Phosphorus-31 MR spectroscopy of normal adult human brain and brain tumours

Mapping hippocampal glutamate in healthy aging with in vivo glutamate-weighted CEST (GluCEST) imaging

Introduction

Hippocampal glutamate (Glu) dysfunction is a pertinent indicator of neurodegeneration, yet mapping typical age-related changes in Glu has been challenging. Here, we use a 7T MRI approach, Glutamate Chemical Exchange Saturation Transfer (GluCEST), to measure bilateral hippocampal Glu in healthy old (HOA) and young (HYA) adults.

Methods

Bilateral hippocampal GluCEST data was acquired from 27 HOA and 22 HYA using 7T MRI. GluCEST differences by age and hemisphere were tested with a linear mixed model. GluCEST asymmetry index was also evaluated by age. Exploratory analyses examined associations between hippocampal GluCEST, age group, and scores on the Montreal Cognitive Assessment (MoCA) and Cognitive Complaints Index (CCI).

Results

GluCEST levels showed an age group and hemisphere interaction. In HOA, GluCEST was higher in left than right hippocampus, but in HYA, GluCEST level was equivalent across hemispheres. HOA had lower GluCEST than HYA in the right hippocampus. GluCEST asymmetry index confirmed significant left asymmetry in HOA. Lower GluCEST levels in HOA were associated with subjective cognitive complaints as measured by the CCI.

Discussion

Hippocampal GluCEST provides insight into age-related neural changes, with lower GluCEST in the right hippocampus in older adults. These findings offer a step toward elucidating the asymmetrical trajectory of hippocampal glutamatergic alterations and their relationship to cognitive phenotypes.

A versatile look-up algorithm for mapping pH values and magnesium ion content using 31P MRSI

31P MRSI allows for the non-invasive mapping of pH and magnesium ion content (Mg) in vivo, by translating the chemical shifts of inorganic phosphate and adenosine-5'-triphosphate (ATP) to pH and Mg via suitable calibration equations, such as the modified Henderson-Hasselbalch equation. However, the required constants in these calibration equations are typically only determined for physiological conditions, posing a particular challenge for their application to diseased tissue, where the biochemical conditions might change manyfold. In this article, we propose a multi-parametric look-up algorithm aiming at the condition-independent determination of pH and Mg by employing multiple quantifiable 31P spectral properties simultaneously. To generate entries for an initial look-up table, measurements from 114 model solutions prepared with varying chemical properties were made at 9.4 T. The number of look-up table entries was increased by inter- and extrapolation using a multi-dimensional function developed based on the Hill equation. The assignment of biochemical parameters, that is, pH and Mg, is realized using probability distributions incorporating specific measurement uncertainties on the quantified spectral parameters, allowing for an estimation of most plausible output values. As proof of concept, we applied a version of the look-up algorithm employing only the chemical shifts of γ- and β-ATP for the determination of pH and Mg to in vivo 3D 31P MRSI data acquired at 7 T from (i) the lower leg muscles of healthy volunteers and (ii) the brains of patients with glioblastoma. The resulting volumetric maps showed plausible values for pH and Mg, partly revealing differences from maps generated using the conventional calibration equations.

Whole-Brain Intracellular pH Mapping of Gliomas Using High-Resolution 31P MR Spectroscopic Imaging at 7.0 T

Malignant tumors commonly exhibit a reversed pH gradient compared with normal tissue, with a more acidic extracellular pH and an alkaline intracellular pH (pHi). In this prospective study, pHi values in gliomas were quantified using high-resolution phosphorous 31 (31P) spectroscopic MRI at 7.0 T and were used to correlate pHi alterations with histopathologic findings. A total of 12 participants (mean age, 58 years ± 18 [SD]; seven male, five female) with histopathologically proven, newly diagnosed glioma were included between September 2018 and November 2019. The 31P spectroscopic MRI scans were acquired using a double-resonant 31P/1H phased-array head coil together with a three-dimensional (3D) 31P chemical shift imaging sequence (5.7-mL voxel volume) performed with a 7.0-T whole-body system. The 3D volumetric segmentations were performed for the whole-tumor volumes (WTVs); tumor subcompartments of necrosis, gadolinium enhancement, and nonenhancing T2 (NCE T2) hyperintensity; and normal-appearing white matter (NAWM), and pHi values were compared. Spearman correlation was used to assess association between pHi and the proliferation index Ki-67. For all study participants, mean pHi values were higher in the WTV (7.057 ± 0.024) compared with NAWM (7.006 ± 0.012; P < .001). In eight participants with high-grade gliomas, pHi was increased in all tumor subcompartments (necrosis, 7.075 ± 0.033; gadolinium enhancement, 7.075 ± 0.024; NCE T2 hyperintensity, 7.043 ± 0.015) compared with NAWM (7.004 ± 0.014; all P < .01). The pHi values of WTV positively correlated with Ki-67 (R2 = 0.74, r = 0.78, P = .001). In conclusion, 31P spectroscopic MRI at 7.0 T enabled high-resolution quantification of pHi in gliomas, with pHi alteration associated with the Ki-67 proliferation index, and may aid in diagnosis and treatment monitoring. Keywords: 31P MRSI, pH, Glioma, Glioblastoma, Ultra-High-Field MRI, Imaging Biomarker, 7 Tesla Supplemental material is available for this article. © RSNA, 2023.

A Multi-Disciplinary Approach to Diagnosis and Treatment of Radionecrosis in Malignant Gliomas and Cerebral Metastases

Radiation necrosis represents a potentially devastating complication after radiation therapy in brain tumors. The establishment of the diagnosis and especially the differentiation from progression and pseudoprogression with its therapeutic implications requires interdisciplinary consent and monitoring. Herein, we want to provide an overview of the diagnostic modalities, therapeutic possibilities and an outlook on future developments to tackle this challenging topic. The aim of this report is to provide an overview of the current morphological, functional, metabolic and evolving imaging tools described in the literature in order to (I) identify the best criteria to distinguish radionecrosis from tumor recurrence after the radio-oncological treatment of malignant gliomas and cerebral metastases, (II) analyze the therapeutic possibilities and (III) give an outlook on future developments to tackle this challenging topic. Additionally, we provide the experience of a tertiary tumor center with this important issue in neuro-oncology and provide an institutional pathway dealing with this problem.

Prodrugs of a 1-Hydroxy-2-oxopiperidin-3-yl Phosphonate Enolase Inhibitor for the Treatment of ENO1-Deleted Cancers

Cancers harboring homozygous deletion of the glycolytic enzyme enolase 1 (ENO1) are selectively vulnerable to inhibition of the paralogous isoform, enolase 2 (ENO2). A previous work described the sustained tumor regression activities of a substrate-competitive phosphonate inhibitor of ENO2, 1-hydroxy-2-oxopiperidin-3-yl phosphonate (HEX) (5), and its bis-pivaloyoxymethyl prodrug, POMHEX (6), in an ENO1-deleted intracranial orthotopic xenograft model of glioblastoma [Nature Metabolism 2020, 2, 1423-1426]. Due to poor pharmacokinetics of bis-ester prodrugs, this study was undertaken to identify potential non-esterase prodrugs for further development. Whereas phosphonoamidate esters were efficiently bioactivated in ENO1-deleted glioma cells, McGuigan prodrugs were not. Other strategies, including cycloSal and lipid prodrugs of 5, exhibited low micromolar IC₅₀ values in ENO1-deleted glioma cells and improved stability in human serum over 6. The activity of select prodrugs was also probed using the NCI-60 cell line screen, supporting its use to examine the relationship between prodrugs and cell line-dependent bioactivation.

Magnetic Resonance Spectroscopy in Diagnosis and Follow-Up of Gliomas: State-of-the-Art

Preoperative grade prediction is important in diagnostics of glioma. Even more important can be follow-up after chemotherapy and radiotherapy of high grade gliomas. In this review we provide an overview of MR-spectroscopy (MRS), technical aspects, and different clinical scenarios in the diagnostics and follow-up of gliomas in pediatric and adult populations. Furthermore, we provide a recap of the current research utility and possible future strategies regarding proton- and phosphorous-MRS in glioma research.

Review and consensus recommendations on clinical APT-weighted imaging approaches at 3T: Application to brain tumors

Amide proton transfer-weighted (APTw) MR imaging shows promise as a biomarker of brain tumor status. Currently used APTw MRI pulse sequences and protocols vary substantially among different institutes, and there are no agreed-on standards in the imaging community. Therefore, the results acquired from different research centers are difficult to compare, which hampers uniform clinical application and interpretation. This paper reviews current clinical APTw imaging approaches and provides a rationale for optimized APTw brain tumor imaging at 3 T, including specific recommendations for pulse sequences, acquisition protocols, and data processing methods. We expect that these consensus recommendations will become the first broadly accepted guidelines for APTw imaging of brain tumors on 3 T MRI systems from different vendors. This will allow more medical centers to use the same or comparable APTw MRI techniques for the detection, characterization, and monitoring of brain tumors, enabling multi-center trials in larger patient cohorts and, ultimately, routine clinical use.

