Metabolic Sodium MRI to Assess Early Response of Breast Cancer to Neoadjuvant Chemotherapy
Phase: NA
Conditions: Breast Cancer, Triple Negative Breast Cancer
Sponsor: NYU Langone Health

 
CONFIDENTIAL 
This material is the property of the NYU School of Medicine and Langone Medical Center.  Do not disclose or use except as 
authorized in writing by the study sponsor 
 
 
 
 
 
 
 
 
Metabolic Sodium MRI to Assess Early Response of Breast Cancer to 
Neoadjuvant Chemotherapy 
 
 
 
 
Primary Investigators: 
Guillaume Madelin, PhD - Radiology 
NYU School of Medicine / Langone Medical Center  
Department of Radiology 
660 1st Avenue, 4th Floor 
New York, NY 10016 
(212) 263-3343 
 
Regulatory Sponsor: 
NYU Langone Medical Center 
Department of Radiology 
660 1st Avenue 
New York, NY 10016 
 
Funding Sponsor: 
National Institute of Health 
 
Protocol Number: 
s17-00269 
 
 
 
 
 
 
Initial version:  08.03.2017 
Amended: 
08.01.2018 
Amended: 
03.06.2019 
Amended:  
08.06.2019 
Amended: 
11.14.2019 
Amended: 
01.27.2020 
Amended:  
04.06.2020 
Amended: 
06.4.2020 
Amended: 
07.21.2020 
Amended: 
09.21.2020 
Amended: 
11.02.2020 
 
 
Clinical Research Protocol 
NCT03750240

Sodium MRI to assess breast cancer NACT 
 
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Table of Contents 
 
STUDY SUMMARY ....................................................................................................................................... 1 
1 
INTRODUCTION ................................................................................................................................... 3 
1.1 
BACKGROUND................................................................................................................................. 3 
1.2 
HYPOTHESIS AND GOAL .................................................................................................................. 4 
1.3 
SODIUM MRI .................................................................................................................................. 4 
1.4 
DCE MRI ....................................................................................................................................... 5 
1.5 
INVESTIGATIONAL DEVICE................................................................................................................ 5 
1.5.1 
MRI scanner at 7 T ................................................................................................................... 5 
1.5.2 
Radiofrequency (RF) coil ......................................................................................................... 6 
1.6 
PRECLINICAL DATA (PRELIMINARY DATA) ......................................................................................... 6 
1.7 
CLINICAL DATA TO DATE ................................................................................................................. 7 
1.8 
RESEARCH RISKS & BENEFITS ........................................................................................................ 8 
1.8.1 
Risk of Investigational Device .................................................................................................. 8 
1.8.2 
Other Risks of Study Participation ......................................................................................... 10 
1.8.3 
Potential benefits .................................................................................................................... 10 
2 
STUDY OBJECTIVES ........................................................................................................................ 10 
2.1 
PRIMARY OBJECTIVE ..................................................................................................................... 10 
2.2 
SECONDARY OBJECTIVE(S) ........................................................................................................... 10 
2.2.1 
Methodological development of metabolic 23Na MRI in breast .............................................. 10 
2.2.2 
Application of 23Na MRI to assess response of breast cancer to NACT ............................... 11 
3 
STUDY DESIGN ................................................................................................................................. 11 
3.1 
GENERAL DESIGN ......................................................................................................................... 11 
3.2 
PRIMARY STUDY ENDPOINTS ......................................................................................................... 12 
3.3 
SECONDARY STUDY ENDPOINTS.................................................................................................... 12 
3.4 
PRIMARY SAFETY ENDPOINTS ....................................................................................................... 13 
4 
SUBJECT SELECTION AND WITHDRAWAL .................................................................................. 13 
4.1 
PATIENT WITH BREAST CANCER ..................................................................................................... 13 
4.1.1 
Inclusion Criteria .................................................................................................................... 13 
4.1.2 
Exclusion Criteria ................................................................................................................... 14 
4.2 
HEALTHY SUBJECTS ...................................................................................................................... 14 
4.2.1 
Inclusion criteria ..................................................................................................................... 14 
4.2.2 
Exclusion criteria .................................................................................................................... 14 
4.3 
SUBJECT RECRUITMENT AND SCREENING ...................................................................................... 15 
4.3.1 
Healthy Subjects .................................................................................................................... 15 
4.3.2 
Breast cancer patients ........................................................................................................... 16 
4.3.3 
Consent forms ........................................................................................................................ 17 
4.4 
REGISTRATION PROCEDURES ........................................................................................................ 18 
4.4.1 
General Guidelines ................................................................................................................ 18 
4.5 
EARLY WITHDRAWAL OF SUBJECTS ............................................................................................... 18 
4.5.1 
When and How to Withdraw Subjects.................................................................................... 18 
4.5.2 
Data Collection and Follow-up for Withdrawn Subjects ......................................................... 19 
5 
STUDY DEVICES AND IMAGING PROCEDURES ........................................................................... 19 
5.1 
DESCRIPTION................................................................................................................................ 19 
5.2 
TREATMENT REGIMEN ................................................................................................................... 19 
5.3 
DESCRIPTION OF THE 1H/23NA RF COIL ......................................................................................... 19 
5.3.1 
Rationale ................................................................................................................................ 19 

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5.3.2 
Methods .................................................................................................................................. 19 
5.3.3 
Testing and validation ............................................................................................................ 20 
5.4 
DESCRIPTION OF THE MRI PROCEDURES ....................................................................................... 20 
5.4.1 
23Na MRI ................................................................................................................................. 20 
5.4.2 
1H MRI .................................................................................................................................... 21 
5.5 
PATHOLOGIC ASSESSMENT OF RESPONSE ...................................................................................... 21 
5.5.1 
Criteria for evaluation of pathologic complete response (pCR) ............................................. 21 
5.5.2 
Determination of pCR............................................................................................................. 21 
5.6 
SUBJECT COMPLIANCE MONITORING ............................................................................................. 21 
5.7 
PRIOR AND CONCOMITANT THERAPY ............................................................................................. 21 
6 
STUDY PROCEDURES ...................................................................................................................... 21 
6.1 
VISIT 1: BASELINE (PRE-NACT) .................................................................................................... 21 
6.2 
VISIT 2: 2-WEEK FOLLOW-UP ......................................................................................................... 22 
6.3 
VISIT 3: 2-MONTH FOLLOW-UP ....................................................................................................... 22 
6.4 
VISIT 4: END OF NACT ................................................................................................................. 22 
7 
STATISTICAL PLAN .......................................................................................................................... 22 
7.1 
SAMPLE SIZE DETERMINATION ...................................................................................................... 22 
7.2 
STATISTICAL METHODS ................................................................................................................. 23 
7.3 
SUBJECT POPULATION(S) FOR ANALYSIS ....................................................................................... 23 
8 
SAFETY AND ADVERSE EVENTS (SAE) ........................................................................................ 23 
8.1 
DEFINITIONS ................................................................................................................................. 23 
8.2 
RECORDING OF ADVERSE DEVICE EFFECTS ................................................................................... 24 
8.3 
REPORTING OF ADVERSE DEVICE EFFECTS AND UNANTICIPATED PROBLEMS .................................. 24 
8.3.1 
Investigator reporting: notifying the NYULMC IRB. ............................................................... 24 
8.3.2 
Investigator reporting: Notifying the IRB ................................................................................ 25 
8.3.3 
Stopping Rules ....................................................................................................................... 26 
8.4 
MEDICAL MONITORING .................................................................................................................. 26 
9 
DATA HANDLING AND RECORD KEEPING ................................................................................... 26 
9.1 
CONFIDENTIALITY.......................................................................................................................... 26 
9.2 
SOURCE DOCUMENTS ................................................................................................................... 27 
9.3 
RECORDS RETENTION ................................................................................................................... 27 
10 
STUDY MONITORING, AUDITING, AND INSPECTING ................................................................... 27 
10.1 
STUDY MONITORING PLAN ............................................................................................................ 27 
10.2 
AUDITING AND INSPECTING ............................................................................................................ 29 
11 
ETHICAL CONSIDERATIONS ........................................................................................................... 30 
12 
STUDY FINANCES ............................................................................................................................. 30 
12.1 
FUNDING SOURCE ........................................................................................................................ 30 
12.2 
CONFLICT OF INTEREST ................................................................................................................. 30 
12.3 
SUBJECT STIPENDS OR PAYMENTS ................................................................................................ 30 
13 
PUBLICATION PLAN ......................................................................................................................... 31 
14 
REFERENCES .................................................................................................................................... 31 
15 
ATTACHMENTS ................................................................................................................................. 35 
 
 
 

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List of Abbreviations 
 
1H 
 
 
Proton 
23Na     
 
Sodium 
3-CM 
 
 
Three-compartment model 
2     
 
 
Extracellular volume fraction 
AC-T 
 
 
Adriamycin+Cyclophosphamide and Taxol 
ADC 
 
 
Apparent Diffusion Coefficient  
aISC 
 
 
apparent Intracellular Sodium Concentration 
aTSC  
 
apparent Total Sodium Concentration 
ATP 
 
 
Adenosine Triphosphate 
B0 
 
 
Constant magnetic field 
B1  
 
 
RF magnetic field 
BC 
 
 
Breast Cancer 
C1 
 
 
Intracellular Sodium Concentration  
C2 
 
 
Extracellular Sodium Concentration  
CCD      
 
Charge Coupled Device 
CV 
 
 
Coefficient of Variation 
DCE 
 
 
Dynamic Contrast-Enhanced  
DFS 
 
 
Disease-Free Survival  
DWI 
 
 
Diffusion Weighted Imaging  
FDA       
 
Food and Drug Administration 
ER 
 
 
Estrogen Receptor status 
FISH 
 
 
Fluorescence In Situ Hybridization 
FLORET 
 
Fermat Looped Orthogonally Encoded Trajectories 
GBCA  
 
Gadolinium-based MRI contrast agent 
Gd 
 
 
Gadolinium 
GFR 
 
 
Glomerular Filtration Rate 
GRE 
 
 
Gradient Echo 
HER2    
 
Human Epidermal growth factor Receptor 2 
HIV 
 
 
Human Immunodeficiency Virus 
HR 
 
 
Hormone Receptor status 
ICC 
 
 
Intra-Class Correlation  
IEC      
 
International Electrotechnical Commission  
IR 
 
 
Inversion Recovery  
IRB  
 
 
Institutional Review Board  
MRI 
 
 
Magnetic Resonance Imaging 
MRF 
 
 
Magnetic Resonance Fingerprinting 
Na+      
 
Sodium ions 
NACT  
 
Neoadjuvant Chemotherapy 
NSD 
 
 
Nephrogenic Fibrosing Dermopathy 
NSF 
 
 
Nephrogenic Systemic Fibrosis  
OS 
 
 
Overall Survival  
pCR 
 
 
Pathologic Complete Response 
PD 
 
 
Proton Density 
PR 
 
 
Progesterone Receptor status  
RF  
 
 
Radiofrequency  
 
 
 
 
 
ROI 
 
 
Region Of Interest 
Rx 
 
 
Receive 
SAE 
 
 
Safety and Adverse Events 
SAR 
 
 
Specific Absorption Rate  

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SNR 
 
 
Signal-to-Noise Ratio 
SPAIR   
 
SPectrally selective Adiabatic Inversion Recovery 
T1 
 
 
Longitudinal relaxation time 
T2    
 
 
Transverse relaxation time 
TA  
 
 
Acquisition Time   
TE  
 
 
Echo Time 
TNBC  
 
Triple Negative Breast Cancer  
TR  
 
 
Repetition Time 
TSC 
 
 
Total Sodium Concentration 
Tx 
 
 
Transmit 
UHF 
  
 
Ultra-high field 
UTE 
 
 
Ultrashort Echo Time  
V1     
 
 
Intracellular volume 
V2 
 
 
Extracellular volume 
Vs 
 
 
Solid volume 
Vt 
 
 
Total volume 
w 
 
 
Water fraction 
 
 
 

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Study Summary 
Title 
Metabolic Sodium MRI to Assess Early Response of Breast Cancer to 
Neoadjuvant Chemotherapy 
Short Title 
Sodium MRI to assess breast cancer NACT 
Protocol Number 
s17-00269 
Methodology 
1. Methodology study: Radiofrequency (RF) coil and MRI protocol 
development on healthy subjects, including patients with benign tumors. 
2. Prospective longitudinal pilot study: 20 patients with any breast cancer, 
some of them undergoing chemotherapy (scanned up to 4 times maximum) 
Study Duration 
3 years (07/01/2017-08/31/2020) 
Study Center(s) 
Multiple centers: 
1. Center for Biomedical Imaging (CBI), Department of Radiology - MRI 
2. NYU Cancer Center - Patient recruitment  
3. Center for Women’s Imaging 
4. NYU Winthrop 
Objectives 
To develop a sodium MRI method to quantify changes in intracellular sodium 
concentration (C1) and extracellular volume fraction (2) in vivo (imaging 
biomarkers of loss of homeostasis), in order to assess the efficacy of 
neoadjuvant, or any other, chemotherapy in breast cancer as early as possible, 
before tumor size reduction can be detected with standard dynamic contrast-
enhanced (DCE) MRI.  
1. Methodological development of metabolic sodium MRI in breast: new RF 
coil, MRI protocol and data processing algorithm for C1 and 2 quantification 
2. Application of sodium MRI to assess response of breast cancer to 
chemotherapy as proof-of-concept: assessment of chemotherapy at up to 4 
time points with sodium MRI, compared with standard DCE MRI for tumor size 
measurement. 
Number of Subjects 
42 Subjects: 24 Healthy Subjects & 18 Women with breast cancer who are 
planning to undergo chemotherapy 
Diagnosis and Main 
Inclusion Criteria 
Women (age ≥ 18 years) with no sign of breast cancer as controls, and women 
newly diagnosed with breast cancer and planned to undergo chemotherapy. 
Study Product and 
Planned Use 
- Dual-tuned 1H/23Na radiofrequency (RF) breast coil for conjoint proton and 
sodium MRI. This coil will be built in-house (aim 1). 
- Whole body Siemens scanner at 7 Tesla (research only scanner). 
- Gadolinium (Gd) based MRI contrast agent for DCE MRI (intravenous 
injection) 
Reference therapy 
Chemotherapy 

