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Diffusion Weighted Imaging of Pediatric and Adolescent Malignancies with Regard to Detection and Delineation Initial Experience2

Posted Jun 30, 2009 Updated Apr 7, 2023
By Sedat Alibek MD , Alexer Cavallaro MD , Alexer Aplas MD , Michael Uder MD , Gundula Staatz MD
7 min read

Rationale and Objective

To assess the value of diffusion weighted imaging (DWI) magnetic resonance imaging (MRI) in pediatric and adolescent tumor patients with focus on detection and delineation of malignant tumors of the central nervous system, chest, abdomen, and musculoskeletal system.

Materials and Methods

Twenty-nine pediatric and adolescent patients (17 males, 12 females, age, 2 months–20 years, mean age: 8.9 years) with clinically suspected malignant tumors were examined with use of a 1.5-T MR scanner with open bore design without sedation or general anesthesia. DWI images were acquired with a single-shot echo planar imaging (EPI) sequence in free breathing with b-values of 0, 500, and 1000 mm/s 2 . Images were assessed by two readers in consensus. Artifacts in DWI were graded as not relevant, acceptable, or nondiagnostic. DWI/apparent diffusion coefficient maps were correlated with T1-weighted post-contrast images, and the detectability and correct delineation of the tumors were graded using a three grade scale.

Results

Free-breathing DWI was successfully performed in all patients. In 27 patients, no relevant artifacts were observed; acceptable artifacts were seen in two patients. In all patients, malignancies were detected both on DWI and T1-weighted gadolinium images. Detection and delineation of tumors were possible in all cases with both sequences; T1-weighted gadolinium imaging was superior to DWI in only three patients. Additionally, small diffusion restricted lymph nodes were detected in three patients.

Conclusion

DWI is reliable for the accurate detection and delineation of malignant pediatric and adolescent tumors.

Diffusion weighted imaging (DWI) is an established imaging technique in magnetic resonance imaging (MRI) and widely used in imaging of the brain and central nervous system (CNS) pathologies, e.g., for early detection of ischemic and malignant changes. DWI applications outside the brain and CNS are becoming increasingly popular because rapid technologic developments of hardware and software, e.g., dedicated multichannel coils, faster and more powerful gradients, and parallel imaging techniques enable good image quality with high contrast-to-noise ratios (CNR) enabling acquisition of additional, functional MRI data within a reasonable scan time even during free breathing. A rapid increase in published data in the last 5 years has been recognized, reporting experiences with DWI in the chest , breast , abdomen , urogenital , and musculoskeletal system . Although these data are encouraging, published data about clinical studies using DWI in pediatric patients outside the brain is rare . More data about the usefulness of DWI regarding detection and delineation of pathology is needed to implement DWI into routine MR protocols.

The purpose of this study was to assess the value of DWI MR in pediatric and adolescent tumor imaging regarding detection and delineation of malignant tumors of the CNS, chest, abdomen, and musculoskeletal system.

Materials and methods

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Table 1

Tumor Entities Found on Histopathologic Specimen Work-up

Histopathologic Diagnosis n Ewing Sarcoma 4 Neuroblastoma 4 Ovarian teratoma 2 B-NHL 2 Medulloblastoma 2 Nephroblastoma 2 Rhabdomyosarcoma 2 ATRT 1 Burkitt-like lymphoma 1 Ependymoma 1 GBM 1 Hodgkin lymphoma 1 Optico-thalamic glioma 1 Pilocytic astrocytoma 1 PNET 1 Pontine astrocytoma 1 Renal sarcoma 1 T-cell lymphoma 1 Total 29

ATRT, atypical teratoid/rhabdoid tumor; GBM, glioblastoma multiforme; PNET, primitive neuroectodermal tumor.

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Results

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Figure 1, Osteosarcoma of the rib infiltrating the right lung, hyperintense on both T1 weighted scan ( left image, short white arrows ) and DWI ( right image, short white arrows ) with image distortion on diffusion weighted imaging scan at anterior tumor margin due to air-tissue border ( right image, white long arrows ).

Table 2

Distribution and Quality of Artifacts on Diffusion Weighted Imaging

Artifact (rating) n No artifact (0) 27 Acceptable artifact (1) 2 Nondiagnostic image (2) 0

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Qualitative Assessment

Tumor Detection

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Figure 2, Nephroblastoma of the left kidney. Excellent depiction with both T1-weighted gadolinium (Gd)+ ( left image ) and diffusion weighted imaging (DWI) sequence ( mid image ). Solid components seen as contrast uptaking areas on T1-weighted Gd+ imaging, hyperintense areas on DWI ( mid image ), and hypointense areas on apparent diffusion coefficient (ADC) map ( right image ). Necrotic parts seen as hypointense signal both on T1-weighted Gd+/DWI image, hyperintense signal on ADC map ( white arrows ).

Figure 3, Neuroblastoma of the left adrenal gland crossing midline ( white arrows ). Equal delineation of tumor with T1-weighted gadolinium+ sequence ( left image ), diffusion weighted imaging ( mid image ), and corresponding apparent diffusion coefficient map ( right image ).

Figure 4, Osteosarcoma of the rib ( white arrows ), hyperintense on diffusion weighted imaging ( left image ), hypointense on apparent diffusion coefficient map ( mid image ), correlating with pathologic gadolinium uptake on T1-weighted images ( right image ).

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Tumor Delineation

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Table 3

Comparison of Tumor Delineation, T1-weighted Post-Gadolinium versus Diffusion Weighted Imaging (DWI)

Tumor Delineation n T1-weighted superior 3 T1-weighted and DWI equal 26 DWI superior 0

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Qualitative Assessment

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Additional Findings

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Figure 5, Small lymph nodes with diffusion restriction on diffusion weighted imaging ( white arrows, mid image ), corresponding low signal intensity on apparent diffusion coefficient map ( right image, dotted circle ), not detectable on T1-weighted gadolinium+ sequence ( left image, white circle ).

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Discussion

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Limitations

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Conclusion

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Academic Radiology, Volume 16, Issue 7
Journals General Radiology
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