Whole-body diffusion-weighted MRI for staging lymphoma at 3.0T: comparative study with MR imaging at 1.5T

Diagnostic Value of Magnetic Resonance Diffusion-Weighted Imaging Combined with Routine Scanning in Body Tumors

The aim of this study was to evaluate the value of whole body magnetic resonance diffusion-weighted imaging (WB-DWI) combined with routine scanning in the diagnosis of body tumors. Sixty-three patients with surgically and pathologically confirmed body tumors admitted to our hospital from October 2019 to October 2021 were scanned by WB-DWI using a 1.5TMR body coil. The images were reconstructed by a three-dimensional maximum intensity projection (3D-MIP) and black-white inversion technique. The lesions detected by WB-DWI were all plain MRI, and 35 cases were enhanced MRI. The number of lesions detected by WB-DWI and WB-DWI combined with routine scanning and the number of cases matching diagnosis were compared. The WB-DWI images of tumor lesions were analyzed, and the apparent diffusion coefficient (ADC) of the lesions was measured, and the ADC value of benign and malignant lesions was compared. There were 236 lesions in 63 patients with clinically confirmed tumors. 46 cases were diagnosed by WB-DWI, the diagnostic coincidence rate was 73.0%, and 207 lesions were detected. Fifty-eight cases were diagnosed by WB-DWI combined with routine scanning, the diagnostic coincidence rate was 92.1%, 236 lesions were detected. There were statistically significant differences in the number of lesions detected and the coincidence rate of tumor diagnosis between the two groups (P < 0.05). The average ADC value of malignant tumor ((1.04 ± 0.46) × 10⁻³ mm²/s) was lower than that of benign tumor ((2.53 ± 0.43) × 10⁻³ mm²/s), and the difference was statistically significant (P < 0.05). In conclusion, MR whole-body diffusion weighted imaging is safe, efficient, radiation-free, and highly sensitive, which is of great significance in the differential diagnosis of benign and malignant lesions. WB-DWI combined with MR routine scanning can further improve the detection rate of lesions and the coincidence rate of tumor diagnosis.

Screening of cancer predisposition syndromes

Pediatric patients with cancer predisposition syndromes are at increased risk of developing malignancies compared with their age-matched peers, necessitating regular surveillance. Screening protocols differ among syndromes and are composed of a number of elements, imaging being one. Surveillance can be initiated in infants, children and adolescents with a tumor known or suspected of being related to a cancer predisposition syndrome or where genetic testing identifies a germline pathogenic gene variant in an asymptomatic child. Pre-symptomatic detection of malignant neoplasms offers potential to improve treatment options and survival outcomes, but the benefits and risks of screening need to be weighed, particularly with variable penetrance in many cancer predisposition syndromes. In this review we discuss the benefits and risks of surveillance imaging and the importance of integrating imaging and non-imaging screening elements. We explore the principles of surveillance imaging with particular reference to whole-body MRI, considering the strategies to minimize false-negative and manage false-positive whole-body MRI results, the value of standardized nomenclature when reporting risk stratification to better guide patient management, and the need for timely communication of results to allay anxiety. Cancer predisposition syndrome screening is a multimodality, multidisciplinary and longitudinal process, so developing formalized frameworks for surveillance imaging programs should enhance diagnostic performance while improving the patient experience.

The diagnostic performance of whole-body MRI in the staging of lymphomas in adult patients compared to PET/CT and enhanced reference standard-systematic review and meta-analysis

BACKGROUND

Morphology highlighted by diffusion weighted imaging (DWI) is the basis of whole-body MRI (wbMRI). The aim of this study was to analyze current knowledge on the diagnostic performance of wbMRI in the pretreatment staging of patients with lymphoma.

METHODS

A search for original articles reporting the diagnostic performance (sensitivity, specificity) of pretreatment (first staging or staging in relapsed patients after complete remission) wbMRI in nodal and extranodal involvement by extracranial lymphoma and the agreement of stage by the Cotswolds-modified Ann Arbor classification in adult patients compared to the reference standard (PET/CT or enhanced reference standard) was conducted in PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov.