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Statistical 
Methodology 
- All statistical tests will be conducted at the two-sided 5% significance. 
- Paired sample t tests will assess the change in each measure in tumor and 
healthy tissue from pre- to each post-onset time point and compare tumor to 
healthy tissue in terms of these changes. 
- Pearson and Spearman rank correlations will assess the association of intra-
tumor changes in C1 and 2 with changes in tumor size. 
- SAS 9.3 software 
 

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1 Introduction 
This document is a protocol for a human research study. This study is to be conducted in accordance with 
US government research regulations, and applicable international standards of Good Clinical Practice, and 
institutional research policies and procedures. 
1.1 Background  
Neoadjuvant chemotherapy (NACT) is administered to treat invasive breast cancer before surgery1-4. 
NACT was originally limited to patients with inoperable locally advanced breast cancer (for whom even 
mastectomy was not an option), in order to shrink the tumor and allow surgery. It is now also frequently 
applied to operable breast cancer in early stage to enable breast-conserving surgery. Patients with small 
tumors may also be offered NACT if their cancer subtype has a high likelihood of response.As the treatment 
for breast cancer has advanced, the latest AJCC Staging for Breast Cancer for breast cancer includes 
genomic assays as well as management based on tumor subtype. NACT does not improve disease-free 
survival (DFS) or overall survival (OS) compared with adjuvant (post-surgery) therapy5,6, but it offers the 
opportunity to evaluate tumor response to treatment in aggressive disease, and guide additional 
therapies for patients with inadequate response7. Pathologic complete response (pCR) is defined as 
the absence of residual invasive and in situ cancer on the resected breast specimen and all sampled 
regional lymph nodes following completion of NACT8,9, and is a significant predictor of long-term survival. 
Therefore, a reliable and early assessment of tumor response to NACT can help identify patients for novel 
treatments to increase their chance of pCR, and thus improve DFS or OS after NACT compared with 
adjuvant therapy. In the past few years, one of the major benefits of NAC is achieving pCR has been 
widened to include patients with luminal A and luminal B tumors.    
Currently, dynamic contrast-enhanced magnetic resonance imaging (DCE MRI)10-13 is the standard 
technique to evaluate tumor shrinkage and residual cancer after NACT. However, DCE MRI often 
overestimates the extent of residual cancer, does not correlate well with histopathological results, and 
cannot distinguish between scar, necrosis, fibrosis and viable residual cancer. It is thus difficult to accurately 
assess the effect of NACT in responder patients with this technique. Diffusion weighted imaging (DWI)13-16 
is also currently investigated to determine therapy response. The apparent diffusion coefficient (ADC) 
calculated from DWI provides a quantitative measure of intra-tumoral water diffusivity, which can be related 
to the tumor cellularity and cell membrane integrity. However, these two MRI techniques can detect only 
structural changes (such as size and cellularity) in breast cancer, which generally take weeks or even 
months to yield measurable changes on MR images17. There is therefore a need to non-invasively quantify 
the metabolic changes in breast cancer within the first weeks (or even days) of therapy, before structural 
changes occur or can be detected. Assessing this early metabolic response to therapy in vivo would be of 
great importance to guide greater life-saving treatment options for the patients, to help the development of 
new drug treatments for different subtypes of cancer, and ultimately to allow tailored breast cancer therapy 
for each patient. For this purpose, we propose to develop metabolic breast sodium (23Na) MRI18,19 
which is based on the direct detection of endogenous sodium ions (Na+) from salt in tissues, instead 
of water protons (1H) as in standard MRI. Sodium MRI does not require intravenous contrast agents, and 
allows a quantitative assessment of important biochemical information such as ion homeostasis (steady-
state maintenance of asymmetric ion concentrations inside and outside cells) that is vital for normal cell 
and also cancer cell viability19-33. 

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1.2 Hypothesis and Goal 
Hypothesis. Cell damage induced by NACT can be characterized by 
loss of ion homeostasis in the abnormal cells forming the malignant 
tumor, through changes in pH, membrane depolarization and 
dysregulation of trans- membrane ion transporters (Na+/K+ pump, 
Na+/H+ and Na+/Ca2+ exchangers), leading ultimately to cancer cell 
death26,27,32,34-36 
and 
subsequent 
tumor 
shrinkage. 
As 
a 
consequence, large variations of Na+ concentrations inside the cells 
are induced, which can be quantified with 23Na MRI in vivo. Measuring 
variations of both intracellular sodium concentration C1 (due to 
cell damage/loss of ion homeostasis) and extracellular volume 
fraction 2 (due to cell death, but also maybe inflammation) with 
23Na MRI will give new metabolic information on the early 
effects of NACT on breast cancer, before tumor size reduction is 
detected with standard MRI19,22,37-43. See Fig 1. 
Goal. We will develop a 23Na MRI method to quantify C1 and 2 in vivo 
as two new metabolic imaging biomarkers of loss of homeostasis, in order to assess the efficacy of NACT 
in breast cancer as early as possible. The long-term benefit for the patient would be the possibility of 
tailored breast cancer therapy.  
Goal for preliminary data: Although the original goal of this study is to assess NACT with 23Na MRI, we 
plan to test the MRI protocol first on patients with any breast cancer (and before any treatment) as proof-
of-concept (1 scan only for each subject), and also on patients with any breast cancer undergoing any 
chemotherapy regime, at multiple time-points: baseline, 2-3 weeks, 2-3 months, after treatment (about 5 
months). This data is expected to be used for a R01 application which will be focusing on more specific 
breast cancer types and therapy regimes (such as the initial goal of this project: triple-negative breast 
cancer patients undergoing NACT).  
1.3 Sodium MRI  
Sodium nuclear magnetic resonance (NMR). The nucleus of 23Na+ has a spin 3/2. It possesses a 
quadrupolar moment that interacts with surrounding electric field gradients, which leads to complex 
relaxation processes in biological tissues and results in short T1 and bi-exponential T2 relaxation times (T1 
 20-40 ms, T2short  0.5-4 ms, T2long  10-25 ms)18. 23Na NMR sensitivity is 9.2% of the 1H sensitivity. In 
healthy breast tissue, the average total 23Na concentration is 35 mM44, which is approximately 1,500 times 
lower than the water 1H concentration in breast tissue (55 M, water fraction 0.5).  As a result, the 23Na 
NMR signal is 16,000 times lower than the 1H signal in breast. High fields 3 T are therefore recommended 
to increase the 23Na signal-to-noise ration (SNR). Since the sodium nuclei exhibit short bi-exponential T2 
relaxation, 3D MRI sequences with ultrashort echo time (UTE) such as Fermat Looped Orthogonally 
Encoded Trajectories (FLORET)45 must be implemented with TE  0.5 ms in order to maximize the signal 
strength. Due to the low 23Na signal, and traditionally crude coil and acquisition methods, 23Na images are 
acquired with coarse resolution (3-5 mm isotropic) at 3 T and below.  
Fluid/extracellular sodium suppression. Inversion recovery (IR) can be used to suppress (or minimize 
the effect of) of fluid signals to increase the sensitivity of 23Na MRI to intracellular sodium in brain46, and 
looks promising for future applications to brain tumors19,39,47. The IR method exploits the T1 difference 
between fluid and motion-restricted compartments (T1  40-50 ms in fluids outside the cells, T1  20-25 ms 
inside the cells). Our group has recently developed a 23Na MRI method based on IR and a 
 
Figure 1. C1-2 diagram. This 
diagram represents the working 
hypothesis 
for 
baseline 
measurements of C1 and 2 in 
healthy breast tissue and in tumors. 
Both C1 and 2 will vary during 
NACT. 

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multicompartment model of brain tissue to estimate C1 and 2 in vivo48,49. We will adapt and improve this 
method to quantify C1 and 2 in breast at 7 T. IR will be applied either using an adiabatic inversion pulse50 
(less sensitive to B0 and B1 inhomogeneities), or a single hard pulse with short duration and large 
bandwidth. Both types of pulse will be compared to optimize uniform fluid suppression while minimizing 
loss of signal from intracellular 23Na. 
1.4 DCE MRI   
Dynamic contrast-enhanced MRI is a standard clinical imaging tool for evaluating the breast and breast 
cancer. DCE-MRI can be used to measure tumor size before and after treatment.   
1.5 Investigational Device 
1.5.1 MRI scanner at 7 T  
All images will be acquired on a whole body 7 T system (Siemens, Erlangen, Germany) with multichannel 
(32 channels) and multinuclear (proton and sodium) capabilities, located on the 1st floor of the Center of 
Biomedical Imaging, Department of Radiology, 660 First Avenue, New York, NY 10016. MRI scanners are 
Class II (moderate risk) medical devices, meaning that an MRI manufacturer is required to submit a 
Premarket Notification 510(k) prior to marketing their MRI System. This device belongs to category B. All 
MRI equipment up to 3 Tesla has received FDA approval and has been in widespread clinical use for many 
years. However, the 7 Tesla MRI system and its hardware equipment are not FDA-approved for routine 
clinical use, although they have been developed and operate according to strict FDA guidelines and 
standards for research purposes only. All new technologies used in this investigation meet or surpass the 
safety standards of the FDA and are considered nonsignificant risk as defined in the “Guidance for Industry 
and FDA Staff–Criteria for Significant Risk Investigations of Magnetic Resonance Diagnostic Devices” 
issued July 14, 2003 (Magnetic resonance devices operating within FDA guidelines up to 8 T are considered 
non-significant risk). 
The 7 T scanner in question is not intended as an implant. It is not purported or represented to be for use 
supporting or sustaining human life, and does not present a potential for serious risks to the health, safety, 
or welfare of a subject. The 7T scanner is a research device and is not for use of substantial importance in 
diagnosing, curing, mitigating, or treating disease or otherwise preventing impairment of human health. It 
is therefore not a significant risk device. 

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1.5.2 Radiofrequency (RF) coil 
We built a dual-tuned multichannel RF coil (with 4 23Na-channels and 1 1H-Helmholtz-channel per breast) 
for bilateral breast 1H/23Na MRI at 7 T. The RF coil will be tested for imaging performance and validated for 
patient safety using a phantom. Coil Committee approval will be sought once the phantom testing is 
completed. The IRB will be provided with the Coil committee approval. No human testing will be conducted 
with investigational coils prior to IRB review and approval of this modification. This device belongs to 
category B. Coil performance is a primary determinant of breast MRI quality. A coil that allows concurrent 
23Na and 1H breast imaging is not yet commercially available and presents technical challenges: complex 
coupling between the 1H and 23Na channels can degrade SNR, coverage, and uniformity. In our previous 
work for cartilage and head imaging, high performance was achieved on both channels by implementing 
new design strategies that alleviated inter-channel coupling and wideband matching that allowed the 23Na 
array to substantially outperform traditional single channel designs. No adverse events have been seen. 
Our Coil Safety Committee will confirm safe operation of the coil such that RF power limits are restricted to 
a level consistent with International Electrotechnical Commission guidelines (IEC). 
The RF coil in question is not intended as an implant. It is not purported or represented to be for use 
supporting or sustaining human life, and does not present a potential for serious risks to the health, safety, 
or welfare of a subject. The coil is not for use of substantial importance in diagnosing, curing, mitigating, or 
treating disease or otherwise preventing impairment of human health. It is therefore not a significant risk 
device. 
1.6 Preclinical Data (Preliminary Data) 
Preliminary 23Na data was acquired at 7 T in breast cancer (without therapy) with a unilateral 4-channel 
prototype RF coil as proof-of-feasibility  (Fig. 2). We generated C1 and 2 maps of breast with 3.75 mm 
isotropic resolution in 21 min for a total of 2 23Na acquisitions necessary to quantify C1 and 2. For this 
purpose, we built a unilateral 1H/23Na coil that consists of a 23Na transmit solenoid, 4-channel 23Na receive 
array, and 1H transmit/receive solenoid (Fig. 3). Two healthy volunteers and one patient with breast cancer 
were scanned with the prototype coil at 7 T using the following MRI protocols:  
1H MRI. T1-weighted (T1w) 3D gradient echo with SPAIR (spectrally selective adiabatic inversion recovery) 
fat suppression, resolution = 0.90.91 mm3, acquisition time TA = 3:33 min. 3D Gradient Echo (GRE) Dixon 
scans for automatic glandular tissue masking (TE = 2, 2.3, 2.6, resolution = 0.90.93.8 mm3, TA = 6 min).  
Figure 2 (A) Preliminary data from a healthy volunteer and a patient with a breast tumor at 7 T with the new prototype 
RF coil. A 3 cm invasive adenocarcinoma was detected in the right breast of the patient after T1-weighted 1H MRI 
during her clinical scan. Notice the local large increase of C1 and 2 in the tumor. (B) Histograms of C1 and 2 in 
healthy tissue and in tumor. These histograms represent the distributions of C1 and 2 measured for bulk tissue 
analysis, using the 3D water mask (from 1H Dixon MRI) applied to the 23Na data. We can notice a large variation in 
the shape of the distributions (mainly skewness and kurtosis) when a lesion is present. 

