Combining in Vitro Diagnostics with in Vivo Imaging for Earlier Detection of Pancreatic Ductal Adenocarcinoma: Challenges and Solutions

Pancreatic ductal adenocarcinoma (PDAC) is the fourth-leading cause of cancer-related death in the United States and is associated with a dismal prognosis, particularly when diagnosed at an advanced stage. Overall survival is significantly improved if PDAC is detected at an early stage prior to the onset of symptoms. At present, there is no suitable screening strategy for the general population. Available diagnostic serum markers are not sensitive or specific enough, and clinically available imaging modalities are inadequate for visualizing early-stage lesions. In this article, the role of currently available blood biomarkers and imaging tests for the early detection of PDAC will be reviewed. Also, the emerging biomarkers and molecularly targeted imaging agents being developed to improve the specificity of current imaging modalities for PDAC will be discussed. A strategy incorporating blood biomarkers and molecularly targeted imaging agents could lead to improved screening and earlier detection of PDAC in the future. (©) RSNA, 2015.

Multimodal MRI and (31)P-MRS investigations of the ACTA1(Asp286Gly) mouse model of nemaline myopathy provide evidence of impaired in vivo muscle function, altered muscle structure and disturbed energy metabolism

Nemaline myopathy (NM), the most common non-dystrophic congenital disease of skeletal muscle, can be caused by mutations in the skeletal muscle α-actin gene (ACTA1) (~25% of all NM cases and up to 50% of severe forms of NM). Muscle function of the recently generated transgenic mouse model carrying the human Asp286Gly mutation in the ACTA1 gene (Tg(ACTA1)(Asp286Gly)) has been mainly investigated in vitro. Therefore, we aimed at providing a comprehensive picture of the in vivo hindlimb muscle function of Tg(ACTA1)(Asp286Gly) mice by combining strictly noninvasive investigations. Skeletal muscle anatomy (hindlimb muscles, intramuscular fat volumes) and microstructure were studied using multimodal magnetic resonance imaging (Dixon, T2, Diffusion Tensor Imaging [DTI]). Energy metabolism was studied using 31-phosphorus Magnetic Resonance Spectroscopy ((31)P-MRS). Skeletal muscle contractile performance was investigated while applying a force-frequency protocol (1-150 Hz) and a fatigue protocol (6 min-1.7 Hz). Tg(ACTA1)(Asp286Gly) mice showed a mild muscle weakness as illustrated by the reduction of both absolute (30%) and specific (15%) maximal force production. Dixon MRI did not show discernable fatty infiltration in Tg(ACTA1)(Asp286Gly) mice indicating that this mouse model does not reproduce human MRI findings. Increased T2 values were observed in Tg(ACTA1)(Asp286Gly) mice and might reflect the occurrence of muscle degeneration/regeneration process. Interestingly, T2 values were linearly related to muscle weakness. DTI experiments indicated lower λ2 and λ3 values in Tg(ACTA1)(Asp286Gly) mice, which might be associated to muscle atrophy and/or the presence of histological anomalies. Finally (31)P-MRS investigations illustrated an increased anaerobic energy cost of contraction in Tg(ACTA1)(Asp286Gly) mice, which might be ascribed to contractile and non-contractile processes. Overall, we provide a unique set of information about the anatomic, metabolic and functional consequences of the Asp286Gly mutation that might be considered as relevant biomarkers for monitoring the severity and/or the progression of NM and for assessing the efficacy of potential therapeutic interventions.

Changes in muscular lipids in unilateral isolated hypertrophy of gastrocnemius muscle can be revealed by 1H MR spectroscopy

Objective

To test whether proton magnetic resonance spectroscopy (¹H-MRS) reveals changes in the lipid content of the gastrocnemius muscle (GM) and soleus muscle (SOL) of a patient with unilateral isolated hypertrophy of the right GM.

Materials and Methods

¹H-MRS was performed on a 1.5 Tesla (T) whole-body unit. Muscular lipids inside SOL and GM were assessed in both calves of the patient by a STEAM (stimulated echo acquisition mode) localization sequence. Results were compared to a control group of four healthy volunteers.

