Theoretical MRI contrast model for exogenous T2 agents

Biomolecular MRI reporters: Evolution of new mechanisms

Magnetic resonance imaging (MRI) is a powerful technique for observing the function of specific cells and molecules inside living organisms. However, compared to optical microscopy, in which fluorescent protein reporters are available to visualize hundreds of cellular functions ranging from gene expression and chemical signaling to biomechanics, to date relatively few such reporters are available for MRI. Efforts to develop MRI-detectable biomolecules have mainly focused on proteins transporting paramagnetic metals for T1 and T2 relaxation enhancement or containing large numbers of exchangeable protons for chemical exchange saturation transfer. While these pioneering developments established several key uses of biomolecular MRI, such as imaging of gene expression and functional biosensing, they also revealed that low molecular sensitivity poses a major challenge for broader adoption in biology and medicine. Recently, new classes of biomolecular reporters have been developed based on alternative contrast mechanisms, including enhancement of spin diffusivity, interactions with hyperpolarized nuclei, and modulation of blood flow. These novel reporters promise to improve sensitivity and enable new forms of multiplexed and functional imaging.

A cCPE-based xenon biosensor for magnetic resonance imaging of claudin-expressing cells

The majority of malignant tumors originate from epithelial cells, and many of them are characterized by an overexpression of claudins (Cldns) and their mislocalization out of tight junctions. We utilized the C-terminal claudin-binding domain of Clostridium perfringens enterotoxin (cCPE), with its high affinity to specific members of the claudin family, as the targeting unit for a claudin-sensitive cancer biosensor. To overcome the poor sensitivity of conventional relaxivity-based magnetic resonance imaging (MRI) contrast agents, we utilized the superior sensitivity of xenon Hyper-CEST biosensors. We labeled cCPE for both xenon MRI and fluorescence detection. As one readout module, we employed a cryptophane (CrA) monoacid and, as the second, a fluorescein molecule. Both were conjugated separately to a biotin molecule via a polyethyleneglycol chemical spacer and later via avidin linked to GST-cCPE. Nontransfected HEK293 cells and HEK293 cells stably expressing Cldn4-FLAG were incubated with the cCPE-based biosensor. Fluorescence-based flow cytometry and xenon MRI demonstrated binding of the biosensor specifically to Cldn4-expressing cells. This study provides proof of concept for the use of cCPE as a carrier for diagnostic contrast agents, a novel approach for potential detection of Cldn3/-4-overexpressing tumors for noninvasive early cancer detection.

Functional ferritin nanoparticles for biomedical applications

Ferritin, a major iron storage protein with a hollow interior cavity, has been reported recently to play many important roles in biomedical and bioengineering applications. Owing to the unique architecture and surface properties, ferritin nanoparticles offer favorable characteristics and can be either genetically or chemically modified to impart functionalities to their surfaces, and therapeutics or probes can be encapsulated in their interiors by controlled and reversible assembly/disassembly. There has been an outburst of interest regarding the employment of functional ferritin nanoparticles in nanomedicine. This review will highlight the recent advances in ferritin nanoparticles for drug delivery, bioassay, and molecular imaging with a particular focus on their biomedical applications.

Magnetic Resonance Microscopy (MRM) of Single Mammalian Myofibers and Myonuclei

Recently, the first magnetic resonance microscopy (MRM) images at the cellular level in isolated mammalian brain tissues were obtained using microsurface coils. These methods can elucidate the cellular origins of MR signals and describe how these signals change over the course of disease progression and therapy. In this work, we explore the capability of these microimaging techniques to visualize mouse muscle fibers and their nuclei. Isolated myofibers expressing lacZ were imaged with and without a stain for β-galactosidase activity (S-Gal + ferric ammonium citrate) that produces both optical and MR contrast. We found that MRM can be used to image single myofibers with 6-μm resolution. The ability to image single myofibers will serve as a valuable tool to study MR properties attributed to healthy and myopathic cells. The ability to image nuclei tagged with MR/Optical gene markers may also find wide use in cell lineage MRI studies.

