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. 2024 Feb 8;6(1):e220229. doi: 10.1148/ryct.220229

Assessment of Feasibility and Interscan Variability of Short-time Cardiac MRI for Cardiotoxicity Evaluation in Breast Cancer

Yoo Jin Hong 1, Kyunghwa Han 1, Hye-Jeong Lee 1, Jin Hur 1, Young Jin Kim 1, Min Jung Kim 1, Byoung Wook Choi 1,✉
PMCID: PMC10912882  PMID: 38329404

Abstract

Purpose

To investigate the feasibility and interscan variability of short-time cardiac MRI protocol after chemotherapy in individuals with breast cancer.

Materials and Methods

A total of 13 healthy female controls (mean age, 52.4 years ± 13.2 [SD]) and 85 female participants with breast cancer (mean age, 51.8 years ± 9.9) undergoing chemotherapy prospectively underwent routine breast MRI and short-time cardiac MRI using a 3-T scanner with peripheral pulse gating in the prone position. Interscan, intercoil, and interobserver reproducibility and variability of native T1 and extracellular volume (ECV), as well as ventricular functional parameters, were measured using the intraclass correlation coefficient (ICC), standard error of measurement (SEM), or coefficient of variation (CoV).

Results

Left ventricular functional parameters had excellent interscan reproducibility (ICC ≥ 0.80). Left ventricular ejection fraction showed low interscan variability in control and chemotherapy participants (SEM, 2.0 and 1.2; CoV, 3.1 and 1.9, respectively). Native T1 showed excellent interscan (ICC, 0.75) and intercoil (ICC, 0.81) reproducibility in the control group and good interscan reproducibility (ICC, 0.72 and 0.73, respectively) in the participants undergoing immediate and remote chemotherapy. Interscan reproducibility for ECV was excellent in the control group and in the remote chemotherapy group (ICC, 0.93 and 0.88, respectively) and fair in the immediate chemotherapy group (ICC, 0.52). In the regional analysis, interscan repeatability and variability of native T1 and ECV were superior in the anteroseptum or inferoseptum than in other segments in the immediate chemotherapy group. Native T1 and ECV had good to excellent interobserver agreement across all groups.

Conclusion

Short-time cardiac MRI showed excellent results for interscan, intercoil, and interobserver reproducibility and variability for ventricular functional or tissue characterization parameters, suggesting that this modality is feasible for routine surveillance of cardiotoxicity evaluation in individuals with breast cancer.

Keywords: Cardiac MRI, Heart, Cardiomyopathy

ClinicalTrials.gov registration no. NCT03301389

Supplemental material is available for this article.

© RSNA, 2024

Keywords: Cardiac MRI, Heart, Cardiomyopathy

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Summary

A short-time cardiac imaging protocol added to breast MRI achieved excellent results for interscan and intercoil reproducibility and variability in ventricular functional or tissue characterization parameters in both healthy controls and participants with breast cancer who underwent chemotherapy.

Key Points

  • ■ A short-time cardiac imaging protocol added to breast MRI in healthy controls and participants with breast cancer had good to excellent interscan agreement (intraclass correlation coefficient [ICC] > 0.70) in left ventricular functional parameters and native T1.

  • ■ In the regional analysis, interscan reproducibility and variability of native T1 and extracellular volume were superior in the anteroseptum or inferoseptum (ICC > 0.80) than in other segments for individuals who underwent immediate chemotherapy.

Introduction

Advances in treatment have improved the life span of patients with breast cancer. However, many anticancer therapies for breast malignancies cause heart problems that often influence the long-term life span of survivors (1,2). Heart failure as a result of cancer therapy is associated with a poorer prognosis than idiopathic cardiomyopathy (3). Thus, the importance of cardiac evaluation in cancer treatment is gaining attention (4,5).