RESULTS

Altogether 15 studies with 519 patients were included in the meta-analysis. The pooled sensitivity and specificity for nodal involvement were 0.93 (95% CI: 0.90 to 0.96) and 0.99 (95% CI: 0.98 to 1.00). For nodal staging, most studies used the size criterion of 10 mm in the short diameter (n=10) and the absence of prominent fatty hilum (n=4). Restricted diffusion on diffusion-weighted imaging as a sign of nodal involvement was either not used (n=5), used for detection (n=4), semi-quantitatively (n=4), or quantitatively (n=1). Only one study (7) relied solely on restricted diffusion as the main criterion for nodal involvement. The pooled sensitivity and specificity for extranodal involvement were 0.89 (95% CI: 0.79 to 0.98) and 0.99 (95% CI: 0.99 to 1.00). Seven studies considered diffuse splenic involvement when its long or vertical axis was greater than 13 cm regardless of the patient's physiognomy. The pooled agreement in staging (Cohen's kappa) was almost perfect (0.90, 95% CI: 0.84 to 0.95).

DISCUSSION

The sensitivity and specificity of wbMRI in the assessment of the nodal and extranodal involvement by lymphoma is high. The agreement of wbMRI with the reference standard is almost perfect.

Whole-Body Magnetic Resonance Imaging: Current Role in Patients with Lymphoma

Imaging of lymphoma is based on the use of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG-PET/CT) and/or contrast-enhanced CT, but concerns have been raised regarding radiation exposure related to imaging scans in patients with cancer, and its association with increased risk of secondary tumors in patients with lymphoma has been established. To date, lymphoproliferative disorders are among the most common indications to perform whole-body magnetic resonance imaging (MRI). Whole-body MRI is superior to contrast-enhanced CT for staging the disease, also being less dependent on histology if compared to ¹⁸F-FDG-PET/CT. As well, it does not require exposure to ionizing radiation and could be used for the surveillance of lymphoma. The current role of whole-body MRI in the diagnostic workup in lymphoma is examined in the present review along with the diagnostic performance in staging, response assessment and surveillance of different lymphoma subtypes.

[Diagnostic imaging of malignant lymphomas]

BACKROUND

Malignant lymphomas represent approximately 5% of all cancers. Imaging procedures play a crucial role concerning initial staging and assessment of the response to treatment.

OBJECTIVE

This article gives an overview of the significance of imaging procedures in the treatment of patients with malignant lymphomas at various times during treatment. These include the initial assessment of the extent of the disease and staging during and after treatment under consideration of the current classification systems.

MATERIAL AND METHODS

A selective literature search was carried out with analysis of dedicated original research articles and reviews as well as a discussion of the clinical guidelines.

RESULTS

Computed tomography (CT) is the basic diagnostic tool in patients with malignant lymphomas. Particularly important is fluorodeoxyglucose (FDG) positron emission tomography (PET) CT, which enables a more accurate stage definition and a better assessment of the response to treatment in FDG-avid lymphoma subtypes. Using the FDG-PET/CT-based Deauville score persisting disease activity can be identified in residual masses and refractory disease can be distinguished from complete metabolic remission. The use of magnetic resonance imaging (MRI) with diffusion-weighted imaging can represent a future alternative but is, however, not yet sufficiently standardized and validated.

CONCLUSION

The standardized analysis and reporting of purely morphological and metabolic imaging procedures is the backbone of treatment decisions in patients with malignant lymphomas.

Whole-body magnetic resonance imaging (WB-MRI) in oncology: an Italian survey

PURPOSE

To perform a survey among all members of the Italian Society of Medical and Interventional Radiology (SIRM) to assess how whole-body MRI (WB-MRI) is performed in oncologic patients in Italy.

METHODS

On March 2019, we administered an online poll to all SIRM members about their use of WB-MRI in 2018 asking 15 questions regarding oncologic indications, imaging protocol, use of contrast media, experience in WB-MRI, duration of scan time and reporting time.

RESULTS

Forty-eight members participated to the survey. WB-MRIs/total MRIs ratio was 1%. Lymphoma was the most common indication (17/48, 35%), followed by myeloma and prostate cancer, with these three tumors representing the most common indication in 39/48 of cases (81%). WB-MRI acquisition time and reporting time were 46-60 min in 22/48 centers (46%) and 20-30 min in 19/48 (40%), respectively. WB-MRIs were mostly performed in 1.5T scanners (43/48, 90%), with surface coils (22/48, 46%) being preferred to Q-body (15/48, 31%) and integrated coils (11/48, 23%). Contrast media were injected in 22/48 of the centers (46%), mainly used for breast cancer (13/22, 59%). DWI was the most used sequence (45/48, 94%), mostly with b800 (27/48, 56%), b0 (24/48, 50%) and b1000 (20/48, 42%) values. In about half of cases, radiologists started evaluating WB-MRI non-contrast morphologic sequences, then checking DWI and post-contrast images.

