Discrimination between Metastatic and Nonmetastatic Mesorectal Lymph Nodes in Rectal Cancer Using Intravoxel Incoherent Motion Diffusion-weighted Magnetic Resonance Imaging

The value of intravoxel incoherent motion diffusion-weighted imaging in predicting perineural invasion for resectable gastric cancer: a prospective study

AIM

To investigate the potential of intravoxel incoherent motion (IVIM) diffusion-weighted imaging to predict perineural invasion (PNI) preoperatively in resectable gastric cancer (GC).

MATERIALS AND METHODS

This study prospectively recruited 85 surgically resected GC patients (58 men, 27 women) aged 60.87 ± 10.17 (39-81) years, who underwent IVIM sequence within 1 week before surgery. According to histopathological PNI diagnoses, patients were divided into PNI positive and negative groups. Conventional apparent diffusion coefficient (ADC) and the IVIM parameters, including true diffusion coefficient (D), pseudodiffusion coefficient (D∗), and pseudodiffusion fraction (f), were compared between the two groups. Morphological MRI features were also analysed. Multivariate logistic regression was used to screen independent predictors of PNI. Receiver-operating characteristic curve analyses were preformed to evaluate the efficacy. Spearman's correlation test was performed to analyse the relationship between MRI parameters and PNI.

RESULTS

Tumour thickness and f in PNI-positive group were higher, whereas the ADC, D were lower than those in PNI-negative group (p<0.05). These four parameters correlated with PNI (p<0.05). The D, f, and tumour thickness were independent predictors of PNI. The area under the curve of ADC, D, f, thickness, and the combined parameter (D + f + thickness) were 0.648, 0.745, 0.698, 0.725, and 0.869, respectively. The combined parameter demonstrated higher efficacy than any other parameters (p<0.05).

CONCLUSION

The ADC, D, and f can effectively distinguish PNI status in GC. The D, f, and thickness were independent predictors of PNI.

Evaluating Mediastinal Lymph Node Metastasis of Non-Small Cell Lung Cancer Using Mono-exponential, Bi-exponential, and Stretched-exponential Models of Diffusion-weighted Imaging

PURPOSE

To explore and compare the diagnostic values of mono-exponential, bi-exponential, and stretched-exponential diffusion-weighted imaging (DWI) parameters of primary lesions and lymph nodes (LNs) to predict mediastinal LN metastasis in patients with non-small cell lung cancer.

PATIENTS AND METHODS

Sixty-one patients with non-small cell lung cancer underwent preoperative magnetic resonance imaging, including multiple b-value DWI. The DWI parameters, including apparent diffusion coefficient (ADC) from a mono-exponential model, true diffusion (D) coefficient, pseudo-diffusion (D*) coefficient, and perfusion fraction (f) from a bi-exponential model, distributed diffusion coefficient (DDC) and intravoxel diffusion heterogeneity index (α) from a stretched-exponential model of primary tumors and LNs and the size characteristics of LNs, were measured and compared. Multivariate logistic regression analysis was used to establish models for predicting mediastinal LN metastasis. Receiver operating characteristic analysis was applied to evaluate diagnostic performances.

RESULTS

The DWI parameters of primary tumors showed no statistical significance between LN metastasis-positive and LN metastasis-negative groups. Nonmetastatic LNs had significantly higher ADC, D, DDC, and α values compared with metastatic LNs (all P < 0.05). The short-dimension, long-dimension, and short-long dimension ratio of metastatic LNs was significantly larger than those of nonmetastatic ones (all P < 0.05). The D value showed the best diagnostic performance among all DWI-derived single parameters, and the short dimension of LNs performed the same among all the size variables. Furthermore, the combination of DWI parameters (ADC and D) and the short dimension of LNs can significantly improve diagnostic efficiency.

CONCLUSIONS

The ADC, D, DDC, and α from the mono-exponential, bi-exponential, and stretched-exponential models were demonstrated efficient in differentiating benign from metastatic LNs, and the combination of ADC, D, and short dimension of LNs may have a better diagnostic performance than DWI or size-derived parameters either in combination or individually.

Application of intravoxel incoherent motion diffusion-weighted imaging for preoperative knowledge of lymphovascular invasion in gastric cancer: a prospective study

PURPOSE

To investigate the potential of intravoxel incoherent motion diffusion-weighted imaging (IVIM) for preoperative prediction of lymphovascular invasion (LVI) in gastric cancer (GC).

METHODS

This study prospectively enrolled 90 patients (62 males, 28 females, 60.79 ± 9.99 years old) who received radical gastrostomy. Abdominal MRI examinations including IVIM were performed within 1 week before surgery. Patients were divided into LVI-positive and -negative group according to pathological diagnosis after surgery. The apparent diffusion coefficient (ADC) and IVIM parameters, including true diffusion coefficient (D), pseudodiffusion coefficient (D*), and pseudodiffusion fraction (f), were compared between the two groups. The relationship between MRI parameters and LVI was studied by Spearman's correlation analysis. Multivariable logistic regression analysis was used to screen independent predictors of LVI. Receiver-operating characteristic curve analyses were applied to evaluate the efficacy.

RESULTS

The ADC, D in LVI-positive group were lower, whereas tumor thickness and f parameter in LVI-positive group were higher than those in LVI-negative group, and they were statistically correlated with LVI (p < 0.05). D, f and tumor thickness were independent risk factors of LVI. The area under the curve of ADC, D, f, thickness, and the combined parameter (D + f + thickness) were 0.667, 0.754, 0.695, 0.792, and 0.876, respectively. The combined parameter demonstrated higher efficacy than any other parameters (p < 0.05).

CONCLUSION

The ADC, D, and f can effectively distinguish LVI status of GC. The D, f and thickness were independent predictors. The combination of the three predictors further improved the efficacy.

Lymph Nodes Evaluation in Rectal Cancer: Where Do We Stand and Future Perspective

The assessment of nodal involvement in patients with rectal cancer (RC) is fundamental in disease management. Magnetic Resonance Imaging (MRI) is routinely used for local and nodal staging of RC by using morphological criteria. The actual dimensional and morphological criteria for nodal assessment present several limitations in terms of sensitivity and specificity. For these reasons, several different techniques, such as Diffusion Weighted Imaging (DWI), Intravoxel Incoherent Motion (IVIM), Diffusion Kurtosis Imaging (DKI), and Dynamic Contrast Enhancement (DCE) in MRI have been introduced but still not fully validated. Positron Emission Tomography (PET)/CT plays a pivotal role in the assessment of LNs; more recently PET/MRI has been introduced. The advantages and limitations of these imaging modalities will be provided in this narrative review. The second part of the review includes experimental techniques, such as iron-oxide particles (SPIO), and dual-energy CT (DECT). Radiomics analysis is an active field of research, and the evidence about LNs in RC will be discussed. The review also discusses the different recommendations between the European and North American guidelines for the evaluation of LNs in RC, from anatomical considerations to structured reporting.