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23Na MRI. FLORET45 sequence with: repetition time TR = 100 ms, 
echo time TE = 0.2 ms, 3 hub of 260 interleaves, 3.75 mm base 
resolution, inversion time TI = 27 ms for IR, TA = 7:50 (no IR) and 
13:10 (IR). The C1 and 2 maps were calculated from linear 
regression of the reference phantom signals (see Fig. 3B and 3C) 
and a 3-compartment model (Fig. 4), after correction of the 23Na RF 
coil sensitivities from the scan of a uniform phantom with both 
acquisitions (with and without IR).  
Results. Our prototype coil and data processing pipeline 
demonstrate feasibility of metabolic breast 23Na MRI (Fig. 2A). For 
healthy volunteers, mean C1 = 13±2 mM and mean 2 = 0.13±0.02 
in glandular tissue, which are in the previously reported 
range19,21,42,49. A healthy subject was scanned twice for repeatability 
testing: both measurements of mean C1 and 2 over 4 slices in 
parenchyma were within the range of 1 standard deviation (C1 = 
12±2 mM and 14±2 mM, 2 = 0.13±0.02 and 0.15±0.02, 
respectively). In tumor, we measured C1 = 62±10mM and 2 = 
0.33±0.04. These elevated values correspond to malignant tumors 
in our baseline hypothesis (Fig. 1) and are clearly differentiable from 
normal glandular and adipose tissues. See Fig. 2B for bulk 
distributions of C1 and 2 values measured with the water mask 
calculated from the Dixon acquisition. 
1.7 Clinical Data to Date  
Although 23Na MRI is under active development around the world 
due to its ability to detect new biochemical information in vivo, its 
application to breast cancer has not yet been sufficiently explored. 
All previous studies on breast tumors either quantified the total 
sodium concentration (TSC) or reported only relative variations of 
total sodium signal without quantification of the TSC. TSC is the 
average of both intracellular and extracellular sodium content, and does not allow discrimination between 
cell damage and loss of homeostasis (through C1) and cell death and/or inflammation (through 2). Prior 
studies on tumor samples showed significant differences in 23Na content between normal tissues (C1  15 
mM, TSC  35-45 mM), benign (+50% in C1) and malignant tumors (+100-200% in C1)19,22,35,39,44. Moreover, 
tumor resistance to certain therapies was correlated with tissue sodium content in animal studies51. The 
first application of 23Na MRI in vivo to patients with breast tumors (at 1.5T) was published in 2004 by Jacobs 
et al.52. They found an increase of around 67% in TSC in tumors compared to glandular tissue. Their 
subsequent work differentiated TSC in benign (26±5 mM) and malignant tumors (53±16 mM), but detected 
a small difference between benign tumor and glandular tissue (34±13 mM).72 Importantly, the same team 
found that 23Na MRI was able to distinguish TSC variations in NACT responders (-20 to -30%) and non-
responders (+5-10%)38,53.  
Though these works showed encouraging results, their impact was hampered by the following important 
limitations: 
1. 
C1 and 2, which are more useful and sensitive biomarkers of early effect of chemotherapy on tumors, 
were not differentiated from TSC, and variations of TSC are difficult to interpret;  
 
Figure 3. RF coil prototype and 
linear 
regression. 
(A) 
New 
prototype 1H/23Na breast coil at 7 T. 
Overlay of the position of the 
solenoid coil for 1H transmit-receive 
(blue), of the solenoid for 
23Na 
transmit (green), and of the 23Na 4 
receive loops (red). (B) Transverse 
23Na image of reference phantoms 
(3% agar with 25, 50, 75, 100, 125 
mM of [Na+]) without IR (left), and 
linear regression of the phantom 
signals (right). (C) 23Na image with 
IR (left), and linear regression of the 
phantom signals (right). 

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2. 
Spatial resolution was limited to 6 mm isotropic due in part to 
the single-channel volume coil operating at low-field (1.5T), 
resulting in significant partial volume effects;  
3. 
New efficient sampling and reconstruction schemes were not 
applied.  
We will remedy these drawbacks by measuring C1 and 2 using a 
combination of highly sensitive techniques, such as efficient 
sampling and reconstruction with FLORET and compressed 
sensing, 13-channel bilateral receive array with wideband matching, 
at ultra-high field (7 T). 
1.8 Research Risks & Benefits 
1.8.1 Risk of Investigational Device 
All MRI equipment up to 3 T has received FDA approval and has 
been in widespread clinical use for many years. However, the 7 T 
MRI system and its hardware equipment are not FDA-approved for 
routine clinical use, although they have been developed and operate 
according to strict FDA guidelines and standards for research 
purposes only. All new technologies used in this investigation meet 
or surpass the safety standards of the FDA and are considered non-
significant risk as defined in the “Guidance for Industry and FDA 
Staff–Criteria for Significant Risk Investigations of Magnetic 
Resonance Diagnostic Devices” issued July 14, 2003 (Magnetic 
resonance devices operating within FDA guidelines up to 8 T are 
considered non-significant risk). We can however notice that despite 
the fact that ultra-high field (UHF) MRI (>7 T) is not yet approved for 
clinical practice, recent improvements in safety and image quality 
have shown superior results for neuroimaging, musculoskeletal and 
breast imaging applications. As a consequence, Siemens is now waiting for FDA approval for a new 7 T 
clinical scanner (Magnetom Terra scanner), which could extend the use of UHF MRI to clinical practice in 
the near future.  
There are 4 categories of risk associated with this study: 
1. 
Risks associated with MRI in general: MRI uses a strong magnetic field to create images of the 
body but there are no known risks or adverse effects resulting directly from exposure to MRI. Because 
of the strong magnetic field, the greatest risk is that a metal object could be pulled into the scanner 
and hit subjects. To reduce this risk, everyone near the magnet will remove all metal from their clothing 
or pockets when in the scanning environment. The door to the scan room will remain closed during the 
exam for subject safety. All subjects will be asked to fill out a standard MRI safety checklist to make 
sure that subjects with metal implants or any other routine contraindication to MRI will not be scanned. 
Subjects who have a pacemaker or metal objects in their body such as shrapnel or metal in the eye 
should not have the scan performed. If subjects have any question about metal implants or metal 
fragments in the body, they should inform the technologist or investigators before entering the magnet 
room. During the MRI examination subjects will be periodically monitored through an intercom and 
visually using a CCD camera, and if any problems arise, the study will be immediately terminated. 
Subjects are given a squeeze ball to communicate with the technologist.  Instructions will be given 
prior to and during the MRI scan. No sedation will be administered. Since 2007, many volunteers and 
 
Figure 
4. 
Three-compartment 
model (3-CM): Compartment 1 = 
intracellular volume V1 (in L) of 
sodium concentration C1 (mM). 
Compartment 
2 
= 
extracellular 
volume V2 of sodium concentration 
C2. Sodium ions are only present in 
the ’water’ volume of the tissue 
(V1+V2). Compartment 3 = volume 
VS with all the ’solid’ components 
within the voxel (cell membranes 
and nuclei, proteins, and other 
metabolites), where sodium content 
is negligible. The total volume is Vt = 
V1+V2+VS. 
Unknown 
values 
of 
interest are C1 and the extracellular 
volume fraction 2 (in red). In this 
simple model, we assume that C2 is 
constant 140 mM, and that the 
water volume fraction w is also 
constant and known 0.65 in breast 
(but planned to be measured with 1H 
MRI in the future). 

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162 patients were scanned on the 7T magnet. We have no documented adverse effects secondary to 
being imaged on a 7T scanner.  
 
2. 
Risks associated with an experimental MRI pulse sequence at 7 T: All MRI equipment up to 3 T 
has received FDA approval and has been in widespread clinical use for many years. However, the 7 
T MRI system and its hardware equipment are not FDA-approved for routine clinical use, although 
they have been developed and operate according to strict FDA guidelines and standards for research 
purposes only. All new technologies used in this investigation meet or surpass the safety standards of 
the FDA and are considered nonsignificant risk as defined in the “Guidance for Industry and FDA Staff–
Criteria for Significant Risk Investigations of Magnetic Resonance Diagnostic Devices” issued July 14, 
2003 (Magnetic resonance devices operating within FDA guidelines up to 8 T are considered non-
significant risk). The RF power deposition (tissue heating) can be higher at 7 T when compared to 
clinical systems (0.5-3T). However, we will not exceed the RF power deposition mandated by FDA. 
Further safeguard is built into the scanner software, such that during the MRI experiments, the scanner 
monitors the RF power. If it detects that RF power has exceeded the allowed limits, it automatically 
stops the scan. This eliminates the risk associated with any inadvertent errors during the scan. 
 
3. Risks associated with Gadolinium-based MRI contrast agent (GBCA) injection for DCE MRI: The 
risks and discomforts from the I.V. needle include the possibility of pain or bruising at the site here the 
needle is inserted. Occasionally, people experience feelings of lightheadedness. In rare instances there 
may be an infection at the site where the needle is inserted. There is also a risk of an allergic reaction 
to the contrast agent. The FDA approves the imaging agent gadolinium for use in MRI. Some subjects, 
(less than 3%) may experience minor discomforts that include nausea and/or headache after injection. 
These side effects usually pass quickly without medical treatment. 
  
Risk of NSF: Nephrogenic systemic fibrosis (NSF) is a rare disorder that occurs in some individuals 
with reduced kidney function, who have been exposed to an intravenous contrast material that contains 
gadolinium. NSF is also known as nephrogenic fibrosing dermopathy or nephrogenic systemic 
fibrosis/nephrogenic fibrosing dermopathy (NSF/NFD). A contrast material is a dye that is sometimes 
used during magnetic resonance imaging (MRI). Gadobutrol (Gadavist; Bayer Healthcare, Whippany, 
NJ), the MRI contrast material used in this study, has a very low rate of adverse reactions and is 
designated as a low risk contrast agent by the European Committee for Medicinal Products for Human 
Use. Gadavist has been used in more than 29 million patients. As of December 2015, there were a total 
of 12 reports of NSF or NSF-like symptoms in patients who reportedly were administered gadobutrol. 
Fewer than 1% of patients develop nausea, vomiting, or headaches. 
Subjects with any kidney disease or other kidney problems, will be asked not to participate in this study. 
Fairly recently (in 2014) evidence indicated that individuals who receive multiple doses of GBCA may 
have traces of gadolinium deposited into their brains for an indeterminate amount of time. To date, 
there is a lack of data indicating whether or not this could be harmful.  
4. 
Risks associated with the development of a new RF coil: Our Coil Safety Committee has confirmed 
safe operation of the coil; infrared, direct, and fiber optic thermometry were carried out to assign RF 
power limits such that tissue heating and the specific absorption rate (SAR) are restricted to a level 
consistent with International Electrotechnical Commission guidelines (IEC)55. Given the high level of 
habitus variability and its potential impact on SAR, we implemented a 5 W/kg limit to provide a two-fold 
buffer over the 10 W/kg limit established by the IEC. 

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1.8.2 Other Risks of Study Participation 
Because the risks of participating in this research study are identical to those arising from the performance 
of clinical MRI, all subjects will undergo the same rigorous screening procedures that are used for clinical 
MR examinations. All subjects will be screened for biomedical implants and devices by questioning at the 
time of recruitment into the study as well as on the day of the examination. Those with potentially MR 
incompatible devices or other hazards such as orbital foreign bodies, will be excluded. If pregnancy is a 
possibility, female subjects will undergo a urine test on the day of the MR examination. If the test is positive, 
then the subject will be excluded from the study. During the MRI experiments, MRI scanner monitors the 
RF power deposition. If it detects any sequence parameters that exceed the allowed RF power limits, it 
automatically stops the sequence and a message is displayed indicating that the sequence cannot be run 
as it exceeds the power deposition limits. This eliminates the risk associated with inadvertent errors during 
scanning time. 
For breast cancer patients who would not undergo clinical MRI examination before neoadjuvant therapy, 
additional information gained from this research MRI may lead to detection of abnormalities and possibly 
to the need for additional biopsies and clip placements if breast conserving therapy is planned. For healthy 
volunteers the research MRI could detect abnormalities in the breast including false positives which could 
result in additional diagnostic workup and biopsies. 
1.8.3 Potential benefits 
As this is a preliminary study, no direct benefit is expected for participants. No treatment change in patients 
will be recommended based on the preliminary results of this study. A possible benefit to the subjects is the 
unlikely event in which an unsuspected but treatable disorder is incidentally noted on the MR images. The 
benefit to society of establishing a non-invasive and quantitative metabolic imaging technique for the early 
assessment of breast cancer response to chemotherapy is considerable as it will help develop reliable 
monitoring of cancer treatment. This could ultimately result in developing tailored therapy for individual 
patients and increase their chances of disease-free survival. 
2 Study Objectives 
2.1 Primary Objective 
We will develop a new robust, quantitative and non-invasive 23Na MRI method to assess new metabolic 
information (C1 and 2) in breast cancer in vivo. The proposed method will allow us to quantify the efficacy 
of NACT in breast cancer as early as possible, before tumor size reduction can be detected by standard 
MRI. For this purpose, we will design and build a 13-channel-receive 23Na array per breast, optimize the 
1H/23Na MRI protocol and data processing (image reconstruction, data quantification, mechanistic model) 
at 7 T. The long-term benefit for the patient would be the possibility of tailored breast cancer therapy. 
2.2 Secondary Objective(s) 
2.2.1 Methodological development of metabolic 23Na MRI in breast 
1. 
Radiofrequency (RF) coil: We will build a dual-tuned multichannel 1H/23Na RF coil (with 13 23Na-
channels and 1 1H-Helmholtz-channel per breast) that will allow bilateral breast 1H/23Na MRI at 7 T. 
2. 
MRI protocol: We will optimize data acquisition (FLORET) and reconstruction (compressed sensing57) 
to generate 23Na images of the breasts with 2.5-3 mm isotropic resolution in 7 min/acquisition. We 
will perform DCE MRI afterwards to prevent influence of the contrast agent on 23Na data. 

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3. 
Data processing: We will develop a software to quantify C1 and 2 based on two 23Na data acquisitions 
(with and without extracellular fluid suppression)49 and a multicompartment model of cancer cells in 
breast. A mechanistic model of loss of ion homeostasis due to chemotherapy will also be developed 
in order to interpret the results. Reproducibility and repeatability48,58 of C1 and 2 quantification will be 
assessed on 8 healthy subjects. 
2.2.2 Application of 23Na MRI to assess response of breast cancer to chemotherapy  
1. Patient scanning: We will scan 20 patients with any breast cancer diagnosis  
a. 10 women will only be scanned at baseline (before any therapeutic intervention) to obtain 
preliminary images of cancerous breast tissue with the new optimized MRI protocol.  
b. 10 women who plan to undergo any chemotherapy will participate to up to 4 scans: (1) baseline;  
(2) after 2-3 weeks of treatment; (3) after 2-3 months of treatment; (4) after treatment (about 5 
months).  
2. 
Assessment of chemotherapy response: We will compare C1, 2 and tumor size at all time-points 
acquired. Using statistical analysis and the mechanistic model, we will assess which measurements 
are best predictors of the outcome at the end of  treatment. 
3 Study Design 
3.1 General Design 
We will design a 1H/23Na RF coil. The investigational coil will first be tested on a phantom before human 
subjects’ involvement. Once phantom testing is complete, all appropriate materials will be submitted to the 
Coil Committee for review and approval. Once Coil Committee approval is obtained, the study modification 
will be submitted to the IRB. No human subjects in Aims 1 or 2 will be enrolled until after approval is obtained 
by both the Coil Committee and the IRB.  
We will then optimize a 23Na breast MRI protocol for quantification of C1 and 2 in vivo at 7 T. 16 healthy 
subjects will be used to design and test the new 1H/23Na RF coil and optimize the final 1H and 23Na MRI 
protocol (Aim 1) that will be applied later to patients in Aim 2 of the project. As shown in Figure 6 in the  
Protocol document, healthy subjects will be scanned for (1) coil testing, (2) fluid suppression optimization, 
(3) relaxation times measurements, and (4) assessment of repeatability and reproducibility of the   proposed 
23Na MRI method to quantify intracellular sodium concentration and extracellular volume fraction in vivo in 
healthy tissue (8 subjects will be  scanned twice for this part of the study)   We will scan 9 patients with any 
breast cancer (before any treatment) to demonstrate the efficacy of sodium imaging in cancerous tissue. 
We will also scan 9 breast cancer patients who undergo chemotherapy. All patients will be scanned up to 
4 times over the duration of chemotherapy (~5 months): (1) at baseline (pre-treatment); (2) after 2-3 weeks 
of treatment; (3) after 2-3 months of treatment); (4) after complete treatment (4-5 months). Each scan 
session will consist of 23Na MRI and 1H MRI. 