Brain pH Measurement Using AACID CEST MRI Incorporating the 2 ppm Amine Resonance

Many pathological conditions lead to altered intracellular pH (pH_i) disrupting normal cellular functions. The chemical exchange saturation transfer (CEST) method, known as Amine and Amide Concentration Independent Detection (AACID), can produce image contrast that is predominantly dependent on tissue intracellular pH_i. The AACID value is linearly related to the ratio of the 3.5 ppm amide CEST effect and the 2.75 ppm amine CEST effect in the physiological range. However, the amine CEST effect at 2 ppm is often more clearly defined in vivo, and may provide greater sensitivity to pH changes. The purpose of the current study was to compare AACID measurement precision utilizing the 2.0 and 2.75 ppm amine CEST effects. We hypothesized that the 2.0 ppm amine CEST resonance would produce measurements with greater sensitivity to pH changes. In the current study, we compare the range of the AACID values obtained in 24 mice with brain tumors and in normal tissue using the 2 ppm and 2.75 ppm amine resonances. All CEST data were acquired on a 9.4T MRI scanner. The AACID measurement range increased by 39% when using the 2 ppm amine resonance compared to the 2.75 ppm resonance, with decreased measurement variability across the brain. These data indicate that in vivo pH measurements made using AACID CEST can be enhanced by incorporating the 2 ppm amine resonance. This approach should be considered for pH measurements made over short intervals when no changes are expected in the concentration of metabolites that contribute to the 2 ppm amine resonance.

Molecular Imaging of Brain Tumors and Drug Delivery Using CEST MRI: Promises and Challenges

Chemical exchange saturation transfer (CEST) magnetic resonance imaging (MRI) detects molecules in their natural forms in a sensitive and non-invasive manner. This makes it a robust approach to assess brain tumors and related molecular alterations using endogenous molecules, such as proteins/peptides, and drugs approved for clinical use. In this review, we will discuss the promises of CEST MRI in the identification of tumors, tumor grading, detecting molecular alterations related to isocitrate dehydrogenase (IDH) and O-6-methylguanine-DNA methyltransferase (MGMT), assessment of treatment effects, and using multiple contrasts of CEST to develop theranostic approaches for cancer treatments. Promising applications include (i) using the CEST contrast of amide protons of proteins/peptides to detect brain tumors, such as glioblastoma multiforme (GBM) and low-grade gliomas; (ii) using multiple CEST contrasts for tumor stratification, and (iii) evaluation of the efficacy of drug delivery without the need of metallic or radioactive labels. These promising applications have raised enthusiasm, however, the use of CEST MRI is not trivial. CEST contrast depends on the pulse sequences, saturation parameters, methods used to analyze the CEST spectrum (i.e., Z-spectrum), and, importantly, how to interpret changes in CEST contrast and related molecular alterations in the brain. Emerging pulse sequence designs and data analysis approaches, including those assisted with deep learning, have enhanced the capability of CEST MRI in detecting molecules in brain tumors. CEST has become a specific marker for tumor grading and has the potential for prognosis and theranostics in brain tumors. With increasing understanding of the technical aspects and associated molecular alterations detected by CEST MRI, this young field is expected to have wide clinical applications in the near future.

31-Phosphorus Magnetic Resonance Spectroscopy in Evaluation of Glioma and Metastases in 3T MRI

Background:  31-Phosphorus magnetic resonance spectroscopy (31-P MRS) has excellent potential for clinical neurological practice because of its noninvasive in-vivo assessment of cellular energy metabolism and the indirect evaluation of the phospholipid composition of the cell membrane, intracellular pH, and intracellular Mg2+ concentration.

Purpose:  The aim of this study was to evaluate the metabolic characteristics of glioma and metastases using 31-P MRS and assess utility to differentiate both.

Study Type:  Prospective study.

Population:  Fifteen consecutive patients with brain tumor.

Field Strength/Sequence:  Three-tesla magnetic resonance imaging/three-dimensional MRS imaging sequence.

Statistical Tests:  Unpaired sample t -test, and one-way analysis of variance with Tukey's post-hoc test.

Results:  Significantly decreased values of phosphomonoesters/inorganic phosphate (PME/Pi) in the tumor group (1.22 ± 0.72) compared with controls (2.28 ± 1.44) with a p -value of 0.041 were observed. There is a significant decrease in phosphocreatine (PCr)/Pi values (energy demand) in the tumor group (2.76 ± 0.73) compared with controls (4.13 ± 1.75) with a p -value of 0.050. Significant increase in Pi/adenosine triphosphate (ATP) was noted in tumor group (0.28 ± 0.09) compared with controls (0.22 ± 0.08) with p -value 0.049. Among tumor group, PME/PCr values were significantly decreased in gliomas (0.35 ± 0.17) than metastasis (0.58 ± 0.23) compared with controls with a p -value of 0.047. A significant decrease in PME/ATP was noted in gliomas (0.25 ± 0.12) than metastasis (0.41 ± 0.14) compared with controls with a p -value of 0.034. The tumor group exhibits alkaline pH (7.12 ± 0.10) compared with the normal parenchyma (7.04 ± 0.06) with a significant p -value of 0.025. Glioma and metastasis could not be differentiated with pH. However, the perilesional edema of glioma shows alkaline pH (7.09 ± 0.06) and metastasis shows acidic pH (7.02 ± 0.05) with a significant p -value of 0.030.

Conclusion:  Our study provides new insight into the cellular constituents and pH of gliomas and metastases and results were significant in differentiation between these two. However, due to the additional high expense, it is available as a research tool in very few institutions in India.

Changes in Brain Energy and Membrane Metabolism in Glioblastoma following Chemoradiation

Brain parenchyma infiltration with glioblastoma (GB) cannot be entirely visualized by conventional magnetic resonance imaging (MRI). The aim of this study was to investigate changes in the energy and membrane metabolism measured with phosphorous MR spectroscopy (31P-MRS) in the presumably “normal-appearing” brain following chemoradiation therapy (CRT) in GB patients in comparison to healthy controls. Twenty (seven female, thirteen male) GB patients underwent a 31P-MRS scan prior to surgery (baseline) and after three months of standard CRT (follow-up examination. The regions of interest “contrast-enhancing (CE) tumor” (if present), “adjacent to the (former) tumor”, “ipsilateral distant” hemisphere, and “contralateral” hemisphere were compared, differentiating between patients with stable (SD) and progressive disease (PD). Metabolite ratios PCr/ATP, Pi/ATP, PCr/Pi, PME/PDE, PME/PCr, and PDE/ATP were investigated. In PD, energy and membrane metabolism in CE tumor areas have a tendency to “normalize” under therapy. In different “normal-appearing” brain areas of GB patients, the energy and membrane metabolism either “normalized” or were “disturbed”, in comparison to baseline or controls. Differences were also detected between patients with SD and PD. 31P-MRS might contribute as an additional imaging biomarker for outcome measurement, which remains to be investigated in a larger cohort.

7 Tesla and Beyond: Advanced Methods and Clinical Applications in Magnetic Resonance Imaging

ABSTRACT

Ultrahigh magnetic fields offer significantly higher signal-to-noise ratio, and several magnetic resonance applications additionally benefit from a higher contrast-to-noise ratio, with static magnetic field strengths of B0 ≥ 7 T currently being referred to as ultrahigh fields (UHFs). The advantages of UHF can be used to resolve structures more precisely or to visualize physiological/pathophysiological effects that would be difficult or even impossible to detect at lower field strengths. However, with these advantages also come challenges, such as inhomogeneities applying standard radiofrequency excitation techniques, higher energy deposition in the human body, and enhanced B0 field inhomogeneities. The advantages but also the challenges of UHF as well as promising advanced methodological developments and clinical applications that particularly benefit from UHF are discussed in this review article.

Imaging and treatment of brain tumors through molecular targeting: Recent clinical advances

Molecular imaging techniques have rapidly progressed over recent decades providing unprecedented in vivo characterization of metabolic pathways and molecular biomarkers. Many of these new techniques have been successfully applied in the field of neuro-oncological imaging to probe tumor biology. Targeting specific signaling or metabolic pathways could help to address several unmet clinical needs that hamper the management of patients with brain tumors. This review aims to provide an overview of the recent advances in brain tumor imaging using molecular targeting with positron emission tomography and magnetic resonance imaging, as well as the role in patient management and possible therapeutic implications.

