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ADC values were shown to be higher in estrogen receptor ER -negative tumors, compared to the ER-positive tumors; whereas the human epidermal growth factor receptor-enriched tumors exhibited the highest ADC values 48 , 63 , 64 , Considering the whole scenario, further studies involving larger cohorts from multiple institutions are required, in order to determine the association between ADC and tumor biomarkers.

Neoadjuvant chemotherapy is increasingly being used for breast cancer treatment. Cytotoxic effects of chemotherapy, including cell lysis, apoptosis and necrosis, cause alterations in the cell membrane integrity, which increases the water mobility in the extracellular space that occurs before the advent of morphologic changes.

Multiple studies have reported that the increase in tumor ADC, in response to treatment, is detectable earlier than the changes in size or vascularity, as measured by DCE MRI, which may denote an early indication of the treatment efficacy 66 , 67 , Moreover, some studies have found that the pretreatment tumor ADC values are predictive of the pathological response; baseline ADC values were observed to be lower in clinical responders, compared to non-responders 69 , 70 , 71 , Residual disease after neoadjuvant chemotherapy may be predicted with greater accuracy by means of the changes in ADC, compared to the changes on DCE MRI in some cases However, in the current literature, there is a wide variability in opinions regarding the utility of DW MRI to monitor and predict treatment response; probably due to the differences in study design, including patient characteristics, treatment regimens, chemotherapy cycle and image timing, DW MRI acquisition parameters and methods of ADC measurement.

In this scenario, further investigation is required, in order to validate ADC as a predictive biomarker for treatment response. DW MRI is a promising tool, which can be used to differentiate between metastatic and nonmetastatic axillary lymph nodes in patients with breast cancer. Scaranelo et al. The use of dedicated axillary protocols may improve the diagnostic performance in nodal staging The limitations of DW MRI for breast cancer screening include the lack of evidence from larger prospective studies and the difficulty of targeting the lesions in vacuum assisted MRI-guided biopsy of the lesions detected only through DW MRI, particularly in the case of small lesions less than 1 cm in size In summary, DW MRI is a rapid, unenhanced technique, which shows the potential to be employed in breast cancer screening and can be used in the accurate differential diagnosis of the breast lesions found in DCE MRI and the monitoring of breast cancer response to neoadjuvant chemotherapy.

Standardized acquisition and interpretation protocols can improve the image quality of DW MRI and reduce the variability in results. High resolution DW MRI using advanced acquisition techniques and postprocessing will facilitate better detection and characterization of subcentimeter cancers and reduce the false-negative and false-positive findings. The results from ongoing prospective clinical studies using standardized and optimized protocols will facilitate the use of DW MRI in unenhanced breast cancer screening.

Conflicts of Interest: The authors have no potential conflicts of interest to disclose. Breast Imaging Open Access. Korean J Radiol. Published online Aug 28, Email: moonwk snu. This article has been cited by 6 articles in This article has been cited by G o o g l e Scholar.

This article has been cited by 7 articles in Scopus. This article has been cited by 8 articles in Web of Science. Go to:. Choice of b Value The choice of b value is important because it determines the ADC value and affects the signal-to-noise ratio of the image and the contrast-to-noise ratio of the lesion 20 , 21 , 22 , Postprocessing Postprocessing may also improve the image quality of DW MRI by correcting the geometric distortions arising from field inhomogeneities and other factors Monitoring and Prediction of Treatment Response Neoadjuvant chemotherapy is increasingly being used for breast cancer treatment.

Axillary Lymph Nodes DW MRI is a promising tool, which can be used to differentiate between metastatic and nonmetastatic axillary lymph nodes in patients with breast cancer. Efficacy of MRI and mammography for breast-cancer screening in women with a familial or genetic predisposition. N Engl J Med ;— JAMA ;— Mammography, breast ultrasound, and magnetic resonance imaging for surveillance of women at high familial risk for breast cancer.

