Quantitative regional oxygen transfer imaging of the human lung

Functional Imaging of Hypoxia: PET and MRI

Molecular and functional imaging have critical roles in cancer care. Existing evidence suggests that noninvasive detection of hypoxia within a particular type of cancer can provide new information regarding the relationship between hypoxia, cancer aggressiveness and altered therapeutic responses. Following the identification of hypoxia inducible factor (HIF), significant progress in understanding the regulation of hypoxia-induced genes has been made. These advances have provided the ability to therapeutically target HIF and tumor-associated hypoxia. Therefore, by utilizing the molecular basis of hypoxia, hypoxia-based theranostic strategies are in the process of being developed which will further personalize care for cancer patients. The aim of this review is to provide an overview of the significance of tumor hypoxia and its relevance in cancer management as well as to lay out the role of imaging in detecting hypoxia within the context of cancer.

3D Oxygen-Enhanced MRI at 3T MR System: Comparison With Thin-Section CT of Quantitative Capability for Pulmonary Functional Loss Assessment and Clinical Stage Classification of COPD in Smokers

BACKGROUND

Oxygen (O₂ )-enhanced MRI is mainly performed by a 2D sequence using 1.5T MR systems but trying to be obtained by a 3D sequence using a 3T MR system.

PURPOSE

To compare the capability of 3D O₂ -enhanced MRI and that of thin-section computed tomography (CT) for pulmonary functional loss assessment and clinical stage classification of chronic obstructive pulmonary disease (COPD) in smokers.

STUDY TYPE

Prospective study.

POPULATION

Fifty six smokers were included.

FIELD STRENGTH/ SEQUENCE

3T, 3D O₂ -enhanced MRIs were performed with a 3D T₁ -weighted fast field echo pulse sequence using the multiple flip angles.

ASSESSMENTS

Smokers were classified into four stages ("Without COPD," "Mild COPD," "Moderate COPD," "Severe or very severe COPD"). Maps of regional changes in T₁ values were generated from O₂ -enhanced MR data. Regions of interest (ROIs) were then placed over the lung on all slices and averaged to determine mean T₁ value change (ΔT₁ ). Quantitative CT used the percentage of low attenuation areas within the entire lung (LAA%).

STATISTICAL TESTS

ΔT₁ and LAA% were correlated with pulmonary functional parameters, and compared for four stages using Tukey's Honestly Significant Difference test. Discrimination analyses were performed and McNemar's test was used for a comparison of the accuracy of the indexes.

RESULTS

There were significantly higher correlations between ΔT₁ and pulmonary functional parameters (-0.83 ≤ r ≤ -0.71, P < 0.05) than between LAA% and the same pulmonary functional parameters (-0.76 ≤ r ≤ -0.69, P < 0.05). ΔT₁ and LAA% of the "Mild COPD" and "Moderate COPD" groups were significantly different from those of the "Severe or Very Severe COPD" group (P < 0.05). Discriminatory accuracy of ΔT₁ (62.5%) and ΔT1 with LAA% (67.9%) was significantly greater than that of LAA% (48.2%, P < 0.05).

DATA CONCLUSION

Compared with thin-section CT, 3D O₂ -enhanced MRI has a similar capability for pulmonary functional assessment but better potential for clinical stage classification in smokers.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY STAGE: 1.

