[Imaging of breast tumors using MR elastography]

Tissue stiffness in BPH patients from magnetic resonance elastography

Background

BPH is commonly found in older men which can lead to lower urinary tract symptoms. Magnetic resonance elastography (MRE) is an innovative, noninvasive imaging technique used to evaluate tissue stiffness. There has not been any study, however, that assessed the tissue stiffness in patients with BPH. A prospective descriptive study was performed to demonstrated MRI and MRE techniques of the prostate gland in ten patients with BPH to assess tissue stiffness, features of BPH on MRI and components of BPH in the area of increased stiffness.

Results

MRI and MRE examinations in all patients were successful without any complications. The mean tissue stiffness of the whole prostate gland was 4.40 ± 0.71 kPa with good reproducibility (ICC 0.82). Stromal components and mixed glandular-stromal components tended to be associated with the areas of increased stiffness on stiffness images, 50.6% for stromal components and 37.9% for mixed glandular-stromal components. Some MRI findings were seen on the patients with high mean stiffness values such as prostatic calcification, type-5 BPH pattern and large prostate volumes.

Conclusions

Prostate MRE is a useful noninvasive reproducible diagnostic tool for evaluating prostate tissue stiffness by both qualitative and quantitative assessments. The mean prostate tissue stiffness from MRE in patients with BPH in this study was 4.40 ± 0.71 kPa. Some MRI features might be associated with increased tissue stiffness.

Trial registration: PID 229. Registered 4 October 2019. http://md.redcap.kku.ac.th

MR Elastography of the Breast: Evolution of Technique, Case Examples, and Future Directions

Recognizing that breast cancers present as firm, stiff lesions, the foundation of breast magnetic resonance elastography (MRE) is to combine tissue stiffness parameters with sensitive breast MR contrast-enhanced imaging. Breast MRE is a non-ionizing, cross-sectional MR imaging technique that provides for quantitative viscoelastic properties, including tissue stiffness, elasticity, and viscosity, of breast tissues. Currently, the technique continues to evolve as research surrounding the use of MRE in breast tissue is still developing. In the setting of a newly diagnosed cancer, associated desmoplasia, stiffening of the surrounding stroma, and necrosis are known to be prognostic factors that can add diagnostic information to patient treatment algorithms. In fact, mechanical properties of the tissue might also influence breast cancer risk. For these reasons, exploration of breast MRE has great clinical value. In this review, we will: (1) address the evolution of the various MRE techniques; (2) provide a brief overview of the current clinical studies in breast MRE with interspersed case examples; and (3) suggest directions for future research.

General review of magnetic resonance elastography

Magnetic resonance elastography (MRE) is an innovative imaging technique for the non-invasive quantification of the biomechanical properties of soft tissues via the direct visualization of propagating shear waves in vivo using a modified phase-contrast magnetic resonance imaging (MRI) sequence. Fundamentally, MRE employs the same physical property that physicians utilize when performing manual palpation - that healthy and diseased tissues can be differentiated on the basis of widely differing mechanical stiffness. By performing “virtual palpation”, MRE is able to provide information that is beyond the capabilities of conventional morphologic imaging modalities. In an era of increasing adoption of multi-parametric imaging approaches for solving complex problems, MRE can be seamlessly incorporated into a standard MRI examination to provide a rapid, reliable and comprehensive imaging evaluation at a single patient appointment. Originally described by the Mayo Clinic in 1995, the technique represents the most accurate non-invasive method for the detection and staging of liver fibrosis and is currently performed in more than 100 centers worldwide. In this general review, the mechanical properties of soft tissues, principles of MRE, clinical applications of MRE in the liver and beyond, and limitations and future directions of this discipline -are discussed. Selected diagrams and images are provided for illustration.

A three-dimensional quality-guided phase unwrapping method for MR elastography

Magnetic resonance elastography (MRE) uses accumulated phases that are acquired at multiple, uniformly spaced relative phase offsets, to estimate harmonic motion information. Heavily wrapped phase occurs when the motion is large and unwrapping procedures are necessary to estimate the displacements required by MRE. Two unwrapping methods were developed and compared in this paper. The first method is a sequentially applied approach. The three-dimensional MRE phase image block for each slice was processed by two-dimensional unwrapping followed by a one-dimensional phase unwrapping approach along the phase-offset direction. This unwrapping approach generally works well for low noise data. However, there are still cases where the two-dimensional unwrapping method fails when noise is high. In this case, the baseline of the corrupted regions within an unwrapped image will not be consistent. Instead of separating the two-dimensional and one-dimensional unwrapping in a sequential approach, an interleaved three-dimensional quality-guided unwrapping method was developed to combine both the two-dimensional phase image continuity and one-dimensional harmonic motion information. The quality of one-dimensional harmonic motion unwrapping was used to guide the three-dimensional unwrapping procedures and it resulted in stronger guidance than in the sequential method. In this work, in vivo results generated by the two methods were compared.

