Publications by authors named "Doris Leithner"

49 Publications

Development and evaluation of a computer-based decision support system for diffuse lung diseases at high-resolution computed tomography.

Acta Radiol 2021 Mar 3:284185121995799. Epub 2021 Mar 3.

Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany.

Background: High-resolution computed tomography (HRCT) is essential in narrowing the possible differential diagnoses of diffuse and interstitial lung diseases.

Purpose: To investigate the value of a novel computer-based decision support system (CDSS) for facilitating diagnosis of diffuse lung diseases at HRCT.

Material And Methods: A CDSS was developed that includes about 100 different illustrations of the most common HRCT signs and patterns and describes the corresponding pathologies in detail. The logical set-up of the software facilitates a structured evaluation. By selecting one or more CT patterns, the program generates a ranked list of the most likely differential diagnoses. Three independent and blinded radiology residents initially evaluated 40 cases with different lung diseases alone; after at least 12 weeks, observers re-evaluated all cases using the CDSS.

Results: In 40 patients, a total of 113 HRCT patterns were evaluated. The percentage of correctly classified patterns was higher with CDSS (96.8%) compared to assessment without CDSS (90.3%;  < 0.01). Moreover, the percentage of correct diagnosis (81.7% vs. 64.2%) and differential diagnoses (89.2% vs. 38.3%) were superior with CDSS compared to evaluation without CDSS (both  < 0.01).

Conclusion: Addition of a CDSS using a structured approach providing explanations of typical HRCT patterns and graphical illustrations significantly improved the performance of trainees in characterizing and correctly identifying diffuse lung diseases.
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http://dx.doi.org/10.1177/0284185121995799DOI Listing
March 2021

Subsequent Marking under Ultrasound Guidance of Vacuum-Assisted Breast Biopsy Areas after Receipt of Histology: A Feasibility Study of a New Technique.

Breast Care (Basel) 2020 Dec 21;15(6):628-634. Epub 2020 Feb 21.

Department of Radiology, Municipal Clinics Frankfurt/Main-Hoechst, Frankfurt am Main, Germany.

Purpose: The aim of this study was to evaluate the feasibility and the accuracy of a secondary, metachronous ultrasound (US)-guided marking of the stereotactic vacuum-assisted breast biopsy (ST-VABB) area.

Materials And Methods: The institutional ethics committee approved the study. The retrospective study included 98 patients. In ST-VABB of 45 women, no tissue markers were deployed at the biopsy site, even if no residual calcifications remained. After histology proved the necessity for a subsequent operation, the biopsy site was marked under US guidance using a coil marker. All interventions were technically successful. No complications occurred. Mammography was done to visualize the coil deployment. The distances from the center of the lesion and the biopsy cavity to the coil location were measured in both planes to evaluate the accuracy of the marking procedure.

Results: In 24 of the 46 cases, the whole lesion was biopsied without residual elements. The mean time between ST-VABB and sonographic marking of the lesion was 9.7 days (median 6.5). The biopsy cavity could be detected in 40 (87%) cases and thus marked exactly. The mean time of US-guided marking was 12.5 min. The mean distance between the coil and the target lesion was 0.6 ± 1.5 cm in the craniocaudal (cc) view and 0.5 ± 1.5 cm in the mediolateral (ml) view for all markings. The mean delta value from the distance nipple-original lesion and from the distance nipple-coil was 0.85 ± 1.2 cm (median 0.5) in the cc view and 0.88 ± 1.2 cm (median 0.6) in the ml view for all cases. Clip migration was not observed.

Conclusion: Our study demonstrates the feasibility and the technical success of secondary metachronous coil marking of the biopsy site under US guidance after receipt of histology. This approach seems to be a cost-effective alternative to the standard procedure of the primary coil marking especially in all completely removed lesions. It may offer advantages for allergic patients.
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http://dx.doi.org/10.1159/000506069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7768143PMC
December 2020

Radiomics of high-resolution computed tomography for the differentiation between cholesteatoma and middle ear inflammation: effects of post-reconstruction methods in a dual-center study.

Eur Radiol 2020 Dec 4. Epub 2020 Dec 4.

Department of Biomedical Imaging and Image-guided Therapy, Division of General and Pediatric Radiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.

Objectives: To evaluate the performance of radiomic features extracted from high-resolution computed tomography (HRCT) for the differentiation between cholesteatoma and middle ear inflammation (MEI), and to investigate the impact of post-reconstruction harmonization and data resampling.

Methods: One hundred patients were included in this retrospective dual-center study: 48 with histology-proven cholesteatoma (center A: 23; center B: 25) and 52 with MEI (A: 27; B: 25). Radiomic features (co-occurrence and run-length matrix, absolute gradient, autoregressive model, Haar wavelet transform) were extracted from manually defined 2D-ROIs. The ten best features for lesion differentiation were selected using probability of error and average correlation coefficients. A multi-layer perceptron feed-forward artificial neural network (MLP-ANN) was used for radiomics-based classification, with histopathology serving as the reference standard (70% of cases for training, 30% for validation). The analysis was performed five times each on (a) unmodified data and on data that were (b) resampled to the same matrix size, and (c) corrected for acquisition protocol differences using ComBat harmonization.

Results: Using unmodified data, the MLP-ANN classification yielded an overall median area under the receiver operating characteristic curve (AUC) of 0.78 (0.72-0.84). Using original data from center A and resampled data from center B, an overall median AUC of 0.88 (0.82-0.99) was yielded, while using ComBat harmonized data, an overall median AUC of 0.89 (0.79-0.92) was revealed.

Conclusion: Radiomic features extracted from HRCT differentiate between cholesteatoma and MEI. When using multi-centric data obtained with differences in CT acquisition parameters, data resampling and ComBat post-reconstruction harmonization clearly improve radiomics-based lesion classification.

Key Points: • Unenhanced high-resolution CT coupled with radiomics analysis may be useful for the differentiation between cholesteatoma and middle ear inflammation. • Pooling of data extracted from inhomogeneous CT datasets does not appear meaningful without further post-processing. • When using multi-centric CT data obtained with differences in acquisition parameters, post-reconstruction harmonization and data resampling clearly improve radiomics-based soft-tissue differentiation.
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http://dx.doi.org/10.1007/s00330-020-07564-4DOI Listing
December 2020

Prevalence and prognostic impact of nonischemic late gadolinium enhancement in stress cardiac magnetic resonance.

J Cardiovasc Med (Hagerstown) 2020 Dec;21(12):980-985

Fondazione Gabriele Monasterio CNR/Regione Toscana.

Aim: To assess the prevalence and prognostic significance of NI-LGE in patients undergoing stress-CMR.

Methods: Stress-CMR with either dipyridamole or adenosine was performed in 283 patients (228 men, 81%) including perfusion imaging, wall motion evaluation and LGE. Follow-up was completed in all enrolled patients (median time: 1850 days; interquartile range: 1225-2705 days). Composite endpoint included cardiac death, ventricular tachycardia, myocardial infarction, stroke, hospitalization for cardiac cause and coronary revascularization performed beyond 90 days from stress-CMR scans.

Results: One hundred and twelve patients (40%) had negative LGE (no-LGE), 140 patients (49%) I-LGE and 31 patients (11%) NI-LGE. Twenty-five events occurred in the no-LGE group, 68 in I-LGE and 11 in the NI-LGE group. On survival curves, patients with NI-LGE had worse prognosis than patients with no-LGE regardless of the presence of inducible perfusion defects. No significant prognostic differences were found between I-LGE and NI-LGE.

Conclusion: NI-LGE can be detected in 11% of patients during stress-CMR providing a diagnosis of nonischemic cardiac disease. Patients with NI-LGE have worse prognosis than those with no-LGE.
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http://dx.doi.org/10.2459/JCM.0000000000001016DOI Listing
December 2020

Influence of contrast material density and kV setting on detectability of calcified plaques on coronary CT angiography.

