Localized in vivo 1H magnetic resonance spectroscopy and in vitro analyses of heterogeneous brain tumors

Perioperative Management of Patients with Glioblastoma

The clinical presentation of glioblastomas is varied, and definitive diagnosis requires pathologic examination and study of the tissue. Management of glioblastomas includes surgery and adjuvant chemotherapy and radiotherapy, with surgery playing an important role in the prognosis of these patients. Awake craniotomy plays a crucial role in tumors in or adjacent to eloquent areas, allowing surgeons to maximize resection, while minimizing iatrogenic deficits. However, the prognosis remains dismal. This article presents the perioperative management of patients with glioblastoma including tools and surgical adjuncts to maximize extent of resection and minimize poor outcomes.

The effects of transcranial direct current stimulation on metabolite changes at the anterior cingulate cortex in neuropathic pain: a pilot study

Background

Neuropathic pain (NP) in individuals with spinal cord injury (SCI) is both common and highly refractory to treatment. Primary motor cortex stimulation can relieve pain by interrupting the transmission of noxious information of descending pain modulatory systems including the anterior cingulate cortex (ACC). Previous research has shown that transcranial direct current stimulation (tDCS) can produce pain relief in individuals with NP. However, the underlying mechanisms for these effects are not yet understood. Research findings suggest the possibility that changes in brain metabolite concentrations produced by tDCS might explain some of these effects. For example, previous research has shown that SCI-related NP is associated with elevated levels of glutamine combined glutamate (Glx) per creatine (Glx/Cr). In addition, decreased N-acetylaspartate (NAA) has been observed in the ACC in individuals with chronic pain.

Methods

We used magnetic resonance spectroscopy (MRS) to study changes in NAA and Glx levels in the ACC after tDCS treatment. Ten patients with SCI with NP were given five daily anodal tDCS sessions, and an MRS evaluation was performed before and after treatment.

Results

The results showed treatment-related reductions in pain, and increases in both Glx/Cr and NAA/Cr in the ACC. The observed increase in NAA/Cr is consistent with the possibility that tDCS improves the descending pain modulation system by increasing the neuronal activity in the ACC.

Conclusion

The findings suggest the possibility that tDCS’s beneficial effects on neuropathic pain may be due, at least in part, to the changes it produces in Glx/Cr and NAA/Cr levels in the ACC. Additional research with larger samples sizes and a control group to evaluate this possibility is warranted.

Interrogating Metabolism in Brain Cancer

This article reviews existing and emerging techniques of interrogating metabolism in brain cancer from well-established proton magnetic resonance spectroscopy to the promising hyperpolarized metabolic imaging and chemical exchange saturation transfer and emerging techniques of imaging inflammation. Some of these techniques are at an early stage of development and clinical trials are in progress in patients to establish the clinical efficacy. It is likely that in vivo metabolomics and metabolic imaging is the next frontier in brain cancer diagnosis and assessing therapeutic efficacy; with the combined knowledge of genomics and proteomics a complete understanding of tumorigenesis in brain might be achieved.

Creatine CEST MRI for Differentiating Gliomas with Different Degrees of Aggressiveness

PURPOSE

Creatine (Cr) is a major metabolite in the bioenergetic system. Measurement of Cr using conventional MR spectroscopy (MRS) suffers from low spatial resolution and relatively long acquisition times. Creatine chemical exchange saturation transfer (CrCEST) magnetic resonance imaging (MRI) is an emerging molecular imaging method for tissue Cr measurements. Our previous study showed that the CrCEST contrast, obtained through multicomponent Z-spectral fitting, was lower in tumors compared to normal brain, which further reduced with tumor progression. The current study was aimed to investigate if CrCEST MRI can also be useful for differentiating gliomas with different degrees of aggressiveness.

PROCEDURES

Intracranial 9L gliosarcoma and F98 glioma bearing rats with matched tumor size were scanned with a 9.4 T MRI scanner at two time points. CEST Z-spectra were collected using a customized sequence with a frequency-selective rectangular saturation pulse (B1 = 50 Hz, duration = 3 s) followed by a single-shot readout. Z spectral data were fitted pixel-wise with five Lorentzian functions, and maps of CrCEST peak amplitude, linewidth, and integral were produced. For comparison, single-voxel proton MR spectroscopy (1H-MRS) was performed to quantify and compare the total Cr concentration in the tumor.

RESULTS

CrCEST contrasts decreased with tumor progression from weeks 3 to 4 in both 9L and F98 phenotypes. More importantly, F98 tumors had significantly lower CrCEST integral compared to 9L tumors. On the other hand, integrals of other Z-spectral components were unable to differentiate both tumor progression and phenotype with limited sample size.

CONCLUSIONS

Given that F98 is a more aggressive tumor than 9L, this study suggests that CrCEST MRI may help differentiate gliomas with different aggressiveness.

Proton MRS imaging in pediatric brain tumors

Magnetic resonance (MR) techniques offer a noninvasive, non-irradiating yet sensitive approach to diagnosing and monitoring pediatric brain tumors. Proton MR spectroscopy (MRS), as an adjunct to MRI, is being more widely applied to monitor the metabolic aspects of brain cancer. In vivo MRS biomarkers represent a promising advance and may influence treatment choice at both initial diagnosis and follow-up, given the inherent difficulties of sequential biopsies to monitor therapeutic response. When combined with anatomical or other types of imaging, MRS provides unique information regarding biochemistry in inoperable brain tumors and can complement neuropathological data, guide biopsies and enhance insight into therapeutic options. The combination of noninvasively acquired prognostic information and the high-resolution anatomical imaging provided by conventional MRI is expected to surpass molecular analysis and DNA microarray gene profiling, both of which, although promising, depend on invasive biopsy. This review focuses on recent data in the field of MRS in children with brain tumors.

