Intravoxel incoherent motion diffusion-weighted imaging of resectable oesophageal squamous cell carcinoma: association with tumour stage

Intravoxel incoherent motion diffusion-weighted imaging in evaluating preoperative staging of esophageal squamous cell carcinoma : Evaluation of preoperative stage of primary tumour and prediction of lymph node metastases from esophageal cancer using IVIM: a prospective study

BACKGROUND

The aim of this research is to prospectively investigate the diagnostic performance of intravoxel incoherent motion (IVIM) using the integrated slice-specific dynamic shimming (iShim) technique in staging primary esophageal squamous cell carcinoma (ESCC) and predicting presence of lymph node metastases from ESCC.

METHODS

Sixty-three patients with ESCC were prospectively enrolled from April 2016 to April 2019. MR and IVIM using iShim technique (b = 0, 25, 50, 75, 100, 200, 400, 600, 800 s/mm2) were performed on 3.0T MRI system before operation. Primary tumour apparent diffusion coefficient (ADC) and IVIM parameters, including true diffusion coefficient (D), pseudodiffusion coefficient (D*), pseudodiffusion fraction (f) were measured by two independent radiologists. The differences in D, D*, f and ADC values of different T and N stages were assessed. Intraclass correlation coefficients (ICCs) were calculated to evaluate the interobserver agreement between two readers. The diagnostic performances of D, D*, f and ADC values in primary tumour staging and prediction of lymph node metastasis of ESCC were determined using receiver operating characteristic (ROC) curve analysis.

RESULTS

The inter-observer consensus was excellent for IVIM parameters and ADC (D: ICC = 0.922; D*: ICC = 0.892; f: ICC = 0.948; ADC: ICC = 0.958). The ADC, D, D* and f values of group T1 + T2 were significantly higher than those of group T3 + T4a [ADC: (2.55 ± 0.43) ×10- 3 mm2/s vs. (2.27 ± 0.40) ×10- 3 mm2/s, t = 2.670, P = 0.010; D: (1.82 ± 0.39) ×10- 3 mm2/s vs. (1.53 ± 0.33) ×10- 3 mm2/s, t = 3.189, P = 0.002; D*: 46.45 (30.30,55.53) ×10- 3 mm2/s vs. 32.30 (18.60,40.95) ×10- 3 mm2/s, z=-2.408, P = 0.016; f: 0.45 ± 0.12 vs. 0.37 ± 0.12, t = 2.538, P = 0.014]. The ADC, D and f values of the lymph nodes-positive (N+) group were significantly lower than those of lymph nodes-negative (N0) group [ADC: (2.10 ± 0.33) ×10- 3 mm2/s vs. (2.55 ± 0.40) ×10- 3 mm2/s, t=-4.564, P < 0.001; D: (1.44 ± 0.30) ×10- 3 mm2/s vs. (1.78 ± 0.37) ×10- 3 mm2/s, t=-3.726, P < 0.001; f: 0.32 ± 0.10 vs. 0.45 ± 0.11, t=-4.524, P < 0.001]. The combination of D, D* and f yielded the highest area under the curve (AUC) (0.814) in distinguishing group T1 + T2 from group T3 + T4a. D combined with f provided the highest diagnostic performance (AUC = 0.849) in identifying group N + and group N0 of ESCC.

CONCLUSIONS

IVIM may be used as an effective functional imaging technique to evaluate preoperative stage of primary tumour and predict presence of lymph node metastases from ESCC.

Application of DKI and IVIM imaging in evaluating histologic grades and clinical stages of clear cell renal cell carcinoma

Purpose

To evaluate the value of quantitative parameters derived from diffusion kurtosis imaging (DKI) and intravoxel incoherent motion (IVIM) in differentiating histologic grades and clinical stages of clear cell renal cell carcinoma (ccRCC).

Materials and methods

A total of 65 patients who were surgically and pathologically diagnosed as ccRCC were recruited in this study. In addition to routine renal magnetic resonance imaging examination, all patients underwent preoperative IVIM and DKI. The corresponding diffusion coefficient (D), pseudo-diffusion coefficient (D*), perfusion fraction (f), mean diffusivity (MD), kurtosis anisotropy (KA), and mean kurtosis (MK) values were obtained. Independent-samples t-test or Mann-Whitney U test was used for comparing the differences in IVIM and DKI parameters among different histologic grades and clinical stages. The diagnostic efficacy of IVIM and DKI parameters was evaluated using the receiver operating characteristic (ROC) curve. Spearman's correlation analysis was used to separately analyze the correlation of each parameter with histologic grades and stages of ccRCC.

