Early prediction of therapy responses and outcomes in breast cancer patients using quantitative ultrasound spectral texture

Exploring Neoadjuvant Chemotherapy, Predictive Models, Radiomic, and Pathological Markers in Breast Cancer: A Comprehensive Review

Breast cancer retains its position as the most prevalent form of malignancy among females on a global scale. The careful selection of appropriate treatment for each patient holds paramount importance in effectively managing breast cancer. Neoadjuvant chemotherapy (NACT) plays a pivotal role in the comprehensive treatment of this disease. Administering chemotherapy before surgery, NACT becomes a powerful tool in reducing tumor size, potentially enabling fewer invasive surgical procedures and even rendering initially inoperable tumors amenable to surgery. However, a significant challenge lies in the varying responses exhibited by different patients towards NACT. To address this challenge, researchers have focused on developing prediction models that can identify those who would benefit from NACT and those who would not. Such models have the potential to reduce treatment costs and contribute to a more efficient and accurate management of breast cancer. Therefore, this review has two objectives: first, to identify the most effective radiomic markers correlated with NACT response, and second, to explore whether integrating radiomic markers extracted from radiological images with pathological markers can enhance the predictive accuracy of NACT response. This review will delve into addressing these research questions and also shed light on the emerging research direction of leveraging artificial intelligence techniques for predicting NACT response, thereby shaping the future landscape of breast cancer treatment.

Quantitative Ultrasound for Evaluation of Tumour Response to Ultrasound-Microbubbles and Hyperthermia

Objectives: Prior study has demonstrated the implementation of quantitative ultrasound (QUS) for determining the therapy response in breast tumour patients. Several QUS parameters quantified from the tumour region showed a significant correlation with the patient's clinical and pathological response. In this study, we aim to identify if there exists such a link between QUS parameters and changes in tumour morphology due to combined ultrasound-stimulated microbubbles (USMB) and hyperthermia (HT) using the breast xenograft model (MDA-MB-231). Method: Tumours grown in the hind leg of severe combined immuno-deficient mice were treated with permutations of USMB and HT. Ultrasound radiofrequency data were collected using a 25 MHz array transducer, from breast tumour-bearing mice prior and post-24-hour treatment. Result: Our result demonstrated an increase in the QUS parameters the mid-band fit and spectral 0-MHz intercept with an increase in HT duration combined with USMB which was found to be reflective of tissue structural changes and cell death detected using haematoxylin and eosin and terminal deoxynucleotidyl transferase dUTP nick end labelling stain. A significant decrease in QUS spectral parameters was observed at an HT duration of 60 minutes, which is possibly due to loss of nuclei by the majority of cells as confirmed using histology analysis. Morphological alterations within the tumour might have contributed to the decrease in backscatter parameters. Conclusion: The work here uses the QUS technique to assess the efficacy of cancer therapy and demonstrates that the changes in ultrasound backscatters mirrored changes in tissue morphology.

Predictive Biomarkers of Response to Neoadjuvant Chemotherapy in Breast Cancer: Current and Future Perspectives for Precision Medicine

Pathological complete response (pCR) after neoadjuvant chemotherapy in patients with early breast cancer is correlated with better survival. Meanwhile, an expanding arsenal of post-neoadjuvant treatment strategies have proven beneficial in the absence of pCR, leading to an increased use of neoadjuvant systemic therapy in patients with early breast cancer and the search for predictive biomarkers of response. The better prediction of response to neoadjuvant chemotherapy could enable the escalation or de-escalation of neoadjuvant treatment strategies, with the ultimate goal of improving the clinical management of early breast cancer. Clinico-pathological prognostic factors are currently used to estimate the potential benefit of neoadjuvant systemic treatment but are not accurate enough to allow for personalized response prediction. Other factors have recently been proposed but are not yet implementable in daily clinical practice or remain of limited utility due to the intertumoral heterogeneity of breast cancer. In this review, we describe the current knowledge about predictive factors for response to neoadjuvant chemotherapy in breast cancer patients and highlight the future perspectives that could lead to the better prediction of response, focusing on the current biomarkers used for clinical decision making and the different gene signatures that have recently been proposed for patient stratification and the prediction of response to therapies. We also discuss the intratumoral phenotypic heterogeneity in breast cancers as well as the emerging techniques and relevant pre-clinical models that could integrate this biological factor currently limiting the reliable prediction of response to neoadjuvant systemic therapy.

Backscatter properties of two-layer phantoms using a high-frequency ultrasound annular array

In a previous study, an annular-array transducer was employed to characterize homogeneous scattering phantoms and excised rat livers using backscatter envelope statistics and frequency domain analysis. A sound field correction method was also applied to take into account the average attenuation of the entire scattering medium. Here, we further generalized the evaluation of backscatter coefficient (BSC) using the annular array in order to study skin tissues with a complicated structure. In layered phantoms composed of two types of media with different scattering characteristics, the BSC was evaluated by the usual attenuation correction method, which revealed an expected large difference from the predicted BSC. In order to improve the BSC estimate, a correction method that applied the attenuation of each layer as a reference combined with a method that corrects based on the attenuation of the analysis position were applied. It was found that the method using the average attenuation of each layer is the most effective. This correction method is well adapted to the extended depth of field provided by an annular array.

Early Changes in Quantitative Ultrasound Imaging Parameters during Neoadjuvant Chemotherapy to Predict Recurrence in Patients with Locally Advanced Breast Cancer

BACKGROUND

This study was conducted to explore the use of quantitative ultrasound (QUS) in predicting recurrence for patients with locally advanced breast cancer (LABC) early during neoadjuvant chemotherapy (NAC).

METHODS

Eighty-three patients with LABC were scanned with 7 MHz ultrasound before starting NAC (week 0) and during treatment (week 4). Spectral parametric maps were generated corresponding to tumor volume. Twenty-four textural features (QUS-Tex¹) were determined from parametric maps acquired using grey-level co-occurrence matrices (GLCM) for each patient, which were further processed to generate 64 texture derivatives (QUS-Tex¹-Tex²), leading to a total of 95 features from each time point. Analysis was carried out on week 4 data and compared to baseline (week 0) data. ∆Week 4 data was obtained from the difference in QUS parameters, texture features (QUS-Tex¹), and texture derivatives (QUS-Tex¹-Tex²) of week 4 data and week 0 data. Patients were divided into two groups: recurrence and non-recurrence. Machine learning algorithms using k-nearest neighbor (k-NN) and support vector machines (SVMs) were used to generate radiomic models. Internal validation was undertaken using leave-one patient out cross-validation method.

RESULTS

With a median follow up of 69 months (range 7-118 months), 28 patients had disease recurrence. The k-NN classifier was the best performing algorithm at week 4 with sensitivity, specificity, accuracy, and area under curve (AUC) of 87%, 75%, 81%, and 0.83, respectively. The inclusion of texture derivatives (QUS-Tex¹-Tex²) in week 4 QUS data analysis led to the improvement of the classifier performances. The AUC increased from 0.70 (0.59 to 0.79, 95% confidence interval) without texture derivatives to 0.83 (0.73 to 0.92) with texture derivatives. The most relevant features separating the two groups were higher-order texture derivatives obtained from scatterer diameter and acoustic concentration-related parametric images.

CONCLUSIONS

This is the first study highlighting the utility of QUS radiomics in the prediction of recurrence during the treatment of LABC. It reflects that the ongoing treatment-related changes can predict clinical outcomes with higher accuracy as compared to pretreatment features alone.

Deep learning of quantitative ultrasound multi-parametric images at pre-treatment to predict breast cancer response to chemotherapy

In this study, a novel deep learning-based methodology was investigated to predict breast cancer response to neo-adjuvant chemotherapy (NAC) using the quantitative ultrasound (QUS) multi-parametric imaging at pre-treatment. QUS multi-parametric images of breast tumors were generated using the data acquired from 181 patients diagnosed with locally advanced breast cancer and planned for NAC followed by surgery. The ground truth response to NAC was identified for each patient after the surgery using the standard clinical and pathological criteria. Two deep convolutional neural network (DCNN) architectures including the residual network and residual attention network (RAN) were explored for extracting optimal feature maps from the parametric images, with a fully connected network for response prediction. In different experiments, the features maps were derived from the tumor core only, as well as the core and its margin. Evaluation results on an independent test set demonstrate that the developed model with the RAN architecture to extract feature maps from the expanded parametric images of the tumor core and margin had the best performance in response prediction with an accuracy of 88% and an area under the receiver operating characteristic curve of 0.86. Ten-year survival analyses indicate statistically significant differences between the survival of the responders and non-responders identified based on the model prediction at pre-treatment and the standard criteria at post-treatment. The results of this study demonstrate the promising capability of DCNNs with attention mechanisms in predicting breast cancer response to NAC prior to the start of treatment using QUS multi-parametric images.