Magnetic resonance spectroscopy - Revisiting the biochemical and molecular milieu of brain tumors

Background

Magnetic resonance spectroscopy (MRS) is an established tool for in-vivo evaluation of the biochemical basis of human diseases. On one hand, such lucid depiction of ‘live biochemistry’ helps one to decipher the true nature of the pathology while on the other hand one can track the response to therapy at sub-cellular level. Brain tumors have been an area of continuous interrogation and instigation for mankind. Evaluation of these lesions by MRS plays a crucial role in the two aspects of disease management described above.

Scope of review

Presented is an overview of the window provided by MRS into the biochemical aspects of brain tumors. We systematically visit each metabolite deciphered by MRS and discuss the role of deconvoluting the biochemical aspects of pathologies (here in context of brain tumors) in the disease management cycle. We further try to unify a radiologist's perspective of disease with that of a biochemist to prove the point that preclinical work is the mother of the treatment we provide at bedside as clinicians. Furthermore, an integrated approach by various scientific experts help resolve a query encountered in everyday practice.

Major conclusions

MR spectroscopy is an integral tool for evaluation and systematic follow-up of brain tumors. A deeper understanding of this technology by a biochemist would help in a swift and more logical development of the technique while a close collaboration with radiologist would enable definitive application of the same.

General significance

The review aims at inciting closer ties between the two specialists enabling a deeper understanding of this valuable technology.

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Magnetic resonance spectroscopy is an established technology for non-invasive assessment of pathological tissue.

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Good understanding of the physical principles of the technique can help one exploit it maximally.

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An array of information from the technique is available and needs deep understanding of the results.

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Newer variations of this technology are being invented to evaluate different aspects of pathologies in a more refined manner.

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We also discuss the limitations of this technology and possible solutions there-off.

Clinical magnetic resonance spectroscopy of the central nervous system

Proton magnetic resonance spectroscopy (1H MRS) is a noninvasive imaging technique that can easily be added to the conventional magnetic resonance (MR) imaging sequences. Using MRS one can directly compare spectra from pathologic or abnormal tissue and normal tissue. Metabolic changes arising from pathology that can be visualized by MRS may not be apparent from anatomy that can be visualized by conventional MR imaging. In addition, metabolic changes may precede anatomic changes. Thus, MRS is used for diagnostics, to observe disease progression, monitor therapeutic treatments, and to understand the pathogenesis of diseases. MRS may have an important impact on patient management. The purpose of this chapter is to provide practical guidance in the clinical application of MRS of the brain. This chapter provides an overview of MRS-detectable metabolites and their significance. In addition some specific current clinical applications of MRS will be discussed, including brain tumors, inborn errors of metabolism, leukodystrophies, ischemia, epilepsy, and neurodegenerative diseases. The chapter concludes with technical considerations and challenges of clinical MRS.

CEST signal at 2ppm (CEST@2ppm) from Z-spectral fitting correlates with creatine distribution in brain tumor

In general, multiple components such as water direct saturation, magnetization transfer (MT), chemical exchange saturation transfer (CEST) and aliphatic nuclear Overhauser effect (NOE) contribute to the Z-spectrum. The conventional CEST quantification method based on asymmetrical analysis may lead to quantification errors due to the semi-solid MT asymmetry and the aliphatic NOE located on a single side of the Z-spectrum. Fitting individual contributors to the Z-spectrum may improve the quantification of each component. In this study, we aim to characterize the multiple exchangeable components from an intracranial tumor model using a simplified Z-spectral fitting method. In this method, the Z-spectrum acquired at low saturation RF amplitude (50 Hz) was modeled as the summation of five Lorentzian functions that correspond to NOE, MT effect, bulk water, amide proton transfer (APT) effect and a CEST peak located at +2 ppm, called CEST@2ppm. With the pixel-wise fitting, the regional variations of these five components in the brain tumor and the normal brain tissue were quantified and summarized. Increased APT effect, decreased NOE and reduced CEST@2ppm were observed in the brain tumor compared with the normal brain tissue. Additionally, CEST@2ppm decreased with tumor progression. CEST@2ppm was found to correlate with the creatine concentration quantified with proton MRS. Based on the correlation curve, the creatine contribution to CEST@2ppm was quantified. The CEST@2ppm signal could be a novel imaging surrogate for in vivo creatine, the important bioenergetics marker. Given its noninvasive nature, this CEST MRI method may have broad applications in cancer bioenergetics.

Lower apparent diffusion coefficients indicate distinct prognosis in low-grade and high-grade glioma

Tumor grade and molecular variants influence the survival of patients with glioma. The apparent diffusion coefficient (ADC) map is a non-invasive tool for evaluating the outcomes and response to therapy in glioma. In this study, we investigated the correlation between the tumor grade and prognostic biomarkers with the ADC in glioma patients. Eighty-two patients with supratentorial glioma were identified via analysis of surgical specimens and neuroradiological data. Using the World Health Organization grade, histological subtype, and molecular variants (1p/19q codeletion, isocitrate dehydrogenase 1/2 mutation, Ki-67 index, O6-methylguanine DNA methyltransferase, P53, and vascular endothelial growth factor immunoactivity) as prognostic biomarkers, we performed receiver operating characteristic analysis and multiple linear regression to assess the association between the magnetic resonance diffusion parameter and mean ADC and the prognostic factors of glioma pathology. Univariate analysis and multiple linear regression revealed inverse correlations between the ADC values and the tumor grade, oligodendrocytoma histology, and 1p/19q codeletion. A threshold mean ADC value could predict the 1p/19q chromosomal status in WHO II gliomas with 72 % sensitivity and 88 % specificity (area under the curve 0.82, 95 % confidence interval 0.68-0.97) and could distinguish low-grade glioma with low-risk factors from the high-risk group (P < 0.01). The mean ADC value could be used as a non-invasive tool to evaluate the prognosis of supratentorial glioma patients. A threshold mean ADC value could be used to predict the 1p/19q codeletion and to identify low-risk low-grade gliomas (LGGs). Lower ADC values are indicative of a favorable prognosis in LGGs.

