MRI for staging lymphoma: Whole‐body or less?

Purpose:

To assess whether whole‐body MRI detects more clinically relevant lesions (i.e., leading to a change in Ann Arbor stage) than an MRI protocol that only includes the head/neck and trunk (i.e., from cranial vertex to groin, excluding the arms) in patients with lymphoma.

Materials and Methods:

One hundred consecutive patients with newly diagnosed lymphoma prospectively underwent T1‐weighted and T2‐weighted short inversion time inversion recovery whole‐body MRI. The number of lymphomatous sites at MRI with a field of view (FOV) limited to the head/neck and trunk, and the additional number of lymphomatous sites at whole‐body MRI and their influence on Ann Arbor stage were determined.

Results:

At MRI with a FOV limited to the head/neck and trunk, 507 sites were classified as lymphomatous. At whole‐body MRI, 7 additional sites outside the head/neck and trunk in 7 patients (7.0%; 95% confidence interval: 3.4–13.8%) were classified as lymphomatous, but Ann Arbor stage never changed.

Conclusion:

Whole‐body MRI did not detect any clinically relevant lesions outside the FOV of an MRI protocol that only includes the head/neck and trunk. Therefore, it may be sufficient to only include the head/neck and trunk when using MRI for staging lymphoma. J. Magn. Reson. Imaging 2011;33:1144–1150. © 2011 Wiley‐Liss, Inc.     

Diffusion-weighted imaging as part of hybrid PET/MRI protocols for whole-body cancer staging: Does it benefit lesion detection?

Purpose

Positron emission tomography/magnetic resonance imaging (PET/MRI) requires efficient scan protocols for whole-body cancer staging. The aim of this study was to evaluate if the application of diffusion-weighted MR imaging (DWI) results in a diagnostic benefit for lesion detection in oncologic patients if added to a whole-body [18F]-fluorodesoxyglucose ([18F]-FDG) PET/MRI protocol.

Methods

25 consecutive oncologic patients (16 men, 9 women; age 57 ± 12 years) prospectively underwent whole-body [18F]-FDG-PET/MRI including DWI on a hybrid PET/MRI scanner. A team of two readers assessed [18F]-FDG PET/MRI without DWI for primary tumors and metastases. In a second session, now considering DWI, readers reassessed [18F]-FDG PET/MRI accordingly. Additionally, the lesion-to-background contrast on [18F]-FDG PET and DWI was rated qualitatively (0, invisible; 1, low; 2, intermediate; 3, high). Wilcoxon's signed-rank test was performed to test for differences in the lesion-to-background contrast.

Results

49 lesions were detected in 16 patients (5 primaries, 44 metastases). All 49 lesions were concordantly detected by [18F]-FDG PET/MRI alone and [18F]-FDG PET/MRI with DWI. The lesion-to-background contrast on DWI compared to [18F]-FDG PET was rated lower in 22 (44.9%) of 49 detected lesions resulting in a significantly higher lesion-to-background contrast on [18F]-FDG PET compared to DWI (P = 0.001).

Conclusions

DWI as part of whole-body [18F]-FDG PET/MRI does not benefit lesion detection. Given the necessity to optimize imaging protocols with regard to patient comfort and efficacy, DWI has to be questioned as a standard tool for whole-body staging in oncologic PET/MRI.     

MRI in staging advanced gastric cancer: is it useful compared with spiral CT?

PURPOSE: During the last decade, rapid progress has been made in MR technology. Our objective was to evaluate the role of MRI in staging advanced gastric cancer (AGC; gastric cancer invading the muscularis propria) and to compare it with that of spiral CT. METHOD: We prospectively performed both MR and CT examinations on 26 patients with AGC proven by endoscopic biopsy. Contrast-enhanced CT and nonenhanced MRI with a 1.0 T scanner using FLASH, HASTE, and true-FISP sequences were obtained in each patient after injection of antiperistaltic drug and ingestion of 1 L of tap water. Fifty-two sets of CT and MR images were analyzed by two radiologists in consensus without any information from other images. T and N staging of AGC was determined according to the TNM classification. All patients underwent surgery within 1 week after both examinations. Diagnostic accuracy of each staging of AGC on CT or MRI was evaluated by comparison with the pathologic results. RESULTS: MRI was slightly superior to CT in T staging (81 vs. 73%, respectively; p < 0.05). Although MRI had a tendency to overstage the pathologic T2 cancer, positive predictability of T2 stage and sensitivity of T3 stage were high (100%, respectively). Regarding the N staging, CT was slightly superior to MRI (73 vs. 65%; p > 0.05). However, both CT and MRI demonstrated the tendency of understaging in N staging. CONCLUSION: Although MRI was superior to spiral CT in T staging, MRI cannot completely replace spiral CT in staging AGC because of its limitation in N staging.     