Many guidelines emphasize the role of multimodal imaging in the diagnosis and monitoring of cancer therapy–related cardiac dysfunction (6). Cardiac MRI is the reference standard for measuring ventricular volume and function, and it enables tissue characterization of the myocardium (7,8). Despite the strength of cardiac MRI, its clinical application as a routine surveillance modality for diagnosis or follow-up in the evaluation of cardiotoxicity is difficult because of high cost, restricted availability, and long scan time. Many existing guidelines recommend cardiac MRI when echocardiography is not available or is not technically feasible (9–11). However, rapid technologic advances have enabled the procurement of high-quality cardiac images in a short time. The most important benefit of cardiac MRI is that it enables tissue characterization (8). Moreover, breast MRI has become an indispensable modality in cancer evaluation and is particularly useful for the evaluation of chemotherapy response (12,13).

In this study, we aimed to examine the feasibility and interscan variability of added short-time cardiac imaging to breast MRI as a routine surveillance imaging protocol for cardiotoxicity and cancer evaluation following chemotherapy in individuals with breast cancer.

Materials and Methods

Study Design and Participants

This prospective study protocol was approved by the regional institutional review board (no. 4-2016-0730) and was conducted according to the tenets of the Helsinki Declaration and its later amendments. Written informed consent was obtained from each individual before study participation. The Cardiac Magnetic Resonance for Early Detection of Cardiotoxicity in Breast Cancer (CareBest) study is a single-center, large-scale prospective study (ClinicalTrials.gov registration no. NCT03301389) of the usefulness of cardiac MRI for cardiotoxicity evaluation in individuals with breast cancer (14). The current study was a preliminary investigation of the feasibility of cardiac imaging during breast MRI. In total, 13 healthy controls who did not have any relevant medical history and 90 individuals with breast cancer were enrolled. The following were excluded: participants who dropped out during scanning (n = 2); those with poor image quality, such as gating failure (n = 2) or severe motion artifact (n = 1); and those with underlying heart disease (n = 2).

Cardiac MRI Protocol

All participants underwent planned breast MRI with an added cardiac imaging protocol with a 3-T scanner (DISCOVERY 750; 750 W; GE HealthCare) with an eight-channel breast coil in the prone position with peripheral pulse gating. The sequences for routine breast MRI included axial T2-weighted fast spin-echo and T2 stimulated inversion recovery (STIR) sequences and diffusion-weighted imaging before administration of contrast material. In addition, three-dimensional dynamic contrast-enhanced images were obtained and a T1-weighted three-dimensional delayed postcontrast sequence was performed in the sagittal plane after injection of contrast material. The added cardiac imaging protocol included short-axis native post-T1 mapping in the midventricle and short-axis cine imaging covering both ventricular myocardia. The native T1 image in the midventricles was acquired between T2 STIR and diffusion imaging, whereas the postcontrast T1 image was acquired after delayed postcontrast imaging at least 15 minutes after contrast enhancement. Cine images were acquired after dynamic imaging in controls and participants. The native and postcontrast T1 maps were acquired using modified Look–Locker inversion recovery before and at least 15 minutes after administration of contrast material (0.1 mmol per kilogram of body weight of gadolinium-based contrast agent [gadobutrol], 604.76 mg/mL) (15,16).

