Characterization of human prostate cancer, benign prostatic hyperplasia and normal prostate by in vitro 1H and 31P magnetic resonance spectroscopy

Magnetic resonance spectroscopy of the malignant prostate gland after radiotherapy: a histopathologic study of diagnostic validity

PURPOSE

Accurate spatial representation of tumor clearance after conformal radiotherapy is an endpoint of clinical importance. Magnetic resonance spectroscopy (MRS) can diagnose malignancy in the untreated prostate gland through measurements of cellular metabolites. In this study we sought to describe spectral metabolic changes in prostatic tissue after radiotherapy and validate a multivariate analytic strategy (based on MRS) that could identify viable tumor.

METHODS AND MATERIALS

Transrectal ultrasound-guided prostate biopsies from 35 patients were obtained 18-36 months after external beam radiotherapy. One hundred sixteen tissue specimens were subjected to 1H MRS, submitted to histopathology, and analyzed for correlation with a multivariate strategy specifically developed for biomedical spectra.

RESULTS

The sensitivity and specificity of MRS in identifying a malignant biopsy were 88.9% and 92% respectively, with an overall classification accuracy of 91.4%. The diagnostic spectral regions identified by our algorithm included those due to choline, creatine, glutamine, and lipid. Citrate, an important discriminating resonance in the untreated prostate gland, was invisible in all spectra, regardless of histology.

CONCLUSIONS

Although the spectral features of prostate tissue markedly change after radiotherapy, MRS combined with multivariate methods of analysis can accurately identify histologically malignant biopsies. MRS shows promise as a modality that could integrate three-dimensional measures of tumor response.

Magnetic resonance imaging and spectroscopic imaging: Improved patient selection and potential for metabolic intermediate endpoints in prostate cancer chemoprevention trials

In the design of prostate cancer chemoprevention trials there is a clear need for improved patient selection and risk stratification, as well as the use of biomarkers that could provide earlier assessment of therapeutic efficacy. Studies in preprostatectomy patients have indicated that the metabolic information provided by 3-dimensional magnetic resonance spectroscopic imaging (3D-MRSI) combined with the morphologic information provided by magnetic resonance imaging (MRI) can improve the assessment of cancer location and extent within the prostate, extracapsular spread, and cancer aggressiveness. Additionally, pre- and posttherapy studies have demonstrated the potential of MRI/3D-MRSI to provide a direct measure of the presence and spatial extent of prostate cancer after therapy, a measure of the time course of response, and information concerning the mechanism of therapeutic response. These studies suggest that the addition of MRI/3D-MRSI data to prostate-specific antigen and biopsy data may improve patient selection and risk stratification for chemoprevention trials, improve tissue sampling for ex vivo molecular marker analysis, and provide shorter-term endpoints in chemoprevention trials. However, future studies are necessary to establish the ability of MRI/3D-MRSI to accurately assess patients with premalignant or very early malignant changes, to validate metabolic markers as intermediate endpoints in chemoprevention trials, and to correlate metabolic endpoints with other promising intermediate biomarkers.

High-resolution proton nuclear magnetic resonance spectroscopy of ovarian cyst fluid

Most ovarian tumors are cystic structures containing variable amounts of fluid. Several studies of ovarian cyst fluid focus on one specific metabolite using conventional assay systems. We examined the potential of (1)H-nuclear magnetic resonance spectroscopy in evaluation of the overall metabolic composition of cyst fluid from different ovarian tumors. Ovarian cyst fluid samples obtained from 40 patients with a primary ovarian tumor (12 malignant and 28 benign) were examined. After deproteinization and pD standardization, we performed (1)H-NMR spectroscopy on a 600 MHz instrument. With (1)H-NMR spectroscopy we found detectable concentrations of 36 metabolites with high intersample variation. A number of unassigned resonances as well as unexpected metabolites were found. We introduce an overall inventory of the low-molecular-weight metabolites in ovarian cyst fluid with corresponding resonances. Significant differences in concentration (p < 0.01) were found for several metabolites (including an unknown metabolite) between malignant and benign ovarian cysts. Furthermore, higher concentrations in malignant- and lower in benign fluids were found compared to normal serum values, indicating local cyst wall metabolic processes in case of malignant transformation. We conclude that (1)H-nuclear magnetic resonance spectroscopy can give an overview of low-molecular-weight proton-containing metabolities present in ovarian cyst fluid samples. The metabolic composition of cyst fluid differs significantly between benign and malignant ovarian tumors. Furthermore, differences between benign subgroups possibly related to histopathological behaviour can be detected. The presence of N-acetyl aspartic acid and 5-oxoproline exclusively in serous cystadenoma samples is remarkable. Future studies will concentrate on these findings and explore the possibilities of extrapolating information from the in vitro studies to in vivo practice, in which metabolic differences between malignant and benign subtypes can be of great importance in a pre-operative phase.

