Proton magnetic resonance spectroscopy in oncology: the fingerprints of cancer?

Metabolic habitat imaging with hemodynamic heterogeneity predicts individual progression-free survival in high-grade glioma

AIM

We design a feasibility study to obtain a set of metabolic-hemodynamic habitats for tackling tumor spatial metabolic patterns with hemodynamic information.

MATERIALS AND METHODS

Preoperative data from 69 high-grade gliomas (HGG) patients with subsequent histologic confirmation of HGG were prospectively collected (January 2016 to March 2020) after concurrent chemoradiotherapy (CCRT). Four vascular habitats were automatically segmented by multiparametric magnetic resonance imaging (MRI). The metabolic information, either at enhancing or edema tumor regions, was obtained by two neuroradiologists. The relative habitat volumes were used for weight estimation procedures for computing the coefficients of a linear regression model using weighted least squares (WLS) for metabolite semiquantifications (i.e. the Cho/NAA ratio and the Cho/Cr ratio) at vascular habitats. Multivariate Cox proportional hazard regression analyses are used to obtain the odds ratio (OR) and develop a nomogram using weighted estimators corresponding to each covariate derived from Cox regression coefficients.

RESULTS

There was a strongly correlation between perfusion indexes and the Cho/Cr ratio (rCBV, r=0.71) or Cho/NAA ratio (rCBV, r=0.66) at high-angiogenic enhancing tumor habitats (HAT) habitat. Compared isocitrate dehydrogenase (IDH) mutation to their wild type, the IDH wild type had significantly decreased Cho/Cr ratio (IDH mutation: Cho/Cr ratio = 2.44 ± 0.33, IDH wildtype: Cho/Cr ratio = 2.66 ± 0.36, p=0.02) and Cho/NAA ratio (IDH mutation: Cho/Cr ratio = 4.59 ± 0.61, IDH wildtype: Cho/Cr ratio = 4.99 ± 0.66, p=0.022) at the HAT. The C-index for the median progression-free survival (PFS) prediction was 0.769 for the Cho/NAA nomogram and 0.747 for the Cho/Cr nomogram through 1000 bootstrapping validation.

CONCLUSIONS

Our findings suggest that spatial metabolism combined with hemodynamic heterogeneity is associated with individual PFS to HGG patients post-CCRT.

Artificial intelligence in neuro-oncology: advances and challenges in brain tumor diagnosis, prognosis, and precision treatment

This review delves into the most recent advancements in applying artificial intelligence (AI) within neuro-oncology, specifically emphasizing work on gliomas, a class of brain tumors that represent a significant global health issue. AI has brought transformative innovations to brain tumor management, utilizing imaging, histopathological, and genomic tools for efficient detection, categorization, outcome prediction, and treatment planning. Assessing its influence across all facets of malignant brain tumor management- diagnosis, prognosis, and therapy- AI models outperform human evaluations in terms of accuracy and specificity. Their ability to discern molecular aspects from imaging may reduce reliance on invasive diagnostics and may accelerate the time to molecular diagnoses. The review covers AI techniques, from classical machine learning to deep learning, highlighting current applications and challenges. Promising directions for future research include multimodal data integration, generative AI, large medical language models, precise tumor delineation and characterization, and addressing racial and gender disparities. Adaptive personalized treatment strategies are also emphasized for optimizing clinical outcomes. Ethical, legal, and social implications are discussed, advocating for transparency and fairness in AI integration for neuro-oncology and providing a holistic understanding of its transformative impact on patient care.

The Use of Magnetic Resonance Imaging in Radiation Therapy Treatment Simulation and Planning

Ever since its introduction as a diagnostic imaging tool the potential of magnetic resonance imaging (MRI) in radiation therapy (RT) treatment simulation and planning has been recognized. Recent technical advances have addressed many of the impediments to use of this technology and as a result have resulted in rapid and growing adoption of MRI in RT. The purpose of this article is to provide a broad review of the multiple uses of MR in the RT treatment simulation and planning process, identify several of the most used clinical scenarios in which MR is integral to the simulation and planning process, highlight existing limitations and provide multiple unmet needs thereby highlighting opportunities for the diagnostic MR imaging community to contribute and collaborate with our oncology colleagues. EVIDENCE LEVEL: 5 TECHNICAL EFFICACY: Stage 5.

Unique magnetic resonance spectroscopy profile of intracranial meningiomas compared to gliomas: a systematic review

BACKGROUND AND PURPOSE

The goal of this study was to systematically review the metabolic profile of meningiomas using magnetic resonance spectroscopy in comparison to gliomas, as measured by mean metabolite ratios.

METHODS

Following the PRISMA guidelines, a systematic literature review was performed using the PubMed, Ovid Embase, Web of Science, and the Cochrane databases from inception to May 2021. Studies were selected based on predetermined inclusion and exclusion criteria.

RESULTS

Eight studies were ultimately selected with 207 patients included. Fifty-nine patients were diagnosed with meningioma (age = 48.4, 66.7% female) and 148 patients diagnosed with glioma (age = 56.4, 49.2% female). Three studies reported elevated Cho/Cr in meningiomas compared to gliomas (5.71 vs. 1.46, p < 0.05, 7.02 vs. 2.62, p < 0.05, and 4.64 vs. 2.52, p = 0.001). One study reported Ala/Cr to be significantly elevated in meningiomas compared to gliomas (1.30 vs. undetectable, p < 0.001). One study reported myo-Inositol/Cr to be significantly elevated in meningiomas in comparison to gliomas (1.44 vs. 1.08, p < 0.05). One study reported Glu/Cr to be significantly elevated in meningiomas in comparison to gliomas (3.47 vs. 0.89, p = 0.002). Two studies reported Cho/NAA to be significantly elevated in meningiomas in comparison to gliomas (4.46 vs. 2.6, p = 0.004, and 5.8 vs. 2.55, p < 0.05). Two studies reported NAA/Cr was significantly elevated in gliomas compared to meningiomas (undetectable vs. 1.54, p < 0.001 and undetectable vs. 0.58, p < 0.05).

