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Yadav VK, Sharma S, Maurya S, Singh RK, Saini J, Jain P, Patir R, Ahlawat S, Das S, Vaishya S, Agarwal S, Singh A, Gupta RK. Presence of Fragmented Intratumoral Thrombosed Microvasculature in the Necrotic and Peri-Necrotic Regions on SWI Differentiates IDH Wild-Type Glioblastoma From IDH Mutant Grade 4 Astrocytoma. J Magn Reson Imaging 2025. [PMID: 39781627 DOI: 10.1002/jmri.29695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2024] [Revised: 12/13/2024] [Accepted: 12/14/2024] [Indexed: 01/12/2025] Open
Abstract
BACKGROUND Isocitrate dehydrogenase (IDH) wild-type (IDHwt) glioblastomas (GB) are more aggressive and have a poorer prognosis than IDH mutant (IDHmt) tumors, emphasizing the need for accurate preoperative differentiation. However, a distinct imaging biomarker for differentiation mostly lacking. Intratumoral thrombosis has been reported as a histopathological biomarker for GB. PURPOSE To evaluate the fragmented intratumoral thrombosed microvasculature (FTV) signs on susceptibility-weighted imaging (SWI) for distinguishing IDHwt and IDHmt tumors. STUDY TYPE Retrospective. SUBJECTS Ninety-seven treatment-naïve patients with histopathologically confirmed IDHwt GB (54 males, 26 females) and IDHmt grade 4 astrocytoma (13 males, 4 females). FIELD STRENGTH/SEQUENCE 3-T, SWI, fluid-attenuated-inversion-recovery (FLAIR), T1-weighted, T2-weighted, PD-weighted, post-contrast T1-weighted and dynamic-contrast-enhanced (DCE)-MRI. ASSESSMENT SWI data were evaluated by three experienced neuroradiologists (S.S., 11 years; J.S., 15 years; R.K.G., 40 years of experience), who assessed FTV presence in necrotic and peri-necrotic regions. FTV was identified as intratumoral susceptibility signal having minimal or no interslice connections. Quantitative DCE-MRI parameters were derived using first-pass-analysis and extended Tofts model. FLAIR abnormal, contrast-enhancing, and necrotic regions were segmented using in-house developed U-Net architecture. STATISTICAL TESTS Fleiss' Kappa, Cohen's Kappa, Shapiro-Wilk test, t tests or Mann-Whitney U test, receiver-operating characteristic (ROC) analysis, confusion matrix. A P-value <0.05 was considered statistically significant. RESULTS Fleiss' kappa test provided 91% inter-rater agreement, and Cohen's kappa provided intrarater agreement ranged from 81% to 97%. The raters' accuracy in distinguishing IDHwt from IDHmt ranged from 92% to 94%. Some of the quantitative DCE-MRI parameters (CBV, Ve, and Ktrans) provided statistically significant differences in differentiating IDHwt and IDHmt. Ktrans demonstrated 80.3% sensitivity and 81.2% specificity, with ROC analysis showing an AUC of 0.77. DATA CONCLUSION FTV signs in necrotic and peri-necrotic regions on SWI demonstrated a high accuracy in distinguishing IDHwt from IDHmt. Qualitative assessment of FTV signs showed almost perfect inter-rater and intrarater agreement. Quantitative DCE-MRI metrics also showed statistically significant differentiation of IDHwt and IDHmt. PLAIN LANGUAGE SUMMARY This study demonstrates that preoperative imaging, particularly the visualization of the fragmented thrombosed vasculature (FTV) sign on susceptibility-weighted imaging (SWI), effectively differentiates isocitrate dehydrogenase (IDH) wild-type (IDHwt) glioblastoma (GB) from IDH mutant (IDHmt) grade 4 astrocytomas. Over 90% of IDHwt GB patients displayed the FTV sign, a specific imaging biomarker absent in IDHmt cases. Perfusion parameters such as cerebral blood volume, Ve, and Ktrans were elevated in IDHwt gliomas, reflecting distinct vascular profiles. SWI offers a noninvasive and accurate diagnostic method, overcoming limitations of histopathology. Despite limitations like unequal sample sizes and retrospective analysis, this study underscores the clinical potential of SWI in improving glioma characterization and aiding treatment planning. LEVEL OF EVIDENCE 4 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Virendra Kumar Yadav
