Mapping of brain tumor metabolites with proton MR spectroscopic imaging: clinical relevance

Metabolic advantages of regulatory T cells dictated by cancer cells

Cancer cells employ glycolysis for their survival and growth (the "Warburg effect"). Consequently, surrounding cells including immune cells in the tumor microenvironment (TME) are exposed to hypoglycemic, hypoxic, and low pH circumstances. Since effector T cells depend on the glycolysis for their survival and functions, the metabolically harsh TME established by cancer cells is unfavorable, resulting in the impairment of effective antitumor immune responses. By contrast, immunosuppressive cells such as regulatory T (Treg) cells can infiltrate, proliferate, survive, and exert immunosuppressive functions in the metabolically harsh TME, indicating the different metabolic dependance between effector T cells and Treg cells. Indeed, some metabolites that are harmful for effector T cells can be utilized by Treg cells; lactic acid, a harmful metabolite for effector T cells, is available for Treg cell proliferation and functions. Deficiency of amino acids such as tryptophan and glutamine in the TME impairs effector T cell activation but increases Treg cell populations. Furthermore, hypoxia upregulates fatty acid oxidation via hypoxia-inducible factor 1α (HIF-1α) and promotes Treg cell migration. Adenosine is induced by the ectonucleotidases CD39 and CD73, which are strongly induced by HIF-1α, and reportedly accelerates Treg cell development by upregulating Foxp3 expression in T cells via A2AR-mediated signals. Therefore, this review focuses on the current views of the unique metabolism of Treg cells dictated by cancer cells. In addition, potential cancer combination therapies with immunotherapy and metabolic molecularly targeted reagents that modulate Treg cells in the TME are discussed to develop "immune metabolism-based precision medicine".

A Novel Approach to Determining Tumor Progression Using a Three-Site Pilot Clinical Trial of Spectroscopic MRI-Guided Radiation Dose Escalation in Glioblastoma

Glioblastoma (GBM) is a fatal disease, with poor prognosis exacerbated by difficulty in assessing tumor extent with imaging. Spectroscopic MRI (sMRI) is a non-contrast imaging technique measuring endogenous metabolite levels of the brain that can serve as biomarkers for tumor extension. We completed a three-site study to assess survival benefits of GBM patients when treated with escalated radiation dose guided by metabolic abnormalities in sMRI. Escalated radiation led to complex post-treatment imaging, requiring unique approaches to discern tumor progression from radiation-related treatment effect through our quantitative imaging platform. The purpose of this study is to determine true tumor recurrence timepoints for patients in our dose-escalation multisite study using novel methodology and to report on median progression-free survival (PFS). Follow-up imaging for all 30 trial patients were collected, lesion volumes segmented and graphed, and imaging uploaded to our platform for visual interpretation. Eighteen months post-enrollment, the median PFS was 16.6 months with a median time to follow-up of 20.3 months. With this new treatment paradigm, incidence rate of tumor recurrence one year from treatment is 30% compared to 60-70% failure under standard care. Based on the delayed tumor progression and improved survival, a randomized phase II trial is under development (EAF211).

Revisiting Concepts of Magnetic Resonance Spectroscopy in the Evaluation of Brain Lesions: An Institutional Experience

Objective Magnetic resonance spectroscopy (MRS) has emerged as a technique due to its ability to characterize the metabolite constituent of any lesion. We have evaluated magnetic resonance (MR) spectral patterns in different neoplastic brain lesions, using the ability of MRS in grading of gliomas. MRS also helps in differentiating between high-grade glioma and metastases.

Method A retrospective observational study in histologically confirmed cases of brain neoplasms in which MRS was performed as a part of preoperative MR imaging. The pattern of metabolite peak was observed and means with standard deviation of different metabolite ratios (choline/creatine, choline/N-acetylaspartate [NAA], NAA/creatine) were calculated for different tumors. Analysis was done to see statistically significant differences in metabolite ratios of different grades of gliomas and to differentiate high-grade gliomas from metastases.

Result A total of 61 cases with brain tumor were included in the study. Of which, 20 cases were of gliomas, 11 metastases, 9 meningiomas, 4 dysembryoplastic neuroepithelial tumors, 6 pituitary macroadenomas, 4 trigeminal schwannomas, 3 craniopharyngiomas, 2 acoustic schwannomas, and 2 medulloblastomas. Statistically significant differences in ratios of metabolite peaks were noted between different grades of gliomas and for high-grade glioma versus metastases.

Conclusion MRS compliments the MR imaging and stands out as problem-solving method to distinguish neoplastic lesions in selected cases and also has a role in grading of gliomas and in differentiation of types of malignancies.

In vivo brain MR spectroscopy in gliomas: clinical and pre-clinical chances

Purpose

Gliomas, the most common primary brain tumours, have recently been re-classified incorporating molecular aspects with important clinical, prognostic, and predictive implications. Concurrently, the reprogramming of metabolism, altering intracellular and extracellular metabolites affecting gene expression, differentiation, and the tumour microenvironment, is increasingly being studied, and alterations in metabolic pathways are becoming hallmarks of cancer. Magnetic resonance spectroscopy (MRS) is a complementary, non-invasive technique capable of quantifying multiple metabolites. The aim of this review focuses on the methodology and analysis techniques in proton MRS (1H MRS), including a brief look at X-nuclei MRS, and on its perspectives for diagnostic and prognostic biomarkers in gliomas in both clinical practice and preclinical research.

Methods

PubMed literature research was performed cross-linking the following key words: glioma, MRS, brain, in-vivo, human, animal model, clinical, pre-clinical, techniques, sequences, 1H, X-nuclei, Artificial Intelligence (AI), hyperpolarization.

Results

We selected clinical works (n = 51), preclinical studies (n = 35) and AI MRS application papers (n = 15) published within the last two decades. The methodological papers (n = 62) were taken into account since the technique first description.

Conclusions

Given the development of treatments targeting specific cancer metabolic pathways, MRS could play a key role in allowing non-invasive assessment for patient diagnosis and stratification, predicting and monitoring treatment responses and prognosis. The characterization of gliomas through MRS will benefit of a wide synergy among scientists and clinicians of different specialties within the context of new translational competences. Head coils, MRI hardware and post-processing analysis progress, advances in research, experts’ consensus recommendations and specific professionalizing programs will make the technique increasingly trustworthy, responsive, accessible.

1H-MR spectroscopy in grading of cerebral glioma: A new view point, MRS image quality assessment

Background

Noninvasive preoperative prediction of histological grading is essential for clinical management of cerebral glioma.

Purpose

This study aimed to investigate the association between the image quality assessment of 1H magnetic resonance spectroscopy and accurate grading of glioma.

Materials and Methods

98 glioma patients confirmed by pathology were retrospectively recruited in this single-center study. All patients underwent 1H-MRS examination at 3.0T before surgery. According to WHO standards, all cases were divided into two groups: low-grade glioma (grade I and II, 48 cases) and high-grade glioma (grades III and IV, 50 cases). The metabolite ratios in both grades were calculated before and after image quality assessment. The area under the receiver operating characteristic (ROC) curve was used to evaluate the capacity of each ratio in glioma grading.

Results

The Cho/Cr, Cho/NAA and NAA/Cr metabolite ratios had certain differences in each glioma group before and after MRS image quality assessment. In the low-grade glioma group, there was a dramatic difference in the Cho/Cr ratio before and after image quality assessment (p = 0.011). After MRS image quality assessment, the accuracy of glioma grading was significantly improved. The Cho/Cr ratio with 83.3% sensitivity and 93.7% specificity is the best index of glioma grading, with the optimal cutoff value of the Cho/Cr ratio being 3.72.