Characterizing intra-tumor regions on quantitative ultrasound parametric images to predict breast cancer response to chemotherapy at pre-treatment

The efficacy of quantitative ultrasound (QUS) multi-parametric imaging in conjunction with unsupervised classification algorithms was investigated for the first time in characterizing intra-tumor regions to predict breast tumor response to chemotherapy before the start of treatment. QUS multi-parametric images of breast tumors were generated using the ultrasound radiofrequency data acquired from 181 patients diagnosed with locally advanced breast cancer and planned for neo-adjuvant chemotherapy followed by surgery. A hidden Markov random field (HMRF) expectation maximization (EM) algorithm was applied to identify distinct intra-tumor regions on QUS multi-parametric images. Several features were extracted from the segmented intra-tumor regions and tumor margin on different parametric images. A multi-step feature selection procedure was applied to construct a QUS biomarker consisting of four features for response prediction. Evaluation results on an independent test set indicated that the developed biomarker coupled with a decision tree model with adaptive boosting (AdaBoost) as the classifier could predict the treatment response of patient at pre-treatment with an accuracy of 85.4% and an area under the receiver operating characteristic (ROC) curve (AUC) of 0.89. In comparison, the biomarkers consisted of the features derived from the entire tumor core (without consideration of the intra-tumor regions), and the entire tumor core and the tumor margin could predict the treatment response of patients with an accuracy of 74.5% and 76.4%, and an AUC of 0.79 and 0.76, respectively. Standard clinical features could predict the therapy response with an accuracy of 69.1% and an AUC of 0.6. Long-term survival analyses indicated that the patients predicted by the developed model as responders had a significantly better survival compared to the non-responders. Similar findings were observed for the two response cohorts identified at post-treatment based on standard clinical and pathological criteria. The results obtained in this study demonstrated the potential of QUS multi-parametric imaging integrated with unsupervised learning methods in identifying distinct intra-tumor regions in breast cancer to characterize its responsiveness to chemotherapy prior to the start of treatment.

A priori prediction of response in multicentre locally advanced breast cancer (LABC) patients using quantitative ultrasound and derivative texture methods

PURPOSE

We develop a multi-centric response predictive model using QUS spectral parametric imaging and novel texture-derivate methods for determining tumour responses to neoadjuvant chemotherapy (NAC) prior to therapy initiation.

MATERIALS AND METHODS

QUS Spectroscopy provided parametric images of mid-band-fit (MBF), spectral-slope (SS), spectral-intercept (SI), average-scatterer-diameter (ASD), and average-acoustic-concentration (AAC) in 78 patients with locally advanced breast cancer (LABC) undergoing NAC. Ultrasound radiofrequency data were collected from Sunnybrook Health Sciences Center (SHSC), University of Texas MD Anderson Cancer Center (MD-ACC), and St. Michaels Hospital (SMH) using two different systems. Texture analysis was used to quantify heterogeneities of QUS parametric images. Further, a second-pass texture analysis was applied to obtain texture-derivate features. QUS, texture- and texture-derivate parameters were determined from both tumour core and a 5-mm tumour margin and were used in comparison to histopathological analysis for developing a response predictive model to classify responders versus non-responders. Model performance was assessed using leave-one-out cross-validation. Three standard classification algorithms including a linear discriminant analysis (LDA), k-nearest-neighbors (KNN), and support vector machines-radial basis function (SVM-RBF) were evaluated.

RESULTS

A combination of tumour core and margin classification resulted in a peak response prediction performance of 88% sensitivity, 78% specificity, 84% accuracy, 0.86 AUC, 84% PPV, and 83% NPV, achieved using the SVM-RBF classification algorithm. Other parameters and classifiers performed less well running from 66% to 80% accuracy.

CONCLUSIONS

A QUS-based framework and novel texture-derivative method enabled accurate prediction of responses to NAC. Multi-centric response predictive model provides indications of the robustness of the approach to variations due to different ultrasound systems and acquisition parameters.

Comparison of methods for texture analysis of QUS parametric images in the characterization of breast lesions

PURPOSE

Accurate and timely diagnosis of breast carcinoma is very crucial because of its high incidence and high morbidity. Screening can improve overall prognosis by detecting the disease early. Biopsy remains as the gold standard for pathological confirmation of malignancy and tumour grading. The development of diagnostic imaging techniques as an alternative for the rapid and accurate characterization of breast masses is necessitated. Quantitative ultrasound (QUS) spectroscopy is a modality well suited for this purpose. This study was carried out to evaluate different texture analysis methods applied on QUS spectral parametric images for the characterization of breast lesions.

METHODS

Parametric images of mid-band-fit (MBF), spectral-slope (SS), spectral-intercept (SI), average scatterer diameter (ASD), and average acoustic concentration (AAC) were determined using QUS spectroscopy from 193 patients with breast lesions. Texture methods were used to quantify heterogeneities of the parametric images. Three statistical-based approaches for texture analysis that include Gray Level Co-occurrence Matrix (GLCM), Gray Level Run-length Matrix (GRLM), and Gray Level Size Zone Matrix (GLSZM) methods were evaluated. QUS and texture-parameters were determined from both tumour core and a 5-mm tumour margin and were used in comparison to histopathological analysis in order to classify breast lesions as either benign or malignant. We developed a diagnostic model using different classification algorithms including linear discriminant analysis (LDA), k-nearest neighbours (KNN), support vector machine with radial basis function kernel (SVM-RBF), and an artificial neural network (ANN). Model performance was evaluated using leave-one-out cross-validation (LOOCV) and hold-out validation.

RESULTS

Classifier performances ranged from 73% to 91% in terms of accuracy dependent on tumour margin inclusion and classifier methodology. Utilizing information from tumour core alone, the ANN achieved the best classification performance of 93% sensitivity, 88% specificity, 91% accuracy, 0.95 AUC using QUS parameters and their GLSZM texture features.

CONCLUSIONS

A QUS-based framework and texture analysis methods enabled classification of breast lesions with >90% accuracy. The results suggest that optimizing method for extracting discriminative textural features from QUS spectral parametric images can improve classification performance. Evaluation of the proposed technique on a larger cohort of patients with proper validation technique demonstrated the robustness and generalization of the approach.

Breast lesion characterization using Quantitative Ultrasound (QUS) and derivative texture methods

PURPOSE

Accurate and timely diagnosis of breast cancer is extremely important because of its high incidence and high morbidity. Early diagnosis of breast cancer through screening can improve overall prognosis. Currently, biopsy remains as the gold standard for tumor pathological confirmation. Development of diagnostic imaging techniques for rapid and accurate characterization of breast lesions is required. We aim to evaluate the usefulness of texture-derivate features of QUS spectral parametric images for non-invasive characterization of breast lesions.

METHODS

QUS Spectroscopy was used to determine parametric images of mid-band fit (MBF), spectral slope (SS), spectral intercept (SI), average scatterer diameter (ASD), and average acoustic concentration (AAC) in 204 patients with suspicious breast lesions. Subsequently, texture analysis techniques were used to generate texture maps from parametric images to quantify heterogeneities of QUS parametric images. Further, a second-pass texture analysis was applied to obtain texture-derivate features. QUS parameters, texture-parameters and texture-derivate parameters were determined from both tumor core and a 5-mm tumor margin and were used in comparison to histopathological analysis in order to develop a diagnostic model for classifying breast lesions as either benign or malignant. Both leave-one-out and hold-out cross-validations were used to evaluate the performance of the diagnostic model. Three standard classification algorithms including a linear discriminant analysis (LDA), k-nearest neighbors (KNN), and support vector machines-radial basis function (SVM-RBF) were evaluated.

RESULTS

Core and margin information using the SVM-RBF attained the best classification performance of 90% sensitivity, 92% specificity, 91% accuracy, and 0.93 AUC utilizing QUS parameters and their texture derivatives, evaluated using leave-one-out cross-validation. Implementation of hold-out cross-validation using combination of both core and margin information and SVM-RBF achieved average accuracy and AUC of 88% and 0.92, respectively.

CONCLUSIONS

QUS-based framework and derivative texture methods enable accurate classification of breast lesions. Evaluation of the proposed technique on a large cohort using hold-out cross-validation demonstrates its robustness and its generalization.