CONCLUSIONS

Significant differences in metabolite ratios between tumor types were reported in Cho/Cr, Ala/Cr, Glu/Cr, Cho/NAA, myoI/Cr and NAA/Cr between meningiomas and gliomas.

Spectral Analysis Based on Hemodynamic Habitat Imaging Predicts Isocitrate Dehydrogenase Status and Prognosis in High-Grade Glioma

BACKGROUND

The intratumoral heterogeneity of high-grade gliomas (HGGs) is associated with isocitrate dehydrogenase (IDH) status and prognosis, which can be established by quantitative radioanalysis of spatial tumor habitats. Therefore, we designed a framework for tackling tumors based on spatial metabolism using the hemodynamic tissue signature (HTS), focusing on metabolic changes in tumor habitat to predict IDH status and assess prognosis in patients with HGG.

METHODS

Preoperative data for 121 patients with HGG with subsequent histologic confirmation of HGG were prospectively collected (January 2016 to December 2020). The HTS was mapped from the image data, chemical shift imaging voxels were selected from the HTS habitat as the region of interest, and the metabolic ratio of the HTS was calculated using weighted least square method fitting. The metabolic rate of the tumor enhancement area was used as a control to analyze the efficacy of each HTS metabolic rate in predicting the IDH status and prognosis of HGG.

RESULTS

Total choline (Cho)/total creatine and Cho/N-acetyl-aspartate showed significant differences between IDH-wildtype and IDH-mutant in high- and low-angiogenic enhanced tumor sites (P < 0.05); Cho/total creatine was an independent risk factor for prognosis of HGG patients in high-angiogenic enhanced tumor habitats, with significant differences in survival time between groups (P < 0.05). The metabolic ratio in the tumor enhanced area could not predict IDH status or evaluate prognosis.

CONCLUSIONS

Spectral analysis based on hemodynamic habitat imaging can clearly distinguish IDH mutations and the prognosis assessment is more accurate, rendering it superior to traditional spectral analysis in tumor enhancement areas.

Small molecule metabolites: discovery of biomarkers and therapeutic targets

Metabolic abnormalities lead to the dysfunction of metabolic pathways and metabolite accumulation or deficiency which is well-recognized hallmarks of diseases. Metabolite signatures that have close proximity to subject's phenotypic informative dimension, are useful for predicting diagnosis and prognosis of diseases as well as monitoring treatments. The lack of early biomarkers could lead to poor diagnosis and serious outcomes. Therefore, noninvasive diagnosis and monitoring methods with high specificity and selectivity are desperately needed. Small molecule metabolites-based metabolomics has become a specialized tool for metabolic biomarker and pathway analysis, for revealing possible mechanisms of human various diseases and deciphering therapeutic potentials. It could help identify functional biomarkers related to phenotypic variation and delineate biochemical pathways changes as early indicators of pathological dysfunction and damage prior to disease development. Recently, scientists have established a large number of metabolic profiles to reveal the underlying mechanisms and metabolic networks for therapeutic target exploration in biomedicine. This review summarized the metabolic analysis on the potential value of small-molecule candidate metabolites as biomarkers with clinical events, which may lead to better diagnosis, prognosis, drug screening and treatment. We also discuss challenges that need to be addressed to fuel the next wave of breakthroughs.

Revisiting the use of proton magnetic resonance spectroscopy in distinguishing between primary and secondary malignant tumors of the central nervous system

BACKGROUND AND PURPOSE

Conventional magnetic resonance images (MRI) has limitations in distinguishing primary from secondary brain tumors. Proton magnetic resonance spectroscopy (1H-MRS) allows evaluation of the concentration of metabolites in a brain lesion and, hence, better characterization of the tumor. Considering that an accurate diagnosis determines the choice of treatment, our purpose was to assess the usefulness of spectroscopy data for differentiating between primary and secondary brain neoplasms.

MATERIALS AND METHODS

We undertook a retrospective analysis of 61 MRI and 1H-MRS images of patients with histologically confirmed tumors (30 primary tumors and 31 metastatic tumors). The metabolite ratios of Cho/Cr and NAA/Cr at short TE were determined from spectroscopic curves, with a single voxel positioned in the enhancing tumor. Additional variables analyzed along with the metabolites, like as age and gender, allowed the construction of a logistic regression model to predict the tumor's nature. The statistical analysis was done using the R software (version 4.0.3 R Core Team, 2020).

RESULTS

The mean NAA/Cr and Cho/Cr ratios were higher in secondary tumors, with a good correlation between NAA/Cr and Cho/Cr (r = 0.61). The mean age of patients with primary tumors was lower than for secondary tumors (43.9 vs 55.9, respectively). Receiver operating characteristic analysis yielded a cut-off value of 0.4 for the NAA/Cr ratio with an accuracy of 73.8%, a sensitivity of 73.3% and a specificity of 74.2% in predicting metastatic tumors.

CONCLUSION

The model was reasonable in predicting the nature of the tumor and provides an additional tool for analyzing brain tumors.

