Use of FDG PET/CT in identification of bone marrow involvement in diffuse large B cell lymphoma and follicular lymphoma: comparison with iliac crest bone marrow biopsy.

Background Non-Hodgkin's lymphoma (NHL) accounts for around 4% of new cancer cases annually. Bone marrow involvement is important for staging and management. Fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) is used increasingly to identify this, in addition to bone marrow biopsy (BMB), which is seen as "gold" reference standard. Purpose To compare determination of bone marrow involvement by FDG PET/CT against BMB in diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma (FL). Material and Methods This was a retrospective study of patients with histologically confirmed NHL at a single UK cancer center undergoing pre-treatment FDG PET/CT and BMB between June 2010 and February 2013. Information was collected from patient notes, cancer registry, histological and imaging reports. Diagnostic accuracy of FDG PET/CT was determined, compared to BMB as the reference standard. Results Twenty-four patients with DLBCL and 12 with FL were included. Five DLBCL patients had bone marrow involvement on PET/CT; all were confirmed on BMB. Three FL patients had marrow involvement on PET/CT but not on BMB; one FL patient had positive BMB but negative PET/CT. Using BMB as the reference standard, the sensitivity and specificity of FDG PET/CT for detecting bone marrow involvement in DLBCL were 100% and 100%, respectively, and in FL were 0% and 72.7%, respectively. Conclusion FDG PET/CT is accurate for detection of bone marrow involvement in newly diagnosed DLBCL, but not FL. In DLBCL, positive FDG PET/CT may negate the need for routine BMB, although BMB in addition or combination may be appropriate if this would influence management or prognosis.

Endovaginal magnetic resonance imaging of stage 1A/1B cervical cancer with A T2- and diffusion-weighted magnetic resonance technique: effect of lesion size and previous cone biopsy on tumor detectability.

OBJECTIVE: To evaluate the effects of previous cone biopsy and lesion size on detectability of stage 1a/1b cervical cancer using endovaginal T2- and diffusion-weighted magnetic resonance imaging. METHODS: One hundred and thirteen patients with cervical tumor were imaged using an endovaginal coil with T2-weighted (T2-W) and diffusion-weighted single-shot echo-planar sequences; 85 managed surgically (58 with prior cone biopsy/LLETZ) were evaluated. T2-W images and ADC maps viewed simultaneously were scored positive or negative for tumor and compared with histology at surgery. MRI tumor volumes, maximum radiological and histological dimensions were recorded. ROC analysis determined the MRI volume with optimal sensitivity/specificity for identifying tumor in those without and with prior cone biopsy/LLETZ and the maximum histological dimension for correctly identifying tumor with MRI. Mean apparent diffusion coefficients (ADCs) from tumor and adjacent normal epithelium were compared. RESULTS: Sensitivity and specificity for detecting tumor in those without (100%; 100% respectively) and with (80%; 78.9% respectively) prior cone biopsy/LLETZ were significantly different (p<0.001). Following cone biopsy/LLETZ, MRI tumor volume of 83 mm3 detected tumor with 80% sensitivity, 94.7% specificity; a 5.3mm maximal histological dimension was detected on MRI with 100% sensitivity, 100% specificity. Tumor ADCs were significantly lower (p<0.001) than paired normal epithelial tissue (median, 988×10(-6) mm2/s vs. 1564×10(-6) mm2/s) but neither tumor nor epithelial ADCs differed significantly between patients with or without prior cone biopsy/LLETZ (p=0.48 and 0.15, respectively). CONCLUSIONS: Endovaginal MRI with T2- and diffusion-weighted sequences has significantly lower sensitivity and specificity for tumor detection following cone biopsy/LLETZ.

Diffusion-weighted imaging in cervical cancer with an endovaginal technique: potential value for improving tumor detection in stage Ia and Ib1 disease.

PURPOSE: To establish apparent diffusion coefficients (ADCs) of invasive cervical carcinoma compared with nontumor cervical epithelium and determine sensitivity and specificity of diffusion-weighted (DW) magnetic resonance (MR) imaging used in conjunction with T2-weighted MR imaging to help detect invasive cervical carcinoma in patients with stage Ia and Ib1 disease. MATERIALS AND METHODS: Local research ethics committee approval was obtained with written consent from each subject. Group 1 comprised patients (mean age, 38.7 years +/- 13.2 [standard deviation]) with histologically confirmed cervical intraepithelial neoplasia (CIN) found on smear (n = 20) or stage Ib1 cervical tumors (n = 18). Patients were imaged with endovaginal T2-weighted fast spin-echo and single-shot DW echo-planar MR imaging of the cervix. ADCs from invasive cervical carcinoma and nontumor regions were compared within (t test) and between (U test) patients. A derived threshold ADC level indicative of invasive cervical carcinoma was used with T2-weighted imaging by two independent observers to identify possible invasive cervical carcinoma in group 2, patients with suspected disease (n = 21; mean age, 42.0 years +/- 16.4). Surgical specimens were the reference standard. Interobserver agreement was assessed. RESULTS: In group 1, ADCs from cervical carcinoma (757 x 10(-6) mm(2)/sec +/- 110) and adjacent epithelium (1331 x 10(-6) mm(2)/sec +/- 159) or CIN (1291 x 10(-6) mm(2)/sec +/- 156) were significantly different (P < .0001). In group 2, respective sensitivity and specificity to help detect invasive cervical carcinoma on T2-weighted images were 55.6% and 75% for observer 1 and 66.7% and 41.7% for observer 2, and 88.9% and 66.7% for observer 1 and 77.8% and 58.3% for observer 2 when ADC maps with a threshold level of 1100 x 10(-6) mm(2)/sec were added. Interobserver agreement was fair (kappa = 0.37) for T2-weighted images alone and good (kappa = 0.80) with ADC included. CONCLUSION: ADCs from invasive cervical carcinoma are significantly lower than those from nontumor epithelium; good interobserver agreement by using T2-weighted and DW MR imaging makes this technique potentially useful to help detect early-stage disease.