The trigger delay was adjusted to acquire the pulse-gated image during the diastolic phase, which served as the reference for the electrocardiographically gated image or cine image. This was done by considering a delay of approximately 300 msec (17) from the pulse-gating peak, as compared with the R peak observed in the electrocardiographically gated image. The acquisition pattern was 3(3s)3(3s)5 (ie, three sets of Look–Locker inversion recovery experiments to collect three, three, and five electrocardiogram-triggered T1-weighted images, respectively, with 3 seconds recovery time between every two Look–Locker experiments). The imaging parameters were as follows: two-dimensional balanced steady-state free precession; matrix, 160 × 128; field of view, 300 × 300 mm; section thickness, 8 mm; repetition time msec/echo time msec, 3.0/1.3; flip angle, 35°; bandwidth, 83.3 kHz; acceleration using array coil spatial sensitivity encoding (ASSET) factor, 2. We performed standard or short-time cine imaging involving both ventricles in a short-axis orientation. A standard short-axis cine imaging protocol was performed using the two-dimensional fast imaging employing steady-state acquisition (FIESTA) sequence. The specific scan parameters were as follows: flip angle, 49°; 1.4/3.6; field of view, 390 × 390 mm; matrix, 204 × 204; section thickness, 8 mm; number of sections adjusted to the size of the ventricles, 10–11; temporal resolution, 50 msec; bandwidth, 111.1 kHz; and ASSET factor, 1. Sequential short-time cine imaging was also performed using the two-dimensional FIESTA sequence in short-axis view with a low spatial resolution. The specific scan parameters were as follows: flip angle, 45°; 3.0/1.1; field of view, 390 × 390 mm; matrix, 160 × 192; measured pixel size, 2.4 × 2.0 mm; section thickness, 8 mm (2-mm gap between adjacent sections); number of sections adjusted to the size of the ventricles, 10–11; temporal resolution, 60 msec; bandwidth, 90.9 kHz; and ASSET factor, 2. The acquisition times for added cardiac imaging for the localized examination, standard or short time (low-resolution) cine, native T1, and post-T1 mappings were recorded. The reported scanning time has included the time for the breath-hold instruction and the pauses between breaths. A direct comparison of cine sequences is provided in Table S1.

The suggested CareBest protocol and time span of routine breast MRI and added short-time cardiac MRI are demonstrated in Figure 1. To test interscan agreement and variability of functional ventricular and tissue characterization parameters, an additional cardiac MRI examination was performed during routine breast MRI, as shown in Figure 2. For evaluating functional parameters, two short-time cine images were acquired in control participants (n = 13). Standard cine imaging and two subsequent short-time cine imaging procedures were performed in participants undergoing immediate chemotherapy (n = 25). For evaluating tissue characterization parameters, two repeated native T1 mappings using a cardiac coil in a supine position were performed in the same controls with functional parameters (n = 13). Subsequently, routine breast scanning and additional cardiac MRI, including two repeated native T1 and post-T1 mapping sequences using a breast coil in the prone position, were conducted. For participants immediately after chemotherapy (n = 49), which included different participants with functional parameters, and those with remote chemotherapy (n = 11) who had completed chemotherapy more than 1 year before scanning, two repeated native T1 and post-T1 mapping sequences using a breast coil in the prone position were performed during breast MRI. To calculate the extracellular volume (ECV), the hematocrit level was obtained from each participant immediately before scanning or within 24 hours after scanning.

Figure 1:

CareBest protocol (short-time cardiac MRI added to clinical breast MRI for cardiotoxicity evaluation). The sequences for clinical breast examination scans include axial T2-weighted fast-spin-echo (T2WFSE), T2-stimulated inversion recovery (STIR) sequences, and diffusion-weighted imaging (DWI) before administration of contrast material. Three-dimensional (3D) dynamic contrast-enhanced images and T1-weighted 3D delayed postcontrast images are acquired in the sagittal plane after injection of contrast material. The added cardiac imaging protocol includes short-axis native, post-T1 mapping in the midventricle, and short-time cine imaging covering both ventricular myocardia. The overall time span and acquisition time of each sequence of the clinical breast scanning and added short-time cardiac MRI are demonstrated. The reference standard images (ie, native T1 map with cardiac coil and standard cine images with breast and cardiac coils) are also demonstrated. ECV = extracellular volume.

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CareBest protocol (short-time cardiac MRI added to clinical breast MRI for cardiotoxicity evaluation). The sequences for clinical breast examination scans include axial T2-weighted fast-spin-echo (T2WFSE), T2-stimulated inversion recovery (STIR) sequences, and diffusion-weighted imaging (DWI) before administration of contrast material. Three-dimensional (3D) dynamic contrast-enhanced images and T1-weighted 3D delayed postcontrast images are acquired in the sagittal plane after injection of contrast material. The added cardiac imaging protocol includes short-axis native, post-T1 mapping in the midventricle, and short-time cine imaging covering both ventricular myocardia. The overall time span and acquisition time of each sequence of the clinical breast scanning and added short-time cardiac MRI are demonstrated. The reference standard images (ie, native T1 map with cardiac coil and standard cine images with breast and cardiac coils) are also demonstrated. ECV = extracellular volume.

