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Jing X, Wielema M, Monroy-Gonzalez AG, Stams TRG, Mahesh SVK, Oudkerk M, Sijens PE, Dorrius MD, van Ooijen PMA. Automated Breast Density Assessment in MRI Using Deep Learning and Radiomics: Strategies for Reducing Inter-Observer Variability. J Magn Reson Imaging 2024; 60:80-91. [PMID: 37846440 DOI: 10.1002/jmri.29058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND Accurate breast density evaluation allows for more precise risk estimation but suffers from high inter-observer variability. PURPOSE To evaluate the feasibility of reducing inter-observer variability of breast density assessment through artificial intelligence (AI) assisted interpretation. STUDY TYPE Retrospective. POPULATION Six hundred and twenty-one patients without breast prosthesis or reconstructions were randomly divided into training (N = 377), validation (N = 98), and independent test (N = 146) datasets. FIELD STRENGTH/SEQUENCE 1.5 T and 3.0 T; T1-weighted spectral attenuated inversion recovery. ASSESSMENT Five radiologists independently assessed each scan in the independent test set to establish the inter-observer variability baseline and to reach a reference standard. Deep learning and three radiomics models were developed for three classification tasks: (i) four Breast Imaging-Reporting and Data System (BI-RADS) breast composition categories (A-D), (ii) dense (categories C, D) vs. non-dense (categories A, B), and (iii) extremely dense (category D) vs. moderately dense (categories A-C). The models were tested against the reference standard on the independent test set. AI-assisted interpretation was performed by majority voting between the models and each radiologist's assessment. STATISTICAL TESTS Inter-observer variability was assessed using linear-weighted kappa (κ) statistics. Kappa statistics, accuracy, and area under the receiver operating characteristic curve (AUC) were used to assess models against reference standard. RESULTS In the independent test set, five readers showed an overall substantial agreement on tasks (i) and (ii), but moderate agreement for task (iii). The best-performing model showed substantial agreement with reference standard for tasks (i) and (ii), but moderate agreement for task (iii). With the assistance of the AI models, almost perfect inter-observer variability was obtained for tasks (i) (mean κ = 0.86), (ii) (mean κ = 0.94), and (iii) (mean κ = 0.94). DATA CONCLUSION Deep learning and radiomics models have the potential to help reduce inter-observer variability of breast density assessment. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY: Stage 1.
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Affiliation(s)
- Xueping Jing
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Machine Learning Lab, Data Science Center in Health (DASH), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mirjam Wielema
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Andrea G Monroy-Gonzalez
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Thom R G Stams
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Shekar V K Mahesh
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Matthijs Oudkerk
- Faculty of Medical Sciences, University of Groningen, Groningen, The Netherlands
- Institute of Diagnostic Accuracy Research B.V., Groningen, The Netherlands
| | - Paul E Sijens
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Monique D Dorrius
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Peter M A van Ooijen
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Machine Learning Lab, Data Science Center in Health (DASH), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Hirsch L, Huang Y, Makse HA, Martinez DF, Hughes M, Eskreis-Winkler S, Pinker K, Morris E, Parra LC, Sutton EJ. [WITHDRAWN] Predicting breast cancer with AI for individual risk-adjusted MRI screening and early detection. ARXIV 2024:arXiv:2312.00067v2. [PMID: 38076513 PMCID: PMC10705586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
This paper has been withdrawn by Lukas Hirsch. Major revisions and rewriting in progress.
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Robustness of radiomics to variations in segmentation methods in multimodal brain MRI. Sci Rep 2022; 12:16712. [PMID: 36202934 PMCID: PMC9537186 DOI: 10.1038/s41598-022-20703-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 09/16/2022] [Indexed: 11/09/2022] Open
Abstract
Radiomics in neuroimaging uses fully automatic segmentation to delineate the anatomical areas for which radiomic features are computed. However, differences among these segmentation methods affect radiomic features to an unknown extent. A scan-rescan dataset (n = 46) of T1-weighted and diffusion tensor images was used. Subjects were split into a sleep-deprivation and a control group. Scans were segmented using four segmentation methods from which radiomic features were computed. First, we measured segmentation agreement using the Dice-coefficient. Second, robustness and reproducibility of radiomic features were measured using the intraclass correlation coefficient (ICC). Last, difference in predictive power was assessed using the Friedman-test on performance in a radiomics-based sleep deprivation classification application. Segmentation agreement was generally high (interquartile range = 0.77–0.90) and median feature robustness to segmentation method variation was higher (ICC > 0.7) than scan-rescan reproducibility (ICC 0.3–0.8). However, classification performance differed significantly among segmentation methods (p < 0.001) ranging from 77 to 84%. Accuracy was higher for more recent deep learning-based segmentation methods. Despite high agreement among segmentation methods, subtle differences significantly affected radiomic features and their predictive power. Consequently, the effect of differences in segmentation methods should be taken into account when designing and evaluating radiomics-based research methods.