Results

The D and MD values were significantly higher in low-grade ccRCC than high-grade ccRCC (all p < 0.001) and in low-stage than high-stage ccRCC (all p < 0.05), and the f value of high-stage ccRCC was lower than that of low-stage ccRCC (p = 0.007). The KA and MK values were significantly higher in low-grade than high-grade ccRCC (p = 0.000 and 0.000, respectively) and in low-stage than high-stage ccRCC (p = 0.000 and 0.000, respectively). The area under the curve (AUC) values of D, D*, f, MD, KA, MK, DKI, and IVIM+DKI values were 0.825, 0.598, 0.626, 0.792, 0.750, 0.754, 0.803, and 0.857, respectively, in grading ccRCC and 0.837, 0.719, 0.710, 0.787, 0.796, 0.784, 0.864, 0.823, and 0.916, respectively, in staging ccRCC. The AUC of IVIM was 0.913 in staging ccRCC. The D, D*, and MD values were negatively correlated with the histologic grades and clinical stages (all p < 0.05), and the KA and MK values showed a positive correlation with histologic grades and clinical stages (all p < 0.05). The f value was also negatively correlated with the ccRCC clinical stage (p = 0.008).

Conclusion

Both the IVIM and DKI values can be used preoperatively to predict the degree of histologic grades and stages in ccRCC, and the D and MD values have better diagnostic performance in the grading and staging. Also, further slightly enhanced diagnostic efficacy was observed in the model with combined IVIM and DKI parameters.

The value of intravoxel incoherent motion model-based diffusion-weighted imaging for predicting long-term outcomes in nasopharyngeal carcinoma

Objective

The aim of this study was to evaluate the prognostic value for survival of parameters derived from intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI) in patients with nasopharyngeal carcinoma (NPC).

Materials

Baseline IVIM-DWI was performed on 97 newly diagnosed NPC patients in this prospective study. The relationships between the pretreatment IVIM-DWI parametric values (apparent diffusion coefficient (ADC), D, D*, and f) of the primary tumors and the patients’ 3-year survival were analyzed in 97 NPC patients who received chemoradiotherapy. The cutoff values of IVIM parameters for local relapse-free survival (LRFS) were identified by a non-parametric log-rank test. The local-regional relapse-free survival (LRRFS), LRFS, regional relapse-free survival (RRFS), distant metastasis-free survival (DMFS), progression-free survival (PFS), and overall survival (OS) rates were calculated by using the Kaplan–Meier method. A Cox proportional hazards model was used to explore the independent predictors for prognosis.

Results

There were 97 participants (mean age, 48.4 ± 10.5 years; 65 men) analyzed. Non-parametric log-rank test results showed that the optimal cutoff values of ADC, D, D*, and f were 0.897 × 10−3 mm2/s, 0.699 × 10−3 mm2/s, 8.71 × 10−3 mm2/s, and 0.198%, respectively. According to the univariable analysis, the higher ADC group demonstrated significantly higher OS rates than the low ADC group (p = 0.036), the higher D group showed significantly higher LRFS and OS rates than the low D group (p = 0.028 and p = 0.017, respectively), and the higher D* group exhibited significantly higher LRFS and OS rates than the lower D* group (p = 0.001 and p = 0.002, respectively). Multivariable analyses indicated that ADC and D were the independent prognostic factors for LRFS (p = 0.041 and p = 0.037, respectively), D was an independent prognostic factor for LRRFS (p = 0.045), D* and f were the independent prognostic factors for OS (p = 0.019 and 0.029, respectively), and f acted was an independent prognostic factor for DMFS (p = 0.020).

Conclusions

Baseline IVIM-DWI perfusion parameters ADC and D, together with diffusion parameter D*, could act as useful factors for predicting long-term outcomes and selecting high-risk patients with NPC.

Predicting Grade of Esophageal Squamous Carcinoma: Can Stretched Exponential Model-Based DWI Perform Better Than Bi-Exponential and Mono-Exponential Model?

Background

To evaluate and compare the potential performance of various diffusion parameters obtained from mono-exponential model (MEM)-, bi-exponential model (BEM)-, and stretched exponential model (SEM)-based diffusion-weighted imaging (DWI) in grading of esophageal squamous carcinoma (ESC).