Figure 2:

Study design and participant enrollment.

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Study design and participant enrollment.

Image Analysis

Ventricular functional analysis.— All images were analyzed using cvi42 image analysis software (Circle Cardiovascular Imaging). Short-axis cine images were analyzed using semiautomated contouring of the endocardial and epicardial borders of both ventricles at end-diastole and end-systole, and the ventricular functional parameters were calculated: right ventricular end-diastolic volume, left ventricular end-diastolic volume, right ventricular end-systolic volume, left ventricular end-systolic volume, cardiac output, stroke volume, right ventricular ejection fraction (RVEF), left ventricular ejection fraction (LVEF), and left ventricular (LV) mass.

T1 mapping image analysis.— The native T1 and the postcontrast T1 images acquired on the mid LV were transferred to the software. Semiautomated contouring of the endocardial and epicardial borders of the left ventricle was performed, and a 10% offset was applied to avoid partial volume artifacts. Global and segmental (ie, anterior, anteroseptal, inferoseptal, inferior, inferolateral, anterolateral segment) native T1, postcontrast T1 values of the myocardium, and native and postcontrast blood T1 values were measured. Images with severe artifacts were excluded from the analysis. Global and segmental ECV values were calculated using native and postcontrast T1 values of the myocardium, blood cavity, and hematocrit levels.

Statistical Analysis

A linear mixed model was used to consider repeated measures in each group. The model included a random intercept for each participant and group as a fixed factor.

Interscan or intercoil variability was measured using intraclass correlation coefficient (ICC), standard error of measurement (SEM), or coefficient of variation (CoV). The 95% CI for ICC was estimated by using the bootstrap method with 1000 resamplings (18,19). Interpretation of the ICC was based on the previous guidelines (18): poor (ICC < 0.40), fair (ICC = 0.40–0.59), good (ICC = 0.60–0.74), and excellent (ICC = 0.75–1.00). The minimal detectable difference (MDD) was defined as twice that of SEM (20,21). All statistical analyses were performed using R software (version 4.0.5; R Foundation for Statistical Computing), and the R package lmerTest was used for the linear mixed model. A two-sided P < .05 was considered to indicate a significant difference.

Results

Participant Characteristics

A total of 13 healthy female controls (mean age, 52.4 years ± 13.2 [SD]) and 85 female participants with breast cancer (mean age, 51.8 years ± 9.9) were included in this study.

Figure 2 outlines participant enrollment and their protocols. Table 1 shows characteristics of all study participants. Participants with breast cancer underwent anthracycline regimen chemotherapy: doxorubicin (60 mg/m2) with cyclophosphamide (600 mg/m2) intravenously every 3 weeks for a total of four cycles (cumulative dose of doxorubicin, 240 mg/m2) or anthracycline regimen followed by a taxane chemotherapy: four cycles of anthracycline followed by taxane (paclitaxel, 80 mg/m2, intravenously once a week for 12 weeks or docetaxel, 75 mg/m2, intravenously every 3 weeks, for a total of four cycles) (14). Added scanning time for cardiac imaging was 2 minutes 16 seconds ± 12 seconds for healthy participants (localized scanning: 10 seconds ± 2; short-time cine: 1 minute 17 seconds ± 11 seconds; native T1 map: 16 seconds ± 2; post-T1 map: 15 seconds ± 1) and 2 minutes 22 seconds ± 13 seconds for participants with breast cancer (localization scanning: 12 seconds ± 11; short-time cine: 1 minute 38 seconds ± 13 seconds; native T1 map: 16 seconds ± 1; post-T1 map: 16 seconds ± 1). In addition, scanning time for standard cine imaging was 2 minutes 32 seconds ± 19 seconds. The time span and acquisition time for each sequence of breast MRI and added short-time cardiac MRI are demonstrated in Figure 1.

