Dynamic contrast-enhanced magnetic resonance imaging biomarkers in head and neck cancer: Potential to guide treatment? A systematic review

Quantitative magnetic resonance imaging biomarkers in oncological clinical trials: Current techniques and standardization challenges

Radiological imaging plays an important role in oncological trials to provide imaging biomarkers for disease staging, stratifying patients, defining dose setting, and evaluating the safety and efficacy of new candidate drugs and innovative treatment. This paper reviews the techniques of most commonly used quantitative magnetic resonance imaging (qMRI) biomarkers (dynamic contrast enhanced, dynamic susceptibility contrast, and diffusion weighted imaging) and their applications in oncological trials. Challenges of incorporating qMRI biomarkers in oncological trials are discussed including understanding biological mechanisms revealed by MRI biomarkers, consideration of rigorous trial design and standardized implementation of qMRI protocols.

Blood transfusion during radical chemo-radiotherapy does not reduce tumour hypoxia in squamous cell cancer of the head and neck

BACKGROUND

Patients with head and neck squamous cell carcinoma (HNSCC) undergoing radical chemo-radiation (CRT) frequently receive transfusion with packed red cells (PRCT) during radiotherapy on the basis that PRCT increases tumour oxygenation and overcomes hypoxia-induced radio-resistance. This is likely to be a significant oversimplification given the fact that tumour hypoxia is the result of several intrinsic and extrinsic factors, including many that are not directly related to serum haemoglobin (Hb). Therefore, we have studied the effect of PRCT on tumour oxygenation in a prospective cohort of patients who developed low Hb during radical CRT for HNSCC.

METHODS

This was a prospective study of 20 patients with HNSCC receiving radical CRT undergoing PRCT for Hb<11.5 g dl-1. Patients underwent pretransfusion and posttransfusion intrinsic susceptibility-weighted (SWI) MRI and dynamic contrast-enhanced (DCE) MRI. Blood samples were obtained at the time of MRI scanning and two further time points for measuring Hb and a panel of serum cytokine markers of tumour hypoxia. 3D T2* and Ktrans maps were calculated from the MRI data for primary tumours and cervical lymph node metastases.

RESULTS

PRCT produced no change (11 patients) or reduced (1 patient) T2* (tumour oxygenation) in 12 of the 16 (75%) evaluable primary tumours. Three of the four patients with improved tumour oxygenation progressed or had partial response following treatment completion. There were variable changes in Ktrans (tumour perfusion or vessel permeability) following PRCT that were of small magnitude for most tumours. Pre- and Post-PRCT levels of measured cytokines were not significantly different.

CONCLUSIONS

This study suggests that PRCT during radical CRT for HNSCC does not improve tumour oxygenation. Therefore, oncologists should consider changing practice according to NICE and American Association of Blood Banks guidelines on PRCT for anaemia.

Correlations Between DCE MRI and Histopathological Parameters in Head and Neck Squamous Cell Carcinoma

BACKGROUND: Dynamic contrast-enhanced magnetic resonance imaging (DCE MRI) can characterize perfusion and vascularization of tissues. DCE MRI parameters can differentiate between malignant and benign lesions and predict tumor grading. The purpose of this study was to correlate DCE MRI findings and various histopathological parameters in head and neck squamous cell carcinoma (HNSCC). PATIENTS AND METHODS: Sixteen patients with histologically proven HNSCC (11 cases primary tumors and in 5 patients with local tumor recurrence) were included in the study. DCE imaging was performed in all cases and the following parameters were estimated: K^trans, V_e, K_ep, and iAUC. The tumor proliferation index was estimated on Ki 67 antigen stained specimens. Microvessel density parameters (stained vessel area, total vessel area, number of vessels, and mean vessel diameter) were estimated on CD31 antigen stained specimens. Spearman's non-parametric rank sum correlation coefficients were calculated between DCE and different histopathological parameters. RESULTS: The mean values of DCE perfusion parameters were as follows: K^trans 0.189 ± 0.056 min⁻¹, K_ep 0.390 ± 0.160 min⁻¹, V_e 0.548 ± 0.119%, and iAUC 22.40 ± 12.57. Significant correlations were observed between K_ep and stained vessel areas (r = 0.51, P = .041) and total vessel areas (r = 0.5118, P = .043); between V_e and mean vessel diameter (r = −0.59, P = .017). Cell count had a tendency to correlate with V_e (r = −0.48, P = .058). In an analysis of the primary HNSCC only, a significant inverse correlation between K^trans and KI 67 was identified (r = −0.62, P = .041). Our analysis showed significant correlations between DCE parameters and histopathological findings in HNSCC.