Clinical value and application of contrast-enhanced ultrasound in the differential diagnosis of malignant and benign breast lesions

The aim of the present study was to assess the performance of contrast-enhanced ultrasound in distinguishing between malignant and benign breast lesions and the diagnostic value of its clinical application. A total of 52 cases with malignant breast tumors and 73 cases with benign breast lesions were included in the study. Time-intensity curves (TICs) for contrast-enhanced ultrasound were recorded, and the perfusion parameters were obtained and analyzed. Typical features of malignant breast tumors included irregular shape and vascular morphology, uneven contrast agent distribution, filling defects and contrast agent retention, ‘fast-out’ wash-out mode, unclear boundaries and uneven internal echo. Benign lesions were characterized by ‘slow-out’ or synchronous wash-out mode. Regarding perfusion, the starting time of the perfusion of the Sone-Vue microbubble contrast (always 20-30 sec) and time to peak (TTP) were significantly earlier for the malignant lesions, while the wash-out time was later. A significantly greater peak intensity, rising slope and area under the TIC were observed for the malignant breast lesions. All of the malignant breast lesions exhibited an enlarged focus scope on ultrasound, while no obvious focus scope enhancement was observed for benign breast lesions. Furthermore, the TICs of 88.4% of malignant breast lesions were of the fast-rising and slow-declining type, while the TICs of 75.3 and 17.8% of the benign breast lesions were of the slow-rising and fast-declining, and fast-rising and fast-declining type, respectively. Receiver operating characteristics analysis indicated that the TTP, wash-out time and rising slope might contribute to the differential diagnosis between malignant and benign breast lesions. In conclusion, TIC parameters of contrast-enhanced ultrasound have promising clinical value in differentiating between malignant and benign breast lesions. The TTP, wash-out time and rising slope may contribute to the diagnosis of patients with breast lesions to facilitate timely treatment and prognostication of breast cancer patients.

Quantitative ultrasound radiomics in predicting response to neoadjuvant chemotherapy in patients with locally advanced breast cancer: Results from multi-institutional study

BACKGROUND

This study was conducted in order to develop a model for predicting response to neoadjuvant chemotherapy (NAC) in patients with locally advanced breast cancer (LABC) using pretreatment quantitative ultrasound (QUS) radiomics.

METHODS

This was a multicenter study involving four sites across North America, and appropriate approval was obtained from the individual ethics committees. Eighty-two patients with LABC were included for final analysis. Primary tumors were scanned using a clinical ultrasound system before NAC was started. The tumors were contoured, and radiofrequency data were acquired and processed from whole tumor regions of interest. QUS spectral parameters were derived from the normalized power spectrum, and texture analysis was performed based on six QUS features using a gray level co-occurrence matrix. Patients were divided into responder or nonresponder classes based on their clinical-pathological response. Classification analysis was performed using machine learning algorithms, which were trained to optimize classification accuracy. Cross-validation was performed using a leave-one-out cross-validation method.

RESULTS

Based on the clinical outcomes of NAC treatment, there were 48 responders and 34 nonresponders. A K-nearest neighbors (K-NN) approach resulted in the best classifier performance, with a sensitivity of 91%, a specificity of 83%, and an accuracy of 87%.

CONCLUSION

QUS-based radiomics can predict response to NAC based on pretreatment features with acceptable accuracy.

Quantitative ultrasound radiomics for therapy response monitoring in patients with locally advanced breast cancer: Multi-institutional study results

BACKGROUND

Neoadjuvant chemotherapy (NAC) is the standard of care for patients with locally advanced breast cancer (LABC). The study was conducted to investigate the utility of quantitative ultrasound (QUS) carried out during NAC to predict the final tumour response in a multi-institutional setting.

METHODS

Fifty-nine patients with LABC were enrolled from three institutions in North America (Sunnybrook Health Sciences Centre (Toronto, Canada), MD Anderson Cancer Centre (Texas, USA), and Princess Margaret Cancer Centre (Toronto, Canada)). QUS data were collected before starting NAC and subsequently at weeks 1 and 4 during chemotherapy. Spectral tumour parametric maps were generated, and textural features determined using grey-level co-occurrence matrices. Patients were divided into two groups based on their pathological outcomes following surgery: responders and non-responders. Machine learning algorithms using Fisher's linear discriminant (FLD), K-nearest neighbour (K-NN), and support vector machine (SVM-RBF) were used to generate response classification models.

RESULTS

Thirty-six patients were classified as responders and twenty-three as non-responders. Among all the models, SVM-RBF had the highest accuracy of 81% at both weeks 1 and week 4 with area under curve (AUC) values of 0.87 each. The inclusion of week 1 and 4 features led to an improvement of the classifier models, with the accuracy and AUC from baseline features only being 76% and 0.68, respectively.

CONCLUSION

QUS data obtained during NAC reflect the ongoing treatment-related changes during chemotherapy and can lead to better classifier performances in predicting the ultimate pathologic response to treatment compared to baseline features alone.

Quantitative Ultrasound Monitoring of Breast Tumour Response to Neoadjuvant Chemotherapy: Comparison of Results Among Clinical Scanners

Quantitative ultrasound (QUS) techniques have been demonstrated to detect cell death in vitro and in vivo. Recently, multi-feature classification models have been incorporated into QUS texture-feature analysis methods to increase further the sensitivity and specificity of detecting treatment response in locally advanced breast cancer patients. To effectively incorporate these analytic methods into clinical applications, QUS and texture-feature estimations should be independent of data acquisition systems. The study here investigated the consistencies of QUS and texture-feature estimation techniques relative to several factors. These included the ultrasound system properties, the effects of tissue heterogeneity and the effects of these factors on the monitoring of response to neoadjuvant chemotherapy. Specifically, tumour-response-detection performance based on QUS and texture parameters using two clinical ultrasound systems was compared. Observed variations in data between the systems were small and the results exhibited good agreement in tumour response predictions obtained from both ultrasound systems. The results obtained in this study suggest that tissue heterogeneity was a dominant feature in the parameters measured with the two different ultrasound systems; whereas differences in ultrasound system beam properties only exhibited a minor impact on texture features. The McNemar statistical test performed on tumour response prediction results from the two systems did not reveal significant differences. Overall, the results in this study demonstrate the potential to achieve reliable and consistent QUS and texture-based analyses across different ultrasound imaging platforms.

Quantitative Ultrasound Imaging for the Differentiation between Fresh and Decellularized Mouse Kidneys

Decellularization is a technique that permits the removal of cells from intact organs while preserving the extracellular matrix (ECM). It has many applications in various fields such as regenerative medicine and tissue engineering. This study aims to differentiate between fresh and decellularized kidneys using quantitative ultrasound (QUS) parameters. Spectral parameters were extracted from the linear fit of the power spectrum of raw radio frequency data and parametric maps were generated corresponding to the regions of interest, from which four textural parameters were estimated. The results of this study indicated that decellularization affects both spectral and textural parameters. The Mid Band Fit mean and contrast were found to be the best spectral and textural predictors of kidney decellularization, respectively.

Quantitative MRI Biomarkers of Stereotactic Radiotherapy Outcome in Brain Metastasis

About 20-40% of cancer patients develop brain metastases, causing significant morbidity and mortality. Stereotactic radiation treatment is an established option that delivers high dose radiation to the target while sparing the surrounding normal tissue. However, up to 20% of metastatic brain tumours progress despite stereotactic treatment, and it can take months before it is evident on follow-up imaging. An early predictor of radiation therapy outcome in terms of tumour local failure (LF) is crucial, and can facilitate treatment adjustments or allow for early salvage treatment. In this study, an MR-based radiomics framework was proposed to derive and investigate quantitative MRI (qMRI) biomarkers for the outcome of LF in brain metastasis patients treated with hypo-fractionated stereotactic radiation therapy (SRT). The qMRI biomarkers were constructed through a multi-step feature extraction/reduction/selection framework using the conventional MR imaging data acquired from 100 patients (133 lesions), and were applied in conjunction with machine learning techniques for outcome prediction and risk assessment. The results indicated that the majority of the features in the optimal qMRI biomarkers characterize the heterogeneity in the surrounding regions of tumour including edema and tumour/lesion margins. The optimal qMRI biomarker consisted of five features that predict the outcome of LF with an area under the curve (AUC) of 0.79, and a cross-validated sensitivity and specificity of 81% and 79%, respectively. The Kaplan-Meier analyses showed a statistically significant difference in local control (p-value < 0.0001) and overall survival (p = 0.01). Findings from this study are a step towards using qMRI for early prediction of local failure in brain metastasis patients treated with SRT. This may facilitate early adjustments in treatment, such as surgical resection or salvage radiation, that can potentially improve treatment outcomes. Investigations on larger cohorts of patients are, however, required for further validation of the technique.

Quantitative Ultrasound Spectroscopy for Differentiation of Hepatocellular Carcinoma from At-Risk and Normal Liver Parenchyma

PURPOSE

Quantitative ultrasound approaches can capture tissue morphologic properties to augment clinical diagnostics. This study aims to clinically assess whether quantitative ultrasound spectroscopy (QUS) parameters measured in hepatocellular carcinoma (HCC) tissues can be differentiated from those measured in at-risk or healthy liver parenchyma.

EXPERIMENTAL DESIGN

This prospective Health Insurance Portability and Accountability Act (HIPAA)-compliant study was approved by the Institutional Review Board. Fifteen patients with HCC, 15 non-HCC patients with chronic liver disease, and 15 healthy volunteers were included (31.1% women; 68.9% men). Ultrasound radiofrequency data were acquired in each patient in both liver lobes at two focal depths (3/9 cm). Region of interests (ROIs) were drawn on HCC and liver parenchyma. The average normalized power spectrum for each ROI was extracted, and a linear regression was fit within the -6 dB bandwidth, from which the midband fit (MBF), spectral intercept (SI), and spectral slope (SS) were extracted. Differences in QUS parameters between the ROIs were tested by a mixed-effects regression.