Advances in Magnetic Resonance Imaging Contrast Agents for Biomarker Detection

Recent advances in magnetic resonance imaging (MRI) contrast agents have provided new capabilities for biomarker detection through molecular imaging. MRI contrast agents based on the T2 exchange mechanism have more recently expanded the armamentarium of agents for molecular imaging. Compared with T1 and T2* agents, T2 exchange agents have a slower chemical exchange rate, which improves the ability to design these MRI contrast agents with greater specificity for detecting the intended biomarker. MRI contrast agents that are detected through chemical exchange saturation transfer (CEST) have even slower chemical exchange rates. Another emerging class of MRI contrast agents uses hyperpolarized (13)C to detect the agent with outstanding sensitivity. These hyperpolarized (13)C agents can be used to track metabolism and monitor characteristics of the tissue microenvironment. Together, these various MRI contrast agents provide excellent opportunities to develop molecular imaging for biomarker detection.

A biomarker-responsive T2ex MRI contrast agent

PURPOSE

This study investigated a fundamentally new type of responsive MRI contrast agent for molecular imaging that alters T₂ exchange (T_2ex ) properties after interacting with a molecular biomarker.

METHODS

The contrast agent Tm-DO3A-oAA was treated with nitric oxide (NO) and O₂ . The R₁ and R₂ relaxation rates of the reactant and product were measured with respect to concentration, temperature, and pH. Chemical exchange saturation transfer (CEST) spectra of the reactant and product were acquired using a 7 Tesla (T) MRI scanner and analyzed to estimate the chemical exchange rates and r_2ex relaxivities.

RESULTS

The reaction of Tm-DO3A-oAA with NO and O₂ caused a 6.4-fold increase in the r₂ relaxivity of the agent, whereas r₁ relaxivity remained unchanged, which demonstrated that Tm-DO3A-oAA is a responsive T_2ex agent. The effects of pH and temperature on the r₂ relaxivities of the reactant and product supported the conclusion that the product's benzimidazole ligand caused the agent to have a fast chemical exchange rate relative to the slow exchange rate of the reactant's ortho-aminoanilide ligand.

CONCLUSIONS

T_2ex MRI contrast agents are a new type of responsive agent that have good detection sensitivity and specificity for detecting a biomarker, which can serve as a new tool for molecular imaging. Magn Reson Med 77:1665-1670, 2017. © 2016 International Society for Magnetic Resonance in Medicine.

Quantitative Assessment of Iron-Labeled Stem-Cell Adhesion at the Vessel Wall in a Vascular Flow Model: Correlation of T2*-Weighted Imaging at 3 T and Histology

PURPOSE

To evaluate the distribution of superparamagnetic iron oxide (SPIO)-labeled cells in a perfused segment of a porcine artery and to estimate the number of adherent cells by means of magnetic resonance (MR) imaging.

MATERIALS AND METHODS

Six vessel specimens (diameters between 0.8 and 1.2 cm) were placed in a bioreactor system, and 2 × 10(4) to 1 × 10(6) SPIO-labeled endothelial colony-forming cells were injected into the artery within the perfused reactor. The area of resulting signal extinctions at the inner wall of the vessels was quantified on MR images by using a high-resolution T2*-weighted sequence with a slice-by-slice approach. After imaging, the labeled cells were quantified histologically.

RESULTS

The total iron load of each cell was 56.5 pg ± 14.4. In the applied range of 2 × 10(4) to 1 × 10(6) cells per vessel, the area of iron-induced signal extinction at the vessel wall on T2*-weighted imaging corresponded to the histologically detected cell number (r = 0.98, P < .001).

CONCLUSIONS

A correlation between the area of signal extinction and the number of labeled cells at the vessel wall was found. This might help to evaluate dose rates in further clinical applications of intravascular cell-based therapies.

A review of responsive MRI contrast agents: 2005-2014

This review focuses on MRI contrast agents that are responsive to a change in a physiological biomarker. The response mechanisms are dependent on six physicochemical characteristics, including the accessibility of water to the agent, tumbling time, proton exchange rate, electron spin state, MR frequency or superparamagnetism of the agent. These characteristics can be affected by changes in concentrations or activities of enzymes, proteins, nucleic acids, metabolites, or metal ions, or changes in redox state, pH, temperature, or light. A total of 117 examples are presented, including ones that employ nuclei other than (1) H, which attests to the creativity of multidisciplinary research efforts to develop responsive MRI contrast agents.