Results

Total amount of muscular lipids in the hypertrophic GM of the patient was clearly increased compared to the controls (38.7 versus 21.8±3.5 a.u.) while intramyocellular lipids of the adjacent SOL were lower compared to the contralateral healthy leg.

Conclusion

Muscular lipids are substrates for metabolism and can be assessed non-invasively by ¹H-MRS. ¹H-MRS is considered to be a helpful tool in clinical assessment of muscle metabolism in cases with muscular hypo- or hypertrophy.

Feasibility of rapid-sequence 31P magnetic resonance spectroscopy in cardiac patients

PURPOSE

To determine the clinical feasibility of rapid-sequence phosphorus-31 magnetic resonance spectroscopy (31P-MRS) of the heart with cardiac patients using a 1.5T clinical MR system.

MATERIAL AND METHODS

Twenty cardiac patients, i.e. dilated cardiomyopathy (DCM) 13 cases, hypertrophic cardiomyopathy (HCM) 3 cases, hypertensive heart diseases (HHD) 3 cases, and aortic regurgitation (AR) 1 case were examined using rapid cardiac 31P-MRS. Complete three-dimensional localization was performed using a two-dimensional phosphorus chemical-shift imaging sequence in combination with 30-mm axial slice-selective excitation. The rapid-sequence 31P-MRS procedure was phase encoded in arrays of 8 x 8 steps with an average of 4 acquisitions. The total examination time, including proton imaging and shimming, for the rapid cardiac 31P-MRS procedure, ranged from 10 to 15 min, depending on the heart rate. Student's t test was used to compare creatine phosphate (PCr)/adenosine triphosphate (ATP) ratios from the cardiac patients with those of the control subjects (n = 13).

RESULTS

The myocardial PCr/ATP ratio obtained by rapid 31P-MRS was significantly lower (P < 0.001) in DCM patients (1.82 +/- 0.33, mean +/- SD), and in patients with global myocardial dysfunction (combined data for 20 patients: 1.89 +/- 0.32) than in normal volunteers (2.96 +/- 0.59). These results are similar to previous studies.

CONCLUSION

Rapid-sequence 31P-MRS may be a valid diagnostic tool for patients with cardiac disease.

13C imaging—a new diagnostic platform

The evolution of magnetic resonance imaging (MRI) has been astounding since the early 1980s, and a broad range of applications has emerged. To date, clinical imaging of nuclei other than protons has been precluded for reasons of sensitivity. However, with the recent development of hyperpolarization techniques, the signal from a given number of nuclei can be increased as much as 100,000 times, sufficient to enable imaging of nonproton nuclei. Technically, imaging of hyperpolarized nuclei offers several unique properties, such as complete lack of background signal and possibility for local and permanent destruction of the signal by means of radio frequency (RF) pulses. These properties allow for improved as well as new techniques within several application areas. Diagnostically, the injected compounds can visualize information about flow, perfusion, excretory function, and metabolic status. In this review article, we explain the concept of hyperpolarization and the techniques to hyperpolarize 13C. An overview of results obtained within angiography, perfusion, and catheter tracking is given, together with a discussion of the particular advantages and limitations. Finally, possible future directions of hyperpolarized 13C MRI are pointed out.

Differentiation of chronic focal pancreatitis from pancreatic carcinoma by in vivo proton magnetic resonance spectroscopy

OBJECTIVE

To determine the differences between the in vivo proton magnetic resonance spectroscopy (H-MRS) features of chronic focal pancreatitis and pancreatic carcinoma and to evaluate the possibility of discriminating chronic focal pancreatitis from pancreatic carcinoma by analysis of in vivo H-MR spectra.