RESULTS

There was a significant intraindividual difference in MBF, SS, and SI between HCC and adjacent liver parenchyma (P < 0.001), and a significant interindividual difference between HCC and at-risk and healthy non-HCC parenchyma (P < 0.001). In patients with HCC, cirrhosis (n = 13) did not significantly change any of the three parameters (P > 0.8) in differentiating HCC from non-HCC parenchyma. MBF (P = 0.12), SI (P = 0.33), and SS (P = 0.57) were not significantly different in non-HCC tissue among the groups.

CONCLUSIONS

The QUS parameters are significantly different in HCC versus non-HCC liver parenchyma, independent of underlying cirrhosis. This could be leveraged for improved HCC detection with ultrasound in the future.

Feasibility of a Support Vector Machine Classifier for Myofascial Pain Syndrome: Diagnostic Case-Control Study

OBJECTIVES

Myofascial pain syndrome (MPS) is the most common cause of chronic pain worldwide. The diagnosis of MPS is subjective, which has created a need for a robust quantitative method of diagnosing MPS. We propose that using a support vector machine (SVM) along with ultrasound (US) texture features can differentiate between healthy and MPS-affected skeletal muscle.

METHODS

B-mode US video data were collected in the upper trapezius muscle of healthy (29) participants and patients with active (21) and latent (19) MPS, using an acquisition method outlined in previous works. Regions of interest were extracted and filtered to obtain a unique set of 917 images where texture features were extracted from each region of interest to characterize each image. These texture features were then used to train 4 separate binary SVM classifiers using nested cross-validation to implement feature selection and hyperparameter tuning. The performance of each kernel was estimated on the data and validated through testing on a final holdout set.

RESULTS

The radial basis function kernel classifier had the greatest Matthews correlation coefficient performance estimate of 0.627 ± 0.073 (mean ± SD) along with the largest area under the curve of 91.0% ± 3.0%. The final holdout test for the radial basis function classifier resulted in 86.96 accuracy, a Matthews correlation coefficient of 0.724, 88% sensitivity, and 86% specificity, validating our earlier performance estimates.

CONCLUSIONS

We have demonstrated that specific US texture features that have been used in other computer-aided diagnostic literature are feasible to use for the classification of healthy and MPS muscle using a binary SVM classifier.

Breast Cancer Treatment Response Monitoring Using Quantitative Ultrasound and Texture Analysis: Comparative Analysis of Analytical Models

PURPOSE

The purpose of this study was to develop computational algorithms to best determine tumor responses early after the start of neoadjuvant chemotherapy, based on quantitative ultrasound (QUS) and textural analysis in patients with locally advanced breast cancer (LABC).

METHODS

A total of 100 LABC patients treated with neoadjuvant chemotherapy were included in this study. Breast tumors were scanned with a clinical ultrasound system prior to treatment, during the first, fourth and eighth weeks of treatment, and prior to surgery. QUS parameters were calculated from ultrasound radio frequency data within tumor regions. Texture features were extracted from each QUS parametric map. Patients were classified into two groups based on identified clinical/pathological response: responders and non-responders. In order to differentiate treatment responders, three multi-feature response classification algorithms, namely a linear discriminant, a k-nearest-neighbor and a nonlinear support vector machine classifier were compared.

RESULTS

All algorithms distinguished responders and non-responders with accuracies ranging between 68% and 92%. In particular, support vector machine performed the best in differentiating responders from non-responders with accuracies of 78%, 90% and 92% at weeks 1, 4 and 8 after the start of treatment, respectively. The most relevant features in separating the two response groups at early stages (weeks 1and 4) were texture features and at a later stage (week 8) were mean QUS parameters, particularly ultrasound backscatter intensity-based parameters.

CONCLUSION

An early stage treatment response prediction model developed by quantitative ultrasound and texture analysis combined with modern computational methods permits offering effective alternatives to standard treatment for refractory patients.

A priori prediction of breast tumour response to chemotherapy using quantitative ultrasound imaging and artificial neural networks

We demonstrate the clinical utility of combining quantitative ultrasound (QUS) imaging of the breast with an artificial neural network (ANN) classifier to predict the response of breast cancer patients to neoadjuvant chemotherapy (NAC) administration prior to the start of treatment.

Using a 6 MHz ultrasound system, radiofrequency (RF) ultrasound data were acquired from 100 patients with biopsy-confirmed locally advanced breast cancer prior to the start of NAC. Quantitative ultrasound mean parameter intensity and texture features were computed from the tumour core and margin, and were compared to the clinical/pathological response and 5-year recurrence-free survival (RFS) of patients. A multi-parametric QUS model in conjunction with an ANN classifier predicted patient response with 96 ± 6% accuracy, and a 0.96 ± 0.08 area under the receiver operating characteristic curve (AUC), compared to 65 ± 10 % accuracy and 0.67 ± 0.14 AUC achieved using a K-Nearest Neighbour (KNN) algorithm. A separate ANN model predicted patient RFS with 85 ± 7% accuracy, and a 0.89 ± 0.11 AUC, whereas the KNN methodology achieved a 58 ± 6 % accuracy and a 0.64 ± 0.09 AUC.

The application of ANN for classifying patient response based on tumour QUS features performs well in terms of predicting response to chemotherapy. The findings here provide a framework for developing personalized a priori chemotherapy selection for patients that are candidates for NAC, potentially resulting in improved patient treatment outcomes and prognosis.

Computer-Aided Theragnosis Based on Tumor Volumetric Information in Breast Cancer

OBJECTIVE

A computer-assisted technology has recently been proposed for the assessment of therapeutic responses to neoadjuvant chemotherapy in patients with locally advanced breast cancer (LABC). The system, however, extracted features from individual scans in a tumor irrespective of its relation to the other scans of the same patient, ignoring the volumetric information. This study addresses this problem by introducing a novel engineered texton-based method in order to account for volumetric information in the design of textural descriptors to represent tumor scans.

METHODS

A noninvasive computer-aided-theragnosis (CAT) system was developed by employing multiparametric QUS spectral and backscatter coefficient maps. The proceeding was composed of two subdictionaries: one built on the "pretreatment" and another on "week " scans, where was 1, 4, or 8. The learned dictionary of each patient was subsequently used to compute the model (histogram of textons) for each scan of the patient. Advanced machine learning techniques including a kernel-based dissimilarity measure to estimate the distances between "pretreatment" and "mid-treatment" scans as an indication of treatment effectiveness, learning from imbalanced data, and supervised learning were subsequently employed on the texton-based features.

RESULTS

The performance of the CAT system was tested using statistical tests of significance and leave-one-subject-out (LOSO) classification on 56 LABC patients. The proposed texton-based CAT system indicated significant differences in changes between the responding and nonresponding patient populations and achieved high accuracy, sensitivity, and specificity in discriminating between the two patient groups early after the start of treatment, i.e., on weeks 1 and 4 of several months of treatment. Specifically, the CAT system achieved the area under curve of 0.81, 0.83, and 0.85 on weeks 1, 4, and 8, respectively.

CONCLUSION

The proposed texton-based CAT system accounted for the volumetric information in "pretreatment" and "mid-treatment" scans of each patient. It was demonstrated that this attribute of the CAT system could boost its performance compared to the cases that the features were extracted from solely individual scans.

High-Frequency Quantitative Ultrasound for Imaging Prostate Cancer Using a Novel Micro-Ultrasound Scanner

Currently, biopsies guided by transrectal ultrasound (TRUS) are the only method for definitive diagnosis of prostate cancer. Studies by our group suggest that quantitative ultrasound (QUS) could provide a more sensitive means of targeting biopsies and directing focal treatments to cancer-suspicious regions in the prostate. Previous studies have utilized ultrasound signals at typical clinical frequencies, i.e., in the 6-MHz range. In the present study, a 29-MHz, TRUS, micro-ultrasound system and transducer (ExactVu micro-ultrasound, Exact Imaging, Markham, Canada) was used to acquire radio frequency data from 163 patients immediately before 12-core biopsy procedures, comprising 1956 cores. These retrospective data are a subset of data acquired in an ongoing, multisite, 2000-patient, randomized, clinical trial (clinicaltrials.gov NCT02079025). Spectrum-based QUS estimates of effective scatter diameter (ESD), effective acoustic concentration (EAC), midband (M), intercept (I) and slope (S) as well as envelope statistics employing a Nakagami distribution were used to train linear discriminant classifiers (LDCs) and support vector machines (SVMs). Classifier performance was assessed using area-under-the-curve (AUC) values obtained from receiver operating characteristic (ROC) analyses with 10-fold cross validation. A combination of ESD and EAC parameters resulted in an AUC value of 0.77 using a LDC. When Nakagami-µ or prostate-specific antigen (PSA) values were added as features, the AUC value increased to 0.79. SVM produced an AUC value of 0.77, using a combination of envelope and spectral QUS estimates. The best classification produced an AUC value of 0.81 using an LDC when combining envelope statistics, PSA, ESD and EAC. In a previous study, B-mode-based scoring and evaluation using the PRI-MUS protocol produced a maximal AUC value of 0.74 for higher Gleason-score values (GS >7) when read by an expert. Our initial results with AUC values of 0.81 are very encouraging for developing a new, predominantly user-independent, prostate-cancer, risk-assessing tool.