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Eskreis-Winkler S, Sutton EJ, D’Alessio D, Gallagher K, Saphier N, Stember J, Martinez DF, Morris EA, Pinker K. Breast MRI Background Parenchymal Enhancement Categorization Using Deep Learning: Outperforming the Radiologist. J Magn Reson Imaging 2022; 56:1068-1076. [PMID: 35167152 PMCID: PMC9376189 DOI: 10.1002/jmri.28111] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Background parenchymal enhancement (BPE) is assessed on breast MRI reports as mandated by the Breast Imaging Reporting and Data System (BI-RADS) but is prone to inter and intrareader variation. Semiautomated and fully automated BPE assessment tools have been developed but none has surpassed radiologist BPE designations. PURPOSE To develop a deep learning model for automated BPE classification and to compare its performance with current standard-of-care radiology report BPE designations. STUDY TYPE Retrospective. POPULATION Consecutive high-risk patients (i.e. >20% lifetime risk of breast cancer) who underwent contrast-enhanced screening breast MRI from October 2013 to January 2019. The study included 5224 breast MRIs, divided into 3998 training, 444 validation, and 782 testing exams. On radiology reports, 1286 exams were categorized as high BPE (i.e., marked or moderate) and 3938 as low BPE (i.e., mild or minimal). FIELD STRENGTH/SEQUENCE A 1.5 T or 3 T system; one precontrast and three postcontrast phases of fat-saturated T1-weighted dynamic contrast-enhanced imaging. ASSESSMENT Breast MRIs were used to develop two deep learning models (Slab artificial intelligence (AI); maximum intensity projection [MIP] AI) for BPE categorization using radiology report BPE labels. Models were tested on a heldout test sets using radiology report BPE and three-reader averaged consensus as the reference standards. STATISTICAL TESTS Model performance was assessed using receiver operating characteristic curve analysis. Associations between high BPE and BI-RADS assessments were evaluated using McNemar's chi-square test (α* = 0.025). RESULTS The Slab AI model significantly outperformed the MIP AI model across the full test set (area under the curve of 0.84 vs. 0.79) using the radiology report reference standard. Using three-reader consensus BPE labels reference standard, our AI model significantly outperformed radiology report BPE labels. Finally, the AI model was significantly more likely than the radiologist to assign "high BPE" to suspicious breast MRIs and significantly less likely than the radiologist to assign "high BPE" to negative breast MRIs. DATA CONCLUSION Fully automated BPE assessments for breast MRIs could be more accurate than BPE assessments from radiology reports. LEVEL OF EVIDENCE 4 TECHNICAL EFFICACY STAGE: 3.
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Affiliation(s)
- Sarah Eskreis-Winkler
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY 10065, USA
| | - Elizabeth J. Sutton
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY 10065, USA
| | - Donna D’Alessio
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY 10065, USA
| | - Katherine Gallagher
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY 10065, USA
| | - Nicole Saphier
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY 10065, USA
| | - Joseph Stember
- Department of Radiology, Neuroradiology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Danny F Martinez
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY 10065, USA
| | | | - Katja Pinker
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY 10065, USA
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The potential of predictive and prognostic breast MRI (P2-bMRI). Eur Radiol Exp 2022; 6:42. [PMID: 35989400 PMCID: PMC9393116 DOI: 10.1186/s41747-022-00291-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 06/08/2022] [Indexed: 11/10/2022] Open
Abstract
Magnetic resonance imaging (MRI) is an important part of breast cancer diagnosis and multimodal workup. It provides unsurpassed soft tissue contrast to analyse the underlying pathophysiology, and it is adopted for a variety of clinical indications. Predictive and prognostic breast MRI (P2-bMRI) is an emerging application next to these indications. The general objective of P2-bMRI is to provide predictive and/or prognostic biomarkers in order to support personalisation of breast cancer treatment. We believe P2-bMRI has a great clinical potential, thanks to the in vivo examination of the whole tumour and of the surrounding tissue, establishing a link between pathophysiology and response to therapy (prediction) as well as patient outcome (prognostication). The tools used for P2-bMRI cover a wide spectrum: standard and advanced multiparametric pulse sequences; structured reporting criteria (for instance BI-RADS descriptors); artificial intelligence methods, including machine learning (with emphasis on radiomics data analysis); and deep learning that have shown compelling potential for this purpose. P2-bMRI reuses the imaging data of examinations performed in the current practice. Accordingly, P2-bMRI could optimise clinical workflow, enabling cost savings and ultimately improving personalisation of treatment. This review introduces the concept of P2-bMRI, focusing on the clinical application of P2-bMRI by using semantic criteria.