Prognostic value of preoperative dynamic contrast-enhanced MRI perfusion parameters for high-grade glioma patients

Introduction

The prognostic value of the dynamic contrast-enhanced (DCE) MRI perfusion and its histogram analysis-derived metrics is not well established for high-grade glioma (HGG) patients. The aim of this prospective study was to investigate DCE perfusion transfer coefficient (K^trans), vascular plasma volume fraction (v_p), extracellular volume fraction (v_e), reverse transfer constant (k_ep), and initial area under gadolinium concentration time curve (IAUGC) as predictors of progression-free (PFS) and overall survival (OS) in HGG patients.

Methods

Sixty-nine patients with suspected anaplastic astrocytoma or glioblastoma underwent preoperative DCE-MRI scans. DCE perfusion whole tumor region histogram parameters, clinical details, and PFS and OS data were obtained. Univariate, multivariate, and Kaplan–Meier survival analyses were conducted. Receiver operating characteristic (ROC) curve analysis was employed to identify perfusion parameters with the best differentiation performance.

Results

On univariate analysis, v_e and skewness of v_p had significant negative impacts, while k_ep had significant positive impact on OS (P < 0.05). v_e was also a negative predictor of PFS (P < 0.05). Patients with lower v_e and IAUGC had longer median PFS and OS on Kaplan–Meier analysis (P < 0.05). K^trans and v_e could also differentiate grade III from IV gliomas (area under the curve 0.819 and 0.791, respectively).

Conclusions

High v_e is a consistent predictor of worse PFS and OS in HGG glioma patients. v_p skewness and k_ep are also predictive for OS. K^trans and v_e demonstrated the best diagnostic performance for differentiating grade III from IV gliomas.

Early responses assessment of neoadjuvant chemotherapy in nasopharyngeal carcinoma by serial dynamic contrast-enhanced MR imaging

PURPOSE

To evaluate the feasibility of utilizing serial dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) prospectively for early prediction of neoadjuvant chemotherapy (NAC) response in nasopharyngeal carcinoma (NPC) patients.

MATERIALS AND METHODS

Sixty-three advanced NPC patients were recruited and received three DCE-MRI exams before treatment (Pre-Tx), 3days (Day3-Tx) and 20days (Day20-Tx) after initiation of chemotherapy (one NAC cycle). Early response to NAC was determined based on the third MRI scan and classified partial response (PR) as responders and stable disease (SD) as non-responders. After intensity-modulated radiotherapy (IMRT), complete response (CR) patients were classified as responders. The kinetic parameters (K^trans, K_ep, v_e, and v_p) derived from extended Tofts' model analysis and their corresponding changes ΔMetrics_(0-X) (X=3 or 20days) were compared between the responders and non-responders using the Student's T-test or Mann-Whitney U test.

RESULTS

Compared to the SD group, the PR group after one NAC cycle presented significantly higher mean K^trans values at baseline (P=0.011) and larger ΔK^trans_(0-3) and ΔK_ep(0-3) values (P=0.003 and 0.031). For the above parameters, we gained acceptable sensitivity (range: 66.8-75.0%) and specificity (range: 60.0-66.7%) to distinguish the non-responders from the responders and their corresponding diagnosis efficacy (range: 0.703-0.767). The PR group patients after one NAC cycle showed persistent inhibition of tumor perfusion by NAC as explored by DCE-MRI parameters comparing to the SD group (P<0.05) and presented a higher cure ratio after IMRT than those who did not (83.3% vs. 73.8%).

CONCLUSIONS

This primarily DCE-MRI based study showed that the early changes of the kinetic parameters during therapy were potential imaging markers to predicting response right after one NAC cycle for NPC patients.

