Breast tomography with synchrotron radiation: preliminary results

Morphological and Chemical Investigation of Ovarian Structures in a Bovine Model by Contrast-Enhanced X-ray Imaging and Microscopy

An improved understanding of an ovary's structures is highly desirable to support advances in folliculogenesis knowledge and reproductive medicine, with particular attention to fertility preservation options for prepubertal girls with malignant tumors. Although currently the golden standard for structural analysis is provided by combining histological sections, staining, and visible 2D microscopic inspection, synchrotron radiation phase-contrast microtomography is becoming a new challenge for three-dimensional studies at micrometric resolution. To this aim, the proper use of contrast agents can improve the visualization of internal structures in ovary tissues, which normally present a low radiopacity. In this study, we report a comparison of four staining protocols, based on iodine or tungsten containing agents, applied to bovine ovarian tissues fixed in Bouin's solution. The microtomography (microCT) analyses at two synchrotron facilities under different set-ups were performed at different energies in order to maximize the image contrast. While tungsten-based agents allow large structures to be well identified, Iodine ones better highlight smaller features, especially when acquired above the K-edge energy of the specific metal. Further scans performed at lower energy where the setup was optimized for overall quality and sensitivity from phase-contrast still provided highly resolved visualization of follicular and intrafollicular structures at different maturation stages, independent of the staining protocol. The analyses were complemented by X-ray Fluorescence mapping on 2D sections, showing that the tungsten-based agent has a higher penetration in this type of tissues.

Assessment of intraductal carcinoma in situ (DCIS) using grating-based X-ray phase-contrast CT at conventional X-ray sources: An experimental ex-vivo study

BACKGROUND

The extent of intraductal carcinoma in situ (DCIS) is commonly underestimated due to the discontinuous growth and lack of microcalcifications. Specimen radiography has been established to reduce the rate of re-excision. However, the predictive value for margin assessment with conventional specimen radiography for DCIS is low. In this study we assessed the potential of grating-based phase-contrast computed tomography (GBPC-CT) at conventional X-ray sources for specimen tomography of DCIS containing samples.

MATERIALS AND METHODS

GBPC-CT was performed on four ex-vivo breast specimens containing DCIS and invasive carcinoma of non-specific type. Phase-contrast and absorption-based datasets were manually matched with corresponding histological slices as the standard of reference.

RESULTS

Matching of CT images and histology was successful. GBPC-CT showed an improved soft tissue contrast compared to absorption-based images revealing more histological details in the same sections. Non-calcifying DCIS exceeding the invasive tumor could be correlated to areas of dilated bright ducts around the tumor.

CONCLUSIONS

GBPC-CT imaging at conventional X-ray sources offers improved depiction quality for the imaging of breast tissue samples compared to absorption-based imaging, allows the identification of diagnostically relevant tissue details, and provides full three-dimensional assessment of sample margins.

Towards breast tomography with synchrotron radiation at Elettra: first images

The aim of the SYRMA-CT collaboration is to set-up the first clinical trial of phase-contrast breast CT with synchrotron radiation (SR). In order to combine high image quality and low delivered dose a number of innovative elements are merged: a CdTe single photon counting detector, state-of-the-art CT reconstruction and phase retrieval algorithms. To facilitate an accurate exam optimization, a Monte Carlo model was developed for dose calculation using GEANT4. In this study, high isotropic spatial resolution (120 μm)(3) CT scans of objects with dimensions and attenuation similar to a human breast were acquired, delivering mean glandular doses in the range of those delivered in clinical breast CT (5-25 mGy). Due to the spatial coherence of the SR beam and the long distance between sample and detector, the images contain, not only absorption, but also phase information from the samples. The application of a phase-retrieval procedure increases the contrast-to-noise ratio of the tomographic images, while the contrast remains almost constant. After applying the simultaneous algebraic reconstruction technique to low-dose phase-retrieved data sets (about 5 mGy) with a reduced number of projections, the spatial resolution was found to be equal to filtered back projection utilizing a four fold higher dose, while the contrast-to-noise ratio was reduced by 30%. These first results indicate the feasibility of clinical breast CT with SR.

