Tissue Sodium Concentration Quantification at 7.0-T MRI as an Early Marker for Chemotherapy Response in Breast Cancer: A Feasibility Study

23Na-MRI for Breast Cancer Diagnosis and Treatment Monitoring: A Scoping Review

(1) Background: Variations in intracellular and extracellular sodium levels have been hypothesized to serve as biomarkers for tumour characterization and therapeutic response. While previous research has explored the feasibility of 23Na-MRI, a comprehensive review of its clinical utility in breast cancer is lacking. This scoping review aims to synthesize existing literature on the potential role of 23Na-MRI in breast cancer diagnosis and treatment monitoring. (2) Methods: This review included English-language studies reporting on quantitative applications of 23Na-MRI in breast cancer. Systematic searches were conducted across PubMed, Emcare, Embase, Scopus, Google Scholar, Cochrane Library, and Medline. (3) Results: Seven primary studies met the inclusion criteria, highlighting the ability of 23Na-MRI to differentiate between malignant and benign breast lesions based on elevated total sodium concentration (TSC) in tumour tissues. 23Na-MRI also showed potential in early prediction of treatment response, with significant reductions in TSC observed in responders. However, the studies varied widely in their protocols, use of phantoms, field strengths, and contrast agent application, limiting inter-study comparability. (4) Conclusion: 23Na-MRI holds promise as a complementary imaging modality for breast cancer diagnosis and treatment monitoring. However, standardization of imaging protocols and technical optimization are essential before it can be translated into clinical practice.

Monensin Inhibits Triple-Negative Breast Cancer in Mice by a Na+-Dependent Cytotoxic Action Unrelated to Cytostatic Effects

Triple-negative breast cancer (TNBC) represents the most aggressive breast cancer subtype, defined by its limited therapeutic options and poor outcomes. This study investigated the therapeutic potential of targeting Na+ homeostasis in TNBC cells to induce TNBC inhibition. For this purpose, BALB/c mice were inoculated with 4T1-Luc2 breast cancer cells and treated with the Na+ ionophore monensin (8 mg/kg) or vehicle alone. Tumor development and cellular Na+ content were assessed using vivo live imaging techniques, while intracellular Na+ variations and cytotoxicity were evaluated through live cell analysis. Monensin treatment increased Na+ levels in cancerous tissues and reduced TNBC mass (monensin: 0.146 ± 0.06; vehicle: 0.468 ± 0.2 cm3; p < 0.001). This treatment induced extensive necrosis in TNBC tumors while preserving the structural and functional integrity of healthy organs and maintaining the proliferative activity of both tumor and normal tissues. Monensin did not alter the expression of proliferating nuclear antigen (PCNA) in 4T1-Luc2 cells but triggered cytotoxicity preceded by intracellular Na+ accumulation. Na+-free conditions prevented both Na+ accumulation and 4T1-Luc2 cell death. Thus, monensin exerts its antitumor effects in TNBC through a Na+-dependent and tumor-specific cytotoxic mechanism, without inducing cytostatic effects on normal or transformed tissues. Collectively, these findings underscore the potential of Na+ ionophores as promising therapeutic agents for TNBC.

23Na MRI: inter-reader reproducibility of normal fibroglandular sodium concentration measurements at 3 T

BACKGROUND

To study the reproducibility of 23Na magnetic resonance imaging (MRI) measurements from breast tissue in healthy volunteers.

METHODS

Using a dual-tuned bilateral 23Na/1H breast coil at 3-T MRI, high-resolution 23Na MRI three-dimensional cones sequences were used to quantify total sodium concentration (TSC) and fluid-attenuated sodium concentration (FASC). B1-corrected TSC and FASC maps were created. Two readers manually measured mean, minimum and maximum TSC and mean FASC values using two sampling methods: large regions of interest (LROIs) and small regions of interest (SROIs) encompassing fibroglandular tissue (FGT) and the highest signal area at the level of the nipple, respectively. The reproducibility of the measurements and correlations between density, age and FGT apparent diffusion coefficient (ADC) values were evaluatedss.

RESULTS

Nine healthy volunteers were included. The inter-reader reproducibility of TSC and FASC using SROIs and LROIs was excellent (intraclass coefficient range 0.945-0.979, p < 0.001), except for the minimum TSC LROI measurements (p = 0.369). The mean/minimum LROI TSC and mean LROI FASC values were lower than the respective SROI values (p < 0.001); the maximum LROI TSC values were higher than the SROI TSC values (p = 0.009). TSC correlated inversely with age but not with FGT ADCs. The mean and maximum FGT TSC and FASC values were higher in dense breasts in comparison to non-dense breasts (p < 0.020).

CONCLUSIONS

The chosen sampling method and the selected descriptive value affect the measured TSC and FASC values, although the inter-reader reproducibility of the measurements is in general excellent.

