Irmandade da Santa Casa de Misericórdia de São Paulo Serviço de

IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
ServiçodeDiagnós:coporImagem-Neurorradiologia
Augusto Lio da Mota Gonçalves Filho
Diego Cardoso Fragoso
Felipe Torres Pacheco
Renato Hoffmann Nunes
Bernd Foerster
Antônio José da Rocha
Antônio Carlos Martins Maia Junior
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
Disclosure
Thereisnoconflictofinterest.
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
Introduc:on
•  AssessmentofCNStumors:
BrainTumor
MRBiological
biomarkers
Therapeu:cstrategy
•  Perfusioncharacteris:csoflesionsbyusingdynamicsuscep:bilityMRimaging
(DSC-MR)hasbecomeanimportantpartoftheini:alevalua:onandfollowupoflesions.
•  Cerebral blood volume has been shown to correlate with the degree of
neovasculariza:onandwithtumorgradingandprognosis.
–  Elec:onofbiopsysamplingarea
LawM,etal.AmericanJournalofNeuroradiology,2003.
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
Introduc:on
•  Diffusion Imaging (DWI) provide unique informa:on on the :ssue
func:onalarchitecture.
Diffusionanisotropy
ApparentDiffusionCoefficient(ADC)
IntravoxelIncoherentMo:on(IVIM)
•  IVIM concept: Blood microcircula:on could contribute to the signal
aWenua:onobservedwithdiffusionMRimaginginthecapillarynetworks
(perfusion).
•  Blood water in randomly oriented capillaries (at voxel level) mimics a
FederauC,etal.AmericanJournalofNeuroradiology,2014
randomwalk(pseudodiffusion).
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
Introduc:on
•  IVIM is a method to quan:ta:vely assess the
microscopic transla:onal mo:ons that occur
ineachimagevoxelatMRimaging.
-  Both pure molecular diffusion and blood
perfusion can be dis:nguished by using IVIMbasedDWimaging. LeBihanD,etal.Radiology1988
•  Other perfusion methods cannot give at the same
:me both informa:on about Diffusion and
Perfusion.
•  DSC-MRlimita:ons:
–  Isaffectedbythefirstpassextravasa:onofcontrast
–  Dependsonagoodarterialinput
–  Useofcontrastagents
AdaptedfromLima,M.,etal.Radiology.Jan,2016
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
Objec:ve
The purpose of this study was to compare the performance in
measuringCNStumorsperfusionbetweentheIVIMMRimaging
andDSC-MRimaging
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
MaterialsandMethods
•  Pa:ents with CNS tumors from August 2015 to January 2016 were
prospec:velyselectedinourins:tu:on.
–  The study was approved by the local ethics commiWee and the pa:ent
consentswerewaived.
InclusionCriteria
ExclusionCriteria
ConfirmedHistopathologicdiagnoses:
High-gradetumors
Low-gradetumors
Examswithpoortechnicalqualityand
ar:factsthatlimitedpost-processing
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
MaterialsandMethods
•  Conven=onalMRImagingProtocol:
–  1.5TMRimagingscannerequippedwith32mul:channelreceiverheadcoils.
–  FLAIR,T1SE,T2TSE,SWIandT1SEpost-contrastimages.
•  DSC-MRImagingProtocol:
–  Agadolinium-basedagent(gadobutrol,Gadovist®)wasintravenouslyinjectedata
dose of 0.2 mL/Kg of body weight and at a rate of 3 mL/s, followed by a 20-mL
salineflush.
–  StandardEPIwereconsecu:velyacquired(TR1950ms,TE43ms,sec:onthickness
6 mm, FOV 230 x 230, acquisi:on matrix 128 x 128). No leakage correc:on was
performed.CBV,MTT,andCBFmapswerecomputedfromimagingdatabyusing
thecommerciallyavailablesolwareOleaSphereV.2.3soGware(OleaMedical,La
Ciotat,France).
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
MaterialsandMethods
•  IVIMMRImaging:
–  Diffusion-weighted spin-echo EPI pulse sequence was used with 10 b-values
(0,4,8,16,30,60,120,250,500,1000s/mm2)in3orthogonaldirec:ons,and
thecorrespondingtracewascalculated.
–  Asingleacquisi:onwasobtained(noaverage).
–  Theimageswereorientedaxiallywithasec:onthicknessof4mm,anFOVof
297︎x297,andamatrixsizeof256x︎256.
–  Diffusion-weightedimaging(DWI)werefiWedtoanIVIMbiexponen:almodel
to elaborate diffusion-coefficient (D), pseudodiffusion-coefficient (D*), and
perfusion-frac:on(f)maps.
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
MaterialsandMethods
•  AnatomicalimageswerereviewedusingOleaSphereV.2.3soGware(Olea
Medical, La Ciotat, France) to determine the solid tumor areas. Cys:c,
necro:c,hemorrhagic,orcalcifica:onandcerebrospinalfluid-filledareas
werecarefullyavoided.
•  The analysis of the voxel-wise calculated parametric maps was based on
hand-drawn region-of-interest (ROI) that were manually placed in
consensus by two neuroradiologists, who were both blinded to the
pathologicresults.
A
B
C
D
Figure1–(A)T1post-contrast;(B)SWI;(C,D,andE)coloredmapsoff,D*andD,respec:vely.