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de Faria Castro Fleury E, Castro C. Magnetic resonance classification proposal for fibrous capsules in breast silicone implants. Clin Imaging 2022; 91:26-31. [PMID: 35986974 DOI: 10.1016/j.clinimag.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To propose a new classification system for evaluating fibrous capsules around silicone implants using magnetic resonance. METHODS We retrospectively evaluated 90 consecutive patients who underwent breast MRI scans at a single center from February to March 2022. All patients with silicone implants and contrast dynamic sequences were included. Two radiologists classified the fibrous capsules according to the proposed classification in four grades. Interobserver variability was calculated for the final score. For comparison purposes, the inter-rater agreement of background parenchymal enhancement and the amount of fibroglandular tissue were also calculated. RESULTS Reader 1 classified 2 (2.2) fibrous capsules as grade 1, 7 (7.8) as grade 2, 18 (20.0) as grade 3, and 63 (70.0) as grade 4, whereas reader 2 classified 1 (1.1), 9 (10.0), 24 (26.7), and 56 (62.2) fibrous capsules, respectively, for each grade. The interobserver agreement for fibrous capsule classification was moderate (ĸ = 0.65). The inter-rater agreement of background parenchymal enhancement and amount of fibroglandular tissue were fair: ĸ = 0.50 and ĸ = 0.44, respectively. CONCLUSION Our study proposes classifying FC by MRI in patients with SI to standardize the description and classification of the findings with good interobserver agreement.
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Affiliation(s)
| | - Caio Castro
- Femme Laboratório da Mulher, São Paulo/ Brazil
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Tian Y, Guida JL, Koka H, Li EN, Zhu B, Sung H, Chan A, Zhang H, Tang E, Guo C, Deng J, Hu N, Lu N, Gierach GL, Li J, Yang XR. Quantitative Mammographic Density Measurements and Molecular Subtypes in Chinese Women With Breast Cancer. JNCI Cancer Spectr 2021; 5:pkaa092. [PMID: 34651101 DOI: 10.1093/jncics/pkaa092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/25/2020] [Accepted: 09/15/2020] [Indexed: 11/14/2022] Open
Abstract
Background Studies investigating associations between mammographic density (MD) and breast cancer subtypes have generated mixed results. We previously showed that having extremely dense breasts was associated with the human epidermal growth factor receptor-2 (HER2)-enriched subtype in Chinese breast cancer patients. Methods In this study, we reevaluated the MD-subtype association in 1549 Chinese breast cancer patients, using VolparaDensity software to obtain quantitative MD measures. All statistical tests were 2-sided. Results Compared with women with luminal A tumors, women with luminal B/HER2- (odds ratio [OR] = 1.20, 95% confidence interval [CI] = 1.04 to 1.38; P = .01), luminal B/HER2+ (OR = 1.22, 95% CI = 1.03 to 1.46; P = .03), and HER2-enriched tumors (OR = 1.30, 95% CI = 1.06 to 1.59; P = .01) had higher fibroglandular dense volume. These associations were stronger in patients with smaller tumors (<2 cm). In contrast, the triple-negative subtype was associated with lower nondense volume (OR = 0.82, 95% CI = 0.68 to 0.99; P = .04), and the association was only seen among older women (age 50 years or older). Conclusion Although biological mechanisms remain to be investigated, the associations for the HER2-enriched and luminal B subtypes with increasing MD may partially explain the higher prevalence of luminal B and HER2+ breast cancers previously reported in Asian women.
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Affiliation(s)
- Yuan Tian
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jennifer L Guida
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Bethesda, MD, USA.,Division of Cancer Control and Population Sciences, National Cancer Institute, NIH, DHHS, Bethesda, MD, USA
| | - Hela Koka
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Bethesda, MD, USA
| | - Er-Ni Li
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Zhu
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Bethesda, MD, USA
| | - Hyuna Sung
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Bethesda, MD, USA.,Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, USA
| | - Ariane Chan
- Science and Technology, Volpara Health Technologies, Wellington, New Zealand
| | - Han Zhang
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Bethesda, MD, USA
| | - Eric Tang
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Bethesda, MD, USA
| | - Changyuan Guo
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Joseph Deng
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Bethesda, MD, USA
| | - Nan Hu
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Bethesda, MD, USA
| | - Ning Lu
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Gretchen L Gierach
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Bethesda, MD, USA
| | - Jing Li
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaohong R Yang
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Bethesda, MD, USA