- Centre for Biomedical Engineering, Indian Institute of Technology Delhi, New Delhi, India
| | - Shalini Sharma
- Department of Radiology, Fortis Memorial Research Institute, Gurugram, India
| | - Satyajit Maurya
- Centre for Biomedical Engineering, Indian Institute of Technology Delhi, New Delhi, India
| | - Rakesh K Singh
- Department of Radiology, Fortis Memorial Research Institute, Gurugram, India
| | - Jitendra Saini
- Department of the Neuroimaging and Interventional Radiology, NIMHANS, Bengaluru, India
| | - Preeti Jain
- Department of Pathology, Agilus-Fortis Memorial Research Institute, Gurugram, India
| | - Rana Patir
- Department of Neurosurgery, Fortis Memorial Research Institute, Gurugram, India
| | - Sunita Ahlawat
- Department of Pathology, Agilus-Fortis Memorial Research Institute, Gurugram, India
| | - Sumanta Das
- Department of the Neuroimaging and Interventional Radiology, NIMHANS, Bengaluru, India
| | - Sandeep Vaishya
- Department of Neurosurgery, Fortis Memorial Research Institute, Gurugram, India
| | - Sumeet Agarwal
- Department of Electrical Engineering, Indian Institute of Technology Delhi, New Delhi, India
- Yardi School of Artificial Intelligence, Indian Institute of Technology Delhi, New Delhi, India
| | - Anup Singh
- Centre for Biomedical Engineering, Indian Institute of Technology Delhi, New Delhi, India
- Yardi School of Artificial Intelligence, Indian Institute of Technology Delhi, New Delhi, India
| | - Rakesh K Gupta
- Department of Radiology, Fortis Memorial Research Institute, Gurugram, India
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Mandel JJ, Youssef M, Yust-Katz S, Patel AJ, Jalali A, Li Z, Wu J, Ludmir EB, de Groot JF. IDH mutation status and the development of venous thromboembolism in astrocytoma patients. J Neurol Sci 2021; 427:117538. [PMID: 34146775 DOI: 10.1016/j.jns.2021.117538] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/21/2021] [Accepted: 06/10/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a very common adverse event for astrocytoma patients, but validation of proposed risk biomarkers has been elusive. We examine whether the status of the isocitrate dehydrogenase (IDH) gene is a risk factor for the development of venous thromboembolism (VTE) in astrocytoma patients. METHODS We conducted a retrospective chart review of 282 astrocytoma patients enrolled in the PROACTIVE (Prospective Assessment of Correlative Biomarker) study at MD Anderson Cancer Center (MDACC) from 9/1/2000 until 12/31/2013. RESULTS We identified 282 astrocytoma patients consisting of 49 IDH mutant astrocytomas and 233 IDH wildtype astrocytomas. Glioblastoma was the initial histopathologic diagnosis in 30 (61.2%) of the IDH mutated astrocytomas compared to 227(97.4%) of the IDH wild type astrocytomas. VTE was identified in 52 (18.4%) of patients. VTE was diagnosed in 7 (14.3%) of the IDH mutated astrocytomas compared to 45(19.3%) of the IDH wild type astrocytoma s (p = 0.4094). Median time to VTE from diagnosis was 2.71 months. Median time to VTE from diagnosis was 2.6 months for IDH mutated astrocytomas compared to 3.06 months for the IDH wild type astrocytomas (p = 0.8663). CONCLUSIONS IDH gene status did not appear as a significant risk factor for the development of venous thromboembolism (VTE) in our cohort of astrocytoma patients. Further research into potential biomarkers for VTE may be warranted.
