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Contrast Enhancement in Breast Cancer and Background Mammary-Gland Tissue During the Super-Early Phase of Dynamic Breast Magnetic Resonance Imaging

Posted Oct 31, 2017 Updated Apr 10, 2023
By Tetsuya Tomida , Atsushi Urikura PhD , Takayoshi Uematsu MD PhD , Kensei Shirata , Yoshihiro Nakaya
10 min read

Rationale and Objectives

We aimed to compare the contrast enhancement between tumor and mammary-gland tissue to distinguish lesions in the super-early phase, during which minimal contrast media uptake is observed in mammary-gland tissue.

Materials and Methods

Dynamic magnetic resonance imaging, including the super-early phase with bolus tracking (BT) method (to determine the optimal imaging start time), was performed by using identical parameters to obtain transverse fat-suppressed T1-weighted images of both breasts. The percent enhancement (PE) and the contrast ratio (CR) indicators for tumor and mammary-gland tissue were assessed in each dynamic phase.

Results

The PE values of the tumor were 62.4% and 151.6%, and those of the mammary gland were 0.3% and 20.7% in the super-early and early phases, respectively. Therefore, virtually no background parenchymal enhancement was observed in the super-early phase. The variation in the PE values during the super-early phase was significantly smaller when the values were determined with the BT method ( P < .05). The CR was highest in the early phase, and the CR in the super-early phase was lower than in the other phases. Early-phase PE and CR were significantly higher in invasive cancer cases than in noninvasive cancer cases ( P < .01). A significant difference in the imaging start time was observed for the anatomic side factor by the BT method.

Conclusion

Background parenchymal enhancement almost never appeared in the super-early phase, but the CR was lower in the super-early phase than in the early phase. The BT method allowed for an optimal imaging start time for the super-early phase and yielded images with less deviation of contrast enhancement.

Introduction

The increase in breast cancer-related morbidity has led to the widespread use of mammography, ultrasonography, and diagnostic imaging modalities in screenings and clinical examinations. Magnetic resonance imaging (MRI) is particularly considered useful for breast cancer examination. The American Cancer Society guidelines recommend MRI screening for patients with a lifetime breast cancer risk of >20% . High-field MRI facilitates higher resolution and faster imaging. When combined with the use of contrast media (CM), MRI can be used to detect breast cancer and examine its spread as well . The use of CM in MRI for breast cancer diagnosis is considered essential by many guidelines . In particular, dynamic MRI is recommended to differentiate benign from malignant tumors. For breast cancer, images are obtained at the early phase, wherein contrast enhancement peaks approximately 60–120 seconds after CM injection, and at the delay phase to confirm CM washout .

The menstrual cycle and other factors impact contrast enhancement in normal mammary-gland tissue . However, the number of contrast-enhanced breast MRI sessions that can be conducted daily is limited in some institutions; hence, it may not be possible to schedule examinations based on the menstrual cycle. In such cases, during conventional dynamic MRI, the CM is also taken up by mammary-gland tissue, sometimes even outside the menstrual cycle, which decreases the contrast with tumor tissue because of background parenchymal enhancement (BPE). Uematsu et al. reported that BPE negatively affects the detection, diagnosis, and staging of breast cancer . BPE is expected to be lower in the super-early phase because normal mammary-gland tissue becomes enhanced more slowly than tumors do . Based on this expectation, super-early-phase images would yield data that could assist in both the detection and diagnosis of breast cancer. Therefore, previous studies have attempted to improve the diagnostic capability of dynamic images by adding imaging during the super-early phase to the standard protocol .

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Materials and Methods

Subjects

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Imaging Sequences

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Table 1

Acquisition Parameters of Fat-Suppressed GRE 3D T1-Weighted Images for Dynamic Breast MRI

Parameters Values Field of view (mm) 330 × 330 Matrix size 400 × 320 TR/TE (ms) 3.42/1.79 Flip angle (degree) 10 Echo train length 33 NEX 1 Slice thickness/gap (mm) 1.8/−0.9 Phase encoding order Centric order Acceleration factor; R–L/H–F 2/1 Half scan factor; R–L/H–F 0.675/0.8 Shimming SmartExam Breast (Philips Healthcare, Amsterdam, The Netherlands) Time per phase (s) 62

GRE, gradient echo; H–F, head-foot; MRI, magnetic resonance imaging; NEX, number of excitations; R–L, right-left; TE, echo time; TR, repetition time.