Phosphorous Magnetic Resonance Spectroscopy and Molecular Markers in IDH1 Wild Type Glioblastoma

Simple Summary

Gliobastoma is one of the deadliest tumors overall, yet the most common malignant brain tumor. The new World Health Organization Classification of Brain Tumors brought changes in how we look at this type of malignancy. Now we know that glioblastoma is rather a spectrum of similar tumors, but with some distinct characteristics that include molecular footprint, response to therapy and with that overall survival, among others. We hypothesised that by employing phosphorous magnetic resonance we will be able to show differences in cellular energy metabolism in these various subtypes of glioblastoma. For example, we found indices of faster cell reproduction and tumor growth in MGMT-methylated and EGFR-amplified tumors. These tumors also could have reduced energetic state or tissue oxygenation due to the increased necrosis. Tumors with EGFR-amplification could have increased apoptotic activity regardless of their MGMT status. Our study indicated various differences in energetic metabolism in tumors with different molecular characteristics, which could potentially be important in future therapeutic strategies.

Abstract

The World Health Organisation’s (WHO) classification of brain tumors requires consideration of both histological appearance and molecular characteristics. Possible differences in brain energy metabolism could be important in designing future therapeutic strategies. Forty-three patients with primary, isocitrate dehydrogenase 1 (IDH1) wild type glioblastomas (GBMs) were included in this study. Pre-operative standard MRI was obtained with additional phosphorous magnetic resonance spectroscopy (31-P-MRS) imaging. Following microsurgical resection of the tumors, biopsy specimens underwent neuropathological diagnostics including standard molecular diagnosis. The spectroscopy results were correlated with epidermal growth factor (EGFR) and O6-Methylguanine-DNA methyltransferase (MGMT) status. EGFR amplified tumors had significantly lower phosphocreatine (PCr) to adenosine triphosphate (ATP)-PCr/ATP and PCr to inorganic phosphate (Pi)-PCr/Pi ratios, and higher Pi/ATP and phosphomonoesters (PME) to phosphodiesters (PDE)-PME/PDE ratio than those without the amplification. Patients with MGMT-methylated tumors had significantly higher cerebral magnesium (Mg) values and PME/PDE ratio, while their PCr/ATP and PCr/Pi ratios were lower than in patients without the methylation. In survival analysis, not-EGFR-amplified, MGMT-methylated GBMs showed the longest survival. This group had lower PCr/Pi ratio when compared to MGMT-methylated, EGFR-amplified group. PCr/Pi ratio was lower also when compared to the MGMT-unmethylated, EGFR not-amplified group, while PCr/ATP ratio was lower than all other examined groups. Differences in energy metabolism in various molecular subtypes of wild-type-GBMs could be important information in future precision medicine approach.

Phosphorous Magnetic Resonance Spectroscopy to Detect Regional Differences of Energy and Membrane Metabolism in Naïve Glioblastoma Multiforme

Simple Summary

Glioblastoma multiforme is a highly aggressive brain tumor, tending to infiltrate even larger zones of brain tissue than visible on conventional magnetic resonance imaging. By application of phosphorus magnetic resonance spectroscopy in patients with naïve glioblastoma multiforme, we tried to demonstrate changes in energy and membrane metabolism not only in affected regions but also in distant brain regions, the opposite brain hemisphere, and in comparison to healthy volunteers. We found reduced energetic states and signs of increased cell membrane turnover in regions of visible tumor and differences to and between the “normal-appearing” brains of glioblastoma patients and the brains of healthy volunteers. Our pilot study confirmed the feasibility of the method, so differences between various genetic mutations or clinical applicability for follow-up monitoring can be assessed in larger cohorts.

Abstract

Background: Glioblastoma multiforme (GBM) is a highly malignant primary brain tumor with infiltration of, on conventional imaging, normal-appearing brain parenchyma. Phosphorus magnetic resonance spectroscopy (31P-MRS) enables the investigation of different energy and membrane metabolites. The aim of this study is to investigate regional differences of 31P-metabolites in GBM brains. Methods: In this study, we investigated 32 patients (13 female and 19 male; mean age 63 years) with naïve GBM using 31P-MRS and conventional MRI. Contrast-enhancing (CE), T2-hyperintense, adjacent and distant ipsilateral areas of the contralateral brain and the brains of age- and gender-matched healthy volunteers were assessed. Moreover, the 31P-MRS results were correlated with quantitative diffusion parameters. Results: Several metabolite ratios between the energy-dependent metabolites and/or the membrane metabolites differed significantly between the CE areas, the T2-hyperintense areas, the more distant areas, and even the brains of healthy volunteers. pH values and Mg²⁺ concentrations were highest in visible tumor areas and decreased with distance from them. These results are in accordance with the literature and correlated with quantitative diffusion parameters. Conclusions: This pilot study shows that 31P-MRS is feasible to show regional differences of energy and membrane metabolism in brains with naïve GBM, particularly between the different “normal-appearing” regions and between the contralateral hemisphere and healthy controls. Differences between various genetic mutations or clinical applicability for follow-up monitoring have to be assessed in a larger cohort.

[Phosphorus MR spectroscopy and 18F-FDG PET/CT in the study of energy metabolism of glial tumors]

OBJECTIVE

To study energy metabolism in glial tumors using dynamic MR spectroscopy and ¹⁸F-FDG PET/CT.

MATERIAL AND METHODS

The study included 19 patients (9 women and 10 men) with newly diagnosed supratentorial glial tumors WHO Grade I-IV (diffuse astrocytoma - 4 cases, oligodendroglioma - 4 cases, anaplastic astrocytoma - 5 cases, glioblastoma - 6 cases). All patients underwent examination and surgical treatment at the Burdenko Neurosurgery Center. Dynamic MR spectroscopy and ¹⁸F-FDG PET/CT were applied in each patient.

RESULTS

We found multiple correlations between the ratio of bioorganic phosphate peaks and parameters of glucose uptake by tumor tissue. These relationships were more significant in patients with high-grade tumors: positive significant correlation between SUVtumor and PME/PCr ratio (R_S=0.75, p=0.01), T/Nmix and βATP/Pi ratio (R_s=0.76, p=0.02), SUVpeaktumor and aATP/Pi ratio (R_S=0.77, p=0.008). Moreover, there were negative correlations between SUVtumor and PCr/bATP ratio (R_S= -0.66, p=0.05), T/Nmix and PDE/bATP ratio (R_S= -0.83, p=0.006), SUVpeaktumor and PDE/aATP ratio (R_S= -0.76, p=0.009).

CONCLUSION

High-grade gliomas were characterized by higher glucose consumption, ATP release (intensification of energy metabolism) and faster cell membrane synthesis. These processes indicate enhanced proliferation of tumor cells (intensification of plastic metabolism).

[Intracellular pH measurement in glioblastoma cells: the possibilities of phosphorus-31 MR spectroscopy]

OBJECTIVE

To analyze intracellular pH measurement with phosphorus-31 MR spectroscopy in glioblastoma cells and to compare these data with intracellular pH in healthy volunteers.

MATERIAL AND METHODS

There were 10 patients aged 41 - 67 years with supratentorial glioblastomas. Intracellular pH in glioblastoma cells was compared with pH in healthy persons.

RESULTS

We found a tendency to increased intracellular pH in glioblastoma cells in comparison with pH in intact brain tissue.

CONCLUSION

Intracellular pH in brain tissue can be used as a potential marker of early abnormalities which could not be detected by conventional MRI. Moreover, these data may be valuable to estimate the efficacy of chemotherapy. The study was supported by Russian Science Foundation (grant No. 18-15-00337).

Current Methods of Magnetic Resonance for Noninvasive Assessment of Molecular Aspects of Pathoetiology in Multiple Sclerosis

Multiple sclerosis (MS) is an autoimmune disease with expanding axonal and neuronal degeneration in the central nervous system leading to motoric dysfunctions, psychical disability, and cognitive impairment during MS progression. The exact cascade of pathological processes (inflammation, demyelination, excitotoxicity, diffuse neuro-axonal degeneration, oxidative and metabolic stress, etc.) causing MS onset is still not fully understood, although several accompanying biomarkers are particularly suitable for the detection of early subclinical changes. Magnetic resonance (MR) methods are generally considered to be the most sensitive diagnostic tools. Their advantages include their noninvasive nature and their ability to image tissue in vivo. In particular, MR spectroscopy (proton 1H and phosphorus 31P MRS) is a powerful analytical tool for the detection and analysis of biomedically relevant metabolites, amino acids, and bioelements, and thus for providing information about neuro-axonal degradation, demyelination, reactive gliosis, mitochondrial and neurotransmitter failure, cellular energetic and membrane alternation, and the imbalance of magnesium homeostasis in specific tissues. Furthermore, the MR relaxometry-based detection of accumulated biogenic iron in the brain tissue is useful in disease evaluation. The early description and understanding of the developing pathological process might be critical for establishing clinically effective MS-modifying therapies.

Lower Lactate Levels and Lower Intracellular pH in Patients with IDH-Mutant versus Wild-Type Gliomas

BACKGROUND AND PURPOSE

Preclinical evidence points toward a metabolic reprogramming in isocitrate dehydrogenase (IDH) mutated tumor cells with down-regulation of the expression of genes that encode for glycolytic metabolism. We noninvasively investigated lactate and Cr concentrations, as well as intracellular pH using ¹H/phosphorus 31 (³¹P) MR spectroscopy in a cohort of patients with gliomas.

