Utility of dynamic contrast-enhanced magnetic resonance imaging for differentiating glioblastoma, primary central nervous system lymphoma and brain metastatic tumor
Introduction
The discrimination of glioblastoma multiformes (GBMs), brain metastatic tumors (MTs) and primary central nervous system lymphomas (PCNSLs) can be very challenging by conventional magnetic resonance imaging (MRI), especially when there are atypical MRI features in PCNSLs, such as necrosis, hemorrhage or heterogeneous enhancement, which are not uncommon nowadays [1], [2]. As the management of these three intra-axial tumors is entirely different, an accurate preoperative differentiation is imperative [3].
Many advanced imaging techniques have been used to distinguishing these three tumors; such as diffusion tensor imaging, proton MR spectroscopy, and dynamic susceptibility contrast-enhanced perfusion-weighted imaging (DSC-PWI) [3], [4], [5], [6]. DSC-PWI is the most widely reported technique. Lower cerebral blood volume (CBV) is reported in PCNSLs as compared to GBMs or MTs. GBMs demonstrate an elevated CBV in the peritumoral region in comparison with brain metastases [3], [7], [8], [9]. However, major disadvantages of DSC-PWI are its low spatial resolution and high sensitivity towards the susceptibility artifacts from hemorrhage, calcification, and metallic surgical implants. Besides, the tumor CBV can be underestimated before leakage correction when blood-brain barrier (BBB) breaks down and contrast leakage presents [9], [10].
Histologically, the capillary ultrastructures of these three tumors are different. Neovascularization and vascular permeability of GBMs can be variable [3]. PCNSLs usually show little neovascularization but increased vascular permeability due to the architectural distortion of the vessels [11]. MTs have similar vasculatures to that of the original tumors, and are reported to have lower microvascular leakage (K2) than in GBMs by DSC-PWI processed with leakage correction [8].
Dynamic contrast-enhanced (DCE) T1-weighted MR perfusion imaging is less sensitive to susceptibility artifacts, and enables a noninvasive analysis of the vascular microenvironment by measuring the volume transfer constant (Ktrans), the flux rate constant (Kep), the fractional blood plasma volume (Vp), and the fractional volume of the extravascular and extracellular space (Ve). It has been increasingly used in clinical trials involving brain tumors, such as glioma grading and predicting the therapeutic response and prognosis [12], [13], [14]. However, to the best of our knowledge, few studies have been performed to compare the vascular permeability among GBMs, PCNSLs and MTs by DCE MR imaging [11], [15].
The aim of our study was to investigate the utility of DCE MR imaging-derived permeability parameters (Ktrans, Kep, Ve, Vp) within the entire contrast-enhancing tumor for the discrimination of GBMs, PCNSLs and MTs.
Section snippets
Patient selection
Our institutional review board approved this retrospective study, and the requirement for informed consent was obtained from all of the patients. From February 2014 to March 2015, 89 patients with histologically confirmed GBMs, PCNSLs and MTs were reviewed. All of the patients underwent conventional MRI and DCE MR imaging preoperatively. For further selection, only patients with no clinical history of previous surgery or treatment were included. Nine patients with poor DCE image quality because
Conventional MR imaging features
The conventional MRI manifestations are summarized in Table 1. According to the findings, both single and multiple lesions were observed in these three tumors. Heterogeneous enhancement and necrosis were more common in GBMs and MTs than in PCNSLs. The following atypical features were observed in a substantial proportion of PCNSL patients: heterogeneous enhancement (n = 8), hemorrhage (n = 4), and necrosis (n = 5). Three solitary MTs showed homogeneous and nodular enhancement, which mimicked PCNSLs.
Quantitative DCE MR imaging parameters in GBMs, PCNSLs, and MTs
Discussion
Distinction of glioblastomas, brain metastatic tumors, and PCNSLs remains an important unsolved clinical problem. In this study, PCNSLs were differentiated from GBMs and MTs by using DCE MR imaging-derived permeability parameters. Significant elevation of Ktrans and Ve value were observed in PCNSLs when compared with GBMs and MTs.
Ktrans is the volume transfer constant of the gadolinium agent between the blood plasma and the extracellular extravascular space (EES). In this study, significantly
Conclusions
Dynamic contrast-enhanced MR imaging facilitated the differentiation of PCNSLs from GBMs and MTs. PCNSLs demonstrated significantly higher Ktrans and Ve values as compared to GBMs and MTs, which implied a larger disruption of BBB and higher vascular permeability.
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2019, European Journal of RadiologyCitation Excerpt :Recently, Abe et al. also observed that PCNSL had an extremely high Ve [12]. In Lu et al.’s study, higher Ve was observed in PCNSL than in GBM and metastasis as well [3]. On the other hand, our study showed that no differences were observed between PCNSL and metastasis in CBF and Ktrans with post-hoc analysis in supplementary materials.
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