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3.2 Primary Study Endpoints 
Milestones are shown in Fig. 5:  
1. 
Month 9 of year 1: The RF coil will be constructed, tested, and validated for breast imaging on a 7 T 
scanner. The 23Na MRI protocol will be ready and scanning of patients with breast cancer can begin.  
2. 
End year 1: The 23Na data processing, including C1 and 2 quantification and mechanistic model of 
NACT effect on tumors, will be optimized and ready to be tested on patients for early assessment of 
NACT.  
3. 
End year 2: We will have scanned 
and compared 12 patients during 
NACT (4 scans each) with 23Na MRI 
and DCE MRI. A co-authored 
manuscript on the results of the 
study will be submitted to a peer-
reviewed journal. 
3.3 Secondary 
Study 
Endpoints 
Sodium data quantification in 3 steps 
1. 
Linear regression: Five reference gel phantoms (Agar 3%) were built with known sodium 
concentrations (25, 50, 75, 100, 125 mM) and pre-measured T1 and T2* relaxation times at 7 T. The 
phantoms were scanned separately to provide a reference to allow 23Na data quantification (see Fig. 
3A-B) under same in vivo conditions (coil filling, shimming, reference voltage). A full density operator 
simulation for spin 3/2 dynamics61,62, implemented in Matlab (Mathworks, Natick, MA, USA), will be 
used to estimate phantom signal loss due to relaxation during RF pulses and delays in the acquisition 
sequence. From this simulation, phantom signal from sequences 1 (FLORET) and 2 (FLORET+IR) will 
be corrected prior to performing linear regression of their signal magnitudes. Linear regression will be 
considered valid only when the coefficient of determination R2>0.99, to ensure robustness against 
noise corruption.  
2. 
The apparent total and intracellular sodium concentration (aTSC, aISC) maps, corresponding to 
sequences 1 and 2 respectively, will be calculated using the parameters from linear regression of the 
phantom signals. These two maps will also be corrected from simulation of the sequence-specific 23Na 
spin dynamics with relaxation times measured in breast tissue on 4 healthy subjects.  
3. 
Intracellular sodium concentration (C1) and extracellular volume fraction (2) quantification is 
based on the combination of a 3-compartment model (Fig. 4) with the aTSC and aISC maps. We 
assume that all extracellular fluid sodium signal (milk ducts, interstitial sodium, plasma) is either 
suppressed by inversion recovery or within noise level of the image. The values of each voxel of the 
aTSC and aISC maps are: aTSC = (C1V1+C2V2)/Vt, and aISC = C1V1/Vt. Using equations in Fig. 4, we 
calculate: 2 = (aTSC−aISC)/C2, and C1 = aISC×C2/(w×C2−aTSC−aISC) for each voxel. 
Biophysical model 
We will develop a biophysical model63-66 of ion homeostasis in breast tumors in order to simulate the 
possible effects of chemotherapy on cancer cells67-69. This model will be composed of an extracellular 
compartment, an intracellular compartment, and inter-compartment membranes. We will simulate ionic 
currents of Na+, K+, Ca2+, Cl-, H+, HCO3- and glutamate (Glu-) between all compartments through their trans-
 
Figure 5.  Timeline with milestones. 

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membrane ion channels and active transporters (ATPases, co-transporters and exchangers)24,27,32,34,70. 
Variable pH, membrane depolarization, ATP depletion and impaired energetic metabolism in cancer cells 
induced by chemotherapy will be inputted to the model to simulate changes in all intracellular ionic 
concentrations and cell volume20,23,25,26,31,71-74. This simulation will be used to interpret and predict the 
biophysical effects of chemotherapy over time on C1 and 2 values measured with 23Na MRI. 
Reproducibility and repeatability 
Reproducibility and repeatability of C1 and 2 quantification will be assessed as described in Ref.48,58 on 8 
healthy volunteers, with all sodium data processed twice (by 2 independent operators). Each subject will 
be scanned 4 times on 2 separate days, without contrast. In one paid scan session of 1 h on each day, the 
same 23Na MRI protocol (FLORET with and without IR) will be performed twice with subject repositioning 
during an intermission period. Data will therefore be: C1 and 2 from 1 region of interest (ROI) in each 
breast, from 4 scans, collected and processed by 2 operators. Restricted maximum likelihood for a mixed 
effects model will estimate the inter-subject variance and the intra-session, inter-session and inter-operator 
(intra-scan) components of intra-subject variance. The estimates will be used to compute the intra-class 
correlation (ICC) and coefficient of variation (CV) for the inter-session and intra-session variation as 
measures of repeatability, and for inter-reader variation as measures of reproducibility. 
 
Spatial analysis 
1. 
Local lesion analysis. Lesions will be manually segmented in 1H T1w images by Co-Investigator Dr 
Linda Moy (breast radiologist with 15+ years experience) and size will be defined as the longest linear 
dimension of the lesion. The ROIs will be transferred to co-registered 23Na images to measure 
intracellular sodium concentration C1 and extracellular volume fraction 2 in lesion.  
2. 
Bulk tissue analysis. We will acquire multi-echo 1H datasets that cover the entire breast volume to 
automatically segment the glandular tissue using the Dixon chemical species separation algorithm75,76, 
which is a masking technique used in our previous work77. The water mask identified in 1H images will 
be transferred to co-registered 23Na images. Finally, C1 and 2 in water mask pixels will be displayed 
in a histogram, which is expected to have a variable distribution shape between normal subjects and 
patients with tumors. 
Assessment of chemotherapy response 
We will compare C1 and 2, and tumor size at all 4 stages of treatment. Using statistical analysis and the 
mechanistic model, we will assess which measurements are best predictors of the outcome at the end of 
AC treatment, and at the end of NACT. The mechanistic model will be used to: (1) interpret the results from 
all imaging modalities from a biophysical point-of-view; (2) simulate and predict the effect of chemotherapy 
on C1 and 2 (metabolic change) first, and the subsequent effect on tumor size (structural change). 
3.4 Primary Safety Endpoints 
N/A 
4 Subject Selection and Withdrawal 
4.1 Patient with breast cancer 
4.1.1 Inclusion Criteria 
• 
Histologically confirmed invasive cancer of the breast.   

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• 
Planned chemotherapy for a subset of patients with breast cancer 
• 
Age ≥ 18 years.  
• 
Non-pregnant and non-lactating. 
• 
Ability to understand and willingness to sign a written consent. 
4.1.2 Exclusion Criteria 
• 
Previous therapy with chemotherapy or targeted therapy for the current breast cancer. Prior endocrine 
therapy for a prior invasive cancer or risk reduction as well as estrogen/progesterone replacement 
therapy is allowed if >6 months prior to study entry. Prior chemotherapy for other cancers is allowed if 
>2 years prior to study entry. 
• 
Contra-indications to MRI (i.e., ferromagnetic prostheses, metallic surgical implants that are not 
compatible with an MRI machine, claustrophobia etc.) 
• 
Medical condition such as uncontrolled infection (including HIV), uncontrolled diabetes mellitus or 
cardiac disease which, in the opinion of the treating physician, would make this protocol unreasonably 
hazardous for the patient.   
• 
Pregnant or lactating women, women using hormonal treatment in the 6 months prior to the study 
• 
Women with history of breast disease, previous ipsilateral breast surgery, or breast implants. 
• 
Psychiatric illness or other conditions and circumstances which could prevent the patient from being 
compliant with the protocol. 
• 
Women with any kidney disease or other kidney problems, who are at risk for developing NSF/NSD 
(Nephrogenic Systemic Fibrosis, or Nephrogenic Fibrosing Dermopathy) due to gadoliunium injection. 
• 
Subjects with Glomerular Filtration Rate (GFR) < 15 ml/min/1.73m2 or who are on dialysis. 
4.2 Healthy subjects 
4.2.1 Inclusion criteria 
• 
Women with no sign of breast cancer as controls 
• 
Age ≥ 18 years  
• 
Non-pregnant and non-lactating 
• 
Ability to understand and willingness to sign a written consent 
• 
Patients with benign tumors (e.g., hyperplasia, cysts, intraductal papillomas, etc.) will be included per 
PI discretion 
4.2.2 Exclusion criteria 
• 
Contra-indications to MRI (i.e., ferromagnetic prostheses, metallic surgical implants that are not 
compatible with an MRI machine, claustrophobia etc.) 
• 
Medical condition such as uncontrolled infection (including HIV), uncontrolled diabetes mellitus or 
cardiac disease which, in the opinion of the treating physician, would make this protocol unreasonably 
hazardous for the patient.   
• 
Pregnant or lactating women, women using hormonal treatment in the 6 months prior to the study. 
• 
Women with history of breast disease, previous breast surgery, or breast implants. 
• 
Patients with a currently active second malignancy other than non-melanoma skin cancers. Patients 
are not considered to have a currently active malignancy if they have completed therapy and are free 
of disease for 3 years. 
• 
Psychiatric illness or other conditions and circumstances which could prevent the patient from being 
compliant with the protocol. 

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• 
If injection of contrast agent: Women with any kidney disease or other kidney problems, who are at 
risk for developing NSF/NSD (Nephrogenic Systemic Fibrosis, or Nephrogenic Fibrosing Dermopathy) 
due to gadoliunium injection. 
• 
If injection of contrast agent: Subjects with GFR < 15 ml/min/1.73m2 or who are on dialysis 
4.3 Subject Recruitment and Screening 
Potential participants for this study will be solicited from a broad base of individuals who meet the conditions 
outlined for the study. This may incidentally include NYU Langone Health employees and/or students, 
whose participation is entirely voluntary. Participation in research is not a requirement for employment, and 
neither the participant’s academic status or grades, nor their employment will be affected by their decision 
to participate in this study. Record of the participation cannot be linked to an academic or employment 
record. To reduce the possibility of the appearance of coercion: 1) NYU staff and students will be made 
aware that their participation will not affect employment or academic status and 2) NYU staff and students 
that directly work on this project will not be allowed to participate. 
4.3.1 Healthy Subjects 
Healthy subjects will be recruited through advertising across NYU Medical Center facilities. Thus, we will 
have brochures for participants to take, placed at the front desks of the Center for Biomedical Imaging and 
at the Laura and Isaac Perlmutter Cancer Center (see brochure in attachments).  
We will also utilize Craigslist, an online classified advertisements website, to advertise the study to healthy 
volunteers. 
All advertisements will be approved by the IRB.  
Participation to the study will not be limited by race or ethnicity, and patients of all ethnic backgrounds will 
be encouraged to participate. The study will be limited to female subjects only.  
Most of the controls (healthy subjects) will be scanned without contrast agent injection for coil and sodium 
MRI protocol optimization. Once enough data has been obtained to optimize the MRI protocol (at the end 
of year 1), we will then expect to scan approximately 4 controls with contrast agent injection to test and 
optimize the DCE MRI sequence timing and resolution. We will ensure that these healthy controls have no 
contraindication to gadolinium contrast agent and they will sign the consent form dedicated to "controls with 
contrasts". As for patients with breast cancer, they will be screened prior to the scan by the research 
coordinator and MR technicians at the CBI. 
Only once the complete 1H+23Na MRI protocol is ready and tested on controls, we will start to scan patients 
with breast cancer to assess treatment response (year 2). 
Prospective subjects will receive detailed information regarding this study; its investigational nature, 
required study procedures, alternative treatments, risks and potential benefits of the study.  They will also 
receive the informed consent document to read. All questions are answered by the PI and qualified research 
personnel.  
Subjects with benign lesions/masses will also be included as healthy subjects, since benign (non-
cancerous) breast conditions are very common, and most women have them.  
  
