31P magnetic resonance spectroscopy of the breast and the influence of the menstrual cycle

Application of in vivo MR methods in the study of breast cancer metabolism

In the last two decades, various in vivo MR methodologies have been evaluated for their potential in the study of cancer metabolism. During malignant transformation, metabolic alterations occur, leading to morphological and functional changes. Among various MR methods, in vivo MRS has been extensively used in breast cancer to study the metabolism of cells, tissues or whole organs. It provides biochemical information at the metabolite level. Altered choline, phospholipid and energy metabolism has been documented using proton (¹ H), phosphorus (³¹ P) and carbon (¹³ C) isotopes. Increased levels of choline-containing compounds, phosphomonoesters and phosphodiesters in breast cancer, which are indicative of altered choline and phospholipid metabolism, have been reported using in vivo, in vitro and ex vivo NMR studies. These changes are reversed on successful therapy, which depends on the treatment regimen given. Monitoring the various tumor intermediary metabolic pathways using nuclear spin hyperpolarization of ¹³ C-labeled substrates by dynamic nuclear polarization has also been recently reported. Furthermore, the utility of various methods such as diffusion, dynamic contrast and perfusion MRI have also been evaluated to study breast tumor metabolism. Parameters such as tumor volume, apparent diffusion coefficient, volume transfer coefficient and extracellular volume ratio are estimated. These parameters provide information on the changes in tumor microstructure, microenvironment, abnormal vasculature, permeability and grade of the tumor. Such changes seen during cancer progression are due to alterations in the tumor metabolism, leading to changes in cell architecture. Due to architectural changes, the tissue mechanical properties are altered; this can be studied using magnetic resonance elastography, which measures the elastic properties of tissues. Moreover, these structural MRI methods can be used to investigate the effect of therapy-induced changes in tumor characteristics. This review discusses the potential of various in vivo MR methodologies in the study of breast cancer metabolism.

Early detection of changes in phospholipid metabolism during neoadjuvant chemotherapy in breast cancer patients using phosphorus magnetic resonance spectroscopy at 7T

The purpose of this work was to investigate whether noninvasive early detection (after the first cycle) of response to neoadjuvant chemotherapy (NAC) in breast cancer patients was possible. ³¹ P-MRSI at 7 T was used to determine different phosphor metabolites ratios and correlate this to pathological response. ³¹ P-MRSI was performed in 12 breast cancer patients treated with NAC. ³¹ P spectra were fitted and aligned to the frequency of phosphoethanolamine (PE). Metabolic signal ratios for phosphomonoesters/phosphodiesters (PME/PDE), phosphocholine/glycerophosphatidylcholine (PC/GPtC), phosphoethanolamine/glycerophosphoethanolamine (PE/GPE) and phosphomonoesters/in-organic phosphate (PME/Pi) were determined from spectral fitting of the individual spectra and the summed spectra before and after the first cycle of NAC. Metabolic ratios were subsequently related to pathological response. Additionally, the correlation between the measured metabolic ratios and Ki-67 levels was determined using linear regression. Four patients had a pathological complete response after treatment, five patients a partial pathological response, and three patients did not respond to NAC. In the summed spectrum after the first cycle of NAC, PME/Pi and PME/PDE decreased by 18 and 13%, respectively. A subtle difference among the different response groups was observed in PME/PDE, where the nonresponders showed an increase and the partial and complete responders a decrease (P = 0.32). No significant changes in metabolic ratios were found. However, a significant association between PE/Pi and the Ki-67 index was found (P = 0.03). We demonstrated that it is possible to detect subtle changes in ³¹ P metabolites with a 7 T MR system after the first cycle of NAC treatment in breast cancer patients. Nonresponders showed different changes in metabolic ratios compared with partial and complete responders, in particular for PME/PDE; however, more patients need to be included to investigate its clinical value.