Fluorescent imaging of cancerous tissues for targeted surgery

To maximize tumor excision and minimize collateral damage are the primary goals of cancer surgery. Emerging molecular imaging techniques have made "image-guided surgery" developed into "molecular imaging-guided surgery", which is termed as "targeted surgery" in this review. Consequently, the precision of surgery can be advanced from tissue-scale to molecule-scale, enabling "targeted surgery" to be a component of "targeted therapy". Evidence from numerous experimental and clinical studies has demonstrated significant benefits of fluorescent imaging in targeted surgery with preoperative molecular diagnostic screening. Fluorescent imaging can help to improve intraoperative staging and enable more radical cytoreduction, detect obscure tumor lesions in special organs, highlight tumor margins, better map lymph node metastases, and identify important normal structures intraoperatively. Though limited tissue penetration of fluorescent imaging and tumor heterogeneity are two major hurdles for current targeted surgery, multimodality imaging and multiplex imaging may provide potential solutions to overcome these issues, respectively. Moreover, though many fluorescent imaging techniques and probes have been investigated, targeted surgery remains at a proof-of-principle stage. The impact of fluorescent imaging on cancer surgery will likely be realized through persistent interdisciplinary amalgamation of research in diverse fields.

Detecting enzyme activities with exogenous MRI contrast agents

This review focuses on exogenous magnetic resonance imaging (MRI) contrast agents that are responsive to enzyme activity. Enzymes can catalyze a change in water access, rotational tumbling time, the proximity of a (19)F-labeled ligand, the aggregation state, the proton chemical-exchange rate between the agent and water, or the chemical shift of (19)F, (31)P, (13)C or a labile (1)H of an agent, all of which can be used to detect enzyme activity. The variety of agents attests to the creativity in developing enzyme-responsive MRI contrast agents.

Phospholipid micelle encapsulated gadolinium oxide nanoparticles for imaging and gene delivery

We encapsulated gadolinium oxide (Gd2O3) nanoparticles within phospholipid micelles as a novel low cytotoxic T1-weighted MRI imaging contrast agent (MGdNPs) that can also deliver small molecules such as DNA plasmids. MGdNPs show relatively good MRI relaxivity values, negligible cytotoxicity, excellent cellular uptake and expression of DNA plasmids in vivo. Biodistribution studies in mice show that intranasal and intraperitoneal administration of MGdNPs can effectively target specific organs.

Quantification of HSV-1-mediated expression of the ferritin MRI reporter in the mouse brain

The development of effective strategies for gene therapy has been hampered by difficulties verifying transgene delivery in vivo and quantifying gene expression non-invasively. Magnetic resonance imaging (MRI) offers high spatial resolution and three-dimensional views, without tissue depth limitations. The iron-storage protein ferritin is a prototype MRI gene reporter. Ferritin forms a paramagnetic ferrihydrite core that can be detected by MRI via its effect on the local magnetic field experienced by water protons. In an effort to better characterize the ferritin reporter for central nervous system applications, we expressed ferritin in the mouse brain in vivo using a neurotropic herpes simplex virus type 1 (HSV-1). We computed three-dimensional maps of MRI transverse relaxation rates in the mouse brain with ascending doses of ferritin-expressing HSV-1. We established that the transverse relaxation rates correlate significantly to the number of inoculated infectious particles. Our results are potentially useful for quantitatively assessing limitations of ferritin reporters for gene therapy applications.

Effects of Iron Oxide Nanoparticle Labeling on Human Endothelial Cells

Iron oxide nanoparticles (INOPS) are a potential contrast agent for magnetic resonance (MR) tracking of transplanted endothelial cells. The objective of this study was to examine the effect of INOPS labeling on endothelial cells. The mixture of INOPS and poly-l-lysine (PLL) was used to label human endothelial cells. Labeling efficiency was examined by Prussian blue staining, transmission electron microscopy, and atomic absorption spectrometry. The effect of iron oxide concentration on cell viability and proliferation were determined. The correlation of reactive oxygen species (ROS) and apoptosis was also examined. In vitro MRI scanning was carried out using a 1.5T MR system. INOPS-PLL could be readily taken up by endothelial cells and subsequently induce MRI signal intensity changes. However, higher labeling concentration (>50 μg/ml) and longer incubation (48 h) can affect cell viability and proliferation. Mitochondrial damage, apoptosis, and autolysosmes were observed under high INOPS-PLL concentrations, which were correlated to ROS production. INOPS-PLL nanoparticles can be used to label transplanted endothelial cells. However, high concentration of INOPS can impair cell viability, possibly through ROS-mediated apoptosis and autophagy.

