Is the ?blooming sign? a promising additional tool to determine malignancy in MR mammography?

Imaging of Benign and Malignant Breast Lesions Using Contrast-Enhanced Ultrasound: A Pictorial Essay

ABSTRACT

Contrast-enhanced ultrasound is a promising noninvasive imaging technique for evaluating benign and malignant breast lesions, as contrast provides information about perfusion and microvasculature. Contrast-enhanced ultrasound is currently off-label use in the breast in the United States, but its clinical and investigational use in breast imaging is gaining popularity. It is important for radiologists to be familiar with the imaging appearances of benign and malignant breast masses using contrast-enhanced ultrasound. This pictorial essay illustrates enhancement patterns of various breast masses from our own experience. Pathologies include subtypes of invasive breast cancer, fibroadenomas, papillary lesions, fibrocystic change, and inflammatory processes. Contrast-enhanced ultrasound pitfalls and limitations are discussed.

Comparative Study of Qualitative and Quantitative Analyses of Contrast-Enhanced Ultrasound and the Diagnostic Value of B-Mode and Color Doppler for Common Benign Tumors in the Parotid Gland

Purpose

To preliminarily identify three common benign parotid gland tumors: pleomorphic adenomas (PA), Warthin tumors (WT), and basal cell adenomas (BCA) by qualitative and quantitative analyses using contrast-enhanced ultrasound (CEUS).

Methods

Preoperative images of parotid gland masses were analyzed, including 129 cases of ultrasonography (US) and color Doppler sonography (CDS) and 110 cases of qualitative and quantitative CEUS. The diagnosis was confirmed by postsurgical pathology outcomes.

Results

PA presented low and heterogeneous enhancement and echo-free area, whereas most WT and BCA presented with high and relatively homogeneous enhancement. Compared with WT and BCA groups, a “slow in” pattern was more common in the PA group and a “slow out” pattern was more frequently noted in the WT group than in the PA and BCA groups. The unique features of qualitative CEUS in the PA group enable distinguishing PA from the 2 other groups. The further distinction among the groups was made based on quantitative parameters of time-intensity curves (TICs), which revealed that the mean peak intensity (PI), mean transit time (MTT), the area under the curve (AUC), and time from peak to one half (HT) exhibited significant differences. ROC analysis was next applied to determine the optimal cutoff points to predict the diagnostic tendency among the groups. When the rising slope (RS) was >2.145, the possibility of BCA was greater than WT.

Conclusions

CEUS ultrasound is of significant value in the differential diagnosis of the 3 common benign parotid gland masses.

Contrast-Enhanced Ultrasonography in the Diagnosis and Treatment Modulation of Breast Cancer

The aim of this paper is to highlight the role of contrast-enhanced ultrasound in breast cancer in terms of diagnosis, staging and follow-up of the post-treatment response. Contrast-enhanced ultrasound (CEUS) is successfully used to diagnose multiple pathologies and has also clinical relevance in breast cancer. CEUS has high accuracy in differentiating benign from malignant lesions by analyzing the enhancement characteristics and calculating the time-intensity curve’s quantitative parameters. It also has a significant role in axillary staging, especially when the lymph nodes are not suspicious on clinical examination and have a normal appearance on gray-scale ultrasound. The most significant clinical impact consists of predicting the response to neoadjuvant chemotherapy, which offers the possibility of adjusting the therapy by dynamically evaluating the patient. CEUS is a high-performance, feasible, non-irradiating, accessible, easy-to-implement imaging method and has proven to be a valuable addition to breast ultrasound.

Multimodal Ultrasound Imaging in Breast Imaging-Reporting and Data System 4 Breast Lesions: A Prediction Model for Malignancy

The purpose of this study was to develop, validate and test a prediction model for discriminating malignant from benign breast lesions using conventional ultrasound (US), US elastography of strain elastography and contrast-enhanced ultrasound (CEUS). The study included 454 patients with breast imaging-reporting and data system (BI-RADS) category 4 breast lesions identified on histologic examinations. Firstly, 228 breast lesions (cohort 1) were analyzed by logistic regression analysis to identify the risk factors, and a breast malignancy prediction model was created. Secondly, the prediction model was validated in cohort 2 (84 patients) and tested in cohort 3 (142 patients) by using analysis of the area under the receiver operating characteristic curve (AUC). Univariate regression indicated that age ≥40 y, taller than wide shape on US, early hyperenhancement on CEUS and enlargement of enhancement area on CEUS were independent risk factors for breast malignancy (all p < 0.05). The logistic regression equation was established as follows: p = 1/1+Exp∑[-5.066 + 3.125 x (if age ≥40 y) + 1.943 x (if taller than wide shape) + 1.479 x (if early hyperenhancement) + 4.167 x (if enlargement of enhancement area). The prediction model showed good discrimination performance with an AUC of 0.967 in cohort 1, 0.948 in cohort 2 and 0.920 in cohort 3. By using the prediction model to selectively downgrade category 4a lesions, the re-rated BI-RADS yield an AUC of 0.880 (95% confidence interval [CI], 0.794-0.965) in cohort 2 and 0.870 (95% CI, 0.801-0.939) in cohort 3. The specificity increased from 0.0% (0/35) to 80.0% (28/35) without loss of sensitivity (from 100.0% to 95.9%, p = 0.153) in cohort 2. Similarly, the specificity increased from 0.0% (0/58) to 77.6% (45/58) without loss of sensitivity (from 100.0% to 96.4%, p = 0.081) in cohort 3. Multimodal US showed good diagnostic performance in predicting breast malignancy of BI-RADS category 4 lesions. Although the loss of sensitivity was existing, the addition of multimodal US to US BI-RADS could improve the specificity in BI-RADS category 4 lesions, which reduced unnecessary biopsies.

Influence of different post-contrast time points on dynamic contrast-enhanced (DCE) MRI T staging in breast cancer

PURPOSE

to assess whether MRI T stage of breast cancer lesions (BCLs) is affected by maximum diameter (MD) measured at different post-contrast time points (TPs) on different acquisition planes on dynamic contrast-enhanced (DCE) MRI sequence.

METHODS

53 DCE-MRI examinations of patients with BCLs were retrospectively selected. MD of BCLs was measured on axial, coronal and sagittal planes on DCE images at five different post-contrast TPs. Friedman test followed by Bonferroni-adjusted Wilcoxon-signed rank test for post-hoc analysis was performed to evaluate differences among the five measurements. Reliability of the measurements was evaluated with the intraclass correlation coefficient analysis. Differences between pathological and MRI T stage assessed at each TP on each acquisition plane were assessed using the Wilcoxon-sign rank test; p values <0.05 were considered statistically significant.