Value of intravoxel incoherent motion and dynamic contrast-enhanced MRI for predicting the early and short-term responses to chemoradiotherapy in nasopharyngeal carcinoma

The aim of the study was to investigate the value of intravoxel incoherent motion diffusion-weighted magnetic resonance imaging (IVIM-DWI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in predicting the early and short-term responses to chemoradiotherapy (CRT) in patients with nasopharyngeal carcinoma (NPC).Forty-three NPC patients underwent IVIM-DWI and DCE-MRI at baseline (pretreatment) and after the first cycle of induction chemotherapy (posttreatment). Based on whether locoregional lesions were identified, patients were divided into the residual and nonresidual groups at the end of CRT and into the good-responder and poor-responder groups 6 months after the end of CRT. The pretreatment and posttreatment IVIM-DWI parameters (ADC, D, D*, and f) and DCE-MRI parameters (K, Kep, and Ve) values and their percentage changes (Δ%) were compared between the residual and nonresidual groups and between the good-responder and poor-responder groups.None of perfusion-related parametric values derived from either DCE-MRI or IVIM-DWI showed significant differences either between the residual and nonresidual groups or between the good-responder and poor-responder groups. The nonresidual group exhibited lower pre-ADC, lower pre-D, and higher Δ%D values than did the residual group (all P <0.05). The good-responder group had lower pre-D and pre-ADC values than did the poor-responder group (both P <0.05). Based on receiver operating characteristic (ROC) curve analysis, pre-D had the highest area under the curve in predicting both the early and short-term responses to CRT for NPC patients (0.817 and 0.854, respectively).IVIM-DWI is more valuable than DCE-MRI in predicting the early and short-term response to CRT for NPC, and furthermore diffusion-related IVIM-DWI parameters (pre-ADC, pre-D, and Δ%D) are more powerful than perfusion-related parameters derived from both IVIM-DWI and DCE-MRI.

Application of Dynamic Contrast-Enhanced MRI Parameters for Differentiating Squamous Cell Carcinoma and Malignant Lymphoma of the Oropharynx

OBJECTIVE

The purpose of this study was to investigate the usefulness of histogram analysis of dynamic contrast-enhanced MRI (DCE-MRI) parameters for the differentiation of squamous cell carcinoma (SCC) and malignant lymphoma of the oropharynx.

MATERIALS AND METHODS

Pretreatment DCE-MRI was performed in 21 patients with pathologically confirmed oropharyngeal SCC and six patients with malignant lymphoma. DCE-MRI parameter maps including the volume transfer constant (K(trans)), flux rate constant (kep), and extravascular extracellular volume fraction (ve) based on the Tofts model were obtained. Enhancing tumors were manually segmented on each slice of the parameter maps, and the data were collected to obtain a histogram for the entire tumor volume. The Wilcoxon rank sum test was used to compare the histogram parameters of each DCE-MRI-derived variable of oropharyngeal SCC and lymphoma.

RESULTS

Histogram analysis of K(trans) and ve maps revealed that the median and mode of K(trans) were significantly higher in SCC than in lymphoma (p = 0.039 and 0.032, respectively), and the mode, skewness, and kurtosis of ve were significantly different in SCC than in lymphoma (p = 0.046, 0.039, and 0.032, respectively). On ROC analysis, the kurtosis of ve had the best discriminative value for distinguishing between oropharyngeal SCC and lymphoma (AUC, 0.865; cutoff value, 2.60; sensitivity, 83.3%; specificity, 90.5%).

CONCLUSION

Our preliminary evidence using histogram analysis of DCE-MRI parameters based on the whole tumor volume suggests that it might be useful for differentiating SCC from malignant lymphoma of the oropharynx.