Proton MRI of the Lung: How to Tame Scarce Protons and Fast Signal Decay

Pulmonary proton MRI techniques offer the unique possibility of assessing lung function and structure without the requirement for hyperpolarization or dedicated hardware, which is mandatory for multinuclear acquisition. Five popular approaches are presented and discussed in this review: 1) oxygen enhanced (OE)-MRI; 2) arterial spin labeling (ASL); 3) Fourier decomposition (FD) MRI and other related methods including self-gated noncontrast-enhanced functional lung (SENCEFUL) MR and phase-resolved functional lung (PREFUL) imaging; 4) dynamic contrast-enhanced (DCE) MRI; and 5) ultrashort TE (UTE) MRI. While DCE MRI is the most established and well-studied perfusion measurement, FD MRI offers a free-breathing test without any contrast agent and is predestined for application in patients with renal failure or with low compliance. Additionally, FD MRI and related methods like PREFUL and SENCEFUL can act as an ionizing radiation-free V/Q scan, since ventilation and perfusion information is acquired simultaneously during one scan. For OE-MRI, different concentrations of oxygen are applied via a facemask to assess the regional change in T₁ , which is caused by the paramagnetic property of oxygen. Since this change is governed by a combination of ventilation, diffusion, and perfusion, a compound functional measurement can be achieved with OE-MRI. The known problem of fast T₂ * decay of the lung parenchyma leading to a low signal-to-noise ratio is bypassed by the UTE acquisition strategy. Computed tomography (CT)-like images allow the assessment of lung structure with high spatial resolution without ionizing radiation. Despite these different branches of proton MRI, common trends are evident among pulmonary proton MRI: 1) free-breathing acquisition with self-gating; 2) application of UTE to preserve a stronger parenchymal signal; and 3) transition from 2D to 3D acquisition. On that note, there is a visible convergence of the different methods and it is not difficult to imagine that future methods will combine different aspects of the presented methods.

Imaging tumour hypoxia with oxygen-enhanced MRI and BOLD MRI

Hypoxia is known to be a poor prognostic indicator for nearly all solid tumours and also is predictive of treatment failure for radiotherapy, chemotherapy, surgery and targeted therapies. Imaging has potential to identify, spatially map and quantify tumour hypoxia prior to therapy, as well as track changes in hypoxia on treatment. At present no hypoxia imaging methods are available for routine clinical use. Research has largely focused on positron emission tomography (PET)-based techniques, but there is gathering evidence that MRI techniques may provide a practical and more readily translational alternative. In this review we focus on the potential for imaging hypoxia by measuring changes in longitudinal relaxation [R1; termed oxygen-enhanced MRI or tumour oxygenation level dependent (TOLD) MRI] and effective transverse relaxation [R2*; termed blood oxygenation level dependent (BOLD) MRI], induced by inhalation of either 100% oxygen or the radiosensitising hyperoxic gas carbogen. We explain the scientific principles behind oxygen-enhanced MRI and BOLD and discuss significant studies and their limitations. All imaging biomarkers require rigorous validation in order to translate into clinical use and the steps required to further develop oxygen-enhanced MRI and BOLD MRI into decision-making tools are discussed.

T1 , T1 contrast, and Ernst-angle images of four rat-lung pathologies

PURPOSE

To initiate the archive of relaxation-weighted images that may help discriminate between pulmonary pathologies relevant to acute respiratory distress syndrome. MRI has the ability to distinguish pathologies by providing a variety of different contrast mechanisms. Lungs have historically been difficult to image with MRI but image quality is sufficient to begin cataloging the appearance of pathologies in T₁ - and T₂ -weighted images. This study documents T₁ and the use of T₁ contrast with four experimental rat lung pathologies.

METHODS

Inversion-recovery and spoiled steady state images were made at 1.89 T to measure T₁ and document contrast in rats with atelectasis, lipopolysaccharide-induced inflammation, ventilator-induced lung injury (VILI), and injury from saline lavage. Higher-resolution Ernst-angle images were made to see patterns of lung infiltrations.

RESULTS

T₁ -weighted images showed minimal contrast between pathologies, similar to T₁ -weighted images of other soft tissues. Images taken shortly after magnetization inversion and displayed with inverted contrast highlight lung pathologies. Ernst-angle images distinguish the effects of T₁ relaxation and spin density and display distinctive patterns. T₁ for pathologies were: atelectasis, 1.25 ± 0.046 s; inflammation from instillation of lipopolysaccharide, 1.24 ± 0.015 s; VILI, 1.55 ± 0.064 s (p = 0.0022 vs. normal lung); and injury from saline lavage, 1.90±0.080 s (p = 0.0022 vs. normal lung; p = 0.0079 vs. VILI). T₁ of normal lung and erector spinae muscle were 1.25 ± 0.028 s and 1.02 ± 0.027 s, respectively (p = 0.0022).

CONCLUSIONS

Traditional T₁ -weighting is subtle. However, images made with inverted magnetization and inverted contrast highlight the pathologies and Ernst-angle images aid in distinguishing pathologies.