Quantitative short echo time 1H MRSI of the peripheral edematous region of human brain tumors in the differentiation between glioblastoma, metastasis, and meningioma

PURPOSE

To assess metabolite levels in peritumoral edematous (PO) and surrounding apparently normal (SAN) brain regions of glioblastoma, metastasis, and meningioma in humans with (1)H-MRSI to find biomarkers that can discriminate between tumors and characterize infiltrative tumor growth.

MATERIALS AND METHODS

Magnetic resonance (MR) spectra (semi-LASER MRSI, 30 msec echo time, 3T) were selected from regions of interest (ROIs) under MRI guidance, and after quality control of MR spectra. Statistical testing between patient groups was performed for mean metabolite ratios of an entire ROI and for the highest value within that ROI.

RESULTS

The highest ratios of the level of choline compounds and the sum of myo-inositol and glycine over N-acetylaspartate and creatine compounds were significantly increased in PO regions of glioblastoma versus that of metastasis and meningioma. In the SAN region of glioblastoma some of these ratios were increased. Differences were less prominent for metabolite levels averaged over entire ROIs.

CONCLUSION

Specific metabolite ratios in PO and SAN regions can be used to discriminate glioblastoma from metastasis and meningioma. An analysis of these ratios averaged over entire ROIs and those with most abnormal values indicates that infiltrative tumor growth in glioblastoma is inhomogeneous and extends into the SAN region.

Heterogeneity in malignant gliomas: a magnetic resonance analysis of spatial distribution of metabolite changes and regional blood volume

First-pass contrast-enhanced dynamic perfusion imaging provides information about the regional cerebral blood volume (rCBV), an increase of which indicates neovascularization. MR spectroscopic imaging informs about metabolite changes in brain tumors, with elevated choline (Cho) values revealing cell proliferation and density, and the glial metabolite creatine (Cr) representing high-energy storage. This study investigates metabolite changes within the tumor voxel of maximal rCBV value (rCBVmax). Anatomically coregistered parameter maps of rCBV, Cho and Cr were evaluated in 36 patients with primary or recurrent WHO grade III or IV gliomas. Apart from Cho and Cr values within the voxel of rCBVmax (Choperf, Crperf), the maximal Cho and Cr values of the tumor tissue were recorded (Chomax, Crmax). The correlation between these parameters was analyzed with Spearman’s rho test while a binomial test was performed to check whether Chomax = Choperf and Crmax = Crperf. We found that, in 29 of the 36 patients, neither Cho nor Cr had their maxima in the voxel of rCBVmax (Choperf, Crperf < Chomax, Crmax, P < 0.001). However, Choperf was highly correlated with Chomax (r = 0.76, P < 0.001) and Crperf with Crmax (r = 0.47, P < 0.001). Further Choperf correlated with Crperf (r = 0.55, P < 0.001). Neither of the spectroscopic parameters (Chomax, Crmax, Choperf, Crperf,) correlated with rCBVmax. In conclusion, in WHO grade III and IV gliomas the voxel with maximal rCBV often differs from the voxel with the maximal Cho and Cr, indicating the spatial divergence between neovascularization and tumor cell proliferation, cell density and glial processes. However, tCho and tCr changes within the area of neovascularization are positively correlated with the maximal increase within the tumor tissue. These results demonstrate aspects of regional tumor heterogeneity as characterized by different MR modalities that, apart from histopathological grading might be crucial for neurosurgical biopsy as well as for antiangiogenetic and future molecular therapies.

Evaluation of MR markers that predict survival in patients with newly diagnosed GBM prior to adjuvant therapy

Purpose Glioblastoma Multiforme (GBM) is the most common and lethal primary brain tumor in adults. The goal of this study was to test the predictive value of MR parameters in relation to the survival of patients with newly diagnosed GBM who were scanned prior to receiving adjuvant radiation and chemotherapy. Methods The study population comprised 68 patients who had surgical resection and were to be treated with fractionated external beam radiation therapy and chemotherapy. Imaging scans included anatomical MRI, diffusion and perfusion weighted imaging and (1)H MRSI. The MR data were acquired 3-5 weeks after surgery and approximately 1 week before treatment with radiation therapy. The diffusion, perfusion and spectroscopic parameter values were quantified and subjected to proportional hazards analysis that was adjusted for age and scanner field strength. Results The patients with larger lesion burden based upon volumes of anatomic lesions, volume of CNI2 (number of voxels within the T2 lesion having choline to NAA index >2), volume of CBV3 (number of pixels within the T2 lesion having relative cerebral blood volume >3), and volume of nADC1.5 (number of pixels within the T2 lesion having normalized apparent diffusion coefficient <1.5) had a higher risk for poor outcome. High intensities of combined measures of lactate and lipid in the T2 and CNI2 regions were also associated with poor survival. Conclusions Our study indicated that several pre-treatment anatomic, physiological and metabolic MR parameters are predictive of survival. This information may be important for stratifying patients to specific treatment protocols and for planning focal therapy.

Therapeutic targets and biomarkers identified in cancer choline phospholipid metabolism

Choline phospholipid metabolism is altered in a wide variety of cancers. The choline metabolite profile of tumors and cancer cells is characterized by an elevation of phosphocholine and total choline-containing compounds. Noninvasive magnetic resonance spectroscopy can be used to detect this elevation as an endogenous biomarker of cancer, or as a predictive biomarker for monitoring tumor response to novel targeted therapies. The enzymes directly causing this elevation, such as choline kinase, phospholipase C and phospholipase D may provide molecular targets for anticancer therapies. Signal transduction pathways that are activated in cancers, such as those mediated by the receptor tyrosine kinases breakpoint cluster region-abelson (Bcr-Abl), c-KIT or epidermal growth factor receptor (EGFR), correlate with the alterations in choline phospholipid metabolism of cancers, and also offer molecular targets for specific anticancer therapies. This review summarizes recently discovered molecular targets in choline phospholipid metabolism and signal transduction pathways, which may lead to novel anticancer therapies potentially being monitored by magnetic resonance spectroscopy techniques.