RELEVANCE STATEMENT

23Na MRI at 3 T allows the quantification of TSC and FASC sodium concentrations. The sodium measurements should be obtained consistently in a uniform manner.

KEY POINTS

• 23Na MRI allows the quantification of total and fluid-attenuated sodium concentrations (TSC/FASC). • Sampling method (large/small region of interest) affects the TSC and FASC values. • Dense breasts have higher TSC and FASC values than non-dense breasts. • The inter-reader reproducibility of TSC and FASC measurements was, in general, excellent. • The results suggest the importance of stratifying the sodium measurements protocol.

Chronic High-Salt Diet Activates Tumor-Initiating Stem Cells Leading to Breast Cancer Proliferation

Several chronic inflammatory diseases have been linked to high-salt (HS) diets. Chronic inflammation is an established causative hallmark of cancer. However, a direct role of HS diets in tumorigenesis is yet to be defined. Previous orthotopic murine breast tumor studies have shown that short-term HS diets caused inhibition of tumor growth through the activation of cytotoxic adaptive immune responses. However, there have been experimental challenges in developing a viable chronic HS-diet-based murine tumor model. To address this, we have developed a novel chronic HS diet tumor model through the sequential passaging of tumor cells in mice under HS dietary conditions. Two orthotopic murine triple-negative breast cancer models, 4T1 tumor cells injected into BALB/c mice and Py230 tumor cells injected into C57Bl/6 mice, were utilized in our study. For the HS diet cohort, prior to orthotopic injection with tumor cells, the mice were kept on a 4% NaCl diet for 2 weeks. For the regular salt (RS) diet cohort, the mice were kept on a 1% NaCl diet. Following syngeneic cancer cell injection, tumors were allowed to grow for 28 days, following which they were collected to isolate immune cell-depleted cancer cells (passage 1, P1). The tumor cells from P1 were reinjected into the next set of non-tumor-bearing mice. This procedure was repeated for three cycles (P2-P4). In P1, compared to the RS diet cohort, we observed reduced tumor kinetics in both murine tumor models on the HS diet. In contrast, by P4, there was significantly higher tumor progression in the HS diet cohort over the RS diet cohort. Flow cytometry analysis demonstrated an 8-fold increase in tumor-initiating stem cells (TISCs) from P1 to P4 of the HS diet cohort, while there were no significant change in TISC frequency with sequential passaging in the RS diet cohort. Molecular studies showed enhanced expression of TGFβR2 and CD80 on TISCs isolated from the P4 HS diet cohort. In vitro studies demonstrated that TGFβ stimulation of these TISCs increased the cellular expression of CD80 molecules. Further, the chronic HS diet selectively induced the glycolytic metabolic phenotype over the mitochondrial oxidative phosphorylation phenotype in TISCs, which is needed for the production of metabolites during tumor cell differentiation and proliferation. The infiltrating CD8 and CD4 T-lymphocytes in P4 tumors demonstrated increased expression of the immune checkpoint inhibitor (ICI) CTLA4, a known binding partner of CD80, to cause immune exhaustion and pro-tumorigenic effects. Interestingly, anti-TGFβ monoclonal antibodies (mAbs) played a synergistic role in further enhancing the anti-tumor effect of anti-CTLA4 mAb. In summary, our findings demonstrated that chronic HS diet increased the frequency of TISCs in tumors leading to blunting of cytotoxic adaptive immune responses causing tumor proliferation. Furthermore, a combination of anti-TGFβ with current ICI-based immunotherapies could exert more favorable anti-cancer clinical outcomes.

Recent technical developments and clinical research applications of sodium (23Na) MRI

Sodium is an essential ion that plays a central role in many physiological processes including the transmembrane electrochemical gradient and the maintenance of the body's homeostasis. Due to the crucial role of sodium in the human body, the sodium nucleus is a promising candidate for non-invasively assessing (patho-)physiological changes. Almost 10 years ago, Madelin et al. provided a comprehensive review of methods and applications of sodium (23Na) MRI (Madelin et al., 2014) [1]. More recent review articles have focused mainly on specific applications of 23Na MRI. For example, several articles covered 23Na MRI applications for diseases such as osteoarthritis (Zbyn et al., 2016, Zaric et al., 2020) [2,3], multiple sclerosis (Petracca et al., 2016, Huhn et al., 2019) [4,5] and brain tumors (Schepkin, 2016) [6], or for imaging certain organs such as the kidneys (Zollner et al., 2016) [7], the brain (Shah et al., 2016, Thulborn et al., 2018) [8,9], and the heart (Bottomley, 2016) [10]. Other articles have reviewed technical developments such as radiofrequency (RF) coils for 23Na MRI (Wiggins et al., 2016, Bangerter et al., 2016) [11,12], pulse sequences (Konstandin et al., 2014) [13], image reconstruction methods (Chen et al., 2021) [14], and interleaved/simultaneous imaging techniques (Lopez Kolkovsky et al., 2022) [15]. In addition, 23Na MRI topics have been covered in review articles with broader topics such as multinuclear MRI or ultra-high-field MRI (Niesporek et al., 2019, Hu et al., 2019, Ladd et al., 2018) [16-18]. During the past decade, various research groups have continued working on technical improvements to sodium MRI and have investigated its potential to serve as a diagnostic and prognostic tool. Clinical research applications of 23Na MRI have covered a broad spectrum of diseases, mainly focusing on the brain, cartilage, and skeletal muscle (see Fig. 1). In this article, we aim to provide a comprehensive summary of methodological and hardware developments, as well as a review of various clinical research applications of sodium (23Na) MRI in the last decade (i.e., published from the beginning of 2013 to the end of 2022).