Conclusion

The image quality of MRS does affect the metabolite ratios and the results of glioma grading. MRS image quality assessment can observably improve the accuracy rate of glioma grading. The Cho/Cr ratio has the best diagnostic performance in differentiating high-grade from low-grade glioma.

Fighting in a wasteland: deleterious metabolites and antitumor immunity

As cancers progress, they produce a local environment that acts to redirect, paralyze, exhaust, or otherwise evade immune detection and destruction. The tumor microenvironment (TME) has long been characterized as a metabolic desert, depleted of essential nutrients such as glucose, oxygen, and amino acids, that starves infiltrating immune cells and renders them dysfunctional. While not incorrect, this perspective is only half the picture. The TME is not a metabolic vacuum, only consuming essential nutrients and never producing by-products. Rather, the by-products of depleted nutrients, “toxic” metabolites in the TME such as lactic acid, kynurenine, ROS, and adenosine, play an important role in shaping immune cell function and cannot be overlooked in cancer immunotherapy. Moreover, while the metabolic landscape is distinct, it is not unique, as these toxic metabolites are encountered in non-tumor tissues, where they evolutionarily shape immune cells and their response. In this Review, we discuss how depletion of essential nutrients and production of toxic metabolites shape the immune response within the TME and how toxic metabolites can be targeted to improve current cancer immunotherapies.

High-Resolution Label-Free Molecular Imaging of Brain Tumor

Molecular imaging has long been recognized as an important tool for diagnosis, characterization, and monitoring of treatment responses of brain tumors. Magnetic resonance spectroscopic imaging (MRSI) is a label-free molecular imaging technique capable of mapping metabolite distributions non-invasively. Several metabolites detectable by MRSI, including Choline, Lactate and N-Acetyl Aspartate, have been proved useful biomarkers for brain tumor characterization. However, clinical application of MRSI has been limited by poor resolution, small spatial coverage, low signal-to-noise ratio and long scan time. This work presents a novel MRSI method for fast, high-resolution metabolic imaging of brain tumor. This method synergistically integrates fast acquisition sequence, sparse sampling, subspace modeling and machine learning to enable 3D mapping of brain metabolites with a spatial resolution of 2.0×3.0×3.0 mm³ in a 7-minute scan. Experimental results obtained from patients with diagnosed brain tumor showed great promise for capturing small-size tumors and revealing intra-tumor metabolic heterogeneities.Clinical Relevance - This paper presents a novel technique for label-free molecular imaging of brain tumor. With further development, this technology may enable many potential clinical applications, from tumor detection, characterization, to assessment of treatment efficacy.

Differentiating Glioblastomas from Solitary Brain Metastases: An Update on the Current Literature of Advanced Imaging Modalities

Differentiating between glioblastomas and solitary brain metastases proves to be a challenging diagnosis for neuroradiologists, as both present with imaging patterns consisting of peritumoral hyperintensities with similar intratumoral texture on traditional magnetic resonance imaging sequences. Early diagnosis is paramount, as each pathology has completely different methods of clinical assessment. In the past decade, recent developments in advanced imaging modalities enabled providers to acquire a more accurate diagnosis earlier in the patient's clinical assessment, thus optimizing clinical outcome. Dynamic susceptibility contrast has been optimized for detecting relative cerebral blood flow and relative cerebral blood volume. Diffusion tensor imaging can be used to detect changes in mean diffusivity. Neurite orientation dispersion and density imaging is an innovative modality detecting changes in intracellular volume fraction, isotropic volume fraction, and extracellular volume fraction. Magnetic resonance spectroscopy is able to assist by providing a metabolic descriptor while detecting variable ratios of choline/N-acetylaspartate, choline/creatine, and N-acetylaspartate/creatine. Finally, radiomics and machine learning algorithms have been devised to assist in improving diagnostic accuracy while often utilizing more than one advanced imaging protocol per patient. In this review, we provide an update on all the current evidence regarding the identification and differentiation of glioblastomas from solitary brain metastases.

Perioperative Management of Patients with Glioblastoma

The clinical presentation of glioblastomas is varied, and definitive diagnosis requires pathologic examination and study of the tissue. Management of glioblastomas includes surgery and adjuvant chemotherapy and radiotherapy, with surgery playing an important role in the prognosis of these patients. Awake craniotomy plays a crucial role in tumors in or adjacent to eloquent areas, allowing surgeons to maximize resection, while minimizing iatrogenic deficits. However, the prognosis remains dismal. This article presents the perioperative management of patients with glioblastoma including tools and surgical adjuncts to maximize extent of resection and minimize poor outcomes.

Simultaneous QSM and metabolic imaging of the brain using SPICE: Further improvements in data acquisition and processing

PURPOSE

To achieve high-resolution mapping of brain tissue susceptibility in simultaneous QSM and metabolic imaging.

METHODS

Simultaneous QSM and metabolic imaging was first achieved using SPICE (spectroscopic imaging by exploiting spatiospectral correlation), but the QSM maps thus obtained were at relatively low-resolution (2.0 × 3.0 × 3.0 mm³ ). We overcome this limitation using an improved SPICE data acquisition method with the following novel features: 1) sampling (k, t)-space in dual densities, 2) sampling central k-space fully to achieve nominal spatial resolution of 3.0 × 3.0 × 3.0 mm³ for metabolic imaging, and 3) sampling outer k-space sparsely to achieve spatial resolution of 1.0 × 1.0 × 1.9 mm³ for QSM. To keep the scan time short, we acquired spatiospectral encodings in echo-planar spectroscopic imaging trajectories in central k-space but in CAIPIRINHA (controlled aliasing in parallel imaging results in higher acceleration) trajectories in outer k-space using blipped phase encodings. For data processing and image reconstruction, a union-of-subspaces model was used, effectively incorporating sensitivity encoding, spatial priors, and spectral priors of individual molecules.

RESULTS

In vivo experiments were carried out to evaluate the feasibility and potential of the proposed method. In a 6-min scan, QSM maps at 1.0 × 1.0 × 1.9 mm³ resolution and metabolic maps at 3.0 × 3.0 × 3.0 mm³ nominal resolution were obtained simultaneously. Compared with the original method, the QSM maps obtained using the new method reveal fine-scale brain structures more clearly.

CONCLUSION

We demonstrated the feasibility of achieving high-resolution QSM simultaneously with metabolic imaging using a modified SPICE acquisition method. The improved capability of SPICE may further enhance its practical utility in brain mapping.

Evaluating Magnetic Resonance Spectroscopy as a Tool for Monitoring Therapeutic Response of Whole Brain Radiotherapy in a Mouse Model for Breast-to-Brain Metastasis

Brain metastases are the most common intracranial tumor in adults and are associated with poor patient prognosis and median survival of only a few months. Treatment options for brain metastasis patients remain limited and largely depend on surgical resection, radio- and/or chemotherapy. The development and pre-clinical testing of novel therapeutic strategies require reliable experimental models and diagnostic tools that closely mimic technologies that are used in the clinic and reflect histopathological and biochemical changes that distinguish tumor progression from therapeutic response. In this study, we sought to test the applicability of magnetic resonance (MR) spectroscopy in combination with MR imaging to closely monitor therapeutic efficacy in a breast-to-brain metastasis model. Given the importance of radiotherapy as the standard of care for the majority of brain metastases patients, we chose to monitor the post-irradiation response by magnetic resonance spectroscopy (MRS) in combination with MR imaging (MRI) using a 7 Tesla small animal scanner. Radiation was applied as whole brain radiotherapy (WBRT) using the image-guided Small Animal Radiation Research Platform (SARRP). Here we describe alterations in different metabolites, including creatine and N-acetylaspartate, that are characteristic for brain metastases progression and lactate, which indicates hypoxia, while choline levels remained stable. Radiotherapy resulted in normalization of metabolite levels indicating tumor stasis or regression in response to treatment. Our data indicate that the use of MR spectroscopy in addition to MRI represents a valuable tool to closely monitor not only volumetrical but also metabolic changes during tumor progression and to evaluate therapeutic efficacy of intervention strategies. Adapting the analytical technology in brain metastasis models to those used in clinical settings will increase the translational significance of experimental evaluation and thus contribute to the advancement of pre-clinical assessment of novel therapeutic strategies to improve treatment options for brain metastases patients.