[Phase contrast imaging of the breast. Basic principles and steps towards clinical implementation]

CLINICAL/METHODICAL ISSUE

Breast cancer is the most common cancer and the leading cause of cancer deaths in women worldwide.

STANDARD RADIOLOGICAL METHODS

Mammography is the only imaging technique approved for nationwide breast cancer screening. Digital full field mammography has improved mammographic image quality. Nevertheless, mammography has a low positive predictive value and a low sensitivity especially in mammographically dense breasts. One of the major limitations is the inherently low contrast between healthy breast parenchyma and breast cancer.

METHODICAL INNOVATIONS

Phase contrast imaging is based on the phase shift that occurs when X-rays encounter a change in refractive index between different materials.

PERFORMANCE

The improved soft tissue contrast makes the technology particularly promising for breast diagnostics.

ACHIEVEMENTS

The studies presented here suggest that phase contrast imaging provides additional diagnostic information both using phase contrast mammography and phase contrast computed tomography (CT).

PRACTICAL RECOMMENDATIONS

This paper provides an overview of the basic principles of the phase contrast imaging and describes recent developments towards in vivo and ex vivo phase contrast imaging of the breast.

Diffraction-enhanced Synchrotron Imaging of Bovine Ovaries Ex Vivo

OBJECTIVES

The objective of this study was to test the hypothesis that diffraction-enhanced imaging (DEI), a synchrotron x-ray imaging technique, would provide greater contrast for evaluating bovine ovaries compared with conventional diagnostic ultrasonography.

MATERIALS AND METHODS

Bovine ovaries were evaluated ex vivo as follows: fresh without radiographic arterial contrast (n = 2), fresh with contrast (n = 1), preserved in 10% formalin without contrast (n = 2), and preserved with contrast (n = 1). Each ovary was imaged with DEI and subsequently with ultrasonography and histology. The ability to visualize and differentiate preantral and antral follicles, corpora lutea (CL), and cumulus oocyte complexes (COCs) were compared using DEI, ultrasonography, and histology. The diameter of follicles and CL were measured and compared using ultrasonography, DEI, and histology. The diameter of the smallest follicle detected was reported using each of the three imaging methods. The number of antral follicles (antral follicle count ≥2 mm) was compared between ultrasonography and DEI.

RESULTS

DEI enabled the detection of 71% of follicles and 67% of CL that were detected ultrasonographically. However, DEI did not allow the detection of COCs and cell layers of the follicle wall that were visualized histologically. Luteal tissues were not easily distinguished using DEI, and DEI was inferior for differentiating follicles and CL compared with ultrasonography. The mean follicle diameter was similar between DEI (4.00 ± 0.35 mm, fresh with contrast; 9.62 ± 2.43 mm, fresh without contrast) and ultrasonography (3.85 ± 0.28 mm, fresh with contrast; 8.97 ± 2.60 mm, fresh without contrast) (P > .05). However, the mean follicle diameter was greater using both DEI (4.00 ± 0.35 mm) and ultrasonography (3.85 ± 0.28 mm) compared with histology (2.21 ± 0.38 mm; P = .01, fresh ovaries with contrast). The mean CL diameter was similar between DEI (11.64 ± 1.67 mm), ultrasonography (9.34 ± 0.35 mm), and histology (9.59 ± 0.36 mm) (P > .05). The mean diameter of the smallest follicle detected was similar between DEI (3.06 ± 0.45 mm) and ultrasonography (2.95 ± 0.74 mm); both DEI and ultrasonographic measurements were greater than histology (0.39 ± 0.04 mm, P < .0001). The mean antral follicle count was similar between ultrasonography (6.50 ± 0.71 mm, fresh with no contrast; 6.50 ± 2.50 mm, preserved with no contrast) and DEI (4.50 ± 0.50 mm, fresh with no contrast; 6.50 ± 0.50 mm, preserved with no contrast) (P > .05).