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Moshina N, Aase HS, Danielsen AS, Haldorsen IS, Lee CI, Zackrisson S, Hofvind S. Comparing Screening Outcomes for Digital Breast Tomosynthesis and Digital Mammography by Automated Breast Density in a Randomized Controlled Trial: Results from the To-Be Trial. Radiology 2020; 297:522-531. [DOI: 10.1148/radiol.2020201150] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Lo Gullo R, Daimiel I, Rossi Saccarelli C, Bitencourt A, Sevilimedu V, Martinez DF, Jochelson MS, Morris EA, Reiner JS, Pinker K. MRI background parenchymal enhancement, fibroglandular tissue, and mammographic breast density in patients with invasive lobular breast cancer on adjuvant endocrine hormonal treatment: associations with survival. Breast Cancer Res 2020; 22:93. [PMID: 32819432 PMCID: PMC7441557 DOI: 10.1186/s13058-020-01329-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/11/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND To investigate if baseline and/or changes in contralateral background parenchymal enhancement (BPE) and fibroglandular tissue (FGT) measured on magnetic resonance imaging (MRI) and mammographic breast density (MD) can be used as imaging biomarkers for overall and recurrence-free survival in patients with invasive lobular carcinomas (ILCs) undergoing adjuvant endocrine treatment. METHODS Women who fulfilled the following inclusion criteria were included in this retrospective HIPAA-compliant IRB-approved study: unilateral ILC, pre-treatment breast MRI and/or mammography from 2000 to 2010, adjuvant endocrine treatment, follow-up MRI, and/or mammography 1-2 years after treatment onset. BPE, FGT, and mammographic MD of the contralateral breast were independently graded by four dedicated breast radiologists according to BI-RADS. Associations between the baseline levels and change in levels of BPE, FGT, and MD with overall survival and recurrence-free survival were assessed using Kaplan-Meier survival curves and Cox regression analysis. RESULTS Two hundred ninety-eight patients (average age = 54.1 years, range = 31-79) fulfilled the inclusion criteria. The average follow-up duration was 11.8 years (range = 2-19). Baseline and change in levels of BPE, FGT, and MD were not significantly associated with recurrence-free or overall survival. Recurrence-free and overall survival were affected by histological subtype (p < 0.0001), number of metastatic axillary lymph nodes (p < 0.0001), age (p = 0.01), and adjuvant endocrine treatment duration (p < 0.001). CONCLUSIONS Qualitative evaluation of BPE, FGT, and mammographic MD changes cannot predict which patients are more likely to benefit from adjuvant endocrine treatment.
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Affiliation(s)
- Roberto Lo Gullo
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, USA
| | - Isaac Daimiel
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, USA
| | - Carolina Rossi Saccarelli
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, USA
| | - Almir Bitencourt
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, USA
| | - Varadan Sevilimedu
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY, 10017, USA
| | - Danny F Martinez
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, USA
| | - Maxine S Jochelson
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, USA
| | - Elizabeth A Morris
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, USA
| | - Jeffrey S Reiner
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, USA
| | - Katja Pinker
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, USA. .,Department of Biomedical Imaging and Image-guided Therapy, Molecular and Gender Imaging Service, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Wien, Austria.
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Lian J, Li K. A Review of Breast Density Implications and Breast Cancer Screening. Clin Breast Cancer 2020; 20:283-290. [DOI: 10.1016/j.clbc.2020.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 02/10/2020] [Accepted: 03/12/2020] [Indexed: 12/15/2022]
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11
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Quantitative Volumetric K-Means Cluster Segmentation of Fibroglandular Tissue and Skin in Breast MRI. J Digit Imaging 2019; 31:425-434. [PMID: 29047034 DOI: 10.1007/s10278-017-0031-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Mammographic breast density (MBD) is the most commonly used method to assess the volume of fibroglandular tissue (FGT). However, MRI could provide a clinically feasible and more accurate alternative. There were three aims in this study: (1) to evaluate a clinically feasible method to quantify FGT with MRI, (2) to assess the inter-rater agreement of MRI-based volumetric measurements and (3) to compare them to measurements acquired using digital mammography and 3D tomosynthesis. This retrospective study examined 72 women (mean age 52.4 ± 12.3 years) with 105 disease-free breasts undergoing diagnostic 3.0-T breast MRI and either digital mammography or tomosynthesis. Two observers analyzed MRI images for breast and FGT volumes and FGT-% from T1-weighted images (0.7-, 2.0-, and 4.0-mm-thick slices) using K-means clustering, data from histogram, and active contour algorithms. Reference values were obtained with Quantra software. Inter-rater agreement for MRI measurements made with 2-mm-thick slices was excellent: for FGT-%, r = 0.994 (95% CI 0.990-0.997); for breast volume, r = 0.985 (95% CI 0.934-0.994); and for FGT volume, r = 0.979 (95% CI 0.958-0.989). MRI-based FGT-% correlated strongly with MBD in mammography (r = 0.819-0.904, P < 0.001) and moderately to high with MBD in tomosynthesis (r = 0.630-0.738, P < 0.001). K-means clustering-based assessments of the proportion of the fibroglandular tissue in the breast at MRI are highly reproducible. In the future, quantitative assessment of FGT-% to complement visual estimation of FGT should be performed on a more regular basis as it provides a component which can be incorporated into the individual's breast cancer risk stratification.