Molecular Effects of Doxorubicin on Choline Metabolism in Breast Cancer

Abnormal choline phospholipid metabolism is a hallmark of cancer. The magnetic resonance spectroscopy (MRS) detected total choline (tCho) signal can serve as an early noninvasive imaging biomarker of chemotherapy response in breast cancer. We have quantified the individual components of the tCho signal, glycerophosphocholine (GPC), phosphocholine (PC) and free choline (Cho), before and after treatment with the commonly used chemotherapeutic drug doxorubicin in weakly metastatic human MCF7 and triple-negative human MDA-MB-231 breast cancer cells. While the tCho concentration did not change following doxorubicin treatment, GPC significantly increased and PC decreased. Of the two phosphatidylcholine-specific PLD enzymes, only PLD1, but not PLD2, mRNA was down-regulated by doxorubicin treatment. For the two reported genes encoding GPC phosphodiesterase, the mRNA of GDPD6, but not GDPD5, decreased following doxorubicin treatment. mRNA levels of choline kinase α (ChKα), which converts Cho to PC, were reduced following doxorubicin treatment. PLD1 and ChKα protein levels decreased following doxorubicin treatment in a concentration dependent manner. Treatment with the PLD1 specific inhibitor VU0155069 sensitized MCF7 and MDA-MB-231 breast cancer cells to doxorubicin-induced cytotoxicity. Low concentrations of 100 nM of doxorubicin increased MDA-MB-231 cell migration. GDPD6, but not PLD1 or ChKα, silencing by siRNA abolished doxorubicin-induced breast cancer cell migration. Doxorubicin induced GPC increase and PC decrease are caused by reductions in PLD1, GDPD6, and ChKα mRNA and protein expression. We have shown that silencing or inhibiting these genes/proteins can promote drug effectiveness and reduce adverse drug effects. Our findings emphasize the importance of detecting PC and GPC individually.

Breast Tissue Metabolism by Magnetic Resonance Spectroscopy

Metabolic alterations are known to occur with oncogenesis and tumor progression. During malignant transformation, the metabolism of cells and tissues is altered. Cancer metabolism can be studied using advanced technologies that detect both metabolites and metabolic activities. Identification, characterization, and quantification of metabolites (metabolomics) are important for metabolic analysis and are usually done by nuclear magnetic resonance (NMR) or by mass spectrometry. In contrast to the magnetic resonance imaging that is used to monitor the tumor morphology during progression of the disease and during therapy, in vivo NMR spectroscopy is used to study and monitor tumor metabolism of cells/tissues by detection of various biochemicals or metabolites involved in various metabolic pathways. Several in vivo, in vitro and ex vivo NMR studies using ¹H and ³¹P magnetic resonance spectroscopy (MRS) nuclei have documented increased levels of total choline containing compounds, phosphomonoesters and phosphodiesters in human breast cancer tissues, which is indicative of altered choline and phospholipid metabolism. These levels get reversed with successful treatment. Another method that increases the sensitivity of substrate detection by using nuclear spin hyperpolarization of ¹³C-lableled substrates by dynamic nuclear polarization has revived a great interest in the study of cancer metabolism. This review discusses breast tissue metabolism studied by various NMR/MRS methods.

Repeatability of (31) P MRSI in the human brain at 7 T with and without the nuclear Overhauser effect

An often-employed strategy to enhance signals in (31) P MRS is the generation of the nuclear Overhauser effect (NOE) by saturation of the water resonance. However, NOE allegedly increases the variability of the (31) P data, because variation is reported in NOE enhancements. This would negate the signal-to-noise (SNR) gain it generates. We hypothesized that the variation in NOE enhancement values is not caused by the variability in NOE itself, but is attributable to measurement uncertainties in the values used to calculate the enhancement. If true, the expected increase in SNR with NOE would improve the repeatability of (31) P MRS measurements. To verify this hypothesis, a repeatability study of native and NOE-enhanced (31) P MRSI was performed in the brains of seven healthy volunteers at 7 T. The repeatability coefficient (RC) and the coefficient of variation in repeated measurements (CoVrepeat ) were determined for each method, and the 95% limits of agreement (LoAs) between native and NOE-enhanced signals were calculated. The variation between the methods, defined by the LoA, is at least as great as that predicted by the RC of each method. The sources of variation in NOE enhancements were determined using variance component analysis. In the seven metabolites with a positive NOE enhancement (nine metabolite resonances assessed), CoVrepeat improved, on average, by 15%. The LoAs could be explained by the RCs of the individual methods for the majority of the metabolites, generally confirming our hypothesis. Variation in NOE enhancement was mainly attributable to the factor repeat, but between-voxel effects were also present for phosphoethanolamine and (glycero)phosphocholine. CoVrepeat and fitting error were strongly correlated and improved with positive NOE. Our findings generally indicate that NOE enhances the signal of metabolites, improving the repeatability of metabolite measurements. Additional variability as a result of NOE was minimal. These findings encourage the use of NOE-enhanced (31) P MRSI. Copyright © 2015 John Wiley & Sons, Ltd.