RESULTS

on axial, coronal and sagittal planes, MD measured at TP1 was significantly different (p < 0.0001) compared to those obtained at the subsequent TPs. No significant differences were found between MD measured at TPs 3, 4 and 5. Intra and inter-observer reliability resulted as very good, with ICC ranging between 0.915-0.992 and 0.845-0.911, respectively. MRI T stage assessed at TP1 on axial and sagittal plane as well as at all TPs on coronal plane was significantly different from pathological T stage.

CONCLUSION

MRI T stage definition of BCLs is significantly affected by the TP used for lesions' MD measurement. TPs 3, 4 and 5 are the preferred TPs for the assessment of MRI T stage of BCLs on both axial and sagittal planes.

Correlation Between Contrast-enhanced Ultrasound Characteristics (Qualitative and Quantitative) and Pathological Prognostic Factors in Breast Cancer

BACKGROUND/AIM

Little is known about the correlation between contrast-enhanced ultrasound (CEUS) characteristics and pathological prognostic factors in breast cancer. The aim of this study was to explore the correlation between CEUS characteristics and pathological prognostic factors.

PATIENTS AND METHODS

A retrospective study with 34 malignant breast lesions was conducted. CEUS characteristics included qualitative characteristics (e.g. lesion's enhancement degree and order, internal lesion homogeneity etc.) and quantitative characteristics (e.g. peak intensity, time to peak etc.). Also, pathological prognostic factors were included (e.g. tumor grade, estrogen receptor status etc.).

RESULTS

Blurred lesion margins were observed more often in tumors of high histological grade (p=0.01) and in estrogen receptor-negative tumors (p=0.049). Furthermore, perilesional enhancement was associated with positive Ki-67 expression (p=0.049), while heterogeneous internal sentinel lymph node enhancement was associated with malignant infiltration of the node (p=0.002).

CONCLUSION

CEUS has the potential to provide a prevision of pathological prognostic factors in malignant breast lesions, helping in the better early patient management.

Fast bilateral breast coverage with high spectral and spatial resolution (HiSS) MRI at 3T

PURPOSE

To develop and assess a full-coverage, sensitivity encoding (SENSE)-accelerated breast high spatial and spectral resolution (HiSS) magnetic resonance imaging (MRI) within clinically reasonable times as a potential nonenhanced MRI protocol for breast density measurement or breast cancer screening.

MATERIALS AND METHODS

Sixteen women with biopsy-proven cancer or suspicious lesions, and 13 women who were healthy volunteers or were screened for breast cancer, received 3T breast MRI exams, including SENSE-accelerated HiSS MRI, which was implemented as a submillimeter spatial resolution echo-planar spectroscopic imaging (EPSI) sequence. In postprocessing, fat and water resonance peak height and integral images were generated from EPSI data. The postprocessing software was custom-designed, and new algorithms were developed to enable processing of whole-coverage axial HiSS datasets. Water peak height HiSS images were compared to pre- and postcontrast T₁ -weighted images. Fat suppression was quantified as parenchymal-to-suppressed-fat signal ratio in HiSS water peak height and nonenhanced T₁ -weighted images, and artifact levels were scored.

RESULTS

Approximately a 4-fold decrease in acquisition speed, with a concurrent 2.5-fold decrease in voxel size, was achieved, with low artifact levels, and with spectral signal-to-noise ratio (SNR) of 45:1. Fat suppression was 1.9 times more effective (P < 0.001) in HiSS images than in T₁ -weighted images (SPAIR), and HiSS images showed higher SNR in the axilla. HiSS MRI visualized 10 of 13 malignant lesions identified on dynamic contrast-enhanced (DCE)-MRI, and did not require skin removal in postprocessing to generate maximum intensity projection images.

CONCLUSION

We demonstrate full-coverage, SENSE-accelerated breast HiSS MRI within clinically reasonable times, as a potential protocol for breast density measurement or breast cancer screening.

LEVEL OF EVIDENCE

2 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2017;46:1341-1348.

The value of "constant sharpness" as a diagnostic sign in MR-Mammography

Purpose

To examine “constant lesion sharpness” as a morphological diagnostic sign in the differential diagnosis between benign and malignant lesions.

Material and methods

This prospective study had institutional review board approval and was HIPAA compliant. In total 1014 consecutive patients were examined (mean age 55 years ± 13 years) and evaluated in our University hospital towards the morphological shape of the lesion borders. The “Constant sharpness Sign” was defined as a lesion remaining continuously sharp for the duration of the dynamic scan. Inclusion criteria were unclear findings (e.g. BIRADS III/IV), Preoperative staging (BRIDAS IV/V), and referred patients from local clinic of gynecology. Exclusion criteria were MRM-examination ≤1 year before, status after surgery and/or biopsy, chemotherapy and/or radiation therapy. Reference Standard was histological verification. Images were diagnosed by two experienced radiologists in consensus, blinded to the standard of reference.

Results

1014 patients with 1084 lesions (436 benign, 648 malignant lesions) were included into the study.

41.5% of benign lesions and 6.8% (181/436) of malignant lesions displayed a constant sharpness as an accompanying morphological sign (P < 0.001). This resulted in a sensitivity of 41.5%, specificity of 93.2%, a positive likelihood ratio of 6.1%, a negative likelihood ratio of 0.63 and an odd’s ratio of 9,7%.

Summary and conclusion

The constant sharpness sign seems to be an accurate predictor of benign breast lesions, which may help to increase the accuracy of MRM as a morphological sign.

Reliability of MRI in measuring the response to neoadjuvant chemotherapy in breast cancer patients and its therapeutic implications

Aim: Neoadjuvant chemotherapy (NAC) has recently been applied in treatment of operable breast cancers to enable breast conservation. We aimed to evaluate the accuracy of MRI in delineating residual tumor and pathological complete response (pCR). Patients & methods: 69 cases treated with NAC were monitored using breast MRI, findings were recorded and compared with histopathology. Results: MRI showed radiological complete response in 19 (27.5%), which correlated with pCR in 12 (63%) cases. However, five (7.3%) patients who achieved pCR were missed. Overall, the sensitivity was 70.6%, specificity 86.5%, positive predictive value 63.2% and negative predictive value of 90.0%. Conclusion: MRI showed promising results for evaluating response to NAC and predicting pCR, results need validation in larger trial.