CONCLUSION

WB-MRI was mainly performed at 1.5T unit, with lymphoma, myeloma and prostate cancer having been the most common indications. The extreme variability in the choice of imaging protocols and use of contrast agents demonstrates the need of a standardization of WB-MRI application in clinical practice.

Whole-Volume ADC Histogram Analysis in Parotid Glands to Identify Patients with Sjögren's Syndrome

At present, no gold standard for diagnosing Sjögren’s syndrome (SS) is available in clinical practice. The 2002 American–European Consensus Group classification criteria are used to diagnose SS. Clinically, it is challenging to distinguish patients with SS from suspected patients undergoing different therapies. A total of 52 patients with SS and 24 patients suspected of having the disease prospectively underwent 3.0-T magnetic resonance (MR) scanning, including diffusion-weighted imaging (b = 0 and 1000 s/mm²). The whole-volume apparent diffusion coefficient (ADC) histogram analysis generated ADC_mean, skewness, kurtosis, and entropy values from bilateral parotid glands. Continuous variables were compared using an independent two-sample t test, and categorical variable compared using the Fisher’s test between the two groups. Receiver operating characteristic (ROC) analysis was used to evaluate the diagnostic performance of the indexes. Fisher’s tests demonstrated that some clinical indexes and MR morphology grades differed significantly between patients with SS and patients suspected of having the disease (all P ≤ 0.001). The parotid entropy value of patients with SS was significantly higher than that of patients suspected of having the disease (P < 0.001). Among MR parameters, entropy combined with kurtosis performed the best in differentiating patients with SS from those suspected of having SS (area under the ROC curve = 0.955). A whole-volume ADC histogram analysis might provide a series of parameters that reflect tissue characteristics.

Whole-Body MR Imaging: The Novel, "Intrinsically Hybrid," Approach to Metastases, Myeloma, Lymphoma, in Bones and Beyond

Whole-body MR imaging (WB-MR imaging) has become a modality of choice for detecting bone metastases in multiple cancers, and bone marrow involvement by multiple myeloma or lymphoma. Combination of anatomic and functional sequences imparts an inherently hybrid dimension to this nonirradiating tool and extends the screening of malignancies outside the skeleton. WB-MR imaging outperforms bone scintigraphy and CT and offers an alternative to PET in many tumors by time of lesion detection and assessment of treatment response. Much work has been done to standardize procedures, optimize sequences, validate indications, confirm preliminary research into new applications, rendering clinical application more user-friendly.

Application of the apparent diffusion coefficient in magnetic resonance imaging in an assessment of the early response to treatment in Hodgkin's and non-Hodgkin's lymphoma - pilot study

Purpose

Lymphoproliferative neoplasms are the largest and most frequently diagnosed entities in the group of haematological malignancies. The aim of the study was to assess whether apparent diffusion coefficient (ADC) measured on the first day of the second cycle of chemotherapy could be a predictor of prognosis and of the final treatment’s outcome.

Material and methods

The study included 27 patients with diagnosed Hodgkin’s and non-Hodgkin’s lymphoma, who had magnetic resonance (MR) performed with diffusion weighted imaging/apparent diffusion coefficient (DWI/ADC) before and on the first day of the second cycle of chemotherapy. Imaging was performed using a 1.5 T MR scanner. ADC was measured in lymphoma infiltration in the area of the lowest signal in the ADC map and the highest signal on β 800 images in post-treatment study. After that, the corresponding area was determined in a pre-treatment study and an ADC value was measured.

Results

The difference between ADC values in pre-treatment (ADC = 720 mm²/s) and post-treatment (ADC = 1059 mm²/s) studies was statistically significant (p < 0.001). Cutoff values for estimating response to treatment were established at the level of ADC 1080 mm²/s, and ADC to muscle ratio at 0.82 in post-treatment study. Patients with ADC > 752 mm²/s before treatment manifested lower probability of progression than patients with ADC < 752 mm²/s.

Conclusions

ADC measurement’s before treatment and on the first day of the second cycle of chemotherapy can be used as a prognostic marker in lymphoma therapy. ADC values lower than 1080 mm²/s and an increase of the ratio after the treatment can be considered as a marker of disease progression.