Triple-negative invasive breast carcinoma: the association between the sonographic appearances with clinicopathological feature

In this study, we aimed to evaluate the clinical and pathological factors that associated with sonographic appearances of triple-negative (TN) invasive breast carcinoma. With the ethical approval, 560 patients who were pathologically confirmed as invasive breast carcinoma were reviewed for ultrasound, clinical, and pathological data. Logistic regression analysis was used to identify the typical sonographic features for TN invasive breast carcinomas. The effect of clinical and pathological factors on the sonographic features of TN invasive breast carcinoma was studied. There were 104 cases of TN invasive breast carcinoma. The independent sonographic features for the TN subgroup included regular shape (odds ratio, OR = 2.14, p = 0.007), no spiculated/angular margin (OR = 1.93, p = 0.035), posterior acoustic enhancement (OR = 2.14, p = 0.004), and no calcifications (OR = 2.10, p = 0.008). Higher pathological grade was significantly associated with regular tumor shape of TN breast cancer (p = 0.012). Higher Ki67 level was significantly associated with regular tumor shape (p = 0.023) and absence of angular/spiculated margin (p = 0.005). Higher human epidermal growth factor receptor 2 (HER2) score was significantly associated with the presence of calcifications (p = 0.033). We conclude that four sonographic features are associated with TN invasive breast carcinoma. Heterogeneity of sonographic features was associated with the pathological grade, Ki67 proliferation level and HER2 score of TN breast cancers.

Ultrasonic histogram assessment of early response to concurrent chemo-radiotherapy in patients with locally advanced cervical cancer: a feasibility study

PURPOSE

To monitor early response for locally advanced cervical cancers undergoing concurrent chemo-radiotherapy (CCRT) by ultrasonic histogram.

METHODS

B-mode ultrasound examinations were performed at 4 time points in thirty-four patients during CCRT. Six ultrasonic histogram parameters were used to assess the echogenicity, homogeneity and heterogeneity of tumors.

RESULTS

I_peak increased rapidly since the first week after therapy initiation, whereas W_low, W_high and A_high changed significantly at the second week. The average ultrasonic histogram progressively moved toward the right and converted into more symmetrical shape.

CONCLUSION

Ultrasonic histogram could be served as a potential marker to monitor early response during CCRT.

Response monitoring of breast cancer patients receiving neoadjuvant chemotherapy using quantitative ultrasound, texture, and molecular features

Background

Pathological response of breast cancer to chemotherapy is a prognostic indicator for long-term disease free and overall survival. Responses of locally advanced breast cancer in the neoadjuvant chemotherapy (NAC) settings are often variable, and the prediction of response is imperfect. The purpose of this study was to detect primary tumor responses early after the start of neoadjuvant chemotherapy using quantitative ultrasound (QUS), textural analysis and molecular features in patients with locally advanced breast cancer.

Methods

The study included ninety six patients treated with neoadjuvant chemotherapy. Breast tumors were scanned with a clinical ultrasound system prior to chemotherapy treatment, during the first, fourth and eighth week of treatment, and prior to surgery. Quantitative ultrasound parameters and scatterer-based features were calculated from ultrasound radio frequency (RF) data within tumor regions of interest. Additionally, texture features were extracted from QUS parametric maps. Prior to therapy, all patients underwent a core needle biopsy and histological subtypes and biomarker ER, PR, and HER2 status were determined. Patients were classified into three treatment response groups based on combination of clinical and pathological analyses: complete responders (CR), partial responders (PR), and non-responders (NR). Response classifications from QUS parameters, receptors status and pathological were compared. Discriminant analysis was performed on extracted parameters using a support vector machine classifier to categorize subjects into CR, PR, and NR groups at all scan times.

Results

Of the 96 patients, the number of CR, PR and NR patients were 21, 52, and 23, respectively. The best prediction of treatment response was achieved with the combination mean QUS values, texture and molecular features with accuracies of 78%, 86% and 83% at weeks 1, 4, and 8, after treatment respectively. Mean QUS parameters or clinical receptors status alone predicted the three response groups with accuracies less than 60% at all scan time points. Recurrence free survival (RFS) of response groups determined based on combined features followed similar trend as determined based on clinical and pathology.

Conclusions

This work demonstrates the potential of using QUS, texture and molecular features for predicting the response of primary breast tumors to chemotherapy early, and guiding the treatment planning of refractory patients.

Breast-Lesion Characterization using Textural Features of Quantitative Ultrasound Parametric Maps

This study evaluated, for the first time, the efficacy of quantitative ultrasound (QUS) spectral parametric maps in conjunction with texture-analysis techniques to differentiate non-invasively benign versus malignant breast lesions. Ultrasound B-mode images and radiofrequency data were acquired from 78 patients with suspicious breast lesions. QUS spectral-analysis techniques were performed on radiofrequency data to generate parametric maps of mid-band fit, spectral slope, spectral intercept, spacing among scatterers, average scatterer diameter, and average acoustic concentration. Texture-analysis techniques were applied to determine imaging biomarkers consisting of mean, contrast, correlation, energy and homogeneity features of parametric maps. These biomarkers were utilized to classify benign versus malignant lesions with leave-one-patient-out cross-validation. Results were compared to histopathology findings from biopsy specimens and radiology reports on MR images to evaluate the accuracy of technique. Among the biomarkers investigated, one mean-value parameter and 14 textural features demonstrated statistically significant differences (p < 0.05) between the two lesion types. A hybrid biomarker developed using a stepwise feature selection method could classify the legions with a sensitivity of 96%, a specificity of 84%, and an AUC of 0.97. Findings from this study pave the way towards adapting novel QUS-based frameworks for breast cancer screening and rapid diagnosis in clinic.

Chemotherapy-Response Monitoring of Breast Cancer Patients Using Quantitative Ultrasound-Based Intra-Tumour Heterogeneities

Anti-cancer therapies including chemotherapy aim to induce tumour cell death. Cell death introduces alterations in cell morphology and tissue micro-structures that cause measurable changes in tissue echogenicity. This study investigated the effectiveness of quantitative ultrasound (QUS) parametric imaging to characterize intra-tumour heterogeneity and monitor the pathological response of breast cancer to chemotherapy in a large cohort of patients (n = 100). Results demonstrated that QUS imaging can non-invasively monitor pathological response and outcome of breast cancer patients to chemotherapy early following treatment initiation. Specifically, QUS biomarkers quantifying spatial heterogeneities in size, concentration and spacing of acoustic scatterers could predict treatment responses of patients with cross-validated accuracies of 82 ± 0.7%, 86 ± 0.7% and 85 ± 0.9% and areas under the receiver operating characteristic (ROC) curve of 0.75 ± 0.1, 0.80 ± 0.1 and 0.89 ± 0.1 at 1, 4 and 8 weeks after the start of treatment, respectively. The patients classified as responders and non-responders using QUS biomarkers demonstrated significantly different survivals, in good agreement with clinical and pathological endpoints. The results form a basis for using early predictive information on survival-linked patient response to facilitate adapting standard anti-cancer treatments on an individual patient basis.

Evaluating pathologic response of breast cancer to neoadjuvant chemotherapy with computer-extracted features from contrast-enhanced ultrasound videos

PURPOSE

To extract quantitative perfusion and texture features with computer assistance from contrast-enhanced ultrasound (CEUS) videos of breast cancer before and after neoadjuvant chemotherapy (NAC), and to evaluate pathologic response to NAC with these features.

METHODS

Forty-two CEUS videos with 140,484 images were acquired from 21 breast cancer patients pre- and post-NAC. Time-intensity curve (TIC) features were calculated including the difference between area under TIC within a tumor and that within a computer-detected reference region (AUT_T-R). Four texture features were extracted including Homogeneity and Contrast. All patients were identified as pathologic responders by Miller and Payne criteria. The features between pre- and post-treatment in these responders were statistically compared, and the discrimination between pre- and post-treatment cancers was assessed with a receiver operating characteristic (ROC) curve.

RESULTS

Compared with the pre-treatment cancers, the post-treatment cancers had significantly lower Homogeneity (p<0.001) and AUT_T-R (p=0.014), as well as higher Contrast (p<0.001), indicating the intratumoral contrast enhancement decreased and became more heterogeneous after NAC in responders. The combination of Homogeneity and AUT_T-R achieved an accuracy of 90.5% and area under ROC curve of 0.946 for discrimination between pre- and post-chemotherapy cancers without cross validation. The accuracy still reached as high as 85.7% under leave-one-out cross validation.