Qualitative, quantitative and combination score systems in differential diagnosis of breast lesions by contrast-enhanced ultrasound

OBJECTIVE

To assess the feasibility of score systems in differential diagnosis of breast lesions by contrast-enhanced ultrasound (CEUS).

METHODS

CEUS was performed in 121 patients with 127 breast lesions by Philips iU22 with Sonovue as contrast agent. Pearson Chi-square χ(2) test, binary logistic regression analysis and Student's t-test are used to identify significant CEUS parameters in differential diagnosis. Based on these significant CEUS parameters, qualitative, quantitative and combination score systems were built by scoring 1 for benign characteristic and scoring 2 for malignant characteristic. Receiver operating characteristic (ROC) curve was applied to evaluate the diagnostic efficacy of different analytical methods.

RESULTS

Pathological results showed 41 benign and 86 malignant lesions. Qualitative analysis and logistic regression analysis showed that there are significant differences in enhancement degree, enhancement order, internal homogeneity, enhancement margin, surrounding vessels and enlargement of diameters (P<0.05) between benign and malignant lesions. Quantitative analysis indicated that malignant lesions tended to show higher peak intensity (PI), larger area under the curve (AUC) and shorter time to peak (TTP) than benign ones (P<0.05). Qualitative score systems showed higher diagnostic efficacy than single quantitative CEUS parameters. The corresponding area under the ROC curve for qualitative, quantitative and combination score systems were 0.897, 0.716 and 0.903 respectively. Z test showed that area under the ROC curve of quantitative score system was statistically smaller than that of other score systems.

CONCLUSIONS

Quantitative score system helps little in improving the diagnostic efficacy of CEUS. While qualitative score system improves the performance of CEUS greatly in discrimination of benign and malignant breast lesions. The application of qualitative could develop the diagnostic performance of CEUS which is clinically promising.

Is "prepectoral edema" a morphologic sign for malignant breast tumors?

RATIONALE AND OBJECTIVES

A variety of morphologic and kinetic signs of benign or malignant breast lesions contribute to a final diagnosis and differential diagnosis in magnetic resonance (MR) mammography (MRM). As a new sign, prepectoral edema (PE) in patients without any history of previous biopsy, operation, radiation, or chemotherapy was detected during routine breast MR examinations. The purpose of this study was to retrospectively evaluate the role of this morphologic sign in the differential diagnosis of breast lesions.

MATERIALS AND METHODS

Between January 2005 and October 2006, a total of 1109 consecutive MRM examinations have been performed in our institution. In this study, only patients who would later be biopsied or operated in our own hospital were included. They had no previous operation, biopsy, intervention, chemotherapy, hormone replacement therapy, or previous mastitis. In total, 162 patients with 180 lesions were included, histologically correlated later-on by open biopsy (124 patients and 136 lesions) or core biopsy (38 patients and 44 lesions). The evaluations were performed by four experienced radiologists in consensus.

RESULTS

One hundred eighty evaluated lesions included 104 malignant lesions (93 invasive and 11 noninvasive cancers) and 76 benign lesions. PE was detected in 2.6% of benign lesions (2 of 76), in none of the Ductal cacinoma in situ (DCIS) cases (0 of 11), and in 25.8% of malignant lesions (24 of 93; P < .000). PE was found significantly more frequently in presence of malignant tumors >2 cm in diameter (48.5%, 17 of 35 vs. 13.8%, 8 of 58; P < .001). PE was not statistically associated to malignant tumor type, presence or absence of additional DCIS, and number of lesions. This resulted in the following diagnostic parameters for PE as an indicator for malignancy: sensitivity of 19.3%, specificity of 97.3%, positive predictive value (PPV) of 92.3%, negative predictive value of 48%, and accuracy of 57.7%.

CONCLUSIONS

In case of occurrence, the "PE sign" seems to be a specific indicator for malignant tumors with a high PPV, independent from its entity.

3D lacunarity in multifractal analysis of breast tumor lesions in dynamic contrast-enhanced magnetic resonance imaging

Dynamic contrast-enhanced magnetic resonance (DCE-MR) of the breast is especially robust for the diagnosis of cancer in high-risk women due to its high sensitivity. Its specificity may be, however, compromised since several benign masses take up contrast agent as malignant lesions do. In this paper, we propose a novel method of 3D multifractal analysis to characterize the spatial complexity (spatial arrangement of texture) of breast tumors at multiple scales. Self-similar properties are extracted from the estimation of the multifractal scaling exponent for each clinical case, using lacunarity as the multifractal measure. These properties include several descriptors of the multifractal spectra reflecting the morphology and internal spatial structure of the enhanced lesions relatively to normal tissue. The results suggest that the combined multifractal characteristics can be effective to distinguish benign and malignant findings, judged by the performance of the support vector machine classification method evaluated by receiver operating characteristics with an area under the curve of 0.96. In addition, this paper confirms the presence of multifractality in DCE-MR volumes of the breast, whereby multiple degrees of self-similarity prevail at multiple scales. The proposed feature extraction and classification method have the potential to complement the interpretation of the radiologists and supply a computer-aided diagnosis system.

Quantitative diagnosis of salivary gland tumors with contrast-enhanced ultrasound--a preliminary study

OBJECTIVE

To quantitatively analyze the value of qualitative diagnosis of salivary gland masses with contrast-enhanced ultrasound (CEUS).

STUDY DESIGN

The enhanced sonographic features of 68 salivary gland masses were analyzed to differentiate them. The final diagnoses were confirmed by biopsy pathology.

RESULTS

We observed from the perfusion kinetics of CEUS that most pleomorphic adenomas manifested lower enhancement and well-defined margins; most Warthin tumors presented with higher enhancement and well-defined margins; and most malignant tumors had higher enhancement and poorly defined margins. Their time-intensity curves showed pleomorphic adenomas were hypovascularized with a poor perfusion, whereas Warthin tumors and malignant tumors were hypervascularized with a rich perfusion. Additionally, malignant tumors showed significantly shortened time to peak and richer maximum signal intensity compared with Warthin tumors.

CONCLUSIONS

The features of salivary gland masses identified with CEUS were helpful in the differential diagnosis of salivary gland masses.

How to measure breast cancer tumoral size at MR imaging?

OBJECTIVE

To compare the accuracy of different MR sequences to measure tumor size.