METHODS

The H-MR spectra from 36 human pancreases were evaluated in vivo. This series included 15 cases of chronic focal pancreatitis and 21 cases of pancreatic carcinoma. All cases were confirmed histopathologically after surgical resection. The ratios of the peak area (P) of all peaks at 1.6-4.1 ppm to lipid (0.9-1.6 ppm) (P [1.6-4.1 ppm]/P [0.9-1.6 ppm]) in the chronic focal pancreatitis and pancreatic carcinoma groups were evaluated, and the results were compared. The sensitivity and specificity of the analysis were also evaluated by in vivo H-MR spectra for discriminating between chronic focal pancreatitis and pancreatic carcinoma.

RESULTS

In vivo H-MR spectra showed significantly less lipid in chronic focal pancreatitis than in pancreatic carcinoma. The ratio of P (1.6-4.1 ppm)/P (0.9-1.6 ppm) in chronic focal pancreatitis was significantly higher than that in pancreatic carcinoma (P < 0.05) because of a decreased peak area of lipids. The means +/- SDs of P (1.6-4.1 ppm)/P (0.9-1.6 ppm) in the chronic focal pancreatitis and pancreatic carcinoma groups were 2.78 +/- 1.67 and 0.51 +/- 0.49, respectively. Using a value of <2.5 as positive for pancreatic cancer, the sensitivity and the specificity for pancreatic cancer were 100% and 53.3%, respectively.

CONCLUSION

Chronic focal pancreatitis and pancreatic carcinoma can be distinguished from each other by analysis of in vivo H-MR spectra, and in vivo H-MRS can be a useful method for making a differential diagnosis between chronic focal pancreatitis and pancreatic carcinoma.

Quantitative hepatic phosphorus-31 magnetic resonance spectroscopy in compensated and decompensated cirrhosis

Few studies have examined the physiological/biochemical status of hepatocytes in patients with compensated and decompensated cirrhosis in situ. Phosphorus-31 magnetic resonance spectroscopy ((31)P MRS) is a noninvasive technique that permits direct assessments of tissue bioenergetics and phospholipid metabolism. Quantitative (31)P MRS was employed to document differences in the hepatic metabolite concentrations among patients with compensated and decompensated cirrhosis as well as healthy controls. All MRS examinations were performed on a 1.5-T General Electric Signa whole body scanner. The concentration of hepatic phosphorylated metabolites among patients with compensated cirrhosis (n = 7) was similar to that among healthy controls (n = 8). However, patients with decompensated cirrhosis (n = 6) had significantly lower levels of hepatic ATP compared with patients with compensated cirrhosis and healthy controls (P < 0.02 and P < 0.009, respectively) and a higher phosphomonoester/phosphodiester ratio than controls (P < 0.003). The results of this study indicate that metabolic disturbances in hepatic energy and phospholipid metabolism exist in patients with decompensated cirrhosis that are not present in patients with compensated cirrhosis or healthy controls. These findings provide new insights into the pathophysiology of hepatic decompensation.

The role of relaxation time corrections for the evaluation of long and short echo time 1H MR spectra of the hippocampus by NUMARIS and LCModel techniques

1H MR spectroscopy is routinely used for lateralization of epileptogenic lesions. The present study deals with the role of relaxation time corrections for the quantitative evaluation of long (TE=135 ms) and short echo time (TE=10 ms) 1H MR spectra of the hippocampus using two methods (operator-guided NUMARIS and LCModel programs). Spectra of left and right hippocampi of 14 volunteers and 14 patients with epilepsy were obtained by PRESS (TR/TE=5000/135 ms) and STEAM (TR/TE=5000/10 ms) sequences with a 1.5-T imager. Evaluation was carried out using Siemens NUMARIS software and the results were compared with data from LCModel processing software. No significant differences between the two methods of processing spectra with TE=135 ms were found. The range of relaxation corrections was determined. Metabolite concentrations in hippocampi calculated from spectra with TE=135 ms and 10 ms after application of correction coefficients did not differ in the range of errors and agreed with published data (135 ms/10 ms: NAA=10.2+/-0.6/10.4+/-1.3 mM, Cho=2.4+/-0.1/2.7+/-0.3 mM, Cr=12.2+/-1.3/11.3+/-1.3 mM). When relaxation time corrections were applied, quantitative results from short and long echo time evaluation with LCModel were in agreement. Signal intensity ratios obtained from long echo time spectra by NUMARIS operator-guided processing also agreed with the LCModel results.