Incidental Findings: 
In some cases, a scan of a volunteer will reveal an incidental abnormality with (or without) a clinical 
significance. Every scan performed in this study is saved and handled under the standard PHI confidentiality 

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restrictions and regulations employed for subjects’ information. Each scan is additionally reviewed by a 
radiologist, who might then detect an abnormality. If clinically useful information is uncovered, either the 
Principal Investigator or another clinician on the study will ask to speak to the subject’s physician to 
communicate these results.  It will be the subject’s responsibility to follow-up with his/her physician outside 
of the study. 
As this is a pilot study, findings from the research project itself will not be communicated directly to individual 
patients. As written in section 7 in all the consent forms, there will be no direct benefit for the subjects to 
participate in the study. However, the new research images are important for future MRI studies and clinical 
uses. The imaging knowledge gained will be of benefit to others in the future. 
4.3.2 Breast cancer patients 
Participation to the study will not be limited by race or ethnicity, and patients of all ethnic backgrounds will 
be encouraged to participate. The study will be limited to female patients only, as this is the predominant 
population with breast cancer. 
Breast cancer patients will be recruited from the NYU Cancer Institute and NYU Winthrop by our co-
investigators. Linda Moy, MD, will identify potential patients who present to the Breast Imaging Center with 
a known diagnosis of breast cancer. Patients who undergo imaging tests (mammography, breast ultrasound 
and/or breast MRI) and are diagnosed with breast cancer will be identified and screened. Similarly, Sylvia 
Adams, MD, an oncologist specializing in breast cancer, and Freya Schnabel, MD and Shubhada Dhage, 
MD, breast surgeons, will also screen patients seen in their offices who meet the inclusion criteria.  
Patients recruited from Winthrop may opt to use the car service, Communicar, free of charge, to be 
transported from their homes to the Center for Biomedical Imaging and back for their appointments. 
Subjects who have been diagnosed with breast cancer and meet inclusion criteria as outlined above will be 
recruited from oncology with an initial discussion of the study. If subjects are interested in participating, the 
PI/co-investigators or study coordinator will meet with each of the subjects at the Cancer Center in a room 
that gives privacy to discuss the study. A copy of the consent will be given to the subjects to read and retain 
and the original signed consent will be retained by the study team, which will document the consent process. 
The subject will be given an opportunity to ask questions and will be encouraged to ask questions. We will 
ask the subjects to verbally describe what they have consented to do so that we know that they understand 
the scope of the research study. When all concerns about the study have been addressed, they will be 
asked to sign the consent form. Subjects must fully understand the potential risks and benefits involved in 
participating in the study. Participation in the research is voluntary and withdrawal from participation will not 
affect an individual’s care in any way. 
Two types of patients with breast cancer will be recruited: (1) patients with any type of breast cancer will be 
recruited for testing and optimizing the MRI procotol (1 scan); (2) patients with any breast cancer who are 
scheduled to receive chemotherapy will be recruited for the longitudinal part of the study (4 scans: at 
baseline, 2-3 weeks, 2-3 months, post-treatment). 
Although we expect to scan all patients with breast cancer with contrast agent injection (gadolinium) for 
DCE MRI, at baseline and at 3 follow-ups (2-3 weeks, 2-3 months, post-treatment), we will prepare an 
informed consent form without contrast agent injection for these patients in case some of them cannot be 
scanned with injection for personal or medical reason at any time-point of the study. 
The Principal Investigator or IRB approved sub-investigator will be responsible for documentation in the 
medical record that consent has been obtained from all participants. A signed copy of the consent form will 
be given to each participant. Original consent forms and informed consent checklists will be stored in a 
study binder that is kept in a locked file cabinet inside of a locked office. If there are any amendments made 

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to the protocol after initial IRB approval, all subjects will be re-consented; that newly signed consent form 
will also be stored in the study binder. 
4.3.3 Consent forms 
The major emphasis in approaching a subject is that:  
1. They fully understand the potential risks involved; 
2. That participation in the research is purely voluntary.  
Informed consent will be obtained from all participants prior to their participation in this research study. 
Informed consent will be obtained in accordance with the FDA regulation 21CFR, Part 50. A copy of the 
approved Subject Informed Consent Form, along with a copy of each subject’s signed and dated consent 
form, will be maintained by the study coordinator in a designated study binder. This file will be locked in a 
file cabinet that is located in a locked room. In the absence of informed consent no research will be 
performed. A copy of the signed informed consent will also be given to the subject. If amendments to the 
protocol are made after initial IRB approval which involve a change to study procedures or alter the risks 
and benefits to study participants, all subjects will be re-consented. The original re-consented forms will be 
locked away in the administrative file with the original forms.   
Four sets of informed consent forms will be available: 
1. 
Informed consent form without contrast agent injection (for healthy subjects). 
2. 
Informed consent form with contrast agent injection (for healthy subjects). 
3. 
Informed consent form without contrast agent injection (for patients with breast cancer). 
4. 
Informed consent form with contrast agent injection (for patients with breast cancer). 
The Principal Investigator will: 
1. 
Obtain signed and dated informed consent from the potential subject before any study specific 
procedures are performed. 
2. 
Determine patient eligibility See Sections 4.1.1, 4.1.2,  4.2.1  and 4.2.2    
3. 
Submit registration to NYU Langone Perlmutter Cancer Center CTO 
4. 
Receive registration confirmation from the Research Coordinator at NYU Perlmutter Cancer Center 
CTO, including a unique study identification number assigned to the patient by the research 
coordinator, which will be distributed to the study team upon registration of the patient. 
The informed consent process and documentation follows the established procedures of the NYULMC IRB. 
The informed consent form is considered to be part of the protocol, and must be submitted by the 
investigator with it for IRB approval. 
If applicable 
For non-English speaking patients, institutional translation services will be utilized. For these patients the 
consent letter and all other information will be administered orally and a witness, not related to the research 
project, will be present while the oral presentation is given. A short form will be utilized for the subject to 
sign in his/her name and the translator and/or witness must sign the short form. The translator will also sign 
the main consent form. 
 
Due to COVID-19 and to keep the safety of both our research team and research subjects, we will be 
collecting consent via telephone during the COVID-19 crisis. A trained Research Assistant will schedule a 
time with eligible interested participants to go over the written consent via telephone. Research Assistants 
will email or mail a copy of the consent to participants in preparation for the telephone consent. After going 

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over the written consent via telephone, research assistants will also send the consent via a RedCap link 
where the participant has the opportunity to read a copy of the written consent and sign electronically, 
confirming that they read and understood the consent. Research Assistants will also document on RedCap 
the time and date of the telephone consent and note that the consent process was done via telephone due 
to COVID-19. 
An IRB-approved phone script will be used to contact patients during the COVID-19 crisis. The phone script 
will be used as an initial determination of a subject’s eligibility. The PI and the research coordinator will 
have access to this collected eligibility data. We will keep this information until the end of the study to avoid 
screening the same ineligible subject more than once. Subjects who do not meet eligibility criteria will have 
their information discarded after the end of the study. 
 
4.4 Registration Procedures 
4.4.1 General Guidelines 
Each patient must sign and date an informed consent form before undergoing any study specific procedure 
unless a procedure is being performed as part of the patient’s standard of care. 
Enrollment in the study requires that all inclusion and exclusion criteria have been met.  Enrollment occurs 
upon confirmation of registration from the NYULMC PCC Clinical Trials Office.  The following materials 
must be submitted to the Research Coordinator for subject registration: 
1. 
Complete signed and dated informed consent form 
2. 
Complete signed and dated informed consent checklist 
3. 
Complete signed and dated eligibility checklist 
4. 
All supporting documentation verifying each criterion has been met 
Registration will occur within 48 hours of research coordinator receipt of all of the above documents.  A 
written confirmation of enrollment including a unique study identification number assigned by the research 
coordinator will be disbursed to the study team upon registration. 
Once eligibility is verified, a unique patient study number will be issued within 24 hours of receiving all 
required registration material. This is the point, at which, the patient is considered on study.  Subjects must 
not start any protocol study specific procedures, unless part of standard of care prior to registration. 
4.5 Early Withdrawal of Subjects 
4.5.1 When and How to Withdraw Subjects 
A subject will be withdrawn from the study if, after signing informed consent, he or she is found to have any 
contraindication for MRI, fails to adhere to the protocol requirements, or if the PI has any safety concerns. 
Inadequate imaging quality due to lack of subject collaboration (ability to remain still) will be considered as 
a cause of withdrawal from the study. Additionally, participation is entirely voluntary, and a subject may 
withdraw from the study at any time. If a subject wishes to withdraw from the study, the following sequence 
of events will occur: 
• 
PI and research coordinator will be alerted immediately by the interviewer, 
• 
PI and research coordinator will meet with the participant to address any concerns,  
• 
PI or research coordinator will provide participant with the telephone number for the NYULMC 
Radiology IRB, should the subject wish to discuss any issues with a representative of the Board.  
If a subject does not wish to participate in a study procedure, or wishes to discontinue the procedure prior 
to its completion, the procedure would be stopped immediately. If there are any safety concerns regarding 

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an individual’s participation in the study, per our exclusion criteria, or a problem that occurs during the study, 
the study will be stopped per standard radiology clinical practice. 
4.5.2 Data Collection and Follow-up for Withdrawn Subjects 
Patients that will be participating in our study will be under the care of an oncologist and are expected to 
have close clinical follow-up. The participation in the research study is voluntary and withdrawal from 
participation will not affect care in any way. Healthy controls will be aware that participation in this study is 
voluntary and they may revoke or withdraw consent at any time. Data from early withdrawn subjects may 
or may not be included in the analyses. In the event that a subject is withdrawn or revokes authorization to 
collect or use PHI, the investigator, by regulation, retains the ability to use all information collected prior to 
the revocation of subject authorization. No follow-up data is required. 
5 Study Devices and Imaging Procedures 
5.1 Description 
1. 
MRI scanner at 7 T: All proton and sodium images will be acquired on a whole body 7 T system 
(Siemens, Erlangen, Germany) with multichannel (32 channels) and multinuclear capabilities. 
2. 
Radiofrequency (RF) coil: We will build a dual-tuned multichannel RF coil (with 13 23Na-channels 
and 1 1H-Helmholtz-channel per breast) that will allow bilateral breast 1H/23Na MRI at 7 T.  
5.2 Treatment Regimen 
Patients who are scheduled to receive 
neoadjuvant 
(preoperative) 
chemotherapy 
(NACT) will be considered for participation in 
this 
study. 
The 
type 
and 
length 
of 
chemotherapy will be determined by the 
treating physician in breast medical oncology, 
according to institutional guidelines. 
5.3 Description of the 1H/23Na RF 
Coil 
5.3.1 Rationale  
We built 8-channel-23Na/2-channel-1H coil for 
bilateral breast imaging at 7 T (Fig. 7) in our 
fully equipped RF laboratory. The array 
provides the following innovations:   
1. 
Well-known raw SNR advantage over volume coils, with expected +50% gain in the breast center and 
+100% in the periphery;  
2. 
Iterative image reconstruction technique will benefit from improved noise properties and domain 
sparsity associated with dense receive arrays to allow 2.5-3 mm isotropic resolution in 23Na images.  
5.3.2 Methods  
Coil performance is a primary determinant of breast MRI quality. A coil that allows concurrent 23Na and 1H 
breast imaging is not yet commercially available and presents technical challenges: complex coupling 
between the 1H and 23Na channels can degrade SNR, coverage, and uniformity. In our previous work for 
cartilage and head imaging, high performance was achieved on both channels by implementing new design 
 
Figure 7. RF coil design. Tx = transmit, Rx = receive. 

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strategies that alleviated inter-channel coupling and 
wideband matching that allowed the 23Na array to 
substantially outperform traditional single channel 
designs78,79.  
Based on previous experience on dual-tuned and 
breast coil design77,79,80, the coil consists of 3 modules 
mounted on concentric dome-shaped layers (Fig. 7):  
1. 
The inner layer houses the 1H transmit/receive 
(Tx/Rx) Helmholtz coil, which provides excellent 
coverage and uniformity to enable standard 1H 
MRI;  
2. 
The middle layer houses the 8-element 23Na Rx 
module , which provides a +50% SNR advantage 
in the center of the breast over a mono-nuclear 
volume coil;  
3. 
The outer layer houses the 23Na Tx Helmholtz coil, 
which will provide high excitation uniformity.  
5.3.3 Testing and validation  
1. 
We have built a multi-layer dielectric phantom with breast and muscle tissue properties (electrical 
permittivity and conductivity) to replicate human loading conditions81.  
2. 
Coil performance was tested at various construction stages in order to measure SNR gain. Transmit 
field uniformity was assessed in flip angle maps82 and SNR will be assessed in gradient- echo images.  
3. 
Our Coil Safety Committee confirmed safe operation of the coil and approved the RF power limits that 
restrict tissue heating and the specific absorption rate (SAR) to a level consistent with International 
Electrotechnical Commission guidelines (IEC)55. Given the high level of habitus variability and its 
potential impact on SAR, we will implement a 5 W/kg limit to provide a 2-fold buffer over the 10 W/kg 
IEC limit.  
5.4 Description of the MRI Procedures 
5.4.1 
23Na MRI 
Sodium scans: Two 23Na data will be acquired: (1) FLORET without IR, and (2) FLORET with IR (Fig. 8). 
We will optimize the acquisition parameters (number of hubs and interleaves, repetition time, averages) in 
order to minimize TE (<0.5 ms) and acquisition time (<7 min) while maximizing SNR (>20) and isotropic 
resolution (2.5-3 mm). The sodium scan is performed without any injection of contrast agent. 
Fluid suppression: Fluids present in breast tissue (in extracellular volume, milk ducts, blood, plasma) are 
assumed to have similar properties as other body fluids ([Na+] = 140 mM, T1 = 30-50 ms, T2 = 20-40 
ms)19,83,84. The inversion pulse power, shape and duration, and inversion time, will be optimized from 
simulation, then on phosphate buffer saline (PBS), and on 2 healthy volunteers.  
Relaxation times: We will measure 23Na T1 and T2* relaxation times in breast tissue on 4 healthy 
volunteers. These parameters will be used for correcting breast signal during the data processing for C1 
and 2 quantification. T1 will be measured with FLORET acquisition with different TRs, and T2* with 
FLORET and different TEs.  
 
Figure 8. RF pulse sequence. (A) chronogram of 
the RF sequence, with RF: radiofrequency, TI: 
inversion time, TE: echo time, TR: repetition time. 
(B) k-space trajectory of the FLORET sequence.  

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5.4.2 
1H MRI  
Pre- and post-contrast T1 weighted DCE MRI will be performed at each time-point of the study with the 
same 1H/23Na RF coil at 7 T and used to measure tumor size. DCE MRI will be acquired subsequent to 
23Na MRI to prevent influence of the contrast agent on 23Na data. DCE MRI will be performed with a fat-
suppressed T1-weighted 3D SPAIR sequence with 1 mm isotropic resolution in 2-3 min, that was optimized 
for 7 T breast MRI. A gadolinium contrast agent (Gadavist) will be delivered in the antecubital vein at 0.1 
mmol/kg. Magnetic Resonance Fingerprinting (MRF) for T1, T2 and proton density (PD) quantification will 
also be included if time permits prior to DCE MRI.  
The contrast Gadavist is lawfully marketed in the United States. The investigation is not intended to be 
reported to FDA as a well-controlled study in support of a new indication and there is no intent to use it to 
support any other significant change in the labeling of the drug. In the case of a prescription drug, the 
investigation is not intended to support a significant change in the advertising for the drug. The investigation 
does not involve a route of administration, dose, patient population, or other factor that significantly 
increases the risk (or decreases the acceptability of the risk) associated with the use of the drug product 
(21 CFR 312.2(b)(1)(iii)). The use of contrast on healthy subjects does not significantly impact the 
risk/benefit ratio associated with use of the contrast. The FDA recommended dosage will be used on healthy 
controls and the data acquired from contrast MRI scans will be used to optimize the resolution of the images.  
5.5 Pathologic assessment of response  
5.5.1 Criteria for evaluation of pathologic complete response (pCR) 
Pathologic complete response in breast and ipsilateral axillary lymph nodes as well as non-axillary sentinel 
nodes (pCR breast and nodes) is defined as no histologic evidence of invasive tumor cells in the surgical 
breast specimen, axillary nodes, or sentinel nodes identified after neoadjuvant chemotherapy. In situ 
carcinoma is allowed. 
5.5.2 Determination of pCR 
The determination of pCR (definition see above) will be performed by the local pathologist following 
examination of tissue (breast and nodes) removed at the time of surgery. Both, pathology evaluation and 
surgery are being performed as standard of care for the patient. No tissue will be stored and/or used for 
this research. 
5.6 Subject Compliance Monitoring 
Because subjects enrolled in the study have breast cancer, they will be closely monitored and are expected 
to have regular visits with their oncologist.   
5.7 Prior and Concomitant Therapy 
This is not a treatment trial, the treating physician will determine subject’s treatment as clinically appropriate. 
6 Study Procedures 
6.1 Visit 1: Baseline 
1. 
The potential study subject will be given ample time to review and sign the informed consent if willing 
to participate in the research study. They will also complete an MRI safety sheet prior to any study 
related procedures taking place. No information will be retained or collected prior to the patient signing 
consent.   

