A breast-specific diffusion-weighted imaging (DWI)-MRI technique is effective for distinguishing between breast lesion types — and improves on dynamic contrast-enhanced (DCE) MRI for this purpose, researchers have reported.

A team led by Stephane Loubrie, PhD, of the University of California San Diego in La Jolla found that information generated by a DWI-MRI technique called restriction spectrum imaging (RSI) showed significant difference between cancers and high-risk benign lesions compared with average-risk benign lesions. The study results were published on 18 September in the Journal of Magnetic Resonance Imaging.

Breast cancer screening with DCE-MRI is recommended for women at high risk of the disease, but it has limitations, including variable specificity and difficulty in distinguishing lesion types, the group explained. What’s needed are “complementary, noninvasive imaging techniques … to improve specificity,” the authors noted, and that’s why using DW-MRI shows promise.

Loubrie’s team conducted a study that assessed the ability of an existing restriction spectrum imaging DWI-MRI model called BS-RSI3C to categorize a range of lesion types in a screening population. The study included 187 women, 49 of whom had undergone mammography and had been recommended for additional imaging and 138 of whom were considered high-risk and were undergoing breast MRI before biopsy. The team estimated five “signal contributions” from the model.

Of these five signals, three showed significant differences in high-risk benign lesions compared with average-risk benign ones and one of the five had the highest area under the receiver operating curve (AUC) for distinguishing combined cancerous and high-risk lesions from average-risk benign ones compared to apparent diffusion coefficient (ADC) values (which DW-MRI generates and which correlate to tissue cellularity).

“The BS-RSI3C model results showed a differentiation between average-risk benign lesions and cancerous lesions in a screening population,” the authors wrote. “This is likely due to the BS-RSI3C model’s known ability to estimate tumor cellularity, which is increased in hypercellular malignant tumors and lesions with abnormal cellularity.”

The study findings could translate to more tailored care for women with breast cancer, according to the team.

“[Our results show] that restriction spectrum imaging has potential to complement standard-of-care DCE-MRI for increased diagnostic specificity and to guide surgical management of breast lesions,” it concluded.

The complete study can be found here. Contract grant sponsor: GE Healthcare Research Grant; Contract grant sponsor: Krueger v. Wyeth Research Award; Contract grant sponsor: RSNA Research Resident Award; Contract grant sponsor: NCI/NIH; Contract grant number: 5R37CA249659.

Researchers led by Dr. Toulsie Ramtohul, from the Curie Institute in Paris found that a radiomics score at pretreatment perfusion MRI performed well in predicting pathologic complete response in these patients, who were being treated with immunotherapy-based regimens. They highlighted that this method has the potential to serve as a biomarker for drug sensitivity heterogeneity in studies that explore less aggressive breast cancer treatment.

“The proposed radiomics score, derived from images obtained using various ‘real-life’ MRI scanner models, demonstrated favorable discrimination and clinical utility for predicting pathologic complete response,” Ramtohul and colleagues wrote.

Radiology researchers over the years have attempted to develop effective methods for predicting how patients being treated for breast cancer may respond to treatment strategies. The researchers noted that predictors of response to neoadjuvant chemotherapy have not been identified for women being treated for triple-negative breast cancer.

Ramtohul and co-authors studied how radiomics derived from pretreatment perfusion MRI could serve as a predictive marker for pathologic complete response in these patients.

The team obtained pretreatment dynamic contrast-enhanced MRI (DCE-MRI) scans by using scanners from multiple vendors. It also used the Tofts model to segment tumors and analyze pharmacokinetic parameters. The following radiomics features were extracted from the images: rate constant for contrast agent plasma-to-interstitial transfer (or K^trans), volume fraction of extravascular and extracellular space (Ve), and maximum contrast agent uptake rate (Slope_max) maps.

The study included 195 women with triple-negative breast cancer who underwent neoadjuvant chemotherapy and were enrolled between 2021 and 2023. The researchers assessed their radiomics model’s performance in a training set (n = 112) and a test set (n = 83).

