Rationale and Objectives
The purpose of this study was to investigate the use of multiparametric, whole-body, diffusion-weighted imaging (WB-DWI) and apparent diffusion coefficient (ADC) maps with T 2 -weighted magnetic resonance imaging (MRI) at 3T for the detection and monitoring of metastatic disease in patients.
Materials and Methods
Fifty-four participants (32 healthy subjects and 22 patients) were scanned with WB-DWI methods using a 3T MRI scanner. Axial, sagittal, or coronal fat-suppressed T 2 -weighted (T 2 WI), T 1 -weighted (T 1 WI), and DWI images were acquired. Total MRI acquisition and set-up time was approximately 45 minutes. Metastatic disease on MRI was confirmed based on T 2 WI characteristics. The number of lesions was established on computed tomography (CT) or positron emission tomography (PET-CT). Whole-body ADC maps and T 2 WI were constructed, and region-of-interests were drawn in normal and abnormal-appearing tissue for quantitative analysis. Statistical analysis was performed using a paired t tests and P < .05 was considered statistically significant.
Results
There were 91 metastatic lesions detected from the CT or PET-CT with a missed recurrent lesion in the prostate. Multiparametric WB-MRI had excellent sensitivity (96%) for detection of metastatic lesions compared to CT. ADC map values and the ADC ratio in metastatic bone lesions were significantly increased ( P < .05) compared to normal bone. In soft tissue, ADC map values and ratios in metastatic lesions were decreased compared to normal soft tissue.
Conclusion
We have demonstrated that multiparametric WB-MRI is feasible for oncologic staging to identify bony and visceral metastasis in breast, prostate, pancreatic, and colorectal cancers. WB-MRI can be tailored to fit the patient, such that an “individualized patient sequence” can be developed for a comprehensive evaluation for staging and response during treatment.
Introduction
Metastatic disease or local recurrences of cancer have an unfavorable prognosis. Treatment approaches for distant metastases are mostly palliative rather than curative. Skeletal or organ metastasis is usually not detected until clinical symptoms appear, or during initial staging of cancer by imaging . If metastatic disease is found, most patients will receive various systemic therapy regimens, with the goal of ameliorating symptoms and improving survival. Although positron emission tomography-computed tomography (PET-CT) covers most of the body, measures the metabolic activity of a tumor, and is used for staging and treatment response, PET may be limited by other factors, such as high uptake in normal organs, variability in tracer uptake in lesions, increased radiation dose, or indeterminate findings due to the size of the lesion (less than 1 cm) . Therefore, there is a need for an imaging method that achieves global tumor assessment and accurate lesion detection for increased confidence in the detection, characterization, and monitoring of treatment response in metastatic disease without an increase in radiation dose.
To address these challenges, developments in whole-body MRI (WB-MRI) technology have resulted in whole-body coverage using anatomic T 1 - or T 2 -weighted imaging at 1.5T . Some of the improvements are specialized surface coils, continuous table movement (CTM), improved respiratory gating, planning software, and pulse sequences. These system improvements in MRI technology have led to impressive results in both oncological and nononcological applications of WB-MRI compared to more conventional imaging methods . As it turns out, most of the applications have been limited to anatomic and qualitative MRI parameters. There is a growing need to accurately quantify functional properties of the tissue, because these metrics represent early biological changes before anatomic MRI parameters. In particular, advanced quantitative MRI parameters such as diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) maps, and dynamic contrast-enhanced-MRI (DCE) can provide metrics of the molecular and vascular characteristics of tumors . There are several reports in the literature about the feasibility of using WB-DWI in different cancers . However, only a few of these WB-DWI methods have been applied to whole-body imaging at 3T . Therefore, we have implemented multiparametric WB-MRI, coupled with DWI and quantitative ADC mapping at 3T, to provide functional and quantitative information about normal and tumor (primary or metastatic) tissue and compare the WB-MRI results to CT or PET-CT results. This development of quantitative DWI WB-MRI provides the opportunity to investigate the detection and characterization of metastatic areas in the body without the need for ionizing radiation.
