Daniel Hausmann

Multi-parametric MRI of rectal cancer – Do quantitative functional MR measurements correlate with radiologic and pathologic tumor stages?

PURPOSE The purpose of this study is two-fold. First, to evaluate, whether functional rectal MRI techniques can be analyzed in a reproducible manner by different readers and second, to assess whether different clinical and pathologic T and N stages can be differentiated by functional MRI measurements. MATERIALS AND METHODS 54 patients (38 men, 16 female; mean age 63.2 ± 12.2 years) with pathologically proven rectal cancer were included in this retrospective IRB-approved study. All patients were referred for a multi-parametric MRI protocol on a 3 Tesla MR-system, consisting of a high-resolution, axial T2 TSE sequence, DWI and perfusion imaging (plasma flow -s PFTumor) prior to any treatment. Two experienced radiologists evaluated the MRI measurements, blinded to clinical data and outcome. Inter-reader correlation and the association of functional MRI parameters with c- and p-staging were analyzed. RESULTS The inter-reader correlation for lymph node (ρ 0.76-0.94; p<0.0002) and primary tumor (ρ 0.78-0.92; p<0.0001) apparent diffusion coefficient and plasma flow (PF) values was good to very good. PFTumor values decreased with cT stage with significant differences identified between cT2 and cT3 tumors (229 versus 107.6 ml/100ml/min; p=0.05). ADCTumor values did not differ significantly. No substantial discrepancies in lymph node ADCLn values or short axis diameter were found among cN1-3 stages, whereas PFLn values were distinct between cN1 versus cN2 stages (p=0.03). In the patients without neoadjuvant RCT no statistically significant differences in the assessed functional parameters on the basis of pathologic stage were found. CONCLUSION This study illustrates that ADC as well as MR perfusion values can be analyzed with good interobserver agreement in patients with rectal cancer. Moreover, MR perfusion parameters may allow accurate differentiation of tumor stages. Both findings suggest that functional MRI parameters may help to discriminate T and N stages for clinical decision making.

Feasibility study of computed vs measured high b-value (1400 s/mm²) diffusion-weighted MR images of the prostate

AIM To evaluate the impact of computed b = 1400 s/mm(2) (C-b1400) vs measured b = 1400 s/mm(2) (M-b1400) diffusion-weighted images (DWI) on lesion detection rate, image quality and quality of lesion demarcation using a modern 3T-MR system based on a small-field-of-view sequence (sFOV). METHODS Thirty patients (PSA: 9.5 ± 8.7 ng/mL; 68 ± 12 years) referred for magnetic resonance imaging (MRI) of the prostate were enrolled in this study. All measurements were performed on a 3T MR system. For DWI, a single-shot EPI diffusion sequence (b = 0, 100, 400, 800 s/mm²) was utilized. C-b1400 was calculated voxelwise from the ADC and diffusion images. Additionally, M-b1400 was acquired for evaluation and comparison. Lesion detection rate and maximum lesion diameters were obtained and compared. Image quality and quality of lesion demarcation were rated according to a 5-point Likert-type scale. Ratios of lesion-to-bladder as well as prostate-to-bladder signal intensity (SI) were calculated to estimate the signal-to-noise-ratio (SNR). RESULTS Twenty-four lesions were detected on M-b1400 images and compared to C-b1400 images. C-b1400 detected three additional cancer suspicious lesions. Overall image quality was rated significantly better and SI ratios were significantly higher on C-b1400 (2.3 ± 0.8 vs 3.1 ± 1.0, P < 0.001; 5.6 ± 1.8 vs 2.8 ± 0.9, P < 0.001). Comparison of lesion size showed no significant differences between C- and M-b1400 (P = 0.22). CONCLUSION Combination of a high b-value extrapolation and sFOV may contribute to increase diagnostic accuracy of DWI without an increase of acquisition time, which may be useful to guide targeted prostate biopsies and to improve quality of multiparametric MRI (mMRI) especially under economical aspects in a private practice setting.

Diagnostic accuracy of 18F choline PET/CT using time-of-flight reconstruction algorithm in prostate cancer patients with biochemical recurrence.