Eur J Radiol 2020 Nov 11;132:109276. Epub 2020 Sep 11.

University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Frankfurt, Germany.

Purpose: To analyze the impact of tube potential and iodine concentration on the visibility of calcified plaques in coronary computed tomography angiography (cCTA).

Methods & Materials: 164 consecutive patients (65.9 % men and a mean age of 57.1 ± 11.3 years) with suspected coronary artery disease underwent calcium scoring (CaSc) scan followed by cCTA with topogram-based automated tube voltage selection (70 kV, 80 kV, 90 kV, 100 kV or 120 kV). In 127 Patients (HC), we injected 50 mL of contrast material (CM) with a concentration of 400 mg iodine per ml and in 37 patients (LC) 50 mL iodine concentration of 280 mg/mL. Sensitivity of cCTA for detecting calcified plaques was calculated with CaSc serving as gold standard. Density of CM enhanced coronary vessels and calcified plaques were quantified by region-of-interest (ROI) measurements in unenhanced and cCTA image series.

Results: Overall sensitivity of cCTA to detect calcified plaques was significantly higher using LC compared to HC (79 % vs. 73 %; p = 0.0035). The impact of LC was impressive at 70 kV with an improved sensitivity of 70 % vs. 57.1 % in HC (p = 0.0082). Furthermore, density values of HC enhanced coronary vessels exceeded those of calcified plaques, especially at low kV levels. In LC, except for the 70 kV setting, higher density values were shown for calculi than enhanced vessels.

Conclusion: Low kV cCTA in routine using highly concentrated CM leads to reduced calcified plaque perceptibility and hence potentially underestimation of stenosis. Thus, low kV cCTA using CM with lower iodine concentration is necessary. In addition, a dose reduction up to 77.7 % can also be benefited.
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http://dx.doi.org/10.1016/j.ejrad.2020.109276DOI Listing
November 2020

Can Follow-up be Avoided for Probably Benign US Masses with No Enhancement on MRI?

Eur Radiol 2021 Feb 1;31(2):975-982. Epub 2020 Sep 1.

Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, USA.

Objectives: To assess whether no enhancement on pre-treatment MRI can rule out malignancy of additional US mass(es) initially assessed as BI-RADS 3 or 4 in women with newly diagnosed breast cancer.

Methods: This retrospective study included consecutive women from 2010-2018 with newly diagnosed breast cancer; at least one additional breast mass (distinct from index cancer) assigned a BI-RADS 3 or 4 on US; and a bilateral contrast-enhanced breast MRI performed within 90 days of US. All malignant masses were pathologically proven; benign masses were pathologically proven or defined as showing at least 2 years of imaging stability. Incidence of malignant masses and NPV were calculated on a per-patient level using proportions and exact 95% CIs.

Results: In 230 patients with 309 additional masses, 140/309 (45%) masses did not enhance while 169/309 (55%) enhanced on MRI. Of the 140 masses seen in 105 women (mean age, 54 years; range 28-82) with no enhancement on MRI, all had adequate follow-up and 140/140 (100%) were benign, of which 89/140 (63.6%) were pathologically proven and 51/140 (36.4%) demonstrated at least 2 years of imaging stability. Pre-treatment MRI demonstrating no enhancement of US mass correlate(s) had an NPV of 100% (95% CI 96.7-100.0).

Conclusions: All BI-RADS 3 and 4 US masses with a non-enhancing correlate on pre-treatment MRI were benign. The incorporation of MRI, when ordered by the referring physician, may decrease unnecessary follow-up imaging and/or biopsy if the initial US BI-RADS assessment and management recommendation were to be retrospectively updated.

Key Points: • Of 309 BI-RADS 3 or 4 US masses with a corresponding mass on MRI, 140/309 (45%) demonstrated no enhancement whereas 169/309 (55%) demonstrated enhancement • All masses classified as BI-RADS 3 or 4 on US without enhancement on MRI were benign • MRI can rule out malignancy in non-enhancing US masses with an NPV of 100.
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http://dx.doi.org/10.1007/s00330-020-07216-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855658PMC
February 2021

Radiomics for Tumor Characterization in Breast Cancer Patients: A Feasibility Study Comparing Contrast-Enhanced Mammography and Magnetic Resonance Imaging.

Diagnostics (Basel) 2020 Jul 18;10(7). Epub 2020 Jul 18.

Memorial Sloan Kettering Cancer Center, Department of Radiology, Breast Imaging Service, New York, NY 10065, USA.

The aim of our intra-individual comparison study was to investigate and compare the potential of radiomics analysis of contrast-enhanced mammography (CEM) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) of the breast for the non-invasive assessment of tumor invasiveness, hormone receptor status, and tumor grade in patients with primary breast cancer. This retrospective study included 48 female patients with 49 biopsy-proven breast cancers who underwent pretreatment breast CEM and MRI. Radiomics analysis was performed by using MaZda software. Radiomics parameters were correlated with tumor histology (invasive vs. non-invasive), hormonal status (HR+ vs. HR-), and grading (low grade G1 + G2 vs. high grade G3). CEM radiomics analysis yielded classification accuracies of up to 92% for invasive vs. non-invasive breast cancers, 95.6% for HR+ vs. HR- breast cancers, and 77.8% for G1 + G2 vs. G3 invasive cancers. MRI radiomics analysis yielded classification accuracies of up to 90% for invasive vs. non-invasive breast cancers, 82.6% for HR+ vs. HR- breast cancers, and 77.8% for G1+G2 vs. G3 cancers. Preliminary results indicate a potential of both radiomics analysis of DCE-MRI and CEM for non-invasive assessment of tumor-invasiveness, hormone receptor status, and tumor grade. CEM may serve as an alternative to MRI if MRI is not available or contraindicated.
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http://dx.doi.org/10.3390/diagnostics10070492DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7400681PMC
July 2020

Non-Invasive Assessment of Breast Cancer Molecular Subtypes with Multiparametric Magnetic Resonance Imaging Radiomics.

J Clin Med 2020 Jun 14;9(6). Epub 2020 Jun 14.

Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.

We evaluated the performance of radiomics and artificial intelligence (AI) from multiparametric magnetic resonance imaging (MRI) for the assessment of breast cancer molecular subtypes. Ninety-one breast cancer patients who underwent 3T dynamic contrast-enhanced (DCE) MRI and diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) mapping were included retrospectively. Radiomic features were extracted from manually drawn regions of interest (n = 704 features per lesion) on initial DCE-MRI and ADC maps. The ten best features for subtype separation were selected using probability of error and average correlation coefficients. For pairwise comparisons with >20 patients in each group, a multi-layer perceptron feed-forward artificial neural network (MLP-ANN) was used (70% of cases for training, 30%, for validation, five times each). For all other separations, linear discriminant analysis (LDA) and leave-one-out cross-validation were applied. Histopathology served as the reference standard. MLP-ANN yielded an overall median area under the receiver-operating-characteristic curve (AUC) of 0.86 (0.77-0.92) for the separation of triple negative (TN) from other cancers. The separation of luminal A and TN cancers yielded an overall median AUC of 0.8 (0.75-0.83). Radiomics and AI from multiparametric MRI may aid in the non-invasive differentiation of TN and luminal A breast cancers from other subtypes.
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http://dx.doi.org/10.3390/jcm9061853DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7356091PMC
June 2020

Can Dual-energy CT-based Virtual Monoenergetic Imaging Improve the Assessment of Hypodense Liver Metastases in Patients With Hepatic Steatosis?

Acad Radiol 2020 May 21. Epub 2020 May 21.

University Hospital Frankfurt, Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany. Electronic address:

Rationale And Objectives: To evaluate the impact of noise-optimized virtual monoenergetic imaging (VMI) on lesion demarcation and measuring accuracy of hypoattenuating liver metastases in patients with fatty liver disease compared to standard reconstructions.