METHODS

Eighty-six women (mean age: 53 years (30-78)) who underwent preoperative MRI for breast cancer were included. Maximal diameters of the index tumor (IT) and of the whole extent of the tumor (WET) were measured on T2-weighted (T2W) sequences, on dynamic contrast-enhanced (DCE) T1-weighted (T1W) sequences and on Maximal Intensity Projection (MIP) reconstructions. Agreements with pathological size were evaluated using concordance correlation coefficient (k).

RESULTS

Median pathological size of IT was 20mm (13-25 mm, interquartile range). Median pathological size of the WET was 29 mm (16-50mm, interquartile range). Measurement of IT showed a good concordance with pathological size, with best results using T2W (k = 0.690) compared to MIP (k = 0.667), early-subtracted DCE frame (k = 0.630) and early-native DCE frame (k = 0.588). IT was visible on T2W in 83.7% and accurately measured within 5mm in 69.9%. Measurement of WET was superior using early-subtracted DCE frame (k = 0.642) compared to late-native frame (k = 0.635), early-native frame (k = 0.631), late-subtracted frame (k = 0.620) and MIP (k = 0.565). However, even using early-subtracted frame, WET was accurately measured within 5mm only 39.3%.

CONCLUSION

If visible, IT size is best measured on T2W with a good accuracy (69%) whereas WET is best estimated on early-subtracted DCE frame. However, when adjacent additional sites exist around IT, suspected surrounding disease components need to be proved by pathological analysis.

Potential application value of contrast-enhanced ultrasound in neoadjuvant chemotherapy of breast cancer

The purpose of this study was to investigate the value of contrast-enhanced ultrasound (CEUS) in evaluating the response of breast cancer to neoadjuvant chemotherapy (NAC). The study included 31 breast cancer patients who were treated with NAC between August 2010 and October 2011. All patients were evaluated by both conventional ultrasound (US) and CEUS. The tumor sizes measured by CEUS were larger and more accurately imaged than those evaluated by US. Necrosis at the tumor center could be detected by CEUS, which showed a local blood perfusion defect in 26 cases (83.9%) before NAC and 27 cases (87.1%) after NAC, whereas US did not show liquefaction in any patient. The CEUS time-intensity curve displayed quantitatively the tumors' blood-perfusion changes; after NAC, blood perfusion reduced, enhancement intensity decreased, time to peak increased, peak intensity reduced, and the wash-in slope reduced (p < 0.05). Overall, the CEUS is a promising tool for evaluating the response of breast cancer to NAC.

The necrosis sign in magnetic resonance-mammography: diagnostic accuracy in 1,084 histologically verified breast lesions

Necrosis sign (NS) is a new descriptor for differential diagnosis of breast lesions in magnetic resonance (MR)-mammography (MRM). This study was designed: (a) to analyze diagnostic accuracy of NS in 1,084 histologically verified breast lesions, (b) to assess performance of NS in subgroups. This study was approved by the local ethical committee. All histologically verified lesions having undergone MR-mammography at our institution over 12 years were evaluated by experienced radiologists (> 500 MRM) according to standard protocols and study design (T1w; 0.1 mmol/kg bw gadolinium diethylenetriamine penta-acetic acid; T2-turbo spin echo (TSE)). Patients with history of breast biopsy (surgically, minimal-invasive), radiation- or chemotherapy ≤ 1 year before MRM were excluded. NS was assessed on T2w-TSE sequences and was rated positive if a hyperintense center in a hypointense lesion could be visualized (chi-squared test). One thousand and eighty-four lesions were available for statistical analysis (648: malignant, 436: benign). NS was significantly associated with malignancy (p < 0.001), providing specificity and positive predictive value (PPV) of 96.1% and 78.8%. Malignant lesions > 20 mm presented significantly more often NS (p < 0.001) than neoplasias ≤ 20 mm. There was no difference regarding prevalence of NS in small versus advanced benign lesions (n.s.), leading to better performance of NS in lesions > 20 mm (PPV: 87.8%). Correlation between NS and Grading of invasive carcinomas was significant. In this study of 1,084 lesions necrosis sign was a specific and highly predictive feature for differential diagnosis in MRM (Specificity: 96.1%; PPV: 78.8%). This particularly counts for advanced lesions (PPV 87.8%). As this new descriptor correlates with Grading, it could be used as an initial estimate of patient's prognosis.

Functional magnetic resonance: biomarkers of response in breast cancer

Functional magnetic resonance (MR) encompasses a spectrum of techniques that depict physiological and molecular processes before morphological changes are visible on conventional imaging. As understanding of the pathophysiological and biomolecular processes involved in breast malignancies evolves, newer functional MR techniques can be employed that define early predictive and surrogate biomarkers for monitoring response to chemotherapy. Neoadjuvant chemotherapy is increasingly used in women with primary breast malignancies to down-stage the tumour and enable successful breast conservation surgery. It also plays a role in the treatment of undetected micrometastases. Cardinal physiological features of tumours that occur as a result of interactions between cancer cells, stromal cells and secreted factors and cytokines and how they change with treatment provide the opportunity to detect changes in the tumour microenvironment prior to any morphological change. Through sequential imaging, tumour response can be assessed and non-responders can be identified early to enable alternative therapies to be considered. This review summarises the functional magnetic resonance biomarkers of response in patients with breast cancer that are currently available and under development. We describe the current state of each biomarker and explore their potential clinical uses and limitations in assessing treatment response. With the aid of selected interesting cases, biomarkers related to dynamic contrast-enhanced MRI, diffusion-weighted MRI, T2*/BOLD and MR spectroscopy are described and illustrated. The potential of newer approaches, such as MR elastography, are also reviewed.

Accuracy of magnetic resonance in suspicious breast lesions: a systematic quantitative review and meta-analysis

Dynamic contrast-enhanced breast magnetic resonance (MR) is a promising emerging technique for evaluating breast lesions. A quantitative systematic review was performed to estimate the accuracy of breast MR in the diagnosis of high-risk breast lesions and breast cancer. A comprehensive search of the Cochrane Library, MEDLINE, CANCERLIT, LILACS, and EMBASE databases was performed from January 1985 to August 2010. The medical subjects heading (MeSH) and text words for the terms "breast neoplasm", "breast lesions", "breast cancer" and "magnetic resonance" were combined with the MeSH term diagnosis ("sensitivity and specificity"). Studies that compared breast MR with paraffin-embedded sections parameters for the diagnosis of breast lesions (benign, high-risk borderline, and breast cancer) were included. Sixty-nine studies were analyzed, which included 9,298 women with 9,884 breast lesions. Interrater overall agreement between breast MR and paraffin section diagnosis was 79% (κ = 0.55), indicating moderate agreement. Pooled sensitivity and specificity were 90% [95% CI 88-92%] and 75% [95% CI 70-79%], respectively. The pooled likelihood positive ratio was 3.64 (95% CI 3.0-4.2) and the negative ratio was 0.12 (95% CI 0.09-0.15). For breast cancer or high-risk lesions versus benign lesions, the AUC was 0.91 for breast MR and the point Q* was 0.84. In summary, breast MR is a useful pre-operative test for predicting the diagnosis of breast lesions.