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2. 
Sodium MRI protocol: 2 or more acquisitions (if necessary) with and without fluid suppression. Time: 
30 min maximum. 
3. 
Proton MRI protocol: Localizer, T2-weighted MRI, T1 weighted MRI pre- and post-contrast (DCE 
MRI). MRF for T1, T2 and PD quantification will also be included if time permits. Time: 30 min 
maximum. 
Note: We will allow a delay of at least 48 hours between the clinical DCE MRI (performed as part of 
the standard clinical procedure for breast cancer diagnosis, at 1.5 T or 3 T) and the first research DCE 
MRI scan at 7 T (baseline data in our study). 
6.2 Visit 2: 2-3-week follow-up 
1. 
Sodium MRI protocol: 2 or more acquisitions (if necessary) with and without fluid suppression. Time: 
30 min maximum. 
2. 
Proton MRI protocol: Localizer, T2-weighted MRI, T1 weighted MRI pre- and post-contrast (DCE 
MRI). MRF for T1, T2 and PD quantification will also be included if time permits. Time: 30 min 
maximum. 
6.3 Visit 3: 2-3-month follow-up 
1. 
Sodium MRI protocol: 2 or more acquisitions (if necessary) with and without fluid suppression. Time: 
30 min maximum. 
2. 
Proton MRI protocol: Localizer, T2-weighted MRI, T1 weighted MRI pre- and post-contrast (DCE 
MRI). MRF for T1, T2 and PD quantification will also be included if time permits. Time: 30 min 
maximum. 
6.4 Visit 4: End of treatment 
1. 
Sodium MRI protocol: 2 or more acquisitions (if necessary) with and without fluid suppression. Time: 
30 min maximum. 
2. 
Proton MRI protocol: Localizer, T2-weighted MRI, T1 weighted MRI pre- and post-contrast (DCE 
MRI). MRF for T1, T2 and PD quantification will also be included if time permits. Time: 30 min 
maximum. 
7 Statistical Plan 
7.1 Sample Size Determination 
As described in Fig. 6, 16 healthy controls will be necessary for RF coil development and optimization of 
the 1H/23Na MRI protocol (including repeatability/reproducibility study) prior to application of the proposed 
method to patients with breast cancer. A greater amount of healthy controls to patients is used in this study 
to help generate an MRI protocol for repeatability and reproducibility. Once the technique is optimized, the 
data necessary to prove the objective can be obtained through 20 patients. From the literature19,22,35,38,39,85, 
we can expect changes in C1 and 2 of 30-50% between time points, and a CV ≤ 20% for each measure in 
patient with breast cancer undergoing neoadjuvant chemotherapy. To detect a 30% change for a CV of 
20%, data is needed from at least 9 patients to achieve 80% power. The study will accrue 20 women to 
allow for 50% attrition. 

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7.2 Statistical Methods 
All statistical tests will be conducted at the two-sided 5% significance. Data from 1 scan before and 3 scans 
after NACT onset for 12 women will be tumor size, C1 and 2 of tumor and of healthy tissue in both the 
affected and contralateral breasts. Local lesions will be manually segmented in DCE images by co-
investigator Dr. Moy; lesion size will be defined by its longest linear dimension. ROIs will be transferred to 
co-registered sodium images to determine the C1 and 2 in the lesion. Paired sample t tests will assess the 
change in each measure in tumor and healthy tissue from pre- to each post-onset time point and compare 
tumor to healthy tissue in terms of these changes. Healthy tissue will be automatically segmented using 3D 
proton multi-echo data processed using the Dixon chemical species separation algorithm. Tissue with > 
50% water content, excluding the local lesion, will be defined as normal glandular tissue. Pearson and 
Spearman rank correlations will assess the association of intra-tumor changes in C1 and 2 with changes 
in tumor size. Focus will be on the correlation of short-term (2 weeks, 2 months) changes in C1 and 2 with 
both short-term and long-term (5 months) 
7.3 Subject Population(s) for Analysis 
Protocol-compliant population:  Any subject who received an imaging procedure. 
8 Safety and Adverse Events (SAE) 
8.1 Definitions 
Unanticipated Problems Involving Risk to Subjects or Others 
Any incident, experience, or outcome that meets all of the following criteria:  
• Unexpected in nature, severity, or frequency  (i.e. not described in study-related documents such 
as the IRB-approved protocol or consent form, the investigators brochure, etc) 
• Related or possibly related to participation in the research (i.e. possibly related means there is a 
reasonable possibility that the incident experience, or outcome may have been caused by the 
procedures involved in the research). ). This will be limited to SAEs associated with the reseach 
MRI, SAEs related to neoadjuvant chemotherapy or surgery WILL NOT be reported for this non-
therapeutic study. 
• Suggests that the research places subjects or others at greater risk of harm (including physical, 
psychological, economic, or social harm). 
Unanticipated Adverse Device Effect  
An Unanticipated Device Effect is any serious adverse effect on health or safety, or any life-threatening 
problem or death caused by, or associated with a device, if that effect, problem, or death was not previously 
identified in nature, severity, or degree of incidence in the investigational plan or application (including a 
supplementary plan or application), or any other unanticipated serious problem associated with a device 
that relates to the rights, safety, or welfare of subjects. 
Serious injury 
Any injury or illness that is any one of the following:  
• life-threatening 
• results in permanent impairment of a body function or permanent damage to body structure 
• necessitates medical or surgical intervention to preclude permanent impairment of a body function 
or permanent damage to a body structure 
 

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Adverse Event 
An adverse event (AE) is any symptom, sign, illness or experience that develops or worsens in severity 
during the course of the study.  Intercurrent illnesses or injuries should be regarded as adverse events.  
Abnormal results of diagnostic procedures are considered to be adverse events if the abnormality: 
• results in study withdrawal 
• is associated with a serious adverse device effect 
• is associated with clinical signs or symptoms 
• leads to additional treatment or to further diagnostic tests 
• is considered by the investigator to be of clinical significance 
8.2 Recording of Adverse Device Effects 
At each contact with the subject, the investigator must seek information on adverse device effects by 
specific questioning and, as appropriate, by examination.  Information on all adverse device effects should 
be recorded immediately in the source document, and also in the appropriate adverse effect module of the 
case report form (CRF).  All clearly related signs, symptoms, and abnormal diagnostic procedures results 
should recorded in the source document, though should be grouped under one diagnosis. 
All adverse device effects occurring during the study period must be recorded.  The clinical course of each 
event should be followed until resolution, stabilization, or until it has been determined that the study 
treatment or participation is not the cause.  Serious adverse device effects that are still ongoing at the end 
of the study period must be followed up to determine the final outcome.  Any serious adverse device effects 
that occur after the study period should be recorded and reported promptly (see section 8.3 below). 
The minimum initial information to be captured in the subject’s source document concerning the adverse 
device effect includes:  
• 
Study identifier 
• 
Study Center 
• 
Subject number 
• 
Device model and serial number 
• 
A description of the event 
• 
Date of onset 
• 
Investigator assessment of the association 
between the event and study treatment 
• 
Current status 
• 
Whether study treatment was discontinued 
• 
Whether the event is serious and reason for 
classification as serious 
8.3 Reporting of Adverse Device Effects and Unanticipated Problems 
8.3.1 Investigator reporting: notifying the NYULMC IRB. 
The following describes events that must be reported to the CTO in an expedited fashion. 
Initial Report: within 24 hours: 
The following events must be reported to the CTO via email within 24 hours of awareness of the event:  
• 
Unanticipated problems related to study participation,  
• 
Serious adverse events, regardless of whether they are unexpected.  
   
 
 
 
Email:  NYUPCCsafetyreports@nyumc.org 
Tel:  212-263-4427 
 

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Follow-up report: within 48 hours: 
As a follow-up to the initial report, within the following 48 hours of awareness of the event, the investigator 
shall provide further information, as applicable, on the unanticipated device event or the unanticipated 
problem in the form of a written narrative.  This should include a copy of the completed Unanticipated 
Problem form, and any other diagnostic information that will assist in the understanding of the event.  All 
report forms must be signed  and dated by the Principal Investigator.  If the Principal Investigator is not 
available at the time of the initial report, then the form can be submitted by a Co-Investigator.  This form 
should be reviewed by the Principal Investigator, whom sign/date initial report upon return. 
Other Reportable events: Deviations from the study protocol 
Deviations from the protocol must receive the investigator’s IRB approval before they are initiated. Any 
protocol deviations initiated without the investigator’s IRB approval that may affect the scientific 
soundness of the study, or affect the rights, safety, or welfare of study subjects, must be reported to the 
investigator’s IRB as soon as a possible, but no later than 5 working days of the protocol deviation. 
8.3.2 Investigator reporting: Notifying the IRB 
Federal regulations require timely reporting by investigators to their local IRB of unanticipated problems 
posing risks to subjects or others.  The following describes the NYULMC IRB reporting requirements, 
though Investigators at participating sites are responsible for meeting the specific requirements of their IRB 
of record. The NYU IRB address is: 
NYU School of Medicine IRB 
 
 
 
1 Park Avenue, 6th Floor 
 
 
 
New York, NY 10016 
 
Report Promptly, but no later than 5 working days: 
Researchers are required to submit reports of the following problems promptly but no later than 10 working 
days from the time the investigator becomes aware of the event: 
• Unanticipated problems including adverse events that are unexpected and related 
– Unexpected: An event is “unexpected” when its specificity and severity are not accurately 
reflected in the protocol-related documents, such as the IRB-approved research protocol, any 
applicable investigator brochure, and the current IRB-approved informed consent document and 
other relevant sources of information, such as product labeling and package inserts.  
– Related to the research procedures: An event is related to the research procedures if in the 
opinion of the principal investigator or sponsor, the event was more likely than not to be caused 
by the research procedures.  
– Harmful: either caused harm to subjects or others, or placed them at increased risk 
• Unanticipated adverse device effect:  Any serious adverse effect on health or safety or any life-
threatening problem or death caused by, or associated with, a device, if that effect, problem, or 
death was not previously identified in nature, severity, or degree of incidence in the investigational 
plan or application (including a supplementary plan or application, or any other unanticipated serious 
problem associated with a device that relates to the rights, safety, or welfare of subjects. 
Other Reportable events: 
The following events also require prompt reporting to the IRB, though no later than10 working days: 

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authorized in writing by the study sponsor 
 
• Complaint of a research subject when the complaint indicates unexpected risks or the complaint 
cannot be resolved by the research team. 
• Protocol deviations or violations (includes intentional and accidental/unintentional deviations 
from the IRB approved protocol) for any of the following situations:  
– one or more participants were placed at increased risk of harm 
– the event has the potential to occur again 
– the deviation was necessary to protect a subject from immediate harm 
 
• Breach of confidentiality 
• Incarceration of a participant when the research was not previously approved under Subpart C 
and the investigator believes it is in the best interest of the subject to remain on the study. 
• New Information indicating a change to the risks or potential benefits of the research, in terms 
of severity or frequency. (e.g. analysis indicates lower-than-expected response rate or a more 
severe or frequent side effect; Other research finds arm of study has no therapeutic value; FDA 
labeling change or withdrawal from market) 
Reporting Process 
The reportable events noted above will be reported to the IRB using the “Reportable New Information” 
submission or as a written report of the event (including a description of the event with information regarding 
its fulfillment of the above criteria, follow-up/resolution and need for revision to consent form and/or other 
study documentation). 
Copies of each report and documentation of IRB notification and receipt will be kept in the Clinical 
Investigator’s study file. 
At the time of each annual review any protocol deviations stated above must be reported to the IRB. 
8.3.3 Stopping Rules 
During the MRI examination subjects will be periodically monitored through an intercom and visually using 
a CCD camera, and if any problems arise, the study will be immediately terminated. Instructions will be 
given prior to and during the MRI scan. 
8.4 Medical Monitoring 
It is the responsibility of the Principal Investigator to oversee the safety of the study at his/her site. This 
safety monitoring will include careful assessment and appropriate reporting of adverse events as noted 
above, as well as the construction and implementation of a site data and safety-monitoring plan detailed 
below. Medical monitoring will include a regular assessment of the number and type of adverse device 
events. The principal investigator in conjugation with the research team will evaluate any adverse device 
events regularly.   
9 Data Handling and Record Keeping 
9.1 Confidentiality 
Information about study subjects will be kept confidential and managed according to the requirements of 
the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  Those regulations require a signed 
subject authorization informing the subject of the following:  

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• What protected health information (PHI) will be collected from subjects in this study 
• Who will have access to that information and why 
• Who will use or disclose that information 
• The rights of a research subject to revoke their authorization for use of their PHI.  
In the event that a subject revokes authorization to collect or use PHI, the investigator, by regulation, retains 
the ability to use all information collected prior to the revocation of subject authorization. For subjects that 
have revoked authorization to collect or use PHI, attempts should be made to obtain permission to collect 
at least vital status (i.e. that the subject is alive) at the end of their scheduled study period. 
9.2 Source Documents 
Source data is all information, original records of clinical findings, observations, or other activities in a 
clinical trial necessary for the reconstruction and evaluation of the trial.  Source data are contained in source 
documents.  Examples of these original documents, and data records include: hospital records, clinical and 
office charts, laboratory notes, memoranda, subjects’ diaries or evaluation checklists, pharmacy dispensing 
records, recorded data from automated instruments, copies or transcriptions certified after verification as 
being accurate and complete, microfiches, photographic negatives, microfilm or magnetic media, x-rays, 
subject files, and records kept at the pharmacy, at the laboratories, and at medico-technical departments 
involved in the clinical trial. 
9.3 Records Retention 
Records pertaining to conducted research must be retained for at least three years after completion of the 
research. IRB records not associated with research or for protocols cancelled without participant enrollment 
will be retained at the facility for at least three years after closure. 
Physical records associated with closed or terminated studies shall, after the three year retention period 
expires, be electronically scanned and thereafter shredded or otherwise destroyed in accordance with 
institutional policy. Electronic records must be retained for at least 3 years on the IRB’s current production 
systems. 
10 Study Monitoring, Auditing, and Inspecting 
10.1 Study Monitoring Plan 
This study will be monitored according to the monitoring plan discussed in this section. The investigator will 
allocate adequate time for such monitoring activities. The Investigator will also ensure that the monitor or 
other compliance or quality assurance reviewer is given access to all the above noted study-related 
documents and study related facilities (e.g. pharmacy, diagnostic laboratory, etc.), and has adequate space 
to conduct the monitoring visit. 
Although this research is not a clinical trial, it will be in compliance with the NYU Institutional Review Board.  
The review of AEs and trial conduct for this trial occurs at several levels: 
(1) Principal Investigator: Adverse events are evaluated monthly by the principal investigator in conjunction 
with the research team.  
(2) Institutional Review Board (IRB): An annual report to the IRB is submitted by the trial PI for continuation 
of the protocol. It includes a summary of all AEs, total enrollment with demographics, protocol violations, 
and current status of subjects as well as available research data. 