Table 1:

Characteristics of Study Participants

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Interscan Agreement and Variability for Ventricular Functional Parameters

In the control group (n = 13), interscan repeatability between repeated short-time cine images was excellent for all LV parameters (ICC ≥ 0.80) and right ventricular end-diastolic volume (ICC: 0.80) and right ventricular end-systolic volume (ICC: 0.79) and good for RVEF (ICC: 0.73) (22). Interscan variability of LVEF and RVEF was relatively low (SEM: 2.0 and 1.7; MDD: 4.0 and 3.4; and CoV: 3.1 and 2.7, respectively) (Table 2). In participants undergoing immediate chemotherapy (n = 25), interscan agreement between two short-time cine images and between standard and short-time cine images was excellent for LV functional parameters (ICC > 0.75) and ranged from good to excellent for RV functional parameters (Table 2). Interscan variability between short-time cine images was also low for LVEF, LV mass, and RVEF (SEM: 1.2, 2.7, and 1.2; MDD: 2.4, 5.4, and 2.4; CoV: 1.9, 3.3, and 1.9, respectively). The interscan variability between standard and short-time cine imaging of LVEF, LV mass, and RVEF was relatively low (SEM: 2.2, 4.2, and 3.1; MDD: 4.4, 8.4, and 6.2; and CoV: 3.5, 5.1, and 4.9, respectively).

Table 2:

Interscan Agreement and Variability for Ventricular Functional Parameters in Controls and Participants with Breast Cancer Undergoing Immediate Chemotherapy

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Interscan Agreement and Variability for Tissue Characterization Parameters

In the control group, the mean global native T1 and ECV of the LV myocardium acquired using the breast coil were 1186.9 msec ± 33.6 and 28.6% ± 1.3, respectively, and the native T1 with the cardiac coil was 1182.4 msec ± 36.4. Interscan agreement between two repeated examinations using the breast coil was excellent for native T1 and ECV (ICC: 0.75, 0.93); interscan variability of native T1 was lower in the two repeated examinations using a breast coil (SEM: 9.3; CoV: 0.78) than in examinations between cardiac and breast coils (SEM: 19.8; CoV: 1.7). The interscan agreement of the native T1 between images acquired using the breast and cardiac coils was also excellent (ICC: 0.81). For the segmental data, in the two repeated examinations using a breast coil, interscan repeatability of native T1 was excellent in the anteroseptal (ICC: 0.75), which was higher than that of other segments. Interscan variability was low in the inferoseptal segment (SEM: 11.4; CoV: 1.0). Interscan agreement of native T1 between images acquired using a breast and a cardiac coil was good to excellent for the anteroseptal, inferoseptal, and anterolateral wall (ICC: 0.68, 0.68, and 0.76, respectively). The interscan variability between segments was similar and slightly low in the anterolateral segment (SEM: 32; CoV: 2.6). For ECV, the interscan repeatability between two repeated examinations using the breast coil was excellent in the anteroseptal wall (ICC: 0.83) and good in the inferoseptal wall (ICC: 0.72). Interscan variability was low in the anterior wall and anteroseptal wall (SEM: 0.43 and 0.44, respectively; CoV: 1.5 and 1.6, respectively) (Table 3). In participants immediately after chemotherapy (n = 49), mean global native T1 (1237.7 msec vs 1186.9 msec) and ECV (34.0% vs 28.6%) values were higher than values for the control group. The interscan repeatability of global native T1 and ECV between the repeated examinations were good and fair (ICC: 0.72 and 0.52, respectively). The SEM and CoV were 6.4 and 0.52, respectively, for global native T1 and 0.28 and 0.82, respectively, for ECV. In the segmental analysis, the interscan repeatability of native T1 and ECV between two repeated images was excellent in the anteroseptal and inferoseptal areas (ICC: 0.82 and 0.76 for native T1; ICC: 0.85 and 0.72 for ECV, respectively), which was higher than in other areas. Interscan variability of native T1 and ECV was also lower in the anteroseptal (for native T1, SEM: 9.5 and CoV: 0.75; for ECV, SEM: 0.48 and CoV: 1.3) and inferoseptal (for native T1, SEM: 9.2 and CoV: 0.73; for ECV, SEM: 0.44 and CoV: 1.3) areas than in other segments. In participants more than 1 year after chemotherapy (n = 11), mean global native T1 (1237.5 msec vs 1186.9 msec) and ECV values (30.7% vs 28.6%) were higher than those in the control group. The interscan repeatability of global native T1 and ECV between repeated scans was good to excellent (ICC = 0.73 and 0.88, respectively). In the regional analysis, interscan repeatability of native T1 was excellent in the anteroseptal and anterolateral wall (ICC: 0.87 and 0.84, respectively). Interscan repeatability of ECV was excellent in the anteroseptal and inferoseptal wall (ICC: 0.96 and 0.81, respectively), except for in the inferior wall. Interscan variability of native T1 and ECV was the lowest in the inferoseptal wall (SEM: 15.2 and 1.6; CoV: 1.2 and 4.9) (Table 3).