Multisection 1H magnetic resonance spectroscopic imaging assessment of glioma response to chemotherapy

This study evaluated the role of proton magnetic resonance spectroscopic imaging (1H MRSI) in assessing the response of low-grade brain tumors to a chemotherapy-only treatment regimen. Specifically, it was of interest to assess if 1H MRSI could detect early tumor response to therapy prior to magnetic resonance imaging (MRI) changes, and to establish which spectral markers were sensitive to regional changes within and around a heterogeneous tumor mass. A total of 14 patients with lower-grade gliomas were evaluated by multislice 1H MRSI, MRI and clinical examination. Changes associated with chemotherapy were assessed by longitudinal comparisons of regional levels of choline (Cho), N-acetyl-L-aspartate (NAA), and lactate (Lac) relative to total creatine. These changes were, in turn, compared to changes on pre- and post-contrast MR images and to each patient's clinical status. In enhancing tumor regions, there was a significant association between an increase in Lac/Cr during treatment and decreased progression-free survival time. At baseline, a low NAA/Cr in normal-appearing brain tissue adjacent to non-enhancing tumor was associated with decreased progression-free survival time, as was an increase in Cho/Cr during chemotherapy. An increase in Cho/Cr and Lac/Cr in normal-appearing brain regions next to non-enhancing tumor in one patient was noted 2 months before MRI showed progressive disease. These results suggest that 1H MRSI can be a powerful adjunct to MRI in the assessment of tumor response to chemotherapy, and that Cho/Cr and Lac/Cr appear to be the most reliable markers of tumor progression and may predict response prior to MRI changes.

Noninvasive magnetic resonance spectroscopic imaging biomarkers to predict the clinical grade of pediatric brain tumors

The diagnosis and therapy of childhood brain tumors, most of which are low grade, can be complicated because of their frequent adjacent location to crucial structures, which limits diagnostic biopsy. Also, although new prognostic biomarkers identified by molecular analysis or DNA microarray gene profiling are promising, they too depend on invasive biopsy. Here, we test the hypothesis that combining information from biologically important intracellular molecules (biomarkers), noninvasively obtained by proton magnetic resonance spectroscopic imaging, will increase the diagnostic accuracy in determining the clinical grade of pediatric brain tumors. We evaluate the proton magnetic resonance spectroscopic imaging exams for 66 children with brain tumors. The intracellular biomarkers for choline-containing compounds (Cho), N-acetylaspartate, total creatine, and lipids and/or lactate were measured at the highest Cho region and normalized to the surrounding healthy tissue total creatine. Neuropathological grading was done with WHO criteria. Normalized Cho and lipids and/or lactate were elevated in high-grade (n = 23) versus low-grade (n = 43) tumors, which multiple logistic regression confirmed are independent predictors of tumor grade (for Cho, odds ratio 24.8, P < 0.001; and for lipids and/or lactate, odds ratio 4.4, P < 0.001). A linear combination of normalized Cho and lipids and/or lactate that maximizes diagnostic accuracy was calculated by maximizing the area under the receiver operating characteristic curve. Proton magnetic resonance spectroscopic imaging, although not a proxy for histology, provides noninvasive, in vivo biomarkers for predicting clinical grades of pediatric brain tumors.

Morphology of proliferating and non-proliferating tumor cell nuclei in glioblastomas correlates with preoperative data from proton-MR-spectroscopy

In contrast to the growing interest in proton-MR-spectroscopy (1HMRS) for preoperative examination of patients with brain tumors, there is nearly no knowledge about a correlation between data from 1HMRS and histomorphology as confirmed by quantitative morphological methods. Whether a correlation can be confirmed between data from 1HMRS and quantitative histomorphology of glioblastomas representing the most frequent type of brain tumors was investigated in the present study. Furthermore, it was of interest, whether correlations between spectroscopic data and histomorphology can be confirmed for proliferating and non-proliferating tumor cell nuclei independently. Using stringent inclusion criteria for this study, 24 patients were investigated by means of preoperative 1HMRS and by means of digital image analysis of paraffin sections from the surgical specimen. Proliferating and non-proliferating tumor cell nuclei were investigated separately in the region with the highest proliferative activity in each tumor using immunohistological staining for the proliferation marker Ki67. Main results showed highly significant correlations between total creatine and variables of nuclear size, as well as correlations between choline and variables of nuclear shape. These results were confirmed for both proliferating and non-proliferating tumor cell nuclei. A significant correlation between N-acetyl-aspartate level and topometric variables (number of neighbors per nucleus, variables describing distances between tumor cell nuclei) was confirmed for proliferating tumor cell nuclei. Discriminant analysis provided a good separation of cases with high and with low values for these spectroscopic variables based on histomorphometric data. In conclusion, the results confirm a direct correlation between data from preoperative 1HMRS and histomorphological characteristics of glioblastomas supporting the biological relevance of spectroscopic data for the examination of brain tumor patients.