“One-stop-shop” staging: Should we prefer FDG-PET/CT or MRI for the detection of bone metastases?

Aim

The aim of this study was to compare the diagnostic accuracy of fully diagnostic, contrast-enhanced whole-body FDG-PET/CT and whole-body MRI for detection of bone metastases in patients suffering from newly diagnosed non-small cell lung cancer and malignant melanoma.

Material and Methods

109 consecutive non-small cell lung cancer (n = 54) and malignant melanoma (n = 55) patients underwent whole-body FDG-PET/CT and whole-body MRI for initial tumor staging. All images were evaluated by four experienced physicians (three radiologists, one nuclear medicine physician). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for detection of bone metastases were determined for both modalities. Statistically significant differences between FDG-PET/CT and MRI were calculated with Fisher's Exact test (p < 0.05). Clinical and imaging follow-up data with a mean follow-up time of 434 days served as the reference standard.

Results

According to the reference standard 11 patients (10%) suffered from bone metastases. The sensitivity, specificity, PPV, NPV, and accuracy for the detection of osseous metastases was 45%, 99%, 83%, 94%, and 94% with whole-body FDG-PET/CT and 64%, 94%, 54%, 96%, and 91% with whole-body MRI. The difference was not statistically significant (p = 0.6147).

Conclusions

FDG-PET/CT and MRI seem to be equally suitable for the detection of skeletal metastases in patients suffering from newly diagnosed non-small cell lung cancer and malignant melanoma. Both modalities go along with a substantial rate of false-negative findings requiring a close follow-up of patients who are staged free of bone metastases at initial staging.     

Whole‐body fat oxidation determined by graded exercise and indirect calorimetry: a role for muscle oxidative capacity?

During whole-body exercise, peak fat oxidation occurs at a moderate intensity. This study investigated whole-body peak fat oxidation in untrained and trained subjects, and the presence of a relation between skeletal muscle oxidative enzyme activity and whole-body peak fat oxidation. Healthy male subjects were recruited and categorized into an untrained (N=8, VO(2max) 3.5+/-0.1 L/min) and a trained (N=8, VO(2max) 4.6+/-0.2 L/min) group. Subjects performed a graded exercise test commencing at 60 W for 8 min followed by 35 W increments every 3 min. On a separate day, muscle biopsies were obtained from vastus lateralis and a 3 h bicycle exercise test was performed at 58% of VO(2max). Whole-body fat oxidation was calculated during prolonged and graded exercise from the respiratory exchange ratio using standard indirect calorimetry equations. Based on the graded exercise test, whole-body peak fat oxidation was determined. The body composition was determined by DEXA. Whole-body peak fat oxidation (250+/-25 and 462+/-33 mg/min) was higher (P<0.05) and occurred at a higher (P<0.05) relative workload (43.5+/-1.8% and 49.9+/-1.2% VO(2max)) in trained compared with untrained subjects, respectively. Muscle citrate synthase activity and beta-hydroxy-acyl-CoA-dehydrogenase activity were higher (49% and 35%, respectively, P<0.05) in trained compared with untrained subjects. Both lean body mass and maximal oxygen uptake were significantly correlated to whole-body peak fat oxidation (r(2)=0.57, P<0.001), but leg muscle oxidative capacity was not correlated to whole-body peak fat oxidation. In conclusion, whole-body peak fat oxidation occurred at a higher relative exercise load in trained compared with untrained subjects. Whole-body peak fat oxidation was not significantly related to leg muscle oxidative capacity, but was related to lean body mass and maximal oxygen uptake. This may suggest that leg muscle oxidative activity is not the main determinant of whole-body peak fat oxidation.     

Is imaging the future of axillary staging in breast cancer?