Methods

Eighty-two patients with pathologically confirmed ESC without treatment underwent multi-b-value DWI scan with 13 b values (0~12,00 s/mm²). The apparent diffusion coefficient (ADC) deriving from the MEM; the pure molecular diffusion (ADC_slow), pseudo-diffusion coefficient (ADC_fast), perfusion, and fraction (f) deriving from the BEM; and the distributed diffusion coefficient (DDC) and water molecular diffusion heterogeneity index (α) deriving from the SEM were calculated and compared between poorly differentiated and well/moderately differentiated ESC, respectively. The prediction parameters and diagnostic efficiency were compared by drawing receiver operating characteristic (ROC) curves.

Results

The ADC, ADC_slow, ADC_fast, and DDC in poorly ESC were significantly lower than those in well/moderately differentiated ones. By using only one parameter, ADC_slow, DDC had the moderate diagnostic efficiency and the areas under the curve (AUC) were 0.758 and 0.813 in differentiating ESC. The DDC had the maximum AUC with sensitivity (88.00%) and specificity (68.42%). Combining ADC with ADC_fast, ADC_slow, and DDC and combining ADC_slow with ADC_fast can provide a higher diagnostic accuracy with AUC ranging from 0.756, 0.771, 0.816, and 0.793, respectively.

Conclusion

Various parameters derived from different DWI models including MEM, BEM, and SEM were potentially helpful in grading ESC. DDC obtained from SEM was the most promising diffusion parameter for predicting the grade of ESC.

Intravoxel Incoherent Motion Model in Differentiating the Pathological Grades of Esophageal Carcinoma: Comparison of Mono-Exponential and Bi-Exponential Fit Model

PURPOSE

To compare the diagnostic efficiency of the mono-exponential model and bi-exponential model deriving from intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI) in differentiating the pathological grade of esophageal squamous cell carcinoma (ESCC).

METHODS

Fifty-four patients with ESCC were divided into three groups of poorly-differentiated (PD), moderately-differentiated (MD), and well-differentiated (WD), and underwent the IVIM-DWI scan. Mono-exponential (Dmono, D*mono, and fmono) and bi-exponential fit parameters (Dbi, D*bi, and fbi) were calculated using the IVIM data for the tumors. Mean parameter values of three groups were compared using a one-way ANOVA followed by post hoc tests. The receiver operating characteristic curve was drawn for differentiating pathological grade of ESCC. Correlations between pathological grades and IVIM parameters were analyzed.

RESULTS

There were significant differences in fmono and fbi among the PD, MD and WD ESCC groups (all p<0.05). The fmono were 0.32 ± 0.07, 0.23 ± 0.08, and 0.16 ± 0.05, respectively, and the fbi were 0.35 ± 0.08, 0.26 ± 0.10, and 0.18 ± 0.07, respectively. There was a significant difference in the Dmono between the WD and the PD group (1.48 ± 0.51* 10-3 mm2/s versus 1.05 ± 0.44*10-3 mm2/s, p<0.05), but there was no significant difference between the WD and MD groups, MD and PD groups (all p>0.05). The D*mono, Dbi, and D*bi showed no significant difference among the three groups (all p>0.05). The area under the curve (AUC) of Dmono, fmono and fbi in differentiating WD from PD ESCC were 0.764, 0.961 and 0.932, and the sensitivity and specificity were 92.9% and 60%, 92.9% and 90%, 85.7% and 100%, respectively. The AUC of fmono and fbi in differentiating MD from PD ESCC were 0.839 and 0.757, and the sensitivity and specificity were 78.6% and 80%, 85.7% and 70%, respectively. The AUC of fmono and fbi in differentiating MD from WD ESCC were 0.746 and 0.740, and the sensitivity and specificity were 65% and 85%, 80% and 60%, respectively. The pathologically differentiated grade was correlated with all IVIM parameters (all p<0.05).

CONCLUSIONS

The mono-exponential IVIM model is superior to the bi-exponential IVIM model in differentiating pathological grades of ESCC, which may be a promising imaging method to predict pathological grades of ESCC.