Regenerative activity and liver function following partial hepatectomy in the rat using (31)P-MR spectroscopy

The aim of the present study was to determine whether alterations in hepatic energy expenditure following partial hepatectomy (PHx), as documented by in vivo hepatic (31)P-MRS, correlate with standard parameters of hepatic regeneration and/or liver function. In addition, we sought to determine whether changes in hepatic energy levels are proportional to the extent of hepatic resection. Adult male Sprague-Dawley rats (4-7 per group) underwent a 40%, 70%, or 90% PHx or sham surgeries. Magnetic resonance spectroscopy (MRS) examinations were performed on each animal 24 or 48 hours thereafter. After MRS examinations, [(3)H]thymidine incorporation into hepatic DNA, proliferating cell nuclear antigen (PCNA) protein expression, and serum bilirubin determinations were performed on each rat. Twenty-four hours following surgery, rats that had undergone 70% PHx had unchanged adenosine triphosphate (ATP) levels but significantly lower ATP/inorganic phosphate (Pi) ratios (P <.05), whereas, at 48 hours post-PHx, both ATP and ATP/Pi levels were lower than in sham- and nonoperated controls (P <.05). Hepatic regeneration and liver dysfunction mirrored these changes; correlations existed between ATP/Pi ratios and [(3)H]thymidine incorporation (r = -0.61, P <.005), PCNA protein expression (r = -0.62, P <.005), and serum bilirubin (r = -0.49, P <.05). For rats that had undergone graded resections, depleted energy levels 48 hours post-PHx were proportional to the extent of resection, degree of enhanced regenerative activity, and liver dysfunction. In conclusion, (31)P-MRS-generated ATP/Pi index is a noninvasive, robust determination that correlates with standard parameters of hepatic regeneration and function.

In vivo proton magnetic resonance spectroscopy of central neurocytomas

OBJECTIVE

The authors report on the metabolic features of central neurocytomas observed during in vivo single-voxel proton magnetic resonance spectroscopy.

METHODS

Volume-selective single-voxel proton magnetic resonance spectroscopy was performed with a 1.5-T unit using a point-resolved spectroscopy sequence (TR/TE = 2000 ms/135 and 270 ms) to obtain spectra of a single 8-cc voxel. The subjects were five patients in the Department of Neurosurgery of Seoul National University Hospital whose central neurocytomas had been diagnosed histologically. The peak intensities of compounds containing choline (Cho), N-acetylaspartate, creatine/phosphocreatine, and lactate were analyzed.

RESULTS

The ratios of Cho to creatine/phosphocreatine and Cho to N-acetylaspartate were significantly higher than ratios in normal brains. A lactate signal was present, and an unidentified signal was also observed at 3.55 ppm, which might have been produced by inositol or glycine.

CONCLUSION

A combination of the signal at 3.55 ppm and a prominent Cho peak seems to be a characteristic feature of central neurocytomas. Volume-selective single-voxel proton magnetic resonance spectroscopy could provide additional information to aid in diagnosing this condition.

A two-compartment phantom for VOI profile measurements in small-bore 31P MR spectroscopy

A two-compartment gel phantom for VOI profile measurements in volume-selective 31P spectroscopy in small-bore units is presented. The phantom is cylindrical with two compartments divided by a very thin (30 microm) polyethene film. This thin film permits measurements with a minimum of susceptibility influences from the partition wall. The phantom was used for evaluation of the volume selection method ISIS (image-selected in vivo spectroscopy). The position of the phantom was fixed in the magnet during the measurements, while the volume of interest (VOI) was moved stepwise over the border. The signal from the two compartments was measured for each position and the data were evaluated following differentiation. We have found this phantom suitable for VOI profile measurements of ISIS in small-bore systems. The phantom forms a useful complement to recommended phantoms for small bore-spectroscopy.

