Faculty Bibliography

OBJECTIVE: To examine the prognostic capabilities of intravoxel incoherent motion (IVIM) metrics and their ability to predict response to neoadjuvant treatment (NAT). Additionally, to observe changes in IVIM metrics between pre- and post-treatment MRI. METHODS: This IRB-approved, HIPAA-compliant retrospective study observed 31 breast cancer patients (32 lesions). Patients underwent standard bilateral breast MRI along with diffusion-weighted imaging before and after NAT. Six patients underwent an additional IVIM-MRI scan 12-14 weeks after initial scan and 2 cycles of treatment. In addition to apparent diffusion coefficients (ADC) from monoexponential decay, IVIM mean values (tissue diffusivity Dt, perfusion fraction fp, and pseudodiffusivity Dp) and histogram metrics were derived using a biexponential model. An additional filter identified voxels of highly vascular tumor tissue (VTT), excluding necrotic or normal tissue. Clinical data include histology of biopsy and clinical response to treatment through RECIST assessment. Comparisons of treatment response were made using Wilcoxon rank-sum tests. RESULTS: Average, kurtosis, and skewness of pseudodiffusion Dp significantly differentiated RECIST responders from nonresponders. ADC and Dt values generally increased ( approximately 70%) and VTT% values generally decreased ( approximately 20%) post-treatment. CONCLUSION: Dp metrics showed prognostic capabilities; slow and heterogeneous pseudodiffusion offer poor prognosis. Baseline ADC/Dt parameters were not significant predictors of response. This work suggests that IVIM mean values and heterogeneity metrics may have prognostic value in the setting of breast cancer NAT.

Purpose To compare fluorine 18 (18F) fluorodeoxyglucose (FDG) combined positron emission tomography (PET) and magnetic resonance (MR) imaging with 18F FDG combined PET and computed tomography (CT) in terms of organ-specific metastatic lesion detection and radiation dose in patients with breast cancer. Materials and Methods From July 2012 to October 2013, this institutional review board-approved HIPAA-compliant prospective study included 51 patients with breast cancer (50 women; mean age, 56 years; range, 32-76 years; one man; aged 70 years) who completed PET/MR imaging with diffusion-weighted and contrast material-enhanced sequences after unenhanced PET/CT. Written informed consent for study participation was obtained. Two independent readers for each modality recorded site and number of lesions. Imaging and clinical follow-up, with consensus in two cases, served as the reference standard. Results There were 242 distant metastatic lesions in 30 patients, 18 breast cancers in 17 patients, and 19 positive axillary nodes in eight patients. On a per-patient basis, PET/MR imaging with diffusion-weighted and contrast-enhanced sequences depicted distant (30 of 30 [100%] for readers 1 and 2) and axillary (eight of eight [100%] for reader 1, seven of eight [88%] for reader 2) metastatic disease at rates similar to those of unenhanced PET/CT (distant metastatic disease: 28 of 29 [96%] for readers 3 and 4, P = .50; axillary metastatic disease: seven of eight [88%] for readers 3 and 4, P > .99) and outperformed PET/CT in the detection of breast cancer (17 of 17 [100%] for readers 1 and 2 vs 11 of 17 [65%] for reader 3 and 10 of 17 [59%] for reader 4; P < .001). PET/MR imaging showed increased sensitivity for liver (40 of 40 [100%] for reader 1 and 32 of 40 [80%] for reader 2 vs 30 of 40 [75%] for reader 3 and 28 of 40 [70%] for reader 4; P < .001) and bone (105 of 107 [98%] for reader 1 and 102 of 107 [95%] for reader 2 vs 106 of 107 [99%] for reader 3 and 93 of 107 [87%] for reader 4; P = .012) metastases and revealed brain metastases in five of 51 (10%) patients. PET/CT trended toward increased sensitivity for lung metastases (20 of 23 [87%] for reader 1 and 17 of 23 [74%] for reader 2 vs 23 of 23 [100%] for reader 3 and 22 of 23 [96%] for reader 4; P = .065). Dose reduction averaged 50% (P < .001). Conclusion In patients with breast cancer, PET/MR imaging may yield better sensitivity for liver and possibly bone metastases but not for pulmonary metastases, as compared with that attained with PET/CT, at about half the radiation dose. (c) RSNA, 2016 Online supplemental material is available for this article.

The significant advances in magnetic resonance imaging (MRI) hardware and software, sequence design, and postprocessing methods have made diffusion-weighted imaging (DWI) an important part of body MRI protocols and have fueled extensive research on quantitative diffusion outside the brain, particularly in the oncologic setting. In this review, we summarize the most up-to-date information on DWI acquisition and clinical applications outside the brain, as discussed in an ISMRM-sponsored symposium held in April 2015. We first introduce recent advances in acquisition, processing, and quality control; then review scientific evidence in major organ systems; and finally describe future directions. J. Magn. Reson. Imaging 2016.