Metabolic Alterations in Sputum and Exhaled Breath Condensate of Early Stage Non-Small Cell Lung Cancer Patients After Surgical Resection: A Pilot Study

Every year, close to two million people world-wide are diagnosed with and die of lung cancer. Most patients present with advanced-stage cancer with limited curative options and poor prognosis. Diagnosis of lung cancer at an early stage provides the best chance for a cure. Low- dose CT screening of the chest in the high-risk population is the current standard of care for early detection of lung cancer. However, CT screening is invasive due to radiation exposure and carries the risk of unnecessary biopsies in non-cancerous tumors. In this pilot study, we present metabolic alterations observed in sputum and breath condensate of the same population of early- stage non-small cell lung cancer (NSCLC) patients cancer before and after surgical resection (SR), which could serve as noninvasive diagnostic tool. Exhaled breath condensate (EBC) (n=35) and sputum (n=15) were collected from early-stage non-small cell lung cancer (NSCLC) patients before and after SR. Median number of days for EBC and sputum collection before and after SR were 7 and 42; and 7 and 36 respectively Nuclear magnetic resonance (NMR) and liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF-MS) were used to analyze the metabolic profile of the collected samples. A total of 26 metabolites with significant alteration post SR were identified, of which 14 (54%) were lipids and 12 constituted nine different chemical metabolite classes. Eighteen metabolites (69%) were significantly upregulated and 8 (31%) were downregulated. Median fold change for all the up- and downregulated metabolites (LC-QTOF-MS) were 10 and 8, respectively. Median fold change (MFC) in concentration of all the up- and downregulated metabolites (NMR) were 0.04 and 0.27, respectively. Furthermore, glucose (median fold change, 0.01, p=0.037), adenosine monophosphate (13 log fold, p=0.0037) and N1, N12- diacetylspermine (8 log fold p=0.011) sputum levels were significantly increased post-SR. These identified sputa and EBC indices of altered metabolism could serve as basis for further exploration of biomarkers for early detection of lung cancer, treatment response, and targets for drug discovery. Validation of these promising results by larger clinical studies is warranted.

The use of biomarkers to stratify surgical care in women with ovarian cancer: Scientific Impact Paper No. 69 March 2022: Scientific Impact Paper No. 69 May 2022

Biomarkers may offer unforeseen insights into clinical diagnosis, as well as the likely course and outcome of a condition. In this paper, the focus is on the use of biological molecules found in body fluids or tissues for diagnosis and prediction of outcome in ovarian cancer patients. In cancer care, biomarkers are being used to develop personalised treatment plans for patients based on the unique characteristics of their tumour. This tailoring of care can be used to pursue specific targets identified by biomarkers, or treat the patient according to specific tumour characteristics. Surgery is one of the core treatments for ovarian cancer, whether it is offered in primary surgery or following chemotherapy in delayed surgery. Biomarkers already exist to guide the treatment of tumours with chemotherapy, but very little research has determined the value of biomarkers in tailoring surgical care for ovarian cancer. Such research is required to identify new biomarkers and assess their effectiveness in a clinical setting as well as to help identify specific tumour types to guide surgery. Biomarkers could help to determine the success of removing the disease surgically, or help to identify tumour deposits that persist after chemotherapy. All of these aspects would improve current practice. This Scientific Impact Paper highlights research that may pave the way towards bespoke surgery according to the biological characteristics of a tumour and aid gynaecological oncologists to provide surgical treatment according to individual need, rather than a blanket approach for all.

Hadamard-encoded dual-voxel SPECIAL: Short-TE MRS acquired in two brain regions simultaneously using Hadamard encoding

PURPOSE

The spin-echo, full-intensity acquired localized (SPECIAL) sequence is a method for single-voxel, localized MRS in vivo with short TEs. In this study we modified the SPECIAL sequence to simultaneously record spectra from two volumes of interest. This new technique is called Hadamard-encoded dual-voxel SPECIAL (HD-SPECIAL).

METHODS

The SPECIAL sequence consists of a spin echo localized to a column of tissue, preceded by a slice-selective inversion pulse in alternating scans to invert a section of the column. Full localization is achieved by subtraction of the inversion-on scans from the inversion-off scans. In HD-SPECIAL, the two-step inversion scheme is replaced by a four-step Hadamard-encoded scheme involving single-band and dual-band inversion pulses to select two regions of the spin-echo column. By appropriate Hadamard combination of the four acquired shots, spectra can be reconstructed from both desired regions. This approach does not rely on parallel imaging reconstruction. Using a 3T scanner, HD-SPECIAL localization is demonstrated both in phantoms and in the human brain in vivo, and the performance of HD-SPECIAL is assessed by comparing with the conventional SPECIAL sequence.

RESULTS

Phantom and in vivo measurements show excellent agreement between measures from HD-SPECIAL and SPECIAL sequences. Relative to consecutive SPECIAL measurements from two regions, HD-SPECIAL reduces the total scan time 2-fold with minimal penalty in terms of spectral quality or SNR.

CONCLUSION

The HD-SPECIAL sequence enables reliable acquisition of MR spectra simultaneously from two regions at 3 T, offering the potential to study interregional variations in metabolite concentrations.