Magnetic resonance mammography of invasive lobular versus ductal carcinoma: systematic comparison of 811 patients reveals high diagnostic accuracy irrespective of typing

OBJECTIVE

Invasive lobular (ILC) and ductal carcinomas (IDC) are the most frequent subtypes of breast cancer. Diagnosis of ILC is often challenging. This study was conducted to (1) evaluate dynamic and morphologic profiles and to (2) compare the diagnostic accuracy of IDC and ILC in magnetic resonance mammography (MRM).

METHODS

Our database consisted of all consecutive MRMs over a 12-year period (standardized protocol: T1-weighted fast low-angle shot; 0.1-mmol gadolinium-diethylenetriaminepentaacetate per kilogram of body weight; T2-weighted turbo spin-echo, 1.5 T; histological verification after MRM), which were evaluated by experienced (>500 MRMs) radiologists in consensus, applying 17 predefined descriptors. All the patients gave written consent; this study was approved by the local institutional review board. Extracting all the ILCs (n = 108), IDCs (n = 347), and benign lesions (n = 436) from the database, the data set of the study was created.In ILC and IDC diagnostic accuracy of single descriptors was calculated and compared separately (chi test). Using all the descriptors, a combined binary logistic regression analysis was applied to calculate the overall diagnostic accuracy for ILC and IDC. The corresponding areas under the curve were compared.

RESULTS

ILC and IDC, showed wash-in and an irregular shape without difference (P = 1.0 and P = 0.4). Wash-out was more typical of IDC (72.6%; ILC, 57.4%; P = 0.007). Perifocal edema was diagnosed more frequently in IDC (45.5%; P = 0.05). For overall accuracy, the areas under the curve were 0.929 for ILC and 0.939 for IDC (P = 0.5).

CONCLUSIONS

The dynamic and morphologic profiles of ILC and IDC were overlapping, and minor differences between both subgroups could be identified. Accordingly, the overall diagnostic accuracy of MRM was high and without difference between both subtypes of breast cancer.

Differential diagnosis of breast lesions 5 mm or less: is there a role for magnetic resonance imaging?

OBJECTIVES

According to magnetic resonance (MR) imaging Breast Imaging Reporting and Data System, foci are small enhanced lesions 5 mm or less in diameter. This study was conducted to (a) assess morphological and dynamic profiles in malignant versus benign foci in breast MR imaging (MRM) and to (b) identify overall diagnostic accuracy of MRM for differential diagnosis of foci.

METHODS

This study was approved by the local institutional review board; all patients gave written consent. All MRM (T1w-FLASH; 0.1 mmol/kg body weight gadolinium-diethylenetriamine penta-acetic acid; T2w-TSE; consecutive 12-year period; with histological verification after MRM were evaluated by 2 experienced (>500 MRM) radiologists in consensus using 16 predefined descriptors and were included into a database. A data set was created by extracting all lesions 5 mm or less (benign, 27; malignant, 61). Accuracy of individual descriptors was assessed (Crosstabs, chi2-test; positive/negative likelihood ratios (LR+/-); diagnostic odds ratio [DOR]). Binary logistic regression analysis was applied to identify overall diagnostic accuracy using all descriptors combined (area under the receiver operating characteristic curve,).

RESULTS

Washout was typically associated with malignancy (P < 0.05; DOR, 3.5). Irregular shape was feasible for differential diagnosis of foci (DOR, 7.3), yet majority of malignancies demonstrated a round shape (55.6%). Additional descriptors such as blooming (DOR, 4.0, LR+, 2.8), adjacent vessel (DOR, 4.8; LR+, 4.5), and root sign (DOR, 5.6; LR+, 4.1) showed a high accuracy. Overall accuracy for differentiation of benign versus malignant foci showed an area under the curve of 0.887 (P = 0.0001).

CONCLUSIONS

Assessment of dynamic and morphological profiles in foci 5 mm or less was feasible. Using all descriptors combined, a high potential for differential diagnosis of foci in magnetic resonance-mammography could be identified.

Clinical MR-mammography: are computer-assisted methods superior to visual or manual measurements for curve type analysis? A systematic approach

RATIONALE AND OBJECTIVES

Enhancement characteristics after administration of a contrast agent are regarded as a major criterion for differential diagnosis in magnetic resonance mammography (MRM). However, no consensus exists about the best measurement method to assess contrast enhancement kinetics. This systematic investigation was performed to compare visual estimation with manual region of interest (ROI) and computer-aided diagnosis (CAD) analysis for time curve measurements in MRM.

MATERIALS AND METHODS

A total of 329 patients undergoing surgery after MRM (1.5 T) were analyzed prospectively. Dynamic data were measured using visual estimation, including ROI as well as CAD methods, and classified depending on initial signal increase and delayed enhancement.

RESULTS

Pathology revealed 469 lesions (279 malignant, 190 benign). Kappa agreement between the methods ranged from 0.78 to 0.81. Diagnostic accuracies of 74.4% (visual), 75.7% (ROI), and 76.6% (CAD) were found without statistical significant differences.

CONCLUSIONS

According to our results, curve type measurements are useful as a diagnostic criterion in breast lesions irrespective of the method used.

Effect of the enhancement threshold on the computer-aided detection of breast cancer using MRI

RATIONALE AND OBJECTIVES

To evaluate the effect that variations in the enhancement threshold have on the diagnostic accuracy of two computer-aided detection (CAD) systems for magnetic resonance based breast cancer screening.

MATERIALS AND METHODS

Informed consent was obtained from all patients participating in cancer screening and this study was approved by the participating institution's review board. This retrospective study was nested in a prospective, single-institution, high-risk, breast screening study involving dynamic contrast-enhanced magnetic resonance imaging. Only those screening examinations (n = 223) for which a histopathological diagnosis was available were included. Two CAD methods were performed: the signal enhancement ratio (SER) and support vector machines (SVMs). Statistical analysis was performed by tracking changes in each CAD test's diagnostic accuracy (eg, receiver-operating characteristic [ROC] curve area, maximum possible sensitivity) with changes in the enhancement threshold.