Materials And Methods: Twenty-eight patients (mean age 62.2 ± 7.7 years) with fatty liver disease and hypoattenuating liver metastases who underwent unenhanced and contrast-enhanced portal-venous dual-energy CT (DECT) were enrolled. Standard linearly blended and VMI series were reconstructed in 10-keV intervals. Lesion-to-parenchyma contrast-to-noise ratio (CNR) was calculated and the best VMI series was further investigated in a subjective evaluation of overall image quality and lesion demarcation. Size measurements were performed independently by measuring all hypodense lesions (n = 58) twice in a predefined sequence. Inter- and intra-rater agreement was assessed using intra-class correlation coefficient (ICC) statistics.

Results: The calculated CNR was greatest at 40-keV VMI (4.3 ± 2.6), significantly higher compared to standard reconstructions (2.9 ± 1.9; p < 0.001). Subjective ratings for overall image quality showed no significant difference between the 2 reconstruction techniques (both medians 4; p = 0.147), while lesion margin demarcation was found to be superior for 40-keV VMI (median 5; p ≤ 0.001). Inter- (ICC, 0.98 for 40-keV VMI; ICC, 0.93 for standard reconstruction) and intra-rater (ICC, 0.99 for 40-keV VMI; ICC, 0.94 for standard image series) analysis showed an excellent agreement for lesion measurements in both reconstruction techniques.

Conclusion: Noise-optimized VMI reconstructions significantly improve contrast and lesion demarcation of hypoattenuating liver metastases in patients with the fatty liver disease compared to standard reconstruction.
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http://dx.doi.org/10.1016/j.acra.2020.03.044DOI Listing
May 2020

In vitro testing of a funnel-shaped tip catheter model to decrease clot migration during mechanical thrombectomy.

Sci Rep 2020 01 20;10(1):633. Epub 2020 Jan 20.

University Medical Center Mainz, Department of Neuroradiology, Langenbeckstraße 1, 55131, Mainz, Germany.

One limitation of mechanical thrombectomy (MT) is clot migration during procedure. This might be caused by abruption of the trapped thrombus at the distal access catheter (DAC) tip during stent-retriever retraction due to the cylindrical shaped tip of the DAC. Aiming to solve this problem, this study evaluates the proof-of-concept of a new designed funnel-shaped tip, in an experimental in vitro setting. Two catheter models, one with a funnel-shaped tip and one with a cylindrical-shaped tip, were compared in an experimental setup. For MT a self-made vessel model and thrombi generated from pig's blood were used. MT was performed 20 times for each device using two different stent-retrievers, 10 times respectively. For the funnel-shaped model: for both stent-retrievers (Trevo XP ProVue 3/20 mm; Trevo XP ProVue 4/20 mm) MT was successful at first pass in 9/10 (90%), respectively. For the cylindrical-shaped model: MT was successful at first pass in 5/10 (50%) with the smaller stent-retriever and in 6/10 (60%) with the larger stent-retriever. The experiments show a better recanalization rate for funnel-shaped tips, than for cylindrical-shaped tips. These results are indicating a good feasibility for this new approach, thus the development of a prototype catheter seems reasonable.
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http://dx.doi.org/10.1038/s41598-019-57315-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6971034PMC
January 2020

Histogram Analysis and Visual Heterogeneity of Diffusion-Weighted Imaging with Apparent Diffusion Coefficient Mapping in the Prediction of Molecular Subtypes of Invasive Breast Cancers.

Contrast Media Mol Imaging 2019 22;2019:2972189. Epub 2019 Nov 22.

Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66 Street, New York, NY 10065, USA.

Objective: To investigate if histogram analysis and visually assessed heterogeneity of diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) mapping can predict molecular subtypes of invasive breast cancers.

Materials And Methods: In this retrospective study, 91 patients with invasive breast carcinoma who underwent preoperative magnetic resonance imaging (MRI) with DWI at our institution were included. Two radiologists delineated a 2-D region of interest (ROI) on ADC maps in consensus. Tumors were also independently classified into low and high heterogeneity based on visual assessment of DWI. First-order statistics extracted through histogram analysis within the ROI of the ADC maps (mean, 10th percentile, 50th percentile, 90th percentile, standard deviation, kurtosis, and skewness) and visually assessed heterogeneity were evaluated for associations with tumor receptor status (ER, PR, and HER2 status) as well as molecular subtype.

Results: HER2-positive lesions demonstrated significantly higher mean (=0.034), Perc50 (=0.046), and Perc90 (=0.040), with AUCs of 0.605, 0.592, and 0.652, respectively, than HER2-negative lesions. No significant differences were found in the histogram values for ER and PR statuses. Neither quantitative histogram analysis based on ADC maps nor qualitative visual heterogeneity assessment of DWI images was able to significantly differentiate between molecular subtypes, i.e., luminal A versus all other subtypes (luminal B, HER2-enriched, and triple negative) combined, luminal A and B combined versus HER2-enriched and triple negative combined, and triple negative versus all other types combined.

Conclusion: Histogram analysis and visual heterogeneity assessment cannot be used to differentiate molecular subtypes of invasive breast cancer.
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http://dx.doi.org/10.1155/2019/2972189DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6893252PMC
July 2020

Limited role of DWI with apparent diffusion coefficient mapping in breast lesions presenting as non-mass enhancement on dynamic contrast-enhanced MRI.

Breast Cancer Res 2019 12 4;21(1):136. Epub 2019 Dec 4.

Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, Suite 705, 300 E 66th Street, New York, NY, 10065, USA.

Background: Available data proving the value of DWI for breast cancer diagnosis is mainly for enhancing masses; DWI may be less sensitive and specific in non-mass enhancement (NME) lesions. The objective of this study was to assess the diagnostic accuracy of DWI using different ROI measurement approaches and ADC metrics in breast lesions presenting as NME lesions on dynamic contrast-enhanced (DCE) MRI.

Methods: In this retrospective study, 95 patients who underwent multiparametric MRI with DCE and DWI from September 2007 to July 2013 and who were diagnosed with a suspicious NME (BI-RADS 4/5) were included. Twenty-nine patients were excluded for lesion non-visibility on DWI (n = 24: 12 benign and 12 malignant) and poor DWI quality (n = 5: 1 benign and 4 malignant). Two readers independently assessed DWI and DCE-MRI findings in two separate randomized readings using different ADC metrics and ROI approaches. NME lesions were classified as either benign (> 1.3 × 10 mm/s) or malignant (≤ 1.3 × 10 mm/s). Histopathology was the standard of reference. ROC curves were plotted, and AUCs were determined. Concordance correlation coefficient (CCC) was measured.

Results: There were 39 malignant (59%) and 27 benign (41%) lesions in 66 (65 women, 1 man) patients (mean age, 51.8 years). The mean ADC value of the darkest part of the tumor (Dptu) achieved the highest diagnostic accuracy, with AUCs of up to 0.71. Inter-reader agreement was highest with Dptu ADC max (CCC 0.42) and lowest with the point tumor (Ptu) ADC min (CCC = - 0.01). Intra-reader agreement was highest with Wtu ADC mean (CCC = 0.44 for reader 1, 0.41 for reader 2), but this was not associated with the highest diagnostic accuracy.

Conclusions: Diagnostic accuracy of DWI with ADC mapping is limited in NME lesions. Thirty-one percent of lesions presenting as NME on DCE-MRI could not be evaluated with DWI, and therefore, DCE-MRI remains indispensable. Best results were achieved using Dptu 2D ROI measurement and ADC mean.
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http://dx.doi.org/10.1186/s13058-019-1208-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6894318PMC
December 2019

Improved coronary artery contrast enhancement using noise-optimised virtual monoenergetic imaging from dual-source dual-energy computed tomography.