Purpose Image quality (IQ) of PET in voluminous body regions can be limited, which impairs the assessment of small metastatic lesions. Time-of-flight (TOF) reconstruction algorithm may deliver an increase of spatial resolution. The purpose of this study was to evaluate the impact of TOF on IQ, lesion detection rate, lesion volume (V) and SUVmax in 18F choline PET/CT of prostate cancer patients with biochemical recurrence compared to standard PET/CT reconstruction (standard). Patients and Materials During a period of 9 months, 32 patients with prostate cancer (mean [SD] age, 71 [7.8] years) and biochemical recurrence were included in this prospective institutional review board–approved study. Each patient underwent a state-of-the-art 3-dimensional 18F choline PET/CT. A total of 76 lesions were assessed by 2 board-certified nuclear medicine physicians and a third-year resident. Lesion volume and SUVmax of local recurrence, lymph nodes, and organ metastases were compared between TOF and standard. Image quality and lesion demarcation were rated according to a 5-point Likert-type scale. Interobserver agreement was assessed. Results Eight additional lesions were detected using TOF (SUVmax, 3.64 [0.95]; V, 0.58 cm3 [0.50]). Image quality was reduced (IQ standard, 1.28; TOF, 1.77; P < 0.01) in calculated TOF images, although quality of lesion demarcation was improved (lesion demarcation: standard, 1.66; TOF, 1.26; P < 0.01). SUVmax was significantly increased in TOF images (SUVmax standard, 6.9 [4.1]; TOF, 8.1 [4.1]; P < 0.01), whereas V did not show significant differences (V standard, 5.3 [10.4] cm3; TOF, 5.4 [10.3] cm3; P = 0.41). Interobserver agreement was good for combined ratings (1 + 2 and 3 + 4). Conclusions Application of TOF seems to be of additional value to detect small metastatic lesions in patients with prostate cancer and biochemical recurrence, which may have further clinical implications for secondary treatment.

Interscanner comparison of dynamic contrast-enhanced MRI in prostate cancer: 1.5 versus 3 T MRI.

PurposeThe aim of the study was the comparison of the diagnostic potential of dynamic contrast-enhanced magnetic resonance imaging to differentiate between prostate carcinoma and normal prostate tissue as well as prostatitis at 2 different field strengths: 1.5 versus 3 T. MethodsSixty-six patients with biopsy and/or prostatectomy of the prostate were included in the study. Magnetic resonance imaging was performed at 1.5 T in 20 patients with biopsy-proven prostate cancer (PC) and in 8 patients with prostatitis; at 3 T, we analyzed 27 patients with prostatectomy-proven PC and 11 patients with prostatitis. All examinations were performed using a combined body and endorectal coil protocol and a 2-dimensional TurboFLASH T1-weighted gradient echo sequence to calculate plasma flow (PF) and mean transit time (MTT) values. A total of 28 of 38 areas of normal prostate tissue, 20 of 27 areas of PC, and 8 of 11 prostatitis were analyzed at 1.5 or 3T. For the normalization, we calculated PC/normal and prostatitis/normal tissue ratios of PF and MTT for each patient. ResultsProstate cancer showed higher PF (P < 0.0001) and shorter MTT (P < 0.0001) at 3 T and at 1.5 T (P < 0.0001 for PF and P = 0.0016 for MTT) compared with the normal tissue. In comparison with the normal tissue, prostatitis had a statistically significant higher PF at 1.5 T (P = 0.0156) but not at 3 T (P = 0.17) and no significantly shorter MTT values both at 3 (P = 0.15) and 1.5 T (P = 0.25). Sensitivity and specificity for differentiating PC from prostatitis with PF were 46% and 88% at 1.5 T (cutoff ratio, 2.3) and 89% and 73% at 3 T (cutoff ratio, 1.2), respectively. Sensitivity and specificity for MTT were 77% and 100% at 1.5 T (cutoff ratio, 0.7) and 70% and 100% at 3 T (cutoff ratio, 0.6), respectively. We found no significant relationship between the Gleason score and PF/MTT (P = 0.17/0.11 for 1.5 T and P = 0.23/0.18 for 3 T). ConclusionsThe differentiation between PC and the normal tissue is possible with both field strengths. Prostate cancer can be better distinguished from prostatitis at 3 T compared with 1.5 T. The differentiation between prostatitis and the normal tissue is limited at both field strengths.

Apparent diffusion coefficient and sodium concentration measurements in human prostate tissue via hydrogen-1 and sodium-23 magnetic resonance imaging in a clinical setting at 3T.

