Magnetic resonance imaging and spectroscopic imaging: Improved patient selection and potential for metabolic intermediate endpoints in prostate cancer chemoprevention trials

Pattern recognition and biomarker validation using quantitative1H-NMR-based metabolomics

The collection of global metabolic data and their interpretation (both spectral and biochemical) using modern spectroscopic techniques and appropriate statistical approaches, are known as 'metabolic profiling', 'metabonomics' or 'metabolomics'. This review addresses 1H-nuclear magnetic resonance (NMR)-based metabolomic principles and their application in biomedical science, with special emphasis on their potential in translational research in transplantation, oncology, and drug toxicity or discovery. Various steps in metabolomics analysis are described in order to illustrate the types of biological samples, their respective handling and preparation for 1H-NMR analysis; provide a rationale for using pattern-recognition techniques (spectral database concept) versus quantitative 1H-NMR-based metabolomics (metabolite database concept); and identify necessary technological and logistical future developments that will allow 1H-NMR-based metabolomics to become an established tool in biomedical research and patient care.

Functional imaging for prostate cancer: therapeutic implications

Functional radionuclide imaging modalities, now commonly combined with anatomical imaging modalities computed tomography (CT) or magnetic resonance imaging (single photon emission computed tomography [SPECT]/CT, positron emission tomography [PET]/CT, and PET/magnetic resonance imaging), are promising tools for the management of prostate cancer, particularly for therapeutic implications. Sensitive detection capability of prostate cancer using these imaging modalities is one issue; however, the treatment of prostate cancer using the information that can be obtained from functional radionuclide imaging techniques is another challenging area. There are not many SPECT or PET radiotracers that can cover the full spectrum of the management of prostate cancer from initial detection to staging, prognosis predictor, and all the way to treatment response assessment. However, when used appropriately, the information from functional radionuclide imaging improves, and sometimes significantly changes, the whole course of the cancer management. The limitations of using SPECT and PET radiotracers with regard to therapeutic implications are not so much different from their limitations solely for the task of detecting prostate cancer; however, the specific imaging target and how this target is reliably imaged by SPECT and PET can potentially make significant impact in the treatment of prostate cancer. Finally, although the localized prostate cancer is considered manageable, there is still significant need for improvement in noninvasive imaging of metastatic prostate cancer, in treatment guidance, and in response assessment from functional imaging, including radionuclide-based techniques. In this review article, we present the rationale of using functional radionuclide imaging and the therapeutic implications for each of radionuclide imaging agent that have been studied in human subjects.

Fast magnetic resonance spectroscopic imaging (MRSI) using wavelet encoding and parallel imaging: in vitro results

In previous work we have shown that wavelet encoding spectroscopic imaging (WE-SI) reduces acquisition time and voxel contamination compared to the standard Chemical Shift Imaging (CSI) also known as phase encoding (PE). In this paper, we combine the wavelet encoding method with parallel imaging (WE-PI) technique to further reduce the acquisition time by the acceleration factor R, and preserve the spatial metabolite distribution. Wavelet encoding provides results with a lower signal-to-noise ratio (SNR) than the phase encoding method. Their combination with parallel imaging, introduces an intrinsic SNR reduction. The rate of SNR reduction is slower in wavelet encoding with PI than PE with parallel imaging (PE-PI). This is due to the fact that in WE-PI, the SNR reduction is a function of the acceleration factor R and the voxel number N, whereas in PE-PI it is a function of the acceleration factor R only.

Implementation of three-dimensional wavelet encoding spectroscopic imaging: in vivo application and method comparison

We have recently proposed a two-dimensional Wavelet Encoding-Spectroscopic Imaging (WE-SI) technique as an alternative to Chemical Shift Imaging (CSI), to reduce acquisition time and crossvoxel contamination in magnetic resonance spectroscopic imaging (MRSI). In this article we describe the extension of the WE-SI technique to three dimensions and its implementation on a clinical 1.5 T General Electric (GE) scanner. Phantom and in vivo studies are carried out to demonstrate the usefulness of this technique for further acquisition time reduction with low voxel contamination. In wavelet encoding, a set of dilated and translated prototype functions called wavelets are used to span a localized space by dividing it into a set of subspaces with predetermined sizes and locations. In spectroscopic imaging, this process is achieved using radiofrequency (RF) pulses with profiles resembling the wavelet shapes. Slice selective excitation and refocusing RF pulses, with single-band and dual-band profiles similar to Haar wavelets, are used in a modified PRESS sequence to acquire 3D WE-SI data. Wavelet dilation and translation are achieved by changing the strength of the localization gradients and frequency shift of the RF pulses, respectively. The desired spatial resolution in each direction sets the corresponding number of dilations (increases in the localization gradients), and consequently, the number of translations (frequency shift) of the Haar wavelets (RF pulses), which are used to collect magnetic resonance (MR) signals from the corresponding subspaces. Data acquisition time is reduced by using the minimum recovery time (TR(min)), also called effective time, when successive MR signals from adjacent subspaces are collected. Inverse wavelet transform is performed on the acquired data to produce metabolite maps. The proposed WE-SI method is compared in terms of acquisition time, pixel bleed, and signal-to-noise ratio to the CSI technique. The study outcome shows that 3D WE-SI provides accurate results while reducing both acquisition time and voxel contamination.