ADNEX Model-Based Diagnosis of Ovarian Cancer Using MRI Images

This exploration aims to investigate the important role of magnetic resonance imaging (MRI) in the diagnosis of ovarian cancer under the ADNEX. From March 2017 to December 2019, 84 patients with ovarian cancer confirmed by pathological operation were selected as the research objects. The consistency of ADNEX, MRI, and ADNEX∗MRI in the diagnosis and staging of ovarian cancer was calculated separately. SPSS 26.0 statistical software was used to compare the accuracy, sensitivity, specificity, and diagnostic value of the two diagnostic methods. The results show that the accuracy and sensitivity of ADNEX are 78.6% and 93.2%, respectively. The accuracy and sensitivity of MRI are 81.2% and 89.4%, respectively. There is no significant difference between the two methods (p < 0.05). The overall consistency rates of ADNEX∗MRI, MRI diagnosis, and ADNEX for ovarian cancer staging are 94.2%, 74%, and 65.4%, respectively. There was a significant difference (p < 0.05). ADNEX∗MRI and MRI diagnosis were compared with each stage of ADNEX. There is a significant difference between the second and fourth stages (p < 0.05), and there is also a significant difference in the fourth stage (p < 0.017). It is concluded that MRI diagnosis of ovarian cancer based on ADNEX is superior to ADNEX and MRI examination alone, which provides a certain reference value for clinical staging of ovarian cancer.

Metabolic Alterations in Pancreatic Cancer Detected by In Vivo 1H-MR Spectroscopy: Correlation with Normal Pancreas, PET Metabolic Activity, Clinical Stages, and Survival Outcome

Objective: To compare the metabolites of in vivo 1H- MRS in pancreatic cancer with normal pancreas, and correlate these metabolites with Positron Emission Tomography (PET) metabolic activity, clinical stages, and survival outcomes. Methods: The prospective study included 58 patients (mean age 62.7 ± 12.1 years, range 34–81 years; 36 men, 22 women) with pathological proof of pancreatic adenocarcinoma, and all of them received 18F-fluorodeoxyglucose (FDG) PET/MRI before treatment. The single-voxel MRS with a point-resolved selective spectroscopy sequence was used to measure metabolites (creatine, Glx (glutamine and glutamate), N-acetylaspartate (NAA), and lipid) of pancreatic cancer and adjacent normal parenchyma, respectively. FDG-PET parameters included SUVmax, metabolic tumor volume (MTV), and total lesion glycolysis (TLG). Non-parametric tests were used to evaluate the differences of MRS metabolites between pancreatic cancer and those in normal pancreas, and their correlation with PET parameters and clinical stages. The correlation with progression-free survival (PFS) and overall survival (OS) was measured using the Kaplan–Meier and Cox proportional hazard models. Results: When compared with normal pancreas, the Glx, NAA, and lipid levels were significantly decreased in pancreatic cancer (all p < 0.05). Creatine, Glx, and lipid levels were all inversely correlated with both MTV (rho = −0.405~−0.454) and TLG (rho = −0.331~−0.441). For correlation with clinical stages, lower lipid levels were found in patients with T4 (vs. <T4, p = 0.038) and lower creatine levels were found in N1 (vs. N0, p = 0.019). Regarding survival outcomes, high TNM stage, low creatine, low Glx, and low lipid levels were associated with both poor PFS and OS (all p < 0.05). Additionally, creatine remained an independent factor for PFS and OS after adjusting for age, sex, tumor size, stages, and other metabolites levels. Conclusions: Decreased MRS metabolites in pancreatic cancer were associated with poor survival outcome, and may be used as prognostic image biomarkers for these patients.

Prognostic and therapeutic evaluation of nasopharyngeal carcinoma by dynamic contrast-enhanced (DCE), diffusion-weighted (DW) magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS)

Nasopharyngeal carcinoma (NPC) is an aggressive head and neck malignancy, and radiotherapy (with or without chemotherapy) is the primary treatment modality. Reliable tumour assessment during the treatment phase, which can portend the efficacy of radiotherapy and early identification of potential treatment failure in radioresistant disease, has been implicit for better cancer management. Technological advancement in the last decade has fostered the development of functional magnetic resonance imaging (fMRI) techniques into a promising tool for diagnostic and therapeutic assessments in head and neck cancer. Apart from conventional morphological assessment, early detection of the physiological environment by fMRI allows a more thorough investigation in monitoring tumour response. This article discusses the relevant fMRI utilities in NPC as an early prognostic and monitoring tool for treatment. Challenges and future developments of fMRI in radiation oncology are also discussed.

Imaging biomarkers for evaluating tumor response: RECIST and beyond

Response Evaluation Criteria in Solid Tumors (RECIST) is the gold standard for assessment of treatment response in solid tumors. Morphologic change of tumor size evaluated by RECIST is often correlated with survival length and has been considered as a surrogate endpoint of therapeutic efficacy. However, the detection of morphologic change alone may not be sufficient for assessing response to new anti-cancer medication in all solid tumors. During the past fifteen years, several molecular-targeted therapies and immunotherapies have emerged in cancer treatment which work by disrupting signaling pathways and inhibited cell growth. Tumor necrosis or lack of tumor progression is associated with a good therapeutic response even in the absence of tumor shrinkage. Therefore, the use of unmodified RECIST criteria to estimate morphological changes of tumor alone may not be sufficient to estimate tumor response for these new anti-cancer drugs. Several studies have reported the low reliability of RECIST in evaluating treatment response in different tumors such as hepatocellular carcinoma, lung cancer, prostate cancer, brain glioma, bone metastasis, and lymphoma. There is an increased need for new medical imaging biomarkers, considering the changes in tumor viability, metabolic activity, and attenuation, which are related to early tumor response. Promising imaging techniques, beyond RECIST, include dynamic contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI), diffusion-weight imaging (DWI), magnetic resonance spectroscopy (MRS), and ¹⁸ F-fluorodeoxyglucose (FDG) positron emission tomography (PET). This review outlines the current RECIST with their limitations and the new emerging concepts of imaging biomarkers in oncology.