Radiofrequency antenna concepts for human cardiac MR at 14.0 T

OBJECTIVE

To examine the feasibility of human cardiac MR (CMR) at 14.0 T using high-density radiofrequency (RF) dipole transceiver arrays in conjunction with static and dynamic parallel transmission (pTx).

MATERIALS AND METHODS

RF arrays comprised of self-grounded bow-tie (SGBT) antennas, bow-tie (BT) antennas, or fractionated dipole (FD) antennas were used in this simulation study. Static and dynamic pTx were applied to enhance transmission field (B₁⁺) uniformity and efficiency in the heart of the human voxel model. B₁⁺ distribution and maximum specific absorption rate averaged over 10 g tissue (SAR_10g) were examined at 7.0 T and 14.0 T.

RESULTS

At 14.0 T static pTx revealed a minimum B₁⁺_ROI efficiency of 0.91 μT/√kW (SGBT), 0.73 μT/√kW (BT), and 0.56 μT/√kW (FD) and maximum SAR_10g of 4.24 W/kg, 1.45 W/kg, and 2.04 W/kg. Dynamic pTx with 8 kT points indicate a balance between B₁⁺_ROI homogeneity (coefficient of variation < 14%) and efficiency (minimum B₁⁺_ROI > 1.11 µT/√kW) at 14.0 T with a maximum SAR_10g < 5.25 W/kg.

DISCUSSION

MRI of the human heart at 14.0 T is feasible from an electrodynamic and theoretical standpoint, provided that multi-channel high-density antennas are arranged accordingly. These findings provide a technical foundation for further explorations into CMR at 14.0 T.

Influence of image contrasts and reconstruction methods on the classification of multiple sclerosis-like lesions in simulated sodium magnetic resonance imaging

PURPOSE

To evaluate the classifiability of small multiple sclerosis (MS)-like lesions in simulated sodium (²³ Na) MRI for different ²³ Na MRI contrasts and reconstruction methods.

METHODS

²³ Na MRI and ²³ Na inversion recovery (IR) MRI of a phantom and simulated brain with and without lesions of different volumes (V = 1.3-38.2 nominal voxels) were simulated 100 times by adding Gaussian noise matching the SNR of real 3T measurements. Each simulation was reconstructed with four different reconstruction methods (Gridding without and with Hamming filter, Compressed sensing (CS) reconstruction without and with anatomical ¹ H prior information). Based on the mean signals within the lesion volumes of simulations with and without lesions, receiver operating characteristics (ROC) were determined and the area under the curve (AUC) was calculated to assess the classifiability for each lesion volume.

RESULTS

Lesions show higher classifiability in ²³ Na MRI than in ²³ Na IR MRI. For typical parameters and SNR of a 3T scan, the voxel normed minimal classifiable lesion volume (AUC > 0.9) is 2.8 voxels for ²³ Na MRI and 19 voxels for ²³ Na IR MRI, respectively. In terms of classifiability, Gridding with Hamming filter and CS without anatomical ¹ H prior outperform CS reconstruction with anatomical ¹ H prior.

CONCLUSION

Reliability of lesion classifiability strongly depends on the lesion volume and the ²³ Na MRI contrast. Additional incorporation of ¹ H prior information in the CS reconstruction was not beneficial for the classification of small MS-like lesions in ²³ Na MRI.

MR-Nucleomics: The study of pathological cellular processes with multinuclear magnetic resonance spectroscopy and imaging in vivo

Clinical medicine has experienced a rapid development in recent decades, during which therapies targeting specific cellular signaling pathways, or specific cell surface receptors, have been increasingly adopted. While these developments in clinical medicine call for improved precision in diagnosis and treatment monitoring, modern medical imaging methods are restricted mainly to anatomical imaging, lagging behind the requirements of precision medicine. Although positron emission tomography and single photon emission computed tomography have been used clinically for studies of metabolism, their applications have been limited by the exposure risk to ionizing radiation, the subsequent limitation in repeated and longitudinal studies, and the incapability in assessing downstream metabolism. Magnetic resonance spectroscopy (MRS) or spectroscopic imaging (MRSI) are, in theory, capable of assessing molecular activities in vivo, although they are often limited by sensitivity. Here, we review some recent developments in MRS and MRSI of multiple nuclei that have potential as molecular imaging tools in the clinic.