IntroductionMultiparametric magnetic resonance imaging (MRI) of the prostate involves morphologic and functional imaging techniques, which could potentially enable to distinguish between common benign prostate diseases, especially prostatitis and prostate cancer. The aim of this study was to determine the apparent diffusion coefficient (ADC) and the tissue sodium concentration (TSC) in 2 different regions of the human prostate, that is, the central gland (CG) and the peripheral gland (PG), by means of standard hydrogen-1 (1H) MRI and quantitative sodium-23 (23Na) MRI at 3 T to increase the spectrum of diagnostic parameters for prostate examinations. MethodsAll measurements were performed on a 3-T clinical whole-body magnetic resonance (MR) scanner. 23Na MR images were acquired with density-adapted 3-dimensional radial sequence and isotropic voxel resolution of 5 × 5 × 5 mm3. After approval by the institutional review board and informed consent were obtained, 8 healthy volunteers were included in this study. Diffusion-weighted imaging and T2-weighted images were also recorded and hence enabled the correlation of measured TSC values with current state-of-the-art 1H MRI techniques. ResultsThe ADC in both subregions was measured to be at normal levels (CG, 1.19 [0.09] ×10−3 mm2/s; PG, 1.54 [0.14] × 10−3 mm2/s) in all 8 volunteers. Good spatial resolution of the 23Na images allowed for an easy identification of the same subregions from the 23Na MR images. In healthy adult volunteers (age, 29 [2] years), the TSC was measured lower in central (55 [15] mmol/L) and higher in peripheral (69 [16] mmol/L) prostate tissue. A correlation between the TSC and the ADC in the 2 subregions was found in the same volunteer group (Pearson correlation coefficient = 0.87). DiscussionFor the first time, TSC was spatially resolved in human prostate tissue by means of 23Na MRI. Interestingly, the herein found TSC values of ∼60 mmol/L were half as high as in a previously reported 23Na MRI study where prostate TSC was measured in 5-month-old mice. Future studies are required to determine the prostate TSC in cancer patients as well as in older volunteers. In conclusion, TSC can be measured in humans with sufficiently high spatial and temporal resolution at 3 T and could hence provide an additional noninvasive marker for the diagnosis of various prostate pathologies.

Comparison of the diagnostic accuracy of whole- body MRI and whole-body CT in stage III/IV malignant melanoma

Background: Malignant melanoma (MM) is dramatically increasing in light‐skinned populations worldwide. Staging and regular follow‐up examinations are essential. The purpose of this study was to compare the diagnostic accuracy of whole‐body MRI with the standard diagnostic algorithm (whole‐body CT and brain MRI) in patients with stage III/IV MM.

Multiparametric magnetic resonance imaging of the prostate: current concepts

Multiparametric MR (mpMR) imaging is rapidly evolving into the mainstay in prostate cancer (PCa) imaging. Generally, the examination consists of T2-weighted sequences, diffusion-weighted imaging (DWI), dynamic contrast-enhanced (DCE) evaluation, and less often proton MR spectroscopy imaging (MRSI). Those functional techniques are related to biological properties of the tumor, so that DWI correlates to cellularity and Gleason scores, DCE correlates to angiogenesis, and MRSI correlates to cell membrane turnover. The combined use of those techniques enhances the diagnostic confidence and allows for better characterization of PCa. The present article reviews and illustrates the technical aspects and clinical applications of each component of mpMR imaging, in a practical approach from the urological standpoint.

Small Field-of-view single-shot EPI-DWI of the prostate: Evaluation of spatially-tailored two-dimensional radiofrequency excitation pulses

PURPOSE Spatially-tailored (RF) excitation pulses in echo-planar imaging (EPI), combined with a decreased FOV in the phase-encoding direction, enable a reduction of k-space acquisition lines, which shortens the echo train length (ETL) and reduces susceptibility artifacts. The purpose of this study was to evaluate the image quality of a zoomed EPI (z-EPI) sequence in diffusion-weighted imaging (DWI) of the prostate in comparison to a conventional single-shot EPI using single-channel (c-EPI1) and multi-channel (c-EPI2) RF excitation, with and without use of an endorectal coil. MATERIALS AND METHODS 33 consecutive patients (mean age: 61 +/- 9 years; mean PSA: 8.67±6.23 ng/ml) with examinations between 10/2012 and 02/2014 were analyzed in this retrospective study. In 26 of 33 patients the initial multiparametric (mp)-MRI was performed on a whole-body 3T scanner (Magnetom Trio, Siemens, Erlangen, Germany) using an endorectal coil (c (conventional)-EPI1). Zoomed-EPI (Z-EPI) examinations of these patients and a complete mp-MRI protocol including c-EPI2 of 7 additional patients were carried out on another 3T wb MR scanner with two-channel dynamic parallel transmit capability (Magnetom Skyra with TimTX TrueShape, Siemens). For z-EPI, the one-dimensional spatially selective RF excitation pulse was replaced by a two-dimensional RF pulse. Degree of image blur and susceptibility artifacts (0=not present to 3= non-diagnostic), maximum image distortion (mm), apparent diffusion coefficient (ADC) values, as well as overall scan preference were evaluated. SNR maps were generated to compare c-EPI2 and z-EPI. RESULTS Overall image quality of z-EPI was preferred by both readers in all examinations with a single exception. Susceptibility artifacts were rated significantly lower on z-EPI compared to both other methods (z-EPI vs c-EPI1: p<0.01; z-EPI vs c-EPI2: p<0.01) as well as image blur (z-EPI vs c-EPI1: p<0.01; z-EPI vs c-EPI2: p<0.01). Image distortion was not statistically significantly reduced with z-EPI (z-EPI vs c-EPI1: p=0.12; z-EPI vs c-EPI2: p=0.42). Interobserver agreement for ratings of susceptibility artifacts, image blur and overall scan preference was good. SNR was higher for z-EPI than for c-EPI1 (n=1). CONCLUSION Z-EPI leads to significant improvements in image quality and artifacts as well as image blur reduction improving prostate DWI and enabling accurate fusion with conventional sequences. The improved fusion could lead to advantages in the field of MRI-guided biopsy suspicous lesions and performance of locally ablative procedures for prostate cancer.