Identification of MRI and 1H MRSI parameters that may predict survival for patients with malignant gliomas

Although MR imaging (MRI) and MR spectroscopic imaging (MRSI) have been applied in the diagnosis and treatment planning for brain tumors, their prognostic significance has not yet been determined. The goal of this study was to identify pre-treatment MRI and MRSI parameters for patients with malignant glioma that may be useful in predicting survival. Two populations of patients with newly-diagnosed malignant glioma were examined with MRI and three-dimensional proton ((1)H) MRSI. Thirty-nine patients (22 grade 3 and 17 glioblastoma multiforme, GBM) were studied prior to surgery, and 33 GBM patients were studied after surgery but prior to treatment with radiation and chemotherapy. Signal intensities of choline (Cho), creatine (Cr), N-acetyl aspartate (NAA), and lactate/lipid (LL) were estimated from the spectra. Recursive partitioning methods were applied to parameters that included age, histological grade, MRI and MRSI variables to generate survival trees. Patients were grouped into high and low risk categories and the corresponding Kaplan-Meier curves were plotted for comparison between groups. The parameters that were selected by recursive partitioning as being predictive of poor outcome were older age, larger contrast enhancement, higher Cho-to-Cr, higher Cho-to-NAA, higher LL and lower Cr-to-NAA abnormalities. The survival functions were significantly different between the sub-groups of patients obtained from the survival tree for both pre-surgery and post-surgery data. The results of this study suggest that pre-treatment MRI and three-dimensional (1)H-MRSI provide information that predicts outcome for patients with malignant gliomas and have drawn attention to variables that should be examined prospectively in future studies using these techniques.

Preoperative proton-MR spectroscopy of gliomas--correlation with quantitative nuclear morphology in surgical specimen

A comparison between data from proton-MR spectroscopy (1HMRS) and quantitative histomorphology of tumor cell nuclei in gliomas has not been reported up to now. Therefore, the question must be answered, if there are any significant correlations between histomorphology of gliomas and quantitative data from 1HMRS concerning tissue metabolites. Surgical glioma specimen (glioblastomas, astrocytomas, oligodendrogliomas) from 46 patients with tumor grades II-IV according to WHO have been evaluated by means of a digital image analysis system using Ki-67-immunostained paraffin sections. Nuclear density, Ki-67-proliferation index, nuclear area and shape variables (roundness factor, Fourier-amplitudes) have been determined from 200 randomly selected tumor cell nuclei in each tumor specimen. These data have been correlated with preoperative data from 1HMRS. A positive correlation between Fourier-amplitudes, choline peak and lipide peak was observed, as well as a negative correlation between these variables and the nuclear roundness factor. This result indicates higher choline and lipide peaks with increasing irregularity of nuclear outlines. Proliferation index Ki-67 was positively correlated with the lipide peak, nuclear density showed a positive correlation with the choline peak. Glioblastomas (n = 29) showed an additional positive correlation between mean nuclear size and total creatine. Anaplastic gliomas (n = 12) showed a positive correlation between lactate peak and the standard deviation of the nuclear roundness factor. Further multivariate analyses have shown, that for the present collective of 46 cases, histometric variables have a higher significance than spectroscopic data for the differentiation of the different tumor grades. These results verify a significant correlation between preoperative data from 1HMRS and histomorphology of tumor cell nuclei in gliomas, supporting the biological significance of both histomorphometry and 1HMRS for the evaluation of these tumors.

Imaging glioblastoma multiforme

Glioblastoma multiforme are infiltrative lesions that have a high degree of heterogeneity, both within and between different patients. Imaging is critical for all phases in the evaluation and treatment of these lesions, but has been limited in providing information that is reliable enough to stratify patients into groups with uniform behavior and to predict outcome. Although magnetic resonance imaging is the method of choice for visualizing anatomic features of the lesion, its results are ambiguous in terms of defining the functional characteristics of the lesion and distinguishing tumor from treatment induced necrosis. Recent advances in magnetic resonance have made possible the routine acquisition of physiological data such as perfusion- and diffusion-weighted images and of metabolic data such as water suppressed proton spectroscopic images. These provide quantitative measurements that are more closely related to the biological properties of the tumor and reflect changes in tumor vascularity, cellularity and proliferation that are associated with tumor progression. As the molecular properties that influence invasion and neoplastic transformation are elucidated, it is critical that noninvasive imaging techniques are available for investigating new therapies and tailoring treatment to individual patient characteristics. The data obtained from patients with glioblastoma multiforme have already demonstrated that these new magnetic resonance techniques are able to contribute to diagnosis, characterization of malignant potential, treatment planning and assessment of response to therapy.

Hypoxia imaging in brain tumors

Assessment of the oxygenation status of brain tumors has been studied increasingly with imaging techniques in light of recent advances in oncology. Tumor oxygen tension is a critical factor influencing the effectiveness of radiation and chemotherapy and malignant progression. Hypoxic tumors are resistant to treatment, and prognostic value of tumor oxygen status is shown in head and neck tumors. Strategies increasing the tumor oxygenation are being investigated to overcome the compromising [figure: see text] effect of hypoxia on tumor treatment. Administration of nicotinamide and inhalation of various high oxygen concentrations have been implemented. Existing methods for assessment of tissue oxygen level are either invasive or insufficient. Accurate and noninvasive means to measure tumor oxygenation are needed for treatment planning, identification of patients who might benefit from oxygenation strategies, and assessing the efficacy of interventions aimed to increase the radiosensitivity of tumors. Of the various imaging techniques used to assess tissue oxygenation, MR spectroscopy and MR imaging are widely available, noninvasive, and clinically applicable techniques. Tumor hypoxia is related closely to insufficient blood flow through chaotic and partially nonfunctional tumor vasculature and the distance between the capillaries and the tumor cells. Information on characteristics of tumor vasculature such as blood volume, perfusion, and increased capillary permeability can be provided with MR imaging. MR imaging techniques can provide a measure of capillary permeability based on contrast enhancement and relative cerebral blood volume estimates using dynamic susceptibility MR imaging. Blood oxygen level dependent contrast MR imaging using gradient echo sequence is intrinsically sensitive to changes in blood oxygen level. Animal models using blood oxygen level-dependent contrast imaging reveal the different responses of normal and tumor vasculature under hyperoxia. Normobaric hyperoxia is used in MR studies as a method to produce MR contrast in tissues. Increased T2* signal intensity of brain tissue has been observed using blood oxygen level-dependent contrast MR imaging. Dynamic blood oxygen level-dependent contrast MR imaging during hyperoxia is suggested to image tumor oxygenation. Quantification of cerebral oxygen saturation using blood oxygen level-dependent MR imaging also has been reported. Quantification of cerebral blood oxygen saturation using MR imaging has promising clinical applications; however, technical difficulties have to be resolved. Blood oxygen level dependent MR imaging is an emerging technique to evaluate the cerebral blood oxygen saturation, and it has the potential and versatility to assess oxygenation status of brain tumors. Upon improvement and validation of current MR techniques, better diagnostic, prognostic, and treatment monitoring capabilities can be provided for patients with brain tumors.