Eur J Radiol 2020 Jan 14;122:108666. Epub 2019 Sep 14.

Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany; Section of Radiological Sciences, Department of Biomedical Sciences and Morphological and Functional Imaging, Policlinico G. Martino - University Hospital Messina, Messina, Italy.

Purpose: To define optimal kiloelectron volt (keV) settings for virtual monoenergetic imaging (VMI) reconstruction at dual-energy coronary computed tomography angiography (DE-CCTA).

Method: Fifty-one DE-CCTA data sets (33 men; mean age, 63.9 ± 13.2 years) were reconstructed as standard linearly-blended images (F_0.6; 60% of 90 kVp, 40% of 150 kVpSn), and with traditional (VMI) and noise-optimised (VMI+) algorithms from 40 to 100 keV in 10-keV intervals. Objective image quality was assessed with signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) measurements. Three observers subjectively evaluated vascular contrast, image sharpness, noise and delineation of coronary plaques.

Results: Median values for objective image analysis were highest in VMI + series at 40 keV (SNR, 44.5; CNR: 33.5), significantly superior (allp < 0.001) to the best VMI series at 70 keV (SNR, 28.1; CNR, 18.4) and standard F_0.6 images (SNR, 23.2; CNR, 15.6). Overall subjective metrics achieved higher scores at 40-keV VMI+ series in comparison to 70-keV VMI series and F_0.6 images (all p < 0.001), with optimal vascular contrast (5; ICC, 0.90), good image sharpness (4; 0.88), low noise (4; 0.82), and optimal plaque delineation (5; 0.89).

Conclusions: DE-CCTA image reconstruction with 40-keV VMI + allows for significant improvement of both objective and subjective image quality.
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http://dx.doi.org/10.1016/j.ejrad.2019.108666DOI Listing
January 2020

Radiomic signatures with contrast-enhanced magnetic resonance imaging for the assessment of breast cancer receptor status and molecular subtypes: initial results.

Breast Cancer Res 2019 09 12;21(1):106. Epub 2019 Sep 12.

Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th St, 7th Floor, New York, NY, 10065, USA.

Background: To evaluate the diagnostic performance of radiomic signatures extracted from contrast-enhanced magnetic resonance imaging (CE-MRI) for the assessment of breast cancer receptor status and molecular subtypes.

Methods: One hundred and forty-three patients with biopsy-proven breast cancer who underwent CE-MRI at 3 T were included in this IRB-approved HIPAA-compliant retrospective study. The training dataset comprised 91 patients (luminal A, n = 49; luminal B, n = 8; HER2-enriched, n = 11; triple negative, n = 23), while the validation dataset comprised 52 patients from a second institution (luminal A, n = 17; luminal B, n = 17; triple negative, n = 18). Radiomic analysis of manually segmented tumors included calculation of features derived from the first-order histogram (HIS), co-occurrence matrix (COM), run-length matrix (RLM), absolute gradient (GRA), autoregressive model (ARM), discrete Haar wavelet transform (WAV), and lesion geometry (GEO). Fisher, probability of error and average correlation (POE + ACC), and mutual information coefficients were used for feature selection. Linear discriminant analysis followed by k-nearest neighbor classification (with leave-one-out cross-validation) was used for pairwise radiomic-based separation of receptor status and molecular subtypes. Histopathology served as the standard of reference.

Results: In the training dataset, radiomic signatures yielded the following accuracies > 80%: luminal B vs. luminal A, 84.2% (mainly based on COM features); luminal B vs. triple negative, 83.9% (mainly based on GEO features); luminal B vs. all others, 89% (mainly based on COM features); and HER2-enriched vs. all others, 81.3% (mainly based on COM features). Radiomic signatures were successfully validated in the separate validation dataset for luminal A vs. luminal B (79.4%) and luminal B vs. triple negative (77.1%).

Conclusions: In this preliminary study, radiomic signatures with CE-MRI enable the assessment of breast cancer receptor status and molecular subtypes with high diagnostic accuracy. These results need to be confirmed in future larger studies.
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http://dx.doi.org/10.1186/s13058-019-1187-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6739929PMC
September 2019

Contrast-Enhanced Mammography and Radiomics Analysis for Noninvasive Breast Cancer Characterization: Initial Results.

Mol Imaging Biol 2020 06;22(3):780-787

Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, USA.

Purpose: To investigate the potential of contrast-enhanced mammography (CEM) and radiomics analysis for the noninvasive differentiation of breast cancer invasiveness, hormone receptor status, and tumor grade.

Procedures: This retrospective study included 100 patients with 103 breast cancers who underwent pretreatment CEM. Radiomics analysis was performed using MAZDA software. Lesions were manually segmented. Radiomic features were derived from first-order histogram (HIS), co-occurrence matrix (COM), run length matrix (RLM), absolute gradient, autoregressive model, the discrete Haar wavelet transform (WAV), and lesion geometry. Fisher, probability of error and average correlation (POE+ACC), and mutual information (MI) coefficients informed feature selection. Linear discriminant analysis followed by k-nearest neighbor classification (with leave-one-out cross-validation) was used for pairwise texture-based separation of tumor invasiveness and hormone receptor status using histopathology as the standard of reference.

Results: Radiomics analysis achieved the highest accuracies of 87.4 % for differentiating invasive from noninvasive cancers based on COM+HIS/MI, 78.4 % for differentiating HR positive from HR negative cancers based on COM+HIS/Fisher, 97.2 % for differentiating human epidermal growth factor receptor 2 (HER2)-positive/HR-negative from HER2-negative/HR-positive cancers based on RLM+WAV/MI, 100 % for differentiating triple-negative from triple-positive breast cancers mainly based on COM+WAV+HIS/POE+ACC, and 82.1 % for differentiating triple-negative from HR-positive cancers mainly based on WAV+HIS/Fisher. Accuracies for differentiating grade 1 vs. grades 2 and 3 cancers were 90 % for invasive cancers (based on COM/MI) and 100 % for noninvasive cancers (almost entirely based on COM/MI).

Conclusions: Radiomics analysis with CEM has potential for noninvasive differentiation of tumors with different degrees of invasiveness, hormone receptor status, and tumor grade.
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http://dx.doi.org/10.1007/s11307-019-01423-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7047570PMC
June 2020

Mammographic screening in male patients at high risk for breast cancer: is it worth it?

Breast Cancer Res Treat 2019 Oct 6;177(3):705-711. Epub 2019 Jul 6.

Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, USA.

Purpose: To investigate the utility of mammography for breast cancer screening in a population of males at increased risk for breast cancer.

Methods: In this HIPAA-compliant institutional review board-approved single-institution study, mammography records and clinical data of 827 male patients who underwent digital mammography from September 2011-July 2018 were analyzed via the electronic medical record. 664 of these men presented with masses, pain, or nipple discharge and were excluded from this study. The remaining 163 asymptomatic men with familial and/or personal history of breast cancer, or with a known germline mutation in BRCA, underwent screening mammography and were included in this analysis.

Results: 163 asymptomatic men (age: mean 63 years, range 24-87 years) underwent 806 screening mammograms. 125/163 (77%) had a personal history of breast cancer and 72/163 (44%) had a family history of breast cancer. 24/163 (15%) were known mutation carriers: 4/24 (17%) BRCA1 and 20/24 (83%) BRCA2. 792/806 (98%) of the screening mammograms were negative (BI-RADS 1 or 2); 10/806 (1.2%) were classified as BI-RADS 3, all of which were eventually downgraded to BI-RADS 2 on follow-up. 4/806 (0.4%) mammograms were abnormal (BI-RADS 4/5): all were malignant. The cancer detection rate in this cohort was 4.9 cancers/1000 examinations.