Diagnostic performance of T2-weighted imaging and intravoxel incoherent motion diffusion-weighted MRI for predicting metastatic axillary lymph nodes in T1 and T2 stage breast cancer

BACKGROUND

Non-invasive modalities for assessing axillary lymph node (ALN) are needed in clinical practice.

PURPOSE

To investigate the suspicious ALN on unenhanced T2-weighted (T2W) imaging and intravoxel incoherent motion diffusion-weighted imaging (IVIM DWI) for predicting ALN metastases (ALNM) in patients with T1-T2 stage breast cancer and clinically negative ALN.

MATERIAL AND METHODS

Two radiologists identified the most suspicious ALN or the largest ALN in negative axilla by T2W imaging features, including short axis (Size-S), long axis (Size-L)/S ratio, fatty hilum, margin, and signal intensity on T2W imaging. The IVIM parameters of these selected ALNs were also obtained. The Mann-Whitney U test or t-test was used to compare the metastatic and non-metastatic ALN groups. Finally, logistic regression analysis with T2W imaging and IVIM features for predicting ALNM was conducted.

RESULTS

This study included 49 patients with metastatic ALNs and 50 patients with non-metastatic ALNs. Using the above conventional features on T2W imaging, the sensitivity and specificity in predicting ALNM were not high. Compared with non-metastatic ALNs, metastatic ALNs had lower pseudo-diffusion coefficient (D*) (P = 0.043). Logistic regression analysis showed that the most useful features for predicting ALNM were signal intensity and D*. The sensitivity and specificity predicting ALNM that satisfied abnormal signal intensity and lower D* were 73.5% and 84%, respectively.

CONCLUSIONS

The abnormal signal intensity on T2W imaging and one IVIM feature (D*) were significantly associated with ALNM, with sensitivity of 73.5% and specificity of 84%.

A Nomogram of Combining IVIM-DWI and MRI Radiomics From the Primary Lesion of Rectal Adenocarcinoma to Assess Nonenlarged Lymph Node Metastasis Preoperatively

BACKGROUND

Lymph node (LN) staging plays an important role in treatment decision-making. Current problem is that preoperative detection of LN involvement is always highly challenging for radiologists.

PURPOSE

To explore the value of the nomogram model combining intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI) and radiomics features from the primary lesion of rectal adenocarcinoma in assessing the non-enlarged lymph node metastasis (N-LNM) preoperatively.

STUDY TYPE

Retrospective.

POPULATION

A total of 126 patients (43% female) comprising a training group (n = 87) and a validation group (n = 39) with pathologically confirmed rectal adenocarcinoma.

FIELD STRENGTH/SEQUENCE

A 3.0 Tesla (T); T₂ -weighted imaging (T₂ WI) with fast spin-echo (FSE) sequence; IVIM-DWI spin-echo echo-planar imaging sequence.

ASSESSMENT

Based on pathological analysis of the surgical specimen, patients were classified into negative LN (LN-) and positive LN (LN+) groups. Apparent diffusion coefficient (ADC), diffusion coefficient (D), pseudo diffusion coefficient (D*) and microvascular volume fraction (f) values of primary lesion of rectal adenocarcinoma were measured. Three-dimensional (3D) radiomics features were measured on T₂ WI and IVIM-DWI. A nomogram model including IVIM-DWI and radiomics features was developed.

STATISTICAL TESTS

General_univariate_analysis and multivariate logistic regression were used for radiomics features selection. The performance of the nomogram was assessed by the receiver operating characteristic (ROC) curve, calibration, and decision curve analysis (DCA).

RESULTS

The LN+ group had a significantly lower D* value ([13.20 ± 13.66 vs. 23.25 ± 18.71] × 10^-3  mm² /sec) and a higher f value (0.43 ± 0.12 vs. 0.34 ± 0.10) than the LN- group in the training cohort. The nomogram model combined D*, f, and radiomics features had a better evaluated performance (AUC = 0.864) than any other model in the training cohort.

DATE CONCLUSION

The nomogram model including IVIM-DWI and MRI radiomics features in the primary lesion of rectal adenocarcinoma was associated with the N-LNM.

EVIDENCE LEVEL

4 TECHNICAL EFFICACY: Stage 2.

Diagnostic Efficiency of Diffusion Sequences and a Clinical Nomogram for Detecting Lymph Node Metastases from Rectal Cancer

RATIONALE AND OBJECTIVES

First, to evaluate and compare three different diffusion sequences (i.e., standard DWI, IVIM, and DKI) for nodal staging. Second, to combine the DWI, and anatomic information to assess metastatic lymph node (LN).

MATERIALS AND METHODS

We retrospectively identified 136 patients of rectal adenocarcinoma who met the inclusion criteria. Three diffusion sequences (i.e., standard DWI, IVIM, and DKI) were performed, and quantitative parameters were evaluated. Univariate and multivariate analyses were used to assess the associations between the anatomic and DWI information and LN pathology. Multivariate logistic regression was used to identify independent risk factors. A nomogram model was established, and the model performance was evaluated by the concordance index (c-index) and calibration curve.

RESULTS

There was a statistical difference in variables (LN long diameter, LN short diameter, LN boundary, LN signal, peri-LN signal intensity, ADC_-1000, ADC_-1400, ADC_-2000, K_app and D) between metastatic and non-metastatic LN for training and validation cohorts (p < 0.05). The ADC value derived from b = 1000 mm/s (ADC_-1000) showed the relative higher AUC (AUC = 0.780) than the ADC value derived from b = 1400 mm/s (ADC_-1400) (AUC = 0.703). The predictive accuracy of the nomogram measured by the c-index was 0.854 and 0.812 in the training and validation cohort, respectively.

CONCLUSION

The IVIM and DKI model's diagnostic efficiency was not significantly improved compared to conventional DWI. The diagnostic accuracy of metastatic LN can be enhanced using the nomogram model, leading to a rational therapeutic choice.

Value of multiple models of diffusion-weighted imaging for improving the nodal staging of preoperatively node-negative rectal cancer

OBJECTIVE

To investigate the parameters of multiple diffusion-weighted imaging (DWI) models for improving nodal staging of preoperatively node-negative rectal cancer.

MATERIALS AND METHODS

A total of 74 rectal cancer patients without suspected metastatic lymph nodes on conventional MRI who underwent direct surgical resection between November 2018 and January 2020 were enrolled in this prospective study. DWI parameters of mono-exponential model (ADC), intravoxel incoherent motion (D, D* and f), stretched exponential model (DDC and α), and diffusion kurtosis imaging (MD and MK) within the whole tumor were measured to predict the nodal staging in rectal cancer patients.