Axial dynamic contrast-enhanced MRI scans show results from two women before they underwent neoadjuvant chemoimmunotherapy for triple-negative breast cancer. (A) T1-enhanced MRI scan, (B) rate constant for contrast agent plasma-to-interstitial transfer (K^trans) map, and (C) maximum contrast agent uptake rate (Slope_max) map in a 56-year-old woman depict a tumor that manifested as a spherical 4-cm mass enhancement (arrow in A) in the right breast with axillary node involvement (arrowhead in A). The radiomics score was high, at 3.3. Histopathologic examination after chemotherapy revealed no invasive residual cancer in the breast or the lymph nodes (pathologic complete response). (D) T1-enhanced MRI scan, (E) K^trans map, and (F) Slope_max map in a 49-year-old woman show a tumor that manifested as a spiculated 3-cm mass enhancement (arrow in D) in the left breast with thickening of the skin (arrowhead in D). The parametric maps show much greater spatial heterogeneity than in the case shown in B and C, with areas of high intensity. The radiomics score was low, at −1.6. Histopathologic examination after chemotherapy revealed a 10-mm invasive residual cancer in the breast (not pathologic complete response). Image courtesy of the RSNA.

The radiomics score achieved area under the curve (AUC) values of 0.84 for the training set and 0.8 for the test set in predicting pathologic complete response. A nomogram incorporating the radiomics score, grade, and Ki-67, meanwhile, achieved an AUC of 0.86 in the test set.

The team also observed significant associations between higher radiomics scores (< 0.25) and the following characteristics: tumor size (p < 0.001), washout enhancement (p = 0.01), androgen receptor expression (p = 0.009), and programmed death ligand 1 expression (p = 0.01). It highlighted that this shows a correlation with tumor immune environment in participants with triple-negative breast cancer.

The study authors highlighted that their radiomics score could potentially be used to improve clinical decision-making.

In an accompanying editorial, Dr. Gaiane Rauch, PhD, from the University of Texas MD Anderson Cancer Center in Houston wrote that the results by Ramtohul et al “confirm the importance of including tumor microenvironment biomarkers” in image-based models. This can further guide escalation or deescalation of neoadjuvant therapy in patients with triple-negative breast cancer.”

“Large-scale multicenter clinical trials that include functional imaging, clinicopathologic, and genomic data are needed,” Rauch added. “The long-term goal is to develop a personalized, response-adapted, biomarker-driven approach to optimize neoadjuvant therapy and improve quality of life and outcomes in patients with triple-negative breast cancer.”

The full results can be found here.

CT assessment of coronary artery disease can have a major impact on the management of patients with stable chest pain, according to a new 10-year analysis from the SCOT-HEART trial presented on Sunday 1 September at the annual congress of the European Society of Cardiology (ESC) in London.

In a special ESC breaking news session, Prof. Michelle Williams, professor of cardiovascular imaging at the University of Edinburgh, U.K., revealed how the latest results show that coronary CT angiography (CCTA) management is associated with a sustained 10-year reduction in coronary heart disease death and nonfatal myocardial infarction and that these long-term benefits are predominantly driven by the prevention of nonfatal myocardial infarction. In addition, this comes at no extra burden on healthcare budgets related to revascularization costs.

“SCOT HEART changes diagnosis and management of patients with stable chest pain, and preventative management is probably driving the reduction in heart attack. People are still more likely to be taking their preventative medication if they’ve had CT-guided management,” she told AuntMinnieEurope.com ahead of the meeting.

Prof. Michelle Williams from Edinburgh.

In this multicenter, parallel group trial, patients with stable chest pain were randomized (1:1) to standard care or standard care plus CCTA. In total, 4,146 patients between the ages of 18 and 75 (1,821, 44% female) were recruited: 2073 in the standard care group and 2073 in the CCTA group, both groups having similar characteristics, including the prevalence of chest pain symptoms by type. The researchers obtained clinical outcomes through record linkage from national registries and the primary outcome was coronary heart disease death or nonfatal myocardial infarction.

After 10 years of follow-up, the research team found that coronary heart disease death or nonfatal myocardial infarction was lower in the CCTA group compared with the standard care group (n = 137, 6.6% vs. n = 171, 8.2%) and this was primarily driven by a reduction in myocardial infarction (n = 90, 4.3% vs. n = 124, 6%).