CONCLUSIONS

The contrast resolution of antral follicles, CL, and COCs in bovine ovaries was inferior using DEI compared with ultrasonography and histology. Alternative synchrotron techniques, such as phase-contrast computed tomography and DEI computed tomography, may prove more effective than DEI for imaging ovaries ex vivo.

Visualizing typical features of breast fibroadenomas using phase-contrast CT: an ex-vivo study

Background

Fibroadenoma is the most common benign solid breast lesion type and a very common cause for histologic assessment. To justify a conservative therapy, a highly specific discrimination between fibroadenomas and other breast lesions is crucial. Phase-contrast imaging offers improved soft-tissue contrast and differentiability of fine structures combined with the potential of 3-dimensional imaging. In this study we assessed the potential of grating-based phase-contrast CT imaging for visualizing diagnostically relevant features of fibroadenomas.

Materials and Methods

Grating-based phase-contrast CT was performed on six ex-vivo formalin-fixed breast specimens containing a fibroadenoma and three samples containing benign changes that resemble fibroadenomas using Talbot Lau interferometry and a polychromatic X-ray source. Phase-contrast and simultaneously acquired absorption-based 3D-datasets were manually matched with corresponding histological slices. The visibility of diagnostically valuable features was assessed in comparison with histology as the gold-standard.

Results

In all cases, matching of grating-based phase-contrast CT images and histology was successfully completed. Grating-based phase-contrast CT showed greatly improved differentiation of fine structures and provided accurate depiction of strands of fibrous tissue within the fibroadenomas as well as of the diagnostically valuable dilated, branched ductuli of the fibroadenomas. A clear demarcation of tumor boundaries in all cases was provided by phase- but not absorption-contrast CT.

Conclusions

Pending successful translation of the technology to a clinical setting and considerable reduction of the required dose, the data presented here suggest that grating-based phase-contrast CT may be used as a supplementary non-invasive diagnostic tool in breast diagnostics. Phase-contrast CT may thus contribute to the reduction of false positive findings and reduce the recall and core biopsy rate in population-based screening. Phase-contrast CT may further be used to assist during histopathological workup, offering a 3D view of the tumor and helping to identify diagnostically valuable tissue sections within large tumors.

X-ray phase-contrast imaging of the breast--advances towards clinical implementation

Breast cancer constitutes about one-quarter of all cancers and is the leading cause of cancer death in women. To reduce breast cancer mortality, mammographic screening programmes have been implemented in many Western countries. However, these programmes remain controversial because of the associated radiation exposure and the need for improvement in terms of diagnostic accuracy. Phase-contrast imaging is a new X-ray-based technology that has been shown to provide enhanced soft-tissue contrast and improved visualization of cancerous structures. Furthermore, there is some indication that these improvements of image quality can be maintained at reduced radiation doses. Thus, X-ray phase-contrast mammography may significantly contribute to advancements in early breast cancer diagnosis. Feasibility studies of X-ray phase-contrast breast CT have provided images that allow resolution of the fine structure of tissue that can otherwise only be obtained by histology. This implies that X-ray phase-contrast imaging may also lead to the development of entirely new (micro-) radiological applications. This review provides a brief overview of the physical characteristics of this new technology and describes recent developments towards clinical implementation of X-ray phase-contrast imaging of the breast.

Personalized estimates of radiation dose from dedicated breast CT in a diagnostic population and comparison with diagnostic mammography