One-Stop Shop: Free-Breathing Dynamic Contrast-Enhanced Magnetic Resonance Imaging of the Kidney Using Iterative Reconstruction and Continuous Golden-Angle Radial Sampling.

Aims and ObjectivesThe purpose of the present study was to evaluate a recently introduced technique for free-breathing dynamic contrast-enhanced renal magnetic resonance imaging (MRI) applying a combination of radial k-space sampling, parallel imaging, and compressed sensing. The technique allows retrospective reconstruction of 2 motion-suppressed sets of images from the same acquisition: one with lower temporal resolution but improved image quality for subjective image analysis, and one with high temporal resolution for quantitative perfusion analysis. Materials and MethodsIn this study, 25 patients underwent a kidney examination, including a prototypical fat-suppressed, golden-angle radial stack-of-stars T1-weighted 3-dimensional spoiled gradient-echo examination (GRASP) performed after contrast agent administration during free breathing. Images were reconstructed at temporal resolutions of 55 spokes per frame (6.2 seconds) and 13 spokes per frame (1.5 seconds). The GRASP images were evaluated by 2 blinded radiologists. First, the reconstructions with low temporal resolution underwent subjective image analysis: the radiologists assessed the best arterial phase and the best renal phase and rated image quality score for each patient on a 5-point Likert-type scale.In addition, the diagnostic confidence was rated according to a 3-point Likert-type scale. Similarly, respiratory motion artifacts and streak artifacts were rated according to a 3-point Likert-type scale.Then, the reconstructions with high temporal resolution were analyzed with a voxel-by-voxel deconvolution approach to determine the renal plasma flow, and the results were compared with values reported in previous literature. ResultsReader 1 and reader 2 rated the overall image quality score for the best arterial phase and the best renal phase with a median image quality score of 4 (good image quality) for both phases, respectively. A high diagnostic confidence (median score of 3) was observed. There were no respiratory motion artifacts in any of the patients. Streak artifacts were present in all of the patients, but did not compromise diagnostic image quality.The estimated renal plasma flow was slightly higher (295 ± 78 mL/100 mL per minute) than reported in previous MRI-based studies, but also closer to the physiologically expected value. ConclusionsDynamic, motion-suppressed contrast-enhanced renal MRI can be performed in high diagnostic quality during free breathing using a combination of golden-angle radial sampling, parallel imaging, and compressed sensing. Both morphologic and quantitative functional information can be acquired within a single acquisition.

The Impact of Acquisition Time on Image Quality in Whole-Body 18F-FDG PET/CT for Cancer Staging

Our objective was to evaluate the impact of acquisition time on image quality, lesion detection rate, standardized uptake values, and lesion volume for 18F-FDG PET in cancer patients. Methods: Over 7 mo, 33 cancer patients were included in this study. In these patients, 63 lesions were independently evaluated by 2 nuclear medicine specialists (experienced and beginner). Two consecutive whole-body 18F-FDG PET/CT scans using a 3-min and 1.5-min acquisition time per bed position were obtained for each patient. Lesions were visually identified, and their locations were compared. The lesion volumes and standardized uptake values of the primary tumor, lymph nodes, and metastases were determined and compared. Image quality was scored using a 5-range Likert-type scale. For all parameters, interobserver agreement was assessed. Results: All relevant lesions could be identified at both acquisition times. Image quality was slightly adversely affected by an acquisition time of 1.5 min but was excellent or good in 85% of the scans. In a patient with increased blood sugar levels, the image quality was rated moderate at 3 min and poor at 1.5 min. The quality of lesion visualization was excellent regardless of the acquisition time. Lesion volume and maximum standardized uptake value on PET images showed an excellent correlation between the 2 acquisition times (Pearson correlation coefficient, 0.99 and 0.97, respectively). Interobserver agreement was excellent (κ > 0.83). Conclusion: Although image quality is slightly poorer, reducing the acquisition time to 1.5 min per bed position seems to be clinically feasible without decreasing the lesion detection rate even for less experienced observers.