RESULTS

The D*, DDC, and MK values were significantly different in patients with pN0 and pN1-2 (all P < 0.001). The D*, DDC, and MK showed good diagnostic performance with the area under the receiver operating characteristic (AUC) of 0.788, 0.827 and 0.799. Multivariate analysis indicated D* (odds ratio, OR = 1.163, P = 0.003) and DDC (OR = 0.007, P = 0.019) as significant predictors of nodal staging. The combination of DDC and D* demonstrated superior diagnostic performance with the AUC, sensitivity, specificity and accuracy of 0.872, 0.800, 0.932 and 0.878, respectively.

CONCLUSION

Multiple functional DWI parameters were potential to identify the rectal cancer patients with micro-nodal involvement for accurate treatment.

Histogram models based on intravoxel incoherent motion diffusion-weighted imaging to predict nodal staging of rectal cancer

PURPOSE

To develop a model based on histogram parameters derived from intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI) for predicting the nodal staging of rectal cancer (RC).

MATERIAL AND METHODS

A total of 95 RC patients who underwent direct surgical resection were enrolled in this prospective study. The nodal staging on conventional magnetic resonance imaging (MRI) was evaluated according to the short axis diameter and morphological characteristics. Histogram parameters were extracted from apparent diffusion coefficient (ADC), true diffusion coefficient (D), pseudo-diffusion coefficient (D*), and perfusion fraction (f) maps. Multivariate binary logistic regression analysis was conducted to establish models for predicting nodal staging among all patients and those underestimated on conventional MRI.

RESULTS

The combined model based on multiple maps demonstrated superior diagnostic performance to single map models, with an area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and accuracy of 0.959, 94.3%, 88.3%, and 90.5%, respectively. The AUC of the combined model was significantly higher than that of the conventional nodal staging (P < 0.001). Additionally, 85.0% of the underestimated patients had suspicious lymph nodes with 5-8 mm short-axis diameter. The histogram model for these subgroups of patients showed good diagnostic efficacy with an AUC, sensitivity, specificity, and accuracy of 0.890, 100%, 75%, and 80.5%.

CONCLUSION

The histogram model based on IVIM-DWI could improve the diagnostic performance of nodal staging of RC. In addition, histogram parameters of IVIM-DWI may help to reduce the uncertainty of nodal staging in underestimated patients on conventional MRI.

Magnetic Resonance Imaging Evaluation of the Accuracy of Various Lymph Node Staging Criteria in Rectal Cancer: A Systematic Review and Meta-Analysis

Background

Magnetic resonance imaging (MRI)-based lymph node staging remains a significant challenge in the treatment of rectal cancer. Pretreatment evaluation of lymph node metastasis guides the formulation of treatment plans. This systematic review aimed to evaluate the diagnostic performance of MRI in lymph node staging using various morphological criteria.

Methods

A systematic search of the EMBASE, Medline, and Cochrane databases was performed. Original articles published between 2000 and January 2021 that used MRI for lymph node staging in rectal cancer were eligible. The included studies were assessed using the QUADAS-2 tool. A bivariate random-effects model was used to conduct a meta-analysis of diagnostic test accuracy.

Results

Thirty-seven studies were eligible for this meta-analysis. The pooled sensitivity, specificity, and diagnostic odds ratio of preoperative MRI for the lymph node stage were 0.73 (95% confidence interval [CI], 0.68–0.77), 0.74 (95% CI, 0.68–0.80), and 7.85 (95% CI, 5.78–10.66), respectively. Criteria for positive mesorectal lymph node metastasis included (A) a short-axis diameter of 5 mm, (B) morphological standard, including an irregular border and mixed-signal intensity within the lymph node, (C) a short-axis diameter of 5 mm with the morphological standard, (D) a short-axis diameter of 8 mm with the morphological standard, and (E) a short-axis diameter of 10 mm with the morphological standard. The pooled sensitivity/specificity for these criteria were 75%/64%, 81%/67%, 74%/79%, 72%/66%, and 62%/91%, respectively. There was no significant difference among the criteria in sensitivity/specificity. The area under the receiver operating characteristic (ROC) curve values of the fitted summary ROC indicated a diagnostic accuracy rate of 0.75–0.81.

Conclusion

MRI scans have minimal accuracy as a reference index for pretreatment staging of various lymph node staging criteria in rectal cancer. Multiple types of evidence should be used in clinical decision-making.

Histogram Analysis of Diffusion-Weighted Magnetic Resonance Imaging as a Biomarker to Predict Lymph Node Metastasis in T3 Stage Rectal Carcinoma

Purpose

This study investigated the predictive value of apparent diffusion coefficient (ADC) histogram parameters of the primary tumor for regional lymph node metastasis (LNM) in pathological T3 stage rectal cancer.

Patients and Methods

We retrospectively studied 175 patients with T3 stage rectal cancer who underwent preoperative MRI, including diffusion-weighted imaging, between January 2015 and October 2017. Based on pathological analysis of surgical specimens, 113 patients were classified into the LN− group and 62 in the LN+ group. We analyzed clinical data, radiological characteristics and histogram parameters derived from ADC maps. Then, receiver operating characteristic curve (ROC) analyses were generated to determine the best diagnostic performance.

Results

The mean (p=0.002, cutoff=1.08×10^–3 s/mm²), coefficient of variation (CV) (p=0.040, cutoff=0.249) of the ADC map, carbohydrate antigen 199, and N stage with magnetic resonance (mrN stage) were independent factors for LNM. Combining these factors yielded the best diagnostic performance, with the area under the ROC curve of 0.838, 72.9% sensitivity, 79.1% specificity, 65.2% positive predictive value, and 84.5% negative predictive value.

Conclusion

With the mean >1.08×10^–3 s/mm² and CV <0.249, the ADC improved the diagnostic performance of LNM in T3 stage rectal cancer, which could assist surgeons with neoadjuvant chemoradiotherapy.

Apparent diffusion coefficient cannot discriminate metastatic and non-metastatic lymph nodes in rectal cancer: a meta-analysis

BACKGROUND

Our aim was to provide data regarding use of diffusion-weighted imaging (DWI) for distinguishing metastatic and non-metastatic lymph nodes (LN) in rectal cancer.

METHODS

MEDLINE library, EMBASE, and SCOPUS database were screened for associations between DWI and metastatic and non-metastatic LN in rectal cancer up to February 2021. Overall, 9 studies were included into the analysis. Number, mean value, and standard deviation of DWI parameters including apparent diffusion coefficient (ADC) values of metastatic and non-metastatic LN were extracted from the literature. The methodological quality of the studies was investigated according to the QUADAS-2 assessment. The meta-analysis was undertaken by using RevMan 5.3 software. DerSimonian, and Laird random-effects models with inverse-variance weights were used to account the heterogeneity between the studies. Mean DWI values including 95% confidence intervals were calculated for metastatic and non-metastatic LN.