Diagnostic Performance of MRI for Esophageal Carcinoma: A Systematic Review and Meta-Analysis

Background Although CT, endoscopic US, and PET are critical in determining the appropriate management of esophageal carcinoma (squamous cell carcinoma and adenocarcinoma), previous reports show that staging accuracy remains low, particularly for nodal involvement sensitivity. Purpose To perform a systematic review and meta-analysis to determine the diagnostic performance of MRI for multiple staging thresholds in patients with biopsy-proven esophageal carcinoma (differentiation of stage T0 disease from stage T1 or higher disease, differentiation of stage T2 or lower disease from stage T3 or higher disease, and differentiation of stage N0 disease from stage N1 or higher disease [where T refers to tumor stage and N refers to nodal stage]). Materials and Methods Studies of the diagnostic performance of MRI in determining the stage of esophageal carcinoma in patients before esophagectomy and pathologic staging between 2000 and 2019 were searched in PubMed, Scopus, Web of Science, and Cochrane Library by a librarian and radiation oncologist. Pooled diagnostic performance of MRI was calculated with a bivariate random effects model. Bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (version 2) tool. Results Twenty studies with a total of 984 patients were included in the analysis. Pooled accuracy for stage T0 versus stage T1 or higher had a sensitivity of 92% (95% CI: 82, 96) and a specificity of 67% (95% CI: 51, 81). Pooled accuracy for stage T2 or lower versus stage T3 or higher had a sensitivity of 86% (95% CI: 76, 92) and a specificity of 86% (95% CI: 75, 93). Pooled accuracy for stage N0 versus stage N1 or higher had a sensitivity of 71% (95% CI: 60, 80) and a specificity of 72% (95% CI: 64, 79). The concern for applicability was low for the patient selection, index test, and reference test domains, except for 10% of studies (two of 20) that had unclear concern for patient selection applicability. Conclusion MRI has high sensitivity but low specificity for the detection of esophageal carcinoma, which shows promise for determining neoadjuvant therapy response and for detecting locally advanced disease for potential trimodality therapy. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Leeflang in this issue.

The application of a gamma distribution model to diffusion-weighted images of the orofacial region

OBJECTIVES

This study evaluated the correlation among the diffusion-derived parameters obtained by monoexponential (ME), intravoxel incoherent motion (IVIM) and γ distribution (GD) models and compared these parameters among representative orofacial tumours.

METHODS

Ninety-two patients who underwent 1.5 T MRI including diffusion-weighted imaging were included. The shape parameter (κ), scale parameter (θ), ratio of the intracellular diffusion (ƒ₁), extracellular diffusion (ƒ₂) and perfusion (ƒ₃) were obtained by the GD model; the true diffusion coefficient (D) and perfusion fraction (f) were obtained by the IVIM model; and the apparent diffusion coefficient (ADC) was obtained by the ME model.

RESULTS

ƒ₁ had a strongly negative correlation with the ADC (ρ = -0.993) and D (ρ = -0.926). A strong positive correlation between f and ƒ₃ (ρ = 0.709) was found. Malignant lymphoma (ML) had the highest ƒ₁, followed by squamous cell carcinoma (SCC), malignant salivary gland tumours, pleomorphic adenoma (Pleo) and angioma. Both the IVIM and GD models suggested the highest perfusion in angioma and the lowest perfusion in ML. The GD model demonstrated a high extracellular component in Pleo and revealed that the T_4a+T_4b SCC group had a lower ƒ₂ than the T₂+T₃ SCC group, and poor to moderately differentiated SCC had a higher ƒ₁ than highly differentiated SCC.

CONCLUSIONS

Given the correlation among the diffusion-derived parameters, the GD model might be a good alternative to the IVIM model. Furthermore, the GD model's parameters were useful for characterizing the pathological structure.

Differentiation of peripheral nerve sheath tumors in patients with neurofibromatosis type 1 using diffusion-weighted magnetic resonance imaging

BACKGROUND

We sought to determine the value of diffusion-weighted (DW) magnetic resonance imaging (MRI) for characterization of benign and malignant peripheral nerve sheath tumors (PNSTs) in patients with neurofibromatosis type 1 (NF1).

METHODS

Twenty-six patients with NF1 and suspicion of malignant transformation of PNSTs were prospectively enrolled and underwent DW MRI at 3T. For a set of benign (n = 55) and malignant (n = 12) PNSTs, functional MRI parameters were derived from both biexponential intravoxel incoherent motion (diffusion coefficient D and perfusion fraction f) and monoexponential data analysis (apparent diffusion coefficients [ADCs]). A panel of morphological MRI features was evaluated using T1- and T2-weighted imaging. Mann-Whitney U-test, Fisher's exact test, and receiver operating characteristic (ROC) analyses were applied to assess the diagnostic accuracy of quantitative and qualitative MRI. Cohen's kappa was used to determine interrater reliability.