The team found no difference in all-cause mortality (n = 168, 8.1% vs. n = 166, 8%) or coronary revascularization between groups (n = 313, 15.1% vs. n = 317, 15.3%).

A 3D reconstruction of a CT coronary angiogram from a patient in the SCOT-HEART trial who had normal coronary arteries. All images courtesy of Prof. Michelle Williams and SCOT-HEART.

Williams, who is also associate director of the British Heart Foundation Data Science Centre, noted that with even longer-term analysis, cardiovascular or all-cause mortality might also show some differences between the CCTA group and the standard care group, but the average age of trial participants (67 years) currently may still be too young to reveal that difference. Interestingly, there has been no change in the use of revascularization with CT management, despite a worry that the improvement in diagnosing coronary artery disease with CT would lead to more invasive coronary angiography.

“We have shown categorically at ten years that this is not the case. The use of invasive coronary angiography is the same between the patients in the standard care and the CT arm. The difference is that those patients with normal coronary arteries aren’t going to the cath lab so we are doing the same number of invasive coronary angiograms, just in people who really need it,” she said.

Williams also flagged how invasive coronary angiography, stents, and grafts were very useful for improving patient symptoms but not for preventing heart attacks in the long term. “For the vast majority of patients, the long-term benefit of CT-guided care is because of the increased use of preventative medication and not revascularization,” she noted.

Furthermore, the trial has demonstrated that people who have had their management guided by CT scans were more likely to be given preventative medication because of the imaging and more likely to still be taking it at 10 years.

A 3D reconstruction and curved planar reformation from a CT coronary angiogram from a patient in the SCOT-HEART trial who had severe obstructive coronary artery disease.

In addition, she noted that females in the CCTA group showed a lower risk of myocardial infarction than males. “Is it that women are undertreated by our current way of assessing risk and CT identifies disease that they didn’t know that they had? It might also be because once someone knows they have coronary artery disease they are more likely to take their tablets or other treatment, and people may react differently depending on whether they are men or women,” Williams said.

This and other topics will be examined more thoroughly in SCOT-HEART 2, recruitment for which began in 2020. This trial aims to explore how to identify and treat coronary artery disease in at-risk asymptomatic individuals, with patients divided between standard care and CCTA-managed care. In addition, the trial seeks to show whether the information from CT impacts lifestyle decisions such as diet, smoking, and activity levels.

The first trial results were presented by Dr. Michael McDermott in the same ESC session. In a subgroup of 400 patients, CT helped this patient group to live more healthily in the short term, not just by taking medication regularly but also by walking more and eating better. Volunteers who live in Scotland and meet the trial criteria can still apply.

10-year impact

SCOT-HEART’s five-year results have already had a major impact on the UK’s National Institute for Health and Care Excellence (NICE) guidelines, and CCTA guidance was adopted as the first-line test in 2016. It has also been incorporated in other European and U.S. guidance.

“The 10-year results confirm and present a really compelling case that this is a good thing to do for patients and hopefully this will help people who are still struggling to implement those guidelines in regions and countries around the world,” Williams noted.

The full title of Sunday’s presentation was: Coronary CT angiography guided management of patients with stable chest pain: 10-year outcomes from the SCOT-HEART trial. Michelle C Williams, Ryan Wereski, Philip Adamson, Anoop Shah, Edwin JR van Beek, Giles Roditi, Colin Berry, Nicholas Boon, Marcus Flather, Steff Lewis, John Norrie, Adam D Timmis, Nicholas L Mills, Marc R Dweck, David E Newby.

CT-derived fractional flow reserve (CT-FFR) and CT myocardial perfusion imaging boost the specificity of coronary CT angiography (CCTA) for ruling out coronary artery disease (CAD) — and perform comparably to CCTA alone.

The study findings highlight alternative options for CAD assessment, wrote a team led by Dr. Martin Soschynski of the University of Freiburg in Germany. The group’s research results were published on 20 August in Radiology.