Imaging the elastic properties of tissue: the 20 year perspective

After 20 years of innovation in techniques that specifically image the biomechanical properties of tissue, the evolution of elastographic imaging can be viewed from its infancy, through a proliferation of approaches to the problem to incorporation on research and then clinical imaging platforms. Ultimately this activity has culminated in clinical trials and improved care for patients. This remarkable progression represents a leading example of translational research that begins with fundamentals of science and engineering and progresses to needed improvements in diagnostic and monitoring capabilities applied to major categories of disease, surgery and interventional procedures. This review summarizes the fundamental principles, the timeline of developments in major categories of elastographic imaging, and concludes with recent results from clinical trials and forward-looking issues.

Magnetic resonance elastography hardware design: A survey

Magnetic resonance elastography (MRE) is an emerging technique capable of measuring the shear modulus of tissue. A suspected tumour can be identified by comparing its properties with those of tissues surrounding it; this can be achieved even in deep-lying areas as long as mechanical excitation is possible. This would allow non-invasive methods for cancer-related diagnosis in areas not accessible with conventional palpation. An actuating mechanism is required to generate the necessary tissue displacements directly on the patient in the scanner and three different approaches, in terms of actuator action and position, exist to derive stiffness measurements. However, the magnetic resonance (MR) environment places considerable constraints on the design of such devices, such as the possibility of mutual interference between electrical components, the scanner field, and radio frequency pulses, and the physical space restrictions of the scanner bore. This paper presents a review of the current solutions that have been developed for MRE devices giving particular consideration to the design criteria including the required vibration frequency and amplitude in different applications, the issue of MR compatibility, actuation principles, design complexity, and scanner synchronization issues. The future challenges in this field are also described.

MR elastography of breast lesions: understanding the solid/liquid duality can improve the specificity of contrast-enhanced MR mammography

The purpose of this analysis is to explore the potential diagnostic gain provided by the viscoelastic shear properties of breast lesions for the improvement of the specificity of contrast enhanced dynamic MR mammography (MRM). The assessment of viscoelastic properties is done via dynamic MR elastography (MRE) and it is demonstrated that the complex shear modulus of in vivo breast tissue follows within the frequency range of clinical MRE a power law behavior. Taking benefit of this frequency behavior, data are interpreted in the framework of the exact model for wave propagation satisfying the causality principle. This allows to obtain the exponent of the frequency power law from the complex shear modulus at one single frequency which is validated experimentally. Thereby, scan time is drastically reduced. It is observed that malignant tumors obtain larger exponents of the power law than benign tumors indicating a more liquid-like behavior. The combination of the Breast Imaging Reporting and Data System (BIRADS) categorization obtained via MRM with viscoelastic information leads to a substantial rise in specificity. Analysis of 39 malignant and 29 benign lesions shows a significant diagnostic gain with an increase of about 20% in specificity at 100% sensitivity.

Performance analysis of steady-state harmonic elastography

Shear modulus estimation can be confounded by the ill-posed nature of the inverse elasticity problem. In this paper, we report the results of experiments conducted on simulated and gelatin phantoms to investigate the effect of various parameters (i.e., regularization, spatial filtering and the subzone generation process) associated with shear modulus reconstruction on the statistical accuracy (mean squared error), and image quality (i.e., contrast and spatial resolution) of the recovered mechanical properties. The results indicate several interesting observations. Firstly, the intrinsic spatial resolution of magnetic resonance elastography (MRE) is dependent on both regularization and spatial filtering. Secondly, the elastographic contrast-to-noise ratio (CNR(e)) increases with increasing regularization and spatial filtering, but it was not affected by the zoning parameters (i.e., the subzones and the extent of the overlap). Thirdly, the statistical accuracy (MSE) of the recovered property improved with increasing regularization, and spatial filtering weight, but the size of the subdomains and their overlap had no significant effect.

Magnetic resonance elastography of the breast: correlation of signal intensity data with viscoelastic properties

OBJECTIVES

We sought to investigate the potential value of magnetic resonance (MR) elastography to improve the differentiation between benign and malignant tumors.

MATERIAL AND METHODS

Measurements of 5 patients with 6 malignant lesions, 11 patients with benign lesions, and 4 patients with no lesions at all were performed at 1.5 Tesla. After breast MR imaging, MR elastography was performed as a targeted measurement. Low-frequency mechanical waves (65 Hz) were transmitted into the breast tissue using an oscillator and were displayed by means of a MR sequence within the phase of the MR image. After reconstruction, the viscoelastic information was correlated with the signal intensity and morphology data.

RESULTS

All examinations were technically successful realized in approximately 25 minutes. Malignant tumors documented higher values of elasticity than benign corresponding with signal intensity and morphologic data.

CONCLUSION

A good separation exists between benign and malignant lesions in elasticity, corresponding with specific signal intensity and morphologic data. Further clinical studies with a larger number of patients are needed for extended validation.