Molecular Imaging in Pediatric Brain Tumors

In the last decade, several radiopharmaceuticals have been developed and investigated for imaging in vivo of pediatric brain tumors with the aim of exploring peculiar metabolic processes as glucose consumption, amino-acid metabolism, and protein synthesis with nuclear medicine techniques. Although the clinical shreds of evidence are limited, preliminary results are encouraging. In this review, we performed web-based and desktop research summarizing the most relevant findings of the literature published to date on this topic. Particular attention was given to the wide spectrum of nuclear medicine advances and trends in pediatric neurooncology and neurosurgery. Furthermore, the role of somatostatin receptor imaging through single-photon emission computed tomography (SPECT) and positron emission tomography (PET) probes, with reference to their potential therapeutic implications, was examined in the peculiar context. Preliminary results show that functional imaging in pediatric brain tumors might lead to significant improvements in terms of diagnostic accuracy and it could be of help in the management of the disease.

New metabolic imaging tools in neuro-oncology

PURPOSE OF REVIEW

The current treatment of gliomas dovetails results of decades-old clinical trials with modern trends in chemotherapy. Molecular characterization now plays a pivotal role, and IDH mutations are key characteristics and the subject of active debate. IDH-mutant tumors produce the 'onco-metabolite', 2-hydroxyglutarate. Metabolic changes have become central to the understanding of tumor biology, and tumors display a fundamental metabolic change called the Warburg Effect. The Warburg Effect represents a preference for glycolysis, as opposed to oxidative phosphorylation. The present review details the clinical context and discusses clinical and preclinical metabolic imaging tools to characterize the Warburg Effect.

RECENT FINDINGS

A clinical Warburg Index is proposed, defined as the lactate concentration measured by H-MRSI over the SUV measured by FDG-PET, to measure the Warburg Effect. A preclinical technique called deuterium metabolic imaging has successfully imaged the Warburg Effect in vivo in glioblastoma.

SUMMARY

Metabolic imaging provides an opportunity to measure the Warburg Effect and other metabolic changes in brain tumors. An increased understanding of metabolic shifts integral to brain cancer has the potential to address multiple contemporary debates on glioma pathophysiology and treatment. Metabolic imaging tools thus have the potential to advance research findings, clinical trial development, and clinical care.

A quantitative SVM approach potentially improves the accuracy of magnetic resonance spectroscopy in the preoperative evaluation of the grades of diffuse gliomas

Objectives

To investigate the association between proton magnetic resonance spectroscopy (¹H-MRS) metabolic features and the grade of gliomas, and to establish a machine-learning model to predict the glioma grade.

Methods

This study included 112 glioma patients who were divided into the training (n = 74) and validation (n = 38) sets based on the time of hospitalization. Twenty-six metabolic features were extracted from the preoperative ¹H-MRS image. The Student's t-test was conducted to screen for differentially expressed features between low- and high-grade gliomas (WHO grades II and III/IV, respectively). Next, the minimum Redundancy Maximum Relevance (mRMR) algorithm was performed to further select features for a support vector machine (SVM) classifier building. Performance of the predictive model was evaluated both in the training and validation sets using ROC curve analysis.

Results

Among the extracted ¹H-MRS metabolic features, thirteen features were differentially expressed. Four features were further selected as grade-predictive imaging signatures using the mRMR algorithm. The predictive performance of the machine-learning model measured by the AUC was 0.825 and 0.820 in the training and validation sets, respectively. This was better than the predictive performances of individual metabolic features, the best of which was 0.812.

Conclusions

¹H-MRS metabolic features could help in predicting the grade of gliomas. The machine-learning model achieved a better prediction performance in grading gliomas than individual features, indicating that it could complement the traditionally used metabolic features.

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¹H-MRS metabolic features could help in predicting the grades of gliomas.

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The machine-learning model performed better than individual metabolic features.

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The use of machine-learning model can complement the metabolic features.

Comparison between Short and Long Echo Time Magnetic Resonance Spectroscopic Imaging at 3T and 7T for Evaluating Brain Metabolites in Patients with Glioma

Three-dimensional proton magnetic resonance spectroscopic imaging (MRSI) is a powerful non-invasive tool for characterizing spatial variations in metabolic profiles for patients with glioma. Metabolic parameters obtained using this technique have been shown to predict treatment response, disease progression, and transformation to a more malignant phenotype. The availability of ultra-high-field MR systems has the potential to improve the characterization of metabolites. The purpose of this study was to compare the metabolite profiles acquired with conventional long echo time (TE) MRSI at 3T with those obtained with short TE MRSI at 3T and 7T in patients with glioma. The data acquisition parameters were optimized separately for each echo time and field strength to obtain volumetric coverage within clinically feasible data acquisition times of 5-10 min. While a higher field strength did provide better detection of metabolites with overlapping peaks, spatial coverage was reduced and the use of inversion recovery to reduce lipid precluded the detection of lipid in regions of necrosis. For serial evaluation of large, heterogeneous lesions, the use of 3T short TE MRSI may thus be preferred. Despite the limited number of metabolites that it is able to detect, the use of 3T long TE MRSI gives the best contrast in choline/N-acetyl aspartate between normal appearing brain and tumor and also allows the separate detection of lactate and lipid. It may therefore be preferred for serial evaluation of patients with high-grade glioma and for detection of malignant transformation in patients with low-grade glioma.

Monocarboxylate transporter 1 is a key player in glioma-endothelial cell crosstalk

Glioblastoma (GBM) is one of the most glycolytic and angiogenic human tumors, characteristics that contribute to the poor prognosis associated with this type of tumor. A lactate shuttle has been described between tumor cells and endothelial cells (ECs), with the monocarboxylate transporters (MCTs) acting as important players in this tumor-EC communication. In this study, we aimed to understand how the tumor microenvironment modulates EC metabolism, and to characterize the role of MCTs in the glioma-brain EC crosstalk. Exposure of human brain microvascular ECs (HBMEC) to GBM cell-conditioned media increased the expression of MCT1, which corresponded to activation of oxidative metabolism and an increase in angiogenic capacity, as determined by increased proliferation, migration, and vessel assembly. Lactate depletion from the microenvironment or inhibition of lactate uptake in HBMEC induced an increase in lactate production and a decrease in proliferation, migration, and vessel assembly. Moreover, addition of lactate to HBMEC media promoted activation of AKT and AMPK pathways and increased expression in NFκB, HIF-1α, and the lactate receptor GPR81. Here, we demonstrate a role for MCT1 as a mediator of lactate signaling between glioma cells and brain ECs. Our results suggest that MCT1 can mediate EC metabolic reprograming, proliferation, and vessel sprouting in response to tumor signaling. Thus, targeting MCT1 in both tumor cells and brain EC may be a promising therapeutic strategy for the treatment of GBM.