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Wengert GJ, Helbich TH, Leithner D, Morris EA, Baltzer PAT, Pinker K. Multimodality Imaging of Breast Parenchymal Density and Correlation with Risk Assessment. CURRENT BREAST CANCER REPORTS 2019; 11:23-33. [PMID: 35496471 PMCID: PMC9044508 DOI: 10.1007/s12609-019-0302-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Purpose of Review Breast density, or the amount of fibroglandular tissue in the breast, has become a recognized and independent marker for breast cancer risk. Public awareness of breast density as a possible risk factor for breast cancer has resulted in legislation for risk stratification purposes in many US states. This review will provide a comprehensive overview of the currently available imaging modalities for qualitative and quantitative breast density assessment and the current evidence on breast density and breast cancer risk assessment. Recent Findings To date, breast density assessment is mainly performed with mammography and to some extent with magnetic resonance imaging. Data indicate that computerized, quantitative techniques in comparison with subjective visual estimations are characterized by higher reproducibility and robustness. Summary Breast density reduces the sensitivity of mammography due to a masking effect and is also a recognized independent risk factor for breast cancer. Standardized breast density assessment using automated volumetric quantitative methods has the potential to be used for risk prediction and stratification and in determining the best screening plan for each woman.
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Wengert GJ, Helbich TH, Kapetas P, Baltzer PA, Pinker K. Density and tailored breast cancer screening: practice and prediction - an overview. Acta Radiol Open 2018; 7:2058460118791212. [PMID: 30245850 PMCID: PMC6144518 DOI: 10.1177/2058460118791212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 06/27/2018] [Indexed: 01/13/2023] Open
Abstract
Mammography, as the primary screening modality, has facilitated a substantial
decrease in breast cancer-related mortality in the general population. However,
the sensitivity of mammography for breast cancer detection is decreased in women
with higher breast densities, which is an independent risk factor for breast
cancer. With increasing public awareness of the implications of a high breast
density, there is an increasing demand for supplemental screening in these
patients. Yet, improvements in breast cancer detection with supplemental
screening methods come at the expense of increased false-positives, recall
rates, patient anxiety, and costs. Therefore, breast cancer screening practice
must change from a general one-size-fits-all approach to a more personalized,
risk-based one that is tailored to the individual woman’s risk, personal
beliefs, and preferences, while accounting for cost, potential harm, and
benefits. This overview will provide an overview of the available breast density assessment
modalities, the current breast density screening recommendations for women at
average risk of breast cancer, and supplemental methods for breast cancer
screening. In addition, we will provide a look at the possibilities for a
risk-adapted breast cancer screening.
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Affiliation(s)
- Georg J Wengert
- Department of Biomedical Imaging and Image-guided Therapy, Division of Molecular and Gender Imaging, Medical University of Vienna, Vienna, Austria
| | - Thomas H Helbich
- Department of Biomedical Imaging and Image-guided Therapy, Division of Molecular and Gender Imaging, Medical University of Vienna, Vienna, Austria
| | - Panagiotis Kapetas
- Department of Biomedical Imaging and Image-guided Therapy, Division of Molecular and Gender Imaging, Medical University of Vienna, Vienna, Austria
| | - Pascal At Baltzer
- Department of Biomedical Imaging and Image-guided Therapy, Division of Molecular and Gender Imaging, Medical University of Vienna, Vienna, Austria
| | - Katja Pinker
- Department of Biomedical Imaging and Image-guided Therapy, Division of Molecular and Gender Imaging, Medical University of Vienna, Vienna, Austria.,Department of Radiology, Breast Imaging Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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14
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Saha A, Harowicz MR, Mazurowski MA. Breast cancer MRI radiomics: An overview of algorithmic features and impact of inter-reader variability in annotating tumors. Med Phys 2018; 45:3076-3085. [PMID: 29663411 DOI: 10.1002/mp.12925] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 03/01/2018] [Accepted: 04/04/2018] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To review features used in MRI radiomics of breast cancer and study the inter-reader stability of the features. METHODS We implemented 529 algorithmic features that can be extracted from tumor and fibroglandular tissue (FGT) in breast MRIs. The features were identified based on a review of the existing literature with consideration of their usage, prognostic ability, and uniqueness. The set was then extended so that it comprehensively describes breast cancer imaging characteristics. The features were classified into 10 groups based on the type of data used to extract them and the type of calculation being performed. For the assessment of inter-reader variability, four fellowship-trained readers annotated tumors on preoperative dynamic contrast-enhanced MRIs for 50 breast cancer patients. Based on the annotations, an algorithm automatically segmented the image and extracted all features resulting in one set of features for each reader. For a given feature, the inter-reader stability was defined as the intraclass correlation coefficient (ICC) computed using the feature values obtained through all readers for all cases. RESULTS The average inter-reader stability for all features was 0.8474 (95% CI: 0.8068-0.8858). The mean inter-reader stability was lower for tumor-based features (0.6348, 95% CI: 0.5391-0.7257) than FGT-based features (0.9984, 95% CI: 0.9970-0.9992). The feature group with the highest inter-reader stability quantifies breast and FGT volume. The feature group with the lowest inter-reader stability quantifies variations in tumor enhancement. CONCLUSIONS Breast MRI radiomics features widely vary in terms of their stability in the presence of inter-reader variability. Appropriate measures need to be taken for reducing this variability in tumor-based radiomics.