RESULTS

ADC values were reported for 1376 LN, 623 (45.3%) metastatic LN, and 754 (54.7%) non-metastatic LN. The calculated mean ADC value (× 10^-3 mm²/s) of metastatic LN was 1.05, 95%CI (0.94, 1.15). The calculated mean ADC value of the non-metastatic LN was 1.17, 95%CI (1.01, 1.33). The calculated sensitivity and specificity were 0.81, 95%CI (0.74, 0.89) and 0.67, 95%CI (0.54, 0.79).

CONCLUSION

No reliable ADC threshold can be recommended for distinguishing of metastatic and non-metastatic LN in rectal cancer.

Value of High-resolution MRI in Detecting Lymph Node Calcifications in Patients with Rectal Cancer

RATIONALE AND OBJECTIVES

To analyze CT and high-resolution MRI findings of nodal metastasis calcifications and determine the value of high-resolution MRI in detecting nodal calcifications in rectal cancer patients.

MATERIALS AND METHODS

In total, 229 rectal cancer patients were included. The CT was reviewed for the presence of nodal calcifications by two radiologists. High-resolution two-dimensional turbo spin-echo T2-weighted imaging (2D-TSE-T2WI) and fat-suppressed gadolinium-enhanced isotropic high-resolution three-dimensional gradient-echo T1-weighted imaging (3D-GRE-T1WI) were independently reviewed for nodal calcifications by the two radiologists at one-month and two-month intervals, respectively. The sensitivities, specificities and accuracies of the two high-resolution MRI in detecting nodal calcifications were calculated using CT results as a reference.

RESULTS

Regional calcified metastatic lymph nodes were found in 28 patients. The node-to-node evaluation revealed that 55 (98.2%) of the 56 calcified lymph nodes were metastatic. Fifty-one (92.7%) calcified metastatic lymph nodes displayed scattered fine punctate calcifications to different degrees on CT. In both types of high-resolution MRI, the calcifications demonstrated a patchy area of markedly reduced signal intensity in corresponding areas that were larger than those on CT. The sensitivity and accuracy of fat-suppressed gadolinium-enhanced isotropic high-resolution 3D-GRE-T1WI were significantly higher than those of high-resolution 2D-TSE-T2WI (76.8% vs 58.9%, P = 0.013; 98.3% vs 97.9%, P = 0.007; respectively).

CONCLUSION

Metastatic nodal calcifications are characteristic imaging findings in rectal cancer. Calcifications are indicated by markedly reduced signal on high-resolution MRI, which will alert radiologists to scrutinize CT for nodal calcifications and aid in the accurate diagnosis of metastatic lymph nodes.

Intravoxel incoherent motion magnetic resonance imaging: basic principles and clinical applications

The purpose of this article was to show basic principles, acquisition, advantages, disadvantages, and clinical applications of intravoxel incoherent motion (IVIM) magnetic resonance imaging (MRI). IVIM MRI as a method was introduced in the late 1980s, but recently it started attracting more interest thanks to its applications in many fields, particularly in oncology and neuroradiology. This imaging technique has been developed with the objective of obtaining not only a functional analysis of different organs but also different types of lesions. Among many accessible tools in diagnostic imaging, IVIM MRI aroused the interest of many researchers in terms of studying its applicability in the evaluation of abdominal organs and diseases. The major conclusion of this article is that IVIM MRI seems to be a very auspicious method to investigate the human body, and that nowadays the most promising clinical application for IVIM perfusion MRI is oncology. However, due to lack of standardisation of image acquisition and analysis, further studies are needed to validate this method in clinical practice.

Assessment of pelvic lymph node metastasis in FIGO IB and IIA cervical cancer using quantitative dynamic contrast-enhanced MRI parameters

PURPOSE

We prospectively determined whether the quantitative parameters derived from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) are useful for predicting pelvic lymph node (LN) status in cervical cancer through node-by-node pathologic validation of images.

METHODS

Overall, 182 LNs harvested from 200 consecutive patients with 2018 FIGO stage IB-IIA cervical cancer (82 metastatic and 100 nonmetastatic) were used for node-by-node assessment. Each LN was quantitatively assessed using Ktrans, Ve, and Kep values. The short-axis diameter, ratio of the long-axis to short-axis diameter, and long-axis diameter were also assessed. Data on metastatic LNs were divided into four groups according to the FIGO staging system. Receiver operating characteristic (ROC) curve analysis was performed to evaluate statistically significant parameters derived from DCE-MRI for the differentiation of metastatic LNs from nonmetastatic LNs.

RESULTS

The mean short-axis diameter of metastatic LNs was significantly larger than that of nonmetastatic LNs (all P < 0.05) despite several overlaps. In comparison with nonmetastatic LNs, metastatic LNs showed a significantly lower Ktrans (all P < 0.05); however, Kep and Ve were not significantly different (all P > 0.05). For IB3 and IIA2 cervical cancer, Ktrans had moderate diagnostic ability for differentiating metastatic LNs from nonmetastatic LNs (for IB3: area under the curve [AUC] 0.740, 95% CI 0.657-0.838, 61.7% sensitivity, 80.2% specificity, P = 0.007; for IIA2: AUC 0.786, 95% CI 0.650-0.846, 60.2% sensitivity, 81.8% specificity, P = 0.008).

CONCLUSION

Ktrans appears to be a useful parameter for detecting metastatic LNs, especially for IB3 and IIA2 cervical cancer.

Value of intravoxel incoherent motion magnetic resonance imaging for differentiating metastatic from nonmetastatic mesorectal lymph nodes with different short-axis diameters in rectal cancer

Background

Conventional magnetic resonance imaging (MRI) does not accurately evaluate lymph node (LN) status, which is essential for the treatment and prognosis assessment in patients with rectal cancer.

Objective

The aim of this study is to evaluate the diagnostic value of intravoxel incoherent motion (IVIM) MRI in differentiating metastatic and nonmetastatic mesorectal LNs with different short-axis diameters in rectal cancer patients.

Materials and Methods

Forty patients (154 LNs) were divided into three groups based on short-axis diameter: 3 mm ≤ × ≤5 mm, 5 mm < × ≤7 mm, and × >7 mm. MRI characteristics and IVIM parameters were compared between the metastatic and nonmetastatic LNs to determine the diagnostic value for discriminating them.

Results

In the 3 mm ≤ × ≤ 5 mm group, mean D values were significantly lower in metastatic than in the nonmetastatic LNs (P < 0.001). In the 5 mm < × ≤7 mm group, mean f values were significantly lower in metastatic than nonmetastatic LNs (P < 0.05). In the × >7 mm group, only the short-axis diameter of metastatic LNs was significantly greater than that of nonmetastatic LNs (P < 0.05). The area under the curve, sensitivity, specificity, and cutoff values were used for differentiating the metastatic from the nonmetastatic LNs.