“CCTA plus CT-FFR and CCTA plus CT perfusion showed no evidence of a difference in diagnostic accuracy metrics for detecting hemodynamically relevant CAD,” the authors reported.

CT-FFR and CT perfusion have been shown to boost CCTA’s specificity when it comes to ruling out CAD, but how the three techniques compare in diagnostic performance has remained unclear, Soschynski and colleagues noted. To address the question, they compared the diagnostic accuracy of CCTA plus CT-FFR; CCTA plus CT perfusion; and sequential CCTA plus CT-FFR and CT perfusion to CCTA alone for detecting “hemodynamically relevant” CAD (defined as patients having at least one coronary stenosis with an invasive FFR of 0.80 or less, or angiographic stenosis greater than 90% at CCTA) via a study that included 105 patients with chest pain referred for CCTA between July 2016 and September 2019. CCTA alone served as the reference standard.

Of the 105 patients, 47% had hemodynamically relevant stenoses at invasive coronary angiography, the investigators reported. They found that the alternative CT imaging techniques performed comparably to CCTA alone, with only specificity showing statistical significance.

“There was no evidence of a difference in diagnostic accuracy between CCTA plus CT-FFR and CCTA plus CT perfusion for detecting hemodynamically relevant CAD … [although the] sequential approach combining CCTA plus CT-FFR with CT perfusion led to improved … specificity with no evidence of a difference in sensitivity compared with CCTA plus CT-FFR,” the group reported.

Slide courtesy of the RSNA.

The study results represent significant progress in assessing CAD, according to an accompanying commentary written by Prof. Valentin Sinitsyn, PhD, of the University Medical Center Moscow Lomonosov State University in Russia.

“[The] study … looks like a big step forward in helping select the optimal strategy for the evaluation and analysis of intermediate coronary stenosis,” he wrote. “For the majority of patients with suspected CAD, it appears that a combination of CCTA and CT-FFR is the preferable option.”

The complete report can be found here.

Digital breast tomosynthesis (DBT) leads to earlier detection of breast cancer, a study published on 30 July in Radiology found.

Researchers led by Dr. Annika Jögi, PhD, from Skåne University Hospital in Lund, Sweden, analyzed data from women who were followed up through their first and second consecutive two-view digital mammography screening rounds after participating in the Malmö Breast Tomosynthesis Screening Trial (MBTST). They found that the cancer detection rate and the fraction of invasive cancers were lower in the first round and then increased in the second round.=

“The reduced detection of less aggressive breast cancer subtypes with favorable prognosis in the first digital mammography screening round following a prospective [DBT] trial indicates screening benefit from tomosynthesis due to earlier detection of invasive cancer,” Jögi and colleagues wrote.

Despite DBT gaining ground on digital mammography for breast cancer screening, the latter is still considered the gold standard.

MBTST was a prospective, population-based paired study conducted between 2010 and 2015 that assessed the sensitivity and specificity of one-view DBT compared with two-view digital mammography in breast cancer screening. Findings indicated that DBT had a higher cancer detection rate, but more recalls than mammography.

Women participating in the trial were followed up through their first two consecutive routine mammography screening examinations. The researchers highlighted that analyzing how DBT screening impacts consecutive screening performance can estimate the modality’s future value in screening settings.

Jögi and fellow researchers studied how DBT adds to early breast cancer detection. They assessed cancer detection rates, including the fraction of invasive cancers and cancer subtypes in consecutive routine digital mammography. The team analyzed two follow-up screening rounds: the first round was performed 18 to 24 months after the MBTST, and the second round was performed 36 to 48 months after the trial.

MBTST had 14,848 participants with a median age of 57 years. Of these women, 12,876 were included in the first round of consecutive screening while 10,883 women were screened in the second round.

Cancer detection rates in MBTST were 6.5 (out of 1,000 women) for digital mammography and 8.7 for DBT. Also, the proportion of invasive cancers was 84.9%.

The team reported that the second round of consecutive screening led to more cancers being detected, including invasive cancers. Also, the odds of luminal A-like cancers were lower in the first round versus screening in the MBTST (p = 0.004), but higher in the second round (p = 0.52).