The Significance of Lactate and Lipid Peaks for Predicting Primary Neuroepithelial Tumor Grade with Proton MR Spectroscopy

Purpose:

¹H-MRS is a non-invasive technique used to assess the metabolic activity of brain tumors. The technique is useful for the preoperative prediction of tumor grade, which is important for treatment planning and accurate prognosis. We used ¹H-MRS to study the lactate peak, which appears in various conditions, including hyperglycemia, ischemia, and hypoxia and lipid peak, which is associated with necrotic cells. The purpose of this study was to retrospectively examine the frequency and significance of lactate and lipid peaks in relation to brain tumor grade.

Materials and Methods:

Fifty-five patients diagnosed with neuroepithelial tumors of Grades I (3 cases), II (11 cases), III (15 cases), and IV (26 cases) were enrolled. Biopsies were excluded. Single voxel (TE = 144 ms) point resolved ¹H-MRS spectroscopy sequences were retrospectively analyzed. An inverted doublet peak at 1.3 ppm was defined as lactate, a negative and positive peak was defined as combined lactate and lipid, and a clear upward peak was defined as lipid.

Results:

Lactate peaks were detected in all grades of brain tumors and were least common in Grade II tumors (9.1%). The frequency of combined lactate-lipid peaks was 0% (Grades I and II), 8.3% (Grade III), and 44% (Grade IV). Grade IV tumors were significantly different to the other grades. There were three cases with a lipid peak. All were glioblastoma.

Conclusions:

The presence of a lac peak may be useful to largely rule out the Grade II tumors, and allow the subsequent differentiation of Grade I tumors from Grade III or IV tumors by conventional imaging. The presence of a lipid peak may be associated with Grade IV tumors.

Interrogating Metabolism in Brain Cancer

This article reviews existing and emerging techniques of interrogating metabolism in brain cancer from well-established proton magnetic resonance spectroscopy to the promising hyperpolarized metabolic imaging and chemical exchange saturation transfer and emerging techniques of imaging inflammation. Some of these techniques are at an early stage of development and clinical trials are in progress in patients to establish the clinical efficacy. It is likely that in vivo metabolomics and metabolic imaging is the next frontier in brain cancer diagnosis and assessing therapeutic efficacy; with the combined knowledge of genomics and proteomics a complete understanding of tumorigenesis in brain might be achieved.

Positron Emission Tomography

Positron emission tomography (PET) is a minimally invasive imaging procedure with a wide range of clinical and research applications. PET allows for the three-dimensional mapping of administered positron-emitting radiopharmaceuticals such as (18)F-fluorodeoxyglucose (for imaging glucose metabolism). PET enables the study of biologic function in both health and disease, in contrast to magnetic resonance imaging (MRI) and computed tomography (CT), that are more suited to study a body's morphologic changes, although functional MRI can also be used to study certain brain functions by measuring blood flow changes during task performance. This chapter first provides an overview of the basic physics principles and instrumentation behind PET methodology, with an introduction to the merits of merging functional PET imaging with anatomic CT or MRI imaging. We then focus on clinical neurologic disorders, and reference research on relevant PET radiopharmaceuticals when applicable. We then provide an overview of PET scan interpretation and findings in several specific neurologic disorders such as dementias, epilepsy, movement disorders, infection, cerebrovascular disorders, and brain tumors.

Magnetic Resonance (MR) Metabolic Imaging in Glioma

This review is focused on describing the use of magnetic resonance (MR) spectroscopy for metabolic imaging of brain tumors. We will first review the MR metabolic imaging findings generated from preclinical models, focusing primarily on in vivo studies, and will then describe the use of metabolic imaging in the clinical setting. We will address relatively well-established (1) H MRS approaches, as well as (31) P MRS, (13) C MRS and emerging hyperpolarized (13) C MRS methodologies, and will describe the use of metabolic imaging for understanding the basic biology of glioma as well as for improving the characterization and monitoring of brain tumors in the clinic.

Emerging methods for disease monitoring in malignant gliomas

MRI remains the backbone of measuring disease burden and treatment response in individuals with malignant gliomas. Traditional radiographic approaches, however, are largely limited to depicting anatomic changes and are not a direct measure of disease burden. For example, contrast enhancement is related to blood-brain barrier integrity rather than actual tumor size. Without accurate measures of disease, common clinical dilemmas include 'pseudo-progression' (e.g., after chemoradiation) or 'pseudo-response' (e.g., with steroid treatment and antiangiogenic agents), which can lead to delays in therapy, premature discontinuation of successful treatments and to unnecessary surgical procedures. This overview focuses on novel, minimally invasive approaches in the area of imaging and blood-based biomarkers that aim to more accurately determine disease status and response to treatment in malignant brain tumors.

History and evolution of brain tumor imaging: insights through radiology

This review recounts the history of brain tumor diagnosis from antiquity to the present and, indirectly, the history of neuroradiology. Imaging of the brain has from the beginning held an enormous interest because of the inherent difficulty of this endeavor due to the presence of the skull. Because of this, most techniques when newly developed have always been used in neuroradiology and, although some have proved to be inappropriate for this purpose, many were easily incorporated into the specialty. The first major advance in modern neuroimaging was contrast agent-enhanced computed tomography, which permitted accurate anatomic localization of brain tumors and, by virtue of contrast enhancement, malignant ones. The most important advances in neuroimaging occurred with the development of magnetic resonance imaging and diffusion-weighted sequences that allowed an indirect estimation of tumor cellularity; this was further refined by the development of perfusion and permeability mapping. From its beginnings with indirect and purely anatomic imaging techniques, neuroradiology now uses a combination of anatomic and physiologic techniques that will play a critical role in biologic tumor imaging and radiologic genomics.

Imaging biomarkers in primary brain tumours

We are getting used to referring to instrumentally detectable biological features in medical language as "imaging biomarkers". These two terms combined reflect the evolution of medical imaging during recent decades, and conceptually comprise the principle of noninvasive detection of internal processes that can become targets for supplementary therapeutic strategies. These targets in oncology include those biological pathways that are associated with several tumour features including independence from growth and growth-inhibitory signals, avoidance of apoptosis and immune system control, unlimited potential for replication, self-sufficiency in vascular supply and neoangiogenesis, acquired tissue invasiveness and metastatic diffusion. Concerning brain tumours, there have been major improvements in neurosurgical techniques and radiotherapy planning, and developments of novel target drugs, thus increasing the need for reproducible, noninvasive, quantitative imaging biomarkers. However, in this context, conventional radiological criteria may be inappropriate to determine the best therapeutic option and subsequently to assess response to therapy. Integration of molecular imaging for the evaluation of brain tumours has for this reason become necessary, and an important role in this setting is played by imaging biomarkers in PET and MRI. In the current review, we describe most relevant techniques and biomarkers used for imaging primary brain tumours in clinical practice, and discuss potential future developments from the experimental context.

The Metabolic Epicenter of Supratentorial Gliomas: A 1H-MRSI Study

Background:

Assessing the impact of glioma location on prognosis remains elusive. We approached the problem using multivoxel proton magnetic resonance spectroscopic imaging (1H-MRSI) to define a tumor “metabolic epicenter”, and examined the relationship of metabolic epicenter location to survival and histopathological grade.