Conclusion

IVIM parameters can differentiate metastatic from nonmetastatic LNs with smaller short-axis diameters (× ≤7 mm) in rectal cancer, and the short-axis diameter is a significant factor in identifying metastatic and nonmetastatic LNs in larger short-axis diameter groups (× >7 mm).

Additional value of MRI-detected EMVI scoring system in rectal cancer: applicability in predicting synchronous metastasis

INTRODUCTION

Extramural vascular invasion (EMVI) has been recommended as an independent prognostic factor for poor overall survival rate in rectal cancer and can be used as a potential biomarker. Early prediction of prevalence of synchronous metastasis can elevate the disease-free survival rate. We aimed to evaluate the magnetic resonance imaging (MRI)-detected EMVI (mrEMVI) scoring system in predicting distant metastasis in T3 rectal cancer.

METHODS

Patients with postoperative histopathologically confirmed T3 rectal cancer without previous treatment from July 2014 to December 2015 were enrolled in this study. Two blinded radiologists evaluated mrEMVI status. mrEMVI was categorized as EMVI-positive or EMVI-negative in T2-weighted images using an mrEMVI scoring system. The results, along with other clinical characteristics (age, sex, tumor location, MRI-detected distance of mesorectal extension, lymphatic invasion, perineural invasion, mrEMVI score, and carcinoembryonic antigen [CEA]), were then correlated with synchronous metastases to determine the risk factors using univariate and multivariate analysis.

RESULTS

Of 180 patients, 38 were confirmed to be mrEMVI-positive, 142 mrEMVI-negative. There were 34 patients with synchronous metastasis, of whom 25 were mrEMVI-positive and 9 were mrEMVI-negative. Three factors were significantly associated with synchronous metastasis: mrEMVI (p = 0.001; odds ratio = 8.665), histopathologic lymphatic invasion (p = 0.001; odds ratio = 12.940), and preoperative CEA (p = 0.026; odds ratio = 4.124). mrEMVI score 4 was more likely for synchronous metastasis (p = 0.044; odds ratio = 9.429) than mrEMVI score 3 in rectal cancer.

CONCLUSIONS

mrEMVI positivity is an independent risk factor for synchronous distant metastasis in rectal cancer. mrEMVI score 4 is a stronger risk factor for synchronous metastasis than mrEMVI score 3 in rectal cancer.

Higher-order diffusion MRI characterization of mesorectal lymph nodes in rectal cancer

PURPOSE

Mesorectal lymph node staging plays an important role in treatment decision making. Here, we explore the benefit of higher-order diffusion MRI models accounting for non-Gaussian diffusion effects to classify mesorectal lymph nodes both 1) ex vivo at ultrahigh field correlated with histology and 2) in vivo in a clinical scanner upon patient staging.

METHODS

The preclinical investigation included 54 mesorectal lymph nodes, which were scanned at 16.4 T with an extensive diffusion MRI acquisition. Eight diffusion models were compared in terms of goodness of fit, lymph node classification ability, and histology correlation. In the clinical part of this study, 10 rectal cancer patients were scanned with diffusion MRI at 1.5 T, and 72 lymph nodes were analyzed with Apparent Diffusion Coefficient (ADC), Intravoxel Incoherent Motion (IVIM), Kurtosis, and IVIM-Kurtosis.

RESULTS

Compartment models including restricted and anisotropic diffusion improved the preclinical data fit, as well as the lymph node classification, compared to standard ADC. The comparison with histology revealed only moderate correlations, and the highest values were observed between diffusion anisotropy metrics and cell area fraction. In the clinical study, the diffusivity from IVIM-Kurtosis was the only metric showing significant differences between benign (0.80 ± 0.30 μm² /ms) and malignant (1.02 ± 0.41 μm² /ms, P = .03) nodes. IVIM-Kurtosis also yielded the largest area under the receiver operating characteristic curve (0.73) and significantly improved the node differentiation when added to the standard visual analysis by experts based on T₂ -weighted imaging.

CONCLUSION

Higher-order diffusion MRI models perform better than standard ADC and may be of added value for mesorectal lymph node classification in rectal cancer patients.

Non-invasive MR assessment of the microstructure and microcirculation in regional lymph nodes for rectal cancer: a study of intravoxel incoherent motion imaging

Background

The aim of this study is to evaluate the microstructure and microcirculation of regional lymph nodes (LNs) in rectal cancer by using non-invasive intravoxel incoherent motion MRI (IVIM-MRI), and to distinguish metastatic from non-metastatic LNs by quantitative parameters.

Methods

All recruited patients underwent IVIM-MRI (b = 0, 5, 10, 20, 30, 40, 60, 80, 100, 150, 200, 400, 600, 1000, 1500 and 2000 s/mm²) on a 3.0 T MRI system. One hundred sixty-eight regional LNs with a short-axis diameter equal to or greater than 5 mm from 116 patients were evaluated by two radiologists independently, including 78 malignant LNs and 90 benign LNs. The following parameters were assessed: the short-axis diameter (S), long-axis diameter (L), short- to long-axis diameter ratio (S/L), pure diffusion coefficient (D), pseudo-diffusion coefficient (D^*), and perfusion factor (f). Intraclass correlation coefficients (ICCs) were calculated to assess the interobserver agreement between two readers. Receiver operating characteristic curves were applied for analyzing statistically significant parameters.

Results

Interobserver agreement of IVIM-MRI parameters between two readers was excellent (ICCs> 0.75). The metastatic group exhibited higher S, L and D (P < 0.001), but lower f (P < 0.001) than the non-metastatic group. The area under the curve (95% CI, sensitivity, specificity) of the multi-parameter combined equation for D, f and S was 0.811 (0.744~0.868, 62.82%, 87.78%). The diagnostic performance of the multi-parameter model was better than that of an individual parameter (P < 0.05).

Conclusion

IVIM-MRI parameters provided information about the microstructure and microcirculation of regional LNs in rectal cancer, also improved diagnostic performance in identifying metastatic LNs.

Differential detection of metastatic and inflammatory lymph nodes using intravoxel incoherent motion diffusion-weighted imaging

PURPOSE

This study sought to monitor the dynamic process of lymph node (LN) metastasis with intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI), and to investigate the impact of disease course on the detection of metastatic LNs by IVIM-DWI.