J Clin Oncol ;— Screening with magnetic resonance imaging and mammography of a UK population at high familial risk of breast cancer: a prospective multicentre cohort study MARIBS. Lancet ;— J Surg Oncol ;— Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk.

Long-term results of screening with magnetic resonance imaging in women with BRCA mutations. Br J Cancer ;— Abbreviated breast magnetic resonance imaging MRI : first postcontrast subtracted images and maximum-intensity projection-a novel approach to breast cancer screening with MRI. Gadolinium-based contrast agent accumulates in the brain even in subjects without severe renal dysfunction: evaluation of autopsy brain specimens with inductively coupled plasma mass spectroscopy.

Radiology ;— Intracranial gadolinium deposition after contrast-enhanced MR imaging. Diffusion weighted magnetic resonance imaging of the breast: protocol optimization, interpretation, and clinical applications. Eur Radiol ;— Diffusion tensor magnetic resonance imaging of breast cancer: associations between diffusion metrics and histological prognostic factors. Diffusion tensor imaging for characterizing tumor microstructure and improving diagnostic performance on breast MRI: a prospective observational study.

Breast Cancer Res ; Intravoxel incoherent motion diffusion-weighted MRI of invasive breast cancer: correlation with prognostic factors and kinetic features acquired with computer-aided diagnosis. J Magn Reson Imaging ;— Spin diffusion measurements: spin echoes in the presence of a time-dependent field gradient.

J Chem Phys ;— Differentiation of clinically benign and malignant breast lesions using diffusion-weighted imaging. Diffusion-weighted MRI for unenhanced breast cancer screening. Investigation of the optimal b-value to detect breast tumors with diffusion weighted imaging by 1.

Cancer Imaging ; Quantitative non-Gaussian diffusion and intravoxel incoherent motion magnetic resonance imaging: differentiation of malignant and benign breast lesions. Invest Radiol ;— Comparison and optimization of 3. Acad Radiol ;— Quantitative diffusion weighted imaging for differentiation of benign and malignant breast lesions: the influence of the choice of b-values.

Principles and applications of echo-planar imaging: a review for the general radiologist. Radiographics ;— High resolution diffusion-weighted imaging using readout-segmented echo-planar imaging, parallel imaging and a two-dimensional navigator-based reacquisition. Magn Reson Med ;— Diagnostic performance of fused diffusion-weighted imaging using unenhanced or postcontrast T1-weighted MR imaging in patients with breast cancer.

Medicine Baltimore ;e Unenhanced magnetic resonance screening using fused diffusion-weighted imaging and maximum-intensity projection in patients with a personal history of breast cancer: role of fused DWI for postoperative screening. Breast Cancer Res Treat ;— Potential of noncontrast magnetic resonance imaging with diffusion-weighted imaging in characterization of breast lesions: intraindividual comparison with dynamic contrast-enhanced magnetic resonance imaging.

High-resolution diffusion-weighted magnetic resonance imaging in patients with locally advanced breast cancer. Comparison of readout segmented echo planar imaging EPI and EPI with reduced field-of-view diffusion-weighted imaging at 3t in patients with breast cancer. Diffusion-weighted breast MRI: clinical applications and emerging techniques. Quantitative diffusion-weighted imaging as an adjunct to conventional breast MRI for improved positive predictive value.

Magn Reson Imaging ;— Fast and noninvasive characterization of suspicious lesions detected at breast cancer X-ray screening: capability of diffusion-weighted MR imaging with MIPs. Computed diffusion-weighted MR imaging may improve tumor detection.

Evaluating the diagnostic sensitivity of computed diffusion-weighted MR imaging in the detection of breast cancer. Analysis of factors influencing the degree of detectability on diffusion-weighted MRI and diffusion background signals in patients with invasive breast cancer. Apparent diffusion coefficient of breast cancer and normal fibroglandular tissue in diffusion-weighted imaging: the effects of menstrual cycle and menopausal status.