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(3) In addition, the quality assurance unit will provide quarterly interim monitoring visits, to verify adherence 
to the protocol; the completeness, accuracy and consistency of the data; and adherence to ICH Good 
Clinical Practice guidelines. 
The PIs will be responsible for gathering and monitoring the data regarding the recruitment rate and 
regarding unanticipated adverse events. This will be limited to SAEs associated with the research MRI, 
SAEs related to neoadjuvant chemotherapy or surgery WILL NOT be reported for this non-therapeutic 
study. This data will be reviewed with the research team every month. Any adverse events will be 
immediately reported in the subject’s file and to the IRB from onset to resolution. We will stop this study if 
a significant adverse event related to the imaging procedure occurs. 
(1) Types of Data or Events: 
• 
Captured data will include recruitment rate and unanticipated adverse events. In general, subject 
outcomes will depend on the standard of care imaging or other exams subjects undergo as part of 
their routine case. However, in cases where experimental data provides potentially treatment 
changing information not seen on conventional imaging, referring physicians will be notified. No 
change to the protocol will result from these possible incidents. 
• 
Adverse events will be graded in severity as follows: 
o 
0 - No adverse event or within normal limits 
o 
1 - Mild adverse event 
o 
2 - Moderate adverse event 
o 
3 - Severe adverse event resulting in hospitalization or the prolongation of existing 
hospitalization, a persistent or significant disability/incapacity, or a congenital anomaly/birth 
defect 
o 
4 - Life-threatening or disabling adverse event 
o 
5 - Fatal adverse event 
• 
Adverse events > level 3 will be reported to the IRB within 24 hours. Other adverse events will be 
reported to the IRB within 5 working days, using the following predefined causal relationships: 
o 
i. Definite: Adverse event(s) will clearly be related to investigational agent(s) or other 
intervention 
o 
ii. Probable: Adverse event(s) will likely be related to investigational agent(s) 
o 
iii. Possible: Adverse event(s) may be related to investigational agent(s) 
o 
iv. Unlikely: Adverse event(s) will doubtfully be related to investigational agent(s) 
• 
Adverse events will be collected at each study visit by the imaging technologist performing the 
procedure. 
 (2) Responsibilities and roles for gathering, evaluating and monitoring the data: 
• 
PIs will gather data regarding recruitment rate. This will be reviewed with the research team every 
month and with the study monitor bi-monthly. 
• 
PI and co-investigators overseeing the procedures will gather data regarding unanticipated adverse 
events. The PI and co-investigators will report any adverse event immediately to the NYU IRB (3) 
Information about the monitoring entity: 
• The Individual Data Monitor will be the PI: Guillaume Madelin, PhD., NYU Langone Medical Center, 
Department Radiology, 660 First Avenue, 4th floor, NY, NY 10016. 

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• The PIs will follow the policies and procedures of the IRB for monitoring this study for safety 
concerns, with ongoing updates from the Co-investigators on a continuous basis. co-PI Ryan 
Brown, PhD, and co-investigator Linda Moy, MD will assist the PI in monitoring the data, assuring 
protocol compliance, and conducting the safety reviews. 
(4) Reporting adverse events and unanticipated problems to the monitoring entity: 
• 
Any adverse events will be immediately reported by the investigator overseeing the procedure to 
the PI.  The PI will ensure that adverse events are reported in the subject’s file and to the IRB from 
onset to resolution.  
• 
A bi-annual report of the data safety monitoring reviews will be prepared and submitted to the 
sponsor and IRB by the study monitor. 
 
(5) Assessments: 
• 
Linda Moy, MD, will review safety data after every major study related visit and at research team 
meetings, which will be conducted at a minimum of every 6 months, and will suspend or modify the 
study (with IRB approval), if indicated. The IRB will be informed if any reasons warrant “holding” 
the study. A review of the study will be submitted to the IRB annually, including when re-approval 
of the protocol is sought. 
• 
The PIs and co-investigators will assess the risk to benefit ratio and determine whether the level of 
risk and patient safety were accurately outlined and accounted for in study application, protocol 
and consent.  
(6) Criteria for action: 
• 
The PIs will ensure that adverse events, whether considered related or not to the imaging 
procedure are reported in the subject’s file and to the IRB from onset to resolution.  If no follow up 
is performed, the PIs will provide justification. Significant adverse events will be reported to the IRB 
according to institution guidelines. 
• 
We will stop this study if a significant adverse event related to the imaging procedure occurs. The 
imaging hardware will then be evaluated the vendor. Only after rigorous QA analysis by the vendor 
will the protocol resume. 
(7) Procedures for Communicating – dissemination of safety information  
As appropriate: 
• 
Any significant deviation will be reported immediately via email to the IRB (irb-full-
board@nyumc.org) using the IRB Reportable Event form. 
New information that would affect the safety of the subject or their decision to participate in the study will 
be provided by the PI or his co-investigators. 
10.2 Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the EC/IRB, the sponsor, 
government regulatory bodies, and University compliance and quality assurance groups of all study related 
documents (e.g. source documents, regulatory documents, data collection instruments, study data etc.). 
The investigator will ensure the capability for inspections of applicable study-related facilities (e.g. 
pharmacy, diagnostic laboratory, etc.). 

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Participation as an investigator in this study implies acceptance of potential inspection by government 
regulatory authorities and applicable University compliance and quality assurance offices. 
11 Ethical Considerations 
This study is to be conducted according to US and international standards of Good Clinical Practice (FDA 
Title 21 part 312 and International Conference on Harmonization guidelines), applicable government 
regulations and Institutional research policies and procedures. 
This protocol and any amendments will be submitted to a properly constituted independent Ethics 
Committee (EC) or Institutional Review Board (IRB), in agreement with local legal prescriptions, for formal 
approval of the study conduct. The decision of the EC/IRB concerning the conduct of the study will be made 
in writing to the investigator and a copy of this decision will be provided to the sponsor before 
commencement of this study. The investigator should provide a list of EC/IRB members and their affiliate 
to the sponsor. 
All subjects for this study will be provided a consent form describing this study and providing sufficient 
information for subjects to make an informed decision about their participation in this study. See Attachment 
for a copy of the Subject Informed Consent Form. This consent form will be submitted with the protocol for 
review and approval by the EC/IRB for the study.  The formal consent of a subject, using the EC/IRB-
approved consent form, must be obtained before that subject undergoes any study procedure. The consent 
form must be signed by the subject or legally acceptable surrogate, and the investigator-designated 
research professional obtaining the consent.  
In addition, describe who will obtain consent and how the process of informed consent will be structured to 
be conducive to rational and thoughtful decision making by the subject/subject’s legally authorized 
representative. If children and/ or cognitively impaired adults will be subjects, include a specific plan to 
assess comprehension during assent or the subject’s agreement Individuals who are authorized to obtain 
consent must be listed on the protocol (or FDA form 1572) and consent form document. If necessary to use 
‘Auditor/Witness’ and/or translator, these roles would be described in this section. Include a plan for 
assessing subject capacity in cognitively impaired subjects. Describe the anticipated degree of impairment 
relative to their ability to consent and the anticipated direct benefits to the subjects. 
12 Study Finances 
12.1 Funding Source 
National Institute of Health 
12.2 Conflict of Interest 
Any investigator who has a conflict of interest with this study (patent ownership, royalties, or financial gain 
greater than the minimum allowable by their institution, etc.) must have the conflict reviewed by a properly 
constituted Conflict of Interest Committee with a Committee-sanctioned conflict management plan that 
has been reviewed and approved by the study sponsor prior to participation in this study.  All NYU 
investigators will follow the applicable University conflict of interest policy(ies). 
12.3 Subject Stipends or Payments 
All subjects (healthy volunteers and patients with breast cancer) will be compensated $50 for each study 
visit. If the subject completes all four visits, she will receive a total of $200. This amount aligns closely with 
other current NYU SoM clinical research protocols. 

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13 Publication Plan 
Any investigator involved with this study is obligated to provide the sponsor with complete test results and 
all data derived from the study. 
14 References 
1. 
Gralow JR, Burstein HJ, Wood W, et al. Preoperative therapy in invasive breast cancer: pathologic 
assessment and systemic therapy issues in operable disease. Journal of Clinical Oncology. 
2008;26(5):814-819. 
2. 
Holmes D, Colfry A, Czerniecki B, et al. Performance and Practice Guideline for the Use of 
Neoadjuvant Systemic Therapy in the Management of Breast Cancer. Annals of Surgical Oncology. 
2015;22(10):3184-3190. 
3. 
Sikov WM, Wolff AC. Neoadjuvant therapy for breast cancer: Rationale, pretreatment evaluation, and 
therapeutic options. UpToDate. 2015. 
4. 
Thompson AM, Moulder-Thompson SL. Neoadjuvant treatment of breast cancer. Annals of Oncology. 
2012;23(suppl 10):x231-x236. 
5. 
Carey LA, Winer EP. Defining success in neoadjuvant breast cancer trials. The Lancet. 
2014;384(9938):115-116. 
6. 
Cortazar P, Zhang L, Untch M, et al. Pathological complete response and long-term clinical benefit in 
breast cancer: the CTNeoBC pooled analysis. The Lancet. 2014;384(9938):164-172. 
7. 
Schott AF, Hayes DF. Defining the benefits of neoadjuvant chemotherapy for breast cancer. Journal 
of Clinical Oncology. 2012;30(15):1747-1749. 
8. 
Food US, Administration D. Guidance for industry: Pathologic complete response in neoadjuvant 
treatment of high-risk early-stage breast cancer: Use as an endpoint to support accelerated approval. 
UCM305501. 2012. 
9. 
von Minckwitz G, Untch M, Blohmer JU, et al. Definition and impact of pathologic complete response 
on prognosis after neoadjuvant chemotherapy in various intrinsic breast cancer subtypes. Journal of 
Clinical Oncology. 2012;30(15):1796-1804. 
10. Drisis S, Metens T, Ignatiadis M, Stathopoulos K, Chao SL, Lemort M. Quantitative DCE-MRI for 
prediction of pathological complete response following neoadjuvant treatment for locally advanced 
breast cancer: the impact of breast cancer subtypes on the diagnostic accuracy. European Radiology. 
2015:1-11. 
11. Gruber S, Pinker K, Zaric O, et al. Dynamic contrast-enhanced magnetic resonance imaging of breast 
tumors at 3 and 7 T: a comparison. Investigative Radiology. 2014;49(5):354-362. 
12. Li X, Arlinghaus LR, Ayers GD, et al. DCE-MRI analysis methods for predicting the response of breast 
cancer to neoadjuvant chemotherapy: Pilot study findings. Magnetic Resonance in Medicine. 
2014;71(4):1592-1602. 
13. Yankeelov TE, Lepage M, Chakravarthy A, et al. Integration of quantitative DCE-MRI and ADC 
mapping to monitor treatment response in human breast cancer: initial results. Magnetic Resonance 
Imaging. 2007;25(1):1-13. 
14. Hahn SY, Ko EY, Han BK, Shin JH, Ko ES. Role of diffusion-weighted imaging as an adjunct to 
contrast-enhanced breast MRI in evaluating residual breast cancer following neoadjuvant 
chemotherapy. European Journal of Radiology. 2014;83(2):283-288. 
15. Richard R, Thomassin I, Chapellier M, et al. Diffusion-weighted MRI in pretreatment prediction of 
response to neoadjuvant chemotherapy in patients with breast cancer. European Radiology. 
2013;23(9):2420-2431. 
16. Thomassin-Naggara I, De Bazelaire C, Chopier J, Bazot M, Marsault C, Trop I. Diffusion-weighted MR 
imaging of the breast: advantages and pitfalls. European Journal of Radiology. 2013;82(3):435-443. 