Methods:

We studied 54 consecutive patients with a supratentorial glioma (astrocytoma or oligodendroglioma, WHO grades II-IV). The metabolic epicenter in each tumor was defined as the 1H-MRSI voxel containing maximum intra-tumoral choline on preoperative imaging. Tumor location was considered the X-Y-Z coordinate position, in a standardized stereotactic space, of the metabolic epicenter. Correlation between epicenter location and survival or grade was assessed.

Results:

Metabolic epicenter location correlated significantly with patient survival for all tumors (r2 = 0.30, p = 0.0002) and astrocytomas alone (r2 = 0.32, p = 0.005). A predictive model based on both metabolic epicenter location and histopathological grade accounted for 70% of the variability in survival, substantially improving on histology alone to predict survival. Location also correlated significantly with grade (r2 = 0.25, p = 0.001): higher grade tumors had a metabolic epicenter closer to the midpoint of the brain.

Conclusions:

The concept of the metabolic epicenter eliminates several problems related to existing methods of classifying glioma location. The location of the metabolic epicenter is strongly correlated with overall survival and histopathological grade, suggesting that it reflects biological factors underlying glioma growth and malignant dedifferentiation. These findings may be clinically relevant to predicting patterns of local glioma recurrence, and in planning resective surgery or radiotherapy.

Inhibition of monocarboxylate transporter-1 (MCT1) by AZD3965 enhances radiosensitivity by reducing lactate transport

Inhibition of the monocarboxylate transporter MCT1 by AZD3965 results in an increase in glycolysis in human tumor cell lines and xenografts. This is indicated by changes in the levels of specific glycolytic metabolites and in changes in glycolytic enzyme kinetics. These drug-induced metabolic changes translate into an inhibition of tumor growth in vivo. Thus, we combined AZD3965 with fractionated radiation to treat small cell lung cancer (SCLC) xenografts and showed that the combination provided a significantly greater therapeutic effect than the use of either modality alone. These results strongly support the notion of combining MCT1 inhibition with radiotherapy in the treatment of SCLC and other solid tumors.

Imaging neuroinflammation? A perspective from MR spectroscopy

Neuroinflammatory mechanisms contribute to the brain pathology resulting from human immunodeficiency virus (HIV) infection. Magnetic resonance spectroscopy (MRS) has been touted as a suitable method for discriminating in vivo markers of neuroinflammation. The present MRS study was conducted in four groups: alcohol dependent (A, n = 37), HIV-infected (H, n = 33), alcohol dependent + HIV infected (HA, n = 38) and healthy control (C, n = 62) individuals to determine whether metabolites would change in a pattern reflecting neuroinflammation. Significant four-group comparisons were evident only for striatal choline-containing compounds (Cho) and myo-inositol (mI), which follow-up analysis demonstrated were due to higher levels in HA compared with C individuals. To explore the potential relevance of elevated Cho and mI, correlations between blood markers, medication status and alcohol consumption were evaluated in H + HA subjects. Having an acquired immune deficiency syndrome (AIDS)-defining event or hepatitis C was associated with higher Cho; lower Cho levels, however, were associated with low thiamine levels and with highly active antiretroviral HIV treatment (HAART). Higher levels of mI were related to greater lifetime alcohol consumed, whereas HAART was associated with lower mI levels. The current results suggest that competing mechanisms can influence in vivo Cho and mI levels, and that elevations in these metabolites cannot necessarily be interpreted as reflecting a single underlying mechanism, including neuroinflammation.

Comparison of perfusion, diffusion, and MR spectroscopy between low-grade enhancing pilocytic astrocytomas and high-grade astrocytomas

BACKGROUND AND PURPOSE

The differentiation of pilocytic astrocytomas and high-grade astrocytomas is sometimes difficult. There are limited comparisons in the literature of the advanced MR imaging findings of pilocytic astrocytomas versus high-grade astrocytomas. The purpose of this study was to assess the MR imaging, PWI, DWI, and MR spectroscopy characteristics of pilocytic astrocytomas compared with high-grade astrocytomas.

MATERIALS AND METHODS

Sixteen patients with pilocytic astrocytomas and 22 patients with high-grade astrocytomas (8-66 years of age; mean, 36 ± 17 years) were evaluated by using a 1.5T MR imaging unit. MR imaging, PWI, DWI, and MR spectroscopy were used to determine the differences between pilocytic astrocytomas and high-grade astrocytomas. The sensitivity, specificity, and the area under the receiver operating characteristic curve of all analyzed parameters at respective cutoff values were determined.

RESULTS

The relative cerebral blood volume values were significantly lower in pilocytic astrocytomas compared with the high-grade astrocytomas (1.4 ± 0.9 versus 3.3 ± 1.4; P = .0008). The ADC values were significantly higher in pilocytic astrocytomas compared with high-grade astrocytomas (1.5 × 10(-3) ± 0.4 versus 1.2 × 10(-3) ± 0.3; P = .01). The lipid-lactate in tumor/creatine in tumor ratios were significantly lower in pilocytic astrocytomas compared with high-grade astrocytomas (8.3 ± 11.2 versus 43.3 ± 59.2; P = .03). The threshold values ≥1.33 for relative cerebral blood volume provide sensitivity, specificity, positive predictive values, and negative predictive values of 100%, 67%, 87%, and 100%, respectively, for differentiating high-grade astrocytomas from pilocytic astrocytomas. The optimal threshold values were ≤1.60 for ADC, ≥7.06 for lipid-lactate in tumor/creatine in tumor, and ≥2.11 for lipid-lactate in tumor/lipid-lactate in normal contralateral tissue.

CONCLUSIONS

Lower relative cerebral blood volume and higher ADC values favor a diagnosis of pilocytic astrocytoma, while higher lipid-lactate in tumor/creatine in tumor ratios plus necrosis favor a diagnosis of high-grade astrocytomas.

Effects of flutamide on [methyl-(3)h]-choline uptake in human prostate cancer-3 cells: a pilot study

BACKGROUND

Positron emission tomography using [methyl-(11)C]-choline is effective in imaging many types of cancer, especially prostate cancer (PC). The antiandrogen flutamide is often used as part of the initial treatment of PC. Data on the effect of flutamide on and methylcholine incorporation into PC-3 cells are lacking in the experimental and literature work.

OBJECTIVES

The aims of this study were to assess whether human PC-3 cells are susceptible to flutamide and whether the drug modulates the uptake of [methyl-(3)H]-choline into these cells.

METHODS

PC-3 cells were treated for 3 days with flutamide (≤100 nmol/L), inhibiting growth by 20% to 70% with control cells included. Two viability tests (cytotoxic analyses), the thiazole blue assay and the trypan blue exclusion method, were used to determine the median inhibitory concentration for flutamide (10 nmol/L). Control and flutamide-treated cells were incubated with [methyl-(3)H]-choline for 10 minutes and then in nonradioactive medium for 10 minutes to simulate the rapid blood clearance of [methyl-(11)C]-choline tracer that occurs within 5 to 20 minutes, and then extracted using organic and aqueous solvents to determine the intracellular distribution of the tracer. Protein assay and flow-cytometry analysis were used to determine protein content and DNA synthesis in both control and treated cells. The uptake of [methyl-(3)H]-choline was normalized to protein content and expressed as mean (SD) dpm/1Jg protein (n = 6).

RESULTS

PC-3 cell proliferation was inhibited with flutamide treatment. After treatment of PC-3 cells with flutamide 10 nmol/L for 3 days, cells accumulated DNA during the S phase. Mean (SD) [methyl-(3)H]-choline uptake was found to be significantly lower with flutamide 10-nmol/L-treated cells compared with control cells (65.95 [0.72] vs 114.21 [0.57] dpm/1Jg protein; P < 0.001); the difference between the 5-nmol/L-treated cells and controls was nonsignificant.