MR imaging of the prostate in clinical practice

Magnetic resonance imaging (MRI) is the imaging tool of choice in the evaluation of prostate cancer. The main applications of MR imaging in the management of prostate cancer are: (1) to guide targeted biopsy when prostate cancer is clinically suspected and previous ultrasound-guided biopsy results are negative; (2) to localize and stage prostate cancer and provide a roadmap for treatment planning; and (3) to detect residual or locally recurrent cancer after treatment. Other MR techniques such as proton MR spectroscopic imaging (MRSI), diffusion-weighted imaging (DWI), and contrast-enhanced MRI (CE-MRI) complement conventional MR imaging by providing metabolic and functional information that can improve the accuracy of prostate cancer detection and characterization. In everyday clinical practice, and to account for patient comfort, MR imaging studies are limited to 1 h. To obtain consistently high-quality images, a well-designed protocol is necessary. Routine MR imaging can be supplemented by other MR techniques such as MRSI, DWI or CE-MRI depending on the expertise available and the clinical questions that need to be answered. This review summarizes the role of MR imaging in the management of prostate cancer and describes practical approaches to implementing anatomic, metabolic and functional MR imaging techniques in the clinic.

[Prostate MRI spectroscopy]

MRI spectroscopy is a non invasive method for detecting active metabolites used as markers. Chorine and citrate are used for analyzing prostate cancer. MRI spectroscopy combines morphologic imaging and metabolic cartography. This combination allows a new approach for the diagnosis of prostate cancer in patients with negative biopsy and high Levels of PSA. With MRI spectroscopy the Local staging of prostate cancer has a better accuracy than with MRI alone. It can also be used for the diagnosis of residual disease and recurrence in patients treated with conservative therapy.

The metabolites citrate, myo-inositol, and spermine are potential age-independent markers of prostate cancer in human expressed prostatic secretions

OBJECTIVES

Due to specific physiological functions, prostatic tissues and fluids have unique metabolic profiles. In this study, proton nuclear magnetic resonance spectroscopy ((1)H-NMRS) is used to assess potential metabolic markers of prostate cancer (PCa) in human expressed prostatic secretions (EPS).

METHODS

Metabolic profiles of EPS from 52 men with PCa and from 26 healthy controls were analyzed using quantitative (1)H-NMRS. The metabolites quantified included citrate, spermine, myo-inositol, lactate, alanine, phosphocholine, glutamine, acetate, and hydroxybutyrate. Logistic regression (LR) was used to model the risk of PCa based on metabolite concentrations while adjusting for age.

RESULTS

The average age of the EPS donors with PCa was 58.0+/-7.0 years and 52.2+/-12.1 for the healthy donors. The median Gleason score for the men with PCa was 7 (range 5-9). The LR models indicated that the absolute concentrations of citrate, myo-inositol, and spermine were highly predictive of PCa and inversely related to the risk of PCa. The areas under the receiver operating characteristic curves (AUROC) for citrate, myo-inositol and spermine were 0.89, 0.87, and 0.79, respectively. At 90% sensitivity, these metabolites had specificities of 74%, 51%, and 34%, respectively. The LR analysis indicated that absolute levels of these three metabolites were independent of age.

CONCLUSIONS

The results indicate that citrate, myo-inositol and spermine are potentially important markers of PCa in human EPS. Further, the absolute concentrations of these metabolites in EPS appear to be independent of age, increasing the potential utility of these markers due to elimination of age as a confounding variable.

[MR spectroscopic imaging for evaluation of prostate cancer]

MR spectroscopic imaging (MRSI) provides a noninvasive method of evaluating metabolic markers of prostate cancer or healthy prostatic tissue (the metabolites choline and citrate), and is performed in conjunction with high-resolution MR anatomic imaging. Multiple studies have showed the incremental role of MRSI combined with the anatomical information provided by MRI for assessment of cancer location and extent within the prostate, staging, and cancer aggressiveness. In addition, MRSI has a potential role for pre- and post-treatment evaluation in non surgical patients. Ongoing technical developments show the potential role of MRSI for guidance of biopsies or focal treatment. Further developments - including new 3T technology - will likely provide improved spectral resolution for better prostate cancer detection and characterization.