Proton MR spectroscopy of prostatic tissue focused on the detection of spermine, a possible biomarker of malignant behavior in prostate cancer

To investigate whether polyamines may be valuable diagnostic and prognostic markers in prostate cancer, the presence of polyamines was studied in various human prostatic tissues using both proton magnetic resonance (MR) spectroscopy and high-pressure liquid chromatography (HPLC). The HPLC results showed that normal and benign hyperplastic prostatic tissues were characterized by a high content of spermine. Spermine levels were reduced in tumor tissue, especially in prostatic carcinoma with metastases, and in xenografts of human prostatic carcinoma cells. These preliminary results indicate that spermine may be used as a biomarker for malignant behavior. The MR spectroscopy study showed that it is possible to detect spermine resonances in prostatic biopsy material by one-dimensional and two-dimensional J-resolved MR spectroscopy at high field (600 MHz). Localized one-dimensional in vitro MR spectra obtained at the clinical field strength of 1.5 T showed spermine signals in the region between 3.0 and 3.3 ppm. In in vivo MR spectra of the human prostate, however, these signals were obscured by resonances of choline (3.2 ppm) and creatine (3.0 ppm).

Treatment planning for prostate implants using magnetic-resonance spectroscopy imaging

PURPOSE

Recent studies have demonstrated that magnetic-resonance spectroscopic imaging (MRSI) of the prostate may effectively distinguish between regions of cancer and normal prostatic epithelium. This diagnostic imaging tool takes advantage of the increased choline plus creatine versus citrate ratio found in malignant compared to normal prostate tissue. The purpose of this study is to describe a novel brachytherapy treatment-planning optimization module using an integer programming technique that will utilize biologic-based optimization. A method is described that registers MRSI to intraoperative-obtained ultrasound images and incorporates this information into a treatment-planning system to achieve dose escalation to intraprostatic tumor deposits.

METHODS

MRSI was obtained for a patient with Gleason 7 clinically localized prostate cancer. The ratios of choline plus creatine to citrate for the prostate were analyzed, and regions of high risk for malignant cells were identified. The ratios representing peaks on the MR spectrum were calculated on a spatial grid covering the prostate tissue. A procedure for mapping points of interest from the MRSI to the ultrasound images is described. An integer-programming technique is described as an optimization module to determine optimal seed distribution for permanent interstitial implantation. MRSI data are incorporated into the treatment-planning system to test the feasibility of dose escalation to positive voxels with relative sparing of surrounding normal tissues. The resultant tumor control probability (TCP) is estimated and compared to TCP for standard brachytherapy-planned implantation.

RESULTS

The proposed brachytherapy treatment-planning system is able to achieve a minimum dose of 120% of the 144 Gy prescription to the MRS positive voxels using (125)I seeds. The preset dose bounds of 100-150% to the prostate and 100-120% to the urethra were maintained. When compared to a standard plan without MRS-guided optimization, the estimated TCP for the MRS-optimized plan is superior. The enhanced TCP was more pronounced for smaller volumes of intraprostatic tumor deposits compared to estimated TCP values for larger lesions.

CONCLUSIONS

Using this brachytherapy-optimization system, we could demonstrate the feasibility of MRS-optimized dose distributions for (125)I permanent prostate implants. Based on probability estimates of anticipated improved TCP, this approach may have an impact on the ability to safely escalate dose and potentially improve outcome for patients with organ-confined but aggressive prostatic cancers. The magnitude of the TCP enhancement, and therefore the risks of ignoring the MR data, appear to be more substantial when the tumor is well localized; however, the gain achievable in TCP may depend quite considerably on the MRS tumor-detection efficiency.

The prostate: MR imaging and spectroscopy. Present and future

The applications of combined MR imaging and MR spectroscopic imaging of prostate cancer have expanded significantly over the past 10 years and have reached the point of clinical trial results to test robustness and clinical significance. MR spectroscopic imaging extends the diagnostic evaluation of prostate cancer beyond the morphologic information provided by MR imaging throughout the detection of cellular metabolites. The combined metabolic and anatomic information provided by MR imaging and MR spectroscopic imaging has allowed a more accurate assessment of the presence, location, extent, and aggressiveness of prostate cancer both before and after treatment. This information has already demonstrated the ability to improve therapeutic planning for individual prostate cancer patients and shows great promise in the assessment of therapeutic response and the evaluation of new treatment regimes.