Investigation of In Vivo Targeting Kinetics of α(v)β(3)-Specific Superparamagnetic Nanoprobes by Time-Resolved MRI

Nanoparticulate imaging probes have become an increasingly important arsenal in the visualization of molecular markers for early diagnosis and post-therapy assessment of diseases. Surface functionalization of these nanoparticles has led to the development of a variety of targeted nanoprobes for various imaging modalities (e.g. PET, MRI, optical). Despite these advances, detailed understanding of the nanoparticle targeting kinetics, particularly at the early time points immediately after injection, is still lacking. In this study, we report the combination of a T₂*-weighted time-resolved-MRI (TR-MRI) method with ultra-sensitive superparamagnetic polymeric micelle (SPPM) nanoprobes to quantify the targeting kinetics of cyclic (RGDfK) (cRGD)-encoded SPPM to angiogenic endothelium in subcutaneous human tumor xenograft models in mice. TR-MRI analyses of the α_vβ₃-targeted and non-targeted SPPMs allowed for the subtraction of blood volume and extravascular signal components from the cRGD-SPPM data, resulting in a specific measurement of the accumulation kinetics of nanoprobes in lung, breast and brain cancer preclinical models. In all three models, α_vβ₃-specific accumulation of SPPM nanoprobes was observed in the first 5 mins after intravenous injection (first order rate constants were in the range of 0.22-0.24 min^-1). Similar α_vβ₃-targeting kinetics was observed for cRGD-SPPM nanoprobes in different tumor xenograft models, consistent with the targeting of mouse angiogenic endothelium despite tumor inoculation from different human cancer cell lines. Results from this study offer new opportunities in the quantitative characterization of the targeting kinetics of cancer-specific nanoparticles to their intended biological targets in an intact animal, which provides fundamental insights on molecular recognition processes in vivo for further development of these nanoprobes.

Contrast visibility for indirect MR arthrography with different protein contents and agent relaxivities at different field strengths: an in vitro model

OBJECTIVES

Protein binding and relaxivity are major determinants of the relative effectiveness of an MR arthrographic contrast agent. We sought to evaluate the optimal concentrations of high and usual relaxivity agents in two different proteinous environments at variable field strength for two MR contrast agents of different relaxivities.

MATERIALS AND METHODS

At 1.5, 3.0 and 7.0 T, gadobenate dimeglumine (Multihance) with high-relaxivity in proteinous environment and gadoteridol (Prohance) with more typical behavior were studied at 1.25, 2.5, 5, and 10 mmol in 1.7 g/dL and 3g/dL albumin (mimicking protein content of normal and inflammatory synovial fluids, respectively) vs. pure normal saline, as a control. Analysis of image signal intensity (SI) and relaxivity values was done.

RESULTS

In our study a change in concentration had no significant effect on T1 SI. In contrast, nearly every change in concentration led to a significant change in T2 SI. In 1.25 mmol concentration, there was no effect on T1 SI of either protein concentrations while higher concentrations showed significant decreased SI in either protein carrier compared to saline. The SI of Gadoteridol was significantly higher (p<0.0001) than that of gadobenate at each of 3T and 7 T, but was significantly lower (p<0.001) at 1.5 T in saline solution while this was not significant for either protein carrier. Both protein carriers had significant effect on T1 (p=0.0124) and T2 (p=0.0118) relaxivities. Also solution concentration significantly (p<0.01) affected both T1 and T2 relaxivities. Field strength did not affect T1 relaxivity (p=0.02511) while it significantly affected T2 relaxivity (p<0.001). This was significant (p=0.035) in case of gadoteridol at 3T.

CONCLUSION

1.25 mmol concentration of both gadoteridol and gadobenate solutions yields the best diagnostic T1 SI specially in higher fields (3T and 7 T) and avoid the deleterious effect of increasing concentration on T2 SI. Gadoteridol is suggested on 3T field indirect MR arthrograms. Protein had no positive effect on either SI or relaxivities in any joint model.