Metabolic Changes in Early-Stage Non-Small Cell Lung Cancer Patients after Surgical Resection

Simple Summary

Considerable progress in the treatment of non–small cell lung cancer (NSCLC) has been made possible by large-scale technologies that scan the gene expression in tumor cells. While gene expression is informative, it is the changes to cellular metabolism that directly affect the initiation and the progression of the disease. Altered metabolic processes in cancer include how the tumor cells handle fat, proteins, and sugar, produce energy, divide (grow), or migrate. We have used nuclear magnetic resonance and mass spectrometry to survey and document the metabolic changes in blood and urine samples collected from NSCLC patients before and after their lung tumors were surgically removed. We found several molecular compounds that changed in abundance in the blood or urine after surgery, many of which are related to cancer cell metabolism. Further documentation of these changes in large patient populations will lead to non-invasive ways to screen, diagnose, or monitor disease progression in lung cancer patients.

Abstract

Metabolic alterations in malignant cells play a vital role in tumor initiation, proliferation, and metastasis. Biofluids from patients with non–small cell lung cancer (NSCLC) harbor metabolic biomarkers with potential clinical applications. In this study, we assessed the changes in the metabolic profile of patients with early-stage NSCLC using mass spectrometry and nuclear magnetic resonance spectroscopy before and after surgical resection. A single cohort of 35 patients provided a total of 29 and 32 pairs of urine and serum samples, respectively, pre-and post-surgery. We identified a profile of 48 metabolites that were significantly different pre- and post-surgery: 17 in urine and 31 in serum. A higher proportion of metabolites were upregulated than downregulated post-surgery (p < 0.01); however, the median fold change (FC) was higher for downregulated than upregulated metabolites (p < 0.05). Purines/pyrimidines and proteins had a larger dysregulation than other classes of metabolites (p < 0.05 for each class). Several of the dysregulated metabolites have been previously associated with cancer, including leucyl proline, asymmetric dimethylarginine, isopentenyladenine, fumaric acid (all downregulated post-surgery), as well as N6-methyladenosine and several deoxycholic acid moieties, which were upregulated post-surgery. This study establishes metabolomic analysis of biofluids as a path to non-invasive diagnostics, screening, and monitoring in NSCLC.

What is the optimal schedule for multiparametric MRS? A magnetic resonance fingerprinting perspective

Clinical magnetic resonance spectroscopy (MRS) mainly concerns itself with the quantification of metabolite concentrations. Metabolite relaxation values, which reflect the microscopic state of specific cellular and sub-cellular environments, could potentially hold additional valuable information, but are rarely acquired within clinical scan times. By varying the flip angle, repetition time and echo time in a preset way (termed a schedule), and matching the resulting signals to a pre-generated dictionary - an approach dubbed magnetic resonance fingerprinting - it is possible to encode the spins' relaxation times into the acquired signal, simultaneously quantifying multiple tissue parameters for each metabolite. Herein, we optimized the schedule to minimize the averaged root mean square error (RMSE) across all estimated parameters: concentrations, longitudinal and transverse relaxation time, and transmitter inhomogeneity. The optimal schedules were validated in phantoms and, subsequently, in a cohort of healthy volunteers, in a 4.5 mL parietal white matter single voxel and an acquisition time under 5 minutes. The average intra-subject, inter-scan coefficients of variation (CVs) for metabolite concentrations, T₁ and T₂ relaxation times were found to be 3.4%, 4.6% and 4.7% in-vivo, respectively, averaged over all major singlets. Coupled metabolites were quantified using the short echo time schedule entries and spectral fitting, and reliable estimates of glutamate+glutamine, glutathione and myo-inositol were obtained.

1H-MRS application in the evaluation of response to photo-thermal therapy using iron oxide-gold core-shell nanoparticles, an in vivo study

BACKGROUND

Photo-thermal therapy (PTT) has been at the center of attention as a new method for cancer treatment in recent years. It is important to predict the response to treatment in the PTT procedure. Using magnetic resonance spectroscopy (MRS) can be considered a novel technique in evaluating changes in metabolites resulted from PTT.

METHODS

In the present project, we conducted an in vivo study to assess the efficacy of ¹H-MRS as a noninvasive technique to evaluate the response to treatment in the early hours following PTT. The BALB/c mice subcutaneously bearing tumor cells (CT26 cell line) were scanned by ¹H-MRS before and after PTT. Iron oxide-gold core-shell (Fe₃O₄@Au) as PTT agent was injected into intra-peritoneal at first and then irradiated by NIR laser. Single-voxel Point RESolved Spectroscopy (PRESS) sequence (TE = 144) was used, and metabolites alternations were evaluated by the non-parametric Wilcoxon test. Besides, Nanoparticle (NP) relaxometry was conducted for negative contrast agents' potentials.

RESULTS

MRS choline (Cho) peak dramatically reduced 24 h post-PTT (p = 0.01) and lipid peak as a marker for necrosis of tumor elevated (p = 0.01) just in group 3 (NPs injection + laser irradiation) 24 h after the procedure.

CONCLUSION

¹H-MRS showed its potential as a method in detecting the changes in metabolites and revealing the outcome accurately. Response to photo-thermal therapy evaluation was achievable only one day after PTT and proved by a 10-day follow-up of the tumor size. Iron oxide-gold core-shell can also be used as a negative contrast agent in MRI images during therapy.