CONCLUSIONS

In this pilot study, flutamide inhibited tumor cell growth and proliferation and decreased (modulated) the uptake of [methyl-(3)H]-choline into androgen receptor-negative PC-3 cells. These results suggest that flutamide might inhibit proliferation by an androgen-independent mechanism.

Magnetic resonance spectroscopy in intracranial tumours of glial origin

BACKGROUND AND PURPOSE

To determine in vivo magnetic resonance spectroscopy (MRS) characteristics of intracranial glial tumours and to assess MRS reliability in glioma grading and discrimination between different histopathological types of tumours.

MATERIAL AND METHODS

Analysis of spectra of 26 patients with glioblastomas, 6 with fibrillary astrocytomas, 4 with anaplastic astrocytomas, 2 with pilocytic astrocytoma, 3 with oligodendrogliomas, 3 with anaplastic oligodendrogliomas and 17 control spectra taken from healthy hemispheres.

RESULTS

All tumours' metabolite ratios, except for Cho/Cr in fibrillary astrocytomas (p = 0.06), were statistically significantly different from the control. The tumours showed decreased Naa and Cr contents and a high Cho signal. The Lac-Lip signal was high in grade III astrocytomas and glioblastomas. Reports that Cho/Cr ratio increases with glioma's grade whereas Naa/Cr decreases were not confirmed. Anaplastic astrocytomas compared to grade II astrocytomas had a statistically significantly greater mI/Cr ratio (p = 0.02). In pilocytic astrocytomas the Naa/Cr value (2.58 ± 0.39) was greater, whilst the Cho/Naa ratio was lower (2.14 ± 0.64) than in the other astrocytomas. The specific feature of oligodendrogliomas was the presence of glutamate/glutamine peak Glx. However, this peak was absent in two out of three anaplastic oligodendrogliomas. Characteristically, the latter tumours had a high Lac-Lip signal.

CONCLUSIONS

MRS in vivo cannot be used as a reliable method for glioma grading. The method is useful in discrimination between WHO grade I and WHO grade II astrocytomas as well as oligodendrogliomas from other gliomas.

Lactate-modulated induction of THBS-1 activates transforming growth factor (TGF)-beta2 and migration of glioma cells in vitro

Background

An important phenomenon observed in glioma metabolism is increased aerobic glycolysis in tumor cells, which is generally referred to as the Warburg effect. Transforming growth factor (TGF)-beta2, which we previously showed to be induced by lactic acid, is a key pathophysiological factor in glioblastoma, leading to increased invasion and severe local immunosuppression after proteolytic cleavage from its latency associated peptide. In this study we tested the hypothesis, that lactate regulates TGF-beta2 expression and glioma cell migration via induction of Thrombospondin-1 (THBS-1), a TGF-beta activating protein.

Methods

Lactate levels were reduced by knockdown of LDH-A using specific small interfering RNA (siRNA) and competitive inhibition of LDH-A by sodium oxamate. Knockdown of THBS-1 was performed using specific siRNA. Western Blot, qRT-PCR, and ELISA were used to investigate expression levels of LDH-A, LDH-B, TGF-beta2 and THBS-1. Migration of cells was examined by Spheroid, Scratch and Boyden Chamber assays.

Results

Knockdown of LDH-A with subsequent decrease of lactate concentration leads to reduced levels of THBS-1 and TGF-beta2 in glioma cells. Lactate addition increases THBS-1 protein, leading to increased activation of TGF-beta2. Inhibition of THBS-1 reduces TGF-beta2 protein and migration of glioma cells. Addition of synthetic THBS-1 can rescue reduced TGF-beta2 protein levels and glioma cell migration in siLDH-A treated cells.

Conclusion

We define a regulatory cascade between lactate, THBS-1 and TGF-beta2, leading to enhanced migration of glioma cells. Our results demonstrate a specific interaction between tumor metabolism and migration and provide a better understanding of the mechanisms underlying glioma cell invasion.

Metabolic mapping of gliomas using hybrid MR-PET imaging: feasibility of the method and spatial distribution of metabolic changes

BACKGROUND AND PURPOSE

The most powerful adjunct to histopathology for the grading of gliomas seems to be the metabolic imaging using positron emission tomography and magnetic resonance spectroscopy (MRS). The purposes of this study were to examine the feasibility of simultaneous acquisition of both techniques for purposes of tumor grading in a newly launched hybrid magnetic resonance positron emission tomography (MR-PET) and to examine the spatial distributions of metabolic changes in gliomas.

MATERIALS AND METHODS

Twenty-eight consecutive patients with gliomas underwent simultaneous methionine (Met) MR-PET imaging for detection of the most malignant tumor part before surgical sampling. After coregistration and fusion of MR-PET and MRS data, tumor to normal brain (T/N) Met uptake ratios and the corresponding metabolites peaks (choline [Cho], creatine [Cr], and N-acetylaspartate [NAA]) in MRS were recorded. The patients were divided into 4 types on the basis of the relation between the Met uptake area and the increased metabolite ratios: type I, the increased Met uptake area had at least 50% overlap or was completely within the area of increased Cho/NAA ratio; type II, the increased Met uptake site had less than 50% overlap of increased Cho/NAA ratio site; type III, the increased Met uptake region had no spatial relationship with the "hot" lesions in the MRS maps; and type IV, there was no pathologically increased Met uptake. The surgical sampling was performed in the tumor part with the highest Met uptake and, in the absence of increased Met accumulation, in the site with the highest Cho/NAA ratio. All surgical samples were referred to the neuropathology division for histological grading.

RESULTS

A total of 16 low-grade gliomas (World Health Organization grade II) and 12 high-grade gliomas (World Health Organization grade III) were included. Three lesions (10%) of type I were identified. Four lesions (14%) were classified as type II and 6 lesions (21%) were classified as type 3, where the increased Met uptake region had no spatial relationship with the hot lesions in the MRS maps. In 15 of the 28 patients (54%), there was no increased Met accumulation (type 4 lesions). Maps of Cho/NAA and Cr/NAA showed a close spatial relationship in most of the patients. Median T/N Met uptake ratio in the pooled surgically sampled tumor sites was 1.6 (range, 1-3), and median Cho/NAA and Cho/Cr ratios were 2.1 (range, 0.9-5.8) and 1.5 (range, 0.5-8.3), respectively. Spearman rank correlations of the metabolic markers in the low-grade gliomas showed significant correlations between Met uptake and Cr/NAA ratio (ρ = 0.59; P = 0.015) as well as between Cho/NAA and Cr/NAA ratios (ρ = 0.79; P = 0.0002). The normalized tumor creatine was significantly higher in anaplastic tumors compared with the low-grade gliomas (P = 0.001). A tendency for a significant positive correlation was found between normalized tumor creatine and Met uptake in the anaplastic tumors.

CONCLUSIONS

Metabolic mapping before histological sampling is feasible using simultaneous MR-PET imaging. High T/N Met uptake ratio reflecting high expression of amino-acid membrane transporters, which is indicative of proliferating tumor cell populations, does not always spatially correlate with neuronal cell loss and cell membrane proliferation (Cho/NAA) seen in MRS. Increased Cr/NAA is associated with increased methionine uptake in low-grade gliomas, whereas normalized creatine in tumor tends to correlate with methionine accumulation, which indicates a possible coupling of these metabolic indices in anaplastic tumors. Thus, spatial distribution differences in gliomas should be taken into account when planning surgical sampling.