METHODS

Twenty female New Zealand rabbits with 2.5-3.0 kg body weight were studied. VX2 cells and egg yolk emulsion were randomly inoculated into one thigh to induce metastatic and inflammatory popliteal LNs, respectively. Eight rabbits underwent IVIM-DWI (14 b values, 0-2000 s/mm²) 2 h prior to, and 14, 21, and 28 days after inoculation (D0, D14, D21, D28). The apparent diffusion coefficient (ADC), true diffusion coefficient (D), pseudodiffusion coefficient (D*), and perfusion fraction (f) were measured and compared between the metastatic and the inflammatory groups at each time point. Three rabbits randomly chosen from the remaining twelve rabbits were sacrificed at each time point to perform hematoxylin and eosin staining and histologic evaluation.

RESULTS

The patterns of dynamic change of D*, ADC, and D were different between the metastatic and the inflammatory LNs. The metastatic group had a lower D* value at D14 (p = .003), and greater ADC and D values at both D21 (p = .001, p = .001) and D28 (p = .021, p = .001), compared to the inflammatory group. The f value of the metastatic group was greater than that of the inflammatory only at D28 (p = .001).

CONCLUSIONS

IVIM-DWI can reflect the dynamic process of LN metastasis, and disease course has a significant influence on the ability of IVIM-DWI to detect metastatic nodes.

Role of intravoxel incoherent motion MRI in preoperative evaluation of DNA mismatch repair status in rectal cancers

AIM

To explore the role of intravoxel incoherent motion (IVIM) magnetic resonance imaging (MRI) in evaluating DNA mismatch repair (MMR) status of rectal cancers preoperatively.

MATERIALS AND METHODS

Seventy-six patients with a diagnosis of rectal cancer confirmed at endoscopic biopsy were enrolled prospectively and underwent IVIM MRI before surgery.

RESULTS

The perfusion fraction (f) values of MMR proteins (MMRP) positive rectal cancers were significantly higher than negative cancers. The f values could differentiate MMRP positive rectal cancers from negative cancers with an area under the curve (AUC) of 0.695. The vascular endothelial growth factor (VEGF) and vascular endothelial growth factor receptor 2 (VEGFR2) expression rates of positive MMRP rectal cancers were significantly higher than negative cancers.

CONCLUSION

This pilot study indicated that the f value derived from IVIM MRI differed significantly between rectal cancers with different MMRP expression levels, which might be involved with different VEGF and VEGFR2 expression rates.

Diffusion-weighted imaging in rectal cancer: current applications and future perspectives

This review summarizes current applications and clinical utility of diffusion-weighted imaging (DWI) for rectal cancer and in addition provides a brief overview of more recent developments (including intravoxel incoherent motion imaging, diffusion kurtosis imaging, and novel postprocessing tools) that are still in more early stages of research. More than 140 papers have been published in the last decade, during which period the use of DWI have slowly moved from mainly qualitative (visual) image interpretation to increasingly advanced methods of quantitative analysis. So far, the largest body of evidence exists for assessment of tumour response to neoadjuvant treatment. In this setting, particularly the benefit of DWI for visual assessment of residual tumour in post-radiation fibrosis has been established and is now increasingly adopted in clinics. Quantitative DWI analysis (mainly the apparent diffusion coefficient) has potential, both for response prediction as well as for tumour prognostication, but protocols require standardization and results need to be prospectively confirmed on larger scale. The role of DWI for further clinical tumour and nodal staging is less well-defined, although there could be a benefit for DWI to help detect lymph nodes. Novel methods of DWI analysis and post-processing are still being developed and optimized; the clinical potential of these tools remains to be established in the upcoming years.

Could intravoxel incoherent motion diffusion-weighted magnetic resonance imaging be feasible and beneficial to the evaluation of gastrointestinal tumors histopathology and the therapeutic response?

Gastrointestinal tumors (GTs) are among the most common tumors of the digestive system and are among the leading causes of cancer death worldwide. Functional magnetic resonance imaging (MRI) is crucial for assessment of histopathological changes and therapeutic responses of GTs before and after chemotherapy and radiotherapy. A new functional MRI technique, intravoxel incoherent motion (IVIM), could reveal more detailed useful information regarding many diseases. Currently, IVIM is widely used for various tumors because the derived parameters (diffusion coefficient, D; pseudo-perfusion diffusion coefficient, D*; and perfusion fraction, f) are thought to be important surrogate imaging biomarkers for gaining insights into tissue physiology. They can simultaneously reflect the microenvironment, microcirculation in the capillary network (perfusion) and diffusion in tumor tissues without contrast agent intravenous administration. The sensitivity and specificity of these parameters used in the evaluation of GTs vary, the results of IVIM in GTs are discrepant and the variability of IVIM measurements in response to chemotherapy and/or radiotherapy in these studies remains a source of controversy. Therefore, there are questions as to whether IVIM diffusion-weighted MRI is feasible and helpful in the evaluation of GTs, and whether it is worthy of expanded use.

Role of Quantitative Dynamic Contrast-Enhanced MRI in Evaluating Regional Lymph Nodes With a Short-Axis Diameter of Less Than 5 mm in Rectal Cancer

OBJECTIVE

The aim of this study was to discriminate metastatic from nonmetastatic regional lymph nodes (LNs) with short-axis diameters of less than 5 mm in rectal cancer using quantitative parameters derived from dynamic contrast-enhanced (DCE) MRI.

SUBJECTS AND METHODS

Sixty-five LNs from 122 patients were evaluated, including malignant LNs (n = 27) and benign LNs (n = 38). The following parameters were assessed: the forward volume transfer constant (K^trans), reverse volume transfer constant (k_ep), fractional extravascular extracellular space volume (Ve), short-axis diameter, long-axis diameter, and short- to long-axis diameter ratio. ROC curves were used to analyze statistically significant parameters.

RESULTS

Metastatic LNs exhibited a lower K^trans than did nonmetastatic LNs (p < 0.001), but the other parameters were not significantly different between the two groups. The AUC of the K^trans was 0.732, with a 95% CI of 0.610-0.854, and the diagnostic cutoff value was 0.088 min^-1 (sensitivity, 60.5%; specificity, 81.5%).

CONCLUSION

K^trans had moderate diagnostic performance in assessing small regional LNs in rectal cancer and appears to be a useful predictor when distinguishing malignant LNs from benign LNs only by morphology is difficult.

Intravoxel incoherent motion magnetic resonance imaging for differentiating metastatic and non-metastatic lymph nodes in pancreatic ductal adenocarcinoma

OBJECTIVES

To evaluate the diagnostic potential of intravoxel incoherent motion (IVIM) DWI for differentiating metastatic and non-metastatic lymph node stations (LNS) in pancreatic ductal adenocarcinoma (PDAC).

METHODS

59 LNS histologically diagnosed following surgical resection from 15 patients were included. IVIM DWI with 12 b values was added to the standard MRI protocol. Evaluation of parameters was performed pre-operatively and included the apparent diffusion coefficient (ADC), pure diffusion coefficient (D), pseudo-diffusion coefficient (D*) and perfusion fraction (f). Diagnostic performance of ADC, D, D* and f for differentiating between metastatic and non-metastatic LNS was evaluated using ROC analysis.