In vivo angiogenesis imaging of solid tumors by alpha(v)beta(3)-targeted, dual-modality micellar nanoprobes

The objective of this study was to develop and evaluate an alpha(v)beta(3)-specific nanoprobe consisting of fluorescent superparamagnetic polymeric micelles (FSPPM) for in vivo imaging of tumor angiogenesis. Spherical micelles were produced using poly(ethylene glycol)-b-poly(d,l-lactide) co-polymers conjugated with tetramethylrhodamine, a fluorescent dye, and loaded with superparamagnetic iron oxide nanoparticles. The resulting micelle diameter was 50-70 nm by dynamic light scattering and transmission electron microscopy measurements. Micelles were encoded with an alpha(v)beta(3)-specific peptide, cyclic RGDfK, and optimized for maximum fluorescence and targeting in alpha(v)beta(3)-overexpressing cells in vitro. In mice, cRGD-FSPPM-treated animals showed alpha(v)beta(3)-specific FSPPM accumulation in human lung cancer subcutaneous tumor xenografts. Together with the histological validation, the three-dimensional gradient echo magnetic resonance imaging (MRI) data provide high spatial resolution mapping and quantification of angiogenic vasculature in an animal tumor model using targeted, ultrasensitive MRI nanoprobes.

Design and characterization of a chimeric ferritin with enhanced iron loading and transverse NMR relaxation rate

This paper describes the design and characterization of a novel ferritin chimera. The iron storage protein ferritin forms a paramagnetic ferrihydrite core. This biomineral, when placed in a magnetic field, can decrease the transverse NMR relaxation times (T (2) and T (2)*) of nearby mobile water protons. Ferritin nucleic acid constructs have recently been studied as "probeless" magnetic resonance imaging (MRI) reporters. Following reporter expression, ferritin sequesters endogenous iron and imparts hypointensity to T (2)- and T (2)*-weighted images in an amount proportional to the ferritin iron load. Wild-type ferritin consists of various ratios of heavy H and light L subunits, and their ratio affects ferritin's stability and iron storage capacity. We report a novel chimeric ferritin with a fixed subunit stoichiometry obtained by fusion of the L and the H subunits (L*H and H*L) using a flexible linker. We characterize these supramolecular ferritins expressed in human cells, including their iron loading characteristics, hydrodynamic size, subcellular localization, and effect on solvent water T (2) relaxation rate. Interestingly, we found that the L*H chimera exhibits a significantly enhanced iron loading ability and T (2) relaxation compared to wild-type ferritin. We suggest that the L*H chimera may be useful as a sensitive MRI reporter molecule.

lacZ as a genetic reporter for real-time MRI

Molecular imaging based on MRI is currently hampered by the lack of genetic reporters for in vivo imaging. We determined that the commercially available substrate S-Gal can be used to detect genetically engineered beta-galactosidase expressing cells by MRI. The effect and specificity of the reaction between beta-galactosidase and S-Gal on MRI contrast were determined both in vitro and in vivo. beta-galactosidase activity in the presence of S-Gal resulted in enhanced T(2) and T*(2) MR-contrast, which was amplified with increasing magnetic field strengths (4.7-17.6 T) in phantom studies. Using both lacZ(+) transgenic animals and lacZ(+) tissue transplants, we were able to detect labeled cells in live animals in real time. Similar to phantom studies, detection of the labeled cells/tissues in vivo was enhanced at high magnetic fields. These results demonstrate that the genetic reporter, lacZ, can be used as an in vivo marker gene using high-field-strength MRI.

Activatable cell penetrating peptides linked to nanoparticles as dual probes for in vivo fluorescence and MR imaging of proteases

High-resolution imaging of molecules intrinsically involved in malignancy and metastasis would be of great value for clinical detection and staging of tumors. We now report in vivo visualization of matrix metalloproteinase activities by MRI and fluorescence of dendrimeric nanoparticles coated with activatable cell penetrating peptides (ACPPs), labeled with Cy5, gadolinium, or both. Uptake of such nanoparticles in tumors is 4- to 15-fold higher than for unconjugated ACPPs. With fluorescent molecules, we are able to detect residual tumor and metastases as small as 200 microm, which can be resected under fluorescence guidance and analyzed histopathologically with fluorescence microscopy. We show that uptake via this mechanism is comparable to that of other near infrared protease sensors, with the added advantage that the approach is translatable to MRI. Once activated, the Gd-labeled nanoparticles deposit high levels (30-50 microM) of Gd in tumor parenchyma with even higher amounts deposited in regions of infiltrative tumor, resulting in useful T(1) contrast lasting several days after injection. These results should improve MRI-guided clinical staging, presurgical planning, and intraoperative fluorescence-guided surgery. The approach may be generalizable to deliver radiation-sensitizing and chemotherapeutic agents.