MATERIALS AND METHODS

Thirty prospectively enrolled, mostly untreated patients with gliomas met the spectral quality criteria (World Health Organization II [n = 7], III [n = 16], IV [n = 7]; IDH-mutant [n = 23]; IDH wild-type [n = 7]; 1p/19q codeletion [n = 9]). MR imaging protocol included 3D ³¹P chemical shift imaging and ¹H single-voxel spectroscopy (point-resolved spectroscopy sequence at TE = 30 ms and TE = 97 ms with optimized echo spacing for detection of 2-hydroxyglutarate) from the tumor area. Values for absolute metabolite concentrations were calculated (phantom replacement method). Intracellular pH was determined from ³¹P chemical shift imaging.

RESULTS

At TE = 97 ms, lactate peaks can be fitted with little impact of lipid/macromolecule contamination. We found a significant difference in lactate concentrations, lactate/Cr ratios, and intracellular pH when comparing tumor voxels of patients with IDH-mutant with those of patients with IDH wild-type gliomas, with reduced lactate levels and near-normal intracellular pH in patients with IDH-mutant gliomas. We additionally found evidence for codependent effects of 1p/19q codeletion and IDH mutations with regard to lactate concentrations for World Health Organization tumor grades II and III, with lower lactate levels in patients exhibiting the codeletion. There was no statistical significance when comparing lactate concentrations between IDH-mutant World Health Organization II and III gliomas.

CONCLUSIONS

We found indirect evidence for metabolic reprogramming in IDH-mutant tumors with significantly lower lactate concentrations compared with IDH wild-type tumors and a near-normal intracellular pH.

Clinical MR Biomarkers

Non-invasive magnetic resonance imaging (MRI) techniques are increasingly applied in the clinic with a fast growing body of evidence regarding its value for clinical decision making. In contrast to biochemical or histological markers, the key advantages of imaging biomarkers are the non-invasive nature and the spatial and temporal resolution of these approaches. The following chapter focuses on clinical applications of novel MR biomarkers in humans with a strong focus on oncologic diseases. These include both clinically established biomarkers (part 1-4) and novel MRI techniques that recently demonstrated high potential for clinical utility (part 5-7).

Brain tumor acidification using drugs simultaneously targeting multiple pH regulatory mechanisms

INTRODUCTION

Non-invasively distinguishing aggressive from non-aggressive brain tumors is an important clinical challenge. Intracellular pH (pH_i) regulation is essential for normal cell function and is normally maintained within a narrow range. Cancer cells are characterized by a reversed intracellular to extracellular pH gradient, compared to healthy cells, that is maintained by several distinct mechanisms. Previous studies have demonstrated acute pH modulation in glioblastoma detectable by chemical exchange saturation transfer (CEST) magnetic resonance imaging (MRI) after blocking individual pH regulatory mechanisms. The purpose of the current study was to simultaneously block five pH regulatory mechanisms while also providing glucose as an energy substrate. We hypothesized that this approach would increase the acute pH modulation effect allowing the identification of aggressive cancer.

METHODS

Using a 9.4 T MRI scanner, CEST spectra were acquired sensitive to pH_i using amine/amide concentration independent detection (AACID). Twelve mice were scanned approximately 11 ± 1 days after implanting 10⁵ U87 human glioblastoma multiforme cells in the brain, before and after intraperitoneal injection of a combination of five drugs (quercetin, cariporide, dichloroacetate, acetazolamide, and pantoprazole) with and without glucose.

RESULTS

Two hours after combination drug injection there was a significant 0.1 ± 0.03 increase in tumor AACID value corresponding to a 0.4 decrease in pH_i. After injecting the drug combination with glucose the AACID value increased by 0.18 ± 0.03 corresponding to a 0.72 decrease in pH_i. AACID values were also slightly increased in contralateral tissue.

CONCLUSIONS

The combined drug treatment with glucose produced a large acute CEST MRI contrast indicating tumor acidification, which could be used to help localize brain cancer and monitor tumor response to chemotherapy.

[Phosphorus (P) magnetic resonance spectroscopy for evaluation of brain tissue metabolism and measuring non-invasive pH. A study involving 23 volunteers. Part I]

Evaluation of brain metabolism is an important part in examination of brain lesions. Phosphorus magnetic resonance spectroscopy opens up great opportunities for studying the energy metabolism and allows noninvasive examination of metabolic processes occurring both in healthy and in pathologic brain tissue by obtaining a spectrum of phosphorus-containing metabolites involved in the turnover of cell membrane phospholipids. The technique presented in this paper was used to conduct ³¹P MR spectroscopy and to estimate the ratio between the peaks of the main metabolites and intracellular pH of the healthy brain tissue of 23 volunteers in the age group under 30 years old in clinical settings. Based on the recorded stable phosphorus spectra of metabolites of the healthy brain tissue, the value of intracellular pH (6.963±0.044) and the ratio of the main PME/PDE peaks (1.17±0.20) were calculated. The database was created to subsequently analyze the metabolic changes in brain tissue spectra in norm and in pathology, as well as the intracellular pH variations that have diagnostic and prognostic value.

An 8-channel receive array for improved 31 P MRSI of the whole brain at 3T

PURPOSE

To demonstrate a ¹ H/³¹ P whole human brain volume coil configuration for 3 Tesla with separate ³¹ P transmit and receive components that maintains ¹ H MRS performance and delivers optimal ³¹ P MRSI with ¹ H decoupling.

METHODS

We developed an 8-channel ³¹ P receive array coil covering the head to be used as an insert for a commercial double-tuned ¹ H/³¹ P birdcage transmit-receive coil. This retains the possibility of using low-power rectangular pulses for ¹ H-decoupled 3D ³¹ P MRSI (nominal resolution 17.6 cm³ ; acquisition duration 13 min) but increases the SNR with the receive sensitivity of ³¹ P surface coils. The performance of the combined coil setup was evaluated by measuring ¹ H and ³¹ P SNR with and without the ³¹ P receive array and by assessing the effect of the receive array on the transmit efficiencies of the birdcage coil.

RESULTS

Compared to the birdcage coil alone, the ³¹ P insert in combination with the birdcage achieved an average ³¹ P SNR gain of 1.4 ± 0.4 in a center partition of the brain. The insert did not cause losses in ¹ H MRS performance and transmit efficiency, whereas for ³¹ P approximately 20% more power was needed to achieve the same γB1.

CONCLUSION

The new coil configuration allows ¹ H MRSI and optimal ¹ H-decoupled 3D ³¹ P MRSI, with increased SNR of the human brain without patient repositioning, for clinical and research purposes at 3 Tesla.

Glutamate weighted imaging contrast in gliomas with 7 Tesla magnetic resonance imaging

Introduction

Diffuse gliomas are incurable malignancies, which undergo inevitable progression and are associated with seizure in 50–90% of cases. Glutamate has the potential to be an important glioma biomarker of survival and local epileptogenicity if it can be accurately quantified noninvasively.

Methods

We applied the glutamate-weighted imaging method GluCEST (glutamate chemical exchange saturation transfer) and single voxel MRS (magnetic resonance spectroscopy) at 7 Telsa (7 T) to patients with gliomas. GluCEST contrast and MRS metabolite concentrations were quantified within the tumour region and peritumoural rim. Clinical variables of tumour aggressiveness (prior adjuvant therapy and previous radiological progression) and epilepsy (any prior seizures, seizure in last month and drug refractory epilepsy) were correlated with respective glutamate concentrations. Images were separated into post-hoc determined patterns and clinical variables were compared across patterns.

Results

Ten adult patients with a histo-molecular (n = 9) or radiological (n = 1) diagnosis of grade II-III diffuse glioma were recruited, 40.3 +/− 12.3 years. Increased tumour GluCEST contrast was associated with prior adjuvant therapy (p = .001), and increased peritumoural GluCEST contrast was associated with both recent seizures (p = .038) and drug refractory epilepsy (p = .029). We distinguished two unique GluCEST contrast patterns with distinct clinical and radiological features. MRS glutamate correlated with GluCEST contrast within the peritumoural voxel (R = 0.89, p = .003) and a positive trend existed in the tumour voxel (R = 0.65, p = .113).

Conclusion

This study supports the role of glutamate in diffuse glioma biology. It further implicates elevated peritumoural glutamate in epileptogenesis and altered tumour glutamate homeostasis in glioma aggressiveness. Given the ability to non-invasively visualise and quantify glutamate, our findings raise the prospect of 7 T GluCEST selecting patients for individualised therapies directed at the glutamate pathway. Larger studies with prospective follow-up are required.

•

7 T GluCEST glioma imaging is feasible, producing high quality quantifiable images.

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Increased peritumoural GluCEST contrast correlates with drug resistant epilepsy.

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Increased tumour GluCEST contrast is associated with prior adjuvant therapy.

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Two GluCEST patterns were identified with distinct clinico-radiological features.

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GluCEST contrast correlates with MRS glutamate in peritumoural regions.