Pediatric brain tumors

Pediatric brain tumors are the most common solid tumor of childhood. This article focuses on the metabolic signature of common pediatric brain tumors using MR spectroscopic analyses.

Noninvasive photoacoustic computed tomography of mouse brain metabolism in vivo

We have demonstrated the feasibility of imaging mouse brain metabolism using photoacoustic computed tomography (PACT), a fast, noninvasive and functional imaging modality with optical contrast and acoustic resolution. Brain responses to forepaw stimulations were imaged transdermally and transcranially. 2-NBDG, which diffuses well across the blood-brain-barrier, provided exogenous contrast for photoacoustic imaging of glucose response. Concurrently, hemoglobin provided endogenous contrast for photoacoustic imaging of hemodynamic response. Glucose and hemodynamic responses were quantitatively decoupled by using two-wavelength measurements. We found that glucose uptake and blood perfusion around the somatosensory region of the contralateral hemisphere were both increased by stimulations, indicating elevated neuron activity. While the glucose response area was more homogenous and confined within the somatosensory region, the hemodynamic response area had a clear vascular pattern and spread wider than the somatosensory region. Our results demonstrate that 2-NBDG-enhanced PACT is a promising tool for noninvasive studies of brain metabolism.

A rare case of gliomatosis cerebri presenting as dementia

Dementia with the onset before the age of 65 years is classified as early-onset dementia. Although uncommon, it has considerable impact on the lives of patients and care givers, alike. A substantial subset of patients may have underlying reversible causes. Yet, many, especially those of the very young may be initially misdiagnosed. A case of young woman with rapid mental decay is described here. She was finally diagnosed with gliomatosis cerebri (GC) involving only right frontal lobe. This atypical radiological feature of GC with primary presentation as memory loss needs special attention and clinicians should be aware of such conditions.

Multimodal assessment of early tumor response to chemotherapy: comparison between diffusion-weighted MRI, 1H-MR spectroscopy of choline and USPIO particles targeted at cell death

The aim of this study was to determine the value of different magnetic resonance (MR) protocols to assess early tumor response to chemotherapy. We used a murine tumor model (TLT) presenting different degrees of response to three different cytotoxic agents. As shown in survival curves, cyclophosphamide (CP) was the most efficient drug followed by 5-fluorouracil (5-FU), whereas the etoposide treatment had little impact on TLT tumors. Three different MR protocols were used at 9.4 Tesla 24 h post-treatment: diffusion-weighted (DW)-MRI, choline measurement by (1) H MRS, and contrast-enhanced MRI using ultrasmall iron oxide nanoparticles (USPIO) targeted at phosphatidylserine. Accumulation of contrast agent in apoptotic tumors was monitored by T(2) -weighted images and quantified by EPR spectroscopy. Necrosis and apoptosis were assessed by histology. Large variations were observed in the measurement of choline peak areas and could not be directly correlated to tumor response. Although the targeted USPIO particles were able to significantly differentiate between the efficiency of each cytotoxic agent and best correlated with survival endpoint, they present the main disadvantage of non-specific tumor accumulation, which could be problematic when transferring the method to the clinic. DW-MRI presents a better compromise by combining longitudinal studies with a high dynamic range; however, DW-MRI was unable to show any significant effect for 5-FU. This study illustrates the need for multimodal imaging in assessing tumor response to treatment to compensate for individual limitations.

High-Grade Cerebral Glioma Characterization: Usefulness of MR Spectroscopy and Perfusion Imaging Associated Evaluation

The aim of our study was to evaluate if both spectroscopy and perfusion magnetic resonance (MR) imaging are necessary to differentiate high grade gliomas from low grade tumour, or if only one of these techniques is sufficient. Sixty-five patients with cerebral glioma were retrospectively evaluated. All patients were studied both with spectroscopy and perfusion imaging. In 43 cases histological examination showed a high grade glioma while a low grade glioma was found in 22 patients. For every patient spectroscopic maximum Cho/NAA ratio and lactate presence was established maximum relative CBV value was evaluated by perfusion MR. Both for Cho/NAA and rCBV threshold values were obtained by means of ROC curves. Then diagnostic sensitivity and specificity for high grade gliomas identification was evaluated for spectroscopic data only (Cho/NAA and lactate presence that was considered a high grade glioma marker), for perfusional data only (rCBV) and finally for both spectroscopic and perfusional data together. Sensitivity was significantly highest evaluating both spectroscopic and perfusional data together (89.7%) in comparison with spectroscopy (74.4%) or perfusion (79.4%) alone. Instead specificity was slightly lower with all data (91.7%) in comparison with spectroscopy (95.8%) and perfusion (95.8%) alone. In conclusion, to characterize high grade gliomas it is more useful to evaluate spectroscopic and perfusional data together with respect only one of these techniques alone.

Neuroimaging in cluster headache and other trigeminal autonomic cephalalgias

The central nervous system mechanisms involved in trigeminal autonomic cephalalgias, a group of primary headaches characterized by strictly unilateral head pain that occurs in association with ipsilateral craniofacial autonomic features, are still not comprehensively understood. However, functional imaging methods have revolutionized our understanding of mechanisms involved in these primary headache syndromes. The present review provides a brief overview of the major modern functional neuroimaging techniques used to examine brain structure, biochemistry, metabolic state, and functional capacity. The available functional neuroimaging data in cluster headache and other TACs will thus be summarized. Although the precise brain structures responsible for these primary headache syndromes still remain to be determined, neuroimaging data suggest a major role for posterior hypothalamus activation in initiating and maintaining attacks. Furthermore, pathophysiological involvement of the pain neuromatrix and of the central descending opiatergic pain control system was observed. Given the rapid advances in functional and structural neuroimaging methodologies, it can be expected that these non-invasive techniques will continue to improve our understanding into the nature of the brain dysfunction in cluster headache and other trigeminal autonomic cephalalgias.

[Multimodal magnetic resonance imaging of brain tumors]

Magnetic resonance imaging arose as a reference for diagnosis, pre-therapeutic and follow-up of brain tumors. Among parameters obtained from standard MRI (of low specificity), only volumetric growth allows prognostic information. The multiple "advanced" sequences have leaded to increase both sensitivity and specificity of brain MRI. Yet, perfusion-weighted imaging and spectroscopy provide metabolic information, and diffusion tensor imaging and cortical activation provide functional information. Characterization, grading, therapeutic management and follow-up have improved, with prognostic information.

MR spectroscopy using normalized and non-normalized metabolite ratios for differentiating recurrent brain tumor from radiation injury

RATIONALE AND OBJECTIVES

To compare the ability of normalized versus non-normalized metabolite ratios to differentiate recurrent brain tumor from radiation injury using magnetic resonance spectroscopy (MRS) in previously treated patients.

MATERIALS AND METHODS

Twenty-five patients with previous diagnosis of primary intracranial neoplasm confirmed with biopsy/resection, previously treated with radiation therapy (range, 54-70 Gy) with or without chemotherapy and new contrast enhancing lesion on a 1.5 T magnetic resonance imaging at the site of the primary neoplasm participated in this retrospective study. After MRS, clinical, radiological, and histopathology data were used to classify new contrast-enhancing lesions as either recurrent neoplasm or radiation injury. Volume of interest included both the lesion and normal-appearing brain on the contralateral side. Non-normalized metabolic ratios were calculated from choline (Cho), creatine (Cr), and N-acetylaspartate (NAA) spectroscopic values obtained within the contrast-enhancing lesion: Cho/Cr, NAA/Cr, and Cho/NAA. Normalized ratios were calculated using the metabolic values from the contralateral normal side: Cho/normal creatinine (nCr), Cho/normal N-acetylaspartate (nNAA), Cho/normal choline, NAA/nNAA, NAA/nCr, and Cr/nCr. Results were correlated with the final diagnosis by Wilcoxon rank-sum analysis.