Glycerophosphocholine and Glycerophosphoethanolamine Are Not the Main Sources of the In Vivo (31)P MRS Phosphodiester Signals from Healthy Fibroglandular Breast Tissue at 7 T

PURPOSE

The identification of the phosphodiester (PDE) (31)P MR signals in the healthy human breast at ultra-high field.

METHODS

In vivo (31)P MRS measurements at 7 T of the PDE signals in the breast were performed investigating the chemical shifts, the transverse- and the longitudinal relaxation times. Chemical shifts and transverse relaxation times were compared with non-ambiguous PDE signals from the liver.

RESULTS

The chemical shifts of the PDE signals are shifted -0.5 ppm with respect to glycerophosphocholine (GPC) and glycerophosphoethanolamine (GPE), and the transverse and longitudinal relaxation times for these signals are a factor 3 to 4 shorter than expected for aqueous GPC and GPE.

CONCLUSION

The available experimental evidence suggests that GPC and GPE are not the main source of the PDE signals measured in fibroglandular breast tissue at 7 T. These signals may predominantly originate from mobile phospholipids.

Dynamic contrast-enhanced breast MRI at 7T and 3T: an intra-individual comparison study

The aim of this study is to compare the current state of lesion identification, the BI-RADS classification and the contrast-enhancement behavior at 7T and 3T breast MRI in the same patient group. Twenty-seven patients with thirty suspicious lesions were selected for this prospective study and underwent both 7T and 3T MRI. All examinations were rated by two radiologists (R1 and R2) independently on image quality, lesion identification and BI-RADS classification. We assessed sensitivity, specificity, NPV and PPV, observer agreement, lesion sizes, and contrast-enhancement-to-noise ratios (CENRs) of mass lesions. Fifteen of seventeen histopathological proven malignant lesions were detected at both field strengths. Image quality of the dynamic series was good at 7T, and excellent at 3T (P = 0.001 for R1 and P = 0.88 for R2). R1 found higher rates of specificity, NPV and PPV at 7T when compared to 3T, while R2 found the same results for sensitivity, specificity, NPV and PPV for both field strengths. The observers showed excellent agreement for BI-RADS categories at 7T (κ = 0.86) and 3T (κ = 0.93). CENRs were higher at 7T (P = 0.015). Lesion sizes were bigger at 7T according to R2 (P = 0.039). Our comparison study shows that 7T MRI allows BI-RADS conform analysis. Technical improvements, such as acquisition of T2w sequences and adjustment of B1+ field inhomogeneity, are still necessary to allow clinical use of 7T breast MRI.

2D AMESING multi-echo (31)P-MRSI of the liver at 7T allows transverse relaxation assessment and T2-weighted averaging for improved SNR

PURPOSE

Liver diseases are a major global health concern often requiring invasive assessment by needle biopsy. (31)P magnetic resonance spectroscopic imaging (MRSI) allows non-invasive probing of important liver metabolites. Recently, the adiabatic multi-echo spectroscopic imaging sequence with spherical k-space sampling (AMESING) was introduced at 7T, enabling acquisition of T2 information. T2-weighed averaging of the multiple echoes improves signal-to-noise ratio (SNR). The purpose of our study was to implement AMESING MRSI of the liver at 3T and 7T, derive localized T2 information and compare T2-weighted average spectra in terms of SNR.

METHODS

Ten male volunteers underwent 2D AMESING MRSI at 3T and 7T after a minimum four-hour fast. SNR was calculated for PC, PE, Pi, GPE, GPC and α-ATP using maximum peak amplitudes and the SD of the noise. Metabolite peak ratios were calculated after fitting in jMRUI. SNR values and peak ratios were compared with the Wilcoxon signed-rank test.

RESULTS

For the first time liver metabolites' T2 values at 7T were measured: PE (55.6±3.5 ms), PC (51.2±2.3 ms), Pi (46.4±1.1 ms), GPE (44.0±0.8 ms), GPC (50.4±0.8 ms) and α-ATP (18.2±0.4 ms). SNR gain using T2-weighted averaging at 7T resulted in a 1.2× SNR gain. In conjunction with higher field strength and improved coil set-up T2-weighted averaging at 7T allowed a total 3.2× SNR gain compared to 3T FID-only.

