Exploring MR regression patterns in rectal cancer during neoadjuvant radiochemotherapy with daily T2- and diffusion-weighted MRI.

BACKGROUND: To date, only limited magnetic resonance imaging (MRI) data are available concerning tumor regression during neoadjuvant radiochemotherapy (RCT) of rectal cancer patients, which is a prerequisite for adaptive radiotherapy (RT) concepts. This exploratory study prospectively evaluated daily fractional MRI during neoadjuvant treatment to analyze the predictive value of MR biomarkers for treatment response. METHODS: Locally advanced rectal cancer patients were examined with daily MRI during neoadjuvant RCT. Contouring of the tumor volume was performed for each MRI scan by using T2- and diffusion-weighted-imaging (DWI)-sequences. The daily apparent-diffusion coefficient (ADC) was calculated. Volumetric and functional tumor changes during RCT were analyzed and correlated with the pathological response after surgical resection. RESULTS: In total, 171 MRI scans of eight patients were analyzed regarding anatomical and functional dynamics during RCT. Pathological complete response (pCR) could be achieved in four patients, and four patients had a pathological partial response (pPR) following neoadjuvant treatment. T2- and DWI-based volumetry proved to be statistically significant in terms of therapeutic response, and volumetric thresholds at week two and week four during RCT were defined for the prediction of pCR. In contrast, the average tumor ADC values widely overlapped between both response groups during RCT and appeared inadequate to predict treatment response in our patient cohort. CONCLUSION: This prospective exploratory study supports the hypothesis that MRI may be able to predict pCR of rectal cancers early during neoadjuvant RCT. Our data therefore provide a useful template to tailor future MR-guided adaptive treatment concepts.

Chronic thromboembolic pulmonary hypertension (CTEPH) - potential role of multidetector-row CT (MD-CT) and MR imaging in the diagnosis and differential diagnosis of the disease.

Chronic thromboembolic pulmonary hypertension (CTEPH) can be defined as pulmonary hypertension (resting mean pulmonary arterial pressure of 25 mm Hg or more determined at right heart catheterization) with persistent pulmonary perfusion defects. It is a rare, but underdiagnosed disease with estimated incidences ranging from 0.5% to 3.8% of patients after an acute pulmonary embolism (PE), and in up to 10% of those with a history of recurrent PE. CTEPH is the only form of pulmonary hypertension that can be surgically treated leading to normalization of pulmonary hemodynamics and exercise capacity in the vast majority of patients. The challenges for imaging in patients with suspected CTEPH are fourfold: the imaging modality should have a high diagnostic accuracy with regard to the presence of CTEPH and allow for differential diagnosis. It should enable detection of patients suitable for PEA with great certainty, and allow for quantification of PH by measuring pulmonary hemodynamics (mPAP and PVR), and finally, it can be used for therapy monitoring. This overview tries to elucidate the potential role of ECG-gated multidetector CT pulmonary angiography (MD-CTPA) and MR imaging, and summarizes the most important results that have been achieved so far. Generally speaking, ECG-gated MD-CTPA is superior to MR in the assessment of parenchymal and vascular pathologies of the lung, and allows for the assessment of cardiac structures. The implementation of iodine maps as a surrogate for lung perfusion enables functional assessment of lung perfusion by CT. MR imaging is the reference standard for the assessment of right heart function and lung perfusion, the latter delineating typical wedge-shaped perfusion defects in patients with CTEPH. New developments show that with MR techniques, an estimation of hemodynamic parameters like mean pulmonary arterial pressure and pulmonary vascular resistance will be possible. CT and MR imaging should be considered as complementary investigations providing comprehensive information in patients with CTEPH.

Dynamic magnetic resonance imaging of the cervical spine with high-resolution 3-dimensional T2-imaging.

PURPOSE: Imaging of the cervical spine in functional positions has so far been limited to conventional X-ray examinations or the scarcely available open magnetic resonance imaging (MRI). An MRI compatible positioning device allows MRI examinations in various positions and even in motion. In combination with high-resolution T2-weighted MRI it allows detailed functional imaging of the cervical spine and nerve roots. To evaluate the utility of this method a population of patients from a clinical study was examined 5 years after anterior cervical discectomy and fusion (ACDF). METHODS: A total of 32 patients (median age 51.5 years, 15 female, 17 male) were examined after a median interval of 64.3 months from ACDF including 16 patients with a titanium cage and 16 with autologous bone graft. The prototype of an MR compatible positioning device (NeuroSwing) was used for MRI of the cervical spine in functional positions on a 1.5 T MRI unit (Siemens Avanto). A real-time true fast imaging with steady-state precession (FISP) sequence [6 mm, TR 704, TE 1.3 ms, matrix 256 x 207, field of view (FoV) 22 cm] was used for monitoring of flexion up to 45° and extension up to 40° or until patient discomfort. A sagittal T2 sampling perfection with application optimized contrast using different flip angle evolution sequence (SPACE sequence, 0.9 mm isotropic voxels, TR 1770, TE 186 ms, matrix 320 x 318, FoV 28 cm) and an axial true FISP sequence (3 mm slices, TR 194, TE 1.9 ms, matrix 256 x 256, FoV 22 cm) were used for imaging in the end positions. RESULTS: Using the motorized positioning device and a real-time true FISP sequence, imaging of the cervical spine in flexion and extension motion was possible in a quality suitable to observe changes in the alignment of vertebral bodies, the width of the spinal canal and the spinal cord itself. The 3D T2-weighted SPACE sequence yielded high quality and resolution images in the maximum flexion and extension positions. Compared to primary axial T2 true FISP slices, axial reconstructions of the T2 SPACE sequence were found to be clearly less affected by metal artifacts with the additional benefit of multiplanar and transforaminal reconstructions. CONCLUSIONS: The combination of a mechanical positioning device and a high-resolution 3D T2-weighted sequence (SPACE) on a conventional 1.5 T MRI allows kinematic imaging of the cervical spine as well as high-resolution imaging in the end positions, even in the presence of metal implants. In this proof of concept study a good visualization of narrowing of the spinal canal in functional positions could be achieved, showing the potential of MRI in functional positions for clinical and research applications.