PURPOSE: To examine heterogeneous breast cancer through intravoxel incoherent motion (IVIM) histogram analysis. MATERIALS AND METHODS: This HIPAA-compliant, IRB-approved retrospective study included 62 patients (age 48.44 +/- 11.14 years, 50 malignant lesions and 12 benign) who underwent contrast-enhanced 3 T breast MRI and diffusion-weighted imaging. Apparent diffusion coefficient (ADC) and IVIM biomarkers of tissue diffusivity (Dt), perfusion fraction (fp), and pseudo-diffusivity (Dp) were calculated using voxel-based analysis for the whole lesion volume. Histogram analysis was performed to quantify tumour heterogeneity. Comparisons were made using Mann-Whitney tests between benign/malignant status, histological subtype, and molecular prognostic factor status while Spearman's rank correlation was used to characterize the association between imaging biomarkers and prognostic factor expression. RESULTS: The average values of the ADC and IVIM biomarkers, Dt and fp, showed significant differences between benign and malignant lesions. Additional significant differences were found in the histogram parameters among tumour subtypes and molecular prognostic factor status. IVIM histogram metrics, particularly fp and Dp, showed significant correlation with hormonal factor expression. CONCLUSION: Advanced diffusion imaging biomarkers show relationships with molecular prognostic factors and breast cancer malignancy. This analysis reveals novel diagnostic metrics that may explain some of the observed variability in treatment response among breast cancer patients. KEY POINTS: * Novel IVIM biomarkers characterize heterogeneous breast cancer. * Histogram analysis enables quantification of tumour heterogeneity. * IVIM biomarkers show relationships with breast cancer malignancy and molecular prognostic factors.

PURPOSE: This study aims to investigate the feasibility of using simultaneous breast MRI and PET to assess the synergy of MR pharmacokinetic and fluorine-18 fluorodeoxyglucose (F-FDG) uptake data to characterize tumor aggressiveness in terms of metastatic burden and Ki67 status. METHODS: Twelve consecutive patients underwent breast and whole-body PET/MRI. During the MR scan, PET events were simultaneously accumulated. MR contrast kinetic model parametric maps were computed using the extended Tofts model, including the volume transfer constant between blood plasma and the interstitial space (K), the transfer constant from the interstitial space to the blood plasma (kep), and the plasmatic volume fraction (Vp). RESULTS: Patients with systemic metastases had a significantly lower kep compared to those with local disease (0.45 vs. 0.99 min, P = 0.011). Metastatic burden correlated positively with K and standardized uptake value (SUV), and negatively with kep. Ki67 positive tumors had a significantly greater K compared to Ki67 negative tumors (0.29 vs. 0.45 min, P = 0.03). A negative correlation was found between metabolic tumor volume and transfer constant (K or Kep). CONCLUSION: These preliminary results suggest that MR pharmacokinetic parameters and FDG-PET may aid in the assessment of tumor aggressiveness and metastatic potential. Future studies are warranted with a larger cohort to further assess the role of pharmacokinetic modeling in simultaneous PET/MRI imaging.

PURPOSE: The aim of the study was to assess whether magnetic resonance imaging (MRI) characteristics can distinguish benign from malignant part-solid pulmonary nodules and predict the aggressiveness of the latter. We also sought to compare MRI-derived parameters with morphologic and physiological values derived from conventional examinations such as computed tomography and positron emission tomography/computed tomography. MATERIALS AND METHODS: This was an institutional review board-approved pilot study of 28 participants (23 women, mean age 73.5+/-13.8 y) with 32 biopsy-proven lesions. 3-T unenhanced pulmonary MRI examinations were performed with regions of interest drawn around lesions for T1, T2, T2*, and diffusion-weighted sequences. Apparent diffusion coefficient (ADC) and T2* values were calculated. Two weeks later the regions of interest were redrawn. MRI parameters were compared with lesion pathology, maximal standard uptake value (SUVmax), and Hounsfield units (HU). MRI lesion visibility was correlated with solid component size and the percentage of solid component. Intraobserver and interobserver agreements were determined. RESULTS: Only ADC values correlated with malignancy (P<0.05). ADC>/=1.28 mum/ms predicted malignancy with 83.3% sensitivity (area under the curve 0.79). ADC and T2* correlated with adenocarcinoma subtypes (P<0.05). No MRI parameters predicted tumor differentiation (P>0.11). SUVmax did not correlate with any MRI parameters (P>0.56). Visibility on T1-weighted images correlated with the percentage of solid components (P<0.03). T1 and T2 values showed significant correlation with HU measurements of the entire nodule (P<0.001 and P<0.024, respectively) and HU measurements of solid components (P=0.031 and 0.008, respectively). CONCLUSIONS: 3 T MRI with quantitative ADC values demonstrated potential for discriminating benign part-solid pulmonary nodules from malignant lesions. ADC and T2* values correlated with adenocarcinoma subtypes. No MRI parameters correlated with SUVmax. T1 and T2 values showed significant correlation with HU measurements of the entire nodule and of the solid components.