Conclusions: In our cohort, screening mammography yielded a cancer detection rate of 4.9 cancers/1000 examinations which is like the detection rate of screening mammography in a population of women at average risk, indicating that screening mammography is of value in male patients at high risk for breast cancer.
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http://dx.doi.org/10.1007/s10549-019-05338-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6745275PMC
October 2019

Multiparametric F-FDG PET/MRI of the Breast: Are There Differences in Imaging Biomarkers of Contralateral Healthy Tissue Between Patients With and Without Breast Cancer?

J Nucl Med 2020 01 28;61(1):20-25. Epub 2019 Jun 28.

Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, New York, New York

The rationale was to assess whether there are differences in multiparametric F-FDG PET/MRI biomarkers of contralateral healthy breast tissue in patients with benign and malignant breast tumors. In this institutional review board-approved prospective single-institution study, 141 women with imaging abnormalities on mammography or sonography (BI-RADS 4/5) underwent combined F-FDG PET/MRI of the breast at 3T with dynamic contrast-enhanced MRI, diffusion-weighted imaging, and the radiotracer F-FDG. In all patients, the following imaging biomarkers were recorded for the contralateral (tumor-free) breast: breast parenchymal uptake (BPU) (from F-FDG PET), mean apparent diffusion coefficient (from diffusion-weighted imaging), background parenchymal enhancement (BPE), and amount of fibroglandular tissue (FGT) (from MRI). Appropriate statistical tests were used to assess differences in F-FDG PET/MRI biomarkers between patients with benign and malignant lesions. There were 100 malignant and 41 benign lesions. BPE was minimal in 61 patients, mild in 56, moderate in 19, and marked in 5. BPE differed significantly ( < 0.001) between patients with benign and malignant lesions, with patients with cancer demonstrating decreased BPE in the contralateral tumor-free breast. FGT approached but did not reach significance ( = 0.055). BPU was 1.5 for patients with minimal BPE, 1.9 for mild BPE, 2.2 for moderate BPE, and 1.9 for marked BPE. BPU differed significantly between patients with benign lesions (mean, 1.9) and patients with malignant lesions (mean, 1.8) ( < 0.001). Mean apparent diffusion coefficient did not differ between groups ( = 0.19). Differences in multiparametric F-FDG PET/MRI biomarkers, obtained from contralateral tumor-free breast tissue, exist between patients with benign and patients with malignant breast tumors. Contralateral BPE, BPU, and FGT are decreased in breast cancer patients and may potentially serve as imaging biomarkers for the presence of malignancy.
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http://dx.doi.org/10.2967/jnumed.119.230003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6954464PMC
January 2020

Radiomic Signatures Derived from Diffusion-Weighted Imaging for the Assessment of Breast Cancer Receptor Status and Molecular Subtypes.

Mol Imaging Biol 2020 04;22(2):453-461

Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th St, 7th Floor, New York, NY, 10065, USA.

Purpose: To compare annotation segmentation approaches and to assess the value of radiomics analysis applied to diffusion-weighted imaging (DWI) for evaluation of breast cancer receptor status and molecular subtyping.

Procedures: In this IRB-approved HIPAA-compliant retrospective study, 91 patients with treatment-naïve breast malignancies proven by image-guided breast biopsy, (luminal A, n = 49; luminal B, n = 8; human epidermal growth factor receptor 2 [HER2]-enriched, n = 11; triple negative [TN], n = 23) underwent multiparametric magnetic resonance imaging (MRI) of the breast at 3 T with dynamic contrast-enhanced MRI, T2-weighted and DW imaging. Lesions were manually segmented on high b-value DW images and segmentation ROIS were propagated to apparent diffusion coefficient (ADC) maps. In addition in a subgroup (n = 79) where lesions were discernable on ADC maps alone, these were also directly segmented there. To derive radiomics signatures, the following features were extracted and analyzed: first-order histogram (HIS), co-occurrence matrix (COM), run-length matrix (RLM), absolute gradient, autoregressive model (ARM), discrete Haar wavelet transform (WAV), and lesion geometry. Fisher, probability of error and average correlation, and mutual information coefficients were used for feature selection. Linear discriminant analysis followed by k-nearest neighbor classification with leave-one-out cross-validation was applied for pairwise differentiation of receptor status and molecular subtyping. Histopathologic results were considered the gold standard.

Results: For lesion that were segmented on DWI and segmentation ROIs were propagated to ADC maps the following classification accuracies > 90% were obtained: luminal B vs. HER2-enriched, 94.7 % (based on COM features); luminal B vs. others, 92.3 % (COM, HIS); and HER2-enriched vs. others, 90.1 % (RLM, COM). For lesions that were segmented directly on ADC maps, better results were achieved yielding the following classification accuracies: luminal B vs. HER2-enriched, 100 % (COM, WAV); luminal A vs. luminal B, 91.5 % (COM, WAV); and luminal B vs. others, 91.1 % (WAV, ARM, COM).

Conclusions: Radiomic signatures from DWI with ADC mapping allows evaluation of breast cancer receptor status and molecular subtyping with high diagnostic accuracy. Better classification accuracies were obtained when breast tumor segmentations could be performed on ADC maps.
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http://dx.doi.org/10.1007/s11307-019-01383-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7062654PMC
April 2020

A multiparametric [F]FDG PET/MRI diagnostic model including imaging biomarkers of the tumor and contralateral healthy breast tissue aids breast cancer diagnosis.

Eur J Nucl Med Mol Imaging 2019 Aug 13;46(9):1878-1888. Epub 2019 Jun 13.

Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th St, 7th Floor, New York, NY, 10065, USA.

Purpose: To develop a multiparametric [F]FDG positron emission tomography/magnetic resonance imaging (PET/MRI) model for breast cancer diagnosis incorporating imaging biomarkers of breast tumors and contralateral healthy breast tissue.

Methods: In this prospective study and retrospective data analysis, 141 patients (mean 57 years) with an imaging abnormality detected on mammography and/or ultrasound (BI-RADS 4/5) underwent combined multiparametric [F]FDG PET/MRI with PET/computed tomography and multiparametric MRI of the breast at 3 T. Images were evaluated and the following were recorded: for the tumor, BI-RADS descriptors on dynamic contrast-enhanced (DCE)-MRI, mean apparent diffusion co-efficient (ADCmean) on diffusion-weighted imaging (DWI), and maximum standard uptake value (SUVmax) on [F]FDG-PET; and for the contralateral healthy breast, background parenchymal enhancement (BPE) and amount of fibroglandular tissue (FGT) on DCE-MRI, ADCmean on DWI, and SUVmax. Histopathology served as standard of reference. Uni-, bi-, and multivariate logistic regression analyses were performed to assess the relationships between malignancy and imaging features. Predictive discrimination of benign and malignant breast lesions was examined using area under the receiver operating characteristic curve (AUC).

Results: There were 100 malignant and 41 benign lesions (size: median 1.9, range 0.5-10 cm). The multivariate regression model incorporating significant univariate predictors identified tumor enhancement kinetics (P = 0.0003), tumor ADCmean (P < 0.001), and BPE of the contralateral healthy breast (P = 0.0019) as independent predictors for breast cancer diagnosis. Other biomarkers did not reach significance. Combination of the three significant biomarkers achieved an AUC value of 0.98 for breast cancer diagnosis.

Conclusion: A multiparametric [F]FDG PET/MRI diagnostic model incorporating both qualitative and quantitative parameters of the tumor and the healthy contralateral tissue aids breast cancer diagnosis.
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http://dx.doi.org/10.1007/s00259-019-04331-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6647078PMC
August 2019

MRI evaluation of axillary and intramammary lymph nodes in the postoperative period.

Breast J 2019 09 7;25(5):916-921. Epub 2019 Jun 7.

Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York.

