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Research ArticleBRAIN

Glioma Grading: Sensitivity, Specificity, and Predictive Values of Perfusion MR Imaging and Proton MR Spectroscopic Imaging Compared with Conventional MR Imaging

Meng Law, Stanley Yang, Hao Wang, James S. Babb, Glyn Johnson, Soonmee Cha, Edmond A. Knopp and David Zagzag
American Journal of Neuroradiology November 2003, 24 (10) 1989-1998;
Meng Law
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Stanley Yang
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Hao Wang
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James S. Babb
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Glyn Johnson
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Soonmee Cha
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Edmond A. Knopp
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David Zagzag
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  • Fig 1.
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    Fig 1.

    20-year-old woman with biopsy-proved high-grade glioma.

    A, Contrast-enhanced axial T1-weighted image (600/14/1 [TR/TE/NEX]) demonstrates an ill-defined nonenhancing mass (arrow) in the right frontal region. The lack of enhancement on the conventional MR image suggests a low-grade glioma.

    B, Axial T2-weighted image (3400/119/1) shows increased signal intensity in the mass, with minimal peritumoral edema. This mass was graded as a low-grade glioma with conventional MR imaging because of lack of enhancement, minimal edema, no necrosis, and no mass effect.

    C, Gradient-echo (1000/54) axial perfusion MR image with rCBV color overlay map shows increased perfusion with a high rCBV of 7.72, in keeping with a high-grade glioma.

    D, Spectrum from proton MR spectroscopy with the PRESS sequence (1500/144) demonstrates markedly elevated Cho and decreased NAA with a Cho/NAA ratio of 2.60, as well as increased lactate (Lac), in keeping with a high-grade glioma.

  • Fig 2.
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    Fig 2.

    43-year-old man with biopsy-proved low-grade glioma.

    A, Contrast-enhanced axial T1-weighted image (600/14/1) demonstrates a peripherally enhancing mass (arrow) in the right frontal region. The presence of contrast material enhancement on the conventional MR image would suggest a high-grade glioma.

    B, Axial T2-weighted image (3400/119/1) shows marked peritumoral edema with possible necrosis and blood products. This mass was graded as a high-grade glioma with conventional MR imaging because of the contrast material enhancement, heterogeneity, blood products, possible necrosis, and degree of edema.

    C, Gradient-echo (1000/54) axial perfusion MR image with rCBV color overlay map shows a low rCBV of 1.70, in keeping with a low-grade glioma.

    D, Spectrum from proton MR spectroscopy with the PRESS sequence (1500/144) demonstrates elevated Cho and slightly decreased NAA with a Cho/NAA ratio of 0.90, which is more in keeping with a low-grade glioma.

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    Fig 3.

    ROC curves for rCBV plus metabolites, rCBV alone, Cho/Cr, and Cho/NAA demonstrate superior sensitivity and specificity of rCBV plus metabolites and rCBV alone compared with conventional MR imaging (cMRI, green asterisk) for glioma grading.

Tables

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    TABLE 1:

    Threshold values for rCBV for differentiation between low- and high-grade gliomas

    DescriptionrCBVSensitivitySpecificityPPVNPVC2 ErrorC1 Error
    Minimum C2 Error*1.7595.057.587.079.314.423.8
    Minimum C1 Error†2.9772.587.594.651.523.820.0
    Same sensitivity as cMRI2.9772.587.594.651.523.820.0
    Same specificity as cMRI2.1887.565.088.263.418.123.0
    • Note.—Conventional MR imaging (cMRI) sensitivity 72.5%, specificity 65.0%, PPV 86.1%, NPV 44.1%, C2 error 29.4%, and C1 error 31.8%.

    • * C2 = the percentage of observed data points misclassified.

    • † C1 = 1 − (sensitivity + specificity)/2. This maximizes the average of sensitivity and specificity.

    • View popup
    TABLE 2:

    Threshold values for Cho/Cr ratio for differentiation between low- and high-grade gliomas

    DescriptionCho/CrSensitivitySpecificityPPVNPVC2 ErrorC1 Error
    Minimum C2 Error*1.0897.512.577.062.523.845.0
    Minimum C1 Error†1.5675.847.581.239.631.338.3
    Same sensitivity as cMRI1.6172.550.081.337.733.138.8
    Same specificity as cMRI1.8855.065.083.533.341.938.8
    • Note.—Conventional MR imaging (cMRI) sensitivity 72.5%, specificity 65.0%, PPV 86.1%, NPV 44.1%, C2 error 29.4%, and C1 error 31.8%.