This study retrospectively analyzed the mean glandular dose (MGD) to 133 breasts from 132 subjects, all women, who participated in a clinical trial evaluating dedicated breast CT in a diagnostic population. The clinical trial was conducted in adherence to a protocol approved by institutional review boards and the study participants provided written informed consent. Individual estimates of MGD to each breast from dedicated breast CT was obtained by combining x-ray beam characteristics with estimates of breast dimensions and fibroglandular fraction from volumetric breast CT images, and using normalized glandular dose coefficients. For each study participant and for the breast corresponding to that imaged with breast CT, an estimate of the MGD from diagnostic mammography (including supplemental views) was obtained from the DICOM image headers for comparison. This estimate uses normalized glandular dose coefficients corresponding to a breast with 50% fibroglandular weight fraction. The median fibroglandular weight fraction for the study cohort determined from volumetric breast CT images was 15%. Hence, the MGD from diagnostic mammography was corrected to be representative of the study cohort. Individualized estimates of MGD from breast CT ranged from 5.7 to 27.8 mGy. Corresponding to the breasts imaged with breast CT, the MGD from diagnostic mammography ranged from 2.6 to 31.6 mGy. The mean (± inter-breast SD) and the median MGD (mGy) from dedicated breast CT exam were 13.9 ± 4.6 and 12.6, respectively. For the corresponding breasts, the mean (± inter-breast SD) and the median MGD (mGy) from diagnostic mammography were 12.4 ± 6.3 and 11.1, respectively. Statistical analysis indicated that at the 0.05 level, the distributions of MGD from dedicated breast CT and diagnostic mammography were significantly different (Wilcoxon signed ranks test, p = 0.007). While the interquartile range and the range (maximum-minimum) of MGD from dedicated breast CT was lower than diagnostic mammography, the median MGD from dedicated breast CT was approximately 13.5% higher than that from diagnostic mammography. The MGD for breast CT is based on a 1.45 mm skin layer and that for diagnostic mammography is based on a 4 mm skin layer; thus, favoring a lower estimate for MGD from diagnostic mammography. The median MGD from dedicated breast CT corresponds to the median MGD from four to five diagnostic mammography views. In comparison, for the same 133 breasts, the mean and the median number of views per breast during diagnostic mammography were 4.53 and 4, respectively. Paired analysis showed that there was approximately equal likelihood of receiving lower MGD from either breast CT or diagnostic mammography. Future work will investigate methods to reduce and optimize radiation dose from dedicated breast CT.

Dedicated breast CT: geometric design considerations to maximize posterior breast coverage

An Institutional Review Board-approved protocol was used to quantify breast tissue inclusion in 52 women, under conditions simulating both craniocaudal (CC) and mediolateral oblique (MLO) views in mammography, dedicated breast CT in the upright subject position, and dedicated breast CT in the prone subject position. Using skin as a surrogate for the underlying breast tissue, the posterior aspect of the breast that is aligned with the chest-wall edge of the breast support in a screen-film mammography system was marked with the study participants positioned for CC and MLO views. The union of skin marks with the study participants positioned for CC and MLO views was considered to represent chest-wall tissue available for imaging with mammography and served as the reference standard. For breast CT, a prone stereotactic breast biopsy unit and a custom-fabricated barrier were used to simulate conditions during prone and upright breast CT, respectively. For the same breast marked on the mammography system, skin marks were made along the breast periphery that was just anterior to the apertures of the prone biopsy unit and the upright barrier. The differences in skin marks between subject positioning simulating breast CT (prone, upright) and mammography were quantified at six anatomic locations. For each location, at least one study participant had a skin mark from breast CT (prone, upright) posterior to mammography. However for all study participants, there was at least one anatomic location where the skin mark from mammography was posterior to that from breast CT (prone, upright) positioning. The maximum amount by which the skin mark from mammography was posterior to breast CT (prone and upright) over all six locations was quantified for each study participant and pair-wise comparison did not exhibit statistically significant difference between prone and upright breast CT (paired t- test, p = 0.4). Quantitatively, for 95% of the study participants the skin mark from mammography was posterior to breast CT (prone or upright) by at the most 9 mm over all six locations. Based on the study observations, geometric design considerations targeting chest-wall coverage with breast CT equivalent to mammography, wherein part of the x-ray beam images through the swale during breast CT are provided. Assuming subjects can extend their chest in to a swale, the optimal swale-depth required to achieve equivalent coverage with breast CT images as mammograms for 95% of the subjects varies in the range of ~30-50 mm for clinical prototypes and was dependent on the system geometry.