Dynamic contrast-enhanced MRI for oncology drug development

Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is a promising tool for evaluating tumor vascularity, as it can provide vasculature-derived, functional, and quantitative parameters. To implement DCE-MRI parameters as biomarkers for monitoring the effect of antiangiogenic or vascular-disrupting treatment, two crucial elements of surrogate endpoint, ie, validation and qualification, should be satisfied. Although early studies have shown the accuracy and reliability of DCE-MRI parameters for evaluating treatment-driven vascular alterations, there have been an increasing number of studies demonstrating the limitations of DCE-MRI parameters as surrogate endpoints. Therefore, in order to improve the application of DCE-MRI parameters in drug development, it is necessary to establish a standardized evaluation method and to determine the correct therapeutics-oriented meaning of individual DCE-MRI parameter. In this regard, this article describes the biophysical background and data acquisition/analysis techniques of DCE-MRI while focusing on the validation and qualification issues. Specifically, the causes of disagreement and confusion encountered in the preclinical and clinical trials using DCE-MRI are presented in detail. Finally, considering these limitations, we present potential strategies to optimize implementation of DCE-MRI. J. Magn. Reson. Imaging 2016;44:251-264.

Head and neck paragangliomas: diffusion weighted and dynamic contrast enhanced magnetic resonance imaging characteristics

Background

To determine the feature values of head and neck paragangliomas on diffusion-weighted imaging (DWI) and dynamic contrast enhanced (DCE) magnetic resonance imaging (MRI).

Methods

Patients with primary head and neck paraganglioma who underwent both DWI and DCE-MRI before treatment between January 2010 and June 2013 were identified. Two radiologists assessed apparent diffusion coefficient (ADC) values on DWI and kinetic characteristics on DCE-MRI. The time intensity curves (TICs) and dynamic parameters, including peak height (PH), maximum enhancement ratio (ER_max), time to peak enhancement (T_peak) and maximum rise slope (Slope_max), were generated and evaluated.

Results

Ten patients with head and neck paraganglioma were retrospectively analyzed. On conventional MRI, the tumors demonstrated as well-circumscribed, strongly enhanced lesions. Mean ADC value of the lesions was 1.12 ± 0.15 × 10⁻³ mm²/s. The TICs demonstrated washout pattern (type-III) in all lesions. The mean PH, ER_max, T_peak and Slope_max value was 121.24 ± 63.99, 193.79 ± 67.18, 8.16 ± 3.29 and 25.42 ± 7.91, respectively.

Conclusions

Head and neck paragangliomas demonstrate distinctive DWI and DCE-MRI results than for other benign tumors which should be taken into account in further evaluation of MRI on head and neck lesions.

Optimized imaging of the midface and orbits

A variety of imaging techniques are available for imaging the midface and orbits. This review article describes the different imaging techniques based on the recent literature and discusses their impact on clinical routine imaging. Imaging protocols are presented for different diseases and the different imaging modalities.

Contemporary role of advanced imaging for bladder cancer staging

Optimized pretreatment staging of bladder urothelial carcinoma is essential in guiding appropriate treatment. This staging process relies heavily on tissue pathology from transurethral resection of bladder tumor as well as imaging for diagnosis of local, regional, nodal, or distant visceral spread. Accurate preoperative staging is critical for appropriate treatment decision making and patient counseling as these are based on the extent of disease involvement, largely classifying the cancer as having local, regional, or distant spread. Currently, the gold standard of transurethral resection of bladder tumor followed by computed tomography imaging with intravenous contrast provides excellent staging specificity in cases of more advanced bladder cancers with suspicion of spread; however, this often under stages patients that can lead to adverse oncologic outcomes in these patients undergoing radical cystectomy. Incorporation of novel imaging modalities including multiparametric magnetic resonance imaging and positron emission tomography imaging have shown promise in improving accuracy of staging for both local and distant disease in patients with bladder urothelial carcinoma.

Validation of functional imaging as a biomarker for radiation treatment response

Major advances in radiotherapy techniques, increasing knowledge of tumour biology and the ability to translate these advances into new therapeutic approaches are important goals towards more individualized cancer treatment. With the development of non-invasive functional and molecular imaging techniques such as positron emission tomography (PET)-CT scanning and MRI, there is now a need to evaluate potential new biomarkers for tumour response prediction, for treatment individualization is not only based on morphological criteria but also on biological tumour characteristics. The goal of individualization of radiotherapy is to improve treatment outcome and potentially reduce chronic treatment toxicity. This review gives an overview of the molecular and functional imaging modalities of tumour hypoxia and tumour cell metabolism, proliferation and perfusion as predictive biomarkers for radiation treatment response in head and neck tumours and in lung tumours. The current status of knowledge on integration of PET/CT/MRI into treatment management and bioimage-guided adaptive radiotherapy are discussed.