Nuclear magnetic resonance spectroscopy study of muscle growth, mdx dystrophy and glucocorticoid treatments: correlation with repair

Proton nuclear magnetic resonance spectroscopy (1H NMR) can be used to study skeletal muscle metabolism. The mdx mouse is a unique animal for studies of muscle regeneration, and models the disease of Duchenne muscular dystrophy (DMD). The goals of this study were to determine the potential of 1H NMR spectroscopy as an alternative to conventional histology in monitoring: (1) normal growth in control muscle and the progression of dystrophy in mdx muscle, and (2) beneficial treatments (glucocorticoids) on mdx dystrophy. Ex vivo 1H NMR spectra of limb and diaphragm muscles were obtained from different ages of control and mdx mice, and from mice which were treated with prednisone or deflazacort. Peaks with contributions from creatine, taurine and lipids were examined. Lower levels of taurine and creatine characterized predystrophy and active dystrophy intervals in mdx muscle compared to control. Levels of taurine increased with stabilization of the disease by repair. A measure of accumulated muscle repair, fiber centronucleation and many spectral peaks were highly and significantly correlated. Greater amounts of lipids were found in the diaphragm compared to limb spectra. Treatment of dystrophy, which improved muscle phenotype, resulted in greater levels of taurine and creatine, especially in the limb muscle. Therefore, 1H NMR differentially discriminates: (1) control and mdx muscle; (2) the progression of mdx dystrophy and developmental stages in normal growth; (3) mild and severe dystrophic phenotypes (diaphragm vs limb); and (4) changes associated with improved muscle phenotype and regeneration (due to treatment or injury). The results focus on monitoring muscle repair, not degeneration. We conclude that 1H NMR is a reliable tool in the objective investigation of muscle repair status during muscular dystrophy.

CT and MR to assess the response of liver tumors to hepatic perfusion

Assessment of the response of liver tumors to hepatic perfusion is strongly based on cross-sectional imaging. CT and MRI have gained considerably in diagnostic accuracy with the introduction of new, fast acquisition techniques such as spiral CT or breath-hold techniques in MRI. In addition, the administration of contrast agents has improved and has led to new injection protocols in spiral CT and the development of liver-specific contrast agents in MRI. Imaging techniques, however, strongly rely on changes in morphology such as size, vascularization and signs of necrosis. Functional signs of tumor metabolism cannot be visualized directly. While most functional imaging techniques at present are based on nuclear medicine, MR spectroscopy (MRS) offers the potential to assess tumor metabolism. Its promise is a direct match between the morphologic information of MRI and the metabolic information provided by MRS. The application of MRS to the liver, however, is still in this infancy. This article will give an overview of the multitude of CT and MR techniques that can be used to monitor tumor response. It will discuss the various signs of tumor regression and some typical complications of hepatic perfusion therapy. In particular, the influence of tumor characteristics-tics on the optimum choice of imaging technique will be demonstrated.

Phosphorus-31 MR spectroscopy in the preoperative evaluation of symptomatic unilateral carotid artery stenosis

PURPOSE

The purpose of this study was to examine the potential of 31P-MRS (MR spectroscopy) in the pre- and postoperative evaluation of patients referred for endarterectomy.

MATERIAL AND METHODS

Nine patients with unilateral, hemodynamically significant stenosis in the region of the common carotid bifurcation were examined pre- and post-operatively with CT, SPECT (regional cerebral blood flow), transcranial Doppler, and duplex sonography, and they also underwent neuropsychologic investigation. Phosphorus-31 MRS of each hemisphere was performed before and 27-148 days after surgery. The relative concentrations of phosphomono- and -diesters, inorganic phosphate, phosphocreatine, and ATP were estimated.

RESULTS

No definite changes in concentrations could be detected for any of the metabolites.

CONCLUSION

The lack of changes was probably due to well-functioning collaterals and to the partial volume effect, whereby changes in a focal region are hidden when larger volumes are studied.