Cancer metabolism in a snapshot: MRS(I)

The contribution of MRS(I) to the in vivo evaluation of cancer-metabolism-derived metrics, mostly since 2016, is reviewed here. Increased carbon consumption by tumour cells, which are highly glycolytic, is now being sampled by ¹³ C magnetic resonance spectroscopic imaging (MRSI) following the injection of hyperpolarized [1-¹³ C] pyruvate (Pyr). Hot-spots of, mostly, increased lactate dehydrogenase activity or flow between Pyr and lactate (Lac) have been seen with cancer progression in prostate (preclinical and in humans), brain and pancreas (both preclinical) tumours. Therapy response is usually signalled by decreased Lac/Pyr ¹³ C-labelled ratio with respect to untreated or non-responding tumour. For therapeutic agents inducing tumour hypoxia, the ¹³ C-labelled Lac/bicarbonate ratio may be a better metric than the Lac/Pyr ratio. ³¹ P MRSI may sample intracellular pH changes from brain tumours (acidification upon antiangiogenic treatment, basification at fast proliferation and relapse). The steady state tumour metabolome pattern is still in use for cancer evaluation. Metrics used for this range from quantification of single oncometabolites (such as 2-hydroxyglutarate in mutant IDH1 glial brain tumours) to selected metabolite ratios (such as total choline to N-acetylaspartate (plain ratio or CNI index)) or the whole ¹ H MRSI(I) pattern through pattern recognition analysis. These approaches have been applied to address different questions such as tumour subtype definition, following/predicting the response to therapy or defining better resection or radiosurgery limits.

Non-invasive exploration of metabolic profile of lung cancer with Magnetic Resonance Spectroscopy and Mass Spectrometry

Background

Lung cancer is a major cause of global morbidity and mortality. Current low dose CT screening is invasive and its role remains contentious. There are no known biomarkers to monitor treatment response, detect disease recurrence and patient selection for adjuvant treatment after curative surgical resection. Hence there is an urgent need to explore non-conventional and non-invasive tools to develop novel biomarkers to improve the outcome of this lethal cancer.

Methods

This is an ongoing exploratory and translational study involving collection of bio fluids from 50 patients with early stage non-small cell lung cancer before and after surgical resection. The primary objective is to identify cancer specific metabolome in body fluids - sputum, exhaled breath condensate, blood and urine of the patients with early stage non-small cell lung cancer using Magnetic Resonance Spectroscopy and Mass Spectroscopy.

Conclusion

The trajectory of change in metabolic profile of body fluids before and after surgical resection may have potential clinical applications in lung cancer screening, as biomarkers for disease recurrence and exploration of novel targets for therapeutic intervention.

How clinical imaging can assess cancer biology

Human cancers represent complex structures, which display substantial inter- and intratumor heterogeneity in their genetic expression and phenotypic features. However, cancers usually exhibit characteristic structural, physiologic, and molecular features and display specific biological capabilities named hallmarks. Many of these tumor traits are imageable through different imaging techniques. Imaging is able to spatially map key cancer features and tumor heterogeneity improving tumor diagnosis, characterization, and management. This paper aims to summarize the current and emerging applications of imaging in tumor biology assessment.

Uterine Leiomyosarcoma: Can MRI Differentiate Leiomyosarcoma From Benign Leiomyoma Before Treatment?

OBJECTIVE

The purpose of this article is to provide background on the epidemiologic, clinical, and economic impact of uterine leiomyomas, summarize the concerns associated with treating women with potential occult leiomyosarcomas (LMSs), and review the known and emerging imaging features of typical and atypical leiomyomas and explain how to differentiate them from LMSs.

CONCLUSION

Surgical management of presumed benign uterine leiomyomas received popular media attention when a case of disseminated LMS occurred after laparoscopic power morcellator-assisted hysterectomy. A subsequent U.S. Food and Drug Administration review found a higher prevalence of unsuspected uterine sarcoma and LMS among patients undergoing myomectomy or hysterectomy for presumed benign leiomyomas than was previously reported. This heightened concern has led to increased pressure on radiologists to distinguish LMSs from leiomyomas.

Functional imaging in pancreatic disease

In addition to the classical morphological evaluation of pancreatic disease, the constant technological advances in imaging techniques based fundamentally on computed tomography and magnetic resonance imaging have enabled the quantitative functional and molecular evaluation of this organ. In many cases, this imaging-based information results in substantial changes to patient management and can be a fundamental tool for the development of biomarkers. The aim of this article is to review the role of emerging functional and molecular techniques based on computed tomography and magnetic resonance imaging in the evaluation of pancreatic disease.

Imaging biomarkers from multiparametric magnetic resonance imaging are associated with survival outcomes in patients with brain metastases from breast cancer

OBJECTIVES

The aim of this study is to investigate the correlation of survival outcomes with imaging biomarkers from multiparametric magnetic resonance imaging (MRI) in patients with brain metastases from breast cancer (BMBC).

METHODS

This study was approved by the institutional review board. Twenty-two patients with BMBC who underwent treatment involving bevacizumab on day 1, etoposide on days 2-4, and cisplatin on day 2 in 21-day cycles were prospectively enrolled for a phase II study. Three brain MRIs were performed: before the treatment, on day 1, and on day 21. Eight imaging biomarkers were derived from dynamic contrast-enhanced MRI (Peak, IAUC₆₀, K^trans, k_ep, v_e), diffusion-weighted imaging [apparent diffusion coefficient (ADC)], and MR spectroscopy (choline/N-acetylaspartate and choline/creatine ratios). The relative changes (Δ) in these biomarkers were correlated with the central nervous system (CNS)-specific progression-free survival (PFS) and overall survival (OS) using the Kaplan-Meier and Cox proportional hazard models.

