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Earlier detection of breast cancer by abbreviated MRI screening using color intensity projections (CIP) applied to high spatiotemporal resolution imaging
Keith S Cover1, Katya M Duvivier2, Pim de Graaf2, Ben J Slotman3, Joost PA Kuijer1, Mark BM Hofman1, and Rudolf M Verdaasdonk1

1Physics and Medical Technology, VU University Medical Center, Amsterdam, Netherlands, 2Radiology, VU University Medical Center, Amsterdam, Netherlands, 3Radiotherapy, VU University Medical Center, Amsterdam, Netherlands

Synopsis

Dynamic contrast enhancement (DCE) MRI is more sensitive than X-ray based mammography for detecting breast cancer especially for the 10% of women with extremely dense breasts. However, full diagnostic protocol (FDP) MR exams are too expensive for screening. Recent abbreviated MR protocols - which require only one quarter of the acquisition time - use high spatial temporal resolution (HSTR) sequences that generate thousands of images. We found color intensity projections (CIP) reduces radiologist reading time for detection of malignant tumours by visualizing their amount and time of enhancement (TOE) especially in combination with the value of the maximum slope (VMS).

Purpose

To perform a preliminary assessment of whether color intensity projections (CIP) [CoverKS2007] speeds up reading in breast cancer screening of the thousands of images generated by high spatial temporal resolution (HSTR) sequences without the use of specialized image viewing tools.

Background

Several studies have reported DCE-MRI to be more sensitive than X-ray based mammography for detecting breast cancer [KuhlCK2014, MangoVL2015]. The increased sensitivity allows tumours to be detected earlier when the disease is more treatable. Typical sensitivities quoted are 70% for mammography and 95% for MRI although for mammography it can be as low as 30% in for women with extremely dense breasts [EmausMJ2015, DOrsiCJ2013]. Compounding the problem, women with extremely dense breasts have a 4 to 6 fold higher risk of breast cancer than women with low density breasts. Unfortunately, MR has been too expensive to screen most women. To reduce screening costs many research institutes have studied “abbreviated” MR protocols that take just 10 to 15 minutes of scanner room time per patient [KuhlCK2014, MangoVL2015, MachidaY2016, JainM2016, GrimmLJ2015, HeacockL2016, MoschettaM2016] as compared to a typical 40 minute full diagnostic protocol (FDP). Recent studies have employed contrast enhancement kinetics with high spatial temporal resolution (HSTR) sequences [PlatelB2014, MannRM2014, AbeH2016, GotoM2016, MannRM2016] that acquire a whole volume of both breasts in under 5 seconds allowing the 50 second wash in interval of contrast agent to be imaged with high spatial resolution. HSTR sequences have demonstrated high sensitivity to breast tumours and high specificity in discriminating malignant and benign tumours. When time to enhancement (TOE) of a breast tumour is less than 8 seconds the tumour is likely malignant while longer than 16 seconds is likely benign [SardanelliF2000, PlatelB2014, GotoM2016]. However, HSTR sequences generate thousands of images per patient and thus are time consuming and costly for a radiologist to read and often require specialized and expensive image review software. Calculated from the HSTR images, the value of maximum slope (VMS) has been used to discriminate between benign and malignant tumours [PlatelB2014, MannRM2014]. T2 images are also helpful as benign tumours are usually bright while malignant are not.

Methods

From January until October 2016 a total of 191 clinical patients - most of which were reviewed for this study - were scanned for breast cancer on a 3T GE Discovery 750 MR system with our FDP. Patients were referred for MRI both for screening of high risk of breast cancer and pre and post treatment scanning. This study was approved by our university's ethics board and informed consent waved. Our FDP included a series of T1 weighted images over 7 minutes as part of the standard enhancement kinetics, T2 weighted images with fat saturation, DWI, and a DISCO-DIXON HSTR sequence [SaranathanM2012]. During the 90 seconds of the HSTR sequence, every 4.26 seconds an image volume of both breasts was acquired with voxels of 0.66x0.66x2.20 mm for both fat and water images. Color intensity projections (CIP) - with the amount of enhancement encoded in the brightness and the TOE encoded in the hue - were calculated from the HSTR images [CoverKS2007]. The exams were reviewed for this study by an highly experienced breast radiologist (KMD).

