advanced neuroimaging of brain tumors annual meeting/handouts... · three goals of presurgical...
TRANSCRIPT
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Advanced Neuroimaging of Brain
TumorsLaszlo Mechtler, M.D.
Chief of Neuro-Oncology
Roswell Park Cancer Institute
Dent Neurologic Institute
Buffalo, New York
Las Vegas 2013 ASN
Current Problems with Anatomic Imaging
Highly sensitive but nonspecific
Cannot reliably differentiate tumor and
treatment effects
Unable to guide specific targeted
therapy
Cannot assess early therapy failure &
predict clinical outcome
Imaging has to do a better job in….
Characterizing brain tumor biology
Guiding therapy
Assessing therapeutic response
Detecting early treatment failure
Distinguishing tumor progression &
treatment effects
Predicting clinical outcome
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Tumor pathology on MRI is most often seen as
Long T1 and long T2
Short T2(hypointensity)
Short T1 (hyperintensity)
Iron within necrosis Hemosiderin (chronic bleed) Deoxyhemoglobin (acute bleed) Melanin Ferritin Calcification High nucleus:cytoplasm ratio (PNET, lymphoma) Dense cellularity Macromolecule content Fibrocollagenous stroma Mucin (colon carcinoma) High protein content (Craniopharyngeoma)Fast flowing blood (Hemangioblastoma, GBM)Air
MelaninManganeseIron CalciumCopperHigh protein (colloid cyst)Methemoglobin (subacute
blood)Fat (lipoma, dermoid)ChlolesterolParamagnetic agent
(gadolinium)Flow-related enhancement
in tumor vessel Calcium
T1-non
PCNSL: Immunocompetent
T2
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PCNSL: Immunocompetent
T1-gad T1-gad
T1-non
Intracranial Lipoma vs. BleedFast MRI
T1-fatsat
T1-non T2
Brain Metastases: melanoma
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Transition from
Anatomy → Physiology → Biology
Advanced Neuroimaging
Diffusion-weighted imaging / DTI
Susceptability Weighted Imaging (SWI)
Proton MR Spectroscopy
Functional MRI
Perfusion-weighted imaging
Intraoperative MRI
Ultra-high field MRI
Heterogeneity of Gliomas on MRI
Grade 2
Grade 3
Grade 4
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Contrast enhancement on MRI is nonspecific!GBM Abscess TB
Demyelinating lesion radiation
necrosis
Pseudoprogression post chemoradiotherapy
Pre XRT
1 month postXRT
1 month on steroids
Bevacizumab + Irinotecan for Recurrent Glioblastoma
Vredenburgh JJ et al. JCO 2007; 25: 4722
T1-Gd response
Pseudoresponse
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Representative case of discordant decrease enhancement and increased FLAIR
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ADC & Glioma
Grade
II
III
IV
L.Mechtler
SWI
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Diffusion Tensor Imaging (DTI)
DTI
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Low-grade astrocytoma
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Metastasis without invasion of corticospinal tract.
GBM with invasion of corticospinal tract.
MRS in Neuro-oncologyPreoperative
1.Differentiate high grade from low-grade gliomas 2.Differentiate GBM-related “edema” from metastases-related “edema”3.refinement of pre-operative differential diagnosis
a.abscessb.tuberculomac.tumefactive demyleinating lesion
4.diagnose meningioma5.diagnose PCNSL
Perioperative1.Localize for stereotactic biopsy2.determination of extent of resection 3.Multivoxel MRS to predict radiotherapy volumes
Postoperative1.monitor malignant transformation of low grade tumors2.monitoring of response to treatment3.Differentiating recurrent GBM from radiation necrosis
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Normal MRS
Myoinsitol-Choline-Creatine-Glutamine/glutamate-N-acetyl aspartate-Lipids/lactate
Decreased NAA signal in neoplasms is from reduced or absent production of these metabolites because normal neurons have been destroyed or displaced by the neoplastic process
Elevated choline peak is a surrogate marker of increased cell membrane turnover caused by tumor growth or normal cell destruction or may at least in part be elevated because of increased production through phospholipase upregulation.
The relative anaerobic environment of many neoplasms and derangements in glucose metabolism result in incomplete glucose breakdown and likely account for the elevated lactate signal
GBM, Tumor Extension Beyond Enhancement
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MULTI VOXEL MRS
MAPS HAVE IMPLICATIONS FOR PROGNOSIS AND RT PLANNING
Cho map shows tumor outside of enhancement in GBM
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Perfusion MRI:Clinical Applications
Glioma grading (astrocytomas only)
Image-guided biopsy
Primary vs Secondary brain tumor
Tumor vs Treatment effect
Tumor-mimicking lesions
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Grade 2 astro
Grade 3 astro
T1
T1 T2
T2 Perfusion
Perfusion
Perfusion MR
Presurgical fMRI
Determine the feasibility of surgical treatment and the risk for inducing neurological deficits (localizing language and motor areas)
Select patients for intraoperative cortical stimulation
Provide guidance for functional neuronavigation
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1.5T vs. 3.0T Motor Task Finger Apposition
Spiral 2D single shot, 200 frames, TR 1000ms, TE 40ms3T 60°; 1.5T 70° (T1› @ 3T: [email protected]~900ms; [email protected]~1400ms)
20cm FOV, 5mm/skip 0, 90x90, 6 slices
70°
60°
G. Glover, Dept. of Radiology
Three goals of presurgical functional MRI include: to determine the feasibility of surgical treatment and
risk for inducing neurologic deficits,
to select patients for intraoperative cortical stimulation, which would be indicated when a functional area is included within the lesion or at the radiological boundary
to provide guidance for functional neuronavigation based on preoperatively acquired structural information using MRI
A 31-year-old women operated 1 year ago for a oligoastrocytoma located in the superior aspect of the left middle frontal gyrus. Asymptomatic
Case 12
Arrows point to NEW lesion
T1w gd+ FLAIR
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Good
Bad
OOPS !!!!!!!!!!!!!!
Functional MRI in the sagittal plane using descriptive naming (H) indicates activation in the left premotor cortex just below the enhancing lesion (arrow). For right hand activation (I) was found adjacent to the posterior margin of the post-op cyst, that was normal on MRS
FMRI
BA C D E
NNAA
NAA
FG H I
These test results aided the neurosurgeon in the resection of the enhancing lesion and adjacent T2W hyperintensities without post-operative residual neurologic deficits. Pathology was consistent with a anaplastic astrocytoma.
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BA C D E
NNAA
NAA
F G H I
Functional MRI and MRS
MRI-PET Fusion(Surface Mapping)
ioMRI Systems
0.12 to 1.5 Tesla
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Operative Progression
Diagnostic Pre-Op Scan
PoleStar® Pre-Op Scan PoleStar® Intra-Op Scans
with surgery progression
GBMioMRI
ioMRI
Resection control
Maintain navigational accuracy despite brain shift
Complication avoidance 1.5T pre-op image
0.15T MRI taken in OR
Brain Shift (Effect on Stereotactic Localization)
Tissue shift occur in surgery due to:
1. Tumor decompression
2. Collapse of brain around the operative site
3. Loss of cerebrospinal fluid
4. Cortical swellingBrain Shift by ioMRI
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AngiogenesisInfiltration Hypoxia
Diffusion Perfusion
LactateMRS
S. Chang et al
Comprehensive Brain imaging –Tumor
T2W T1W IR
FLAIR DWI
FiberTrak Perfusion
Venous Bold MRS
Latest Rush to
Higher Fields?
Latest Rush to
Higher Fields?
TESLA ENVY?????????
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Thank you for your patience !
Koszi Adam es David