The study authors highlighted that the lower cancer detection rate and proportion of luminal A-like cancers in the first follow-up screening round points to earlier detection of slow-growing, less aggressive cancers.

“Less proliferative luminal A-like cancers may be diagnosed earlier and have a better prognosis with more sensitive screening, as they are subclinically present for a longer time,” they added.

However, the first follow-up screening round had a higher rate of interval cancers compared to the second round (2.2 per 1,000 vs. 1.5 per 1,000). The authors wrote that this suggests earlier detection of relevant fast-growing cancers at DBT, but they noted this should be interpreted with caution due to the small number of interval cancers found in the study.

The researchers concluded that they are performing a cost-effectiveness analysis of DBT screening at their institution.

In an accompanying editorial, Dr. Regina Hooley and Dr. Liane Philpotts from Yale School of Medicine wrote that the study’s results are “noteworthy” and provide evidence on the value of DBT screening. They called for more studies to establish best practices, develop more personalized screening with DBT and mammography based on breast cancer risk, age, and breast density, and determine the added value of supplemental screening with other modalities.

“We need the data now, but even if provided with all the dedicated resources to support more long-term trials, it will take many years to solve the screening puzzle and someday end the screening mammography debate,” they wrote.

The full results can be found here.

Annual lung cancer screening (LCS) in Austria using low-dose CT for a high-risk asymptomatic population would be cost-effective in a national program, despite some uncertainties around healthcare costing data, according to research published at MDPI.

A new Austrian national lung cancer screening modeling study estimated a cost of €945 million in additional screening costs, using volume-based CT over 17 screening rounds, according to the research team led by Hilde ten Berge from the Center for Diagnostic Accuracy and colleagues at the Medical University of Vienna, Johannes Kepler University, and others.

The volume-based CT principle is based on measuring the increase in volume of the lung nodule over time, according to the Center for Diagnostic Accuracy. Volume CT is believed to be a better predictive value for developing lung cancer than looking at the increase in diameter.

Since the Dutch-Belgium NEderlands-Leuvens Longkanker ScreeningsONderzoek (NELSON) trial — the largest European randomized control trial investigating lung cancer screening — found a positive effect of low-dose volume CT screening in reducing lung cancer mortality rates, countries throughout the European Union have been establishing and rolling out their programs.

In Germany, national lung cancer screening began on 1 July. The modeling study cites data from Italy as well. And, as of June 2023, the U.K. was set for annual targeted lung health checks (TLHC), rolling out screening mostly with mobile scanning units parked in convenient places, such as supermarket car parks.

The Austrian Society of Roentgenology and the Austrian Society of Pneumology have recommended lung cancer screening implementation in Austria, the authors noted. Moreover, there is an intention to initiate the implementation of screening pilots to evaluate the practical and socioeconomic aspects of screening in the country.

For the Austria study, researchers used a base-case analysis to assess the cost-effectiveness of screening versus no screening program. They considered cost data associated with CT scanning in Germany and Italy, rather than comparing the models themselves.

The study involved 17 screening rounds, determined by referencing the mean age of participants (58 years) and the upper boundary of the age inclusion criteria based on the NELSON study (74 years). Ten Berge and colleagues estimated a 24% mortality reduction as a result of implementing a nationwide lung cancer screening program.

At an uptake rate of 50%, 300,277 eligible individuals would participate in the program. Annual screening would yield 56,122 incremental quality-adjusted life years (QALYs) and 84,049 life years gained compared to no screening, with an incremental cost-effectiveness ratio (ICER) of €24,627 per QALY gained or €16,444 per life-year saved, the authors noted. This study referenced a CT scan cost of €280 from earlier data sourced from the Austrian National Lung Cancer Audit and the unit cost database of Vienna’s Department of Health Economics.

“LCS resulted in a stage shift from late to early-stage detection, with 51% of the lung cancer cases being detected in stage I,” wrote ten Berge and colleagues. This stage shift resulted in nearly 12,000 premature lung cancer deaths being averted.