PITRE: software for phase-sensitive X-ray image processing and tomography reconstruction

Synchrotron-radiation computed tomography has been applied in many research fields. Here, PITRE (Phase-sensitive X-ray Image processing and Tomography REconstruction) and PITRE_BM (PITRE Batch Manager) are presented. PITRE supports phase retrieval for propagation-based phase-contrast imaging/tomography (PPCI/PPCT), extracts apparent absorption, refractive and scattering information of diffraction enhanced imaging (DEI), and allows parallel-beam tomography reconstruction for conventional absorption CT data and for PPCT phase retrieved and DEI-CT extracted information. PITRE_BM is a batch processing manager for PITRE: it executes a series of tasks, created via PITRE, without manual intervention. Both PITRE and PITRE_BM are coded in Interactive Data Language (IDL), and have a user-friendly graphical user interface. They are freeware and can run on Microsoft Windows systems via IDL Virtual Machine, which can be downloaded for free and does not require a license. The data-processing principle and some examples of application will be presented.

The mammography project at the SYRMEP beamline

A clinical program for X-ray phase contrast (PhC) mammography with synchrotron radiation (SR) has been started in March 2006 at the SYRMEP beamline of Elettra, the SR facility in Trieste, Italy. The original beamline layout has been modified substantially and a clinical facility has been realized. In order to fulfill all security requirements, dedicated systems have been designed and implemented, following redundancy criteria and "fail safe" philosophy. Planar radiographic images are obtained by scanning simultaneously the patient and the detector through the stationary and laminar SR beam. In this first phase of the project a commercial screen-film system has been used as image receptor. Upon approval by the respective authorities, the mammography program is about half way to conclusion. Up to now about 50 patients have been examined. The patients are volunteers recruited by the radiologist after conventional examinations at the hospital resulted in an uncertain diagnosis. As an example one case of PhC SR mammography is shown and compared to conventional digital mammography. Preliminary analysis shows the high diagnostic quality of the PhC SR images that were acquired with equal or less delivered dose compared to the conventional ones.

High-resolution CT by diffraction-enhanced x-ray imaging: mapping of breast tissue samples and comparison with their histo-pathology

The aim of this study was to introduce high-resolution computed tomography (CT) of breast tumours using the diffraction-enhanced x-ray imaging (DEI) technique and to compare results with radiological and histo-pathological examinations. X-ray CT images of tumour-bearing breast tissue samples were acquired by monochromatic synchrotron radiation (SR). Due to the narrow beam and a large sample-to-detector distance scattering is rejected in the absorption contrast images (SR-CT). Large contrast enhancement is achieved by the use of the DEI-CT method, where the effects of refraction and scatter rejection are analysed by crystal optics. Clinical mammograms and CT images were recorded as reference material for a radiological examination. Three malignant and benign samples were studied in detail. Their radiographs were compared with optical images of stained histological sections. The DEI-CT images map accurately the morphology of the samples, including collagen strands and micro-calcifications of dimensions less than 0.1 mm. Histo-pathological examination and reading of the radiographs were done independently, and the conclusions were in general agreement. High-resolution DEI-CT images show strong contrast and permit visualization of details invisible in clinical radiographs. The radiation dose may be reduced by an order of magnitude without compromising image quality, which would make possible clinical in vivo DEI-CT with future compact SR sources.

Analyser-based mammography using single-image reconstruction

We implement an algorithm that is able to decode a single analyser-based x-ray phase-contrast image of a sample, converting it into an equivalent conventional absorption-contrast radiograph. The algorithm assumes the projection approximation for x-ray propagation in a single-material object embedded in a substrate of approximately uniform thickness. Unlike the phase-contrast images, which have both directional bias and a bias towards edges present in the sample, the reconstructed images are directly interpretable in terms of the projected absorption coefficient of the sample. The technique was applied to a Leeds TOR[MAM] phantom, which is designed to test mammogram quality by the inclusion of simulated microcalcifications, filaments and circular discs. This phantom was imaged at varying doses using three modalities: analyser-based synchrotron phase-contrast images converted to equivalent absorption radiographs using our algorithm, slot-scanned synchrotron imaging and imaging using a conventional mammography unit. Features in the resulting images were then assigned a quality score by volunteers. The single-image reconstruction method achieved higher scores at equivalent and lower doses than the conventional mammography images, but no improvement of visualization of the simulated microcalcifications, and some degradation in image quality at reduced doses for filament features.