Characterization of untreated gliomas by magnetic resonance spectroscopic imaging

Although there are trends in the morphologic, metabolic, hemodynamic, and structural properties of untreated gliomas that are reflected in MR measurements, there is considerable heterogeneity both within and between lesions of the same histologic grade. The spatial extent of the abnormality in ADC and RA images is similar to the T2 lesion, but there is no obvious difference in intensity between grades. The rCBV is significantly increased in the enhancing volume of grade 4 lesions but is similar or reduced in intensity for most grade 3 lesions. There are clear differences between the enhancing volumes and the regions with increased Cho that may be highly significant for planning focal therapy. The location and intensity of the Lac/Lip peaks are consistent with those representing regions of necrosis for grade 4 lesions. The fact that small Lac/Lip peaks can also be seen in grade 2 and grade 3 lesions suggests that their presence may be indicative of regions that are likely to progress to a higher grade. If this were the case, it would be valuable for directing biopsies. The correlations between rCBV, Cho, and ADC suggest that cellularity, membrane turnover, and vascularity are linked in grade 4 lesions. It is not clear whether there is any relationship between these parameters regions in grade 2 or grade 3 gliomas. While further work is required to optimize the methodology associated with these MR parameters, it seems likely that combining the information from such measurements may be valuable for predicting outcome and tailoring therapy to individual patients.

In vivo molecular imaging for planning radiation therapy of gliomas: an application of 1H MRSI

Gliomas are infiltrative lesions that typically have poorly defined margins on conventional magnetic resonance (MR) and computed tomography (CT) images. This presents a considerable challenge for planning radiation and other forms of focal therapy, and introduces the possibility of both under-treating macroscopic tumor, and over-treating regions of normal brain tissue. New therapy systems are able to deliver radiation more precisely and accurately to irregular three-dimensional target volumes, and have placed a premium on definition of the spatial extent of the lesion. Proton MR spectroscopic imaging (H-MRSI) has been proposed as an in vivo molecular imaging technique that assists in targeting and predicts response to radiation therapy for patients with gliomas. The evidence that supports the use of H-MRSI for planning radiation treatment is reviewed, together with the technical requirements for implementing data acquisition and analysis procedures in a clinical setting. Although there is room for improvement in the spatial resolution and chemical specificity obtained at the conventional field strength of 1.5 T, there are clear benefits to integrating H-MRSI into treatment planning and follow-up examinations. Further work is required to integrate the results of the H-MRSI examination into the treatment planning workstation, and to improve the quality of the data using more sensitive phased array coils and higher field strength magnets.

Analysis of the spatial characteristics of metabolic abnormalities in newly diagnosed glioma patients

PURPOSE

To evaluate the role of 3D MR spectroscopic imaging (MRSI) as a tool for characterizing heterogeneity within a lesion in glioma patients.

MATERIALS AND METHODS

Forty-nine patients with newly diagnosed glioma were studied with 3D water-suppressed proton (1-H) MRSI. Signal intensities from choline (Cho), creatine (Cr), N-acytel aspartate (NAA), and lactate/lipid (LL) were estimated from the spectra. Regions of interest (ROIs) corresponding to the metabolic abnormalities were defined and compared with the anatomic lesions.

RESULTS

This study showed that the tumor burden measured with either the volumes of the metabolic abnormalities or the metabolic levels in the most abnormal voxels was correlated with the degree of malignancy of the tumor. The volumes of elevated Cho and decreased NAA were useful for distinguishing low-grade from high-grade lesions. The volume of abnormal LL was correlated with the existence of necrosis and with the volume of contrast-enhancing lesions in high-grade lesions. The differences in the volume of abnormal LL were also statistically significant between patients in each grade.

CONCLUSION

These 3D-MRSI data provide important additional information to conventional MRI for evaluating and characterizing gliomas.

Three-dimensional magnetic resonance spectroscopic imaging of histologically confirmed brain tumors

The goal of this study was to determine whether presurgical metabolite levels measured by 3D MR Spectroscopic Imaging (MRSI) can accurately detect viable cancer within human brain tumor masses. A total of 31 patients (33 exams, 39 pathology correlations) with brain tumors were studied prior to surgical biopsy and/or resection. The 3D MRSI was obtained with a spatial resolution of 0.2 to 1 cc throughout the majority of the mass and adjacent brain tissue using PRESS-CSI localization. Levels of choline, creatine and NAA were estimated from the locations of the resected tissue and normalized to normal appearing brain tissue. The data were correlated with subsequent histologic analysis of the biopsy tissue samples. Although there were large variations in the metabolite ratios, all regions of confirmed cancer demonstrated significant choline levels and a mean choline/NAA ratio of 5.84 + 2.58 with the lowest value being 1.3. This lowest value is greater than 4 standard deviations above the mean (0.52 +/- 0.13) found in 8 normal volunteers. The choline signal intensities in confirmed cancers were significantly elevated compared to normal appearing brain tissue with a mean ratio of 1.71 +/- 0.69. Spectra with no significant metabolite levels were observed in the non-enhancing necrotic core of the tumor masses. The results of this study indicate that 3D MRSI of brain tumors can detect abnormal metabolite levels in regions of viable cancer and grades and can differentiate cancer from necrosis and/or normal brain tissue.