Repeatability assessment of sodium (23Na) MRI at 7.0 T in healthy human calf muscle and preliminary results on tissue sodium concentrations in subjects with Addison's disease

OBJECTIVES

To determine the relaxation times of the sodium nucleus, and to investigate the repeatability of quantitative, in vivo TSC measurements using sodium magnetic resonance imaging (23Na-MRI) in human skeletal muscle and explore the discriminatory value of the method by comparing TSCs between healthy subjects and patients with Addison's disease.

MATERIALS AND METHODS

In this prospective study, ten healthy subjects and five patients with Addison's disease were involved. 23Na-MRI data sets were acquired using a density-adapted, three-dimensional radial projection reconstruction pulse sequence (DA-3DPR) with a modification for the relaxation times measurements. Differences in TSC between muscle groups and between healthy participants were analysed using a nonparametric Friedman ANOVA test. An interclass correlation coefficient (ICC) was used as the repeatability index. Wilcoxon rank sum test was used for evaluation of differences in TSC between study participants.

RESULTS

The mean T1 in the gastrocnemius medialis (GM), the tibialis anterior (TA), and the soleus (S) was 25.9 ± 2.0 ms, 27.6 ± 2.0 ms, and 28.2 ± 2.0 ms, respectively. The mean short component of T2*, T2*short were GM: 3.6 ± 2.0 ms; TA: 3.2 ± 0.5 ms; and S: 3.0 ± 1.0 ms, and the mean long component of T2*, T2*long, were GM: 12.9 ± 0.9 ms; TA: 12.8 ± 0.7 ms; and S: 12.9 ± 2.0 ms, respectively. In healthy volunteers, TSC values in the GM were 19.9 ±0.1  mmol/L, 13.8 ±0.2 mmol/L in TA, and 12.6 ± 0.2 mmol/L in S, and were significantly different (p = 0.0005). The ICCs for GM, TA and S were 0.784, 0.818, 0.807, respectively. In patients with Addison's disease, TSC in GC, TA, and S were 10.2 ± 1.0 mmol/L, 8.4 ± 0.6 mmol/L, and 7.2 ± 0.1 mmol/L, respectively.

CONCLUSIONS

TSC quantification in a healthy subject's calf at 7.0 T is reliable; the technique is able to distinguish sodium level differences between muscles and between healthy subjects and Addison's disease patients.

Compressed Sensing in Sodium Magnetic Resonance Imaging: Techniques, Applications, and Future Prospects

Sodium (²³ Na) yields the second strongest nuclear magnetic resonance (NMR) signal in biological tissues and plays a vital role in cell physiology. Sodium magnetic resonance imaging (MRI) can provide insights into cell integrity and tissue viability relative to pathologies without significant anatomical alternations, and thus it is considered to be a potential surrogate biomarker that provides complementary information for standard hydrogen (¹ H) MRI in a noninvasive and quantitative manner. However, sodium MRI suffers from a relatively low signal-to-noise ratio and long acquisition times due to its relatively low NMR sensitivity. Compressed sensing-based (CS-based) methods have been shown to accelerate sodium imaging and/or improve sodium image quality significantly. In this manuscript, the basic concepts of CS and how CS might be applied to improve sodium MRI are described, and the historical milestones of CS-based sodium MRI are briefly presented. Representative advanced techniques and evaluation methods are discussed in detail, followed by an expose of clinical applications in multiple anatomical regions and diseases as well as thoughts and suggestions on potential future research prospects of CS in sodium MRI. EVIDENCE LEVEL: 5 TECHNICAL EFFICACY: Stage 1.

7 Tesla and Beyond: Advanced Methods and Clinical Applications in Magnetic Resonance Imaging

ABSTRACT

Ultrahigh magnetic fields offer significantly higher signal-to-noise ratio, and several magnetic resonance applications additionally benefit from a higher contrast-to-noise ratio, with static magnetic field strengths of B0 ≥ 7 T currently being referred to as ultrahigh fields (UHFs). The advantages of UHF can be used to resolve structures more precisely or to visualize physiological/pathophysiological effects that would be difficult or even impossible to detect at lower field strengths. However, with these advantages also come challenges, such as inhomogeneities applying standard radiofrequency excitation techniques, higher energy deposition in the human body, and enhanced B0 field inhomogeneities. The advantages but also the challenges of UHF as well as promising advanced methodological developments and clinical applications that particularly benefit from UHF are discussed in this review article.