RESULTS

Malignant PNSTs demonstrated significantly lower diffusivity (P < 0.0001) compared with benign PNSTs. The perfusion fraction f was significantly higher in malignant PNSTs (P < 0.001). In ROC analysis, functional MRI parameters showed high diagnostic accuracy for differentiation of PNSTs (eg, ADCmean, 92% sensitivity with 98% specificity, AUC 0.98; Dmean, 92% sensitivity with 98% specificity, AUC 0.98). By contrast, morphological imaging features had only limited sensitivity (18-94%) and specificity (18-82%) for identification of malignancy. Interrater reliability was higher for monoexponential data analysis.

CONCLUSION

DW imaging shows better diagnostic performance than morphological features and allows accurate differentiation of benign and malignant peripheral nerve sheath tumors in NF1.

Apparent diffusion coefficient values and non-homogeneity of diffusion in brain tumors in diffusion-weighted MRI

Background

The values that have been received from apparent diffusion coefficient (ADC) maps of diffusion-weighted magnetic resonance imaging (DW-MRI) might play a vital role in evaluating tumors and their grading scale.

Purpose

To investigate the predictive role of this heterogeneity in brain tumor pathologies and its correlation with Ki-67.

Material and Methods

A total of 124 patients with brain tumors underwent brain MRI with gadolinium injection. ADC and standard deviation of each lesion have been obtained from manual localization of the region of interest on the ADC map. A receiver operating characteristic analysis was conducted to determine the minimum cut-off values of the mean ADC and mean standard deviation of ADC maps having the highest sensitivity and specificity to differentiate high-grade and low-grade tumors.

Results

Mean ADC values in the region of interest were significantly lower for malignant tumors (grade IV and metastasis) than grade I brain tumors, while a higher mean standard deviation was observed. In a more detailed comparison of tumor groups, the mean standard deviation of the ADC for glioblastoma multiform was significantly higher than meningioma grade I ( P < 0.001) and metastasis was significantly higher than grade III and IV astrocytic tumors ( P = 0.004). The analysis of Ki-67 proliferation index and mean ADC values in gliomas showed a significant inverse correlation between the parameters (r = –0.0429, P < 0.001) and direct correlation between Ki-67 and mean standard deviation of the ADC (r = 0.551, P < 0.001). As an index for the ADC to differentiate high-grade and low-grade tumors, the cut-off values of 1.40*10−3 mm2/s for mean ADC and 45*10−3 mm2/s for mean standard deviation have the highest combination of sensitivity, specificity, and area under the curve.

Conclusion

The mean value and standard deviation of the ADC could be considered for differentiating between low-grade and high-grade brain tumors, as two available non-invasive methods.

Computed tomography volumetry of esophageal cancer - the role of semiautomatic assessment

Background

The clinical and research value of Computed Tomography (CT) volumetry of esophageal cancer tumor size remains controversial. Development in CT technique and image analysis has made CT volumetry less cumbersome and it has gained renewed attention. The aim of this study was to assess esophageal tumor volume by semi-automatic measurements as compared to manual.

Methods

A total of 23 esophageal cancer patients (median age 65, range 51–71), undergoing CT in the portal-venous phase for tumor staging, were retrospectively included between 2007 and 2012. One radiology resident and one consultant radiologist measured the tumor volume by semiautomatic segmentation and manual segmentation. Reproducibility of the respective measurements was assessed by intraclass correlation coefficients (ICC) and by average deviation from mean.

Results

Mean tumor volume was 46 ml (range 5-137 ml) using manual segmentation and 42 ml (range 3-111 ml) using semiautomatic segmentation. Semiautomatic measurement provided better inter-observer agreement than traditional manual segmentation. The ICC was significantly higher for semiautomatic segmentation in comparison to manual segmentation (0.86, 0.56, p < 0.01). The average absolute percentage difference from mean was reduced from 24 to 14% (p < 0.001) when using semiautomatic segmentation.

Conclusions

Semiautomatic analysis outperforms manual analysis for assessment of esophageal tumor volume, improving reproducibility.