Whole body MRI with qualitative and quantitative analysis of DWI for assessment of bone marrow involvement in lymphoma

AIM

Our study aimed to investigate the role of qualitative and quantitative whole body MRI with DWI for assessment of bone marrow involvement (BMI) in newly diagnosed lymphoma using FDG PET-CT and bone marrow biopsy (BMB) as reference standard.

MATERIALS AND METHODS

We retrospectively evaluated 56 patients with newly diagnosed lymphoma (21 Hodgkin's lymphoma and 35 non-Hodgkin's lymphoma) who underwent random unilateral BMB, FDG PET-CT and Wb-MRI-DWI for initial staging. In a patient-based analysis, results of Wb-MRI-DWI were compared with FDG PET-CT and BMB. For quantitative analysis, mean ADC values of posterior iliac crest were correlated with BMI and bone marrow cellularity.

RESULTS

WB-MR-DWI obtained excellent concordance with FDG PET-CT both in HL (k = 1.000; 95% CI 1.000-1.000) and in DLBCL (k = 1.000; 95% CI 1.000-1.000). In other NHL, WB-MRI-DWI obtained a good correlation with BMB (k = 0.611; 95% CI 0.295-0.927) while FDG PET-CT had poor concordance (k = 0.067; 95% CI 0.372-0.505). WB-MR-DWI has no false negative errors but 4 false positive results consisting in focal lesions consensually reported by FDG PET-CT and resolved after therapy. No significant correlation between ADC mean value and BMI was found (p = 0.0586).

CONCLUSION

Our data suggest that Wb-MRI-DWI is a valid technique for BMI assessment in lymphoma patients, thanks to its excellent concordance with FDG PET-CT and good concordance with BMB (superior than FDG PET-CT). If further investigations will confirm our results on larger patient groups, it could become a useful tool in the clinical workup.

Body Diffusion-weighted MR Imaging in Oncology: Imaging at 3 T

Advances in hardware and software enable high-quality body diffusion-weighted images to be acquired for oncologic assessment. 3.0 T affords improved signal/noise for higher spatial resolution and smaller field-of-view diffusion-weighted imaging (DWI). DWI at 3.0 T can be applied as at 1.5 T to improve tumor detection, disease characterization, and the assessment of treatment response. DWI at 3.0 T can be acquired on a hybrid PET-MR imaging system, to allow functional MR information to be combined with molecular imaging.

Whole-body MRI with diffusion-weighted imaging: a valuable alternative to contrast-enhanced CT for initial staging of aggressive lymphoma

AIM

To compare the accuracy of whole-body magnetic resonance imaging (Wb-MRI) with diffusion-weighted imaging (DWI) to that of contrast-enhanced computed tomography (CE-CT) and 2-[(18)F]-fluoro-2-deoxy-d-glucose ((18)F-FDG) positron-emission tomography co-registered with low dose-CT (PET-CT) in defining lymphoma disease stage.

MATERIALS AND METHODS

From February 2010 to May 2014, 41 lymphoma patients underwent Wb-MRI-DWI, CE-CT, and (18)F-FDG PET-CT. Histological subtypes included aggressive B-cell (n=11), follicular (n=13), mantle cell (n=3), and Hodgkin's (n=14) lymphoma. To compare the procedures, the reference standard (RS) assessment was defined by combining the results from (18)F-FDG PET-CT, CE-CT, and bone marrow (BM) histology, modifications after therapy, and histological re-assessments of uncertain lesions.

RESULTS

Among 1025 nodal sites, 217 had disease involvement according to the RS. CE-CT yielded 23 false-negative and 11 false-positive errors. Wb-MRI-DWI failed to recognise 17 localisations and had six false-positive errors; (18)F-FDG PET-CT had no errors. Among 458 extranodal sites, 37 were positive according to the RS. (18)F-FDG PET-CT yielded four false-negative and two false-positive results. CE-CT yielded 17 false-negative errors. Wb-MRI-DWI yielded a single false-negative error. Wb-MRI-DWI was the most reliable imaging technique for BM evaluation. Considering each procedure alone, the final stage would have been missed in four cases using (18)F-FDG PET-CT, 12 cases using CE-CT, and none using Wb-MRI-DWI.

CONCLUSION

The present data support Wb-MRI-DWI as a sensitive and specific imaging technique for lymphoma evaluation, supporting its use in place of CE-CT for staging.