Multiparametric MR diffusion-weighted imaging for monitoring the ultra-early treatment effect of sorafenib in human hepatocellular carcinoma xenografts

Prediction of therapeutic response of advanced hepatocellular carcinoma to combined targeted immunotherapy by MRI

PURPOSE

To assess the value of pre-treatment MRI in predicting treatment response to combined targeted immunotherapy in advanced hepatocellular carcinoma (HCC).

METHODS

Totally 35 HCC participants who underwent pre-treatment contrast-enhanced MRI and received combined tyrosine kinase inhibitor (TKI) and anti-PD-1 antibody treatment were enrolled. Univariable and multivariable logistic regression analyses were carried out for comparing clinical and MRI characteristics between patients with therapeutic response and those without. A predictive model based on MRI data and the corresponding nomogram were developed using data generated by multivariate analysis, and the diagnostic performance was evaluated. A cutoff for the combined index was measured by receiver operating characteristic curve analysis, and progression-free survival (PFS) rates were compared between cases with high and low combined index values.

RESULTS

Fifteen (42.86%) cases achieved overall response during treatment. Multivariable analysis revealed that homogeneous signal (odds ratio [OR] = 13.51, P = 0.010) and no arterial peritumoral enhancement (APE; OR = 10.29, P = 0.024) independently predicted treatment response. The combined model including both significant MRI parameters showed a satisfactory predictive performance with the largest area under the curve of 0.837 (95%CI 0.673-0.939), and both sensitivity and specificity of 80.0%. HCCs with high-combined index had higher PFS rate compared with those showing a low value (P = 0.034).

CONCLUSION

The combination of pre-treatment MRI features of homogeneous signal and no APE could be used for predicting treatment response to combined targeted immunotherapy in advanced HCC.

Noninvasive Imaging for Assessment of the Efficacy of Therapeutic Agents for Hepatocellular Carcinoma

Morphological imaging techniques are typically used in the anti-cancer drug efficacy evaluation process. However, these techniques can evaluate the therapeutic efficacy only when the tumor shows anatomic changes-usually at later stages, when the therapeutic effects are poor. In contrast, molecular imaging allows noninvasive monitoring of tumor growth, assessment of drug metabolism, and evaluation of therapeutic efficacy at the molecular and cellular levels. Multimodality molecular imaging, which combines the advantages of various imaging modalities, provides even more comprehensive therapeutic efficacy assessment in preclinical and clinical studies. This review provides an overview of molecular imaging evaluation of therapeutic efficacy of the anti-tumor drugs in hepatocellular carcinoma (HCC) both in preclinical and clinical research, which holds great promise in guiding HCC treatment into the era of precision medicine.

Differentiation of peripheral nerve sheath tumors in patients with neurofibromatosis type 1 using diffusion-weighted magnetic resonance imaging

BACKGROUND

We sought to determine the value of diffusion-weighted (DW) magnetic resonance imaging (MRI) for characterization of benign and malignant peripheral nerve sheath tumors (PNSTs) in patients with neurofibromatosis type 1 (NF1).

METHODS

Twenty-six patients with NF1 and suspicion of malignant transformation of PNSTs were prospectively enrolled and underwent DW MRI at 3T. For a set of benign (n = 55) and malignant (n = 12) PNSTs, functional MRI parameters were derived from both biexponential intravoxel incoherent motion (diffusion coefficient D and perfusion fraction f) and monoexponential data analysis (apparent diffusion coefficients [ADCs]). A panel of morphological MRI features was evaluated using T1- and T2-weighted imaging. Mann-Whitney U-test, Fisher's exact test, and receiver operating characteristic (ROC) analyses were applied to assess the diagnostic accuracy of quantitative and qualitative MRI. Cohen's kappa was used to determine interrater reliability.

RESULTS

Malignant PNSTs demonstrated significantly lower diffusivity (P < 0.0001) compared with benign PNSTs. The perfusion fraction f was significantly higher in malignant PNSTs (P < 0.001). In ROC analysis, functional MRI parameters showed high diagnostic accuracy for differentiation of PNSTs (eg, ADCmean, 92% sensitivity with 98% specificity, AUC 0.98; Dmean, 92% sensitivity with 98% specificity, AUC 0.98). By contrast, morphological imaging features had only limited sensitivity (18-94%) and specificity (18-82%) for identification of malignancy. Interrater reliability was higher for monoexponential data analysis.

CONCLUSION

DW imaging shows better diagnostic performance than morphological features and allows accurate differentiation of benign and malignant peripheral nerve sheath tumors in NF1.