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Contrast Imaging Protocol

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Figure 1, The schema shows the process of dynamic imaging with the BT method in the present study. Before injecting contrast media, precontrast images were acquired as reference. According to the BT method, the trigger for starting the super-early phase was when the contrast media reached the aortic arch. The early phase, which followed the super-early phase, was started 1–2 minutes after the injection. The scanning of the diseased breast in the sagittal plane was followed by the delay phase at approximately 5 minutes after the injection. BT, bolus tracking.

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Comparisons of Contrast Values and Images

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Comparison of Contrast by Pathologic Type

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Analysis of the Imaging Start Time for the Super-Early Phase with the BT Method

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Statistical Analysis

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Results

PE

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Table 2

Background Characteristics of the Examined Patients in This Study

Characteristics Scanning Method Bolus Tracking Fixed-Time_P_ -Value Number of patients 62 50 Number of tumors 69 55 Mean age, years (SD) 55.3 (12.3) 55.3 (11.1) 0.991 Mean weight, kg (SD) 53.8 (8.1) 53.5 (9.0) 0.984

SD, standard deviation.

Figure 2, PE for tumor and mammary-gland tissue with the BT and fixed-time methods. For the tumor tissue, the PE showed the maximum value on the time-signal intensity curve during the early phase with both methods, whereas the “washout” was observed only during the delay phase. All the PEs of the mammary-gland tissue were considerably lower than those of the tumor tissue. Although the PE gradually increased, only minimal enhancement of the mammary-gland tissue was observed during the super-early phase. All error bars show 95% confidence interval. BT, bolus tracking; PE, percent enhancement.

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Table 3

Mean and Standard Deviation Values of PE During the Dynamic Phases, Obtained With the Bolus-Tracking and Fixed-Time Methods

Dynamic Phase Scanning Method_P_ -Value Bolus Tracking Fixed-Time Super-early Mean 62.4 72.8 0.189 SD 37.1 47.8 0.049 Early Mean 151.6 158.2 0.426 SD 48.6 43.1 0.366 Delay Mean 141.4 153.0 0.095 SD 38.9 37.5 0.775

SD, standard deviation.

The P -value for the mean and SD were calculated by Welch t test and F test, respectively.

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CR

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Comparison of Contrast Enhancement by Pathologic Type

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Table 4

Categorization of PE and CR According to Pathologic Type in the Different Dynamic Phases

Dynamic Phase Pathologic Type Number of Tumors PE CR Mean_t_ Test Mean_t_ Test Super-early IDC 54 67.7P = .054 0.29P = .064 DCIS 10 42.8 0.20 Early IDC 54 161.9P = .00018 0.41P = .0011 DCIS 10 101.0 0.30 Delay IDC 54 146.9P = .0047 0.33P = .34 DCIS 10 110.2 0.30

CR, contrast ratio; DCIS, ductal carcinoma in situ; IDC, invasive ductal carcinoma; PE, percent enhancement.

Figure 3, The time-intensity curves of the PE for invasive and noninvasive cancer. The PE tended to be higher in invasive cancer cases during all the phases. All error bars show 95% confidence interval. PE, percent enhancement.

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Differences in the Imaging Start Time for the Super-Early Phase by the BT Method

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Discussion

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Figure 4, A 10-mm invasive ductal carcinoma in a 46-year-old woman. ( a ) A bilateral fat-suppressed dynamic breast MR image obtained during the super-early phase shows very good contrast between the tumor tissue (arrow) and normal mammary-gland tissue. ( b ) A bilateral fat-suppressed dynamic breast MR image obtained during the early phase shows good contrast between the tumor tissue (arrow) and normal mammary-gland tissue. However, moderate BPE appears at the early phase. ( c ) A bilateral fat-suppressed dynamic breast MR image obtained during the delay phase shows poor contrast between the tumor tissue (arrow) and normal mammary-gland tissue. The lesion was obscured by marked BPE. BPE, background parenchymal enhancement; MR, magnetic resonance.

Figure 5, A 15-mm noninvasive ductal carcinoma in a 51-year-old woman. ( a ) A bilateral fat-suppressed dynamic breast MR image obtained during the super-early phase shows good contrast between the tumor tissue (arrow) and normal mammary-gland tissue. ( b ) A bilateral fat-suppressed dynamic breast MR image obtained during the early phase shows poor contrast between the tumor tissue (arrow) and normal mammary-gland tissue because moderate BPE makes ill-defined margins between the two types of tissue. ( c ) A bilateral fat-suppressed dynamic breast MR image obtained during the delay phase shows poor contrast between the tumor tissue (arrow) and normal mammary-gland tissue. The lesion was completely obscured by marked BPE. BPE, background parenchymal enhancement; MR, magnetic resonance.

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Conclusions

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Academic Radiology, Volume 24, Issue 11
Journals General Radiology
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