    • * C2 = the percentage of observed data points misclassified.

    • † C1 = 1 − (sensitivity + specificity)/2. This maximizes the average of sensitivity and specificity.

    • View popup
    TABLE 3:

    Threshold values for Cho/NAA ratio for differentiation between low- and high-grade gliomas

    DescriptionCho/NAASensitivitySpecificityPPVNPVC2 ErrorC1 Error
    Minimum C2 Error*0.7596.710.076.350.025.046.7
    Minimum C1 Error†1.6074.262.585.644.628.831.7
    Same sensitivity as cMRI1.6672.562.585.343.130.032.5
    Same specificity as cMRI1.7867.565.085.340.033.133.8
    • Note.—Conventional MR imaging (cMRI) sensitivity 72.5%, specificity 65.0%, PPV 86.1%, NPV 44.1%, C2 error 29.4%, and C1 error 31.8%.

    • * C2 = the percentage of observed data points misclassified.

    • † C1 = 1 − (sensitivity + specificity)/2. This maximizes the average of sensitivity and specificity.

    • View popup
    TABLE 4:

    rCBV, Cho/Cr ratio, and Cho/NAA ratio together for differentiation between low- and high-grade glioma

    DescriptionSensitivitySpecificityPPVNPVC2 ErrorC1 Error
    Minimum C2 Error*93.360.087.575.015.023.3
    Minimum C1 Error†70.892.596.651.423.718.3
    Same sensitivity as cMRI72.587.594.651.523.820.0
    Same specificity as cMRI89.265.088.466.716.922.9
    • Note.—Conventional MR imaging (cMRI) sensitivity 72.5%, specificity 65.0%, PPV 86.1%, NPV 44.1%, C2 error 29.4%, and C1 error 31.8%.

    • * C2 = the percentage of observed data points misclassified.

    • † C1 = 1 − (sensitivity + specificity)/2. This maximizes the average of sensitivity and specificity.

    • View popup
    TABLE 5:

    Perfusion MR measure and metabolite ratios for low- and high-grade gliomas and normal values

    Technique and MeasureLow-Grade Glioma (n = 40)High-Grade Glioma (n = 120)P Value*
    RangeMeanSDRangeMeanSD
    Perfusion MR imaging
     rCBV0.77–9.842.141.670.96–19.805.183.29< 0.0001
    MR Spectroscopy
     Cho/Cr0.85–4.001.750.600.83–13.802.431.920.0121
     Cho/NAA0.60–6.801.961.430.53–28.903.223.650.001
     NAA/Cr0.33–3.601.200.710.10–3.930.900.620.0038
    Normal values†
     Cho/Cr0.43–1.370.880.190.44–2.000.870.240.425
     NAA/Cr1.11–2.891.720.410.45–4.741.730.510.958
    • * Mann-Whitney test.

    • † Ratios in normal-appearing contralateral brain.

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American Journal of Neuroradiology: 24 (10)
American Journal of Neuroradiology
Vol. 24, Issue 10
1 Nov 2003
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Glioma Grading: Sensitivity, Specificity, and Predictive Values of Perfusion MR Imaging and Proton MR Spectroscopic Imaging Compared with Conventional MR Imaging
Meng Law, Stanley Yang, Hao Wang, James S. Babb, Glyn Johnson, Soonmee Cha, Edmond A. Knopp, David Zagzag
American Journal of Neuroradiology Nov 2003, 24 (10) 1989-1998;

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Glioma Grading: Sensitivity, Specificity, and Predictive Values of Perfusion MR Imaging and Proton MR Spectroscopic Imaging Compared with Conventional MR Imaging
Meng Law, Stanley Yang, Hao Wang, James S. Babb, Glyn Johnson, Soonmee Cha, Edmond A. Knopp, David Zagzag
American Journal of Neuroradiology Nov 2003, 24 (10) 1989-1998;
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