Downregulation of B7-H4 suppresses tumor progression of hepatocellular carcinoma

B7-H4, as a member of the B7 superfamily, was overexpressed in various types of cancers. However, the effects of B7-H4 on the aggressiveness of HCC and the underlying mechanisms have not yet been fully explored. For this purpose, B7-H4 expression was detected by Flow cytometry and Western blotting, it was highly expressed in several HCC cell lines but not in normal LO2 cell line. Knockdown B7-H4 expression induced HCC cells apoptosis by flow cytometry and colony formation assays and increased several apoptosis-related proteins, including survivin, cleaved caspase-3, cleaved caspase-7, and Bax, while the pro-growth protein survivin was reduced. Then the proliferation and cell cycle were suppressed after treated by siB7-H4. Moreover, the level of B7-H4 was significantly correlated with cell migration. In vivo, intra-tumor injection of siRNA targeting B7-H4 can significantly inhibited the growth of HepG2 cells in nude mice. Finally, regions of interest were manually traced on T1WI, T2WI, DWI and ADC of MR images. ADC values were increased in HCC xenografts after B7-H4 siRNA treatment. These data indicated that downregulation of B7-H4 suppressed the proliferation and migration and promoted apoptosis in vitro and in vivo. Blocking the B7-H4 channel might be a potential therapeutic strategy for HCC.

Evaluation of intratumoral heterogeneity by using diffusion kurtosis imaging and stretched exponential diffusion-weighted imaging in an orthotopic hepatocellular carcinoma xenograft model

Background

To investigate the value of diffusion kurtosis imaging (DKI) and diffusion-weighted imaging (DWI) with a stretched exponential model (SEM) in the evaluation of tumor heterogeneity in an orthotopic hepatocellular carcinoma (HCC) xenograft model.

Methods

Thirty orthotopic HCC xenograft nude mice models were established and randomly divided into two groups, the sorafenib induction group (n=15) and control group (n=15). Every mouse in each group underwent MRI with DKI and SEM on a 1.5T MR scanner at 7, 14, and 21 days after sorafenib intervention. DKI and SEM parameters including mean kurtosis (MK), mean diffusivity (MD), α, and distributed diffusion coefficient (DDC) were measured, calculated, and compared between the two groups and among different time points. Sequential correlations between histopathological results including necrotic fraction (NF), micro-vessel density (MVD), Ki-67 index, standard deviation (SD), and kurtosis from hematoxylin-eosin staining, and DKI and SEM parameters were analyzed.

Results

MK, MD, and DDC of HCC in the sorafenib induction group were significantly higher than those in the control group at each time point (P<0.05), while α was significantly lower (P<0.05). Significantly positive correlations were found between MK and NF (r=0.693, P=0.010), SD (r =0.785, P=0.003), kurtosis (r=0.779, P=0.003), between MD and NF (r=0.794, P=0.003), SD (r=0.629, P=0.020), kurtosis (r=0.645, P=0.018), and between DDC and NF (r=0.800, P=0.003), SD (r=0.636, P=0.020), kurtosis (r=0.664, P=0.016), and significantly negative correlations were observed between α and NF (r=-0.704, P=0.009), SD (r=-0.754, P=0.003), and kurtosis (r=-0.792, P=0.003) in the sorafenib induction group.

Conclusions

DKI and SEM parameters may be potentially useful for evaluating intratumoral heterogeneity in HCC.

Evaluation of non-monoexponential diffusion models for hepatocellular carcinoma using b values up to 2000 s/mm2 : A short-term repeatability study

BACKGROUND

Non-monoexponential diffusion models are being used increasingly for the characterization and curative effect evaluation of hepatocellular carcinoma (HCC). But the fitting quality of the models and the repeatability of their parameters have not been assessed for HCC.

PURPOSE

To evaluate kurtosis, stretched exponential, and statistical models for diffusion-weighted imaging (DWI) of HCC, using b-values up to 2000 s/mm² , in terms of fitting quality and repeatability.

STUDY TYPE

Prospective.

POPULATION

Eighteen patients with HCC.

FIELD STRENGTH/SEQUENCE

Conventional and DW images (b = 0, 200, 500, 1000, 1500, 2000 s/mm² ) were acquired at 3.0T.

ASSESSMENT

The parameters of the kurtosis, stretched exponential, and statistical models were calculated on regions of interest (ROIs) of each lesion.

STATISTICAL TESTS

The fitting quality was evaluated through comparing the fitting residuals produced on the average data of ROI between different models using a paired t-test or Wilcoxon rank-sum test. Repeatability of the fitted parameters at the median values on the voxelwise data of ROI was assessed using the within coefficient of variation (WCV), the intraclass correlation coefficient (ICC), and the 95% Bland-Altman limits of agreements (BA-LA). The repeatability was divided into four levels: excellent, good, acceptable, and poor, referring to the values of ICC and WCV.

