Rationale and objectives
To determine the diagnostic value of apparent diffusion coefficient (ADC) maps in the assessment of response to chemotherapy in patients with multiple myeloma (MM).
Materials and methods
Fourteen patients (seven women) with MM underwent whole-body magnetic resonance imaging (WB-MRI) study on a 1.5T scanner, before and after chemotherapy. DWI with background body signal suppression (DWIBS) sequences ( b values: 0, 500, and 1000 mm 2 /sec) were qualitatively analyzed, along with T1 turbo spine echo and short tau inversion recovery T2-weighted images, to evaluate bone lesions. On ADC maps, regions of interest were manually drawn along contours of lesions. The ADC values percentage variation (ΔADC) before (MR1) and after (MR2) chemotherapy were calculated and compared between responders (11 of 14) and nonresponders (3 of 14). The percentage of plasma cells by the means of the bone marrow aspirate was evaluated as parameter for response to chemotherapy.
Results
Twenty-four lesions, hyperintense on DWIBS as compared to normal bone marrow, were evaluated. In responder group, the mean ADC values were 0.63 ± 0.24 × 10 -3 mm 2 /s on MR1 and 1.04 ± 0.46 × 10 -3 mm 2 /s on MR2; partial or complete signal intensity decrease during follow-up on DWIBS was found along with a reduction of plasma cells infiltration in the bone marrow. The mean ADC values for nonresponders were 0.61 ± 0.05 × 10 -3 mm 2 /s on MR1 and 0.69 ± 0.09 × 10 -3 mm 2 /s on MR2. The mean variation of ΔADC in responders (Δ = 66%) was significantly different ( P < .05) than in nonresponders (Δ = 15%).
Conclusions
WB-MRI with DWIBS sequences, by evaluating posttreatment changes of ADC values, might represent a complementary diagnostic tool in the assessment of response to chemotherapy in MM patients.
In the past decades, magnetic resonance imaging (MRI) has shown a high diagnostic and prognostic value in monoclonal plasma cell disorders . It has also been included as additional imaging tool for diagnosis and staging protocols of multiple myeloma (MM) , but, to date, there is insufficient evidence to recommend routine MRI after treatment because most of the findings are not specific .
In MM follow-up, the role of imaging is still limited, relying on skeletal survey although bone marrow aspirate and laboratory parameters (serum and urinary M-protein measurements) are the mainstay of the evaluation of response to chemotherapy. According to the most recent guidelines, plain films should be repeated after clinical or laboratory evidence of disease progression , but on conventional radiographs, lytic bone lesions rarely demonstrate signs of healing. Moreover, the evidence of new vertebral compressions may not indicate disease progression, occurring even after an effective therapy . Therefore, an accurate imaging technique able to detect treatment-related changes could increase the ability to monitor MM patients, even those with reduced or absent M-protein secretion.
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Materials and methods
Study Population
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MRI Technique
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Table 1
Whole-Body Magnetic Resonance Imaging Protocol (1.5T), Acquired with Patient Positioned Supine and Using Built-In Body Coil Combined with Stepping Table Technique
Sequence T2 STIR T1 TSE DWIBS Slice thickness, mm 4 4 4 Plane of acquisition Coronal (C) and sagittal (S) Coronal (C) and sagittal (S) Axial Range of scan_Coronal_ : skull vertex to feet. Sagittal : axial skeleton_Coronal_ : skull vertex to feet. Sagittal : axial skeleton Skull vertex to feet_b_ values / / 0, 500, 1000 s/mm 2 TR 1400 1000 1400 TE 64 17.50 66 TI 165 — 180 FA 90° 90° 90° NSA 2 1 2 Voxel size C: 1.27 × 1.82 mm 3 S: 1.17 × 1.53 mm 3 C: 1.58 × 1.97 mm 3 S: 1.38 × 1.75 mm 3 5 × 4.97 mm 3
DWIBS, diffusion-weighted imaging with background body signal suppression; FA, flip angle; NSA, number of signals acquired; STIR, short tau inversion recovery; TE, echo time; TI, inversion time; TR, repetition time; TSE, turbo spine echo.