Viscoelastic shear properties of in vivo breast lesions measured by MR elastography

Elastography is a technique to assess the viscoelastic properties of tissue by measuring an acoustic wave propagating though the object. Here, the technique is applied in the course of standard MR mammography to 15 patients with different pathologies (six breast cancer cases, six fibroadenoma cases and three mastopathy cases). Low-frequency mechanical waves are coupled longitudinally into the tissue in order to obtain sufficient wave amplitude throughout the entire breast. This leads to the presence of a substantial fraction of compressional waves, which contribute to the total displacement field. It is shown theoretically that the correct evaluation of these contributions from the compressional wave is rather difficult due to the almost incompressible nature of tissue. To overcome this problem, it is proposed to apply the curl-operator to the measured displacement field in order to completely remove contributions from the compressional wave. Results from simulations and a breast phantom demonstrate the feasibility of the technique. The in vivo results show a good separation between breast cancer and benign fibroadenoma utilizing the shear modulus. Breast cancer appears on average 2.2 (P<.001) times stiffer. All breast cancer cases showed a good delineation to the surrounding breast tissue with an average elevation of a factor of 3.3 (P< 1.4 x 10(-6)). The results as obtained for the shear viscosity do not indicate to be useful for separating benign from malignant lesions.

Vibrography during tumor neurosurgery

OBJECTIVE

The aim of this study was to determine whether elastography, a sonographically based real-time strain imaging method for registering the elastic properties of tissue, can be used in brain tumor surgery.

METHODS

A modification of classic elastography called vibrography was applied in these measurements with static compression replaced by low-frequency axial vibration. Twenty patients were examined with this technique during brain tumor surgery. A conventional sonographic system with a custom-designed radio frequency (RF) interface was used. The RF data were digitized with a 50-MHz, 12-bit peripheral component interconnect analog/digital converter for real-time or offline processing. Sonographic RF data were acquired with a 6.5-MHz endocavity curved array. A special applicator equipped with a stepping motor moved the ultrasonic probe and produced a low-frequency mechanical vibration of approximately 5 to 10 Hz with a vibration amplitude of 0.3 mm.

RESULTS

Detection of tumors was possible in 18 of 20 cases. Brain tissue was normally color coded orange or red. Three major groups of tumors with different elastic properties relative to brain tissue could be differentiated. In 3 cases, the stiffness of the tumor was identical to that of brain tissue, but the tumors were surrounded by a thin yellow border. Six tumors displayed higher strain than brain, whereas 7 tumors exhibited lower strain than the surrounding cerebrum. Two patients could not be assigned clearly to either of these groups.

CONCLUSIONS

These findings indicate that vibrography is a feasible imaging method for brain tumor surgery and may have numerous potential applications in neurosurgery if further improvements are made.

Modality independent elastography (MIE): a new approach to elasticity imaging

The correlation between tissue stiffness and health is an accepted form of organ disease assessment. As a result, there has been a significant amount of interest in developing methods to image elasticity parameters (i.e., elastography). The modality independent elastography (MIE) method combines a nonlinear optimization framework, computer models of soft-tissue deformation, and standard measures of image similarity to reconstruct elastic property distributions within soft tissue. In this paper, simulation results demonstrate successful elasticity image reconstructions in breast cross-sectional images acquired from magnetic resonance (MR) imaging. Results from phantom experiments illustrate its modality independence by reconstructing elasticity images of the same phantom in both MR and computed tomographic imaging units. Additional results regarding the performance of a new multigrid strategy to MIE and the implementation of a parallel architecture are also presented.

Reproducibility of mammary gland structure during repeat setups in a supine position

PURPOSE

In breast conserving therapy, complete excision of the tumor with an acceptable cosmetic outcome depends on accurate localization in terms of both the position of the lesion and its extent. We hypothesize that preoperative contrast-enhanced magnetic resonance (MR) imaging of the patient in a supine position may be used for accurate tumor localization and marking of its extent immediately prior to surgery. Our aims in this study are to assess the reproducibility of mammary gland structure during repeat setups in a supine position, to evaluate the effect of a breast immobilization device, and to derive reproducibility margins that take internal tissue shifts into account occurring between repeat setups.

MATERIALS & METHODS

The reproducibility of mammary gland structure during repeat setups in a supine position is estimated by quantification of tissue shifts in the breasts of healthy volunteers between repeat MR setups. For each volunteer fiducials are identified and registered with their counter locations in corresponding MR volumes. The difference in position denotes the shift of breast tissue. The dependence on breast volume and the part of the breast, as well as the effect of a breast immobilization cast are studied.

RESULTS

The tissue shifts are small with a mean standard deviation on the order of 1.5 mm, being slightly larger in large breasts (V> 1000 cm3), and in the posterior part (toward the pectoral muscle) of both small and large breasts. The application of a breast immobilization cast reduces the tissue shifts in large breasts. A reproducibility margin on the order of 5 mm will take the internal tissue shifts into account that occur between repeat setups.

CONCLUSION

The results demonstrate a high reproducibility of mammary gland structure during repeat setups in a supine position.