OBJECTIVE: To measure background parenchymal enhancement (BPE) and compare with other contrast enhancement values and diffusion-weighted MRI parameters in healthy and cancerous breast tissue at the clinical level. MATERIALS AND METHODS: This HIPAA-compliant, IRB approved retrospective study enrolled 77 patients (38 patients with breast cancer - mean age 51.8+/-10.0 years; 39 high-risk patients for screening evaluation - mean age 46.3+/-11.7 years), who underwent contrast-enhanced 3T breast MRI. Contrast enhanced MRI and diffusion-weighted imaging were performed to quantify BPE, lesion contrast enhancement, and apparent diffusion coefficient (ADC) metrics in fibroglandular tissue (FGT) and lesions. RESULTS: BPE did not correlate with ADC values. Mean BPE for the lesion-bearing patients was higher (43.9%) compared to that of the high-risk screening patients (28.3%, p=0.004). Significant correlation (r=0.37, p<0.05) was found between BPE and lesion contrast enhancement. CONCLUSION: No significant association was observed between parenchymal or lesion enhancement with conventional apparent diffusion metrics, suggesting that proliferative processes are not co-regulated in cancerous and parenchymal tissue.

PURPOSE: To compare fitting methods and sampling strategies, including the implementation of an optimized b-value selection for improved estimation of intravoxel incoherent motion (IVIM) parameters in breast cancer. METHODS: Fourteen patients (age, 48.4 +/- 14.27 years) with cancerous lesions underwent 3 Tesla breast MRI examination for a HIPAA-compliant, institutional review board approved diffusion MR study. IVIM biomarkers were calculated using "free" versus "segmented" fitting for conventional or optimized (repetitions of key b-values) b-value selection. Monte Carlo simulations were performed over a range of IVIM parameters to evaluate methods of analysis. Relative bias values, relative error, and coefficients of variation (CV) were obtained for assessment of methods. Statistical paired t-tests were used for comparison of experimental mean values and errors from each fitting and sampling method. RESULTS: Comparison of the different analysis/sampling methods in simulations and experiments showed that the "segmented" analysis and the optimized method have higher precision and accuracy, in general, compared with "free" fitting of conventional sampling when considering all parameters. Regarding relative bias, IVIM parameters fp and Dt differed significantly between "segmented" and "free" fitting methods. CONCLUSION: IVIM analysis may improve using optimized selection and "segmented" analysis, potentially enabling better differentiation of breast cancer subtypes and monitoring of treatment. Magn Reson Med, 2014. (c) 2014 Wiley Periodicals, Inc.

When diffusion biomarkers display transient changes, i.e. in muscle following exercise, traditional diffusion-tensor imaging (DTI) methods lack the temporal resolution to resolve the dynamics. This article presents an MRI method for dynamic diffusion-tensor acquisitions on a clinical 3T scanner. This method, the Single-Line Multiple-Echo Diffusion-Tensor Acquisition Technique (SL-MEDITATE), achieves a high temporal resolution (4 s) by rapid diffusion encoding through the acquisition of multiple echoes with unique diffusion sensitization and limiting the readout to a single line volume. The method is demonstrated in a rotating anisotropic phantom, a flow phantom with adjustable flow speed and in vivo skeletal calf muscle of healthy volunteers following a plantar flexion exercise. The rotating and flow-varying phantom experiments show that SL-MEDITATE correctly identifies the rotation of the first diffusion eigenvector and the changes in diffusion-tensor parameter magnitudes, respectively. Immediately following exercise, the in vivo mean diffusivity (MD) time courses show, before the well-known increase, an initial decrease that is not typically observed in traditional DTI. In conclusion, SL-MEDITATE can be used to capture transient changes in tissue anisotropy in a single line. Future progress might allow for dynamic DTI when combined with appropriate k-space trajectories and compressed sensing reconstruction

PURPOSE: We used a combined intravoxel incoherent motion-diffusion tensor imaging (IVIM-DTI) methodology to distinguish structural from flow effects on renal diffusion anisotropy. METHODS: Eight volunteers were examined with IVIM-DTI at 3T with 20 diffusion directions and 10 b-values. Mean diffusivity (MD) and fractional anisotropy (FA) from DTI analysis were calculated for low (b 200 s/mm2 ), and full b-value ranges. IVIM-parameters perfusion-fraction fP , pseudo-diffusivity Dp , and tissue-diffusivity Dt were first calculated independently on a voxelwise basis for all directions. After estimating a fixed isotropic fp from these data, global anisotropies of Dt and Dp in the cortex and medulla were determined in a constrained cylindrical description and visualized using polar plots and cosine scatterplots. RESULTS: For all b-value ranges, medullary FA was significantly higher than that of the cortex. The corticomedullary difference was smaller for the high b-value range. Significantly higher fp and Dt were determined for the cortex and showed a significantly higher directional variance in the medulla. Polar plot analysis displayed nearly isotropic Dp and Dt in the cortex and anisotropy in the medulla. CONCLUSION: Both flow and microstructure apparently contribute to the medullary diffusion anisotropy. The described novel method may be useful in separating decreased tubular flow from irreversible structural tubular damage, for example, in diabetic nephropathy or during allograft rejection. Magn Reson Med, 2014. (c) 2014 Wiley Periodicals, Inc.