Dynamic Contrast-Enhanced Perfusion MRI of High Grade Brain Gliomas Obtained with Arterial or Venous Waveform Input Function

BACKGROUND AND PURPOSE

The aim of this study was to evaluate the differences in dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) perfusion estimates of high-grade brain gliomas (HGG) due to the use of an input function (IF) obtained respectively from arterial (AIF) and venous (VIF) approaches by two different commercially available software applications.

METHODS

This prospective study includes 20 patients with pathologically confirmed diagnosis of high-grade gliomas. The data source was processed by using two DCE dedicated commercial packages, both based on the extended Toft model, but the first customized to obtain input function from arterial measurement and the second from sagittal sinus sampling. The quantitative parametric perfusion maps estimated from the two software packages were compared by means of a region of interest (ROI) analysis. The resulting input functions from venous and arterial data were also compared.

RESULTS

No significant difference has been found between the perfusion parameters obtained with the two different software packages (P-value < .05). The comparison of the VIFs and AIFs obtained by the two packages showed no statistical differences.

CONCLUSIONS

Direct comparison of DCE-MRI measurements with IF generated by means of arterial or venous waveform led to no statistical difference in quantitative metrics for evaluating HGG. However, additional research involving DCE-MRI acquisition protocols and post-processing would be beneficial to further substantiate the effectiveness of venous approach as the IF method compared with arterial-based IF measurement.

Simultaneous PET/MR head-neck cancer imaging: Preliminary clinical experience and multiparametric evaluation

PURPOSE

To evaluate the role of simultaneous hybrid PET/MR imaging and to correlate metabolic PET data with morpho-functional parameters derived by MRI in patients with head-neck cancer.

METHODS

Forty-four patients, with histologically confirmed head and neck malignancy (22 primary tumors and 22 follow-up) were studied. Patients initially received a clinical exam and endoscopy with direct biopsy. Next patients underwent whole body PET/CT followed by PET/MR of the head/neck region. PET and MRI studies were separately evaluated by two blinded groups (both included one radiologist and one nuclear physician) in order to define the presence or absence of lesions/recurrences. Regions of interest (ROIs) analysis was conducted on the primary lesion at the level of maximum size on metabolic (SUV and MTV), diffusion (ADC) and perfusion (K(trans), Ve, kep and iAUC) parameters.

RESULTS

PET/MR examinations were successfully performed on all 44 patients. Agreement between the two blinded groups was found in anatomic allocation of lesions by PET/MR (Primary tumors: Cohen's kappa 0.93;

FOLLOW-UP

Cohen's kappa 0.89). There was a significant correlation between CT-SUV measures and MR (e.g., CT-SUV VOI vs.

MR-SUV VOI

ρ=0.97, p<0.001 for the entire sample). There was also significant positive correlations between the ROI area, SUV measures, and the metabolic parameters (SUV and MTV) obtained during both PET/CT and PET/MR. A significant negative correlation was observed between ADC and K(trans) values in the primary tumors. In addition, a significant negative correlation existed between MR SUV and ADC in recurrent tumors.

CONCLUSION

Our study demonstrates the feasibility of PET/MR imaging for primary tumors and recurrent tumors evaluations of head/neck malignant lesions. When assessing HNC, PET/MR allows simultaneous collection of multiparametric metabolic and functional data. This technique therefore allows for a more complete characterization of malignant lesions.

Diffusion kurtosis imaging predicts neoadjuvant chemotherapy responses within 4 days in advanced nasopharyngeal carcinoma patients

PURPOSE

To explore the clinical value of diffusion kurtosis imaging (DKI) and monoexponential diffusion-weighted imaging (DWI) for predicting early response to neoadjuvant chemotherapy (NAC) in patients with nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

Fifty-nine patients with stage III-IVb NPC underwent four 3.0T MR scans: prior to, and on the 4th, 21st, 42nd days after NAC initiation. The parameters of DKI (corrected diffusion coefficient, D; excess diffusion kurtosis coefficient, K) and monoexponential DWI (apparent diffusion coefficient, ADC) were obtained at the first three scans. Statistical methods included Student's t-test or Mann-Whitney U-test, receiver operating characteristic (ROC) curve analyses and paired X(2) test.