Molecular imaging without radiopharmaceuticals?

The limitations on the sensitivity for detecting small changes in MRI, CT, and ultrasound pulse-echo images are used to estimate the practical requirements for molecular imaging and targeted contrast enhancement for these modalities. These types of imaging are highly unlikely to approach the sensitivity for detecting molecular processes of radionuclear methods, and the prospects for achieving sufficient concentrations of appropriate agents in vivo are poor for several types of applications such as small-molecule targeting of specific receptors. However, using relatively large carrier systems such as particles and liposomes, sufficient concentrations of paramagnetic agents may be delivered to achieve MR-signal changes adequate for detection. The use of higher-resolution MR images will aid the prospects for molecular imaging in small animals. Theoretic considerations also predict that a similar approach, using rather large particles or carriers of materials with a high atomic number, may also be successful for CT, especially with additional developments such as the use of monochromatic x-rays. The prospects of molecular imaging by x-ray imaging may not be as bleak as has been predicted. For ultrasound detection, gas-filled bubbles can provide a sufficient backscattered sound intensity to be detectable at concentrations and sizes not much different from agents designed for these other modalities.

Detection and quantification of magnetically labeled cells by cellular MRI

Labeling cells with superparamagnetic iron oxide (SPIO) nanoparticles, paramagnetic contrast agent (gadolinium) or perfluorocarbons allows for the possibility of tracking single or clusters of labeled cells within target tissues following either direct implantation or intravenous injection. This review summarizes the practical issues regarding detection and quantification of magnetically labeled cells with various MRI contrast agents with a focus on SPIO nanoparticles.

Enzyme-responsive PARACEST MRI contrast agents: a new biomedical imaging approach for studies of the proteasome

Proteases are important biomarkers for many biological processes and are popular targets for therapeutics investigations. A protease can be detected by monitoring changes in the paramagnetic chemical exchange saturation transfer (PARACEST) effect of a MRI contrast agent that serves as a substrate for the protease. To translate this type of responsive PARACEST MRI contrast agent to in vivo applications, the sensitivity, timing, specificity and validation of the response of the agent must be evaluated. This report demonstrates that PARACEST MRI contrast agents can be used to detect nanomolar concentrations of proteases, can be designed to preferentially detect the protease caspase-3 relative to caspase-8, and can be detected within the 15 min time frame of typical MRI studies. The response can be validated using an unresponsive PARACEST MRI contrast agent as a control. A survey of the MEROPS database shows that this approach may also be applied to detect other proteases, and therefore may represent a new platform technology for studies of the proteasome.

Hypopharyngeal cancer

Hypopharyngeal cancers are usually squamous cell carcinomas (SCCs) that has the worst prognosis among the head and neck cancers. Overall, 5-year survival rate remains poor despite recent improvements in diagnostic imaging, radiation and chemotherapy, and improved surgical techniques. Hypopharyngeal cancers tend to present with advanced primary disease, and nodal metastasis is highly likely. The most important features determining prognosis are the size and extent of local spread of the primary carcinoma and the extent of involvement of regional lymph nodes. Distant metastasis at presentation is more common in hypopharyngeal cancers than in other head and neck cancers. Poor survival rate is partly due to emergence of second primary cancers but also to development of distant metastasis. Contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) remain the mainstay of initial radiological evaluation of hypopharyngeal cancer. Imaging usually results in upstaging of the tumor at presentation. Meticulous evaluation of the extent of the primary tumor with attention to spread to the subsites of the hypopharynx, larynx, and cartilage invasion are necessary for accurate staging. After surgery and radiation therapy, it is difficult with CT and MR to differentiate residual and recurrent tumor from edema and scarring. Fluorine 18-fluoro-deoxy-glucose -positron emission tomography (FDG-PET) has high sensitivity in detection of occult, residual, and recurrent tumors but has low specificity. Combined PET and CT increase specificity and are increasingly being used to image posttreatment cases. Other newer imaging modalities such as diffusion-weighted imaging (DWI), MR spectroscopy, and MRI with superparamagnetic iron oxide (SPIO) contrast agent are reported to be useful and should be used more widely in difficult cases.