RESULTS

The enhancement threshold plays a significant role in affecting a CAD test's potential sensitivity, ROC curve area, and number of assumed true and false-positive predictions per cancerous examination. A high threshold can also limit the CAD-based detection of the full size of a lesion.

CONCLUSIONS

Enhancement thresholds can limit a CAD test's ability to diagnose a lesion's full size and as such should not be raised above 60%. The clinically used SER method exhibits a high rate of false positives at low enhancement thresholds and as such the threshold should not be set lower than 50%. The SVM method yielded better results in our study than the SER method at clinically realistic enhancement thresholds.

Clinical implementation of a multislice high spectral and spatial resolution-based MRI sequence to achieve unilateral full-breast coverage

High-resolution, single-slice, high spatial and spectral resolution (HiSS) breast magnetic resonance imaging (MRI) provides improved lesion conspicuity, margin definition and internal definition, as compared to conventional clinical MRI - and thus may provide better lesion characterization and increase breast MRI specificity. Volumetric HiSS imaging is highly desirable, but was considered to be time-prohibitive. Specifically, the concern was that faster acquisition times -- necessitating a lower spectral resolution -- could compromise established advantages of HiSS imaging. In this pilot study, we demonstrate for the first time a fast, clinically practical, HiSS-based sequence that achieves full unilateral breast coverage, while preserving essential qualities of full-spectral resolution HiSS imaging. We imaged five patients of varying breast sizes at 1.5 T, with HiSS acquisitions performed after the standard clinical protocol, and lasting an average of 8.5 min. Maximum intensity projection (MIP) images of HiSS data were constructed and compared to MIPs of conventional clinical images. Single-slice images through three lesions were also compared. HiSS images achieved better fat suppression than the clinical fat-saturated sequence (fat signal SNR was reduced by 50% in HiSS images) as well as increased conspicuity, as assessed qualitatively by an experienced radiologist. Thus, we show that volumetric HiSS imaging can conserve the advantages of single-slice HiSS imaging and that further technical development of volumetric HiSS is desirable.

Evaluation of breast lesions with contrast-enhanced ultrasound using the microvascular imaging technique: initial observations

The objective of this study was to evaluate the usefulness of contrast-enhanced ultrasound using the microvascular imaging technique in the diagnosis of breast lesions. In 104 patients with 104 breast lesions scheduled for surgery, conventional and contrast-enhanced ultrasound using the microvascular imaging technique were performed after administration of SonoVue. The enhancement patterns of breast lesions were classified as no enhancement, peripheral enhancement, homogeneous enhancement, regional enhancement, or heterogeneous enhancement based on the morphologic features of enhancement. The diagnostic value of contrast-enhanced ultrasound using the microvascular imaging technique was analyzed with the observers blinded to the clinical data and pathology (which served as the gold standard). None of the enhancement patterns was suggestive of benignity, with a sensitivity of 18.3%, specificity of 97.7%, positive predictive value (PPV) of 91.7%, negative predictive value (NPV) of 46.2%, and accuracy of 51.5%. The peripheral enhancement pattern was suggestive of malignancy, with a sensitivity of 39.5%, specificity of 98.3%, PPV of 94.4%, NPV of 69.4%, and accuracy of 73.8%. Homogeneous, regional, and heterogeneous enhancement patterns did not show meaningful diagnostic information. Contrast-enhanced ultrasound using the microvascular imaging technique provides diagnostic information on breast lesions.

Inflammatory breast carcinoma in magnetic resonance imaging: a comparison with locally advanced breast cancer

RATIONALE AND OBJECTIVES

Although inflammatory breast carcinoma (IBC) accounts for 1%-4% of all breast cancer cases, the appearance of this highly malignant tumor in magnetic resonance imaging (MRI) is still not well characterized. The aim of this study was to identify typical imaging features of IBC in comparison with noninflammatory locally advanced breast carcinoma (LABC).

MATERIALS AND METHODS

MRIs of 48 patients with IBC were compared with an equivalent cohort of 52 subjects with LABC. Age and histopathologic subtype were equivalent between the two groups. To delineate characteristic features, a multitude of dynamic and morphologic parameters were evaluated using T1- and T2-weighted sequences.

RESULTS

No significant differences of prevalences could be found for the following criteria: dynamic tumor signal characteristics, prominent vessels, perifocal edema, axillary lymph node involvement, morphology of focal masses, and morphologic pattern of non-mass like enhancement. Otherwise, the quantity of focal masses and the spatial distribution of the tumoral infiltration significantly differed between the two cancer groups. The following parameters occurred more frequently in the IBC cases: edema (cutaneous/subcutaneous 81.3%, perimamillar 70.8%, diffuse 89.6%, prepectoral 72.9%, intramuscular pectoral 41.7%), thickening (75.0%) and pathologic enhancement (60.4%) of Cooper's ligaments, skin thickening (83.3%), punched-out sign (initially strong, focal increase of some dermal or subcutaneous parts followed by slow-continuous enhancement of the surrounding skin; 56.3%).

CONCLUSIONS

Inflammatory breast carcinoma seems to represent a specific biological entity resulting in typical MRI characteristics. Some of the parameters are supposed to visualize the characteristic extensive lymphovascular infiltration and therefore may improve the diagnosis of IBC.

Meta-analysis of MR imaging in the diagnosis of breast lesions

PURPOSE

To determine, in a meta-analysis, the diagnostic performance of contrast material-enhanced magnetic resonance (MR) imaging in patients with breast lesions.

MATERIALS AND METHODS

Studies to assess the diagnostic performance of MR imaging in patients suspected of having breast cancer who underwent MR imaging and biopsy from January 1985 through March 2005 were reviewed for inclusion. A summary receiver operating characteristic curve was constructed, and pooled weighted estimates of sensitivity and specificity were calculated by using the recently developed bivariate approach for diagnostic meta-analysis.

RESULTS

Of 251 eligible studies, 44 were included in the meta-analysis (sample size range, 14-821; cancer prevalence, 23%-84%). Pooled weighted estimates of sensitivity and specificity were 0.90 (95% confidence interval: 0.88, 0.92) and 0.72 (95% confidence interval: 0.67, 0.77), respectively. The performance of breast MR imaging was influenced by the prevalence of cancer in the studied population (P = .05) and by whether two criteria (ie, morphology, enhancement, and kinetic enhancement pattern)--versus one or three criteria--were used to differentiate benign from malignant lesions (P = .02).