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Affiliation(s)
- Jacob J Mandel
- Baylor College of Medicine, Department of Neurology and Neurosurgery, One Baylor Plaza, MS NB302, Houston, TX 77030, United States of America
| | | | - Shlomit Yust-Katz
- Rabin Medical Center, Department of Neurosurgery, 39 Jabotinski St, Petah Tikva, Israel; Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Akash J Patel
- Baylor College of Medicine, Department of Neurology and Neurosurgery, One Baylor Plaza, MS NB302, Houston, TX 77030, United States of America
| | - Ali Jalali
- Baylor College of Medicine, Department of Neurology and Neurosurgery, One Baylor Plaza, MS NB302, Houston, TX 77030, United States of America
| | - Ziyi Li
- The University of Texas MD Anderson Cancer Center, Department of Biostatistics, Unit 1409, P. O. Box 301402, Houston, TX 77230-1402, United States of America
| | - Jimin Wu
- The University of Texas MD Anderson Cancer Center, Department of Biostatistics, Unit 1409, P. O. Box 301402, Houston, TX 77230-1402, United States of America
| | - Ethan B Ludmir
- The University of Texas MD Anderson Cancer Center, Division of Radiation Oncology - Unit 1422, 1400 Pressler St., FCT6.5000, Houston, TX 77030, United States of America
| | - John F de Groot
- The University of Texas MD Anderson Cancer Center, Department of Neuro-Oncology, Unit 431, 1515 Holcombe Blvd, Houston, TX 77030-4009, United States of America.
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Abstract
Vascular complications in patients with glioma most commonly include venous and arterial thromboembolism; however, treatment-induced vasculopathies are also problematic, especially in long-term survivors. The interactions between treatment such as radiation and chemotherapy, the coagulation cascade, endothelium, and regulators of angiogenesis are complex, drive glioma growth and invasion, and create common management problems in the clinic. We review the incidence of thrombotic complications in glioma, the biology of the coagulome as related to glioma progression, prevention and treatment of thrombosis, the role of anticoagulants as anticancer therapy, and vascular complications such as ischemic stroke and intracranial bleeding. The coagulation cascade is intimately involved in cancer-related thrombosis, glioma progression, and vascular complications of glioma therapy. Tissue factor is the principal initiator of coagulation and is upregulated in a glioma subtype-specific fashion. Short-term (perioperative) antithrombotic prophylaxis is effective, but long-term anticoagulation, although attractive, is not routinely indicated. Most patients with symptomatic venous thromboembolism can be safely anticoagulated, including those on anti-vascular endothelial growth factor therapeutics such as bevacizumab. Initial therapy should include low-molecular-weight heparin, and protracted anticoagulant treatment, perhaps indefinitely, is indicated. Many complex interactions resulting in vessel wall injury can lead to ischemic stroke, intracranial and intratumoral hemorrhage, and long-term sequelae such as cognitive impairment.
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Affiliation(s)
- Emilie Le Rhun
- Neuro-oncology, Department of Neurosurgery, University Hospital and Breast Unit, Department of Medical Oncology, Oscar Lambret Center, Lille, France
| | - James R Perry
- Division of Neurology, Odette Cancer Centre and Sunnybrook Health Science Centre, University of Toronto, Toronto, Canada.
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Frisius J, Ebeling M, Karst M, Fahlbusch R, Schedel I, Gerganov V, Samii A, Lüdemann W. Prevention of venous thromboembolic complications with and without intermittent pneumatic compression in neurosurgical cranial procedures using intraoperative magnetic resonance imaging. A retrospective analysis. Clin Neurol Neurosurg 2015; 133:46-54. [DOI: 10.1016/j.clineuro.2015.03.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 02/27/2015] [Accepted: 03/05/2015] [Indexed: 11/16/2022]
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Abstract
The coagulation system constitutes an important facet of the unique vascular microenvironment in which primary and metastatic brain tumors evolve and progress. While brain tumor cells express tissue factor (TF) and other effectors of the coagulation system (coagulome), their propensity to induce local and peripheral thrombosis is highly diverse, most dramatic in the case of glioblastoma multiforme (GBM), and less obvious in pediatric tumors. While the immediate medical needs often frame the discussion on current clinical challenges, the coagulation pathway may contribute to brain tumor progression through subtle, context-dependent, and non-coagulant effects, such as induction of inflammation, angiogenesis, or by responding to iatrogenic insults (e.g. surgery). In this regard, the emerging molecular diversity of brain tumor suptypes (e.g. in glioma and medulloblastoma) highlights the link between oncogenic pathways and the tumor repertoire of coagulation system regulators (coagulome). This relationship may influence the mechanisms of spontaneous and therapeutically provoked tumor cell interactions with the coagulation system as a whole. Indeed, oncogenes (EGFR, MET) and tumor suppressors (PTEN, TP53) may alter the expression, activity, and vesicular release of tissue factor (TF), and cause other changes. Conversely, the coagulant microenvironment may also influence the molecular evolution of brain tumor cells through selective and instructive cues. We suggest that effective targeting of the coagulation system in brain tumors should be explored through molecular stratification, stage-specific analysis, and more personalized approaches including thromboprophylaxis and adjuvant treatment aimed at improvement of patient survival.