Materials and Methods
Clinical Subjects
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Metastatic Lesion Classification
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MRI Imaging
WB-MRI Protocol
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Proton MR Imaging
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Quantitative Diffusion-Weighted Imaging and Apparent Diffusion Coefficient Mapping
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2D PACE Respiratory Gating
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Computed Tomography and Positron Emission Tomography
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Radiological Image Preprocessing and Analysis
Normal and Lesion Tissue Analysis
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NormalizedADCvalue=ADCvalueoflesionADCvalueofnormaltissue Normalized
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Statistical Analysis
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Results
Clinical Characteristics
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Radiological Metrics
Conventional Metastatic Imaging
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WB-MRI
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Diffusion-Weighted Imaging-ADC Mapping
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TABLE 1
Regional ADC Map Values From Healthy Subjects
Normals (n = 32) ADC 10 −3 mm 2 /s ADC 10 −3 mm 2 /s Tissue Normal (Rt) SD (±) Normal (Lt) SD (±) ADC ratio Cerebral cortex 0.83 0.14 0.83 0.06 1.00 Cerebellum 0.68 0.06 0.70 0.06 0.97 Lateral ventricle 3.01 0.41 3.14 0.19 0.96 Breast glandular 1.94 0.33 1.91 0.27 1.02 Gall bladder 2.85 0.28 Liver 1.16 0.22 1.12 0.26 1.04 Spleen 0.79 0.07 Pancreas(tail) 1.40 0.19 Kidney 1.93 0.14 1.94 0.11 0.99 Prostate (PZ) 1.68 0.17 1.69 0.23 0.99 Iliac crest 0.43 0.17 0.45 0.18 0.96 Femur 0.21 0.16 0.23 0.15 0.91 Pelvis 0.43 0.13 0.48 0.18 0.90 Psoas muscle 1.35 0.23 1.34 0.20 1.01 Urinary bladder 3.20 0.21 Uterus 1.27 0.20 Vertebral disk 1.59 0.19 Vertebral bone (cervical) 0.43 0.18 Vertebral bone (thoracic) 0.29 0.20 Vertebral bone (lumbar) 0.33 0.20
ADC, apparent diffusion coefficient; Lt, Left; PZ, peripheral zone; Rt, right; SD, standard deviation.
ADC Ratio = contralateral tissue divided by ipsilateral tissue ADC map values.
TABLE 2
Regional Normal ADC Map Values From Patients
Patients (n = 22) ADC 10 −3 mm 2 /s ADC 10 −3 mm 2 /s Tissue Normal (Rt) SD (±) Normal (Lt) SD (±) ADC ratio Cerebral cortex 0.82 0.08 0.84 0.14 0.98 Cerebellum 0.67 0.12 0.66 0.12 1.02 Lateral ventricle 3.30 0.24 3.23 0.22 1.02 Breast glandular 1.85 0.58 1.61 0.08 1.15 Gall bladder 2.75 0.20 Liver 0.99 0.24 1.01 0.22 0.98 Spleen 0.78 0.11 Pancreas(tail) 1.54 0.24 Kidney 1.85 0.17 1.85 0.13 1.00 Prostate (PZ) 1.45 0.15 1.42 0.10 1.02 Iliac crest 0.31 0.19 0.32 0.20 0.97 Femur 0.17 0.15 0.23 0.17 0.74 Pelvis 0.32 0.14 0.24 0.26 1.33 Psoas muscle 1.19 0.27 1.32 0.19 0.90 Urinary bladder 2.90 0.24 Uterus 1.42 0.13 Vertebral disk 1.53 0.16 Vertebral bone (cervical) 0.60 0.17 Vertebral bone (thoracic) 0.27 0.18 Vertebral bone (lumbar) 0.33 0.21
ADC, apparent diffusion coefficient; Lt, Left; PZ, peripheral zone; Rt, right; SD, standard deviation.
Ratio = contralateral tissue divided by ipsilateral tissue ADC map values.
TABLE 3
ADC Map Values From Metastatic Lesions in Patients
Metastatic Lesions ADC 10 −3 mm 2 /s ADC 10 − mm 2 /s Tissue Lesion SD (±) Normal SD (±) Ratio Vertebral bone (thoracic) 0.82 0.13 0.27 0.18 3.04 Vertebral bone (lumbar) 0.99 0.19 0.33 0.21 3.00 Pelvis 0.90 0.10 0.17 0.15 5.29 Femur 1.60 0.23 0.32 0.14 5.00 Iliac crest 0.84 0.45 0.32 0.07 2.63 Liver 0.88 0.27 1.12 0.26 0.79 Prostate (PZ) 1.00 0.07 1.45 0.15 0.69
ADC, apparent diffusion coefficient; Lt, left; PZ, peripheral zone; Rt, right; SD, standard deviation.
Ratio = Lesion tissue divided by normal tissue ADC.
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ADC Ratios and Standardized Uptake Values in Normal and Lesion Tissue
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Discussion
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Conclusions
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