CONCLUSIONS

The computer-extracted CEUS features show reduced and more heterogeneous neovascularization of cancer after NAC. The features achieve high accuracy for discriminating between pre- and post-chemotherapy cancers in responders and thus are potentially valuable for tumor response evaluation in clinical practice.

High frequency ultrasound imaging and simulations of sea urchin oocytes

High frequency ultrasound backscatter signals from sea urchin oocytes were measured using a 40 MHz transducer and compared to numerical simulations. The Faran scattering model was used to calculate the ultrasound scattered from single oocytes in suspension. The urchin oocytes are non-nucleated with uniform size and biomechanical properties; the backscatter from each cell is similar and easy to simulate, unlike typical nucleated mammalian cells. The time domain signal measured from single oocytes in suspension showed two distinct peaks, and the power spectrum was periodic with minima spaced approximately 10 MHz apart. Good agreement to the Faran scattering model was observed. Measurements from tightly packed oocyte cell pellets showed similar periodic features in the power spectra, which was a result of the uniform size and consistent biomechanical properties of the cells. Numerical simulations that calculated the ultrasound scattered from individual oocytes within a three dimensional volume showed good agreement to the measured signals and B-scan images. A cepstral analysis of the signal was used to calculate the size of the cells, which was 78.7 μm (measured) and 81.4 μm (simulated). This work supports the single scattering approximation, where ultrasound is discretely scattered from single cells within a bulk homogeneous sample, and that multiple scattering has a negligible effect. This technique can be applied towards understanding the complex scattering behaviour from heterogeneous tissues.

Low-frequency ultrasound radiosensitization and therapy response monitoring of tumors: an in vivo study

A new framework has been introduced in this paper for tumor radiosensitization and therapy response monitoring using low-frequency ultrasound. Human fibrosarcoma xenografts grown in severe combined immunodeficiency (SCID) mice (n = 108) were treated using ultrasound-stimulated microbubbles at various concentration and exposed to different doses of radiation. Low-frequency ultrasound radiofrequency (RF) data were acquired from tumors prior to and at different times after treatment. Quantitative ultrasound (QUS) techniques were applied to generate spectral parametric maps of tumors. Textural analysis were performed to quantify spatial heterogeneities within QUS parametric maps. A hybrid model was developed using multiple regression analysis to predict extent of histological tumor cell death non-invasively based on QUS spectral and textural biomarkers. Results of immunohistochemistry on excised tumor sections demonstrated increases in cell death with higher concentration of microbubbles and radiation dose. Quantitative ultrasound results indicated changes that paralleled increases in histological cell death. Specifically, the hybrid QUS biomarker demonstrated a good correlation with extent of tumor cell death observed from immunohistochemistry. A linear discriminant analysis applied in conjunction with the receiver operating characteristic (ROC) curve analysis indicated that the hybrid QUS biomarker can classify tumor cell death fractions with an area under the curve of 91.2. The results obtained in this research suggest that low-frequency ultrasound can concurrently be used to enhance radiation therapy and evaluate tumor response to treatment.

Using Flow Characteristics in Three-Dimensional Power Doppler Ultrasound Imaging to Predict Complete Responses in Patients Undergoing Neoadjuvant Chemotherapy

OBJECTIVES

Strategies are needed for the identification of a poor response to treatment and determination of appropriate chemotherapy strategies for patients in the early stages of neoadjuvant chemotherapy for breast cancer. We hypothesize that power Doppler ultrasound imaging can provide useful information on predicting response to neoadjuvant chemotherapy.

METHODS

The solid directional flow of vessels in breast tumors was used as a marker of pathologic complete responses (pCR) in patients undergoing neoadjuvant chemotherapy. Thirty-one breast cancer patients who received neoadjuvant chemotherapy and had tumors of 2 to 5 cm were recruited. Three-dimensional power Doppler ultrasound with high-definition flow imaging technology was used to acquire the indices of tumor blood flow/volume, and the chemotherapy response prediction was established, followed by support vector machine classification.

RESULTS

The accuracy of pCR prediction before the first chemotherapy treatment was 83.87% (area under the ROC curve [AUC] = 0.6957). After the second chemotherapy treatment, the accuracy of was 87.9% (AUC = 0.756). Trend analysis showed that good and poor responders exhibited different trends in vascular flow during chemotherapy.

CONCLUSIONS

This preliminary study demonstrates the feasibility of using the vascular flow in breast tumors to predict chemotherapeutic efficacy.

Predicting breast cancer response to neoadjuvant chemotherapy using pretreatment diffuse optical spectroscopic texture analysis

Background:

Diffuse optical spectroscopy (DOS) has been demonstrated capable of monitoring response to neoadjuvant chemotherapy (NAC) in locally advanced breast cancer (LABC) patients. In this study, we evaluate texture features of pretreatment DOS functional maps for predicting LABC response to NAC.

Methods:

Locally advanced breast cancer patients (n=37) underwent DOS breast imaging before starting NAC. Breast tissue parametric maps were constructed and texture analyses were performed based on grey-level co-occurrence matrices for feature extraction. Ground truth labels as responders (R) or non-responders (NR) were assigned to patients based on Miller–Payne pathological response criteria. The capability of DOS textural features computed on volumetric tumour data before the start of treatment (i.e., ‘pretreatment’) to predict patient responses to NAC was evaluated using a leave-one-out validation scheme at subject level. Data were analysed using a logistic regression, naive Bayes, and k-nearest neighbour classifiers.

Results:

Data indicated that textural characteristics of pretreatment DOS parametric maps can differentiate between treatment response outcomes. The HbO₂ homogeneity resulted in the highest accuracy among univariate parameters in predicting response to chemotherapy: sensitivity (%Sn) and specificity (%Sp) were 86.5% and 89.0%, respectively, and accuracy was 87.8%. The highest predictors using multivariate (binary) combination features were the Hb-contrast+HbO₂-homogeneity, which resulted in a %Sn/%Sp=78.0/81.0% and an accuracy of 79.5%.

Conclusions:

This study demonstrated that the pretreatment DOS texture features can predict breast cancer response to NAC and potentially guide treatments.

A priori Prediction of Neoadjuvant Chemotherapy Response and Survival in Breast Cancer Patients using Quantitative Ultrasound

Quantitative ultrasound (QUS) can probe tissue structure and analyze tumour characteristics. Using a 6-MHz ultrasound system, radiofrequency data were acquired from 56 locally advanced breast cancer patients prior to their neoadjuvant chemotherapy (NAC) and QUS texture features were computed from regions of interest in tumour cores and their margins as potential predictive and prognostic indicators. Breast tumour molecular features were also collected and used for analysis. A multiparametric QUS model was constructed, which demonstrated a response prediction accuracy of 88% and ability to predict patient 5-year survival rates (p = 0.01). QUS features demonstrated superior performance in comparison to molecular markers and the combination of QUS and molecular markers did not improve response prediction. This study demonstrates, for the first time, that non-invasive QUS features in the core and margin of breast tumours can indicate breast cancer response to neoadjuvant chemotherapy (NAC) and predict five-year recurrence-free survival.

Effect of chromatin structure on quantitative ultrasound parameters

High-frequency ultrasound (~20 MHz) techniques were investigated using in vitro and ex vivo models to determine whether alterations in chromatin structure are responsible for ultrasound backscatter changes in biological samples. Acute myeloid leukemia (AML) cells and their isolated nuclei were exposed to various chromatin altering treatments. These included 10 different ionic environments, DNA cleaving and unfolding agents, as well as DNA condensing agents. Raw radiofrequency (RF) data was used to generate quantitative ultrasound parameters from spectral and form factor analyses. Chromatin structure was evaluated using electron microscopy. Results indicated that trends in quantitative ultrasound parameters mirrored trends in biophysical chromatin structure parameters. In general, higher ordered states of chromatin compaction resulted in increases to ultrasound paramaters of midband fit, spectral intercept, and estimated scatterer concentration, while samples with decondensed forms of chromatin followed an opposite trend. Experiments with isolated nuclei demonstrated that chromatin changes alone were sufficient to account for these observations. Experiments with ex vivo samples indicated similar effects of chromatin structure changes. The results obtained in this research provide a mechanistic explanation for ultrasound investigations studying scattering from cells and tissues undergoing biological processes affecting chromatin.

Computer aided prognosis for cell death categorization and prediction in vivo using quantitative ultrasound and machine learning techniques

PURPOSE

At present, a one-size-fits-all approach is typically used for cancer therapy in patients. This is mainly because there is no current imaging-based clinical standard for the early assessment and monitoring of cancer treatment response. Here, the authors have developed, for the first time, a complete computer-aided-prognosis (CAP) system based on multiparametric quantitative ultrasound (QUS) spectroscopy methods in association with texture descriptors and advanced machine learning techniques. This system was used to noninvasively categorize and predict cell death levels in fibrosarcoma mouse tumors treated using ultrasound-stimulated microbubbles as novel endothelial-cell radiosensitizers.