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Patients and Imaging Analysis
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Hystopathologic Analysis
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Statistical Analysis
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Results
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Table 2
Apparent Diffusion Coefficient (ADC) Values and Percentage Variation of ADC (ΔADC%) of Evaluated Lesions (Both as Focal or Diffuse Involvement), in Responder Versus Nonresponder Patients, Before (ADC1) and After (ADC2) Chemotherapy
Lesions Responders Mean ± SD Nonresponders Mean ± SD Rank-Sum Test ( P Value <.05) ADC1/pretherapy (× 10 −3 mm 2 /s) 0.63 ± 0.24 0.61 ± 0.05 .71 ADC2/posttherapy (× 10 −3 mm 2 /s) 1.04 ± 0.46 0.69 ± 0.09 .18 ΔADC% 66% 15% .05
SD, standard deviation.
![Figure 2, Whole-body magnetic resonance imaging (WB-MRI) study of a 67 years old female with histologically proven MM. (a–d) Coronal T1 turbo spine echo (TSE) (a) and short tau inversion recovery (STIR) T2 (b) weighted and axial diffusion-weighted imaging with background body signal suppression (DWIBS) ( c , b value = 1000 s/mm 2 ) images of the femurs. At time of diagnosis, the WB examination demonstrates a focal lesion in the right femoral diaphysis, characterized by hypointensity on T1 [ large arrow on (a) ] and high signal intensity both on STIR and DWIBS [ large and thin arrow on (b) and (c) , respectively]. The corresponding apparent diffusion coefficient (ADC) value on ADC map [ thin arrow on (d) ] was 0.68 × 10 −3 mm 2s. (e–h) Posttreatment coronal T1 TSE (e) and STIR T2 (f) weighted and axial DWBIS ( g , b value = 1000 s/mm 2 ) images. The primary lesion is still detectable on standard anatomical sequences, even if with a partial decrease of signal intensity on the fat sat image [ large arrows on (e) and (f) , respectively]. DWIBS shows a marked decrease of signal intensity alteration. The ADC value calculated on the corresponding ADC map [ thin arrow on (h) ] increased (0.85 × 10 −3 mm 2s), as neoplastic cellular load is reduced by therapy.](https://storage.googleapis.com/dl.dentistrykey.com/clinical/ApparentDiffusionCoefficientMapsIntegratedinWholeBodyMRIExaminationfortheEvaluationofTumorResponsetoChemotherapyinPatientswithMultipleMyeloma/1_1s20S1076633215002494.jpg)
![Figure 3, Pre- and post-chemotherapy evaluation in a 49-year-old woman with MM. (a–d) Sagittal T1 turbo spine echo (TSE) (a) and short tau inversion recovery (STIR) T2 (b) weighted and axial diffusion-weighted imaging with background body signal suppression (DWIBS) ( c , b value = 1000 s/mm 2 ) images show a diffuse pattern of infiltration of the dorsal axial skeleton, hypointense on T1 and slightly hyperintense on STIR sequences, and with marked high signal intensity on DWIBS image [ thin arrow on (c) ]. The apparent diffusion coefficient (ADC) value, calculated on the corresponding map at the level of D11 [ thin arrow on (d) ], was 0.57 × 10 −3 mm 2s. On the highest b value DWIBS image, also the spleen is still characterized by a high signal intensity [ curved arrow on (d) ]. (e–h) Sagittal T1 TSE (e) and STIR T2 (f) weighted and axial DWBIS ( g , b value = 1000 s/mm 2 ) images after chemotherapy demonstrate no significant change of signal intensity's alterations of bone marrow. Also, the corresponding ADC value measured on the ADC map (h) does not show any variation (0.61 × 10 −3 mm 2s), as per no response to the treatment.](https://storage.googleapis.com/dl.dentistrykey.com/clinical/ApparentDiffusionCoefficientMapsIntegratedinWholeBodyMRIExaminationfortheEvaluationofTumorResponsetoChemotherapyinPatientswithMultipleMyeloma/2_1s20S1076633215002494.jpg)
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Discussion
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