CONCLUSION

AMESING 2D MRSI of the liver at 7T provides T2 values that allow T2-weighted averaging of data from multiple echoes resulting in improved SNR.

Saturation-transfer effects and longitudinal relaxation times of (31) P metabolites in fibroglandular breast tissue at 7T

PURPOSE

To investigate longitudinal relaxation times and saturation-transfer effects of phosphorous metabolites in breast fibroglandular tissue in vivo with (31) P MR spectroscopy at 7T.

METHODS

Progressive saturation with adiabatic half passage excitation was used to determine T1 values of (31) P metabolites in a group of six healthy volunteers. Saturation-transfer experiments were performed in seven healthy volunteers by saturating at 0 ppm and 10 ppm with sinc-Gaussian pulses (90 ms; 10-ms pulse interval; B1 = 17 μT) prior to excitation. Localization was performed by surface coils and one-dimensional chemical shift imaging. Data were analyzed via spectral fitting with the JMRUI software package, and T1 values were obtained by fitting the data to the signal equation.

RESULTS

The determined longitudinal relaxation time values at 7T were as follows: phosphoethanolamine, 4.0 ± 0.2 s; phosphocholine, 1.8 ± 0.2 s; inorganic phosphate, 6.1 ± 0.1 s; phosphodiesters, glycerophosphatidylethanolamine plus glycerophosphocholine, 2.1 ± 0.1, and glycerophosphatidylethanolamine, 1.5 ± 0.1s; γ-ATP, 2.1 ± 0.1 s; and α-ATP, 2.0 ± 0.1 s. Saturation-transfer measurements with saturation pulses at 0 ppm showed a significant signal reduction in the phosphodiester 2-3 ppm range, whereas the γ-ATP signal at -2.5 ppm was not affected significantly.

CONCLUSION

Longitudinal relaxation times of phosphorous metabolites in fibroglandular tissue revealed relatively low T1 values for phosphodiesters. Saturation-transfer measurements showed that the phosphodiester signals were the only signals that were affected significantly, possibly indicating the presence of mobile phospholipids. Magn Reson Med 76:402-407, 2016. © 2015 Wiley Periodicals, Inc.

Improving the hyperpolarization of (31)P nuclei by synthetic design

Traditional ³¹P NMR or MRI measurements suffer from low sensitivity relative to ¹H detection and consequently require longer scan times. We show here that hyperpolarization of ³¹P nuclei through reversible interactions with parahydrogen can deliver substantial signal enhancements in a range of regioisomeric phosphonate esters containing a heteroaromatic motif which were synthesized in order to identify the optimum molecular scaffold for polarization transfer. A 3588-fold ³¹P signal enhancement (2.34% polarization) was returned for a partially deuterated pyridyl substituted phosphonate ester. This hyperpolarization level is sufficient to allow single scan ³¹P MR images of a phantom to be recorded at a 9.4 T observation field in seconds that have signal-to-noise ratios of up to 94.4 when the analyte concentration is 10 mM. In contrast, a 12 h 2048 scan measurement under standard conditions yields a signal-to-noise ratio of just 11.4. ³¹P-hyperpolarized images are also reported from a 7 T preclinical scanner.

Detection of alterations in membrane metabolism during neoadjuvant chemotherapy in patients with breast cancer using phosphorus magnetic resonance spectroscopy at 7 Tesla

Here we investigate the feasibility of tumor metabolism monitoring in T1c to T3 breast cancer during neoadjuvant chemotherapy by means of phosphorus (³¹P) magnetic resonance spectroscopy at 7 tesla (T). Five breast cancer patients were examined using a ³¹P MRSI sequence, prior to-, halfway-, and after neoadjuvant chemotherapy. The ³¹P MRSI data were analyzed on group and individual level and compared to a spectrum of a group of healthy volunteers. Ratios of phosphomonoesters (PME) to phosphodiesters (PDE) and phosphomonoesters to inorganic phosphate (Pi) were determined. Histopathologic assessment showed four partial responders and one complete responder to chemotherapy. The ³¹P spectrum of the patient group was distinctly different from the ³¹P spectrum of healthy volunteers and transformed its shape during the course of chemotherapy towards the shape of the spectrum of the healthy volunteers. Prior to chemotherapy the PME to PDE signal ratio and the PME to Pi signal ratio were high, and during the course of the chemotherapy these ratios normalized to the value of the healthy volunteers. Metabolite T₂ values in tumor tissue tended to be lower than those for healthy glandular tissue. Assessment of individual patients showed that four out of five had a significant drop of the PME to Pi ratio by a factor of 2 or more. On average, the pH of the tumor, calculated from chemical shift variation of Pi, was 0.19 units lower before chemotherapy. We have demonstrated that the sensitivity of ³¹P MRSI in breast cancer at 7 T is sufficient to detect alterations in membrane metabolism during neoadjuvant chemotherapy, which may be used for early assessment of treatment efficacy.