Results and Discussion

Five cases (Figures 1 to 5) were selected from the MR exams to demonstrate the promising results of reading HSTR images using the combination of CIP-TOE and VMS. The performance of the CIP-TOE and VMS compared to that of the FDP, in terms of reading time especially for negative exams and the detections of lesions, merits a formal study with several independent radiologists and detailed statistical evaluation. Also, no "show stoppers" were found for using CIP-TOE and VMS as part of an abbreviated breast screening protocol that uses only the T2 and DISCO sequences and non specialized image review software. Thus, further study is warranted.

Conclusion

The results of this informal preliminary study provides encouraging evidence that the CIP-TOE visualization tool - in combination with VMS and without the use of specialized image viewing tools - can substantially reduce a radiologist reading time of the thousands of images generated by HSTR sequences in breast cancer screening. A more formal study with several independent radiologists is justified to confirm this result.

Acknowledgements

The work has been funded by the VU University Medical Center in Amsterdam.

References

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Figures

Figure 1 A 52 year old female with palpable mass. MRI FDP revealed a 5 cm irregular mass, with satellite lesions and 10 suspicious lymph nodes. (a) CIP- TOE with the aorta in red (0.0 s) and malignancies in orange and yellow (4.3 s to 8.5 s). (b) The value of the maximum slope (VMS) has voxel values up to 62.5º consistent with a malignancy. (c) Single parameter TOE is hard to read. (d) DISCO image one frame after the aorta enhancement demonstrates early TOE in CIP suggests high grade. Pathology yielded an IDC malignancy grade 2 and 3.

Figure 2 MRI screening of a 29 year old female with history of radiation therapy to treat Burkitt lymfoma. MRI FDP showed a new oval mass medial in her breast. (a) CIP mass TOE of 12.8 seconds which is suspicious for malignancy. (b) The VMS ranges from 35º to 50º. (c) subtracted DISCO series at 8.6 seconds. (d) The mass is not very bright on a T2 with fat saturation. Pathology found a fibroadenoma. CIP aids in the detection of lesions in background enhancement. Along with the FDP, CIPs sometimes indicates fibroadenomas are suspicious even though they are benign.

Figure 3 6 month follow up of a 45 year old woman with a resected grade3 DCIS in her breast. MRI FDP showed background enhancement (not shown). Mammography did not show any suspicious microcalcifications in either breast. On the FDP standard kinetics (not shown) it is very difficult to diagnose the DCIS medial in her breast. (a) CIP shows early non mass enhancement. (b) VMS yields approximately 28-30 degrees. (c-d) Subtracted and non-subtracted DISCO 13 seconds after aorta enhancement do not clearly show lesion. MRI guided biopsy revealed a grade 1 DCIS, of micropappilar and solid type.

Figure 4 MRI screening of 45 year old female with Rb-gene mutation. The MRI FDP showed an area of enhancement lateral in the right breast. (a) The CIP image shows blue (21.3 s) indicating benign. (b) VMS images range up to 56.5 degrees, which is suspicious for malignancy. (c) The lesion is very bright on T2. (d) The standard enhancement kinetics from the FDP, based on 7 minutes of imaging, indicates a malignant tumor. The lesion has been stable for 6 years on imaging and is pathologically benign. Thus only the CIP and T2 predict the pathology accurately.

Figure 5 MR screening of a 31 year old BRCA+ women. (a) CIP is mostly green with some yellow (8.5 s to 12.8 s) indicating possible malignancy (b) The VMS has a maximum of 24.7º suggesting benign, but the area of non-mass pops out. (c-d) The lesion is difficult to pick out on high resolution T1 from the FDP even with subtraction. The standard kinetics curve from the FDP is not shown as the enhancement was too slow and low to give a color curve. An ultrasound targeted biopsy revealed an invasive carcinoma grade II.

Proc. Intl. Soc. Mag. Reson. Med. 25 (2017)
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