A quality-control method for SPECT-based dosimetry in targeted radionuclide therapy.

Dosimetry for targeted radionuclide therapy is necessary for treatment planning and radiation protection. Currently, there are no standard methods either for performing dosimetry or to evaluate the uncertainties inherent in the dosimetric calculations. In this paper, we present an experimental method using polymer gel dosimeters, whereby absorbed-dose distributions resulting from nonuniform distributions of activity may be determined directly from T(2) magnetic resonance imaging (MRI) as well as from scintigraphic images. A phantom containing a nonuniform distribution of I-131 was prepared by mixing 58 MBq of activity within the gel as it was solidifying. The resulting absorbed-dose distribution was determined directly from the MRI and from sequential single-photon emission computed tomography (SPECT) images using the Medical Internal Radiation Dose (MIRD) schema. The MRI data were quantified using 12 calibration vials uniformly irradiated by 0-12 MBq of I-131. The agreement between the two absorbed-dose maps was verified by convolving the MRI-based absorbed-dose map with the SPECT system point spread function, which gave a correlation coefficient of 0.96. It was seen that the absorbed-dose distribution, as imaged by the MRI, was misrepresented by the SPECT owing to its relatively poor spatial resolution, which included a shift of the voxel containing the maximum absorbed dose. This technique could provide an independent benchmark for assessing patient-specific dosimetry and, therefore, could be used as a basis for quality control for dosimetry.

A complete distortion correction for MR images: II. Rectification of static-field inhomogeneities by similarity-based profile mapping.

Radiotherapy treatment planning relies on the use of geometrically correct images. This paper presents a fully automatic tool for correcting MR images for the effects of B(0) inhomogeneities. The post-processing method is based on the gradient-reversal technique of Chang and Fitzpatrick (1992 IEEE Trans. Med. Imaging 11 319-29) which combines two identical images acquired with a forward- and a reversed read gradient. This paper demonstrates how maximization of mutual information for registration of forward and reverse read gradient images allows the elimination of user interaction for the correction. Image quality is preserved to a degree not reported previously.

An exploratory study into the role of dynamic contrast-enhanced magnetic resonance imaging or perfusion computed tomography for detection of intratumoral hypoxia in head-and-neck cancer.

PURPOSE: Hypoxia in patients with head-and-neck cancer (HNC) is well established and known to cause radiation resistance and treatment failure in the management of HNC. This study examines the role of parameters derived from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and perfusion computed tomography (CT) as surrogate markers of intratumoral hypoxia, defined by using the exogenous marker of hypoxia pimonidazole and the endogenous marker carbonic anhydrase 9 (CA9). METHODS AND MATERIALS: Patients with HNC underwent preoperative DCE-MRI, perfusion CT, and pimonidazole infusion. Imaging parameters were correlated with pimonidazole and CA9 staining. The strength of correlations was tested by using a two-tailed Spearman's rank correlation coefficient. RESULTS: Twenty-three regions of interest were analyzed from the 7 patients who completed the DCE-MRI studies. A number of statistically significant correlations were seen between DCE-MRI parameters (volume transfer between blood plasma and extracellular extravascular space [EES], volume of EES, rate constant between EES and blood plasma, time at arrival of contrast inflow, time to peak, average gradient, and time to onset) and areas with a pimonidazole score of 4. In the case of CA9 staining, only a weak correlation was shown with wash-in rate. There were no significant correlations between perfusion CT parameters and pimonidazole staining or CA9 expression. CONCLUSION: Intratumoral hypoxia in patients with HNC may be predicted by using DCE-MRI; however, perfusion CT requires further investigation.

Diffusion-weighted magnetic resonance imaging and its application to cancer.

Diffusion-weighted magnetic resonance imaging (DW-MRI) provides image contrast through measurement of the diffusion properties of water within tissues. Application of diffusion sensitising gradients to the MR pulse sequence allows water molecular displacement over distances of 1-20 microm to be recognised. Diffusion can be predominantly unidirectional (anisotropic) or not (isotropic). Combining images obtained with different amounts of diffusion weighting provides an apparent diffusion coefficient (ADC) map. In cancer imaging DW-MRI has been used to distinguish brain tumours from peritumoural oedema. It is also increasingly exploited to differentiate benign and malignant lesions in liver, breast and prostate where increased cellularity of malignant lesions restricts water motion in a reduced extracellular space. It is proving valuable in monitoring treatment where changes due to cell swelling and apoptosis are measurable as changes in ADC at an earlier stage than subsequent conventional radiological response indicators.