RESULTS

There were no significant differences in the survival outcomes as per the changes in the biomarkers on day 1. On day 21, those with a low ΔK^trans (p = 0.024) or ΔADC (p = 0.053) reduction had shorter CNS-specific PFS; further, those with a low ΔPeak (p = 0.012) or ΔIAUC₆₀ (p = 0.04) reduction had shorter OS compared with those with high reductions. In multivariate analyses, ΔK^trans and ΔPeak were independent prognostic factors for CNS-specific PFS and OS, respectively, after controlling for age, size, hormone receptors, and performance status.

CONCLUSIONS

Multiparametric MRI may help predict the survival outcomes in patients with BMBC.

KEY POINTS

• Decreased angiogenesis after chemotherapy on day 21 indicated good survival outcome. • ΔK ^trans was an independent prognostic factors for CNS-specific PFS. • ΔPeak was an independent prognostic factors for OS. • Multiparametric MRI helps clinicians to assess patients with BMBC. • High-risk patients may benefit from more intensive follow-up or treatment strategies.

Hyperpolarized carbon-13 magnetic resonance spectroscopic imaging: a clinical tool for studying tumour metabolism

Glucose metabolism in tumours is reprogrammed away from oxidative metabolism, even in the presence of oxygen. Non-invasive imaging techniques can probe these alterations in cancer metabolism providing tools to detect tumours and their response to therapy. Although Positron Emission Tomography with (18F)2-fluoro-2-deoxy-D-glucose (18F-FDG PET) is an established clinical tool to probe cancer metabolism, it has poor spatial resolution and soft tissue contrast, utilizes ionizing radiation and only probes glucose uptake and phosphorylation and not further downstream metabolism. Magnetic Resonance Spectroscopy (MRS) has the capability to non-invasively detect and distinguish molecules within tissue but has low sensitivity and can only detect selected nuclei. Dynamic Nuclear Polarization (DNP) is a technique which greatly increases the signal-to-noise ratio (SNR) achieved with MR by significantly increasing nuclear spin polarization and this method has now been translated into human imaging. This review provides a brief overview of this process, also termed Hyperpolarized Carbon-13 Magnetic Resonance Spectroscopic Imaging (HP 13C-MRSI), its applications in preclinical imaging, an outline of the current human trials that are ongoing, as well as future potential applications in oncology.

Imaging markers of response to combined BRAF and MEK inhibition in BRAF mutated vemurafenib-sensitive and resistant melanomas

A majority of patients with a V600x melanoma respond quickly to BRAF/MEK inhibition (BRAFi/MEKi) and have an obvious clinical benefit. Nearly all the patients after this initial phase will develop resistance. Therefore, non-invasive early markers of response/non-response are needed in order to identify those patients who, due to intrinsic or acquired resistance, do not respond to treatment and would be eligible for alternative treatments.

The aim of this study was to investigate the value of magnetic resonance spectroscopy (¹H-MRS) of choline and diffusion-weighted magnetic resonance imaging (DW-MRI) as early markers of response to BRAF inhibition (BRAFi) with vemurafenib alone or in combination with MEK inhibition (MEKi) with trametinib, in BRAFi-sensitive and BRAFi-resistant melanoma xenografts.

Tumor response was significantly improved by the combination of BRAFi and MEKi, compared to BRAFi alone, only in sensitive xenografts; thus indicating that vemurafenib-resistant A375R xenografts were cross-resistant to the inhibition of MEK, as confirmed by immunohistochemistry analysis for phosphorylated ERK.

In vivo¹H-MRS showed that in sensitive melanoma xenografts, a significant blockage of ERK phosphorylation, but not a decrease in cell proliferation, was required to affect total choline (tCho) levels, thus suggesting that tCho could serve as a pharmacodynamic (PD) marker for agents targeting the MAPK cascade. In addition, early effects of the combination therapy on tumor cellularity could be detected via DW-MRI. In particular, skewness and kurtosis of the apparent diffusion coefficient (ADC) distribution may be useful to detect changes in the diffusional heterogeneity that might not affect the global ADC value.

Background, current role, and potential applications of radiogenomics

With the genomic revolution in the early 1990s, medical research has been driven to study the basis of human disease on a genomic level and to devise precise cancer therapies tailored to the specific genetic makeup of a tumor. To match novel therapeutic concepts conceived in the era of precision medicine, diagnostic tests must be equally sufficient, multilayered, and complex to identify the relevant genetic alterations that render cancers susceptible to treatment. With significant advances in training and medical imaging techniques, image analysis and the development of high-throughput methods to extract and correlate multiple imaging parameters with genomic data, a new direction in medical research has emerged. This novel approach has been termed radiogenomics. Radiogenomics aims to correlate imaging characteristics (ie, the imaging phenotype) with gene expression patterns, gene mutations, and other genome-related characteristics and is designed to facilitate a deeper understanding of tumor biology and capture the intrinsic tumor heterogeneity. Ultimately, the goal of radiogenomics is to develop imaging biomarkers for outcome that incorporate both phenotypic and genotypic metrics. Due to the noninvasive nature of medical imaging and its ubiquitous use in clinical practice, the field of radiogenomics is rapidly evolving and initial results are encouraging. In this article, we briefly discuss the background and then summarize the current role and the potential of radiogenomics in brain, liver, prostate, gynecological, and breast tumors.

LEVEL OF EVIDENCE

5 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2017;47:604-620.