Combined proton MR spectroscopy and dynamic contrast enhanced MR imaging of human intracranial tumours in vivo

A study was undertaken to determine if the vascular characteristics measured by dynamic contrast-enhanced magnetic resonance imaging (primarily permeability surface area product and extracellular-extravascular tissue volume fraction) would be beneficial in explaining the inter-lesion metabolic heterogeneity displayed by human intracranial tumours. Magnetic resonance spectroscopy was carried out using a single-voxel STEAM sequence and dynamic imaging was carried out using a combination of pre-contrast proton density-weighted FSPGR images (to remove the influence of native tissue T1), bolus injection of Gd-DTPA and subsequent T1-weighted FSPGR dynamic imaging. A two-compartment pharmacokinetic model was employed to determine vascular characteristics. Results obtained from 12 meningiomas suggest a possible correlation between the level of lipids/macromolecules and permeability surface area product, although the confounding issue of extra-voxel contamination arising from lipids in the scalp and skull marrow cannot be ruled out in the more superficial lesions. Results obtained from 11 gliomas (four low and seven high grade) demonstrate that permeability surface area product is not specific for the range of vascular characteristics and metabolite profiles observed in gliomas and is therefore unable to explain metabolic heterogeneity in these lesions.

Relationships between choline magnetic resonance spectroscopy, apparent diffusion coefficient and quantitative histopathology in human glioma

This study sought to correlate quantitative presurgical proton magnetic resonance spectroscopic imaging (1H-MRSI) and diffusion imaging (DI) results with quantitative histopathological features of resected glioma tissue. The primary hypotheses were (1) glioma choline signal correlates with cell density, (2) glioma apparent diffusion coefficient (ADC) correlates inversely with cell density, (3) glioma choline signal correlates with cell proliferative index. Eighteen adult glioma patients were preoperatively imaged with 1H-MRSI and DI as part of clinically-indicated MRI evaluations. Cell density and proliferative index readings were made on surgical specimens obtained at surgery performed within 12 days of the radiologic scans. The resected tissue location was identified by comparing preoperative and postoperative MRI. The tumor to contralateral normalized choline signal ratio (nCho) and the ADC from resected tumor regions were measured from the preoperative imaging data. Counts of nuclei per high power field in 5-10 fields provided a quantitative measure of cell density. MIB-1 immunohistochemistry provided an index of the proportion of proliferating cells. There was a statistically significant inverse linear correlation between glioma ADC and cell density. There was also a statistically significant linear correlation between the glioma nCho and the cell density. The nCho measure did not significantly correlate with proliferative index. The results indicate that both ADC and spectroscopic choline measures are related to glioma cell density. Therefore they may prove useful for differentiating dense cellular neoplastic lesions from those that contain large proportions of acellular necrotic space.

Serial evaluation of patients with brain tumors using volume MRI and 3D 1H MRSI

Patients with brain tumors are routinely monitored for tumor progression and response to therapy using magnetic resonance imaging (MRI). Although serial changes in gadolinium enhancing lesions provide valuable information for making treatment decisions, they do not address the fate of non-enhancing lesions and are unable to distinguish treatment induced necrosis from residual or recurrent tumor. The introduction of a non-invasive methodology, which could identify an active tumor more reliably, would have a major impact upon patient care and evaluation of new therapies. There is now compelling evidence that magnetic resonance spectroscopic imaging (MRSI) can provide such information as an add-on to a conventional MRI examination. We discuss data acquisition and analysis procedures which are required to perform such serial MRI-MRSI examinations and compare their results with data from histology, contrast enhanced MRI, MR cerebral blood volume imaging and FDG-PET. Applications to the serial assessment of response to therapy are illustrated by considering populations of patients being treated with brachytherapy and gamma knife radiosurgery.

Variation of post-treatment H-MRSI choline intensity in pediatric gliomas

Pediatric brain gliomas are not always amenable for complete surgical excision, therefore adjuvant treatment for a large tumor mass is often required. As tumor volume shrinkage may not be a reliable method for assessing response to treatment, information about the tumor growth potential is desirable for an adequate follow-up of the patients. Choline (Cho) signal intensity, determined by proton magnetic resonance spectroscopy imaging (H-MRSI), has proved to be a reliable indicator of the metabolic activity and of tumor progression in various intracranial tumors. In this study we have sought to determine if H-MRSI can be of use in monitoring the response of pediatric gliomas to different forms of therapy. We performed pretreatment and post-treatment H-MRSI in 10 children with biopsed or partially excised brain gliomas. The follow-up period ranged between 6 and 40 months. A total of 38 H-MRSI were performed. All the patients had chemotherapy or radiotherapy. As an indicator of tumor activity we utilized the ratio between tumor/brain Cho signal intensity. Treatment response was evaluated as a function of tumor volume and clinical outcome. In 6 patients whose tumor volume decreased or remained stable we observed that the Cho ratio decreased (p < 0.01) after treatment and remained low during longitudinal follow-up. In the 4 patients whose tumors progressed the Cho ratio increased after treatment. These observations suggest that serial H-MRSI can provide valuable information regarding the response to therapy in pediatric gliomas and therefore be of use in the follow-up of these neoplasms of childhood.

