Magnetic Resonance Imaging has gained popularity in breast cancer diagnosis since the introduction of contrast media, and recent developments in MRI have demonstrated a new potential use in diagnosis. Indeed, the application of in vivo spectroscopy to mammary tissue has revealed that the spectral appearance of choline could be a marker of malignancy, but early diagnosis and unambiguous breast cancer characterization could benefit by a standardized protocol for the simultaneous use of Dynamic Contrast Enhancement MRI and Magnetic Resonance Spectroscopy and combined interpretation of associated markers. A total of 29 female patients took part in the study. The combined protocol was performed on a General Electric Signa HDtx 1.5 Tesla, and the DCE data analysis was performed through an evaluation of the ROI signal intensity over time. The MRS data analysis evaluated choline concentration and the signal to noise ratio of the choline peak. Sensitivity, specificity and accuracy were assessed by the Receiver Operating Characteristic methodology for Dynamic Contrast Enhancement, Magnetic Resonance Spectroscopy and their linear combination. We performed a linear combination of Dynamic Contrast Enhancement MRI and 1H-Magnetic Resonance Spectroscopy by distribution free approach to obtain a high level diagnostic index. Combining the results of the two diagnostic tests has resulted in a new, very effective, diagnostic index able to discriminate between patients with and without malignant disease.
 Boetes, C., Barentsz, J.O., Mus, R.D., Van Der Sluis, R.F., van Erning, L.J., Hendriks, J.H., Holland, R. and Ruys, S.H. (1994) MR characterization of suspicious breast lesions with a gadolinium-enhanced TurboFLASH subtraction technique. Radiology, 193, 777-781.
 Kuhl, C. (2007) The current status of breast MR imaging part I. Choice of technique, image interpretation, diagnostic accuracy, and transfer to clinical practice1. Radiology, 244, 356-378. doi:10.1148/radiol.2442051620
 Bartella, L., Morris, E.A., Dershaw, D.D., et al. (2006) Proton MR spectroscopy with choline peak as malignancy marker improves positive predictive value for breast cancer diagnosis: Preliminary study. Radiology, 239, 686- 692. doi:10.1148/radiol.2393051046
 Cecil, K.M., Schnall, M.D., Siegelman, E.S., et al. (2001) The evaluation of human breast lesions with magnetic resonance imaging and proton magnetic resonance spectroscopy. Breast Cancer Research and Treatment, 68, 45- 54. doi:10.1023/A:1017911211090
 Katz-Brull, R., Lavin, P.T. and Lenkinski, R.E. (2002) Clinical utility of proton magnetic resonance spectroscopy in characterizing breast lesions. Journal of the National Cancer Institute, 94, 1197-1203. doi:10.1093/jnci/94.16.1197
 Sardanelli, F., Fausto, A., Di Leo, G., et al. (2009) In vivo proton MR spectroscopy of the breast using the total cho-line peak integral as a marker of malignancy. American Journal of Roentgenology, 192, 1608-1617. doi:10.2214/AJR.07.3521
 Jacobs, M.A., Barker, P.B., Argani, P., et al. (2004) Combined dynamic contrast enhanced breast MR and proton spectroscopic imaging: A feasibility study. Journal of Magnetic Resonance Imaging, 21, 23-28. doi:10.1002/jmri.20239
 Dorrius, M.D., Pijnappel, R.M., van der Weide Jansen, M., et al. (2012) The added value of quantitative multi-voxel MR spectroscopy in breast magnetic resonance imaging. European radiology, 22, 915-922. doi:10.1007/s00330-011-2322-0
 Meisamy, S., Bolan, P.J., Baker, E.H., et al. (2005) Adding in vivo quantitative 1h MR spectroscopy to improve diagnostic accuracy of breast MR imaging: Preliminary results of observer performance study at 4.0 T. Radiology, 236, 465-475. doi:10.1148/radiol.2362040836
 Lipnick, S., Liu, X., Sayre, J., et al. (2010) Combined DCE-MRI and single voxel 2D MRS for differentiation between benign and malignant breast lesions. NMR in Biomedicine, 23, 922-930. doi:10.1002/nbm.1511
 Ordidge, R.J., Bendall, M.R., Gordon, R.E., et al. (1985) Volume selection for in vivo biological spectroscopy. In: Govil, G., Khetrapal, C.L. and Saran, A., Eds., Magnetic Resonance in Biology and Medicine, McGraw-Hill, New Delhi, 387-397.
 Kuhl, C.K., Mielcareck, P., Klaschik, S., et al. (1999) Dynamic breast MR imaging: Are signal intensity time course data useful for differential diagnosis of enhancing lesions? Radiology, 211, 101-110.
 Baik, H.M., Su, M.Y., Yu, H., et al. (2006) Quantification of choline-containing compounds in malignant breast tumors by 1 H MR spectroscopy using water as an internal reference at 1.5 T. Magnetic Resonance Materials in Physics, Biology and Medicine, 19, 96-104.
 Vanhamme, L., Van Den Boogaart, A. and Van Huffel, S. (1997) Improved method for accurate and efficient quantification of MRS data with use of prior knowledge. Journal of Magnetic Resonance, 129, 35-43. doi:10.1006/jmre.1997.1244
 Stefan, D., Di Cesare, F., Andrasescu, A., et al. (2009) Quantitation of magnetic resonance spectroscopy signals: The jMRUI software package. Measurement Science and Technology, 20, 104035. doi:10.1088/0957-0233/20/10/104035
 Bolan, P.J., Meisamy, S., Baker, E.H., et al. (2003) In vivo quantification of choline compounds in the breast with 1H MR spectroscopy. Magnetic Resonance in Medicine, 50, 1134-1143. doi:10.1002/mrm.10654
 Bakken, I.J., Gribbestad, I.S., Singstad, T.E., et al. (2001) External standard method for the in vivo quantification of choline containing compounds in breast tumors by proton MR spectroscopy at 1.5 Tesla. Magnetic Resonance in Medicine, 46, 189-192. doi:10.1002/mrm.1175
 Baek, H.M., Chen, J.H., Yu, H.J., et al. (2008) Detection of choline signal in human breast lesions with chemical shift imaging. Journal of Magnetic Resonance Imaging, 27, 1114-1121. doi:10.1002/jmri.21309
 Baik, H.M., Su, M.Y., Yu, H.J., et al. (2005) Proton chemical shift imaging for monitoring early treatment response of breast cancer to neoadjuvant chemotherapy. Proceedings of the 13th Annual ISMRM, 7-13 May 2005, Miami.
 Do, R., Moy, L., Salibi, N., et al. (2006) Can MRS improve our ability to distinguish between benign and malignant lesions? Proceedings of the 14th Annual ISMRM, 6-12 May 2006, Seattle, Washington DC.
 Jacobs, M.A., Barker, P.B., Bottomley, P.A., et al. (2004) Proton magnetic resonance spectroscopic imaging of human breast cancer: A preliminary study. Journal of Magnetic Resonance Imaging, 19, 68-75. doi:10.1002/jmri.10427
 Stanwell, P., Gluch, L., Clark, D., et al. (2005) Specificity of choline metabolites for in vivo diagnosis of breast cancer using 1 H MRS at 1.5 T. European Radiology, 15, 1037-1043. doi:10.1007/s00330-004-2475-1
 Huang, W., Tudorica, L.A., Li, X., et al. (2011) Discrimination of benign and malignant breast lesions by using shutter-speed dynamic contrast-enhanced MR imaging. Radiology, 261, 394-403. doi:10.1148/radiol.11102413