Table 3:

Intercoil and Interscan Agreement and Variability for Tissue Characterization Parameters in Controls and Participants with Breast Cancer

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Interobserver Agreement

For interobserver agreement, most of the functional parameters had excellent interobserver agreement results (Table S2); native T1 showed excellent agreement in all groups. ECV showed good interobserver agreement in immediate chemotherapy participants (ICC: 0.64) and excellent interobserver agreement in controls and remote chemotherapy participants (Table 4).

Table 4:

Interobserver Agreement for Tissue Characterization Parameters in Controls and Participants with Breast Cancer

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Discussion

Cardiac evaluation during chemotherapy for breast cancer is clinically important (23). It is efficient to perform an additional cardiac evaluation during routine breast cancer surveillance because of the close proximity of the heart to the breast. To this end, a quick cardiac imaging protocol was added to breast MRI in the current study for healthy controls and participants with breast cancer who underwent chemotherapy. This new cardiac protocol does not require any change in coil or patient positioning and takes less than 3 minutes, including the time required for axis adjustment. Our preliminary results indicated that the protocol had high interscan agreement and low variability in both ventricular functional and tissue characterization parameters. In particular, LVEF, which is the diagnostic criterion for cardiotoxicity, showed high interscan agreement in both the control and breast cancer groups. In addition, the MDD of LVEF was less than 5%, showing lower variability than the diagnostic criterion (24). LV mass, which is an important parameter of cardiotoxicity (25–28), had lower variability than other cardiac MRI parameters. RVEF also showed low variability in the participants with breast cancer. Tissue characterization parameters, native T1, and ECV values showed high intercoil and interscan interobserver agreements in both groups.

Of note, our data showed a significant increase in T1 and ECV immediately after chemotherapy. In the subgroup analysis, the interscan agreements of native T1 and ECV were higher in participants for whom chemotherapy was completed more than 1 year before the examination than in participants immediately after chemotherapy. In the regional analysis, interscan agreements were higher in the LV septum than in the other areas. It seems to be sufficient to obtain myocardial T1 and ECV in the septum in controls and individuals with breast cancer. In our study, short-time cardiac MRI was performed with peripheral pulse-gating, which takes no time other than attaching the machine to the finger. Our results demonstrate that the T1 and ECV measurements obtained from the healthy individuals exhibit high agreement with those derived from ECG gating and cardiac coil. Therefore, we assert that T1 mapping via pulse gating is a viable approach.