CONCLUSION

MR imaging of the breast has high sensitivity and lower specificity in the evaluation of breast lesions.

SUPPLEMENTAL MATERIAL

http://radiology.rsnajnls.org/cgi/content/full/2461061298/DC1.

Incidental PET/CT Detection of Breast Cancer in a Patient with Negative Mammogram and Breast Sonogram

We present the case of a 57-year-old woman with known Hodgkins lymphoma who presented with PET/CT findings of a breast mass and diseased axillary lymph node despite negative results from a recent routine mammogram and ultrasound. Needle biopsy of the mass and lymph node confirmed a diagnosis of infiltrating ductal carcinoma of the breast with nodal metastases.

Morphologic blooming in breast MRI as a characterization of margin for discriminating benign from malignant lesions

RATIONALE AND OBJECTIVES

Develop a fully automated, objective method for evaluating morphology on breast magnetic resonance (MR) images and evaluate effectiveness of the new morphologic method for detecting breast cancers.

MATERIALS AND METHODS

We present a new automated method (morphologic blooming) for identifying and classifying breast lesions on MR that measures margin sharpness, a characteristic related to blooming, defined as rapid enhancement, with a border that is initially sharp but becomes unsharp after 7 minutes. Independent training sets (98 biopsy-proven lesions) and testing sets (179 breasts, 127 patients, acquired at five institutions) were used. Morphologic blooming was evaluated as a stand-alone feature and as an adjunct to kinetics using free-response receiver operating characteristic and sensitivity analysis. Dependence of false-positive (FP) rates on acquisition times and pathologies of contralateral breasts were evaluated.

RESULTS

Sensitivity of morphologic blooming was 80% with 2.46 FP per noncancerous breast: FPs did not vary significantly by acquisition times. FPs varied significantly by pathologies of contralateral breasts (cancerous contralateral: 4.29 FP/breast; noncancerous contralateral: 0.48 FP/breast; P < .0001). Evaluation of 45 cancers showed suspicious morphologies on 10/15 (67%) cancers with benign-like kinetics and suspicious kinetics on 5/10 (50%) cancers with benign-like morphologies.

CONCLUSION

We present a new, fully automated method of identifying and classifying margin sharpness of breast lesions on MR that can be used to direct radiologists' attention to lesions with suspicious morphologies. Morphologic blooming may have important utility for assisting radiologists in identifying cancers with benign-like kinetics and discriminating normal tissues that exhibit cancer-like enhancement curves and for improving the performance of computer-aided detection systems.

Breast MR imaging in women at high-risk of breast cancer. Is something changing in early breast cancer detection?

In the last few years, several papers have addressed the introduction of contrast-enhanced MR imaging for screening women at high risk for breast cancer. Taking in consideration five prospective studies, on 3,571 screened women with hereditary predisposition to the disease and 9,652 rounds, we found that 168 patients were diagnosed with breast cancer (155 screen-detected, eight interval, and five cancers excluded from analysis) with a detection rate per year of 1.7%. These cancers were small (49% equal to or less than 10 mm in diameter) but aggressive, 82% being invasive and 49% with histologic grade 3; however, only 19% of these invasive cancers were associated with nodal involvement. The pooled sensitivity was 16% for clinical breast examination, 40% for mammography, 43% for ultrasound, and 81% for MR. The positive predictive value (calculated on the basis of the number of invasive diagnostic procedures due to false positives) was 33%, 47%, 18%, and 53%, respectively. Aim of the present article is to present the historical development of MR imaging of breast tumors that made this application theoretically and technically possible, to explain what strategic problems we face in the presence of a hereditary predisposition to the disease, to review the main results of the published studies, and to outline open problems and future perspectives.

Evaluation of the internal vertebral venous plexus, vertebral canal, dural sac, and vertebral body via nonselective computed tomographic venography in the cervical vertebral column in healthy dogs

OBJECTIVE

To evaluate nonselective computed tomographic (CT) venography for evaluating the cervical internal vertebral venous plexus (IVVP), define the diameter and area dimensions of the IVVP, and determine the relationship between dimensions of the cervical IVVP and other vertebral components in medium-sized dogs. Animals-6 healthy dogs that weighed 18 to 27 kg. Procedure-Helical CT scans were performed from C1 to C7 before and after IV injection of contrast medium (480 mg of iodine/kg) and a continuous infusion (240 mg of iodine/kg). Image data were transferred to a CT workstation, and measurements were performed on displayed transverse images. Diameter and area measurements of the vertebral canal, dural sac, IVVP, and vertebral body were obtained at C3 to C7.

RESULTS

Opacification of vertebral venous structures was achieved in all dogs with no adverse reactions. Sagittal diameters of the IVVP for C3 to C7 ranged from 0.6 to 3.2 mm. Transverse diameters ranged from 2.32 to 5.74 mm. The IVVP area represented 12.4% of the mean vertebral canal transverse area and 30.61% of the mean vertebral epidural space area. Area measurements of the IVVP were significantly correlated with vertebral canal area and dural sac area.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that nonselective CT venography is a safe, sensitive method for performing morphometric assessments of the cervical IVVP in dogs. Findings support the theory that there may be a physiologic or developmental relationship between cervical vertebral canal components.

Fat suppression with spectrally selective inversion vs. high spectral and spatial resolution MRI of breast lesions: Qualitative and quantitative comparisons

PURPOSE

To compare conventional fat-suppressed MR images of the breast to images derived from high spectral and spatial resolution MR data. Image quality and the level of fat suppression are compared qualitatively and quantitatively.

MATERIALS AND METHODS

Women with suspicious breast lesions found on X-ray mammography were imaged on 1.5 Tesla GE SIGNA scanners. High spectral and spatial resolution (HiSS) data were acquired using echo-planar spectroscopic imaging. Images with intensity proportional to the water signal peak height in each voxel were synthesized. Conventional fat-suppressed images were acquired using a frequency selective inversion method. The experimental (HiSS) and conventional images were compared by experienced radiologists to evaluate the quality of fat suppression. In addition, fat suppression and image quality were evaluated quantitatively.

RESULTS

Fat suppression, tumor edge delineation, lesion conspicuity, and image texture were improved in the peak height images derived from HiSS data.

CONCLUSION

The results demonstrate that the water peak height images obtained from HiSS data potentially could improve the quality of fat suppression, detection and diagnosis of breast cancer. HiSS allowed detection of lesions and evaluation of lesion morphology prior to contrast media injection. J. Magn. Reson. Imaging 2006. (c) 2006 Wiley-Liss, Inc.