RESULTS

D(pre) in responders group (RG) was significantly lower than nonresponders group (NRG) (1.029 ± 0.033 vs. 1.184 ± 0.055, ×10(-3) mm(2) /s, P = 0.020). ADC(day4) and ΔD(day4) were the most useful parameters of the two diffusional models to distinguish RG from NRG, respectively (area under the curve, 0.761 vs. 0.895). ΔD(day4) was more sensitive than ADC(day4) to predict treatment response to NAC (P = 0.006).

CONCLUSION

Both DKI and monoexponential DWI showed potential to predict treatment response to NAC prior to morphological change. DKI may be superior to monoexponential DWI for predicting early response to NAC in patients with locally advanced NPC.

Multimodality functional imaging in radiation therapy planning: relationships between dynamic contrast-enhanced MRI, diffusion-weighted MRI, and 18F-FDG PET

OBJECTIVES

Biologically guided radiotherapy needs an understanding of how different functional imaging techniques interact and link together. We analyse three functional imaging techniques that can be useful tools for achieving this objective.

MATERIALS AND METHODS

The three different imaging modalities from one selected patient are ADC maps, DCE-MRI, and 18F-FDG PET/CT, because they are widely used and give a great amount of complementary information. We show the relationship between these three datasets and evaluate them as markers for tumour response or hypoxia marker. Thus, vascularization measured using DCE-MRI parameters can determine tumour hypoxia, and ADC maps can be used for evaluating tumour response.

RESULTS

ADC and DCE-MRI include information from 18F-FDG, as glucose metabolism is associated with hypoxia and tumour cell density, although 18F-FDG includes more information about the malignancy of the tumour. The main disadvantage of ADC maps is the distortion, and we used only low distorted regions, and extracellular volume calculated from DCE-MRI can be considered equivalent to ADC in well-vascularized areas.

CONCLUSION

A dataset for achieving the biologically guided radiotherapy must include a tumour density study and a hypoxia marker. This information can be achieved using only MRI data or only PET/CT studies or mixing both datasets.

Tumor plasma flow determined by dynamic contrast-enhanced MRI predicts response to induction chemotherapy in head and neck cancer

OBJECTIVES

Non-response to induction chemotherapy (IC) occurs in 30% of head and neck squamous cell carcinoma (HNSCC) and has been predicted by tumor plasma flow (Fp) derived by perfusion computed tomography. The present study was designed to test whether baseline tumor Fp determined by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) would predict IC response.

MATERIALS AND METHODS

A prospective open study powered to test the relationship between tumor Fp and response to IC (docetaxel, cisplatin, 5-fluorouracil) enrolled 50 patients with stage IV HNSCC. Response after two IC cycles was measured by MRI using Response Evaluation Criteria in Solid Tumors in 37 patients. Tumor Fp (primary end point) and multiple parameters in tumors and lymph nodes (secondary end points) were generated at baseline. Differences in baseline DCE-MRI parameters according to IC response were assessed by the Mann-Whitney U test, and predictive value by receiver operating characteristic (ROC) analysis.

RESULTS

Median baseline tumor Fp was 53.2ml/100ml/min in 25 responders and 23.9 in 12 non-responders (U 82; P=0.027; area under ROC curve (AUC) 0.73). Median baseline Fp in lymph nodes was 25.8ml/100ml/min for 37 nodes in 25 responders and 17.1 for 15 nodes in 12 non-responders (U 186, P=0.066; AUC 0.67). Frequency of IC response in 37 patients was 68% overall, 83% for tumor Fp above the median (40.6ml/100ml/min) and 45% below the median. Other DCE-MRI parameters were not associated with IC response.

CONCLUSION

Pre-treatment tumor Fp determined by DCE-MRI predicts IC response in HNSCC.