Currently, assessment of LVEF using echocardiography is the standard diagnostic criterion for cardiotoxicity evaluation in patients with cancer. The most common criterion for cancer therapy–related cardiac dysfunction is a 10% decrease from the baseline LVEF or an absolute value of LVEF of less than 53%, which is the standard level in two-dimensional echocardiography (24). However, there are some differences in the published definitions of cardiotoxicity (29). Furthermore, echocardiography has some limitations in interscan reproducibility, and the results may vary across operators (27), although three-dimensional echocardiography has lower variability than two-dimensional echocardiography (6,30,31). Cardiac MRI enables highly accurate measurements of the ventricular volume and function, and the interscan variability is low because it is not affected by readers or the surrounding environment (31,32). A previous study that compared coefficient variability in LVEF measurements between cardiac MRI and echocardiography showed that cardiac MRI demonstrated a markedly lower interstudy reproducibility (3.7% vs 11.5%). LVEF and LV mass, which are important parameters of cardiotoxicity (26,27), had lower variability than other cardiac MRI parameters. Similar results were observed in the current study. LVEF had high interscan agreement with low variability in cardiac imaging using a breast coil, and this result was consistent across both groups. Furthermore, a recent study that compared intra- and interobserver test-retest variability between cardiac MRI and echocardiography in patients undergoing cancer therapy showed that cardiac MRI exhibited low variability (20).

Despite these promising results, the routine use of cardiac MRI in cardio-oncology for surveillance is not feasible because of limited accessibility or adaptations, the relatively high cost, and long scanning time. Thus, most existing guidelines do not recommend cardiac MRI as a routine surveillance tool despite its high accuracy and reproducibility. It is recommended only in cases with poor echocardiographic image quality or when echocardiography is not technically feasible (9–11). However, cardiac MRI is a useful tool with which to identify changes in ventricular volumes and ejection fraction, especially in patients with poor-quality echocardiographic images, if a discrepancy between measurements of LV function exists, or if myocardial tissue characterization and perfusion assessment for ischemia are simultaneously planned (33). The cardiac MRI protocol applied in this study requires only short additional scanning time (<3 minutes) and can be added to routine breast MRI for cancer evaluation, thereby overcoming the limitations of conventional cardiac MRI and increasing its feasibility as a routine surveillance imaging tool. Myocardial edema, inflammation, and fibrosis caused by myocyte injury induced by chemotherapeutic agents can be observed using T1, T2, and ECV images (6,7,33). Many clinical studies have demonstrated that T1, T2, and ECV can be used as early tissue markers of cardiotoxicity (34–37). Our study indicated that native T1 and ECV for tissue characterization had high intercoil agreement, interscan repeatability, and low variability.

Several limitations of this study should be acknowledged. Although cardiac MRI was performed in those who underwent breast MRI, interscan or coil variability of T2 values indicated that T2 mapping could not be conducted because of time limitations. Future investigation is required to this end. Moreover, interscan variability between standard and short-scan cine could not be assessed in the control group, also because of time limitations. Finally, there was a trade-off between enhanced spatial resolution and reduced scanning time. Applying a recent technique, such as the compressed sensing technique or real-time imaging, would allow high-quality cine images to be obtained in a shorter scanning time.

In conclusion, a short-time cardiac MRI protocol combined with breast MRI achieved excellent results for interscan and coil reproducibility and variability in ventricular functional or tissue characterization parameters and is thus a feasible strategy for routine cardiac evaluation in individuals with breast cancer that can potentially overcome the drawbacks of standard cardiac MRI.

Acknowledgments

Acknowledgment

The authors thank the research team at GE HealthCare Korea for the technical support for T1 mapping imaging.

Supported by a Basic Science Research Program through the National Research Foundation of Korea, funded by the Ministry of Science ICT and Future Planning (NRF-2017R1A2B4009661, NRF-2020R1F1A1074983) and faculty research grant from Yonsei University College of Medicine (6-2020-0223).

Disclosures of conflicts of interest: Y.J.H. No relevant relationships. K.H. No relevant relationships. H.J.L. No relevant relationships. J.H. No relevant relationships. Y.J.K. No relevant relationships. M.J.K. No relevant relationships. B.W.C. No relevant relationships.

Abbreviations:

ASSET
array coil spatial sensitivity encoding
CoV
coefficient of variation
ECV
extracellular volume
FIESTA
fast imaging employing steady-state acquisition
ICC
intraclass correlation coefficient
LV
left ventricle
LVEF
left ventricular ejection fraction
MDD
minimal detectable difference
RVEF
right ventricular ejection fraction
SEM
standard error of measurement
STIR
stimulated inversion recovery

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