RESULTS

Metastatic LNS had significantly lower D, D*, f and ADC values than the non-metastatic LNS (p< 0.01). The best diagnostic performance was found in D, with an area under the ROC curve of 0.979, while the area under the ROC curve values of D*, f and ADC were 0.867, 0.855 and 0.940, respectively. The optimal cut-off values for distinguishing metastatic and non-metastatic lymph nodes were D = 1.180 × 10-3 mm2/s; D* = 14.750 × 10-3 mm2/s, f = 20.65 %, and ADC = 1.390 × 10-3 mm2/s.

CONCLUSION

IVIM DWI is useful for differentiating between metastatic and non-metastatic LNS in PDAC.

KEY POINTS

• IVIM DWI is feasible for diagnosing LN metastasis in PDAC. • Metastatic LNS has lower D, D*, f, ADC values than non-metastatic LNS. • D-value from IVIM model has best diagnostic performance, followed by ADC value. • D* has the lowest AUC value.

Improved detection of a tumorous involvement of the mesorectal fascia and locoregional lymph nodes in locally advanced rectal cancer using DCE-MRI

PURPOSE

The prediction of an infiltration of the mesorectal fascia (MRF) and malignant lymph nodes is essential for treatment planning and prognosis of patients with rectal cancer. The aim of this study was to assess the additional diagnostic value of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for the detection of a malignant involvement of the MRF and of mesorectal lymph nodes in patients with locally advanced rectal cancer.

METHODS

In this prospective study, 22 patients with locally advanced rectal cancer were examined with 1.5-T MRI between September 2012 and April 2015. Histopathological assessment of tumor size, tumor infiltration to the MRF, and malignant involvement of locoregional lymph nodes served as standard of reference. Sensitivity and specificity of detecting MRF infiltration and malignant nodes (nodal cut-off size [NCO] ≥ 5 and ≥ 10 mm, respectively) was determined by conventional MRI (cMRI; precontrast and postcontrast T1-weighted, T2-weighted, and diffusion-weighted images) and by additional semi-quantitative DCE-MRI maps (cMRI+DCE-MRI).

RESULTS

Compared to cMRI, additional semi-quantitative DCE-MRI maps significantly increased sensitivity (86 vs. 71% [NCO ≥ 5 mm]/29% [NCO ≥ 10 mm]) and specificity (90 vs. 70% [NCO ≥ 5 mm]) of detecting malignant lymph nodes (p < 0.05). Moreover, DCE-MRI significantly augmented specificity (91 vs. 82%) of discovering a MRF infiltration (p < 0.05), while there was no change in sensitivity (83%; p > 0.05).

CONCLUSION

DCE-MRI considerably increases both sensitivity and specificity for the detection of small mesorectal lymph node metastases (≥ 5 mm but < 10 mm) and sufficiently improves specificity of a suspected MRF infiltration in patients with locally advanced rectal cancer.

Intravoxel incoherent motion diffusion-weighted magnetic resonance imaging in characterization of axillary lymph nodes: Preliminary animal experience

PURPOSE

To investigate the diagnostic value of intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI) for discriminating axillary metastatic from non-metastatic lymph nodes (LNs) in rabbit models.

MATERIALS AND METHODS

The institutional animal care and use committee approved this study. Forty New Zealand white rabbits were randomly divided into two groups. The axillary LN models were created by inoculating VX2 cell suspension and complete Freund's adjuvant in the mammary glands of 20 female rabbits of each group, respectively. Conventional MRI and IVIM DWI were performed after animal models successfully established. Images of axillary LNs were analyzed with regard to long-axis diameter (L), short-axis diameter (S), apparent diffusion coefficient (ADC) and IVIM parameters (D, D*, f). Receiver operating characteristic analyses were conducted to determine the diagnostic performance of aforementioned criteria.

RESULTS

A total of 42 metastatic and 30 non-metastatic LNs were successfully isolated. ADC and D of metastatic LNs were significantly lower than those of non-metastatic ones (all P < 0.001), whereas D* was statistically higher (P = 0.033). L, S, and f showed no significant difference between the two groups (P = 0.089, 0.058, 0.054, respectively). Optimal cutoff values, area under the curve, sensitivity, and specificity for differentiation were as follows: ADC = 1.101 × 10^-3 mm²/s, 0.886, 78.6%, 90.0%; D = 0.938 × 10^-3 mm²/s, 0.927, 83.3%, 93.3%; and D* = 12.635 × 10^-3 mm²/s, 0.657, 52.4%, 80.0%.

CONCLUSION

IVIM DWI is useful to distinguish metastatic from non-metastatic LNs in axilla. D was the most discriminative variable for predicting metastatic LNs.

Advanced Imaging Techniques in Evaluation of Colorectal Cancer

Imaging techniques are clinical decision-making tools in the evaluation of patients with colorectal cancer (CRC). The aim of this article is to discuss the potential of recent advances in imaging for diagnosis, prognosis, therapy planning, and assessment of response to treatment of CRC. Recent developments and new clinical applications of conventional imaging techniques such as virtual colonoscopy, dual-energy spectral computed tomography, elastography, advanced computing techniques (including volumetric rendering techniques and machine learning), magnetic resonance (MR) imaging-based magnetization transfer, and new liver imaging techniques, which may offer additional clinical information in patients with CRC, are summarized. In addition, the clinical value of functional and molecular imaging techniques such as diffusion-weighted MR imaging, dynamic contrast material-enhanced imaging, blood oxygen level-dependent imaging, lymphography with contrast agents, positron emission tomography with different radiotracers, and MR spectroscopy is reviewed, and the advantages and disadvantages of these modalities are evaluated. Finally, the future role of imaging-based analysis of tumor heterogeneity and multiparametric imaging, the development of radiomics and radiogenomics, and future challenges for imaging of patients with CRC are discussed. Online supplemental material is available for this article. ^©RSNA, 2018.

Discrimination of Malignant versus Benign Mediastinal Lymph Nodes Using Diffusion MRI with an IVIM Model

OBJECTIVES

To investigate the value of an intravoxel incoherent motion (IVIM) diffusion model for discriminating malignant versus benign mediastinal lymph nodes (MLN).

METHODS

Thirty-five subjects with enlarged MLN were scanned at 1.5 Tesla. Diffusion-weighted imaging was performed with eight b-values. IVIM parameters D, D*, and f, as well as apparent diffusion coefficient (ADC) from a mono-exponential model were obtained. 91 nodes (49 malignant and 42 benign) were analysed with pathologic (n=90) or radiologic (n=1) confirmations. Receiver operating characteristic (ROC) analysis was used to evaluate the diagnostic performance.