E
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
MaterialsandMethods
A
E
B
C
D
Figure 2 – (A) rCBV map; (B, C, and D) colored
maps of f, D* and D, respec:vely; (E) DSC-MR
signalintensitygraphic.
•  ROIs were manually matched trough the images by using anatomic
landmarks.
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
MaterialsandMethods
•  Sta=s=calanalysis:
–  Parameters ADC, D, D*, and f in tumor sites were tested for differences
betweenthelow-gradeandhigh-gradetumorsbasedonone-wayANOVAand
itscorrela:onwithrCBVerCBFvalues.
–  Anormaldistribu:onofthedatawasassumed.
–  Wecalculatedthepearsonlinearcorrela:oncoefficientbetweenvariablesof
IVIMmetricsandrCBVerCBF.
–  Sta:s:calanalysiswasperformedwithsolware(SPSSv.21.0,Chicago,IL).
–  Sta:s:calsignificancewasdefinedatP<0.05.
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
Results
GRADE
HIGH
1
2
3
4
5
6
7
8
9
10
11
12
13
14
LOW
1
2
3
4
5
6
7
8
9
10
11
TOTAL
AGE(YR)
45
83
58
48
37
66
48
16
42
50
69
61
52
61
11
41
46
47
30
22
35
16
31
22
29
42
SEX
M
M
M
M
M
M
M
M
M
F
F
F
M
M
F
M
M
F
M
M
F
F
M
M
F
17M/8F
PATHOLOGICDIAGNOSIS
GBM
GBM
GBM
GBM
AnaplasticAstrocytoma
GBM
AnaplasticAstrocytoma
Highglioma
Metastasis–Undifferentiatedcarcinoma
Metastasis–Lung
Metastasis–Esophagus
Metastasis–Breast
Metastasis–Lung
GBM
GlioneuronalPapilar
DiffuseAstrocytoma
DiffuseAstrocytoma
Oligodendroglioma
DiffuseAstrocytoma
DiffuseAstrocytoma
DiffuseAstrocytoma
PilocyticAstrocytoma
Oligodendroglioma
DiffuseAstrocytoma
Oligodendroglioma
-
25
Table1:Pa:entdemographicsandhistologicdiagnosis.
WHOGRADE
IV
IV
IV
IV
III
IV
III
III/IV
IV
IV
IV
IV
IV
IV
I
II
II
II
II
II
II
I
II
II
II
-
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
Results
•  D*wasn’tsignificantlydifferentamonghigh-gradeandlow-gradetumors
(P=0.391).
Graphic1:Box-plot(median,25thand75thpercen:les,minimum,maximum,andoutliers)ofD*asmeasuredinROIsofthemaximumperfusionfrac:on.
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
Results
•  Dwassignificantlyhigherinlow-grade(2108.18±91.71)comparedwith
high-gradetumors(2030.71±138.75,P=0.020).
•  Dhasgoodcorrela:ontoADC(r=0.80)
r=0.80
Graphic2:Box-plot(median,25thand75thpercen:les,minimum,maximum,and
outliers)ofDasmeasuredinROIsofthemaximumperfusionfrac:on.
Graphic3:DispersionplotcomparingDwithADC.
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
Results
•  Theperfusionfrac:on(f)isthepercentageofincoherentsignalarising
fromthemicrovascularcompartment.
•  fwassignificantlyhigherinhigh-grade(11.33±5.85)comparedwithlowgradetumors(2.81±1.18,P=0.002).
Graphic4:Box-plot(median,25thand75thpercen:les,minimum,maximum,andoutliers)offasmeasuredinROIsofthemaximumperfusionfrac:on.
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
Results
•  fhasgoodcorrela:ontorCBV(r=0.64)andmoderatecorrela:ontorCBF
(r=0.59).
r=0.64
Graphic5:DispersionplotcomparingfwithrCBV.
r=0.59
Graphic6:DispersionplotcomparingfwithrCBF.
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
Discussion
•  InlinewiththeworkconductedbyNanxiShenetal,ourresultsshowthat
D (slow diffusion) posi:vely correlated with ADC and thus can be an
alterna:vemethodtoassesstumordiffusion.
•  The f (perfusion frac:on) showed good correla:on with rCBV from DSCMR, confirming recent studies and allowing the evalua:on of capillary
densityoftumors.
•  Although posi:ve results were achieved, we believe there are s:ll some
conflic:ng findings to be beWer understood for the appropriate use of
IVIMderivedperfusionparameters.
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
Conclusion
•  ThestudyofperfusionwithIVIMMRimaginghasgoodperformanceinthe
non-invasiveevalua:onofthecerebralbloodvolume,withouttheuseof
intravenousgadolinium,andwasfoundtobeusefulintheassessmentof
biologicbehaviorofSNCtumors.
Limita=ons:
Futureperspec=ves:
IVIM has many theore:c advantages that
Smallcohortstudied
Increasedacquisi:on:meandar:facts
Lackofacquisi:onprotocolstandardiza:on
can raise interest in the scien:fic
community:
•  Itisintrinsicallyquan:ta:ve
•  Does not require a precise knowledge of the
arterialinputfunc:on
•  Doesnotrequirecontrastmedia
•  Enables the acquisi:on of perfusion and
diffusioninforma:oninasinglesequence.
IrmandadedaSantaCasadeMisericórdiadeSãoPaulo
References
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