Quantification of prostate MRSI data by model-based time domain fitting and frequency domain analysis

This paper compares two spectral processing methods for obtaining quantitative measures from in vivo prostate spectra, evaluates their effectiveness, and discusses the necessary modifications for accurate results. A frequency domain analysis (FDA) method based on peak integration was compared with a time domain fitting (TDF) method, a model-based nonlinear least squares fitting algorithm. The accuracy of both methods at estimating the choline + creatine + polyamines to citrate ratio (CCP:C) was tested using Monte Carlo simulations, empirical phantom MRSI data and in vivo MRSI data. The paper discusses the different approaches employed to achieve the quantification of the overlapping choline, creatine and polyamine resonances. Monte Carlo simulations showed induced biases on the estimated CCP:C ratios. Both methods were successful in identifying tumor tissue, provided that the CCP:C ratio was greater than a given (normal) threshold. Both methods predicted the same voxel condition in 94% of the in vivo voxels (68 out of 72). Both TDF and FDA methods had the ability to identify malignant voxels in an artifact-free case study using the estimated CCP:C ratio. Comparing the ratios estimated by the TDF and the FDA, the methods predicted the same spectrum type in 17 out of 18 voxels of the in vivo case study (94.4%).

Magnetic resonance in surgical oncology: II - literature review

Ex vivo and in vivo applications of magnetic resonance spectroscopy have been developed which aid in distinguishing malignant from normal tissues. Studies of breast, colon, cervix, oesophageal and prostate cancer reveal both the successes and failings of present technology. Verification that these non-invasive tests might supplant conventional histology in obtaining spatial diagnostic and chemical prognostic information remains for the time being illusive.

Prostate Cancer: Precision of Integrating Functional MR Imaging with Radiation Therapy Treatment by Using Fiducial Gold Markers

The use of intensity-modulated radiation therapy for treatment of dominant intraprostatic lesions may require integration of functional magnetic resonance (MR) imaging with treatment-planning computed tomography (CT). The purpose of this study was to compare prospectively the landmark and iterative closest point methods for registration of CT and MR images of the prostate gland after placement of fiducial markers. The study was approved by the institutional ethics review board, and informed consent was obtained. CT and MR images were registered by using fiducial gold markers that were inserted into the prostate. Two image registration methods--a commonly available landmark method and dedicated iterative closest point method--were compared. Precision was assessed for a data set of 21 patients by using five operators. Precision of the iterative closest point method (1.1 mm) was significantly better (P < .01) than that of the landmark method (2.0 mm). Furthermore, a method is described by which multimodal MR imaging data are reduced into a single interpreted volume that, after registration, can be incorporated into treatment planning.

Optimal timing for in vivo1H-MR spectroscopic imaging of the human prostate at 3T

Proton MR spectroscopic imaging ((1)H-MRSI) of the human prostate, which has an interesting clinical potential, may be improved by increasing the magnetic field strength from 1.5T to 3T. Both theoretical and practical considerations are necessary to optimize the pulse timing for spectroscopic imaging of the human prostate at 3T. For in vivo detection of the strongly coupled spin system of citrate, not only should the spectral shape of the signal be easy to identify, but the timing used should produce MR signals at reasonably short echo times (TEs). In this study the spectral shape of the methylene protons of citrate was simulated with density matrix calculations and checked with phantom measurements. Different calculated optimal spectral shapes were measured in patients with prostate cancer with a 2D spectroscopic imaging sequence. T(1) and T(2) relaxation times were calculated for citrate and choline, the two major metabolites of interest in the prostate. We conclude that the optimum timing for in vivo point-resolved spectroscopy (PRESS) imaging at 3T is an interpulse timing sequence of 90 degrees-25 ms-180 degrees- 37.5 ms-180 degrees-12.5 ms-echo. A short repetition time (TR) of 750 ms partially saturates choline signals, but increases the SNR per unit time for citrate, and accommodates a maximum number of weighted averages of an elliptically sampled k-space for accurate localization and minimal contamination of the individual spectra. This is illustrated by means of a 3D spectroscopic imaging experiment in a complete prostate in vivo.

Fast acquisition-weighted three-dimensional proton MR spectroscopic imaging of the human prostate

The clinical application of 3D proton spectroscopic imaging (3D SI) of the human prostate requires a robust suppression of periprostatic lipid signal contamination, minimal intervoxel signal contamination, and the shortest possible measurement time. In this work, a weighted elliptical sampling of k-space, combined with k-space filtering and pulse repetition time (TR) reduction minimized lipid signals, intervoxel contamination, and measurement time. At 1.5 T, the MR-visible prostate metabolites citrate, creatine, and choline can now be mapped over the entire human prostate with uncontaminated spherical voxels, with a volume down to 0.37 cm3, in measurement times of 7-15 min.