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Affiliation(s)
- Esterina D'Asti
- Department of Pediatrics, McGill University. Montreal Children's Hospital, The Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Yi Fang
- Department of Pediatrics, McGill University. Montreal Children's Hospital, The Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Janusz Rak
- Department of Pediatrics, McGill University. Montreal Children's Hospital, The Research Institute of the McGill University Health Centre, Montreal, QC, Canada
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Abstract
Venous thromboembolism (VTE) is common throughout the course of disease in high-grade glioma (HGG). The interactions between the coagulation cascade, endothelium, and regulation of angiogenesis are complex and drive glioblastoma growth and invasion. We reviewed the incidence of VTE in HGG, the biology of the coagulome as related to glioblastoma progression, prevention and treatment of thrombosis, and the putative role of anticoagulants as anti-cancer therapy. VTE can be significantly reduced during the postoperative period with adherence to the use of mechanical and medical thromboprophylaxis. Activation of the coagulation cascade occurs throughout the course of disease because of a variety of complex interactions, including tumor hypoxia, upregulation of VEGR expression, and increases in both tumor cell-specific tissue factor (TF) expression and inducible TF expression in numerous intrinsic regulatory pathways. Long-term anticoagulation to prevent VTE is an attractive therapy; however, the therapeutic window is narrow and current data do not support its routine use. Most patients with proven symptomatic VTE can be safely anticoagulated, including those receiving anti-VEGF therapy, such as bevacizumab. Initial therapy should include low molecular weight heparin (LMWH), and protracted anticoagulant treatment, perhaps indefinitely, is indicated for patients with HGG because of the ongoing risk of thrombosis. A variety of coagulation- and tumor-related proteins, such as TF and circulating microparticles, may serve as potential disease-specific biomarkers in relation to disease recurrence, monitoring of therapy, and as potential therapeutic targets.
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Affiliation(s)
- James R Perry
- Division of Neurology and Odette Cancer Centre, University of Toronto, Canada.
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Anand M, Brat DJ. Oncogenic regulation of tissue factor and thrombosis in cancer. Thromb Res 2012; 129 Suppl 1:S46-9. [DOI: 10.1016/s0049-3848(12)70015-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Prayson NF, Koch P, Angelov L, Prayson RA. Microscopic thrombi in anaplastic astrocytoma predict worse survival? Ann Diagn Pathol 2011; 15:389-93. [PMID: 21849253 DOI: 10.1016/j.anndiagpath.2011.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 05/12/2011] [Accepted: 05/26/2011] [Indexed: 11/18/2022]
Abstract
The purpose of this study is to determine whether anaplastic astrocytoma patients with intratumoral vascular thrombi have a worse survival than anaplastic astrocytoma patients without thrombi. A retrospective review of 101 patients (60 males; mean age, 53.3 years) with anaplastic astrocytoma (World Health Organization grade III) was conducted. Thrombi were counted relative to the number of involved blood vessels in the initially resected tumor (69 biopsies, 32 subtotal resections) and were correlated with survival and development of postoperative deep venous thrombosis (DVT). Of tumors with thrombi (n = 17), the percentage of blood vessels with thrombi ranged from 1.5% to 20% (mean, 5.6%). Of these patients, 16 died of tumor (mean survival, 15.4 months), and 1 patient was alive with tumor at 180 months. Eighty-four patients with anaplastic astrocytoma had no intravascular tumor thrombi; 75 of these patients died of tumor (mean survival, 26.5 months), 4 patients were alive, and 5 patients were lost to follow-up. Evidence of DVT was found in 2 (18.2%) of 11 tested patients with thrombi vs 10 (18.5%) of 54 patients without thrombi. Patients with microscopic intratumoral thrombi (17% of anaplastic astrocytoma) had a worse survival compared with patients without thrombi; the difference did not reach statistical significance. There was no correlation between the presence of intratumoral thrombi and the development of DVT.
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