Diffusion-weighted MRI: influence of intravoxel fat signal and breast density on breast tumor conspicuity and apparent diffusion coefficient measurements. Evaluation of breast cancer morphology using diffusion-weighted and dynamic contrast-enhanced MRI: intermethod and interobserver agreement. Diffusion-weighted imaging of breast lesions: region-of-interest placement and different ADC parameters influence apparent diffusion coefficient values.

Clin Cancer Res ;— Magnetic resonance MR differential diagnosis of breast tumors using apparent diffusion coefficient ADC on 1. ADC mapping of benign and malignant breast tumors. Magn Reson Med Sci ;— Triple-negative invasive breast cancer on dynamic contrast-enhanced and diffusion-weighted MR imaging: comparison with other breast cancer subtypes. Performance of DWI as a rapid unenhanced technique for detecting mammographically occult breast cancer in elevated-risk women with dense breasts.

Diffusion-weighted MRI as an adjunct to mammography in women under 50 years of age: an initial study. Diffusion-weighted imaging with apparent diffusion coefficient mapping for breast cancer detection as a standalone parameter: comparison with dynamic contrast-enhanced and multiparametric magnetic resonance imaging. Breast magnetic resonance imaging: diffusion-weighted imaging. Nonmalignant breast lesions: ADCs of benign and high-risk subtypes assessed as false-positive at dynamic enhanced MR imaging.

Diffusion-weighted MRI in the body: applications and challenges in oncology. Diffusion-weighted imaging of mucinous carcinoma of the breast: evaluation of apparent diffusion coefficient and signal intensity in correlation with histologic findings. Differential diagnosis of mammographically and clinically occult breast lesions on diffusion-weighted MRI. Accuracy of combined dynamic contrast-enhanced magnetic resonance imaging and diffusion-weighted imaging for breast cancer detection: a meta-analysis.

Acta Radiol ;— Diffusion-weighted imaging improves the diagnostic accuracy of conventional 3. MRI-only lesions: application of diffusion-weighted imaging obviates unnecessary MR-guided breast biopsies. Invasive ductal carcinoma: correlation of apparent diffusion coefficient value with pathological prognostic factors.

NMR Biomed ;— Diffusion-weighted imaging in breast cancer: relationship between apparent diffusion coefficient and tumour aggressiveness. Clin Radiol ;— Quantitative apparent diffusion coefficient as a noninvasive imaging biomarker for the differentiation of invasive breast cancer and ductal carcinoma in situ.

Correlations between diffusion-weighted imaging and breast cancer biomarkers. Correlation of the apparent diffusion coefficient value and dynamic magnetic resonance imaging findings with prognostic factors in invasive ductal carcinoma. Correlation of the apparent diffusion coefficiency values on diffusion-weighted imaging with prognostic factors for breast cancer. Br J Radiol ;e—e Diffusion changes precede size reduction in neoadjuvant treatment of breast cancer.

Longitudinal study of the assessment by MRI and diffusion-weighted imaging of tumor response in patients with locally advanced breast cancer undergoing neoadjuvant chemotherapy. Multi-site clinical evaluation of DW-MRI as a treatment response metric for breast cancer patients undergoing neoadjuvant chemotherapy. PLoS One ;e On HRUS, majority of the skin lesions appear as hypoechoic cutaneous or subcutaneous thickening.

Color and Power Doppler studies help to identify vascularity in the lesions. Presence of abnormal intra- or peritumoral low-resistance pulsatile flow signals suggests the malignant nature of the cutaneous lesion. Significance of HRUS evaluation in cutaneous lesions[ 6 , 10 , 17 , 18 , 19 , 20 ]. Seborrheic keratoses are epidermal in origin, well delimited, very superficial, as though laid on the skin, and may be misdiagnosed as melanoma.

Harland et al. Von Recklinghausen disease neurofibromatosis usually presents as multiple nodules localized in the epidermis. In case of neoplastic degeneration of a nodule, variations in the sonographic pattern with inhomogeneous structure and ill-defined margins are seen.