Dynamic Magnetic Resonance Tomography and Proton Magnetic Resonance Spectroscopy of Prostate Cancers in Rats Treated by Radiotherapy

RATIONALE AND OBJECTIVES

To establish an experimental setting for monitoring perfusion and metabolism in orthotopic prostate cancer at 1.5 T using dynamic contrast-enhanced magnetic resonance imaging (DCE MRI) and 1H-MR spectroscopy (MRS).

METHODS

Dunning rat prostate cancer cells were injected into the prostate by open surgery. Twelve tumor-bearing rats (5 of these irradiated) and 6 healthy controls were followed up using gadolinium-diethylenetriaminepentaacetic acid -enhanced dynamic MRI and 1H-MRS. Amplitude and the exchange rate constant kep were calculated (2-compartment model). From 1H-MR spectra, ratios of choline (Cho) and creatine (tCr) were calculated. All tumors were examined histologically.

RESULTS

On DCE MRI parameter maps, tumors showed increased vascularization. kep and microvessel density were correlated (r = 0.97). Tumors showed elevated Cho/tCr and an unexpected lipid fraction (2.0-2.2 parts per million). Irradiation slowed tumor growth significantly. Changes of perfusion and metabolism could be detected in all tumors during follow up.

CONCLUSION

DCE MRI and 1H-MRS has potential to characterize orthotopic Dunning prostate cancer in rats, which is a promising model similar to human prostate carcinomas.

Combined magnetic resonance imaging and spectroscopic imaging approach to molecular imaging of prostate cancer

Magnetic resonance spectroscopic imaging (MRSI) provides a noninvasive method of detecting small molecular markers (historically the metabolites choline and citrate) within the cytosol and extracellular spaces of the prostate, and is performed in conjunction with high-resolution anatomic imaging. Recent studies in pre-prostatectomy patients have indicated that the metabolic information provided by MRSI combined with the anatomical information provided by MRI can significantly improve the assessment of cancer location and extent within the prostate, extracapsular spread, and cancer aggressiveness. Additionally, pre- and post-therapy studies have demonstrated the potential of MRI/MRSI to provide a direct measure of the presence and spatial extent of prostate cancer after therapy, a measure of the time course of response, and information concerning the mechanism of therapeutic response. In addition to detecting metabolic biomarkers of disease behavior and therapeutic response, MRI/MRSI guidance can improve tissue selection for ex vivo analysis. High-resolution magic angle spinning ((1)H HR-MAS) spectroscopy provides a full chemical analysis of MRI/MRSI-targeted tissues prior to pathologic and immunohistochemical analyses of the same tissue. Preliminary (1)H HR-MAS spectroscopy studies have already identified unique spectral patterns for healthy glandular and stromal tissues and prostate cancer, determined the composition of the composite in vivo choline peak, and identified the polyamine spermine as a new metabolic marker of prostate cancer. The addition of imaging sequences that provide other functional information within the same exam (dynamic contrast uptake imaging and diffusion-weighted imaging) have also demonstrated the potential to further increase the accuracy of prostate cancer detection and characterization.

Prostate cryoablation: a scientific rationale for future modifications

This investigation was designed to identify potential directions for future modification of the percutaneous prostate cryoablation procedure. An analysis of prostate cancer location and volume in radical prostatectomy specimens was performed to evaluate the potential clinical consequences of these proposed modifications. A list of recommendations for improvements in the prostate cryoablation procedure was compiled from informal discussions held with participants in 9 training courses and conferences on prostate cryoablation over 18 months. Subsequently, a population of 112 consecutive, sagittally sectioned whole-mount radical prostatectomy samples was evaluated for prostate cancer volume, number of individual foci, and location to examine the disease-specific outcomes of these proposed modifications. The most common areas for potential alterations in the current cryoablation technique include modifications that would further simplify the procedure, continue to reduce real and perceived toxicity, and augment efficacy. Importantly, modifications designed to reduce treatment side effects could conflict with efforts designed to improve eradication of prostate cancer. Pathologic analysis revealed multifocal cancer in 79.5% of the samples, with 66% of cases exhibiting cancer within 5 mm of the urethra. The median volume of the index cancer was 1.6 cm3, whereas the median volume of the smaller ancillary lesions was 0.3 cm3. Prostate parenchymal-sparing alterations, proposed to reduce incontinence and erectile dysfunction by targeting the index cancer, would likely eradicate clinically significant cancer in 79% of men. The recent enthusiasm for prostate cryoablation as a reasonable minimally invasive treatment option for men with clinically localized cancer is likely to result in modifications of the established surgical technique. Knowledge of the anatomic location and cancer volume within the prostate gland is an important adjunct to planning such alterations. It is possible that parenchymal-sparing modifications to total gland prostate cryoablation can eradicate clinically significant cancer in most men, with a reduction in toxicity and cost.