Three-dimensional magnetic resonance spectroscopic imaging of brain and prostate cancer

Clinical applications of magnetic resonance spectroscopic imaging (MRSI) for the study of brain and prostate cancer have expanded significantly over the past 10 years. Proton MRSI studies of the brain and prostate have demonstrated the feasibility of noninvasively assessing human cancers based on metabolite levels before and after therapy in a clinically reasonable amount of time. MRSI provides a unique biochemical "window" to study cellular metabolism noninvasively. MRSI studies have demonstrated dramatic spectral differences between normal brain tissue (low choline and high N-acetyl aspartate, NAA) and prostate (low choline and high citrate) compared to brain (low NAA, high choline) and prostate (low citrate, high choline) tumors. The presence of edema and necrosis in both the prostate and brain was reflected by a reduction of the intensity of all resonances due to reduced cell density. MRSI was able to discriminate necrosis (absence of all metabolites, except lipids and lactate) from viable normal tissue and cancer following therapy. The results of current MRSI studies also provide evidence that the magnitude of metabolic changes in regions of cancer before therapy as well as the magnitude and time course of metabolic changes after therapy can improve our understanding of cancer aggressiveness and mechanisms of therapeutic response. Clinically, combined MRI/MRSI has already demonstrated the potential for improved diagnosis, staging and treatment planning of brain and prostate cancer. Additionally, studies are under way to determine the accuracy of anatomic and metabolic parameters in providing an objective quantitative basis for assessing disease progression and response to therapy.

Human prostate: multisection proton MR spectroscopic imaging with a single spin-echo sequence--preliminary experience

The authors investigated the feasibility of a multisection proton magnetic resonance (MR) spectroscopic imaging technique for the acquisition of metabolic information in the human prostate. Multisection MR spectroscopic imaging was performed of a citrate phantom and of the prostates of eight adult volunteers. High-quality proton MR spectra and citrate metabolite maps of the prostate were obtained with this method.

In vivo proton magnetic resonance spectroscopy of diseased prostate: spectroscopic features of malignant versus benign pathology

In vivo Proton Magnetic Resonance Spectroscopy appears potentially useful for non-invasive discrimination between benign prostatic hyperplasia (BPH) and prostate carcinoma (PC). Aiming to delimit the range within which spectra from one or the other pathology should occur, and establish extreme spectroscopic features of malignant versus benign prostate disease, we performed endorectal proton MR spectroscopy on 20 patients severely affected of either benign prostatic hyperplasia (BPH) (n = 10) or prostate cancer (PC) (n = 10). They were selected on the basis of the large volume and homogeneity of their lesions, which were histologically confirmed after spectroscopy. Consequently, high-quality short-TE proton spectra with well-resolved metabolite signals, and practically free of volume averaging issues were obtained in all cases. Apart from the typical citrate, creatine, and choline signals of prostate spectra, both BPH and PC spectra showed a peak centered at 3.6 ppm which was assigned to myo-inositol. The intensity of this contribution was found significantly increased in PC cases compared to BPH. Possible relationships between neoplastic transformation and the metabolic pathways in which myo-inositol participates are discussed. Average spectroscopic profiles were calculated for both advanced pathologies, and showed obvious differentiated features. In quantitative terms, the ratio of citrate to choline peak areas as well as that of creatine to myo-inositol appeared as the most convenient to discriminate between advanced PC cases (both ratios below 1.0) and advanced BPH cases (both ratios above 1.0).

Citrate in the diagnosis of prostate cancer

BACKGROUND

One of the major current problems involved in prostate cancer (PCa) is the unavailability of sensitive, accurate, and preferably noninvasive procedures for the diagnosis of PCa. Moreover, procedures are needed which will permit the early detection, staging, location, and estimation of the volume of malignancy, and preferably a mapping of the prostate for follow-up of progression and regression of the malignancy.

METHODS

The unique citrate relationships of the prostate, coupled with recent developments and technological advancements in magnetic resonance spectroscopy (MRS) for the in situ determination of citrate levels, now provides an excellent diagnostic procedure which can achieve all these goals. There exist strong, compelling basic and clinical studies in support of the employment of 1H MRS measurements of citrate and other associated metabolites in the diagnosis of PCa.