A Cutaneous neurofibromas seen as circumscribed browncolored nodules in a patient with neurofibromatosis type 1. B HRUS shows well-defined, hypoechoic epidermal lesion, just above the dermis. Nevi are polychromic maculopapular or slightly elevated plaque-like pigmentary lesions with irregular contour.

The nevic cells are located at the dermo-epidermal junction, and during malignant transformation, the transition from the radial growth phase to the vertical growth phase begins with progression in depth. A Benign nevus seen as black, slightly elevated, plaquelike pigmentary lesions. B HRUS shows hypoechoic, homogeneous, oval, intradermal lesion with well-defined borders.

Pilonidal cysts commonly develop in intergluteal region from entrapped hair follicles, and chronic repetitive local trauma may play a role in etiology. HRUS helps in preventing postoperative recurrences by providing accurate details regarding the location, depth, extent, and branching of pilonidal sinus.

A Pilonidal cyst in intergluteal region presenting as an abscess. B HRUS shows long, irregular hypoechoic tract in the dermis and subcutaneous tissue, with linear internal foci corresponding to hair fragments. Pilomatrixoma, also known as calcifying epithelioma of Malherbe or trichomatricoma, is a benign skin tumor arising from hair follicle matrix.

A Pilomatrixoma seen as a nodule with hypoechoic rim and hyperechoic center, giving a target appearance. B Vascular malformation seen superficially in cutaneous layers as multiple arterial and venous vessels with arteriovenous shunts. HRUS and Color Doppler can evaluate vascular lesions like hemangiomas and vascular malformations that are seen superficially in cutaneous layers as multiple arterial and venous vessels with arteriovenous shunts.

Basal cell carcinoma BCC is the most common skin cancer, often located in head and neck regions and areas of skin subjected to chronic sun exposure. Uhara et al. A Basal cell carcinoma on face, seen as pigmented nodular lesion with rolled-up margins. B HRUS shows irregular, hypoechoic, heterogeneous lesion in the dermis, with posterior shadowing and intralesional vessels on Color Doppler.

Squamous cell carcinoma is the second most common cancer of the skin with a major tendency to local relapse and with frequent lymph nodal metastases. The tumor growth causes infiltration of the adjacent tissue and erosion of the underlying cartilages and bones. A Invasive squamous cell carcinoma arising from a neglected, chronic nonhealing ulcer.

B HRUS shows irregular, hypoechoic, highly vascular, heterogeneous lesion invading the dermis and subcutaneous layers, with loss of normal cutaneous architecture. Malignant melanoma is a lethal but curable skin cancer and early detection is the basis for reducing the mortality rate.

The histopathologically measured thickness Breslow index is the single most important prognostic factor in the management of malignant melanoma which can be measured accurately and noninvasively by using HRUS. A Malignant melanoma seen as an elevated pigmented lesion with irregular shape and borders. B HRUS shows well-defined, solid, homogenously hypoechoic lesion in the dermis with multiple vessels arising from the base, suggestive of high vascular density. Cutaneous metastases involving the skin and subcutaneous tissue are seen in 0.

A Cutaneous metastases seen as a nodule on the chest in a patient with carcinoma lung. B HRUS shows well-circumscribed, solid, hypoechoic lesion, with multiple internal vessels arising from the periphery. Cutaneous lymphoma can present itself in a diffuse or a nodular form. A Primary cutaneous lymphoma appearing as a reddish smooth nodule.

B HRUS shows hypoechoic coalescing nodules, with ill-defined margins in the dermis and the subcutaneous layer with intralesional vessels. HFUS is also useful in the evaluation of diffuse cutaneous diseases. HFUS systems are suited to follow inflammatory skin diseases over time, for example, dermatitis, hypersensitivity reactions, and psoriasis.

A Psoriasis seen as sharply demarcated chronic erythematous plaques covered by silvery-white scales. B HRUS shows thickened, hyperechoic epidermis and dermis compared to contralateral normal skin, as the superficial scales produce a hyperreflective band of variable thickness. Scleroderma is a sclerosis of the skin of unknown etiology that can manifest itself in localized morphea or generalized forms.