Interpretation of breast MRI: correlation of kinetic and morphological parameters with pathological findings

Breast MRI (magnetic resonance imaging) has emerged as a highly sensitive modality for imaging of breast tumors. Differences in MR enhancement characteristics between benign and malignant lesions are believed to reflect differences in vascularity, vessel permeability, and extracellular diffusion space. However, interpretation of breast MRI remains a challenging task. Precise MR-pathologic correlations may also lead to an improved understanding of the histological heterogeneity of breast cancers and definitions of diagnostic criteria.

Potential MRI Interpretation Model: Differentiation of Benign from Malignant Breast Masses

OBJECTIVE

Our objective was to increase the accuracy of breast MRI using a semiquantitative analysis of typical MRI features and their diagnostic potential. The prevalence of recently reported MRI signs of breast lesions were analyzed and compared with other well-known signs.

CONCLUSION

New MRI features, especially from T2-weighted images, are promising for more reliable and accurate interpretation of breast lesions. Prospective studies of these findings are required to define cut-off values and test clinical practicality.

Further Signs in the Evaluation of Magnetic Resonance Mammography

PURPOSE

To increase accuracy and reliability of magnetic resonance breast imaging, a new evaluation method might be helpful. The recently suggested evaluation method (Fischer U, et al) resulted in a relevant number of equivocal cases (3 or 4 points). Additional morphologic and dynamic signs as an extension of this score were evaluated.

METHOD AND MATERIALS

One hundred thirty-two histologically verified lesions were evaluated by 3 radiologists double-blinded using 2 evaluation methods: 1) method 1 (according to Fischer, et al): 2pt: initial signal increase >100%, washout, centripetal enhancement, 1pt: initial signal increase 50-100%, plateau phenomenon, centrifugal inhomogeneous enhancement, irregular borders, linear, stellar or dendritic structure; and 2) method 2 (according to Malich, et al): 3pt: hook sign (sign of pectoral invasion), 2pt: unifocal edema, blooming. 1pt: hypointensity in T2, lymph nodes >10 mm, skin thickening, adjacent vessels, a lesion's distorted inner architecture, disruption of the mamillary edge; -1pt: isointensity in T2, no edema, enhancing septations; -3pt: hyperintensity in T2, non enhancing septations. Method 1 judged a lesion to be malignant if 5 or more points were given and benign if 2 or less points were given, respectively. Method 2 (mean value of 3 radiologists) was tested in those cases in which a clear possible decision using method 1 was not sufficiently possible.

RESULTS

Method 1 alone resulted in a negative predictive value of 96.8% and a positive predictive value of 90.8% (without carcinoma in situ), a sensitivity of 83.1%, a specificity of 58.8%, and revealed uncertain results (3 and 4 points) in 29 cases (out of 132; 22%). Adding the new scoring system in these 29 equivocal cases and an increase of 2 or more points by using method 2 is supposed to be a sign of malignancy; findings suggest a sensitivity of 90.9% and a specificity of 60% if an increase of maximum 1 is observed in benign lesions. In conclusion, our results show that Göttingen score alone has a sensitivity of 83.1%, a specificity of 58.8%; the second evaluation method reveals a sensitivity of 90.9% and a specificity of 60% in equivocal cases of Göttingen score. Göttingen score then reaches in all cases and second, adding the second evaluation method in equivocal cases, a sensitivity of 97% and a specificity of 76.5%.

CONCLUSION

The application of a second evaluation method in those cases remaining unclear in Göttingen score can lead to a decrease of uncertainty and a higher sensitivity and specificity of diagnosis in MR mammography. In this study, Göttingen score reaches a sensitivity of 83.1% and a specificity of 58.8%, increasing to a sensitivity of 97% and a specificity of 76.5% when being extended by a second evaluation method in unclear cases.

Dynamic contrast-enhanced MRI and sonography in patients receiving primary chemotherapy for breast cancer

We compared dynamic contrast-enhanced MRI (DCE-MRI) and sonography (US) for monitoring tumour size in 21 patients with breast cancer undergoing primary chemotherapy (PCT) followed by surgery. The correlation between DCE-MRI and US measurements of tumour size, defined as the product of the two major diameters, was 0.555 (P=0.009), 0.782 (P<0.001), and 0.793 (P<0.001) at baseline, and after two and four cycles of PCT, respectively. The median tumour size was significantly larger when measured by DCE-MRI than by US at baseline (1472 vs 900 mm(2), P<0.001) and after two cycles of PCT (600 vs 400 mm(2), P=0.009). After PCT, the median tumour size measured by the two techniques was similar (256 vs 289 mm(2) for DCE-MRI and US, respectively, P=0.859). The correlation with the histopathological major tumour diameter was 0.824 (P<0.001) and 0.705 (P<0.001) for post-treatment DCE-MRI and US, respectively. Measurements of the final major tumour diameter by DCE-MRI tended to be more precise, including cases achieving a pathological complete response. Randomized trials are warranted to establish the clinical impact of the initial discrepancy in tumour size estimates between DCE-MRI and US, and the trend towards a better definition of the final tumour size provided by DCE-MRI in this clinical setting.

Application of an exogenous hyperoxic contrast agent in MR mammography: initial results

There is interest in applying novel methods to dynamic MR mammography (MRM). One such possibility is to administer an exogenous hyperoxic contrast agent, such as carbogen (95-98% O2 and 2-5% CO2) or pure oxygen (100% O2). We report our first experiences with these agents in a patient with an invasive lobular carcinoma. Fourteen dynamic series were acquired with an rf-spoiled 2D multislice gradient echo sequence, including three measurements while breathing air, four measurements with 100% oxygen, three measurements with air and four measurements with carbogen. Afterwards, 0.1 mmol/kg bw of Gd-DTPA was administered to obtain dynamic T1-weighted double-echo 3D axial gradient echo images (TR/TE1/TE2/alpha=7.8 ms/2 ms/4.76 ms/15 degrees) every 90 s up to 4.5 min after injection. The lesion was well delineated on the contrast-enhanced images, contrary to magnitude images reconstructed from the raw data sets acquired during air/oxygen/carbogen breathing. A ROI-based median-filtered signal-time course revealed a tumor signal increase of roughly 15% between scans acquired during air and oxygen breathing. Though preliminary, these first results are encouraging concerning the exploration of these alternative contrast agents in MRM in greater detail.