Editorial for "Radiomics Based on Multimodal MRI for the Differential Diagnosis of Benign and Malignant Breast Lesions".

LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY STAGE: 2 J. Magn. Reson. Imaging 2020;52:608-609.

Pubovisceralis Muscle Fiber Architecture Determination: Comparison Between Biomechanical Modeling and Diffusion Tensor Imaging.

Biomechanical analysis of pelvic floor dysfunction requires knowledge of certain biomechanical parameters, such as muscle fiber direction, in order to adequately model function. Magnetic resonance (MR) diffusion tensor imaging (DTI) provides an estimate of overall muscle fiber directionality based on the mathematical description of water diffusivity. This work aimed at evaluating the concurrence between pubovisceralis muscle fiber representations obtained from DTI, and the maximum principal stress lines obtained through the finite element method. Seven datasets from axial T2-weighted images were used to build numerical models, and muscle fiber orientation estimated from the DT images. The in-plane projections of the first eigenvector of both vector fields describing muscle fiber orientation were extracted and compared. The directional consistency was evaluated by calculating the angle between the normalized vectors for the entire muscle and also for the right and left insertions, middle portions, and anorectal area. The values varied between 28° ± 6 (right middle portion) and 34° ± 9 (anorectal area), and were higher than the angular precision of the DT estimates, evaluated using wild bootstrapping analysis. Angular dispersion ranged from 17° ± 4 (left middle portion) to 23° ± 5 (anorectal area). Further studies are needed to examine acceptability of these differences when integrating the vectors estimated from DTI in the numerical analysis.

The Visual Word Form Area remains in the dominant hemisphere for language in late-onset left occipital lobe epilepsies: A postsurgery analysis of two cases.

Automatic recognition of words from letter strings is a critical processing step in reading that is lateralized to the left-hemisphere middle fusiform gyrus in the so-called Visual Word Form Area (VWFA). Surgical lesions in this location can lead to irreversible alexia. Very early left hemispheric lesions can lead to transfer of the VWFA to the nondominant hemisphere, but it is currently unknown if this capability is preserved in epilepsies developing after reading acquisition. In this study, we aimed to determine the lateralization of the VWFA in late-onset left inferior occipital lobe epilepsies and also the effect of surgical disconnection from the adjacent secondary visual areas. Two patients with focal epilepsies with onset near the VWFA underwent to surgery for epilepsy, with sparing of this area. Neuropsychology evaluations were performed before and after surgery, as well as quantitative evaluation of the speed of word reading. Comparison of the surgical localization of the lesion, with the BOLD activation associated with the contrast of words-strings, was performed, as well as a study of the associated main white fiber pathways using diffusion-weighted imaging. Neither of the patients developed alexia after surgery (similar word reading speed before and after surgery) despite the fact that the inferior occipital surgical lesions reached the neighborhood (less than 1cm) of the VWFA. Surgeries partly disconnected the VWFA from left secondary visual areas, suggesting that pathways connecting to the posterior visual ventral stream were severely affected but did not induce alexia. The anterior and superior limits of the resection suggest that the critical connection between the VWFA and the Wernicke's Angular Gyrus cortex was not affected, which is supported by the detection of this tract with probabilistic tractography. Left occipital lobe epilepsies developing after reading acquisition did not produce atypical localizations of the VWFA, even with foci in the close neighborhood. Surgery for occipital lobe epilepsy should take this into consideration, as well as the fact that disconnection from the left secondary visual areas may not produce alexia.

Fat suppression techniques (STIR vs. SPAIR) on diffusion-weighted imaging of breast lesions at 3.0 T: preliminary experience.

PURPOSE: The aim of this work was to perform a qualitative and quantitative comparison of the performance of two fat suppression techniques on breast diffusion-weighted imaging (DWI). MATERIALS AND METHODS: Fifty-one women underwent clinical breast magnetic resonance imaging, including DWI with short TI inversion recovery (STIR) and spectral attenuated inversion recovery (SPAIR). Four were excluded from the analysis due to image artefacts. Rating of fat suppression uniformity and lesion visibility were performed. Agreement between the two sequences was evaluated. Additionally, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and apparent diffusion coefficient (ADC) values for normal gland, benign and malignant lesions were compared. Receiver operating characteristic analysis was also performed. RESULTS: From the 52 lesions found, 47 were detected by both sequences. DWI-STIR evidenced more homogeneous fat suppression (p = 0.03). Although these lesions were seen with both techniques, DWI-SPAIR evidenced higher score for lesion visibility in nine of them. SNR and CNR were comparable, except for SNR in benign lesions (p < 0.01), which was higher for DWI-SPAIR. Mean ADC values for lesions were similar. ADC for normal fibroglandular tissue was higher when using DWI-STIR (p = 0.006). Sensitivity, specificity, accuracy and area under the curve values were alike: 84.0 % for both; 77.3, 71.4 %; 80.9, 78.3 %; 82.5, 81.3 % for DWI-SPAIR and DWI-STIR, respectively. CONCLUSION: DWI-STIR showed superior fat suppression homogeneity. No differences were found for SNR and CNR, except for SNR in benign lesions. ADCs for lesions were comparable. Findings in this study are consistent with previous studies at 1.5 T, meaning that both fat suppression techniques are appropriate for breast DWI at 3.0 T.