It is characterized by thickening of the dermis, and subcutaneous layers with the formation of gross connecting bands, in advanced stages. A Morphea presenting as multiple, superficial, ill-defined erythematous to violaceous lesions.

B HRUS shows diffusely thickened, slightly hypoechoic dermis in the area of lesions compared to contralateral normal skin. Contact dermatitis is an inflammatory skin reaction dermatitis resulting from exposure of skin to allergens allergic contact dermatitis or irritants irritant contact dermatitis. A Contact dermatitis over the neck. B HRUS shows thickened dermis with inhomogeneous echotexture and foci of hypoechoic edema compared to contralateral normal skin.

In dermal edema, echogenicity of dermis is decreased, but there are marked differences in the distribution of the low echogenic region in various diseases. B HRUS shows thickened grossly hypoechoic dermis compared to the hyperechoic dermis in the contralateral normal skin.

Foreign bodies can be found in skin and subcutaneous tissue in the setting of post-trauma or post-therapeutic procedures. They can be fragments of wood, metal, glass, suture materials, subcutaneous implantable devices, orthopedic implants, tissue expanders used in plastic and reconstructive surgery, etc.

Fillers can be biodegradable and temporary like hyaluronic acid most commonly used or permanent nonreabsorbable molecules like silicone, polymethylmethacrylate, and calcium hydroxyapatite. A Infected foreign body thorn in soft tissues seen as echogenic focus with small surrounding collection pus. B Retained suture seen as an echogenic linear structure within the surrounding abscess along with a draining tract up to the skin surface. HRUS is of significant value in the management of nonpalpable or slightly palpable cutaneous tumors or lymph nodes suspicious for malignant involvement.

It can be used to guide percutaneous procedures like fine needle aspirations and biopsies for cytology and histology sampling and also for surgical excision of lesions using a dermographic marker or a guidewire. The limitation of USG is that in its current version, it cannot detect lesions that are epidermal only or that measure less than 0.

Contrast-enhanced USG is a recent technique under evaluation using ultrasound contrast agents to increase the sensitivity of Doppler examination. It is useful in morphologic and functional assessment of lesions, providing quantitative perfusion parameters, which can be biomarkers for new antiangiogenic therapy monitoring. Ultrasound elastography can help in noninvasive detection and characterization of malignant cutaneous tumors, while reducing unnecessary biopsies. Recent studies have also reported that ultrasound elastography has considerable clinical potential in the assessment of cutaneous pressure ulcers, lymphedema, and age-related changes in the skin.

HFUS has multiple applications both in the clinical and research settings. An important goal of future studies is to distinguish between benign and malignant lesions. HRUS is a simple, reliable, relatively cost-effective, generally available, noninvasive method that can be used along with the physical examination for the assessment, diagnosis, and management of many cutaneous diseases. Kiran Mahajan, Ph. Source of Support: Nil.

Conflict of Interest: None declared. Indian J Radiol Imaging. Author information Copyright and License information Disclaimer. Correspondence: Dr. E-mail: moc. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles in PMC. Abstract High-resolution variable frequency ultrasound imaging is increasingly being used in the noninvasive evaluation of various cutaneous diseases.

Keywords: Color Doppler, dermatology, high-resolution ultrasound, skin. Introduction Ultrasonic imaging has been used in the field of dermatology for nearly 30 years. Instrumentation The HRUS for cutaneous imaging in radiology department generally uses variable frequency transducers MHz that are able to focus on different tissue layers by modifying the applied frequency according to the depth of the tissue imaged. Open in a separate window. Examination protocol The evaluation of cutaneous lesions in radiology department is generally carried out with linear array high-frequency transducers operating bandwidth of MHz with standardized scanner's settings overall gain, time gain compensation, Doppler gain, power output.