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Affiliation(s)
- Ashirbani Saha
- Department of Radiology, Duke University School of Medicine, 2424 Erwin Road, Suite 302, Durham, NC, 27705, USA
| | - Michael R Harowicz
- Department of Radiology, Duke University School of Medicine, 2424 Erwin Road, Suite 302, Durham, NC, 27705, USA
| | - Maciej A Mazurowski
- Department of Radiology, Duke University School of Medicine, 2424 Erwin Road, Suite 302, Durham, NC, 27705, USA.,Department of Electrical and Computer Engineering, Duke University, Box 90291, Durham, NC, 27708, USA.,Duke University Medical Physics Program, DUMC 2729, 2424 Erwin Road, Suite 101, Durham, NC, 27705, USA
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15
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Woitek R, Pfeiler G, Farr A, Kapetas P, Furtner J, Bernathova M, Schöpf V, Clauser P, Marino MA, Pinker K, Baltzer PA, Helbich TH. MRI-based quantification of residual fibroglandular tissue of the breast after conservative mastectomies. Eur J Radiol 2018; 104:1-7. [PMID: 29857853 DOI: 10.1016/j.ejrad.2018.04.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 04/23/2018] [Accepted: 04/25/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE Skin-sparing and nipple-sparing mastectomies (SSM; NSM) remove the breast's fibroglandular tissue (FGT), thereby reducing breast cancer risk. The postoperative presence of residual FGT (RFGT) is associated with remaining cancer risk. This study evaluated the role of MRI in the quantitative assessment of RFGT and its impact on the estimation of the remaining breast cancer risk. METHODS The postoperative MRI scans (following EUSOMA recommendations) of 58 patients who had undergone SSM or NSM between 2003 and 2013, as well as preoperative MRI scans that were available in 25 of these patients, were retrospectively evaluated for the presence and location of RFGT by three radiologists. Two different observers quantitatively assessed the volume and percentage of retromamillary and other RFGT (RFGTrm and RFGTother) were assessed. The Fisher's exact test, the Student's t-test, and intraclass coherence were used to compare patient groups and to assess reproducibility. RESULTS RFGT was found in 20% of all breasts and significantly more frequently after NSM than SSM (50% vs. 13%, p = .003). RFGTrm and RFGTother were more prevalent after NSM (p < 0.001; p = .127). RFGT ranged from 0.5 to 26% of the preoperative FGT, with higher percentages after NSM than SSM (p = .181). CONCLUSIONS The prevalence and percentage of RFGT found on MRI indicate a considerable remaining postoperative breast cancer risk in some women.
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Affiliation(s)
- Ramona Woitek
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria
| | - Georg Pfeiler
- Department of Obstetrics and Gynecology, Medical University of Vienna, Austria
| | - Alex Farr
- Department of Obstetrics and Gynecology, Medical University of Vienna, Austria
| | - Panagiotis Kapetas
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria
| | - Julia Furtner
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria
| | - Maria Bernathova
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria
| | | | - Paola Clauser
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria
| | - Maria A Marino
- Department of Biomedical Sciences and Morphologic and Functional Imaging, Policlinico Universitario G. Martino, University of Messina, Messina, Italy
| | - Katja Pinker
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria; Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - Pascal A Baltzer
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria
| | - Thomas H Helbich
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria.
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16
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Bartolotta TV, Orlando A, Cantisani V, Matranga D, Ienzi R, Cirino A, Amato F, Di Vittorio ML, Midiri M, Lagalla R. Focal breast lesion characterization according to the BI-RADS US lexicon: role of a computer-aided decision-making support. Radiol Med 2018; 123:498-506. [PMID: 29569216 DOI: 10.1007/s11547-018-0874-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 03/13/2018] [Indexed: 01/10/2023]
Affiliation(s)
- Tommaso Vincenzo Bartolotta
- Department of Radiology Di.Bi.MED, Policlinico P. Giaccone-University of Palermo, Via Del Vespro 129, 90127, Palermo, Italy.