Region of interest demarcation for quantification of the apparent diffusion coefficient in breast lesions and its interobserver variability.

PURPOSE: We aimed to compare two different methods of region of interest (ROI) demarcation and determine interobserver variability on apparent diffusion coefficient (ADC) in breast lesions. METHODS: Thirty-two patients with 39 lesions were evaluated with a 3.0 Tesla scanner using a diffusion-weighted sequence with several b-values. Two observers independently performed the ADC measurements using: 1) a small fixed area of 10 mm2 ROI within the area with highest restriction; 2) a large ROI so as to include the whole lesion. Differences were assessed using the Wilcoxon-rank test. Bland-Altman method and Spearman coefficient were applied for interobserver variability and correlation analysis. RESULTS: ADC values measured using the two ROI demarcation methods were significantly different for both observers (P = 0.026; P = 0.033). There was no interobserver variability in ADC values using either method (large ROI, P = 0.21; small ROI, P = 0.64). ADC values of malignant lesions were significantly different between the two methods (P < 0.001). Variability in ADC was ≤0.008×10-3 mm2/s for both methods. When using the same method, ADC values were significantly correlated between the observers (small ROI: r=0.990, P < 0.001; large ROI: r=0.985, P < 0.001). CONCLUSION: The choice of ROI demarcation method influences ADC measurements. Small ROIs show less overlap in ADC values and higher ADC reproducibility, suggesting that this method may improve lesion discrimination. Interobserver variability was low for both methods.

Exploring the 3D geometry of the diffusion kurtosis tensor--impact on the development of robust tractography procedures and novel biomarkers.

Diffusion kurtosis imaging (DKI) is a diffusion-weighted technique which overcomes limitations of the commonly used diffusion tensor imaging approach. This technique models non-Gaussian behaviour of water diffusion by the diffusion kurtosis tensor (KT), which can be used to provide indices of tissue heterogeneity and a better characterisation of the spatial architecture of tissue microstructure. In this study, the geometry of the KT is elucidated using synthetic data generated from multi-compartmental models, where diffusion heterogeneity between intra- and extra-cellular media is taken into account, as well as the sensitivity of the results to each model parameter and to synthetic noise. Furthermore, based on the assumption that the maxima of the KT are distributed perpendicularly to the direction of well-aligned fibres, a novel algorithm for estimating fibre direction directly from the KT is proposed and compared to the fibre directions extracted from DKI-based orientation distribution function (ODF) estimates previously proposed in the literature. Synthetic data results showed that, for fibres crossing at high intersection angles, direction estimates extracted directly from the KT have smaller errors than the DKI-based ODF estimation approaches (DKI-ODF). Nevertheless, the proposed method showed smaller angular resolution and lower stability to changes of the simulation parameters. On real data, tractography performed on these KT fibre estimates suggests a higher sensitivity than the DKI-based ODF in resolving lateral corpus callosum fibres reaching the pre-central cortex when diffusion acquisition is performed with five b-values. Using faster acquisition schemes, KT-based tractography did not show improved performance over the DKI-ODF procedures. Nevertheless, it is shown that direct KT fibre estimates are more adequate for computing a generalised version of radial kurtosis maps.

Application of the diffusion kurtosis model for the study of breast lesions.

OBJECTIVES: To evaluate diffusion-weighted imaging (DWI) and diffusion kurtosis imaging (DKI) in the differentiation and characterisation of breast lesions. METHODS: Thirty-six women underwent breast magnetic resonance imaging (MRI) including a DWI sequence with multiple b-values (50-3,000 s/mm(2)). Mean values for apparent diffusion coefficient (ADC), mean diffusivity (MD) and mean kurtosis (MK) were calculated by lesion type and histological subtype. Differences and correlation between parameters were determined. RESULTS: Forty-four lesions were found. There were significant differences between benign and malignant lesions for all parameters (ADC, p = 0.017; MD, p = 0.028; MK, p = 0.017). ADC and MD were higher for benign (1.96 ± 0.41 × 10(-3) and 2.17 ± 0.42 × 10(-3) mm(2)/s, respectively) than for malignant lesions (1.33 ± 0.18 × 10(-3) and 1.52 ± 0.50 × 10(-3) mm(2)/s). MK was higher for malignant (0.61 ± 0.27) than benign lesions (0.37 ± 0.18). We found differences between invasive ductal carcinoma (IDC) and fibroadenoma (FA) for all parameters (ADC, MD and MK): p = 0.016, 0.022 and 0.016, respectively. FA and fibrocystic change (FC) showed differences only in MK (p = 0.016). CONCLUSIONS: Diffusion in breast lesions follows a non-Gaussian distribution. MK enables differentiation and characterisation of breast lesions, providing new insights into microstructural complexity. To confirm these results, further investigation in a broader sample should be performed.