Our study aimed to evaluate if breast-conserving surgery and adjuvant treatment could affect the morphological features of axillary and intramammary lymph nodes on magnetic resonance imaging (MRI) in patients with invasive breast cancer and clinically negative axilla. In this single-center study, we retrospectively evaluated 50 patients who had (a) breast-conserving surgery, (b) clinically negative axilla, (c) preoperative MRI within 3 months before surgery, and (d) postoperative MRI within 12 months after surgery. Axillary and intramammary lymph nodes on postoperative MRI were identified and then compared with preoperative MRI by two breast radiologists with regards to the following: enlargement, cortical thickening, presence of fatty hilum, irregularity, heterogeneity, matting, and axillary lymph node asymmetry. Three hundred and two axillary and eight intramammary lymph nodes were evaluated. Enlargement and cortical thickening were seen in 5/50 (10%) patients in three axillary and two intramammary lymph nodes. None of the lymph nodes on postoperative MRI demonstrated occurrence of lack of fatty hilum, irregularity, heterogeneity, matting or axillary lymph node asymmetry. No evidence of recurrence was observed on 2-year follow-up. Lymph node enlargement and cortical thickening may be observed in a few patients in the postoperative period. Nevertheless, in patients with clinically negative axilla, these changes in morphology are often related to treatment rather than malignancy and favor short-term follow-up as an alternative to lymph node biopsy.
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http://dx.doi.org/10.1111/tbj.13355DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6754287PMC
September 2019

Proton MR spectroscopy in the breast: Technical innovations and clinical applications.

J Magn Reson Imaging 2019 10 7;50(4):1033-1046. Epub 2019 Mar 7.

Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA.

Proton magnetic resonance spectroscopy (MRS) is a promising noninvasive diagnostic technique for investigation of breast cancer metabolism. Spectroscopic imaging data may be obtained following contrast-enhanced MRI by applying the point-resolved spectroscopy sequence (PRESS) or the stimulated echo acquisition mode (STEAM) sequence from the MR voxel encompassing the breast lesion. Total choline signal (tCho) measured in vivo using either a qualitative or quantitative approach has been used as a diagnostic test in the workup of malignant breast lesions. In addition to tCho metabolites, other relevant metabolites, including multiple lipids, can be detected and monitored. MRS has been heavily investigated as an adjunct to morphologic and dynamic MRI to improve diagnostic accuracy in breast cancer, obviating unnecessary benign biopsies. Besides its use in the staging of breast cancer, other promising applications have been recently investigated, including the assessment of treatment response and therapy monitoring. This review provides guidance on spectroscopic acquisition and quantification methods and highlights current and evolving clinical applications of proton MRS. Level of Evidence 5 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2019.
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http://dx.doi.org/10.1002/jmri.26700DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6732054PMC
October 2019

Diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) mapping as a quantitative imaging biomarker for prediction of immunohistochemical receptor status, proliferation rate, and molecular subtypes of breast cancer.

J Magn Reson Imaging 2019 09 27;50(3):836-846. Epub 2019 Feb 27.

Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA.

Background: Diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) mapping is one of the most useful additional MRI parameters to improve diagnostic accuracy and is now often used in a multiparameric imaging setting for breast tumor detection and characterization.

Purpose: To evaluate whether different ADC metrics can also be used for prediction of receptor status, proliferation rate, and molecular subtype in invasive breast cancer.

Study Type: Retrospective.

Subjects: In all, 107 patients with invasive breast cancer met the inclusion criteria (mean age 57 years, range 32-87) and underwent multiparametric breast MRI.

Field Strength/sequence: 3 T, readout-segmented echo planar imaging (rsEPI) with IR fat suppression, dynamic contrast-enhanced (DCE) T -weighted imaging, T -weighted turbo-spin echo (TSE) with fatsat.

Assessment: Two readers independently drew a region of interest on ADC maps on the whole tumor (WTu), and on its darkest part (DpTu). Minimum, mean, and maximum ADC values of both WTu and DpTu were compared for receptor status, proliferation rate, and molecular subtypes.

Statistical Tests: Wilcoxon rank sum, Mann-Whitney U-tests for associations between radiologic features and histopathology; histogram and q-q plots, Shapiro-Wilk's test to assess normality, concordance correlation coefficient for precision and accuracy; receiver operating characteristics curve analysis.

Results: Estrogen receptor (ER) and progesterone receptor (PR) status had significantly different ADC values for both readers. Maximum WTu (P = 0.0004 and 0.0005) and mean WTu (P = 0.0101 and 0.0136) were significantly lower for ER-positive tumors, while PR-positive tumors had significantly lower maximum WTu values (P = 0.0089 and 0.0047). Maximum WTu ADC was the only metric that was significantly different for molecular subtypes for both readers (P = 0.0100 and 0.0132) and enabled differentiation of luminal tumors from nonluminal (P = 0.0068 and 0.0069) with an area under the curve of 0.685 for both readers.

Data Conclusion: Maximum WTu ADC values may be used to differentiate luminal from other molecular subtypes of breast cancer.

Level Of Evidence: 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:836-846.
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http://dx.doi.org/10.1002/jmri.26697DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6767396PMC
September 2019

Comparison of Radiation Dose and Image Quality of Contrast-Enhanced Dual-Source CT of the Chest: Single-Versus Dual-Energy and Second-Versus Third-Generation Technology.

AJR Am J Roentgenol 2019 04 30;212(4):741-747. Epub 2019 Jan 30.

1 Department of Diagnostic and Interventional Radiology, Division of Experimental and Imaging, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany.

Objective: The purpose of this study was to compare radiation dose and image quality of single- and dual-energy CT (SECT, DECT) examinations of the chest in matched cohorts for second and third-generation dual-source CT (DSCT) systems.

Materials And Methods: We analyzed 200 patients (100 men; mean age, 61.7 ± 14.8 years old; 100 women, mean age, 59.4 ± 15.1 years old), matched by sex and body mass index, who had undergone clinically indicated contrast-enhanced chest CT. Four study groups, each consisting of 50 patients, were evaluated. Contrast-enhanced chest CT was performed using vendor-preset second-generation DSCT (group A, 120-kV SECT; group C, 80/Sn140-kV DECT) or third-generation DSCT (group B, 90-kV SECT; group D, 90/Sn150-kV DECT) protocols. Radiation dose assessment was normalized to a scan range of 27.5 cm. Image quality was objectively analyzed using dose-independent figure-of-merit (FOM) contrast-to-noise ratio (CNR) calculations and subjectively evaluated by three independent radiologists.

Results: Direct comparison of effective radiation dose for second-generation DSCT groups A and C showed statistically significant lower radiation dose values for DECT compared with SECT acquisition (3.2 ± 1.2 mSv vs 2.3 ± 0.6 mSv, p ≤ 0.004), but differences between third-generation SECT and DECT were not significant (1.2 ± 0.9 mSv vs 1.3 ± 0.6 mSv, p = 0.412). FOM CNR analysis revealed highest values for third-generation DECT (p ≤ 0.043). Differences in subjective image quality between the four groups were not statistically significant (p ≥ 0.179).

Conclusion: Contrast-enhanced DECT examinations of the chest can be performed routinely with second- and third-generation DSCT systems without either increased radiation exposure or decreased image quality compared with SECT acquisition.
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http://dx.doi.org/10.2214/AJR.18.20065DOI Listing
April 2019

Quantitative in vivo proton MR spectroscopic assessment of lipid metabolism: Value for breast cancer diagnosis and prognosis.

J Magn Reson Imaging 2019 07 3;50(1):239-249. Epub 2019 Jan 3.

Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA.

Background: Breast magnetic resonance spectroscopy ( H-MRS) has been largely based on choline metabolites; however, other relevant metabolites can be detected and monitored.

Purpose: To investigate whether lipid metabolite concentrations detected with H-MRS can be used for the noninvasive differentiation of benign and malignant breast tumors, differentiation among molecular breast cancer subtypes, and prediction of long-term survival outcomes.