Sodium MRI to assess breast cancer NACT 
 
Page 32 
Version: 11/2/2020  
 
 
 
CONFIDENTIAL 
This material is the property of the NYU School of Medicine and Langone Medical Center.  Do not disclose or use except as 
authorized in writing by the study sponsor 
 
17. Brindle K. New approaches for imaging tumour responses to treatment. Nature Reviews Cancer. 
2008;8(2):94-107. 
18. Madelin G, Lee JS, Regatte RR, Jerschow A. Sodium MRI: Methods and applications. Progress in 
NMR Spectroscopy. 2014;79:14-47. 
19. Madelin G, Regatte RR. Biomedical applications of sodium MRI in vivo. Journal of Magnetic 
Resonance Imaging. 2013;38:511-529. 
20. Becchetti A. Ion channels and transporters in cancer. 1. Ion channels and cell proliferation in cancer. 
American Journal of Physiology-Cell Physiology. 2011;301(2):C255-C265. 
21. Boada FE, LaVerde G, Jungreis C, Nemoto E, Tanase C, Hancu I. Loss of cell ion homeostasis and 
cell viability in the brain: what sodium MRI can tell us. Current Topics in Developmental Biology. 
2005;70:77-101. 
22. Cameron IL, Smith NKR, Pool TB, Sparks RL. Intracellular concentration of sodium and other elements 
as related to mitogenesis and oncogenesis in vivo. Cancer Research. 1980;40(5):1493-1500. 
23. Cuddapah VA, Sontheimer H. Ion channels and tranporters in cancer. 2. Ion channels and the control 
of cancer cell migration. American Journal of Physiology-Cell Physiology. 2011;301(3):C541-C549. 
24. Leanza L, Biasutto L, Manago A, Gulbins E, Zoratti M, Szabo I. Intracellular ion channels and cancer. 
Frontiers in Physiology. 2013;4(227):1-7. 
25. Litan A, Langhans SA. Cancer as a channelopathy: ion channels and pumps in tumor development 
and progression. Frontiers in Cellular Neuroscience. 2015;9(86):1-11. 
26. Pedersen SF, Stock C. Ion channels and transporters in cancer: pathophysiology, regulation, and 
clinical potential. Cancer Research. 2013;73(6):1658-1661. 
27. Prevarskaya N, Skryma R, Shuba Y. Ion channels and the hallmarks of cancer. Trends in Molecular 
Medicine. 2010;16(3):107-121. 
28. Repke KRH. The role of the Na+/K+ pump in normal and cancer cell proliferation: Springer; 1988. 
29. Reshkin SJ, Cardone RA, Harguindey S. Na+-H+ exchanger, pH regulation and cancer. Recent 
Patents on Anti-Cancer Drug Discovery. 2013;8(1):85-99. 
30. Schwab A, Fabian A, Hanley PJ, Stock C. Role of ion channels and transporters in cell migration. 
Physiological Reviews. 2012;92(4):1865-1913. 
31. Yang M, Brackenbury WJ. Membrane potential and cancer progression. Frontiers in Physiology. 
2013;4(185):1-10. 
32. Yu SP, Canzoniero LMT, Choi DW. Ion homeostasis and apoptosis. Current Opinion in Cell Biology. 
2001;13(4):405-411. 
33. Yu SP, Choi DW. Ions, cell volume, and apoptosis. PNAS. 2000;97(17):9360-9362. 
34. Kunzelmann K. Ion channels and cancer. Journal of Membrane Biology. 2005;205(3):159-173. 
35. Li L, Li P, Fang J, et al. Simultaneous Quantitation of Na+ and K+ in Single Normal and Cancer Cells 
Using a New Near-infrared Fluorescent Probe. Analytical Chemistry. 2015;87:6057-6063. 
36. Li M, Xiong ZG. Ion channels as targets for cancer therapy. International Journal of Physiology, 
Pathophysiology and Pharmacology. 2011;3(2):156. 
37. Babsky AM, Hekmatyar SK, Zhang H, Solomon JL, Bansal N. Application of 23 Na MRI to monitor 
chemotherapeutic response in RIF-1 tumors. Neoplasia. 2005;7(7):658-666. 
38. Jacobs MA, Ouwerkerk R, Wolff AC, et al. Monitoring of neoadjuvant chemotherapy using 
multiparametric, 23Na sodium MR, and multimodality (PET/CT/MRI) imaging in locally advanced 
breast cancer. Breast Cancer Research and Treatment. 2011;128(1):119-126. 
39. Kline RP, Wu EX, Petrylak DP, et al. Rapid in vivo monitoring of chemotherapeutic response using 
weighted sodium magnetic resonance imaging. Clinical Cancer Research. 2000;6(6):2146-2156. 
40. Schepkin VD, Chenevert TL, Kuszpit K, et al. Sodium and proton diffusion MRI as biomarkers for early 
therapeutic response in subcutaneous tumors. Magnetic Resonance Imaging. 2006;24(3):273-278. 

Sodium MRI to assess breast cancer NACT 
 
Page 33 
Version: 11/2/2020  
 
 
 
CONFIDENTIAL 
This material is the property of the NYU School of Medicine and Langone Medical Center.  Do not disclose or use except as 
authorized in writing by the study sponsor 
 
41. Schepkin VD, Lee KC, Kuszpit K, et al. Proton and sodium MRI assessment of emerging tumor 
chemotherapeutic resistance. NMR in Biomedicine. 2006;19(8):1035-1042. 
42. Sykov\'a E, Mazel T, Vargov\'a L, Vo\vr iveI, Prokopov\'a KaS. Extracellular space diffusion and 
pathological states. Progress in Brain Research. 2000;125:155-178. 
43. Winter PM, Poptani H, Bansal N. Effects of chemotherapy by 1, 3-bis (2-chloroethyl)-1-nitrosourea on 
single-quantum-and triple-quantum-filtered 23Na and 31P nuclear magnetic resonance of the 
subcutaneously implanted 9L glioma. Cancer Research. 2001;61(5):2002-2007. 
44. Ouwerkerk R, Jacobs MA, Macura KJ, et al. Elevated tissue sodium concentration in malignant breast 
lesions detected with non-invasive 23Na MRI. Breast Cancer Research and Treatment. 
2007;106(2):151-160. 
45. Pipe JG, Zwart NR, Aboussouan EA, Robison RK, Devaraj A, Johnson KO. A new design and rationale 
for 3D orthogonally oversampled k-space trajectories. Magnetic Resonance in Medicine. 
2011;66(5):1303-1311. 
46. Stobbe R, Beaulieu C. In vivo sodium magnetic resonance imaging of the human brain using soft 
inversion recovery fluid attenuation. Magnetic Resonance in Medicine. 2005;54(5):1305-1310. 
47. Nagel AM, Bock M, Hartmann C, et al. The potential of relaxation-weighted sodium magnetic 
resonance imaging as demonstrated on brain tumors. Investigative Radiology. 2011;46(9):539-547. 
48. Madelin G, Babb JS, Xia D, Regatte RR. Repeatability of Quantitative Sodium Magnetic Resonance 
Imaging for Estimating Pseudo-Intracellular Sodium Concentration and Pseudo-Extracellular Volume 
Fraction in Brain at 3 T. PloS ONE. 2015;10(3):e0118692. 
49. Madelin G, Kline R, Walvick R, Regatte RR. A method for estimating intracellular sodium concentration 
and extracellular volume fraction in brain in vivo using sodium magnetic resonance imaging. Scientific 
Reports. 2014;4:4763. 
50. Garwood M, DelaBarre L. The return of the frequency sweep: designing adiabatic pulses for 
contemporary NMR. Journal of Magnetic Resonance. 2001;153(2):155-177. 
51. Schepkin VD, Bejarano FC, Morgan T, Gower-Winter S, Ozambela M, Levenson CW. In vivo magnetic 
resonance imaging of sodium and diffusion in rat glioma at 21.1 T. Magnetic Resonance in Medicine. 
2012;67(4):1159-1166. 
52. Jacobs MA, Ouwerkerk R, Wolff AC, et al. Multiparametric and multinuclear magnetic resonance 
imaging of human breast cancer: current applications. Technology in Cancer Research \& Treatment. 
2004;3(6):543-550. 
53. Jacobs MA, Stearns V, Wolff AC, et al. Multiparametric magnetic resonance imaging, spectroscopy 
and multinuclear (23 Na) imaging monitoring of preoperative chemotherapy for locally advanced breast 
cancer. Academic Radiology. 2010;17(12):1477-1485. 
54. Rieke V, Butts Pauly K. MR thermometry. Journal of Magnetic Resonance Imaging. 2008;27(2):376-
390. 
55. Commission IE. Medical electrical equipment. Part 2-33: particular requirements for the basic safety 
and essential performance of magnetic resonance equipment for medical diagnosis. International 
Standard IEC. 2010:60601-60602. 
56. Christ A, Kainz W, Hahn EG, et al. The Virtual Family--development of surface-based anatomical 
models of two adults and two children for dosimetric simulations. Physics in Medicine and Biology. 
2009;55(2):N23. 
57. Lustig M, Donoho DL, Santos JM, Pauly JM. Compressed sensing MRI. IEEE Signal Processing 
Magazine. 2008;25(2):72-82. 
58. Madelin G, Babb JS, Xia D, Chang G, Jerschow A, Regatte RR. Reproducibility and repeatability of 
quantitative sodium magnetic resonance imaging in vivo in articular cartilage at 3 T and 7 T. Magnetic 
Resonance in Medicine. 2012;68(3):841-849. 

Sodium MRI to assess breast cancer NACT 
 
Page 34 
Version: 11/2/2020  
 
 
 
CONFIDENTIAL 
This material is the property of the NYU School of Medicine and Langone Medical Center.  Do not disclose or use except as 
authorized in writing by the study sponsor 
 
59. Boyle P. Triple-negative breast cancer: epidemiological considerations and recommendations. Annals 
of Oncology. 2012;23(suppl 6):vi7-vi12. 
60. Joensuu H, Gligorov J. Adjuvant treatments for triple-negative breast cancers. Annals of Oncology. 
2012;23(suppl 6):vi40-vi45. 
61. Jerschow A. From nuclear structure to the quadrupolar NMR interaction and high-resolution 
spectroscopy. Progress in NMR Spectroscopy. 2005;46(1):63-78. 
62. Lee JS, Regatte RR, Jerschow A. Optimal excitation of Na nuclear spins in the presence of residual 
quadrupolar coupling and quadrupolar relaxation. Journal of Chemical Physics. 2009;131:174501. 
63. Blaustein MP, Kao JPY, Matteson DR. Cellular Physiology and Neurophysiology: Mosby Physiology 
Monograph Series: Elsevier Health Sciences; 2011. 
64. Fall CP, Marland ES, Wagner JM, Tyson JJ. Computational Cell Biology. Interdisciplinary Applied 
Mathematics. 2002. 
65. Hoppensteadt FC, Peskin C. Modeling and simulation in medicine and the life sciences. Vol 10: 
Springer Science \& Business Media; 2012. 
66. Liu W. Introduction to Modeling Biological Cellular Control Systems. Vol 6: Springer Science \& 
Business Media; 2012. 
67. Cooper GM, Hausman RE. The cell: a molecular approach: ASM Press; 2009. 
68. Hanahan D, Weinberg RA. Hallmarks of cancer: the next generation. Cell. 2011;144(5):646-674. 
69. Weinberg R. The biology of cancer: Garland Science; 2013. 
70. Lang F, Lepple-Wienhues A, Paulmichl M, Szabo I, Siemen D, Gulbins E. Ion channels, cell volume, 
and apoptotic cell death. Cellular Physiology and Biochemistry. 1998;8(6):285-292. 
71. Lehen'kyi V, Shapovalov G, Skryma R, Prevarskaya N. Ion channnels and transporters in cancer. 5. 
Ion channels in control of cancer and cell apoptosis. American Journal of Physiology-Cell Physiology. 
2011;301(6):C1281-C1289. 
72. Mijatovic T, Jungwirth U, Heffeter P, et al. The Na+/K+-ATPase is the Achilles Heel of multi-drug-
resistant cancer cells. Cancer Letters. 2009;282(1):30-34. 
73. Orlov SN, Platonova AA, Hamet P, Grygorczyk R. Cell volume and monovalent ion transporters: their 
role in cell death machinery triggering and progression. American Journal of Physiology-Cell 
Physiology. 2013;305(4):C361-C372. 
74. Pla AF, Avanzato D, Munaron L, Ambudkar IS. Ion channels and transporters in cancer. 6. 
Vascularizing the tumor: TRP channels as molecular targets. American Journal of Physiology-Cell 
Physiology. 2012;302(1):C9-C15. 
75. Glover GH, Schneider E. Three-point dixon technique for true water/fat decomposition with B0 
inhomogeneity correction. Magnetic Resonance in Medicine. 1991;18(2):371-383. 
76. Reeder SB, Wen Z, Yu H, et al. Multicoil Dixon chemical species separation with an iterative least-
squares estimation method. Magnetic Resonance in Medicine. 2004;51(1):35-45. 
77. Brown R, Storey P, Geppert C, et al. Breast MRI at 7 Tesla with a bilateral coil and T1-weighted 
acquisition with robust fat suppression: image evaluation and comparison with 3 Tesla. European 
Radiology. 2013;23(11):2969-2978. 
78. Brown R, Lakshmanan K, Madelin G, et al. A flexible nested sodium and proton coil array with 
wideband matching for knee cartilage MRI at 3T. Magnetic Resonance in Medicine. 2015. 
79. Brown R, Madelin G, Lattanzi R, et al. Design of a nested eight-channel sodium and four-channel 
proton coil for 7T knee imaging. Magnetic Resonance in Medicine. 2013;70(1):259-268. 
80. Brown R, Storey P, Geppert C, et al. Breast MRI at 7 Tesla with a bilateral coil and robust fat 
suppression. Journal of Magnetic Resonance Imaging. 2014;39(3):540-549. 
81. Duan Q, Duyn JH, Gudino N, et al. Characterization of a dielectric phantom for high-field magnetic 
resonance imaging applications. Medical Physics. 2014;41(10):102303. 

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82. Yarnykh VL. Actual flip-angle imaging in the pulsed steady state: A method for rapid three-dimensional 
mapping of the transmitted radiofrequency field. Magnetic Resonance in Medicine. 2007;57(1):192-
200. 
83. Constantinides CD, Gillen JS, Boada FE, Pomper MG, Bottomley PA. Human Skeletal Muscle: Sodium 
MR Imaging and Quantification. Potential Applications in Exercise and Disease. Radiology. 
2000;216(2):559-568. 
84. Ouwerkerk R. Sodium MRI. Magnetic Resonance Neuroimaging: Springer; 2011:175-201. 
85. Schepkin VD. Sodium MRI of glioma in animal models at ultrahigh magnetic fields. NMR in 
Biomedicine. 2015. 
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Brochure for recruitment of healthy subjects 
 
 

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CONFIDENTIAL 
This material is the property of the NYU School of Medicine and Langone Medical Center.  Do not disclose or use except as authorized in writing by the study sponsor 
 

 
CONFIDENTIAL 
This material is the property of the NYU School of Medicine and Langone Medical Center.  Do not disclose or use except as authorized in writing by the study sponsor