METHODS

Sarcoma xenograft tumor-bearing mice were treated using ultrasound-stimulated microbubbles, alone or in combination with x-ray radiation therapy, as a new antivascular treatment. Therapy effects were assessed at 2-3, 24, and 72 h after treatment using a high-frequency ultrasound. Two-dimensional spectral parametric maps were generated using the power spectra of the raw radiofrequency echo signal. Subsequently, the distances between "pretreatment" and "post-treatment" scans were computed as an indication of treatment efficacy, using a kernel-based metric on textural features extracted from 2D parametric maps. A supervised learning paradigm was used to either categorize cell death levels as low, medium, or high using a classifier, or to "continuously" predict the levels of cell death using a regressor.

RESULTS

The developed CAP system performed at a high level for the classification of cell death levels. The area under curve of the receiver operating characteristic was 0.87 for the classification of cell death levels to both low/medium and medium/high levels. Moreover, the prediction of cell death levels using the proposed CAP system achieved a good correlation (r = 0.68,  p < 0.001) with histological cell death levels as the ground truth. A statistical test of significance between individual treatment groups with the corresponding control group demonstrated that the predicted levels indicated the same significant changes in cell death as those indicated by the ground-truth levels.

CONCLUSIONS

The technology developed in this study addresses a gap in the current standard of care by introducing a quality control step that generates potentially actionable metrics needed to enhance treatment decision-making. The study establishes a noninvasive framework for quantifying levels of cancer treatment response developed preclinically in tumors using QUS imaging in conjunction with machine learning techniques. The framework can potentially facilitate the detection of refractory responses in patients to a certain cancer treatment early on in the course of therapy to enable switching to more efficacious treatments.

Photoacoustic signal characterization of cancer treatment response: Correlation with changes in tumor oxygenation

Frequency analysis of the photoacoustic radiofrequency signals and oxygen saturation estimates were used to monitor the in-vivo response of a novel, thermosensitive liposome treatment. The liposome encapsulated doxorubicin (HaT-DOX) releasing it rapidly (<20 s) when the tumor was exposed to mild hyperthermia (43 °C). Photoacoustic imaging (VevoLAZR, 750/850 nm, 40 MHz) of EMT-6 breast cancer tumors was performed 30 min pre- and post-treatment and up to 7 days post-treatment (at 2/5/24 h timepoints). HaT-DOX-treatment responders exhibited on average a 22% drop in oxygen saturation 2 h post-treatment and a decrease (45% at 750 nm and 73% at 850 nm) in the slope of the normalized PA frequency spectra. The spectral slope parameter correlated with treatment-induced hemorrhaging which increased the optical absorber effective size via interstitial red blood cell leakage. Combining frequency analysis and oxygen saturation estimates differentiated treatment responders from non-responders/control animals by probing the treatment-induced structural changes of blood vessel.

Photoacoustic Imaging of Cancer Treatment Response: Early Detection of Therapeutic Effect from Thermosensitive Liposomes

Imaging methods capable of indicating the potential for success of an individualized treatment course, during or immediately following the treatment, could improve therapeutic outcomes. Temperature Sensitive Liposomes (TSLs) provide an effective way to deliver chemotherapeutics to a localized tumoral area heated to mild-hyperthermia (HT). The high drug levels reached in the tumor vasculature lead to increased tumor regression via the cascade of events during and immediately following treatment. For a TSL carrying doxorubicin (DOX) these include the rapid and intense exposure of endothelial cells to high drug concentrations, hemorrhage, blood coagulation and vascular shutdown. In this study, ultrasound-guided photoacoustic imaging was used to probe the changes to tumors following treatment with the TSL, HaT-DOX (Heat activated cytoToxic). Levels of oxygen saturation (sO2) were studied in a longitudinal manner, from 30 min pre-treatment to 7 days post-treatment. The efficacious treatments of HT-HaT-DOX were shown to induce a significant drop in sO2 (>10%) as early as 30 min post-treatment that led to tumor regression (in 90% of cases); HT-Saline and non-efficacious HT-HaT-DOX (10% of cases) treatments did not show any significant change in sO2 at these timepoints. The changes in sO2 were further corroborated with histological data, using the vascular and perfusion markers CD31 and FITC-lectin. These results allowed us to further surmise a plausible mechanism of the cellular events taking place in the TSL treated tumor regions over the first 24 hours post-treatment. The potential for using photoacoustic imaging to measure tumor sO2 as a surrogate prognostic marker for predicting therapeutic outcome with a TSL treatment is demonstrated.

Early detection of chemotherapy-refractory patients by monitoring textural alterations in diffuse optical spectroscopic images

PURPOSE

Changes in textural characteristics of diffuse optical spectroscopic (DOS) functional images, accompanied by alterations in their mean values, are demonstrated here for the first time as early surrogates of ultimate treatment response in locally advanced breast cancer (LABC) patients receiving neoadjuvant chemotherapy (NAC). NAC, as a standard component of treatment for LABC patient, induces measurable heterogeneous changes in tumor metabolism which were evaluated using DOS-based metabolic maps. This study characterizes such inhomogeneous nature of response development, by determining alterations in textural properties of DOS images apparent at early stages of therapy, followed later by gross changes in mean values of these functional metabolic maps.

METHODS

Twelve LABC patients undergoing NAC were scanned before and at four times after treatment initiation, and tomographic DOS images were reconstructed at each time. Ultimate responses of patients were determined clinically and pathologically, based on a reduction in tumor size and assessment of residual tumor cellularity. The mean-value parameters and textural features were extracted from volumetric DOS images for several functional and metabolic parameters prior to the treatment initiation. Changes in these DOS-based biomarkers were also monitored over the course of treatment. The measured biomarkers were applied to differentiate patient responses noninvasively and compared to clinical and pathologic responses.

RESULTS

Responding and nonresponding patients demonstrated different changes in DOS-based textural and mean-value parameters during chemotherapy. Whereas none of the biomarkers measured prior the start of therapy demonstrated a significant difference between the two patient populations, statistically significant differences were observed at week one after treatment initiation using the relative change in contrast/homogeneity of seven functional maps (0.001<p<0.049), and mean value of water content in tissue (p=0.010). The cross-validated sensitivity and specificity of these parameters at week one of therapy ranged between 80%-100% and 67%-100%, respectively. Higher levels of statistically significant differences were exhibited at week four after start of treatment, with cross-validated sensitivities and specificities ranging between 80% and 100% for three textural and three mean-value parameters. The combination of the textural and mean-value parameters in a "hybrid" profile could better separate the two patient populations early on during a course of treatment, with cross-validated sensitivities and specificities of up to 100% (p=0.001).

CONCLUSIONS

The results of this study suggest that alterations in textural characteristics of DOS images, in conjunction with changes in their mean values, can classify noninvasively the ultimate clinical and pathologic response of LABC patients to chemotherapy, as early as one week after start of their treatment. This provides a basis for using DOS imaging as a tool for therapy personalization.

Quantitative ultrasound assessment of breast tumor response to chemotherapy using a multi-parameter approach

PURPOSE

This study demonstrated the ability of quantitative ultrasound (QUS) parameters in providing an early prediction of tumor response to neoadjuvant chemotherapy (NAC) in patients with locally advanced breast cancer (LABC).

METHODS

Using a 6-MHz array transducer, ultrasound radiofrequency (RF) data were collected from 58 LABC patients prior to NAC treatment and at weeks 1, 4, and 8 of their treatment, and prior to surgery. QUS parameters including midband fit (MBF), spectral slope (SS), spectral intercept (SI), spacing among scatterers (SAS), attenuation coefficient estimate (ACE), average scatterer diameter (ASD), and average acoustic concentration (AAC) were determined from the tumor region of interest. Ultrasound data were compared with the ultimate clinical and pathological response of the patient's tumor to treatment and patient recurrence-free survival.

RESULTS

Multi-parameter discriminant analysis using the κ-nearest-neighbor classifier demonstrated that the best response classification could be achieved using the combination of MBF, SS, and SAS, with an accuracy of 60 ± 10% at week 1, 77 ± 8% at week 4 and 75 ± 6% at week 8. Furthermore, when the QUS measurements at each time (week) were combined with pre-treatment (week 0) QUS values, the classification accuracies improved (70 ± 9% at week 1, 80 ± 5% at week 4, and 81 ± 6% at week 8). Finally, the multi-parameter QUS model demonstrated a significant difference in survival rates of responding and non-responding patients at weeks 1 and 4 (p=0.035, and 0.027, respectively).

CONCLUSION

This study demonstrated for the first time, using new parameters tested on relatively large patient cohort and leave-one-out classifier evaluation, that a hybrid QUS biomarker including MBF, SS, and SAS could, with relatively high sensitivity and specificity, detect the response of LABC tumors to NAC as early as after 4 weeks of therapy. The findings of this study also suggested that incorporating pre-treatment QUS parameters of a tumor improved the classification results. This work demonstrated the potential of QUS and machine learning methods for the early assessment of breast tumor response to NAC and providing personalized medicine with regards to the treatment planning of refractory patients.