Dynamic and steady-state oxygen-dependent lung relaxometry using inversion recovery ultra-fast steady-state free precession imaging at 1.5 T

PURPOSE

To demonstrate the feasibility of oxygen-dependent relaxometry in human lung using an inversion recovery ultra-fast steady-state free precession (IR-ufSSFP) technique.

METHODS

Electrocardiogram-triggered pulmonary relaxometry with IR-ufSSFP was performed in 7 healthy human subjects at 1.5 T. The data were acquired under both normoxic and hyperoxic conditions. In a single breath-hold of less than 9 seconds, 30 transient state IR-ufSSFP images were acquired, yielding longitudinal (T1) and transversal (T2) relaxometry parameter maps using voxel-wise nonlinear fitting. Possible spatial misalignments between consecutive IR-ufSSFP parameter maps were corrected using elastic image registration. Furthermore, dynamic relaxometry oxygen wash-in and wash-out scans were performed in one volunteer. From this, T₁ -related wash-in and wash-out time constants (τ_wi , τ_wo ) were calculated voxel-wise on registered maps using an exponential fitting model.

RESULTS

For healthy lung, observed T1 values were 1399 ± 77 and 1290 ± 76 ms under normoxic and hyperoxic conditions, respectively. Oxygen-related reduction of T1 was statistically significant in every volunteer. No statistically significant change, however, was observed in T2, with normoxic and hyperoxic T2 values of 55 ± 16 and 56 ± 17 ms, respectively. The observed average τ_wi was 87.0 ± 28.7 seconds, whereas the average τ_wo was 73.5 ± 21.6 seconds.

CONCLUSION

IR-ufSSFP allows fast, steady-state, and dynamic oxygen-dependent relaxometry of the human lung. Magn Reson Med 79:839-845, 2018. © 2017 International Society for Magnetic Resonance in Medicine.

Pulmonary relaxometry with inversion recovery ultra-fast steady-state free precession at 1.5T

PURPOSE

To present a technique for simultaneous mapping of T₁ , T₂ , and relative spin density (M₀ ) in human lung using inversion recovery ultra-fast steady-state free precession (IR-ufSSFP) imaging.

METHODS

Pulmonary relaxometry with IR-ufSSFP is based on an interleaved time series acquisition of 2D images acquired at 1.5T. The technique was tested in a phantom and in four healthy volunteers using breath-hold and electrocardiogram triggering. Typically, 30 transient state images were acquired in a single breath-hold within < 10 s. From the signal time course, voxel-wise nonlinear fitting yielded T₁ , T₂ , and M₀ parameter maps. Furthermore, off-resonance and B1 effects were investigated in a phantom.

RESULTS

In the phantom, the observed T₁ of 829 ± 2 ms and T₂ of 105 ± 4 ms were in agreement with the reference T₁ of 858 ± 1 ms and T₂ of 104 ± 1 ms using spin echo methods. In volunteers, the average T₁ of 1375 ± 102 ms and T₂ of 66 ± 26 ms of lung tissue were in good agreement with the literature and were observed to be independent of the respiratory phase. Overall, high reproducibility was shown in a volunteer, yielding coefficient of variations of 0.03 for M₀ , 0.004 for T₁ , and 0.04 for T₂ measurements.

CONCLUSION

IR-ufSSFP allows for fast and simultaneous quantitative mapping of the human lung. Magn Reson Med 77:74-82, 2017. © 2016 International Society for Magnetic Resonance in Medicine.

Oxygen-Enhanced MRI Accurately Identifies, Quantifies, and Maps Tumor Hypoxia in Preclinical Cancer Models