RESULTS

This review provides the background leading to the current status of MRS citrate analysis, summarizes the data from clinical trials, and describes the applications of the procedure for the diagnosis of PCa and follow-up of patients. The use of MRS studies in defining the functional, as well as pathological relationships of the prostate, is also discussed.

CONCLUSIONS

This review is intended to be informative to the prostate- and oncology-interested community, and, hopefully, to engender much-needed interest and support in future research regarding the prostate relationships described in this report.

In vivo differential diagnosis of prostate cancer and benign prostatic hyperplasia: localized proton magnetic resonance spectroscopy using external-body surface coil

Localized proton-stimulated echo acquisition mode (STEAM) spectroscopy was performed in seven patients with benign prostatic hyperplasia (BPH), six patients with prostate cancer, and seven healthy volunteers to determine whether citrate levels detected using a saddle-type external-body surface coil (two loops of 13 cm x 17 cm) could reliably discriminate BPH from prostatic cancer. Relative area ratios of citrate level to choline plus creatine or citrate to lipid signal were compared with postoperative pathologic histology findings. The metabolic signals were well detectable as much as the line width of water resonance was ranging from 5 to 9 hz. Average SNRs of citrate in BPH and prostate cancer were 11.4 and 1.9, respectively. The major finding was consistently lower citrate levels in prostate cancer compared with BPH and normal prostate central gland. This was significantly (p < 0.01) reflected by lower mean citrate/[creatine+choline] peak area ratio and citrate/lipid peak area ratio observed for region of cancer (0.446 +/- 0.063, 0.097 +/- 0.030) compared with BPH (1.458 +/- 0.107, 0.786 +/- 0.162) and normal central gland (1.418 +/- 0.129, 0.175 +/- 0.011), respectively. These studies demonstrate the potential of citrate spectrum detected by an external-body surface coil as an in vivo marker for discriminating prostate cancer from BPH.

In vivo quantification of citrate concentration and water T2 relaxation time of the pathologic prostate gland using 1H MRS and MRI

We have previously reported a striking correlation between water T2 relaxation time and citrate concentration in the normal prostate (Liney G.P.; Lowry M.; Turnbull L.W.; Manton D.J.; Knowles A.J.; Blackband S.J.; Horsman A. Proton MR T2 maps correlate with the citrate concentration in the prostate. NMR Biomed. 9:59-64; 1996). In this study we present data from similar studies of the pathologic gland. The findings support the hypothesis that measurement of both citrate concentration and water T2 relaxation time in vivo may aid the differentiation of prostatic carcinoma from benign disease and normal tissue.

Proton MR spectroscopy of the normal human prostate with an endorectal coil and a double spin-echo pulse sequence

This report describes the use of an endorectal coil and a double spin-echo pulse sequence for localized 1H MR spectroscopy of the normal prostate in volunteers. The spectra showed well-resolved signals for citrate, (phospho)choline, and creatine protons. Additional signals were assigned to taurine and myoinositol protons. J modulation of the main and outer peaks of citrate could be monitored in vivo. Apparent relaxation times T1 and T2 have been estimated for the methyl protons of cholines and creatine. An effective T1 relaxation time was estimated for the main peaks of the citrate multiplet. Ratios of the integrals of these resonances have been evaluated, and tissue contents of choline and creatine were estimated using the H2O signal as an internal reference. Spectroscopic imaging experiments revealed a lower relative citrate signal in central parts of the prostate than in peripheral parts.

Proton MR T2 maps correlate with the citrate concentration in the prostate

A significant correlation between water T2 relaxation time and citrate concentration in the normal prostate is demonstrated using spatially localized spectroscopy and water T2 maps. These data imply that MR images may be used to infer the concentration of citrate at high spatial resolution. Preliminary results in patients demonstrate that this relationship is maintained in benign prostatic hyperplasia (BPH) and prostatic carcinoma. The determination of citrate concentration and water T2 may aid the differentiation of prostate carcinoma from BPH and normal tissue.