Magnetic Resonance Spectroscopy and its Clinical Applications: A Review

In vivo NMR spectroscopy is known as magnetic resonance spectroscopy (MRS). MRS has been applied as both a research and a clinical tool in order to detect visible or nonvisible abnormalities. The adaptability of MRS allows a technique that can probe a wide variety of metabolic uses across different tissues. Although MRS is mostly applied for brain tissue, it can be used for detection, localization, staging, tumour aggressiveness evaluation, and tumour response assessment of breast, prostate, hepatic, and other cancers. In this article, the medical applications of MRS in the brain, including tumours, neural and psychiatric disorder studies, breast, prostate, hepatic, gastrointestinal, and genitourinary investigations have been reviewed.

Magnetic Resonance and Ultrastructural Characterization of PEGylation-associated Vacuolation in Nonclinical Models

Conjugation with polyethylene glycol (PEG) is a strategy for improving the pharmaceutical properties of therapeutic proteins. In nonclinical studies of PEGylated compounds, microscopic tissue vacuolation is often observed, characterized ultrastructurally in this report by lysosomal distension. Although PEGylation-associated vacuolation appears to be of limited toxicologic concern when alternative therapies are limited, the risk-benefit considerations may be impacted by uncertainty about reversibility, lack of methods for monitoring PEG accumulation in vivo without biopsy, and the variability in tissues affected depending on species studied. We demonstrate the use of magnetic resonance spectroscopy (MRS) to measure PEG concentrations at multiple time points in vivo in the kidney with comparison to PEG concentrations ex vivo in body fluids and tissue extracts using nuclear magnetic resonance (NMR) spectroscopy. Furthermore, we demonstrate the use of these techniques to study distribution and elimination of PEG in a dog model of PEGylation-associated vacuolation. This report suggests that MRS could be further investigated as a feasible imaging-based method for monitoring PEG accumulation in a clinical setting in conjunction with NMR quantitation of PEG in plasma and urine.

Evaluation of human glioma using in-vivo proton magnetic resonance spectroscopy combined with expression of cyclooxygenase-2: a preliminary clinical trial

We sought to investigate the correlation between in-vivo proton magnetic resonance spectroscopy (H-MRS) and cyclooxygenase-2 (COX-2) expression in human glioma, and to advance their roles in diagnostic mapping and monitoring of glioma biological behavior. Thirty-nine patients with different grades of glioma (WHO classification I-IV) included in this study were scanned at 3.0 T MR before operation or biopsy puncture. Tumor morphology and H-MRS metabolites ratio [choline (Cho)/creatine (Cr)] were evaluated independently by two experienced radiologists. Paraffin-embedded glioma specimens were detected for the COX-2 expression using immunohistochemistry. Parametric and nonparametric tests including correlation, logistic regression and receiver operating characteristic analysis were applied to assess the predicative roles and relation diagram of H-MRS and COX-2. The COX-2 expression showed a significant difference between low and high grade gliomas (P<0.01). Varying degrees of COX-2 expression have positive correlation with the Cho/Cr values in tumor zone (r=0.49, P=0.013), and showed not significant correlation with sex, age, and tumor location. For patients with high grade gliomas after surgery and radiation, COX-2 was associated with shortened survival in univariate analysis (P=0.025). The COX-2, Cho/Cr value and age were the significant prognostic indicators shown in multivariate survival analysis. The COX-2 and Cho/Cr value of H-MRS have correlation, and are both positive indicators for overall survival of human high grade glioma, and could be combined as a joint role to provide more evidences to assess the biological behavior.

In vivo imaging techniques: a new era for histochemical analysis

In vivo imaging techniques can be integrated with classical histochemistry to create an actual histochemistry of water. In particular, Magnetic Resonance Imaging (MRI), an imaging technique primarily used as diagnostic tool in clinical/preclinical research, has excellent anatomical resolution, unlimited penetration depth and intrinsic soft tissue contrast. Thanks to the technological development, MRI is not only capable to provide morphological information but also and more interestingly functional, biophysical and molecular. In this paper we describe the main features of several advanced imaging techniques, such as MRI microscopy, Magnetic Resonance Spectroscopy, functional MRI, Diffusion Tensor Imaging and MRI with contrast agent as a useful support to classical histochemistry.

Cholinergic Machinery as Relevant Target in Acute Lymphoblastic T Leukemia

Various types of non-neuronal cells, including tumors, are able to produce acetylcholine (ACh), which acts as an autocrine/paracrine growth factor. T lymphocytes represent a key component of the non-neuronal cholinergic system. T cells-derived ACh is involved in a stimulation of their activation and proliferation, and acts as a regulator of immune response. The aim of the present work was to summarize the data about components of cholinergic machinery in T lymphocytes, with an emphasis on the comparison of healthy and leukemic T cells. Cell lines derived from acute lymphoblastic leukemias of T lineage (T-ALL) were found to produce a considerably higher amount of ACh than healthy T lymphocytes. Additionally, ACh produced by T-ALL is not efficiently hydrolyzed, because acetylcholinesterase (AChE) activity is drastically decreased in these cells. Up-regulation of muscarinic ACh receptors was also demonstrated at expression and functional level, whereas nicotinic ACh receptors seem to play a less important role and not form functional channels in cells derived from T-ALL. We hypothesized that ACh over-produced in T-ALL may act as an autocrine growth factor and play an important role in leukemic clonal expansion through shaping of intracellular Ca²⁺ signals. We suggest that cholinergic machinery may be attractive targets for new drugs against T-ALL. Specifically, testing of high affinity antagonists of muscarinic ACh receptors as well as antagomiRs, which interfere with miRNAs involved in the suppression of AChE expression, may be the first choice options.