The Monocarboxylate transporter inhibitor Quercetin induces intracellular acidification in a mouse model of Glioblastoma Multiforme: in-vivo detection using magnetic resonance imaging

The response of tumor intracellular pH to a pharmacological challenge could help identify aggressive cancer. Chemical exchange saturation transfer (CEST) is an MRI contrast mechanism that is dependent on intracellular pH (pH_i). pH_i is important in the maintenance of normal cell function and is normally maintained within a narrow range by the activity of transporters located at the plasma membrane. In cancer, changes in pH_i have been correlated with both cell proliferation and cell death. Quercetin is a bioflavonoid and monocarboxylate transporter (MCT) inhibitor. Since MCTs plays a significant role in maintaining pH balance in the tumor microenvironment, we hypothesized that systemically administered quercetin could selectively acidify brain tumors. The goals of the current study were to determine whether CEST MRI measurements sensitive to tumor pH could detect acidification after quercetin injection and to measure the magnitude of the pH change (ΔpH). Using a 9.4 T MRI, amine and amide concentration independent detection (AACID) CEST spectra were acquired in six mice approximately 15 ± 1 days after implanting 10⁵ U87 human glioblastoma multiforme cells in the brain, before and after administration of quercetin (dose: 200 mg/kg) by intraperitoneal injection. Three additional mice were studied as controls and received only vehicle dimethyl sulfoxide (DMSO) injection. Repeated measures t-test was used to compare AACID changes in tumor and contralateral tissue regions of interest. Two hours after quercetin injection there was a significant increase in tumor AACID by 0.07 ± 0.03 corresponding to a 0.27 decrease in pH_i, and no change in AACID in contralateral tissue. There was also a small average increase in AACID in tumors within the three mice injected with DMSO only. The use of the natural compound quercetin in combination with pH weighted MRI represents a unique approach to cancer detection that does not require injection of an imaging contrast agent.

In vivo detection of acute intracellular acidification in glioblastoma multiforme following a single dose of cariporide

Glioblastoma is an aggressive brain cancer that is very difficult to treat. Clinically, it is important to be able to distinguish aggressive from non-aggressive brain tumors. Previous studies have shown that some drugs can induce a rapid change in intracellular pH that could help to identify aggressive cancer. The sodium proton exchanger (NHE1) plays a significant role in maintaining pH balance in the tumor microenvironment. Cariporide is a sodium proton exchange inhibitor that is well tolerated by humans in cardiac applications. We hypothesized that cariporide could selectively acidify brain tumors. The purpose of this study was to determine whether amine/amide concentration-independent detection (AACID) chemical exchange saturation transfer (CEST) MRI measurement of tumor pH_i could detect acidification after cariporide injection. Using a 9.4T MRI scanner, CEST spectra were acquired in six mice approximately 14 days after implanting 10⁵ U87 human glioblastoma multiforme cells in the brain, before and after administration of cariporide (dose: 6 mg/kg) by intraperitoneal injection. Three additional mice were studied as controls and received only vehicle injection (DMSO + PBS). Repeated measures t test was used to examine changes in tumor and contralateral tissue regions of interest. Two hours after cariporide injection, there was a significant 0.12 ± 0.03 increase in tumor AACID value corresponding to a 0.48 decrease in pH_i and no change in AACID value in contralateral tissue. A small but significant increase of 0.04 ± 0.017 in tumor AACID value was also observed following vehicle injection. This study demonstrates that acute CEST MRI contrast changes, indicative of intracellular acidification, after administration of cariporide could help localize glioblastoma.

Amide Proton Transfer Imaging Allows Detection of Glioma Grades and Tumor Proliferation: Comparison with Ki-67 Expression and Proton MR Spectroscopy Imaging

BACKGROUND AND PURPOSE

Prognosis in glioma depends strongly on tumor grade and proliferation. In this prospective study of patients with untreated primary cerebral gliomas, we investigated whether amide proton transfer-weighted imaging could reveal tumor proliferation and reliably distinguish low-grade from high-grade gliomas compared with Ki-67 expression and proton MR spectroscopy imaging.

MATERIALS AND METHODS

This study included 42 patients with low-grade (n = 28) or high-grade (n = 14) glioma, all of whom underwent conventional MR imaging, proton MR spectroscopy imaging, and amide proton transfer-weighted imaging on the same 3T scanner within 2 weeks before surgery. We assessed metabolites of choline and N-acetylaspartate from proton MR spectroscopy imaging and the asymmetric magnetization transfer ratio at 3.5 ppm from amide proton transfer-weighted imaging and compared them with histopathologic grade and immunohistochemical expression of the proliferation marker Ki-67 in the resected specimens.

RESULTS

The asymmetric magnetization transfer ratio at 3.5 ppm values measured by different readers showed good concordance and were significantly higher in high-grade gliomas than in low-grade gliomas (3.61% ± 0.155 versus 2.64% ± 0.185, P = .0016), with sensitivity and specificity values of 92.9% and 71.4%, respectively, at a cutoff value of 2.93%. The asymmetric magnetization transfer ratio at 3.5 ppm values correlated with tumor grade (r = 0.506, P = .0006) and Ki-67 labeling index (r = 0.502, P = .002). For all patients, the asymmetric magnetization transfer ratio at 3.5 ppm correlated positively with choline (r = 0.43, P = .009) and choline/N-acetylaspartate ratio (r = 0.42, P = .01) and negatively with N-acetylaspartate (r = -0.455, P = .005). These correlations held for patients with low-grade gliomas versus those with high-grade gliomas, but the correlation coefficients were higher in high-grade gliomas (choline: r = 0.547, P = .053; N-acetylaspartate: r = -0.644, P = .017; choline/N-acetylaspartate: r = 0.583, P = .036).

CONCLUSIONS

The asymmetric magnetization transfer ratio at 3.5 ppm may serve as a potential biomarker not only for assessing proliferation, but also for predicting histopathologic grades in gliomas.

Predicting IDH mutation status in grade II gliomas using amide proton transfer-weighted (APTw) MRI

PURPOSE

To assess the amide proton transfer-weighted (APTw) MRI features of isocitrate dehydrogenase (IDH)-wildtype and IDH-mutant grade II gliomas and to test the hypothesis that the APTw signal is a surrogate imaging marker for identifying IDH mutation status preoperatively.

METHODS

Twenty-seven patients with pathologically confirmed low-grade glioma, who were previously scanned at 3T, were retrospectively analyzed. The Mann-Whitney test was used to evaluate relationships between APTw intensities for IDH-mutant and IDH-wildtype groups, and receiver operator characteristic (ROC) analysis was used to assess the diagnostic performance of APTw.

RESULTS

Based on histopathology and molecular analysis, seven cases were diagnosed as IDH-wildtype grade II gliomas and 20 cases as IDH-mutant grade II gliomas. The maximum and minimum APTw values, based on multiple regions of interest, as well as the whole-tumor histogram-based mean and 50th percentile APTw values, were significantly higher in the IDH-wildtype gliomas than in the IDH-mutant groups. This corresponded to the areas under the ROC curves of 0.89, 0.76, 0.75, and 0.75, respectively, for the prediction of the IDH mutation status.

CONCLUSION

IDH-wildtype lesions typically were associated with relatively high APTw signal intensities as compared with IDH-mutant lesions. The APTw signal could be a valuable imaging biomarker by which to identify IDH1 mutation status in grade II gliomas. Magn Reson Med 78:1100-1109, 2017. © 2017 International Society for Magnetic Resonance in Medicine.

Rapid and simultaneous measurement of phosphorus metabolite pool size ratio and reaction kinetics of enzymes in vivo

PURPOSE

The metabolites phosphocreatine (PCr), adenosine triphosphate (ATP), and in-organic phosphate (Pi) are biochemically coupled. Their pool sizes, assessed by their magnetization ratios, have been extensively studied and reflect bioenergetics status in vivo. However, most such studies have ignored chemical exchange and T₁ relaxation effects. In this work, we aimed to extend the T1nom method to simultaneously quantify the reaction rate constants as well as phosphorus metabolite pool size ratios under partially relaxed conditions.

MATERIALS AND METHODS

Modified Bloch-McConnell equations were used to simulate the effects of chemical exchanges on T₁ relaxation times and magnetization ratios among PCr, γ-ATP, and Pi. The T1nom method with iteration approach was used to measure both reaction constants and metabolite pool size ratios. To validate our method, in vivo data from rat brains (N = 8) at 9.4 Tesla were acquired under two conditions, i.e., approximately full relaxation (TR = 9 s) and partial relaxation (TR = 3 s). We compared metabolite pool size ratios and reaction constants before and after correcting the chemical exchange and T₁ relaxation effects.

RESULTS

There were significant errors in underestimation of PCr/γATP by 12 % (P = 0.03) and overestimation of ATP/Pi ratios by 14 % (P = 0.04) when not considering chemical exchange effects. These errors were minimized using our iteration approach, resulting in no significant differences (PCr/γATP, P = 0.47; ATP/Pi, P = 0.81) in metabolite pool size ratios and reaction constants between the two measurements (i.e., short versus long TR conditions).