Study Type: Retrospective.

Subjects: In all, 168 women, aged ≥18 years.

Field Strength/sequence: Dynamic contrast-enhanced MRI at 1.5 T: sagittal 3D spoiled gradient recalled sequence with fat saturation, flip angle = 10°, repetition time / echo time (TR/TE) = 7.4/4.2 msec, slice thickness = 3.0 mm, field of view (FOV) = 20 cm, and matrix size = 256 × 192. H-MRS: PRESS with TR/TE = 2000/135 msec, water suppression, and 128 scan averages, in addition to 16 reference scans without water suppression.

Assessment: MRS quantitative analysis of lipid resonances using the LCModel was performed. Histopathology was the reference standard.

Statistical Tests: Categorical data were described using absolute numbers and percentages. For metric data, means (plus 95% confidence interval [CI]) and standard deviations as well as median, minimum, and maximum were calculated. Due to skewed data, the latter were more adequate; unpaired Mann-Whitney U-tests were performed to compare groups without and with Bonferroni correction. ROC analyses were also performed.

Results: There were 111 malignant and 57 benign lesions. Mean voxel size was 4.4 ± 4.6 cm . Six lipid metabolite peaks were quantified: L09, L13 + L16, L21 + L23, L28, L41 + L43, and L52 + L53. Malignant lesions showed lower L09, L21 + L23, and L52 + L53 than benign lesions (P = 0.022, 0.027, and 0.0006). Similar results were observed for Luminal A or Luminal A/B vs. other molecular subtypes. At follow-up, patients were split into two groups based on median values for the six peaks; recurrence-free survival was significantly different between groups for L09, L21 + L23, and L28 (P = 0.0173, 0.0024, and 0.0045).

Data Conclusion: Quantitative in vivo H-MRS assessment of lipid metabolism may provide an additional noninvasive imaging biomarker to guide therapeutic decisions in breast cancer.

Level Of Evidence: 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:239-249.
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http://dx.doi.org/10.1002/jmri.26622DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6579700PMC
July 2019

Gadolinium-enhanced imaging of pediatric thoracic lymphoma: is intravenous contrast really necessary?

Eur Radiol 2019 May 13;29(5):2553-2559. Epub 2018 Dec 13.

Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.

Objectives: Increasing awareness of potential side effects from gadolinium-based contrast agents has underlined the need for contrast-free magnetic resonance imaging (MRI). Numerous recent articles evaluated the risk of potential brain deposits, with the result that research is putting the focus more on alternative unenhanced imaging techniques. The aim of this study was to determine the need for contrast media for chest MRI in primary staging and follow-up care of lymphoma.

Methods: This monocentric, retrospective study encompassed patients under 25 years of age who had undergone histopathological examination of thoracic lymph nodes and at least one chest MRI examination with unenhanced and contrast-enhanced sequences. Seven different thoracic lymph node stations including mediastinal, hilar, periclavicular, and axillary regions were evaluated by two readers regarding lesion diameter, number, shape, necrosis, and infiltration of surrounding structures. Findings were categorized into suspicious (> 1 cm; round; necrosis; infiltration) or non-suspicious.

Results: Fifty-one patients (mean age, 16.0 ± 3.7 yrs) with thoracic Hodgkin (70.6%) and non-Hodgkin lymphoma (25.5%) and lymphadenopathy (3.9%) were retrospectively included. Most lymph nodes categorized as suspicious were located in the mediastinal station (86.4%). High agreement (κ = 0.81) between unenhanced and contrast-enhanced sequences was found for both suspicious and non-suspicious lymph nodes. Significant (p < 0.001), but small difference (1 mm) was observed only in sizing mediastinal lymph nodes (all other p > 0.05). No significant difference (smallest p = 0.08) was shown for the use of five different types of contrast media.

Conclusion: MRI in young patients with thoracic lymphoma can safely be done without the use of contrast agent.

Key Point: • Thoracic magnetic resonance imaging in young lymphoma patients can safely be done without gadolinium-based contrast agents.
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http://dx.doi.org/10.1007/s00330-018-5859-3DOI Listing
May 2019

Intraductal Papilloma Without Atypia on Image- Guided Breast Biopsy: Upgrade Rates to Carcinoma at Surgical Excision.

Breast Care (Basel) 2018 Oct 13;13(5):364-368. Epub 2018 Jul 13.

Institute of Radiology (RZI), Klinikum Frankfurt Höchst, Academic Teaching Hospital of the University of Frankfurt, Frankfurt/M., Germany.

Background: The management of intraductal papilloma without atypia (IDP) in breast needle biopsy remains controversial. This study investigates the upgrade rate of IDP to carcinoma and clinical and radiologic features predictive of an upgrade.

Methods: Patients with a diagnosis of IDP on image-guided (mammography, ultrasound, magnetic resonance imaging) core needle or vacuum-assisted biopsy and surgical excision of this lesion at a certified breast center between 2007 and 2017 were included in this institutional review board-approved retrospective study. Appropriate statistical tests were performed to assess clinical and radiologic characteristics associated with an upgrade to malignancy at excision.

Results: For 60 women with 62 surgically removed IDPs, the upgrade rate to malignancy was 16.1% (10 upgrades, 4 invasive ductal carcinoma, 6 ductal carcinoma in situ). IDPs with upgrade to carcinoma showed a significantly greater distance to the nipple (63.5 vs. 36.8 mm; p = 0.012). No significant associations were found between upgrade to carcinoma and age, menopausal status, lesion size, microcalcifications, BI-RADS descriptors, initial BI-RADS category, and biopsy modality.

Conclusion: The upgrade rate at excision for IDPs diagnosed with needle biopsy was higher than expected according to some guideline recommendations. Observation only might not be appropriate for all patients with IDP, particularly for those with peripheral IDP.
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http://dx.doi.org/10.1159/000489096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6257098PMC
October 2018

Multi-observer comparison study between unenhanced quiescent-interval single-shot magnetic resonance angiography and invasive carbon dioxide angiography in patients with peripheral arterial disease and chronic renal insufficiency.

Eur J Radiol 2018 Nov 28;108:140-146. Epub 2018 Sep 28.

Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany.

Objectives: Non-contrast-enhanced quiescent-interval single-shot magnetic resonance angiography (QISS-MRA) and invasive carbon dioxide (CO2) angiography are suggested as nephroprotective methods for accurate staging of peripheral arterial disease (PAD) in patients with chronic renal insufficiency (CRI). The aim of our study was to compare the image quality of both examinations.

Methods: 16 consecutive PAD patients with highly impaired renal function (estimated glomerular filtration rate (eGFR) < 30 ml/min/1.73 m²) who underwent 3 T MRA with QISS and catheter angiography with CO2 within 90 days were retrospectively included. Subjective image quality was determined using a five-point Likert scale (1, non-diagnostic; 5, excellent) and presence of significant (≥50%) stenoses of pelvic and lower extremity arteries (21-segment-model) was evaluated per-region and per-segment, respectively, in random order by four independent readers with different levels of experience. CO2 angiography of an experienced interventional radiologist was considered the standard reference method.

Results: 167 segments were available for direct comparison with a prevalence of ≥50% stenoses of 28.1%. QISS-MRA yield was: sensitivity 91.5%, specificity 94.2%, positive predictive value 86.0% and negative predictive value 96.6%, with an intraclass correlation coeffcient (ICC) of 0.88. Median values of qualitative imaging parameters for QISS-MRA were as follows: arterial signal intensity: 4 (pelvis), 5 (thigh), 5 (calf); venous overlay: 4, 5, 5; susceptibility artifacts: 5, 5, 5; motion artifacts: 4, 5, 5; ECG-related artifacts: 5, 5, 5. ICC-values for image quality were 0.74, 0.73, 0.93, 0.69 and 0.79, respectively. Arterial opacification at CO2 angiography was rated 3, 4, 3, with an ICC of 0.63.

