Differentiation of glioblastoma and primary CNS lymphomas using susceptibility weighted imaging

https://doi.org/10.1016/j.ejrad.2012.11.002Get rights and content

Abstract

Introduction

Reliable differentiation between glioblastoma and primary CNS lymphoma (PCNSL) using conventional MR imaging is challenging, since both entities may show similar appearance on structural MR imaging. Here we analyzed if the appearance of intratumoural susceptibility signals (ITSS) on susceptibility weighted imaging (SWI) may differentiate between both entities.

Methods and materials

SWI and contrast enhanced T1-weighted images were acquired from 15 patients with newly diagnosed PCNSL (14 B-cell PCNSL, 1 T-cell PCNSL) and 117 patients with newly diagnosed glioblastoma with a 3 Tesla MR. Additional phase images were available in 8 patients with PCNSL and 88 patients with glioblastoma. Appearance of ITSS was assessed by two readers on SWI and the size of the enhancing lesions on contrast enhanced T1-weighted images were measured. Furthermore it was assessed if ITSS displayed more clearly on SWI or on phase images.

Results

ITSS were detected in 106 (reader 1) and 109 (reader 2) glioblastoma, respectively. Both readers identified ITSS within the T-cell PCNSL while both readers did not identify any ITSS within the 14 Bcell PCNSL. Interrarter variability as determined by Cohen κ was excellent for glioblastoma (κ = 0.938) and for PCNSL (κ = 1). The medium size of the enhancing lesion of the glioblastoma that did not harbour ITSS was significantly smaller than the size of the glioblastoma exhibiting ITSS (p < 0.008). All identified ITSS displayed more clearly on SWI than on phase images.

Conclusion

Presence of ITSS differentiates reliably between glioblastoma and B-cell PCNSL and provides a fast bases for the clinical decision without causing any postprocessing work.

Introduction

Reliable differentiation between glioblastoma and primary CNS lymphoma (PCNSL) using conventional MR imaging is challenging, since both entities may show similar appearance on structural MR imaging [1]. Consequently histological verification usually is required before onset of therapy [2].

However, pathological findings may be hindered and a definitive diagnosis sometimes cannot be established due to presurgical steroid therapy in PCNSL. Since symptomatic patients with PCNSL often present with lesions of considerable size, steroid administration is sometimes clinically indicated before any surgical procedure, in most instances stereotactic biopsy [3]. Recognizing PCNSL with the help of novel imaging techniques could therefore be essential in avoiding steroid therapy and in facilitating attempts at biopsy [4], [5], [6], [7], [8], [9], [10].

Recently, a new imaging MRI technique, termed susceptibility-weighted-imaging (SWI), has been reported to improve differential diagnosis of solitary enhancing brain lesions by the combination of phase and magnitude images [11], [12], [13]. The basis for the assessment of brain lesions on SWI are low-signal-intensity structures so termed “intratumoural susceptibility signals” (ITSS) that usually cannot be visualized on conventional MR imaging (Fig. 1, Fig. 2). Park et al. defined ITSS as low signal intensity and fine linear or dot-like structures, with or without conglomeration, seen within the tumour [14]. Here we analyzed if the appearance of ITSS can contribute to the differential diagnosis of glioblastoma and PCNSL. Furthermore we assessed qualitatively if ITSS display more clearly on SWI or on phase images.

Section snippets

Patients

A total of 15 patients were pathologically confirmed as PCNSL and a total of 117 patients were pathologically confirmed as glioblastoma between January 2010 and October 2011.

The study was approved by the institutional review board in Heidelberg. All patients were treated at the Medical Center in Heidelberg and written informed consent was obtained. All patients received the MRI examination prior to biopsy or resection. None of the 15 patients diagnosed with PCNSL received steroids prior to the

Discussion

Our study proves that differentiation between B-cell PCNSL and glioblastoma can be achieved with high sensitivity and specificity by the simple appearance of ITSS on SWI. Since ITSS displayed more clearly in all investigated tumours on SWI than on phase images we do not think that an additional analysis of phase images is beneficial and may therefore be skipped. Physical source of the ITSS may potentially be calcifications or blood depositions as both appear hypointense on SWI. Currently a

Conclusion

Appearance of ITSS in SWI can differentiate between glioblastoma and B-cell PCNSL with high sensitivity and specificity. In contrast to other advanced imaging techniques it does not require any postprocessing and may therefore deliver fast initial orientation in clinical practice.

Conflict of interest

All authors declare no conflict of interests.

References (18)

There are more references available in the full text version of this article.

Cited by (48)

  • Differentiation between primary CNS lymphoma and atypical glioblastoma according to major genomic alterations using diffusion and susceptibility-weighted MR imaging

    2021, European Journal of Radiology
    Citation Excerpt :

    Susceptibility weighted imaging (SWI) has also been described to be a promising tool for grading glioma since it reflects microvascularity and micro bleeding as well as areas of necrosis [18]. Peters et al. [19] and Radbruch et al. [20] described the potential utility of SWI in distinguishing GBs from PCNSLs by using intratumoral susceptibility signals (ITSS). Although advanced MRI techniques appear to be needed in distinguishing PCNSL from atypical GB, most prior studies have included all PCNSL and GB cases, irrespective of their structural MRI findings [21].

  • Multiparametric imaging-based differentiation of lymphoma and glioblastoma: using T1-perfusion, diffusion, and susceptibility-weighted MRI

    2018, Clinical Radiology
    Citation Excerpt :

    In the initial studies of Kim et al. and Peters et al., GBM could be discriminated from PCNSL with high sensitivity and specificity.39,41 Radbruch et al. also drew similar conclusions and found SWI useful for discrimination of PCNSL and lymphoma.40 Lee et al. noted haemorrhage in approximately 18% patients of lymphoma, and they correlated this finding along with the presence of necrosis with presence of underlying Epstein–Barr virus (EBV) positivity of PCNSL tumours.6

  • Accuracy of Susceptibility-Weighted Imaging and Dynamic Susceptibility Contrast Magnetic Resonance Imaging for Differentiating High-Grade Glioma from Primary Central Nervous System Lymphomas: Meta-Analysis

    2018, World Neurosurgery
    Citation Excerpt :

    On account of the inefficiency of conventional MRI in differentiating PCNSL from glioma, plenty of studies have been performed to find out the most reliable imaging techniques.3-5 In recent years, susceptibility-weighted imaging (SWI), a novel MRI technique, was reported to display a high level of differential diagnosis through the assessment of intratumoral susceptibility signals, which was defined as intratumoral imaging findings with low-signal intensity or dotlike structure.6,7 SWI is a promising tool for reflecting microvascularity and microbleeding.

View all citing articles on Scopus
View full text