CONCLUSION

Our method can facilitate broad biomedical applications of ³¹ P magnetization saturation transfer spectroscopy, requiring high temporal and/or spatial resolution for assessment of altered bioenergetics.

LEVEL OF EVIDENCE

2 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2018;47:210-221.

Adenosine Triphosphate Metabolism Measured by Phosphorus Magnetic Resonance Spectroscopy: A Potential Biomarker for Multiple Sclerosis Severity

BACKGROUND/AIMS

Phosphorus magnetic resonance spectroscopy (31P-MRS) has previously shown abnormal changes in energy metabolites in the brain of multiple sclerosis (MS) patients. However, the relationship between these energy metabolites - particularly adenosine triphosphate (ATP) - and the disease severity remains unclear. The objective of this study was to determine whether measuring ATP metabolites can help to predict disease severity in MS patients.

METHODS

31P-MRS at 3 tesla was performed in 9 relapsing remitting (RRMS), 9 secondary progressive MS patients (SPMS), and 10 age-matched healthy controls. ATP metabolites (expressed as %) in normally appearing white matter of the centrum semiovale were compared between patients and healthy controls. The relationship between Expanded Disability Status Scale (EDSS) and ATP metabolites was evaluated.

RESULTS

RRMS and SPMS patients had higher phosphocreatine (PCr) and lower phosphodiesters than healthy controls. In addition, RRMS patients had higher β-ATP% than SPMS patients. β-ATP% was negatively correlated with EDSS in all patients.

CONCLUSION

Our findings suggest a defective PCr metabolism in both patient groups, and a higher state of energy production in RRMS that might reflect a compensatory mechanism in face of the increased needs. The correlation of β-ATP with EDSS makes it a candidate biomarker for assessing MS disease severity.

Considerations in applying compressed sensing to in vivo phosphorus MR spectroscopic imaging of human brain at 3T

The purpose of this study was to apply compressed sensing method for accelerated phosphorus MR spectroscopic imaging (³¹P-MRSI) of human brain in vivo at 3T. Fast ³¹P-MRSI data of five volunteers were acquired on a 3T clinical MR scanner using pulse-acquire sequence with a pseudorandom undersampling pattern for a data reduction factor of 5.33 and were reconstructed using compressed sensing. Additionally, simulated ³¹P-MRSI human brain tumor datasets were created to analyze the effects of k-space sampling pattern, data matrix size, regularization parameters of the reconstruction, and noise on the compressed sensing accelerated ³¹P-MRSI data. The ³¹P metabolite peak ratios of the full and compressed sensing accelerated datasets of healthy volunteers in vivo were similar according to the results of a Bland-Altman test. The estimated effective spatial resolution increased with reduction factor and sampling more at the k-space center. A lower regularization parameter for both total variation and L1-norm penalties resulted in a better compressed sensing reconstruction of ³¹P-MRSI. Although the root-mean-square error increased with noise levels, the compressed sensing reconstruction was robust for up to a reduction factor of 10 for the simulated data that had sharply defined tumor borders. As a result, compressed sensing was successfully applied to accelerate ³¹P-MRSI of human brain in vivo at 3T.

Efficacy of in vivo31Phosphorus Magnetic Resonance Spectroscopy in Differentiation and Staging of Adult Human Brain Tumors

The aim of this study was to evaluate the efficacy of 31P magnetic resonance spectroscopy (31P-MRS) in the differentiation and staging of brain tumors. Fifteen volunteers and 44 patients with brain tumors (14 meningiomas, 13 low- and 17 high-grade gliomas) were prospectively evaluated by 31P-MRS. The pH (r=0.493, p<0.001), [Mg+2] (r=0.850, p<0.001) PME/α-ATP (r=0.776, p<0.001), PDE/α-ATP (r=-0.569, p<0.001) and (PCr+β-ATP)/Pi ratios were well correlated with tumor differentiation. High-grade gliomas had significantly higher pH (r=0.912, p<0.001) and [Mg+2] (r=0.855, p<0.001) and PME/α-ATP (r=0.894, p<0.001) ratio, and lower PCr/α-ATP (r= −0.959, p<0.001), Pi/α-ATP (r= −0.788, p<0.001) and PDE/α-ATP ratios (r=−0.968, p<0.001) than those of low-grade gliomas. Changes in 31P-MRS parameters by the degree of malignancy are good indicators of increased anaerobic metabolism and hypoxia of tumoral tissue to compensate intratumoral energy deficiency. 31P-MRS parameters are very useful for grading and differentiation of brain tumors.

Insight into the quantitative metrics of chemical exchange saturation transfer (CEST) imaging

PURPOSE

To evaluate the reliability of four CEST imaging metrics for brain tumors, at varied saturation power levels and magnetic field strengths (3-9.4 Tesla (T)).

METHODS

A five-pool proton exchange model (free water, semisolid, amide, amine, and NOE-related protons) was used for the simulations. For the in vivo study, eight glioma-bearing rats were scanned at 4.7 T. The CEST ratio (CESTR), CESTR normalized with the reference value (CESTR^nr ), inverse Z-spectrum-based (MTR_Rex ), and apparent exchange-related relaxation (AREX) were compared.

RESULTS

The simulated CEST signal intensities using MTR_Rex and AREX were substantially increased at relatively high radiofrequency (RF) saturation powers at 3 T and 4.7 T, whereas CESTR and CESTR^nr metrics remained relatively stable. There were tremendously high MTR_Rex and AREX signals around the water frequency at all field strengths because of the small denominators. In the rat tumor study at 4.7 T, both CESTR and CESTR^nr showed clear contrasts in the tumor with respect to the normal tissue across all saturation power levels (0.5-3 μT), whereas the AREX showed negligible to negative insignificant contrasts.

CONCLUSIONS

CEST metrics must be carefully selected based on the different experimental settings. CESTR and CESTR^nr are more reliable at 3 T (a clinical field strength) and 4.7 T. Magn Reson Med 77:1853-1865, 2017. © 2016 International Society for Magnetic Resonance in Medicine.

Quantitative assessment of the effects of water proton concentration and water T1 changes on amide proton transfer (APT) and nuclear overhauser enhancement (NOE) MRI: The origin of the APT imaging signal in brain tumor

PURPOSE

To quantify pure chemical exchange-dependent saturation transfer (CEST) related amide proton transfer (APT) and nuclear Overhauser enhancement (NOE) signals in a rat glioma model and to investigate the mixed effects of water content and water T₁ on APT and NOE imaging signals.

METHODS

Eleven U87 tumor-bearing rats were scanned at 4.7 T. A relatively accurate mathematical approach, based on extrapolated semisolid magnetization-transfer reference signals, was used to remove the concurrent effects of direct water saturation and semisolid magnetization-transfer. Pure APT and NOE signals, in addition to the commonly used magnetization-transfer-ratio asymmetry at 3.5 ppm, MTR_asym (3.5ppm), were assessed.

RESULTS

The measured APT signal intensity of the tumor (11.06%, much larger than the value reported in the literature) was the major contributor (approximately 80.6%) to the MTR_asym (3.5ppm) contrast between the tumor and the contralateral brain region. Both the water content ([water proton]) and water T₁ (T_1w ) were increased in the tumor, but there were no significant correlations among APT, NOE, or MTR_asym (3.5ppm) signals and T_1w /[water proton].

CONCLUSION

The effect of increasing T_1w on the CEST signal in the tumor was mostly eliminated by the effect of increasing water content, and the observed APT-weighted hyperintensity in the tumor should be dominated by the increased amide proton concentration. Magn Reson Med 77:855-863, 2017. © 2016 International Society for Magnetic Resonance in Medicine.

PH Measurements of the Brain Using Phosphorus Magnetic Resonance Spectroscopy ((31)PMRS) in Healthy Men - Comparison of Two Analysis Methods

Background

Intracellular pH provides information on homeostatic mechanisms in neurons and glial cells. The aim of this study was to define pH of the brain of male volunteers using phosphorus magnetic resonance spectroscopy (³¹PMRS) and to compare two methods of calculating this value.

Material/Methods

In this study, 35 healthy, young, male volunteers (mean age: 25 years) were examined by ³¹PMRS in 1.5 T MR system (Signa Excite, GE). The FID CSI (Free Induction Decay Chemical Shift Imaging) sequence was used with the following parameters: TR=4000 ms, FA=90°, NEX=2. Volume of interest (VOI) was selected depending on the size of the volunteers’ brain (11–14 cm³, mean 11.53 cm³). Raw data were analyzed using SAGE (GE) software.

Results

Based on the chemical shift of peaks in the ³¹PMRS spectrum, intracellular pH was calculated using two equations. In both methods the mean pH was slightly alkaline (7.07 and 7.08). Results were compared with a t-test. Significant difference (p<0.05) was found between these two methods.