RESULTS

The mean values of D, ADC, and f for the malignant group were significantly lower than those for the benign group (p<0.001), while D* showed no significant difference (p=0.281). In the ROC analysis, the combination of D and f produced the largest area under the curve (0.953) compared to ADC or other individual IVIM parameters, leading to the best specificity (92.9%) and diagnostic accuracy (90.1%).

CONCLUSION

This study demonstrates that the combination of IVIM parameters can improve differentiation between malignant and benign MLN as compared to using ADC alone.

KEY POINTS

• Diffusion MRI is useful for non-invasively discriminating malignant versus benign lymph nodes. • A mono-exponential model is not adequate to characterise diffusion process in lymph nodes. • IVIM model is advantageous over mono-exponential model for assessing lymph node malignancy. • Combination of IVIM parameters improves differentiation of malignant versus benign lymph nodes.

Intravoxel Incoherent Motion Diffusion-Weighted Magnetic Resonance Imaging of Cervical Cancer With Different b-Values

OBJECTIVE

The aims of this study were to evaluate the dependence of diffusion parameters on the b values adopted for intravoxel incoherent motion diffusion-weighted magnetic resonance imaging and to investigate the application value of multiple diffusion parameters obtained from monoexponential and biexponential models in subjects with a normal cervix and in cervical cancer patients.

METHODS

A total of 120 female patients with cervical cancer and 21 female control subjects with a normal cervix underwent diffusion-weighted magnetic resonance imaging with 13 b values (0-2000 s/mm) at 3 T. The standard apparent diffusion coefficient (Dst), diffusion coefficient (D), pseudodiffusion coefficient (D*), and perfusion fraction (f) were calculated by fitting with monoexponential and biexponential models at 2 different ranges of b values: 0 to 1000 and 0 to 2000 s/mm. A univariate analysis was performed to identify factors that could distinguish cervical carcinoma from normal cervical tissue. Parameters that correlated with the pathological grade and stage of cervical cancer were also evaluated. Receiver operating characteristic curves were used to evaluate the diagnostic efficiency of every parameter.

RESULTS

All the tested parameters, except the D* of the 2 different ranges of b value groups, significantly differed between the patients with cervical carcinoma and control subjects (P < 0.01). D2000, Dst2000, and D1000 showed comparable diagnostic value, with an area under the curve of 0.923, 0.909, and 0.907, respectively. Dst2000, D2000, Dst1000, and D1000 differed significantly among the 3 degrees of cervical stromal infiltration depth (P < 0.05).

CONCLUSIONS

D2000 and Dst2000 tended to outperform D1000 in terms of diagnostic efficiency, but there was no significant difference in their ability to differentiate cervical carcinoma from normal cervix. Cervical cancers with lower Dst and D values tended to have greater infiltration depth.

A preliminary exploration of the intravoxel incoherent motion applied in the preoperative evaluation of mediastinal lymph node metastasis of lung cancer

BACKGROUND

The aim of this study was to investigate the diagnostic value of the intravoxel incoherent motion (IVIM) for distinguishing non-metastatic from metastatic mediastinal lymph nodes in lung cancer.

METHODS

IVIM-diffusion weighted imaging (DWI) exams were performed preoperatively on 66 patients with lung cancer from October 2015 to June 2016 in Beijing Chao-Yang Hospital, Capital Medical University. Fifty patients underwent enhanced chest computed tomography (CT) in our hospital, while the other 16 patients already had enhanced chest CT images when they were admitted. The patients' complete preoperative examination included chest magnetic resonance imaging (MRI), enhanced chest CT, head MRI, bone scanning and cardiopulmonary function testing. None of the patients were receiving any treatment for their cancer prior to their evaluation and surgery, including neoadjuvant chemotherapy, radiation therapy, immunotherapy or gene targeted therapy. The following IVIM parameters of the mediastinal lymph nodes were measured: the short axis diameter, apparent diffusion coefficient (ADC), diffusion coefficient (D), pseudo-diffusion coefficient (D*), and perfusion fraction (f). All of the patients underwent lobectomy and lymph node dissection. We compared the CT and MRI results and analysed the IVIM parameters of the pathologically determined non-metastatic and metastatic mediastinal lymph nodes in our 50 patients to generate the ROC curves and determine the best cut-off value for diagnosis. The remaining 16 patients' IVIM parameters were used to verify the diagnostic cut-off value. This study was approved by the institutional research ethics committee of Beijing Chao-Yang Hospital (2014-S-166), and all the patients signed the MRI informed consent.

RESULTS

In this study, MRI was used to measure 140 groups of mediastinal lymph nodes in 50 cases, and the results showed that 19 groups of mediastinal lymph nodes were metastatic, while 121 groups of mediastinal lymph nodes were non-metastatic. The pathological analysis showed that 20 groups of mediastinal lymph nodes were metastatic and 120 groups of mediastinal lymph nodes were non-metastatic. CT was used to measure 273 groups of mediastinal lymph nodes, and the result showed that 34 groups of mediastinal lymph nodes were metastatic, while 239 groups of mediastinal lymph nodes were non-metastatic. The pathological analysis showed that 20 groups of mediastinal lymph nodes were metastatic and 253 groups of mediastinal lymph nodes were non-metastatic. The ADC, D, D*, f values and the short axis diameters of the non-metastatic lymph nodes (n=121) were 2.9370±0.743×10^-3, 0.533±0.175×10^-3, 0.384±0.121×10^-3 mm²/s, 0.426±0.120, 6.903±1.831 mm, respectively, and 1.863±0.691×10^-3, 0.454±0.204×10^-3, 0.358±0.106×10^-3 mm²/s, 0.413±0.085, 7.705±2.213 mm, respectively, for the metastatic lymph nodes (n=19). The ADC and D values of the non-metastatic lymph nodes were significantly higher than the values for the metastatic lymph nodes (P<0.01); the other parameters (D*, f, and short axis diameter) did not show significantly different results between the two groups. The optimal cut-off values [area under the curve (AUC), sensitivity, and specificity] for distinguishing metastatic from non-metastatic lymph nodes were as follows: ADC =1.890×10^-3 mm²/s (0.897, 93.3%, 80.0%), Youden index 0.733; and D =0.344×10^-3 mm²/s (0.651, 90.8%, 50.0%), Youden index 0.651. When these cut-off values were applied as the diagnostic criteria in the remaining cases and compared with the pathology results, the diagnostic performance was good.

CONCLUSIONS

IVIM is useful to distinguish metastatic from non-metastatic lymph nodes in lung cancer. The ADC and the D values are significantly lower in metastatic lymph nodes, making these parameters more sensitive than the other parameters (D*, f, and short axis diameter). As a result, IVIM can be used in the N-stage diagnosis of lung cancer.