The aim of this work is to review the techniques and clinical applications of diffusion-weighted magnetic resonance (MR) imaging of the breast. Diffusion-weighted MR imaging plays a role in the differentiation breast cancer from benign lesions, the characterization of malignancy, and the detection of tumor extension. The apparent diffusion coefficient of breast cancer is correlated with tumor cellularity and some prognostic factors of breast cancer. It can be used for the differentiation of recurrent tumors from posttreatment changes and monitoring of patients after chemotherapy. Diffusion-weighted MR imaging is used for the characterization of breast mass, diagnosis, and the grading and staging of breast cancer, as well as prediction of the responses of patients with breast cancer to chemotherapy.
Diffusion-weighted magnetic resonance (MR) imaging detects Brownian motion of water protons, thus reflecting the biologic character of tissue. The apparent diffusion coefficient (ADC) is used to quantify the Brownian motion. Diffusion-weighted MR imaging detects early changes in the morphology and physiology of tissues associated with changes in water content, such as changes in the permeability of cell membranes, cell swelling, and/or cell lysis. Areas of diseased tissue are highlighted with increased signal intensity on diffusion-weighted MR imaging. A decrease in the ADC is expected with increased intracellular tissue caused by either cell swelling or increased cellular density . Diffusion-weighted imaging has a potential role for the characterization of breast mass and treatment monitoring after chemotherapy .
The aim of this work is to review the techniques and clinical applications of diffusion-weighted MR imaging of the breast.
Techniques
Diffusion-Weighted Technique
No consensus exists among different research groups regarding the best diffusion-weighted technique for the breast. Most groups perform diffusion-weighted imaging on the basis of an echo-planar imaging (EPI) approach. Other groups apply turbo spin-echo techniques. Although EPI is fast and has a high signal-to-noise ratio, it is distorted by susceptibility and chemical shift artifacts as well as breathing and other motion artifacts. Geometric distortion arises from susceptibility differences between tissues or at air-tissue interfaces. Parallel imaging such as sensitivity encoding reduces the number of phase encoding steps and the time required to fill the k-space, which leads to decreased susceptibility and chemical shift artifacts . The typical parameters of single-shot EPI are as follows: repetition time, 700 ms; echo time, 75 ms; thickness gap, 5 mm; number of signals acquired, 6; slice number, 25; b value, 500, and 1000 mm 2 /s; scan time, 2 minutes; field of view, 320 mm; matrix size, 256 × 128; and voxel size, 1.25 × 1.25 × 5 mm. Turbo spin-echo techniques, such as the half-Fourier acquisition single-shot turbo spin-echo sequence, can also be used to acquire diffusion-weighted data, with the inherent advantage of using spin echoes rather than gradient echoes. There are no chemical shift or susceptibility artifacts, but the ability to detect tumors is limited .
Fat Suppression Technique
One limitation of diffusion-weighted imaging of the breast is the high content of fatty tissue in the breast, which makes a fat saturation technique essential to identifying breast mass on breast diffusion-weighted MR imaging. The two main fat suppression techniques used are the short time inversion recovery and chemical shift selective suppression (CHESS) methods. The short time inversion recovery method applies 180° prepulse and provides steady fat suppression, but its signal-to-noise ratio is lower than that of CHESS. The CHESS method does not always provide uniform fat suppression, but its signal-to-noise ratio is higher. In the CHESS method, shimming during imaging is applied to control the nonuniform fat suppression effect . Diffusion-weighted MR imaging of the breast with both sequences has a high potential to differentiate between benign and malignant breast lesions. Because of significant better lesion delineation, better selectivity, and shorter acquisition time the diffusion-weighted EPI CHESS sequence is superior .
b Value
The optimum b value applied should sufficiently suppress the background signal of the mammary gland and provide adequate cancer signal without perfusion effect. ADCs with b values < 400 mm 2 /s are affected not only by the molecular diffusion of water but also by the microcirculation of blood in the capillary network. Because invasive ductal cancer has an increased number and size of capillaries, the ADC of invasive ductal cancer can be strongly affected by perfusion when the b value is small. The background and cancer signals are separated considerably when the b value is 750 mm 2 /s. As the b value increases up to 1000 mm 2 /s, the background signal decreases to near noise levels, whereas the cancer signal remains at a significant level. In severe mastopathy, the background mammary gland signal may not be suppressed sufficiently. The spread of cancers that develop mainly through breast ducts is not as restricted as that of invasive cancers. Therefore, if the b value is set too high, cancers may be detected in a reduced form .
MR Imaging at 3 T
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Effect of Contrast Medium
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Normal appearance
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Clinical applications
Differentiation of Breast Cancer From Benign Lesions
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Characterization of Malignancy
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Ductal Carcinoma
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Mucinous Carcinoma
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Other Pathologic Types
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Peritumoral Spread
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Correlation of the ADC with Tumor Cellularity
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Correlation of the ADC with Prognostic Parameters
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Benign Breast Lesions
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Monitoring of Treatment Response
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Screening
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Advantages
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Disadvantages
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Conclusion
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