| | - Alessia Orlando
- Department of Radiology Di.Bi.MED, Policlinico P. Giaccone-University of Palermo, Via Del Vespro 129, 90127, Palermo, Italy
| | - Vito Cantisani
- Department of Radiology, Oncology, and Anatomy Pathology, Policlinico Umberto-University Sapienza, Rome, Italy
| | - Domenica Matranga
- Department of Sciences for Health Promotion and Mother, Child Care, Policlinico P. Giaccone-University of Palermo, Via Del Vespro 129, 90127, Palermo, Italy
| | - Raffele Ienzi
- Department of Radiology Di.Bi.MED, Policlinico P. Giaccone-University of Palermo, Via Del Vespro 129, 90127, Palermo, Italy
| | - Alessandra Cirino
- Department of Radiology Di.Bi.MED, Policlinico P. Giaccone-University of Palermo, Via Del Vespro 129, 90127, Palermo, Italy
| | - Francesco Amato
- Department of Radiology Di.Bi.MED, Policlinico P. Giaccone-University of Palermo, Via Del Vespro 129, 90127, Palermo, Italy
| | - Maria Laura Di Vittorio
- Department of Radiology Di.Bi.MED, Policlinico P. Giaccone-University of Palermo, Via Del Vespro 129, 90127, Palermo, Italy
| | - Massimo Midiri
- Department of Radiology Di.Bi.MED, Policlinico P. Giaccone-University of Palermo, Via Del Vespro 129, 90127, Palermo, Italy
| | - Roberto Lagalla
- Department of Radiology Di.Bi.MED, Policlinico P. Giaccone-University of Palermo, Via Del Vespro 129, 90127, Palermo, Italy
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17
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Hu X, Jiang L, Li Q, Gu Y. Quantitative assessment of background parenchymal enhancement in breast magnetic resonance images predicts the risk of breast cancer. Oncotarget 2018; 8:10620-10627. [PMID: 27895314 PMCID: PMC5354686 DOI: 10.18632/oncotarget.13538] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 11/01/2016] [Indexed: 12/21/2022] Open
Abstract
The objective of this study was to evaluate the association betweenthe quantitative assessment of background parenchymal enhancement rate (BPER) and breast cancer. From 14,033 consecutive patients who underwent breast MRI in our center, we randomly selected 101 normal controls. Then, we selected 101 women with benign breast lesions and 101 women with breast cancer who were matched for age and menstruation status. We evaluated BPER at early (2 minutes), medium (4 minutes) and late (6 minutes) enhanced time phases of breast MRI for quantitative assessment. Odds ratios (ORs) for risk of breast cancer were calculated using the receiver operating curve. The BPER increased in a time-dependent manner after enhancement in both premenopausal and postmenopausal women. Premenopausal women had higher BPER than postmenopausal women at early, medium and late enhanced phases. In the normal population, the OR for probability of breast cancer for premenopausal women with high BPER was 4.1 (95% CI: 1.7–9.7) and 4.6 (95% CI: 1.7–12.0) for postmenopausal women. The OR of breast cancer morbidity in premenopausal women with high BPER was 2.6 (95% CI: 1.1–6.4) and 2.8 (95% CI: 1.2–6.1) for postmenopausal women. The BPER was found to be a predictive factor of breast cancer morbidity. Different time phases should be used to assess BPER in premenopausal and postmenopausal women.
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Affiliation(s)
- Xiaoxin Hu
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Luan Jiang
- Center for Advanced Medical Imaging Technology, Shanghai Advanced Research Institute, Chinese Academy of Sciences, Shanghai, China
| | - Qiang Li
- Center for Advanced Medical Imaging Technology, Shanghai Advanced Research Institute, Chinese Academy of Sciences, Shanghai, China
| | - Yajia Gu
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
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18
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Wengert GJ, Pinker K, Helbich TH, Vogl WD, Spijker SM, Bickel H, Polanec SH, Baltzer PA. Accuracy of fully automated, quantitative, volumetric measurement of the amount of fibroglandular breast tissue using MRI: correlation with anthropomorphic breast phantoms. NMR IN BIOMEDICINE 2017; 30:e3705. [PMID: 28295818 DOI: 10.1002/nbm.3705] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 01/09/2017] [Accepted: 01/09/2017] [Indexed: 06/06/2023]
Abstract
To demonstrate the accuracy of fully automated, quantitative, volumetric measurement of the amount of fibroglandular breast tissue (FGT), using MRI, and to investigate the impact of different MRI sequences using anthropomorphic breast phantoms as the ground truth. In this study, 10 anthropomorphic breast phantoms that consisted of different known fractions of adipose and protein tissue, which closely resembled normal breast parenchyma, were developed. Anthropomorphic breast phantoms were imaged with a 1.5 T unit (Siemens, Avantofit) using an 18-channel breast coil. The sequence protocol consisted of an isotropic Dixon sequence (Di), an anisotropic Dixon sequence (Da), and T1 3D FLASH sequences with and without fat saturation (T1). Fully automated, quantitative, volumetric measurement of FGT for all anthropomorphic phantoms and sequences was performed and correlated with the amounts of fatty and protein components in the phantoms as the ground truth. Fully automated, quantitative, volumetric measurements of FGT with MRI for all sequences ranged from 5.86 to 61.05% (mean 33.36%). The isotropic Dixon sequence yielded the highest accuracy (median 0.51%-0.78%) and precision (median range 0.19%) compared with anisotropic Dixon (median 1.92%-2.09%; median range 0.55%) and T1 -weighted sequences (median 2.54%-2.46%; median range 0.82%). All sequences yielded good correlation with the FGT content of the anthropomorphic phantoms. The best correlation of FGT measurements was identified for Dixon sequences (Di, R2 = 0.999; Da, R2 = 0.998) compared with conventional T1 -weighted sequences (R2 = 0.971). MRI yields accurate, fully automated, quantitative, volumetric measurements of FGT, an increasingly important and sensitive imaging biomarker for breast cancer risk. Compared with conventional T1 sequences, Dixon-type sequences show the highest correlation and reproducibility for automated, quantitative, volumetric FGT measurements using anthropomorphic breast phantoms as the ground truth.