Axillary management in patients with breast cancer has become much less invasive with the introduction of sentinel lymph node biopsy (SLNB). However, over 70 % of SLNBs are negative, questioning the generic use of this invasive procedure. Emerging evidence indicates that breast cancer patients with a low axillary burden of disease do not benefit from axillary lymph node dissection (ALND). Non-invasive techniques such as paramagnetic iron oxide contrast-enhanced magnetic resonance imaging (MRI) may provide genuine alternatives to axillary staging and should be evaluated within clinical trials. Selective axillary surgery could then be offered based on imaging findings and for therapeutic intent. This non-operative approach would reduce morbidity further and facilitate interpretation of follow-up imaging. Key Points ? Modern imaging and biopsy greatly help the axillary staging of breast cancer. ? Superparamagnetic iron oxide (SPIO)-enhanced MRI offers a further advance. ? Sentinel lymph node biopsy may become redundant with SPIO-enhanced MRI. ? Selective therapeutic axillary surgery should be based upon preoperative imaging findings.     

Performance of gadofosveset-enhanced MRI for staging rectal cancer nodes: can the initial promising results be reproduced?

Objectives

A previous study showed promising results for gadofosveset-trisodium as a lymph node magnetic resonance imaging (MRI) contrast agent in rectal cancer. The aim of this study was to prospectively confirm the diagnostic performance of gadofosveset MRI for nodal (re)staging in rectal cancer in a second patient cohort.

Methods

Seventy-one rectal cancer patients were prospectively included, of whom 13 (group I) underwent a primary staging gadofosveset MRI (1.5-T) followed by surgery (± preoperative 5 × 5 Gy) and 58 (group II) underwent both primary staging and restaging gadofosveset MRI after a long course of chemoradiotherapy followed by surgery. Nodal status was scored as (y)cN0 or (y)cN+ by two independent readers (R1, R2) with different experience levels. Results were correlated with histology on a node-by-node basis.

Results

Sensitivity, specificity and area under the receiver operating characteristics curve (AUC) were 94 %, 79 % and 0.89 for the more experienced R1 and 50 %, 83 % and 0.74 for the non-experienced R2. R2’s performance improved considerably after a learning curve, to an AUC of 0.83. Misinterpretations mainly occurred in nodes located in the superior mesorectum, nodes located in between vessels and nodes containing micrometastases.

Conclusions

This prospective study confirms the good diagnostic performance of gadofosveset MRI for nodal (re)staging in rectal cancer.

Key Points

? Gadofosveset-enhanced MRI shows high performance for nodal (re)staging in rectal cancer. ? Gadofosveset MRI may facilitate better selection of patients for personalised treatment. ? Results can be reproduced by non-expert readers. ? Experience of 50–60 cases is required to achieve required expertise level. ? Main pitfalls are nodes located between vessels and nodes containing micrometastases.     

Routine use of dual time 18F-FDG PET for staging of preoperative lung cancer: does it affect clinical management?

Objective

The objective of this study was to compare the diagnostic accuracy of dual-time-point 18F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET) to single-time-point ¹⁸F-FDG PET for staging of preoperative lung cancer.

Methods

Between November 2008 and December 2009, 107 patients who were diagnosed as having lung cancer or strongly suspected of having lung cancer were enrolled. They underwent dual-time-point ¹⁸F-FDG PET following conventional imaging. Dual-time-point ¹⁸F-FDG PET imaging (whole body) was performed at 1-h (early) post-FDG injection and repeated (2 h delayed) after injection. The diagnostic accuracy of pre-PET staging and post-PET staging was retrospectively evaluated, and the diagnostic accuracy of dual-time-point ¹⁸F-FDG PET was compared to that of single-time-point ¹⁸F-FDG PET.

Results

In 100 patients, the early ¹⁸F-FDG PET scan resulted in upstaging of the tumor in ten (10 %) and down-staging of the tumor in five (5 %) compared to the conventional scan. The delayed phase of ¹⁸F-FDG PET provided no additional information on staging for lung cancer patients. The remaining seven patients were diagnosed as not having lung cancer.

Conclusion

This study confirmed that dual-time-point ¹⁸F-FDG PET is useful for differential diagnosis between benign and malignant lesions, but has no major impact on staging and therapeutic management of patients with pathologically proven lung cancer.