Indications USG has been used in the evaluation of benign and malignant neoplasms, inflammatory diseases, infectious diseases, and in the forum of cosmetic dermatology. The current indications for HRUS in dermatology are as follows:[ 1 , 5 , 8 , 9 , 10 , 11 , 12 ] Measurement of thickness, invasion depth, and assessment of the borders of skin tumors, and follow-up after surgery, cryotherapy, and laser treatment e.

Monitoring the course and therapeutic efficacy of the treatment of diseases with skin sclerosis e. Monitoring the effects of topical and systemic drugs on the skin e. Evaluation of allergic dermatitis, nodular erythema, dermatomyositis, sarcoidosis, lymphedema of the limbs, wound healing, scars and follow-up of localized burn lesions. Evaluation of nail involvement in systemic diseases and nail bed lesions like glomus tumors, nail bed cysts, subungual exostosis. Anatomy In vivo , normal skin is made of three layers: The epidermis thickness 0.

Figure 1. Figure 2. Skin tumors On HRUS, majority of the skin lesions appear as hypoechoic cutaneous or subcutaneous thickening. Benign dermatological conditions Seborrheic keratoses are epidermal in origin, well delimited, very superficial, as though laid on the skin, and may be misdiagnosed as melanoma. Figure 3. Figure 4.

Figure 5. Figure 6. Figure 7. Malignant tumors Basal cell carcinoma BCC is the most common skin cancer, often located in head and neck regions and areas of skin subjected to chronic sun exposure. Figure 8. Figure 9. Figure Diffuse cutaneous diseases HFUS is also useful in the evaluation of diffuse cutaneous diseases. Exogenous components Foreign bodies can be found in skin and subcutaneous tissue in the setting of post-trauma or post-therapeutic procedures.

Interventions HRUS is of significant value in the management of nonpalpable or slightly palpable cutaneous tumors or lymph nodes suspicious for malignant involvement. Limitations The limitation of USG is that in its current version, it cannot detect lesions that are epidermal only or that measure less than 0.

Future developments Contrast-enhanced USG is a recent technique under evaluation using ultrasound contrast agents to increase the sensitivity of Doppler examination. Conclusion HFUS has multiple applications both in the clinical and research settings. Acknowledgments Dr. References 1. Ultrasound in dermatology: Principles and applications. J Am Acad Dermatol.

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Pips financial An area of restricted diffusion, such as a breast cancer lesion, appears bright on the DW image and dark on the ADC map Fig. A Invasive squamous cell carcinoma arising from a neglected, chronic nonhealing ulcer. The new PMC design is here! Foreign bodies can be found in skin and subcutaneous tissue in the setting of post-trauma or post-therapeutic procedures. J Surg Oncol ;— Diffusion-weighted imaging improves the diagnostic accuracy of conventional 3. Imaging of melanoma: usefulness of ultrasonography before and after contrast injection for diagnosis and early evaluation of treatment.
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Investing papilloma radiopaedia radiology DW MRI has demonstrated the potential to improve the specificity of breast MRI, facilitate the evaluation of tumor response to neoadjuvant chemotherapy and can be employed in unenhanced MRI screening. Ministry of Health and Welfare. Ultrasonic B-scanning of the human skin. Accuracy of combined dynamic contrast-enhanced magnetic resonance imaging and diffusion-weighted imaging for breast cancer detection: a meta-analysis. Currently, advanced DW MRI techniques to improve the image quality and achieve higher spatial resolution are under research. Sagittal image from dynamic contrast-enhanced MRI A shows an irregular enhancing mass arrow in the left breast at the 1 o'clock position. Moreover, triple-negative cancer with extensive necrosis can present with high ADC values

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MR imaging is often a key component in surgical planning for myxoid neoplasms; determination of whether the tumor traverses the pelvic diaphragm. High-resolution variable frequency ultrasound imaging is increasingly being used in the noninvasive evaluation of various cutaneous diseases. Although benign, giant fibroadenomas should be excised because of their similar clinicoradiological presentation to the malignant phyllodes.