Conclusions

The ³¹PMRS method enables non-invasive in vivo measurements of pH. The choice of the calculation method is crucial for computing this value. Comparing the results obtained by different teams can be done in a fully credible way only if the calculations were performed using the same formula.

Energy status and metabolism in intracranial space occupying lesions: a prospective 31p spectroscopic study

AIM

Intracranial space occupying lesions can be infective or tumour. There are various advanced Magnetic resonance imaging techniques like perfusion, diffusion and proton spectroscopy which can differentiate between them. However, (31) Phosphorus spectroscopy studies the energy status and the metabolism pattern of various tissues and can be used potentially to differentiate between them depending on their Metabolism pattern. Thus, we aimed to study energy status of various intracranial lesions and try to differentiate between them including grades of gliomas.

MATERIALS AND METHODS

(31)PMRS was done in 1.5T MRI in 43 patients prior to surgery or through/via stereo-tactic biopsy, of which 25 were men and 18 women with mean age 41.34 y ranging from 7-71 y. Single voxel phosphorus spectroscopy was done from the solid portion of the lesions and data was analysed and post processed.

RESULTS

Study includes Lymphoma (n=6), Grade 1 and 2 glioma (n=5), grade 3 glioma (n=9), grade 4 glioma(n=6), metastases (n=5), tuberculoma (n=7) and pyogenic abscesses (n=5). The integral values of PME, Pi, PDE, γ-ATP, α-ATP, β-ATP with reference to the position of PCr were calculated along with various ratios. Integral values of Pi and PDE were significantly increased in metastases but decreased in gliomas grade 1-2 compared to other pathologic conditions. Mean integral values of LEP (low energy phosphates) and total phosphates were significantly decreased in gliomas grades 1 and 2 and increased in metastases when compared with other pathologic conditions. PCr /Pi was increased in glioma grades 1, 2 and 3 but decreased in metastases; the significance was observed only in gliomas grade 3 and metastases. Metabolic ratios of PDE/β ATP and Pi/βATP were decreased in glioma grades 1 and 2 and increased in metastases with statistical significance.

CONCLUSION

(31)PMRS may help in differentiating primary from secondary lesions and assess grades of gliomas.

Widespread pH abnormalities in patients with malformations of cortical development and epilepsy: a phosphorus-31 brain MR spectroscopy study

INTRODUCTION

Neuroimaging studies demonstrate that not only the lesions of malformations of cortical development (MCD) but also the normal-appearing parenchyma (NAP) present metabolic impairments, as revealed with (1)H-MRS. We have previously detected biochemical disturbances in MCD lesions with phosphorus-31 magnetic resonance spectroscopy (31P-MRS). Our hypothesis is that pH abnormalities extend beyond the visible lesions.

METHODS

Three-dimensional 31P-MRS at 3.0 T was performed in 37 patients with epilepsy and MCD, and in 31 matched-control subjects. The patients were assigned into three main MCD subgroups: cortical dysplasia (n=10); heterotopia (n=14); schizencephaly/polymicrogyria (n=13). Voxels (12.5 cm3) were selected in five homologous regions containing NAP: right putamen; left putamen; frontoparietal parasagittal cortex; right centrum semiovale; and left centrum semiovale. Robust methods of quantification were applied, and the intracellular pH was calculated with the chemical shifts of inorganic phosphate (Pi) relative to phosphocreatine (PCr).

RESULTS

In comparison to controls and considering a Bonferroni adjusted p-value <0.01, MCD patients presented significant reduction in intracellular pH in the frontoparietal parasagittal cortex (6.985±0.022), right centrum semiovale (7.004±0.029), and left centrum semiovale (6.995±0.030), compared to controls (mean values±standard deviations of 7.087±0.048, 7.096±0.042, 7.088±0.045, respectively). Dunnet and Dunn tests demonstrated that the differences in pH values remained statistically significant in all MCD subgroups. No significant differences were found for the putamina.

CONCLUSION

The present study demonstrates widespread acidosis in the NAP, and reinforces the idea that MCD visible lesions are only the tip of the iceberg.

Multimodal imaging of gliomas in the context of evolving cellular and molecular therapies

The vast majority of malignant gliomas relapse after surgery and standard radio-chemotherapy. Novel molecular and cellular therapies are thus being developed, targeting specific aspects of tumor growth. While histopathology remains the gold standard for tumor classification, neuroimaging has over the years taken a central role in the diagnosis and treatment follow up of brain tumors. It is used to detect and localize lesions, define the target area for biopsies, plan surgical and radiation interventions and assess tumor progression and treatment outcome. In recent years the application of novel drugs including anti-angiogenic agents that affect the tumor vasculature, has drastically modulated the outcome of brain tumor imaging. To properly evaluate the effects of emerging experimental therapies and successfully support treatment decisions, neuroimaging will have to evolve. Multi-modal imaging systems with existing and new contrast agents, molecular tracers, technological advances and advanced data analysis can all contribute to the establishment of disease relevant biomarkers that will improve disease management and patient care. In this review, we address the challenges of glioma imaging in the context of novel molecular and cellular therapies, and take a prospective look at emerging experimental and pre-clinical imaging techniques that bear the promise of meeting these challenges.

Effect of altitude on brain intracellular pH and inorganic phosphate levels

Normal brain activity is associated with task-related pH changes. Although central nervous system syndromes associated with significant acidosis and alkalosis are well understood, the effects of less dramatic and chronic changes in brain pH are uncertain. One environmental factor known to alter brain pH is the extreme, acute change in altitude encountered by mountaineers. However, the effect of long-term exposure to moderate altitude has not been studied. The aim of this two-site study was to measure brain intracellular pH and phosphate-bearing metabolite levels at two altitudes in healthy volunteers, using phosphorus-31 magnetic resonance spectroscopy ((31)P-MRS). Increased brain pH and reduced inorganic phosphate (Pi) levels were found in healthy subjects who were long-term residents of Salt Lake City, UT (4720ft/1438m), compared with residents of Belmont, MA (20ft/6m). Brain intracellular pH at the altitude of 4720ft was more alkaline than that observed near sea level. In addition, the ratio of inorganic phosphate to total phosphate signal also shifted toward lower values in the Salt Lake City region compared with the Belmont area. These results suggest that long-term residence at moderate altitude is associated with brain chemical changes.

Amide proton transfer imaging of adult diffuse gliomas: correlation with histopathological grades

BACKGROUND

Amide proton transfer (APT) imaging is a novel molecular MRI technique to detect endogenous mobile proteins and peptides through chemical exchange saturation transfer. We prospectively assessed the usefulness of APT imaging in predicting the histological grade of adult diffuse gliomas.

METHODS

Thirty-six consecutive patients with histopathologically proven diffuse glioma (48.1 ± 14.7 y old, 16 males and 20 females) were included in the study. APT MRI was conducted on a 3T clinical scanner and was obtained with 2 s saturation at 25 saturation frequency offsets ω = -6 to +6 ppm (step 0.5 ppm). δB0 maps were acquired separately for a point-by-point δB0 correction. APT signal intensity (SI) was defined as magnetization transfer asymmetry at 3.5 ppm: magnetization transfer ratio (MTR)asym = (S[-3.5 ppm] - S[+3.5 ppm])/S0. Regions of interest were carefully placed by 2 neuroradiologists in solid parts within brain tumors. The APT SI was compared with World Health Organization grade, Ki-67 labeling index (LI), and cell density.

RESULTS

The mean APT SI values were 2.1 ± 0.4% in grade II gliomas (n = 8), 3.2 ± 0.9% in grade III gliomas (n = 10), and 4.1 ± 1.0% in grade IV gliomas (n = 18). Significant differences in APT intensity were observed between grades II and III (P < .05) and grades III and IV (P < .05), as well as between grades II and IV (P < .001). There were positive correlations between APT SI and Ki-67 LI (P = .01, R = 0.43) and between APT SI and cell density (P < .05, R = 0.38). The gliomas with microscopic necrosis showed higher APT SI than those without necrosis (P < .001).

CONCLUSIONS

APT imaging can predict the histopathological grades of adult diffuse gliomas.

Accelerated phosphorus magnetic resonance spectroscopic imaging using compressed sensing

This study aims at assessing the performance of compressed sensing method for faster phosphorus magnetic resonance spectroscopic imaging ((31)P-MRSI) of human brain. A simulated 2D (31)P-MRSI dataset containing a tumor region and a healthy region was created based on the metabolite peak intensities and ratios of a volunteer dataset acquired at 3T. k-space data was randomly undersampled, and reconstructed using compressed sensing algorithm. This simulation study showed that compressed sensing reconstruction could be applied for faster (31)P-MRSI. Future studies will measure the performance of compressed sensing reconstruction for (31)P-MRSI in volunteers and patients with brain tumors.

Application of 31P MR spectroscopy to the brain tumors

Objective

To evaluate the clinical feasibility and obtain useful parameters of ³¹P magnetic resonance spectroscopy (MRS) study for making the differential diagnosis of brain tumors.