Increased sensitivity of 31P MRSI using direct detection integrated with multi-echo polarization transfer (DIMEPT)

Here, we show that the sensitivity of (31)P MRSI of (31)P spins J-coupled to protons can be increased by almost a factor of three when compared with an optimal direct detection free induction decay. By direct detection integrated with multi-echo polarization transfer (DIMEPT), multiple signals from polarization transfer and direct detection can be acquired in one repetition time, with minimal mutual interference, provided that the number of refocusing pulses in the multi-echo polarization transfer part is even. The DIMEPT sequence was implemented on a 7-T body scanner and tested on a phantom and on the breasts of five healthy volunteers. The in vivo signal-to-noise ratio (SNR) enhancement for the J-coupled phosphomonoesters was 270% when compared with an Ernst angle pulse-acquire sequence. However, the phosphodiester signals, presumably mainly mobile phospholipids, had T2 values that were too short to be enhanced. Uncoupled (31)P spins, with sufficiently long T2 values, such as inorganic phosphate, were SNR enhanced by a factor of 1.9 relative to an Ernst-angle excitation pulse-acquire sequence by multi-echo direct detection.

1H/31P polarization transfer at 9.4 Tesla for improved specificity of detecting phosphomonoesters and phosphodiesters in breast tumor models

PURPOSE

To assess the ability of a polarization transfer (PT) magnetic resonance spectroscopy (MRS) technique to improve the detection of the individual phospholipid metabolites phosphocholine (PC), phosphoethanolamine (PE), glycerophosphocholine (GPC), and glycerophosphoethanolamine (GPE) in vivo in breast tumor xenografts.

MATERIALS AND METHODS

The adiabatic version of refocused insensitive nuclei enhanced by polarization transfer (BINEPT) MRS was tested at 9.4 Tesla in phantoms and animal models. BINEPT and pulse-acquire (PA) 31P MRS was acquired consecutively from the same orthotopic MCF-7 (n = 10) and MDA-MB-231 (n = 10) breast tumor xenografts. After in vivo MRS measurements, animals were euthanized, tumors were extracted and high resolution (HR)-MRS was performed. Signal to noise ratios (SNRs) and metabolite ratios were compared for BINEPT and PA MRS, and were also measured and compared with that from HR-MRS.

RESULTS

BINEPT exclusively detected metabolites with 1H-31P coupling such as PC, PE, GPC, and GPE, thereby creating a significantly improved, flat baseline because overlapping resonances from immobile and partly mobile phospholipids were removed without loss of sensitivity. GPE and GPC were more accurately detected by BINEPT in vivo, which enabled a reliable quantification of metabolite ratios such as PE/GPE and PC/GPC, which are important markers of tumor aggressiveness and treatment response.

CONCLUSION

BINEPT is advantageous over PA for detecting and quantifying the individual phospholipid metabolites PC, PE, GPC, and GPE in vivo at high magnetic field strength. As BINEPT can be used clinically, alterations in these phospholipid metabolites can be assessed in vivo for cancer diagnosis and treatment monitoring.

Post-traumatic oedema of the foot after tibial fracture

A total of 97 patients with diaphyseal tibial fractures treated with functional bracing were studied prospectively. Persistent ipsilateral foot swelling was present in 84.5 per cent of the patients. Most of the swellings subsided with time, but a small percentage of them persisted for a duration of 2 years or more after injury. The time for disappearance of the swelling in 50 per cent of the patients was 18.6 weeks. The development of oedema is not related to the age and sex of the patients, the configuration, type and level of the fractures, or the association of a fibular fracture. The bone healed quicker in those who did not have swelling of the foot. Once the swelling has developed, it seems to run its own course and its disappearance is not related to the age and sex, the configuration, type and level of fractures, the association of a fibular fracture, or the time for fracture healing. This complication does not have any adverse effect on the functional recovery of the patients.