Those eligible would either undergo an annual screening with volume CT until a confirmed diagnosis or choose not to participate. Screening participants with negative screen results would enter the sequent screening in the next year. Individuals who did not participate in the screening, alongside those in the no-screening arm, would be diagnosed through standard clinical care after the presentation of lung-cancer-related symptoms.

For this study, scenario analyses investigated the influence of diverse screening uptake rates, with estimations derived from existing cancer screening programs (colorectal cancer, breast cancer) established in Austria. Scenario analyses also explored reduced CT scan expenses as noted in neighboring countries such as Germany and Italy.

Researchers considered expenses encompassing participant recruitment, screening, diagnostic procedures, treatments, ongoing aftercare care, and palliative care to evaluate the cost-effectiveness from a healthcare payer perspective.

Diagnostic costs included expenses incurred after receiving a positive scan or after the clinical presentation of lung-cancer-related symptoms in the nonscreening cohort and the non-participants, the authors noted. Additional costs were accounted for general practitioner or pulmonologist consultation and CT scans. Aftercare consisted of regular chest CT scans and pulmonologist consultations following the initial treatments.

An important point ten Berge and colleagues made is that the use of AI as an impartial reader is expected to “drastically reduce” the workload of radiologists in the future by reducing CT scanning costs.

“Another European country moving towards implementation is a very good sign,” former president of the European Society of Thoracic Imaging (ESTI) Prof. Marie-Pierre Revel told AuntMinnieEurope.com recently.

Efforts should prioritize the strategic management of budget allocations, specifically targeting reductions in CT scan costs in the context of LCS implementation in Austria, stated ten Berge and colleagues.

The full research is available here.

Adding dynamic CT perfusion (DynCTP) to cardiac CT angiography (CCTA) shortens time to diagnosis of coronary artery disease (CAD), according to research presented at the Society of Cardiovascular Computed Tomography (SCCT) meeting in Washington, DC.

A team led by David Vilades Medel, PhD, of Hospital de la Santa Creu i Sant Pau in Barcelona, Spain, found that the combination cut time to diagnosis by 42% and decreased the need for further functional tests by 48%.

“In our center, implementing a CCTA plus DynCTP diagnostic algorithm in symptomatic patients with suspected CAD or known CCS [chronic coronary syndrome] significantly shortened the diagnostic process and number of additional tests,” the group reported.

CCTA is a valuable tool for diagnosing symptomatic patients with suspected CAD or a history of CCS, the researchers noted. DynCTP illuminates the effect of coronary stenosis on blood flow and is used to detect myocardial ischemia, adding functional information to anatomical studies and “[integrating] the diagnostic process into a single noninvasive imaging technique,” they wrote.

Medel’s group investigated the clinical performance of a diagnostic algorithm based on CCTA plus DynCTP in symptomatic patients with suspected CAD or a history of CCS, comparing it with the CCTA-only algorithm. Their study included 204 patients divided into two cohorts: one that underwent a CCTA-only algorithm from January 2017 to January 2019 and a second that underwent a diagnostic algorithm based on CCTA plus DynCTP from April 2021 to May 2023 (DynCTP was performed if a patient’s Coronary Artery Disease Reporting and Data System [CAD-RADS] score equal to or higher than 3 or inconclusive). The team matched study participants by gender, cardiovascular risk factors prevalence, and atherosclerotic burden as indicated by their CAD-RADS score, then noted the following:

• Functional tests (stress echo, stress cardiac magnetic resonance, or treadmill test)
• Cardiac catheterizations
• Major cardiovascular events such as cardiovascular mortality, acute coronary syndrome, and the need for revascularization

Overall, adding DynCTP improved the performance metrics of CCTA, Medel and colleagues reported.

The team did not report significant differences between the groups in the number of cardiac catheterizations performed (cohort 1, 27% vs. cohort 2, 33%) or major cardiovascular events (cohort 1, 24% vs. cohort 2, 28%).

“In our center, implementing a CCTA plus DynCTP diagnostic algorithm in symptomatic patients with suspected CAD or known CCS significantly shortened the diagnostic process and number of additional tests,” the investigators concluded. “This approach also increased the percentage of patients referred to invasive catheterization with prior functional information.”