Inverse correlation between choline magnetic resonance spectroscopy signal intensity and the apparent diffusion coefficient in human glioma

Magnetic resonance spectroscopy and diffusion magnetic resonance imaging (MRI) characteristics of human intracranial glioma were studied. Present knowledge suggests a hypothetical inverse relationship between the characteristic choline signal intensity elevation and the apparent diffusion coefficient (ADC) in glioma. Twenty cases of glioma were examined with diffusion-weighted echoplanar imaging and proton magnetic resonance spectroscopic imaging (1H-MRSI). A statistically significant inverse correlation between the choline signal intensity and the ADC was found (P = 0.0004) in radiologically defined tumor-containing regions. This study is the first in which diffusion MRI and 1H-MRSI were used to evaluate human intracranial glioma jointly. It provides insight into how to interpret choline signal intensity elevation in terms of tumor cellularity and proliferative potential when ADC images are also available.

Pediatric low-grade gliomas: prognosis with proton magnetic resonance spectroscopic imaging

OBJECTIVE

Our aim was to assess the correlation between the low-grade glioma (LGG) metabolic profile and tumor progression. Using in vivo proton magnetic resonance spectroscopic imaging, we specifically asked whether and which metabolic features are associated with tumor regrowth or recurrence.

METHODS

Eleven pediatric patients with histologically proven partially resected (<20% resection) midline LGG were treated and followed up for a period of 2 years. All patients underwent proton magnetic resonance spectroscopic imaging studies before any management was determined. Tumor progression was defined as radiological evidence of mass enlargement (>25%) during the follow-up period. Proton magnetic resonance spectroscopic imaging was performed using a PRESS-CSI sequence on a General Electric 1.5-tesla scanner (General Electric Medical System, Waukesha, WI). The signal intensities of N-acetylaspartate, choline (CHO), and creatine from the tumor and the normal brain were used to calculate normalized metabolite intensities and metabolite ratios.

RESULTS

Tumors that progressed during a 2-year period displayed higher normalized CHO than those that remained stable (Mann-Whitney test, P < 0.03). The majority (five of six) of the rapidly growing LGG showed values of normalized CHO of at least 1, whereas the nonprogressors had a normalized CHO value of less than 1.

CONCLUSION

In association with pediatric LGG, high normalized CHO values seem to herald the potential for rapid tumor growth. These observations may be valuable for defining subsets of patients with LGG who may benefit from early therapeutic interventions.

Improved water and lipid suppression for 3D PRESS CSI using RF band selective inversion with gradient dephasing (BASING)

A T1 insensitive solvent suppression technique-band selective inversion with gradient dephasing (BASING)-was developed to suppress water and lipids for 1H magnetic resonance spectroscopy (MRS). BASING, which consists of a frequency selective RF inversion pulse surrounded by spoiler gradient pulses of opposite signs, was used to dephase stopband resonances and minimally impact passband metabolites. Passband phase linearity was achieved with a dual BASING scheme. Using the Shinnar-Le Roux algorithm, a highpass filter was designed to suppress water and rephase the lactate methyl doublet independently of TE, and water/lipid bandstop filters were designed for the brain and prostate. Phantom and in vivo experimental 3D PRESS CSI data were acquired at 1.5 T to compare BASING with CHESS and STIR suppression. With BASING, the measured suppression factor was over 100 times higher than with CHESS or STIR causing baseline distortions to be removed. It was shown that BASING can be incorporated into a variety of sequences to offer improved suppression in the presence of B1 and T1 inhomogeneites.

Improved solvent suppression and increased spatial excitation bandwidths for three-dimensional PRESS CSI using phase-compensating spectral/spatial spin-echo pulses

Dual phase-compensating spectral/spatial echo-planar (EP) spin-echo (SE) pulses were incorporated into the point resolved spectroscopy (PRESS) excitation sequence to improve water and lipid suppression for 1H chemical shift imaging (CSI) and to decrease the dependence of the PRESS box location upon chemical shift. The asymmetric EPSE pulses (either minimum or maximum phase in the chemical shift domain) were substituted for the two PRESS SE pulses to yield zero phase spectra. Three different pulses were designed and tested at 1.5 T. Pulse 1, targeted for brain CSI (TE > 85 msec), passed choline to lipid resonances, suppressed water, and rephased the methyl lactate doublet independently of TE. Pulse 2, targeted for general purpose shorter TE PRESS, possessed both high chemical shift and spatial domain bandwidths. Pulse 3, designed for prostate CSI, passed choline to citrate resonances while suppressing lipids and water. The three pulses possessed spatial bandwidths ranging between 3.3 and 5.0 kHz, more than three times higher than that offered by one-dimensional SE pulses of equivalent maximum B1 amplitude. Phantom and in vivo experimental results demonstrated that, for EPSE pulses 1 and 2, suppression factors higher than 10(4) were achieved. The increased spatial bandwidths resulted in less contamination by signals from outside the designated PRESS excited region and a significant improvement in the uniformity of metabolite intensities for voxels located near edges of the PRESS box.

In vivo proton magnetic resonance spectroscopy of the normal aging human brain

The effect of age on brain metabolite concentrations was evaluated using localized proton magnetic resonance spectroscopy. This technique allows in vivo measurements of N-acetyl compounds (NA), total creatine (CR), choline-containing compounds (CHO), myo-inositol (MI), glutamate and glutamine (GLX), as well as the percentage of cerebrospinal fluid (CSF) and the brain water content within the brain region studied. Frontal gray matter and frontal white matter brain regions were examined in 36 normal healthy volunteers (19-78 years of age). Using a rigorous absolute quantitation method, with an external reference and atrophy correction, we found relatively stable concentrations of NA, a neuronal marker. In contrast, CR, CHO, MI, and the percentage of CSF increased in the gray matter with age. However, the brain water content decreased significantly with age (r = -0.72; p < 0.0001). No significant age-related changes in metabolite concentrations, CSF or brain water content were observed in the white matter regions. These findings demonstrate that biochemical alterations are associated with aging in the frontal gray matter. There might be an increase in the brain density as indicated by increased metabolite concentrations and decreased brain water content with aging.