RESULTS

Two of three non-normalized ratios, Cho/NAA (sensitivity 86%, specificity 90%) and NAA/Cr (sensitivity 93%, specificity 70%) significantly associated with tumor recurrence even after correcting for multiple comparisons. Of the six normalized ratios, only Cho/nNAA significantly correlated with tumor recurrence (sensitivity 73%, specificity 40%), but did not remain significant after correcting for multiple comparisons.

CONCLUSION

Cho/NAA and NAA/Cr were the two ratios with the best discriminating ability and both had better discriminating ability than their corresponding normalized ratios (Area under the curve = 0.92 versus 0.77, AUC= 0.85 vs. 0.66), respectively.

Assessment of therapeutic response and treatment planning for brain tumors using metabolic and physiological MRI

MRI is routinely used for diagnosis, treatment planning and assessment of response to therapy for patients with glioma. Gliomas are spatially heterogeneous and infiltrative lesions that are quite variable in terms of their response to therapy. Patients classified as having low-grade histology have a median overall survival of 7 years or more, but need to be monitored carefully to make sure that their tumor does not upgrade to a more malignant phenotype. Patients with the most aggressive grade IV histology have a median overall survival of 12-15 months and often undergo multiple surgeries and adjuvant therapies in an attempt to control their disease. Despite improvements in the spatial resolution and sensitivity of anatomic images, there remain considerable ambiguities in the interpretation of changes in the size of the gadolinium-enhancing lesion on T(1) -weighted images as a measure of treatment response, and in differentiating between treatment effects and infiltrating tumor within the larger T(2) lesion. The planning of focal therapies, such as surgery, radiation and targeted drug delivery, as well as a more reliable assessment of the response to therapy, would benefit considerably from the integration of metabolic and physiological imaging techniques into routine clinical MR examinations. Advanced methods that have been shown to provide valuable data for patients with glioma are diffusion, perfusion and spectroscopic imaging. Multiparametric examinations that include the acquisition of such data are able to assess tumor cellularity, hypoxia, disruption of normal tissue architecture, changes in vascular density and vessel permeability, in addition to the standard measures of changes in the volume of enhancing and nonenhancing anatomic lesions. This is particularly critical for the interpretation of the results of Phase I and Phase II clinical trials of novel therapies, which are increasingly including agents that are designed to have anti-angiogenic and anti-proliferative properties as opposed to having a direct effect on tumor cell viability.

Tumor metabolism of lactate: the influence and therapeutic potential for MCT and CD147 regulation

Tumor metabolism consists of complex interactions between oxygenation states, metabolites, ions, the vascular network and signaling cascades. Accumulation of lactate within tumors has been correlated with poor clinical outcomes. While its production has negative implications, potentially contributing to tumor progression, the implications of the ability of tumors to utilize lactate can offer new therapeutic targets for the future. Monocarboxylate transporters (MCTs) of the SLC16A gene family influence substrate availability, the metabolic path of lactate and pH balance within the tumor. CD147, a chaperone to some MCT subtypes, contributes to tumor progression and metastasis. The implications and consequences of lactate utilization by tumors are currently unknown; therefore future research is needed on the intricacies of tumor metabolism. The possibility of metabolic modification of the tumor microenvironment via regulation or manipulation of MCT1 and CD147 may prove to be promising avenues of therapeutic options.

Proton MRS detects metabolic changes in hormone sensitive and resistant human prostate cancer models CWR22 and CWR22r

17-Allylamino, 17-demethoxygeldanamycin (17-AAG), an effective inhibitor of the heat shock protein hsp90, preferentially inhibiting tumor hsp90 compared to hsp90 from normal cells, has shown promising results against several cancers, including hormone-resistant prostate cancer. Levels of several oncogenic proteins critical to tumor growth and progression, such as androgen receptor and HER2/neu, were reduced 4 h post 17-allylamino, 17-demethoxygeldanamycin treatment. Posttreatment metabolic changes have also been observed in several tumor cell lines. In this study, total choline distributions in hormone sensitive CWR22 and hormone resistant CWR22r prostate cancer xenograft tumors in mice were measured before and at 4 h and 48 h after a single-bolus 17-allylamino, 17-demethoxygeldanamycin treatment at 100 mg/kg, using proton MR spectroscopy. Our results show that tumor total choline levels declined 4 h after the treatment for CWR22 (P = 0.001) and 48 h post treatment for CWR22r (P = 0.003). Metabolic changes, in particular of total choline intensity detected by proton magnetic resonance spectroscopic imaging (MRSI), are consistent with the observed immunohistochemistry changes, tumor growth inhibition for CWR22r (P = 0.01 at 14 days post treatment), and a constant prostate specific antigen level versus increasing prostate specific antigen for control CWR22 (P = 0.01). Metabolic changes in total choline by proton MRSI can be used as an early biomarker of response for advanced-stage prostate cancer in targeted therapy such as 17-allylamino, 17-demethoxygeldanamycin.

The potential of proton beam radiation therapy in intracranial and ocular tumours

A group of oncologists and hospital physicists have estimated the number of patients in Sweden suitable for proton beam therapy. The estimations have been based on current statistics of tumour incidence, number of patients potentially eligible for radiation treatment, scientific support from clinical trials and model dose planning studies and knowledge of the dose-response relations of different tumours and normal tissues. In intracranial benign and malignant tumours, it is estimated that between 130 and 180 patients each year are candidates for proton beam therapy. Of these, between 50 and 75 patients have malignant glioma, 30-40 meningeoma, 20-25 arteriovenous malformations, 20-25 skull base tumours and 10-15 pituitary adenoma. In addition, 15 patients with ocular melanoma are candidates.

Design of cosine modulated very selective suppression pulses for MR spectroscopic imaging at 3T

The advantages of using a 3 Tesla (T) scanner for MR spectroscopic imaging (MRSI) of brain tissue include improved spectral resolution and increased sensitivity. Very selective saturation (VSS) pulses are important for maximizing selectivity for PRESS MRSI and minimizing chemical shift misregistration by saturating signals from outside the selected region. Although three-dimensional (3D) PRESS MRSI is able to provide excellent quality metabolic data for patients with brain tumors and has been shown to be important for defining tumor burden, the method is currently limited by how much of the anatomic lesion can be covered within a single examination. In this study we designed and implemented cosine modulated VSS pulses that were optimized for 3T MRSI acquisitions. This provided improved coverage and suppression of unwanted lipid signals with a smaller number of pulses. The use of the improved pulse sequence was validated in volunteer studies, and in clinical 3D MRSI exams of brain tumors.

A case of unilateral thalamic hemorrhagic infarction as a result of the vein of Galen and straight sinus thrombosis

Straight sinus vein thrombosis represents 15% of all diagnosed sinus vein thrombosis. Thrombotic occlusion of the deep cerebral venous system, the straight sinus, and the vein of Galen causes centrally located and usually bilateral thalamic infarcts. Unilateral thalamic venous infarction is extremely rare. The clinical and radiologic findings can be nonspecific and diagnostically challenging. We report a patient with this unusual condition and review the available literature.