Conclusions: Image quality of non-invasive unenhanced MR angiography with QISS was preferred over invasive CO2 angiography, whilst taking into account that it offers high diagnostic performance for the detection and ruling out of PAD.
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http://dx.doi.org/10.1016/j.ejrad.2018.09.029DOI Listing
November 2018

Multiparametric MRI model with dynamic contrast-enhanced and diffusion-weighted imaging enables breast cancer diagnosis with high accuracy.

J Magn Reson Imaging 2019 03 30;49(3):864-874. Epub 2018 Oct 30.

Memorial Sloan Kettering Cancer Center, Department of Radiology, Breast Imaging Service, NY, New York, USA.

Background: The MRI Breast Imaging-Reporting and Data System (BI-RADS) lexicon recommends that a breast MRI protocol contain T -weighted and dynamic contrast-enhanced (DCE) MRI sequences. The addition of diffusion-weighted imaging (DWI) significantly improves diagnostic accuracy. This study aims to clarify which descriptors from DCE-MRI, DWI, and T -weighted imaging are most strongly associated with a breast cancer diagnosis.

Purpose/hypothesis: To develop a multiparametric MRI (mpMRI) model for breast cancer diagnosis incorporating American College of Radiology (ACR) BI-RADS recommended descriptors for breast MRI with DCE, T -weighted imaging, and DWI with apparent diffusion coefficient (ADC) mapping.

Study Type: Retrospective.

Subjects: In all, 188 patients (mean 51.6 years) with 210 breast tumors (136 malignant and 74 benign) who underwent mpMRI from December 2010 to September 2014.

Field Strength/sequence: IR inversion recovert DCE-MRI dynamic contrast-enhanced magnetic resonance imaging VIBE Volume-Interpolated-Breathhold-Examination FLASH turbo fast-low-angle-shot TWIST Time-resolved angiography with stochastic Trajectories.

Assessment: Two radiologists in consensus and another radiologist independently evaluated the mpMRI data. Characteristics for mass (n = 182) and nonmass (n = 28) lesions were recorded on DCE and T -weighted imaging according to BI-RADS, as well as DWI descriptors. Two separate models were analyzed, using DCE-MRI BI-RADS descriptors, T -weighted imagines, and ADCmean as either a continuous or binary form using a previously published ADC cutoff value of ≤1.25 × 10 mm /sec for differentiation between benign and malignant lesions. Histopathology was the standard of reference.

Statistical Tests: χ test, Fisher's exact test, Kruskal-Wallis test, Pearson correlation coefficient, multivariate logistic regression analysis, Hosmer-Lemeshow test of goodness-of-fit, receiver operating characteristics analysis.

Results: In Model 1, ADCmean (P = 0.0031), mass margins with DCE (P = 0.0016), and delayed enhancement with DCE (P = 0.0016) were significantly and independently associated with breast cancer diagnosis; Model 2 identified ADCmean (P = 0.0031), mass margins with DCE (P = 0.0012), initial enhancement (P = 0.0422), and delayed enhancement with DCE (P = 0.0065) to be significantly independently associated with breast cancer diagnosis. T -weighted imaging variables were not included in the final models. DATA CONCLUSION: mpMRI with DCE-MRI and DWI with ADC mapping enables accurate breast cancer diagnosis. A model using quantitative and qualitative descriptors from DCE-MRI and DWI identifies breast cancer with a high diagnostic accuracy. T -weighted imaging does not significantly contribute to breast cancer diagnosis.

Level Of Evidence: 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:864-874.
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http://dx.doi.org/10.1002/jmri.26285DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6375760PMC
March 2019

Abbreviated MRI of the Breast: Does It Provide Value?

J Magn Reson Imaging 2019 06 8;49(7):e85-e100. Epub 2018 Sep 8.

Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA.

MRI of the breast is the most sensitive test for breast cancer detection and outperforms conventional imaging with mammography, digital breast tomosynthesis, or ultrasound. However, the long scan time and relatively high costs limit its widespread use. Hence, it is currently only routinely implemented in the screening of women at an increased risk of breast cancer. To overcome these limitations, abbreviated dynamic contrast-enhanced (DCE)-MRI protocols have been introduced that substantially shorten image acquisition and interpretation time while maintaining a high diagnostic accuracy. Efforts to develop abbreviated MRI protocols reflect the increasing scrutiny of the disproportionate contribution of radiology to the rising overall healthcare expenditures. Healthcare policy makers are now focusing on curbing the use of advanced imaging examinations such as MRI while continuing to promote the quality and appropriateness of imaging. An important cornerstone of value-based healthcare defines value as the patient's outcome over costs. Therefore, the concept of a fast, abbreviated MRI exam is very appealing, given its high diagnostic accuracy coupled with the possibility of a marked reduction in the cost of an MRI examination. Given recent concerns about gadolinium-based contrast agents, unenhanced MRI techniques such as diffusion-weighted imaging (DWI) are also being investigated for breast cancer diagnosis. Although further larger prospective studies, standardized imaging protocol, and reproducibility studies are necessary, initial results with abbreviated MRI protocols suggest that it seems feasible to offer screening breast DCE-MRI to a broader population. This article aims to give an overview of abbreviated and fast breast MRI protocols, their utility for breast cancer detection, and their emerging role in the new value-based healthcare paradigm that has replaced the fee-for-service model. Level of Evidence: 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:e85-e100.
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http://dx.doi.org/10.1002/jmri.26291DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6408315PMC
June 2019

Dual-energy CT in patients with colorectal cancer: Improved assessment of hypoattenuating liver metastases using noise-optimized virtual monoenergetic imaging.

Eur J Radiol 2018 Sep 31;106:184-191. Epub 2018 Jul 31.

Division of Experimental and Translational Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany. Electronic address:

Purpose: To assess the value of the noise-optimized virtual monoenergetic imaging (VMI+) technique on quantitative and qualitative image parameters in patients with hypoattenuating liver metastases from colorectal cancer (CRC) at abdominal dual-energy CT (DECT).

Materials And Methods: Fifty-three consecutive patients (mean age, 70.3 ± 11.4 years; range, 44-86 years) with histologically proven, hypoattenuating liver metastases from CRC were retrospectively included in this IRB-approved study. DECT datasets were reconstructed as standard linearly-blended M_0.6 image series, traditional virtual monoenergetic images (VMI), and noise-optimized VMI+ series. VMI and VMI+ reconstructions were obtained at energy levels ranging from 40 to 100-keV with 10-keV increments. Signal attenuation of liver parenchyma and liver metastases was measured to calculate signal-to-noise (SNR) and contrast-to-noise (CNR) ratios. Each image series was subjectively rated by three blinded radiologists with regard to image quality, lesion delineation, and image noise using a five-point Likert scale.

Results: Quantitative image quality parameters peaked at 40-keV VMI+ (SNR, 8.1 ± 3.4; CNR, 6.5 ± 2.6) with statistically significant differences in comparison with standard reconstructions and all traditional VMI series (P ≤  0.001). Qualitative image analysis revealed best rating scores for 60-keV VMI+ series (median, 5) with significant differences compared to linearly-blended M_0.6 and all traditional VMI series (P ≤  0.001). Lesion delineation showed significantly superior ratings for 40-keV VMI+ series compared to all other reconstructions (median, 5) (P ≤  0.001).

Conclusion: Low-keV VMI+ reconstructions demonstrate significantly increased quantitative and qualitative image quality parameters in patients with hypoattenuating liver metastases from CRC in comparison with standard reconstructions and traditional VMI series at abdominal DECT. Best lesion delineation can be achieved at 40-keV VMI+.
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http://dx.doi.org/10.1016/j.ejrad.2018.07.027DOI Listing
September 2018