Precision medicine: Now, not when

Precision medicine aims to fix what is wrong with today's healthcare: a lack of targeted interventions tailored to the person. It encompasses many aspects of health; chief among these is one's genetic profile. Researchers are making progress as gene-sequencing technologies get better and cheaper. Although there is cause for optimism, as several initiatives at Sunnybrook Research Institute show, scientific, systemic, and logistical challenges must be surmounted before advances can be integrated into the clinic. Despite these barriers, precision medicine is the only way forward.

Multiparametric monitoring of chemotherapy treatment response in locally advanced breast cancer using quantitative ultrasound and diffuse optical spectroscopy

PURPOSE

This study evaluated pathological response to neoadjuvant chemotherapy using quantitative ultrasound (QUS) and diffuse optical spectroscopy imaging (DOSI) biomarkers in locally advanced breast cancer (LABC).

MATERIALS AND METHODS

The institution's ethics review board approved this study. Subjects (n = 22) gave written informed consent prior to participating. US and DOSI data were acquired, relative to the start of neoadjuvant chemotherapy, at weeks 0, 1, 4, 8 and preoperatively. QUS parameters including the mid-band fit (MBF), 0-MHz intercept (SI), and the spectral slope (SS) were determined from tumor ultrasound data using spectral analysis. In the same patients, DOSI was used to measure parameters relating to tumor hemoglobin and composition. Discriminant analysis and receiver-operating characteristic (ROC) analysis was used to classify clinical and pathological response during treatment and to estimate the area under the curve (AUC). Additionally, multivariate analysis was carried out for pairwise QUS/DOSI parameter combinations using a logistic regression model.

RESULTS

Individual QUS and DOSI parameters, including the (SI), oxy-hemoglobin (HbO2), and total hemoglobin (HbT) were significant markers for response after one week of treatment (p < 0.01). Multivariate (pairwise) combinations increased the sensitivity, specificity and AUC at this time; the SI + HbO2 showed a sensitivity/specificity of 100%, and an AUC of 1.0.

CONCLUSIONS

QUS and DOSI demonstrated potential as coincident markers for treatment response and may potentially facilitate response-guided therapies. Multivariate QUS and DOSI parameters increased the sensitivity and specificity of classifying LABC patients as early as one week after treatment.

Functional imaging of hepatocellular carcinoma

Imaging plays a key role in the clinical management of hepatocellular carcinoma (HCC), but conventional imaging techniques have limited sensitivity in visualizing small tumors and assessing response to locoregional treatments and sorafenib. Functional imaging techniques allow visualization of organ and tumor physiology. Assessment of functional characteristics of tissue, such as metabolism, proliferation and stiffness, may overcome some of the limitations of structural imaging. In particular, novel molecular imaging agents offer a potential tool for early diagnosis of HCC, and radiomics may aid in response assessment and generate prognostic models. Further prospective research is warranted to evaluate emerging techniques and their cost-effectiveness in the context of HCC in order to improve detection and response assessment.

Computer Aided Theragnosis Using Quantitative Ultrasound Spectroscopy and Maximum Mean Discrepancy in Locally Advanced Breast Cancer

A noninvasive computer-aided-theragnosis (CAT) system was developed for the early therapeutic cancer response assessment in patients with locally advanced breast cancer (LABC) treated with neoadjuvant chemotherapy. The proposed CAT system was based on multi-parametric quantitative ultrasound (QUS) spectroscopic methods in conjunction with advanced machine learning techniques. Specifically, a kernel-based metric named maximum mean discrepancy (MMD), a technique for learning from imbalanced data based on random undersampling, and supervised learning were investigated with response-monitoring data from LABC patients. The CAT system was tested on 56 patients using statistical significance tests and leave-one-subject-out classification techniques. Textural features using state-of-the-art local binary patterns (LBP), and gray-scale intensity features were extracted from the spectral parametric maps in the proposed CAT system. The system indicated significant differences in changes between the responding and non-responding patient populations as well as high accuracy, sensitivity, and specificity in discriminating between the two patient groups early after the start of treatment, i.e., on weeks 1 and 4 of several months of treatment. The proposed CAT system achieved an accuracy of 85%, 87%, and 90% on weeks 1, 4 and 8, respectively. The sensitivity and specificity of developed CAT system for the same times was 85%, 95%, 90% and 85%, 85%, 91%, respectively. The proposed CAT system thus establishes a noninvasive framework for monitoring cancer treatment response in tumors using clinical ultrasound imaging in conjunction with machine learning techniques. Such a framework can potentially facilitate the detection of refractory responses in patients to treatment early on during a course of therapy to enable possibly switching to more efficacious treatments.

Quantification of Ultrasonic Scattering Properties of In Vivo Tumor Cell Death in Mouse Models of Breast Cancer

INTRODUCTION: Quantitative ultrasound parameters based on form factor models were investigated as potential biomarkers of cell death in breast tumor (MDA-231) xenografts treated with chemotherapy. METHODS: Ultrasound backscatter radiofrequency data were acquired from MDA-231 breast cancer tumor–bearing mice (n = 20) before and after the administration of chemotherapy drugs at two ultrasound frequencies: 7 MHz and 20 MHz. Radiofrequency spectral analysis involved estimating the backscatter coefficient from regions of interest in the center of the tumor, to which form factor models were fitted, resulting in estimates of average scatterer diameter and average acoustic concentration (AAC). RESULTS: The ∆AAC parameter extracted from the spherical Gaussian model was found to be the most effective cell death biomarker (at the lower frequency range, r² = 0.40). At both frequencies, AAC in the treated tumors increased significantly (P = .026 and .035 at low and high frequencies, respectively) 24 hours after treatment compared with control tumors. Furthermore, stepwise multiple linear regression analysis of the low-frequency data revealed that a multiparameter quantitative ultrasound model was strongly correlated to cell death determined histologically posttreatment (r² = 0.74). CONCLUSION: The Gaussian form factor model–based scattering parameters can potentially be used to track the extent of cell death at clinically relevant frequencies (7 MHz). The 20-MHz results agreed with previous findings in which parameters related to the backscatter intensity (i.e., AAC) increased with cell death. The findings suggested that, in addition to the backscatter coefficient parameter ∆AAC, biological features including tumor heterogeneity and initial tumor volume were important factors in the prediction of cell death response.

Quantitative ultrasound spectroscopic imaging for characterization of disease extent in prostate cancer patients

Three-dimensional quantitative ultrasound spectroscopic imaging of prostate was investigated clinically for the noninvasive detection and extent characterization of disease in cancer patients and compared to whole-mount, whole-gland histopathology of radical prostatectomy specimens. Fifteen patients with prostate cancer underwent a volumetric transrectal ultrasound scan before radical prostatectomy. Conventional-frequency (~5MHz) ultrasound images and radiofrequency data were collected from patients. Normalized power spectra were used as the basis of quantitative ultrasound spectroscopy. Specifically, color-coded parametric maps of 0-MHz intercept, midband fit, and spectral slope were computed and used to characterize prostate tissue in ultrasound images. Areas of cancer were identified in whole-mount histopathology specimens, and disease extent was correlated to that estimated from quantitative ultrasound parametric images. Midband fit and 0-MHz intercept parameters were found to be best associated with the presence of disease as located on histopathology whole-mount sections. Obtained results indicated a correlation between disease extent estimated noninvasively based on midband fit parametric images and that identified histopathologically on prostatectomy specimens, with an r(2) value of 0.71 (P<.0001). The 0-MHz intercept parameter demonstrated a lower level of correlation with histopathology. Spectral slope parametric maps offered no discrimination of disease. Multiple regression analysis produced a hybrid disease characterization model (r(2)=0.764, P<.05), implying that the midband fit biomarker had the greatest correlation with the histopathologic extent of disease. This work demonstrates that quantitative ultrasound spectroscopic imaging can be used for detecting prostate cancer and characterizing disease extent noninvasively, with corresponding gross three-dimensional histopathologic correlation.

Optical coherence tomography spectral analysis for detecting apoptosis in vitro and in vivo

Apoptosis is a form of programmed cell death characterized by a series of predictable morphological changes at the subcellular level, which modify the light-scattering properties of cells. We present a spectroscopic optical coherence tomography (OCT) technique to detect changes in subcellular morphology related to apoptosis in vitro and in vivo. OCT data were acquired from acute myeloid leukemia (AML) cells treated with cisplatin over a 48-h period. The backscatter spectrum of the OCT signal acquired from the cell samples was characterized by calculating its in vitro integrated backscatter (IB) and spectral slope (SS). The IB increased with treatment duration, while the SS decreased, with the most significant changes occurring after 24 to 48 h of treatment. These changes coincided with striking morphological transformations in the cells and their nuclei. Similar trends in the spectral parameter values were observed in vivo in solid tumors grown from AML cells in mice, which were treated with chemotherapy and radiation. Our results provide a strong foundation from which future experiments may be designed to further understand the effect of cellular morphology and kinetics of apoptosis on the OCT signal and demonstrate the feasibility of using this technique in vivo.