RESULTS

Among three models, the stretched exponential model provided the best fit to HCC (P < 0.05), whereas the statistical model produced the largest fitting residuals (P < 0.05). The repeatability of K from the kurtosis model was excellent (ICC 0.915; WCV 8.79%), while the distributed diffusion coefficient (DDC) from the stretched model was just acceptable (ICC 0.477; WCV 27.83%). The repeatability was good for other diffusion-related parameters.

DATA CONCLUSION

Considering the model fit and repeatability, the kurtosis and stretched exponential models are the preferred models for the description of the DW signals of HCC with respect to the statistical model.

LEVEL OF EVIDENCE

2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:297-304.

Diffusion MRI of cancer: From low to high b-values

Following its success in early detection of cerebral ischemia, diffusion-weighted imaging (DWI) has been increasingly used in cancer diagnosis and treatment evaluation. These applications are propelled by the rapid development of novel diffusion models to extract biologically valuable information from diffusion-weighted MR signals, and significant advances in MR hardware that has enabled image acquisition with high b-values. This article reviews recent technical developments and clinical applications in cancer imaging using DWI, with a special emphasis on high b-value diffusion models. The article is organized in four sections. First, we provide an overview of diffusion models that are relevant to cancer imaging. The model parameters are discussed in relation to three tissue properties-cellularity, vascularity, and microstructures. An emphasis is placed on characterization of microstructural heterogeneity, given its novelty and close relevance to cancer. Second, we illustrate diffusion MR clinical applications in each of the following three categories: 1) cancer detection and diagnosis; 2) cancer grading, staging, and classification; and 3) cancer treatment response prediction and evaluation. Third, we discuss several practical issues, including selection of image acquisition parameters, reproducibility and reliability, motion management, image distortion, etc., that are commonly encountered when applying DWI to cancer in clinical settings. Lastly, we highlight a few ongoing challenges and provide some possible future directions, particularly in the area of establishing standards via well-organized multicenter clinical trials to accelerate clinical translation of advanced DWI techniques to improving cancer care on a large scale. Level of Evidence: 5 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:23-40.

Imaging evaluation of sorafenib for treatment of advanced hepatocellular carcinoma

Sorafenib, which is a novel targeted agent, plays an important role in treating advanced hepatocellular carcinoma (HCC) through its antiangiogenic and antiproliferative effects. However, conventional morphology-based radiographic evaluation systems may underestimate the efficacy of sorafenib in HCC due to a lack of apparent tumor shrinkage or altered tumor morphology in many cases. This calls for the development of more accurate imaging methods for evaluating sorafenib. The introduction of tumor burden measurements based on viability and other evolving imaging approaches for assessing therapeutic effects are promising for overcoming some of the limitations of the morphology-based criteria. In this review, we summarize various imaging methods that are used to assess treatment responses of advanced HCC to sorafenib. Imaging markers predictive of prognosis in advanced HCC after treatment with sorafenib are also included and discussed.

Associations between apparent diffusion coefficient and electromyography parameters in myositis-A preliminary study

OBJECTIVE

MRI is widely used in several muscle disorders. Diffusion-weighted imaging (DWI) is an emergent imaging modality sensitive to microstructural alterations in tissue. The apparent diffusion coefficient (ADC) is used to quantify the random motion of water molecules. Electromyography (EMG) is a clinically used diagnostic tool in myositis. The aim of this study was to elucidate possible associations between ADC values and EMG findings in myositis patients.

METHOD

Seven patients (eight investigated muscles) with myositis (mean age 51.43 ± 19 years) were included in this study. The diagnosis was confirmed by histopathology in every case. DWI was obtained with a 1.5-T scanner using two b-values 0 and 1000 s/mm². In all patients, a needle electromyography (EMG) was performed within 3 days to the MRI. The following EMG parameters were studied: motor unit action potential (MUAP) amplitudes and durations, as well as pathological spontaneous activity. Spearman's correlation coefficient was used to analyze associations between investigated parameters.

RESULTS

The estimated mean ADC _mean value was 1.51 ± 0.29 × 10^-3 mm²/s, mean ADC _min was 1.28 ± 0.27 × 10^-3 mm²/s, and mean ADC _max was 1.73 ± 0.28 × 10^-3 mm²/s. Correlation analysis identified significant associations between ADC _mean and duration of the MUAP (p = .78 P = .0279) and between ADC _min and duration of the MUAP (p = .85, P = .01). There were no significant differences according to pathological spontaneous activity.

CONCLUSION

ADC _mean and ADC _min showed strong positive correlations with the duration of the MUAP in myositis patients. Both modalities might similarly reflect muscle fiber loss in myositis patients.