Download Role of Proton magnetic resonance Spectroscopy and Diffusion

Role of Proton magnetic resonance Spectroscopy and
Diffusion weighted imaging in characterizing benign and
malignant breast lesions
Poster No.:
C-0739
Congress:
ECR 2013
Type:
Scientific Exhibit
Authors:
M. M. Makboul, H. M. K. Imam, H. Megaly, M. Zidan; Assiut/EG
Keywords:
Breast, MR-Spectroscopy, MR, MR-Diffusion/Perfusion,
Comparative studies, Diagnostic procedure, Cancer, Pathology
DOI:
10.1594/ecr2013/C-0739
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Purpose
Breast cancer is a major health problem in women and early detection is of prime
importance. Breast magnetic resonance imaging (MRI) provides both physical and
physiologic tissue features that are useful in discriminating malignant from benign lesions
(1). Contrast enhanced MRI is valuable for diagnosis of small tumors in dense breast
and the structural and kinetic parameters improved the specificity of diagnosing benign
from malignant lesions. It is a complimentary modality for preoperative staging, to follow
response to therapy, to detect recurrence and for screening high risk women (2).
Dynamic contrast enhanced imaging detect changes in the vascularity, vascular
permeability, interstitial pressure and extracellular space. However it provides no direct
information about tumor cellularity. Diffusion weighted MRI provides unique information
about cellularity and the state of molecular motion of water (3). The apparent diffusion
coefficient (ADC) value may be an effective parameter for distinguishing between benign
and malignant breast lesions because tumor cellularity significantly influences ADC
values (4).
Molecular information has been expected to be useful for diagnosis of breast lesions. Invivo MR spectroscopy (MRS) is a valuable method to obtain the biochemical status of
normal and diseased tissues. MRS helps to increase the specificity of MRI and to monitor
tumor response (5).
The purpose of this study investigates if Diffusion weighted imaging and MR spectroscopy
would be useful for characterizing benign and malignant breast lesions when combined
to contrast enhanced magnetic resonance imaging.
Methods and Materials
Patients:
Till now 19 patients out of intended 50 patients with suspicious breast lesions based on
physical examination and ultrasonography were included.
Exclusion criteria were: patients who had contraindication to MR imaging (e.g.,
pacemaker, metallic implant). The ages of these patients ranged from 22 to 62 years
(mean age 42years).
MR imaging protocol:
Page 2 of 12
These patients each underwent an MRI examination as a part of an institutional research
study on dynamic contrast enhanced MRI, diffusion weighted imaging and Magnetic
resonance spectroscopy. MRI was performed using a 1.5 T system (Avanto, Siemens
Healthcare).
Patients were placed in a prone position in a breast coil and MRI was performed using
the following sequences: Axial T1WI (TR/TE,636/12ms ), fat suppressed T2WI (TR/TE,
11520/59ms ) were obtained for conventional MRI examination.
Dynamic MRI was performed before and 6 times after intravenous administration of a
bolus of gadopentetate dimeglumin (0.1mmol/kg, Magnevist) at a rate of 2ml/s followed
by 20 ml saline flush administered using an automatic injector. In this study 6 consecutive
T1WI sequences were obtained in 7 minutes. After subtracting the initial unenhanced
images from the remaining enhanced images, the regions of interest (ROIs) were placed
on the most enhancing area within the mass. Time intensity curves were constructed to
quantitatively show time dependent enhancement in these ROIs.
For DWI, axial with single shot echoplanar imaging (EPI) was performed at b values
50, 400, 800, 1000 and 1500 with the following parameters TR/TE 2100/80ms , 4 mm
slice thickness, Fov 250mm, Apparent diffusion coefficient (ADC) map were automatically
calculated by MR machine software. Averaged ADC values were measured on ADC
maps to quantify the diffusional properties of the mass.
1
After all of MRI sequences had been performed, Single-voxel H MRS was performed
by point resolved spectroscopy sequence with TR 1570, TE 100, voxel size about
(1.5x1.5x1.5cm). The voxel for MRS measurement was placed at center of the mass to
avoid a contamination signal from normal tissue. Shimming was performed automatically
for optimization of the homogeneity in each volume of interest.
1
H MRS using the residual water as a reference (4.7ppm). Spectra obtained in malignant
breast lesions, an observed resonance at 3.23ppm is consistent with phosphocholine, in
spectra from benign breast lesions and some normal breast tissue in lactating female a
recorded resonance at 3.27, 3.28ppm thought to originate from glycerophosphocholine,
taurine or myoinositol (6).
Results
Till now only 19 patients underwent MRI examination of breast. From 19 case, 25 lesions
were detected and the lesions were 14 malignant (56%), and 11 benign (44%) confirmed
with pathology results. Their mean size of the lesions was 4±2.7cm.
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Our preliminary results for dynamic MRI, 10 lesions show type I curve, 2 lesions show
type II curve and 13 lesions show type III curve.
-3
2
For diffusion WI, Mean ADCs of malignant lesions (0.82±0.08×10 mm /s)were lower
-3
2
than those of benign lesions (1.7 ±0.26×10 mm /s) (table1).
True
False
Total
Positive
13 carcinoma
4 benign
17
Negative
7 benign
1 carcinoma
8
Total
20
5
Table 1. Results of diffusion- weighted imaging
25
1
H MRS done for 17 cases out of 19 cases and choline was detected in 21 lesions out
of 23 lesions and 2 lesions revealed no detected choline (table2).