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Affiliation(s)
- Georg J Wengert
- Medical University of Vienna, Department of Biomedical Imaging and Image-Guided Therapy, Division of Molecular and Gender Imaging, Vienna, Austria
| | - Katja Pinker
- Medical University of Vienna, Department of Biomedical Imaging and Image-Guided Therapy, Division of Molecular and Gender Imaging, Vienna, Austria
- Memorial Sloan-Kettering Cancer Center, Dept. of Radiology, New York, USA
| | - Thomas H Helbich
- Medical University of Vienna, Department of Biomedical Imaging and Image-Guided Therapy, Division of Molecular and Gender Imaging, Vienna, Austria
| | - Wolf-Dieter Vogl
- Medical University of Vienna, Department of Biomedical Imaging and Image-Guided Therapy, Division of Molecular and Gender Imaging, Vienna, Austria
| | - Sylvia M Spijker
- University of Vienna, Department of Pharmaceutical Technology and Biopharmaceutics, Faculty of Life Science, Vienna, Austria
| | - Hubert Bickel
- Medical University of Vienna, Department of Biomedical Imaging and Image-Guided Therapy, Division of Molecular and Gender Imaging, Vienna, Austria
| | - Stephan H Polanec
- Medical University of Vienna, Department of Biomedical Imaging and Image-Guided Therapy, Division of Molecular and Gender Imaging, Vienna, Austria
| | - Pascal A Baltzer
- Medical University of Vienna, Department of Biomedical Imaging and Image-Guided Therapy, Division of Molecular and Gender Imaging, Vienna, Austria
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19
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Li H, Weiss WA, Medved M, Abe H, Newstead GM, Karczmar GS, Giger ML. Breast density estimation from high spectral and spatial resolution MRI. J Med Imaging (Bellingham) 2017; 3:044507. [PMID: 28042590 DOI: 10.1117/1.jmi.3.4.044507] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 12/05/2016] [Indexed: 11/14/2022] Open
Abstract
A three-dimensional breast density estimation method is presented for high spectral and spatial resolution (HiSS) MR imaging. Twenty-two patients were recruited (under an Institutional Review Board--approved Health Insurance Portability and Accountability Act-compliant protocol) for high-risk breast cancer screening. Each patient received standard-of-care clinical digital x-ray mammograms and MR scans, as well as HiSS scans. The algorithm for breast density estimation includes breast mask generating, breast skin removal, and breast percentage density calculation. The inter- and intra-user variabilities of the HiSS-based density estimation were determined using correlation analysis and limits of agreement. Correlation analysis was also performed between the HiSS-based density estimation and radiologists' breast imaging-reporting and data system (BI-RADS) density ratings. A correlation coefficient of 0.91 ([Formula: see text]) was obtained between left and right breast density estimations. An interclass correlation coefficient of 0.99 ([Formula: see text]) indicated high reliability for the inter-user variability of the HiSS-based breast density estimations. A moderate correlation coefficient of 0.55 ([Formula: see text]) was observed between HiSS-based breast density estimations and radiologists' BI-RADS. In summary, an objective density estimation method using HiSS spectral data from breast MRI was developed. The high reproducibility with low inter- and low intra-user variabilities shown in this preliminary study suggest that such a HiSS-based density metric may be potentially beneficial in programs requiring breast density such as in breast cancer risk assessment and monitoring effects of therapy.
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Affiliation(s)
- Hui Li
- University of Chicago , Department of Radiology, 5841 South Maryland Avenue, MC 2026, Chicago, Illinois 60637, United States
| | - William A Weiss
- University of Chicago , Department of Radiology, 5841 South Maryland Avenue, MC 2026, Chicago, Illinois 60637, United States
| | - Milica Medved
- University of Chicago , Department of Radiology, 5841 South Maryland Avenue, MC 2026, Chicago, Illinois 60637, United States
| | - Hiroyuki Abe
- University of Chicago , Department of Radiology, 5841 South Maryland Avenue, MC 2026, Chicago, Illinois 60637, United States
| | - Gillian M Newstead
- University of Chicago , Department of Radiology, 5841 South Maryland Avenue, MC 2026, Chicago, Illinois 60637, United States
| | - Gregory S Karczmar
- University of Chicago , Department of Radiology, 5841 South Maryland Avenue, MC 2026, Chicago, Illinois 60637, United States
| | - Maryellen L Giger
- University of Chicago , Department of Radiology, 5841 South Maryland Avenue, MC 2026, Chicago, Illinois 60637, United States
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