Materials and Methods

Twenty-eight patients with brain tumorous lesions (22 cases of brain tumor and 6 cases of abscess) and 11 normal volunteers were included. The patients were classified into the astrocytoma group, lymphoma group, metastasis group and the abscess group. We obtained the intracellular pH and the metabolite ratios of phosphomonoesters/phosophodiesters (PME/PDE), PME/inorganic phosphate (Pi), PDE/Pi, PME/adenosine triphosphate (ATP), PDE/ATP, PME/phosphocreatine (PCr), PDE/PCr, PCr/ATP, PCr/Pi, and ATP/Pi, and evaluated the statistical significances.

Results

The brain tumors had a tendency of alkalization (pH = 7.28 ± 0.27, p = 0.090), especially the pH of the lymphoma was significantly increased (pH = 7.45 ± 0.32, p = 0.013). The brain tumor group showed increased PME/PDE ratio compared with that in the normal control group (p = 0.012). The ratios of PME/PDE, PDE/Pi, PME/PCr and PDE/PCr showed statistically significant differences between each brain lesion groups (p < 0.05). The astrocytoma showed an increased PME/PDE and PME/PCr ratio. The ratios of PDE/Pi, PME/PCr, and PDE/PCr in lymphoma group were lower than those in the control group and astrocytoma group. The metastasis group showed an increased PME/PDE ratio, compared with that in the normal control group.

Conclusion

We have obtained the clinically applicable ³¹P MRS, and the pH, PME/PDE, PDE/Pi, PME/PCr, and PDE/PCr ratios are helpful for differentiating among the different types of brain tumors.

Phospholipid metabolites in recurrent glioblastoma: in vivo markers detect different tumor phenotypes before and under antiangiogenic therapy

Purpose

Metabolic changes upon antiangiogenic therapy of recurrent glioblastomas (rGBMs) may provide new biomarkers for treatment efficacy. Since in vitro models showed that phospholipid membrane metabolism provides specific information on tumor growth we employed in-vivo MR-spectroscopic imaging (MRSI) of human rGBMs before and under bevacizumab (BVZ) to measure concentrations of phosphocholine (PCho), phosphoethanolamine (PEth), glycerophosphocholine (GPC), and glyceroethanolamine (GPE).

Methods

¹H and ³¹P MRSI was prospectively performed in 32 patients with rGBMs before and under BVZ therapy at 8 weeks intervals until tumor progression. Patients were dichotomized into subjects with long overall survival (OS) (>median OS) and short OS (<median OS) survival time from BVZ-onset. Metabolite concentrations from tumor tissue and their ratios were compared to contralateral normal-appearing tissue (control).

Results

Before BVZ, ¹H-detectable choline signals (total GPC and PCho) in rGBMs were elevated but significance failed after dichotomizing. For metabolite ratios obtained by ³¹P MRSI, the short-OS group showed higher PCho/GPC (p = 0.004) in rGBMs compared to control tissue before BVZ while PEth/GPE was elevated in rGBMs of both groups (long-OS p = 0.04; short-OS p = 0.003). Under BVZ, PCho/GPC and PEth/GPE in the tumor initially decreased (p = 0.04) but only PCho/GPC re-increased upon tumor progression (p = 0.02). Intriguingly, in normal-appearing tissue an initial PEth/GPE decrease (p = 0.047) was followed by an increase at the time of tumor progression (p = 0.031).

Conclusion

An elevated PCho/GPC ratio in the short-OS group suggests that it is a negative predictive marker for BVZ efficacy. These gliomas may represent a malignant phenotype even growing under anti-VEGF treatment. Elevated PEth/GPE may represent an in-vivo biomarker more sensitive to GBM infiltration than MRI.

Specific biomarkers of receptors, pathways of inhibition and targeted therapies: clinical applications

A deeper understanding of the role of specific genes, proteins, pathways and networks in health and disease, coupled with the development of technologies to assay these molecules and pathways in patients, promises to revolutionise the practice of clinical medicine. In particular, the discovery and development of novel drugs targeted to disease-specific alterations could benefit significantly from non-invasive imaging techniques assessing the dynamics of specific disease-related parameters. Here we review the application of imaging biomarkers in the management of patients with brain tumours, especially malignant glioma. This first part of the review focuses on imaging biomarkers of general biochemical and physiological processes related to tumour growth such as energy, protein, DNA and membrane metabolism, vascular function, hypoxia and cell death. These imaging biomarkers are an integral part of current clinical practice in the management of primary brain tumours. The second article of the review discusses the use of imaging biomarkers of specific disease-related molecular genetic alterations such as apoptosis, angiogenesis, cell membrane receptors and signalling pathways. Current applications of these biomarkers are mostly confined to experimental small animal research to develop and validate these novel imaging strategies with future extrapolation in the clinical setting as the primary objective.

Magnetic resonance spectroscopy of cancer metabolism and response to therapy

Magnetic resonance spectroscopy allows noninvasive in vivo measurements of biochemical information from living systems, ranging from cultured cells through experimental animals to humans. Studies of biopsies or extracts offer deeper insights by detecting more metabolites and resolving metabolites that cannot be distinguished in vivo. The pharmacokinetics of certain drugs, especially fluorinated drugs, can be directly measured in vivo. This review briefly describes these methods and their applications to cancer metabolism, including glycolysis, hypoxia, bioenergetics, tumor pH, and tumor responses to radiotherapy and chemotherapy.

Phosphorus magnetic resonance spectroscopy in malformations of cortical development

PURPOSE

The aim of this study was to evaluate phospholipid metabolism in patients with malformations of cortical development (MCDs).

METHODS

Thirty-seven patients with MCDs and 31 control subjects were studied using three-dimensional phosphorus magnetic resonance spectroscopy ((31)P-MRS) at 3.0 T. The voxels in the lesions and in the frontoparietal cortex of the control subjects were compared (the effective volumes were 12.5 cm(3)). Robust quantification methods were applied to fit the time-domain data to the following resonances: phosphoethanolamine (PE); phosphocholine (PC); inorganic phosphate (Pi); glycerophosphoethanolamine (GPE); glycerophosphocholine (GPC); phosphocreatine (PCr); and α-, β-, and γ-adenosine triphosphate (ATP). We also estimated the total ATP (ATP(t) = α-+β-+γ-ATP), phosphodiesters (PDE = GPC+GPE), phosphomonoesters (PME = PE+PC), and the PME/PDE, PCr/ATP(t) and PCr/Pi ratios. The magnesium (Mg(2+)) levels and pH values were calculated based on PCr, Pi, and β-ATP chemical shifts.

KEY FINDINGS

Compared to controls and assuming that a p-value < 0.05 indicates statistical significance, the patients with MCDs exhibited significantly lower pH values and higher Mg(2+) levels. In addition, the patients with MCDs had lower GPC and PDE and an increased PME/PDE ratio.

SIGNIFICANCE

Mg(2+) and pH are important in the regulation of bioenergetics and are involved in many electrical activity pathways in the brain. Our data support the idea that neurometabolic impairments occur during seizure onset and propagation. The GPC, PDE, and PME/PDE abnormalities also demonstrate that there are membrane turnover disturbances in patients with MCDs.

Bevacizumab impairs oxidative energy metabolism and shows antitumoral effects in recurrent glioblastomas: a 31P/1H MRSI and quantitative magnetic resonance imaging study

Bevacizumab shows unprecedented rates of response in recurrent glioblastomas (GBM), but the detailed mechanisms are still unclear. We employed in vivo magnetic resonance spectroscopic imaging (MRSI) and quantitative magnetic resonance imaging to investigate whether bevacizumab alters oxygen and energy metabolism and whether this effect has antitumoral activity in recurrent GBM. (31)P and (1)H MRSI, apparent diffusion coefficient (ADC), and high-resolution T2 and T2' mapping (indirect marker of oxygen extraction) were investigated in 16 patients with recurrent GBM at 3 Tesla before and 1.5-2 months after initiation of therapy with bevacizumab. Changes of metabolite concentrations and of the quantitative values in the tumor and normal appearing brain tissue were calculated. The Wilcoxon signed-ranks test was used to evaluate differences for tumor/edema versus control as well as changes before versus after commencement of therapy. Survival analyses were performed for significant parameters. Tumor T2', pH, ADC, and T2 decreased significantly in patients responding to bevacizumab therapy (n = 10). Patients with at least 25% T2' decrease during treatment showed longer progression-free and overall survival durations. Levels of high-energy metabolites were lower at baseline; these persisted under therapy. Glycerophosphoethanolamine as catabolic phospholipid metabolite increased in responders. The MRSI data support the hypothesis that bevacizumab induces relative tumor hypoxia (T2' decrease) and affects energy homeostasis in recurrent GBM, suggesting that bevacizumab impairs vascular function. The antiangiogenic effect of bevacizumab is predictive of better outcome and seems to induce antitumoral activity in the responding GBMs.