bladder Syndrome After Radiotherapy of Malignant Neoplasm of Small Pelvis Organs: An Observational, Non-Interventional Clinical Study Assessing VESIcare®/Solifenacin Treatment Results.

BACKGROUND Radiotherapy is explicitly indicated as one of the excluding factors in diagnosing overactive bladder syndrome (OAB). Nevertheless, symptoms of OAB such as urgent episodes, incontinence, pollakiuria, and nocturia, which are consequences of irradiation, led us to test the effectiveness of VESIcare®/Solifenacin in patients demonstrating these symptoms after radiation therapy of small pelvis organs due to malignant neoplasm. MATERIAL AND METHODS We conducted an observatory clinical study including 300 consecutive patients with symptoms of post-irradiation bladder; 271 of those patients completed the study. The observation time was 6 months and consisted of 3 consecutive visits taking place at 12-week intervals. We used VESIcare® at a dose of 5 mg a day. Every sixth patient was examined urodynamically at the beginning and at the end of the observation period, with an inflow speed of 50 ml/s. RESULTS We noticed improvement and decline in the average number of episodes a day in the following parameters: number of micturitions a day (-36%, P<0.01), nocturia (-50%, P<0.01), urgent episodes (-41%, P<0.03), and episodes of incontinence (-43%, P<0.01). The patients' quality of life improved. The average maximal cystometric volume increased by 34 ml (21%, p<0.01), average bladder volume of "first desire" increased by 42 ml (49%, P<0.01), and average detrusor muscle pressure at maximal cystometric volume diminished by 9 cmH2O (-36%, P<0.03). CONCLUSIONS The substance is well-tolerated. Solifenacin administered long-term to patients with symptoms of OAB after radiotherapy of a malignant neoplasm of the small pelvis organs has a daily impact in decreasing number of urgent episodes, incontinence, pollakiuria, and nocturia.