There is a clinical need for noninvasive biomarkers of tumor hypoxia for prognostic and predictive studies, radiotherapy planning, and therapy monitoring. Oxygen-enhanced MRI (OE-MRI) is an emerging imaging technique for quantifying the spatial distribution and extent of tumor oxygen delivery in vivo. In OE-MRI, the longitudinal relaxation rate of protons (ΔR1) changes in proportion to the concentration of molecular oxygen dissolved in plasma or interstitial tissue fluid. Therefore, well-oxygenated tissues show positive ΔR1. We hypothesized that the fraction of tumor tissue refractory to oxygen challenge (lack of positive ΔR1, termed "Oxy-R fraction") would be a robust biomarker of hypoxia in models with varying vascular and hypoxic features. Here, we demonstrate that OE-MRI signals are accurate, precise, and sensitive to changes in tumor pO2 in highly vascular 786-0 renal cancer xenografts. Furthermore, we show that Oxy-R fraction can quantify the hypoxic fraction in multiple models with differing hypoxic and vascular phenotypes, when used in combination with measurements of tumor perfusion. Finally, Oxy-R fraction can detect dynamic changes in hypoxia induced by the vasomodulator agent hydralazine. In contrast, more conventional biomarkers of hypoxia (derived from blood oxygenation-level dependent MRI and dynamic contrast-enhanced MRI) did not relate to tumor hypoxia consistently. Our results show that the Oxy-R fraction accurately quantifies tumor hypoxia noninvasively and is immediately translatable to the clinic.

Noninvasive quantification of airway inflammation following segmental allergen challenge with functional MR imaging: a proof of concept study

PURPOSE

To evaluate oxygen-enhanced T1-mapping magnetic resonance (MR) imaging as a noninvasive method for visualization and quantification of regional inflammation after segmental allergen challenge in asthmatic patients compared with control subjects.

MATERIALS AND METHODS

After institutional review board approval, nine asthmatic and four healthy individuals gave written informed consent. MR imaging (1.5 T) was performed by using an inversion-recovery snapshot fast low-angle shot sequence before (0 hours) and 6 hours and 24 hours after segmental allergen challenge by using either normal- or low-dose allergen or saline. The volume of lung tissue with increased relaxation times was determined by using a threshold-based method. As a biomarker for oxygen transfer from the lungs into the blood, the oxygen transfer function ( OTF oxygen transfer function ) was calculated. After the third MR imaging examination, eosinophils in bronchoalveolar lavage fluid were counted. Differences between times and segments were analyzed with nonparametric Wilcoxon matched-pairs test and Spearman correlation.

RESULTS

In lung segments treated with the standard dose of allergen, the OTF oxygen transfer function was decreased at 6 hours in asthmatic patients, compared with saline-treated segments (P = .0078). In asthmatic patients at 24 hours, the volume over threshold was significantly increased in normal allergen dose-treated segments compared with saline-treated segments (P = .004). In corresponding lung segments, the volume over threshold at 24 hours in the asthmatic group showed a positive correlation (r = 0.65, P = .0001) and the OTF oxygen transfer function at 6 hours showed an inverse correlation (r = -0.67, P = .0001) with the percentage of eosinophils in the bronchoalveolar lavage fluid.

CONCLUSION

OTF oxygen transfer function and volume over threshold are noninvasive MR imaging-derived parameters to visualize and quantify the regional allergic reaction after segmental endobronchial allergen challenge.

Clinical use of oxygen-enhanced T1 mapping MRI of the lung: reproducibility and impact of closed versus loose fit oxygen delivery system

PURPOSE

To evaluate the reproducibility of oxygen-enhanced magnetic resonance imaging (MRI), and the influence of different gas delivery methods, in a clinical environment.

MATERIALS AND METHODS

Twelve healthy volunteers were examined on two visits with an inversion recovery snapshot fast low angle shot sequence on a 1.5 T system. Coronal slices were obtained breathing room air as well as 100% oxygen with a flow rate of 15 L/min. For oxygen delivery a standard nontight face mask and a full closed air-cushion face mask were used. T1 relaxation times and the oxygen transfer function (OTF) were calculated.

RESULTS

The mean T1 values did not change significantly between the two visits (P > 0.05). The T1 values breathing 100% oxygen obtained using the full closed mask were significantly lower (1093 ± 38 msec; P < 0.05) compared to the standard mask (1157 ± 52 msec). Accordingly, the OTF was significantly higher for the full closed mask (P < 0.05). The OTF changed significantly on the second visit using the standard mask (P < 0.05). The full closed mask showed lower interindividual variation for both the T1 values (3.5% vs. 4.5%) as well as the OTF (12.4% vs. 22.0%) and no difference of the OTF on the second visit (P > 0.05).

CONCLUSION

Oxygen-enhanced T1 mapping MRI produces reproducible data when using a full closed face mask.