Sequence parameters of double spin-echo sequences affect quantification of citrate

Quantification of citrate by localized 1H spectroscopy is usually performed using the water signal as reference, but the signal behavior of the J-coupled AB spin system of citrate after multipulse excitation is not as trivial as for uncoupled substances. The influence of the timing scheme of double spin-echo sequences and of the spatial flip angle distribution of (nonideal) refocusing pulses was analyzed systematically for the citrate resonances. Both single echo times of the double spin-echo sequence were varied between 20 ms and 250 ms in theoretical and experimental approaches. Relatively long total echo times (TE > 120 ms) provide high selectivity to citrate signals, since signals from triglycerides at 2.6 ppm are markedly reduced. Asymmetrical timing schemes of the double spin-echo sequence with one short single echo time of 20 ms and one longer single echo time of about 120 ms result in high integral signal from the central lines of citrate, whereas symmetrical timing leads to high sensitivity for total echo times TE near 100 ms. The integral citrate signals in spectra with relatively long echo times (TE > 120 ms) were found to depend markedly on the type of the refocusing pulses, affecting quantitative citrate measurements in vitro and in vivo.

In vitro proton magnetic resonance spectroscopy of four human prostate cancer cell lines

There is accumulating evidence that some biochemical pathways observable by magnetic resonance spectroscopy, e.g., citrate acid and phospholipid metabolism, are altered in human prostate cancer. Four well-established human prostate cancer cell lines were therefore studied with magnetic resonance spectroscopy to compare differences in metabolic content with tumor biological behavior. Herein we demonstrate that, although each cell line has its own metabolic profile, relative creatine and citrate levels can be used to discriminate the androgen-dependent LNCaP cell line from the androgen-independent DU-145, TSU, and PC-3 cell lines.

Citrate as an in vivo marker to discriminate prostate cancer from benign prostatic hyperplasia and normal prostate peripheral zone: detection via localized proton spectroscopy

OBJECTIVES

This study was designed to determine whether citrate levels detected by localized 1H spectroscopy could reliably discriminate regions of prostate adenocarcinoma from surrounding regions of normal peripheral zone and benign prostatic hyperplasia (BPH).

METHODS

In 28 patients and 5 volunteers stimulated echo proton spectroscopy was used in conjunction with endorectal surface coils to obtain water-suppressed 1H spectra from regions of normal prostate peripheral zone, BPH, and prostate cancer. 1H spectra from prostate cancer patients were correlated with pathologic areas identified on T2-weighted endorectal coil magnetic resonance (MR) images and histologic study of the step-sectioned gland after surgery.

RESULTS

The major finding of in vivo studies was consistently lower citrate levels in prostate cancer compared with BPH and normal prostate peripheral zone. This was reflected by significantly (P < 0.05) lower mean citrate/(creatine plus choline) peak area ratio observed for regions of cancer (0.67 +/- 0.17) compared with BPH (1.21 +/- 0.29) and normal peripheral zone (1.46 +/- 0.28). Moreover, there was no overlap of individual cancer and normal peripheral zone citrate ratios and no significant difference between citrate ratios in regions of normal peripheral zone in young volunteers (1.28 +/- 0.14) and age-matched patients (1.46 +/- 0.28). The observed alterations in vivo citrate levels were supported by citrate concentration data obtained from extracts of histologically proven samples of normal, benign, and malignant prostatic tissues removed at surgery. In vitro citrate levels in the normal peripheral zone (30.9 +/- 8.5 mumol/g wet weight) and BPH (46.3 +/- 5.4 mumol/g wet weight) were significantly higher than those for prostate cancer (3.74 +/- 0.54 mumol/g wet weight).

CONCLUSIONS

These studies further demonstrate the potential of citrate as an in vivo marker for discriminating prostate cancer from surrounding regions of normal peripheral zone and BPH.

Magnetic resonance spectroscopy detects metabolic differences between seven Dunning rat prostate tumor sublines with different biological behavior

In this study, it was investigated whether prostate tumor biological parameters correlate with metabolic profiles. 1H and 31P magnetic resonance spectra were acquired from perchloric acid extracts of seven Dunning R-3327 prostate tumor sublines. Several metabolic ratios, for example, phosphocholine/total phosphate, choline/total creatine, and inositol/total creatine, did not correlate specifically with one biological characteristics but, based on each of these ratios, the well-differentiated, nonmetastatic, and hormone-dependent sublines could be discriminated from the poorly differentiated or anaplastic, metastatic, and hormone-independent sublines. The glycerophosphoethanolamine/total phosphate, glycerophosphocholine/total phosphate, and phosphocreatine/total phosphate ratios correlated with differentiation grade, and the differences in glycerophosphorylglycerol/total phosphate ratio between metastatic and nonmetastatic sublines was highly significant. No correlation for hormonal sensitivity with any of the metabolites measured could be found, neither by 31P nor by 1H MRS.