True
False
Total
Positive
10 carcinoma
5 benign
15
Negative
5 benign
1 carcinoma
6
Total
15
6
21
Table2. Results of proton MR spectroscopy
Images for this section:
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Fig. 1: 35-year old female patient that was misdiagnosed as right breast abscess. Axial
T1 post-contrast subtracted image shows a heterogeneously strong enhanced large right
breast mass.
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Fig. 2: 35-year old female patient that was misdiagnosed as right breast abscess. timeintensity type III curve.
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Fig. 3: 35-year old female patient that was misdiagnosed as right breast abscess.
Diffusion weighted images shows restricted diffusion with 0.9x10-3mm2/s)on ADC map.
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Fig. 4: 35-year old female patient that was misdiagnosed as right breast abscess. MR
spectroscopy shows choline peak at 3.23ppm.
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Fig. 5: 35-year old female patient that was misdiagnosed as right breast abscess. MR
spectroscopy shows choline peak at 3.23ppm.
Page 9 of 12
Conclusion
Magnetic resonance imaging became an important modality in evaluating breast lesions.
Dynamic contrast enhanced magnetic resonance imaging has been useful for the
detection, diagnosis and give information about morphology and kinetics of the lesions
(7).
In our study we try to evaluate role of diffusion WI and proton magnetic resonance
spectroscopy in characterizing benign and malignant breast lesions when combined to
contrast enhanced magnetic resonance imaging.
Diffusion WI reflects changes in water molecule mobility caused by alterations of the
tissue environment due to pathologic process, therefore, measurement of the motion
of water molecules can provide an additional features that may further increase the
specificity of MRI.
Malignant lesions in general have more tightly packed cells and lower ADC value as
compared with benign lesions (8).
Till now in our study we in agreement with the previous studies (9, 10) where cut off
value of 1.13-1.5x10-3mm2/s) for benign lesions and 0.85-1.1x10-3mm2/s) for malignant
lesions.
In vivo proton magnetic resonance spectroscopy provides useful information about the
pathology of breast lesions by the measurement of diagnostic chemicals visible on the
MR time scale. Using the residual water signal as reference (4.7ppm), a choline peak at
3.27-3.28ppm assigned to glycerophosphocholine, taurine, and myo-inositol was defined
as benign, whereas a peak resonance at 3.22-3.23ppm assigned to phosphocholine was
defined as malignant (5). Till now in our study we are in agreement with these previous
studies in most of cases.
1
In conclusion, MRI in combination with DWI and H MRS may improve the specificity of
breast MRI and thereby influence patient treatment options.
References
1.Cecil, K.M., Schnall, M.D. and Siegelman, E.S. The evaluation of human breast lesions
with magnetic resonance imaging and proton magnetic resonance spectroscopy. Breast
Cancer Res. Treat., 2001, 68:45-54.
Page 10 of 12
2. Cheung, Y.C., Chen, S.C., Su, M.Y. et al. Monitoring the size and response of
locally advanced breast cancers to neoadjuvant chemotherapy (weekly paclitaxel and
epirubicin) with serial enhanced MRI. Breast Cancer Res. Treat., 2003, 78:51-8.
3. Wenkel E, Geppert C, Schulz-Wendtland R, Uder M, Kiefer B, Bautz W, Janka R.
Diffusion weighted imaging in breast MRI: comparison of two different pulse sequences:
Acad Radiol 2007;14:1077-83.
4. Rubesova E, Grell AS, De Maertelaer V, Metens T, Chao SL, Lemort M. Quantitative
diffusion imaging in breast cancer: a clinical prospective study. J Magn Reson Imaging
2006;24:319-324.
5. Bartella L, Morris EA, Dershaw DD, et al. Proton MR spectroscopy with choline peak
as malignancy marker improves positive predictive value for breast cancer diagnosis:
preliminary study. Radiology 2006; 239:686-692.
6. Sharma U, Jagannathan NR. In vivo magnetic resonance spectroscopy in breast
cancer. Amsterdam, the Netherlands: Springer, 2007.
7. Bartella L, Smith CS, Dershaw DD, Liberman L. Imaging breast cancer. Radiol Clin
North Am 2007; 45:45-67.
8. Odoguardi F, Cilotti A, Marini C, Moretti M, Mazzotta D, Vaccaro A, et al. Role of
Diffusion -Weighted Imaging (DWI) in Magnetic Resonance (MR) of the breast. University
of PISA, Italy: 2005.
9. Belli P, Costantini M, Bufi E, Magistrelli A, La Torre G, Bonomo L. Diffusion-weighted
imaging in breast lesion evaluation. Radiol Med 2010; 115:51-69.
10. Hatakenaka M, Soeda H, Yabuuchi H, Matsuo Y, Kamitani T, Oda Y, Tsuneyoshi
M, Honda H. Apparent diffusion coefficients of breast tumors: clinical application. Magn
Reson Med Sci 2008; 7:23-9.
Personal Information
H. M. K. Imam, Professor of radiodiagnosis, Faculty of Medicine, Assiut University.
[email protected]
M. M. Makboul, Assisstant Lecturer of radiodiagnosis, Faculty of Medicine, Assiut
University
[email protected]
Page 11 of 12
H. Megaly, Assisstant Professor of radiodiagnosis, Faculty of Medicine, Assiut University
M. Zidan; Lecturer of radiodiagnosis, Faculty of medicine, Assiut University
[email protected]
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