Imaging hypoxia in gliomas

Hypoxia plays a central role in tumour development, angiogenesis, growth and resistance to treatment. Owing to constant developments in medical imaging technology, significant advances have been made towards in vitro and in vivo imaging of hypoxia in a variety of tumours, including gliomas of the central nervous system. The aim of this article is to review the literature on imaging approaches currently available for measuring hypoxia in human gliomas and provide an insight into recent advances and future directions in this field. After a brief overview of hypoxia and its importance in gliomas, several methods of measuring hypoxia will be presented. These range from invasive monitoring by Eppendorf polarographic O(2) microelectrodes, positron electron tomography (PET) tracers based on 2-nitroimidazole compounds [(18)F-labelled fluoro-misonidazole ((18)F-MISO) or 1-(2-[((18))F]fluoro-1-[hydroxymethyl]ethoxy)methyl-2-nitroimidazole (FRP-170)], (64)Cu-ATSM Cu-diacetyl-bis(N4-methylthiosemicarbazone) (Cu-ATSM) or (99m)Tc- and (68)Ga-labelled metronidazole (MN) agents to advanced MRI methods, such as blood oxygenation level dependent (BOLD) MRI, oxygen-enhanced MRI, diffusion-weighted MRI (DWI-MRI), dynamic contrast-enhanced MRI (DCE-MRI) and (1)H-magnetic resonance spectroscopy.

Measurement of arterial plasma oxygenation in dynamic oxygen-enhanced MRI

Inhaled oxygen can be used as a contrast agent for magnetic resonance imaging, due to the T(1) shortening effect of the oxygen dissolved in blood and tissue water. In this study, blood T(1) was measured dynamically in 14 volunteers (seven smokers, seven never-smokers) as the inhaled gas was switched from medical air to 100% oxygen and back to medical air. These T(1) values were converted to changes in partial pressure of oxygen, which were found to be in agreement with literature values. There were differences in curve shape and curve height between the smoker and never-smoker groups, suggesting differences in lung function due to smoking-related damage. These curves could be used as an input function for modeling of oxygen uptake in tissues. The differences between groups highlight the importance of measuring such an input function for each individual rather than relying on an assumed measurement.

[Oxygen-enhanced functional MR lung imaging]

Current diagnostic tools for the assessment of lung function are limited by global measurements or the need for radioactive tracers. Ideally, these tools should allow quantitative, regional distinct analyses without exposure to radiation. The current paper presents oxygen-enhanced functional MRI for assessment of lung ventilation. First applied in humans in 1996, a considerable amount of experience is now available on 1.5T scanners. The generation of quantitative T1-maps shows a high clinical potential. Low-field MR scanners, which are mostly open-designed, are especially interesting for functional lung imaging. The open design has advantages in respect to patient comfort by lower noise production and easy access to the patients and the costs are lower (no need for helium cooling). Lower signal-to-noise ratios can be overcome by changing the relaxation times. New navigator techniques allow further compensations. This article focuses on the presentation of low-field scanners and the application of T1 and T2(*) maps is described for healthy volunteers and first patients.

Comparison of normal tissue R1 and R*2 modulation by oxygen and carbogen

Magnetic resonance imaging has shown promise for evaluating tissue oxygenation. In this study differences in the tissue longitudinal relaxation rate (R(1)) and effective transverse relaxation rate (R(*)(2)), induced by inhalation of pure oxygen and carbogen, were evaluated in 10 healthy subjects. Significant reductions in R(1) were demonstrated following both oxygen and carbogen inhalation in the spleen (both P < 0.001), liver (P = 0.002 air vs. oxygen; P = 0.001 air vs. carbogen), skeletal muscle (both P < 0.001), and renal cortex (P = 0.005 air vs. oxygen; P = 0.008 air vs. carbogen). No significant change in R(*)(2) occurred following pure oxygen in any organ. However, a significant increase in R(*)(2) was observed in the spleen (P < 0.001), liver (P = 0.001), skeletal muscle (P = 0.026), and renal cortex (P = 0.001) following carbogen inhalation, an opposite effect to that observed in many studies of tumor pathophysiology. Changes in R(1) and R(*)(2) were independent of the gas administration order in the spleen and skeletal muscle. These findings suggest that the R(1) and R(*)(2) responses to hyperoxic gases are independent biomarkers of oxygen physiology.