Transcript scanner abdominal

DANYLO HALYTSKY LVIV NATIONAL
MEDICAL UNIVERSITY
UROLOGY DEPARTMENT | RADIOLOGY DEPARTMENT, LVIV, UKRAINE
THE DIFFERENTIAL DIAGNOSTICS OF THE
MALIGNANT RENAL LESIONS: THE APPLICATION OF
THE DIFFUSION-WEIGHTED IMAGING OF THE
RENAL CELL CARCINOMA
Mytsyk Yulian, M.D., Ph.D., Associate Professor
Background
• Renal cell carcinoma (RCC) accounts for about 3% of malignant
tumors of the adult population1.
• In the oncourology given type of tumors ranks third after prostate
and bladder cancer1.
Dynamics of morbidity and mortality in patients with RCC in the USA1 and in
Ukraine2
Morbidity in the USA
Morbidity in Ukraine
Mortality in the USA
Mortality in Ukraine
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13.1 13.5
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14.9 15.4 15
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7.34 7.6
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4.1
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3.9 3.9 3.9
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3.2
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3.1
3.3
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3.2 3.2 3.1
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2003 2004 2005 2006 2007 2008 2009 2010 2011
2003 2004 2005 2006 2007 2008 2009 2010 2011
1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2009. CA: A Cancer Journal for Clinicians 2009;59(4):225–49.
2. Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin
KA (eds). SEER Cancer Statistics Review, 1975-2011, National Cancer Institute.
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Among various histological subtypes of RCC clear-cell subtype
(ccRCC) is the most common which appears in 80-90% of
pathological conclusions1.
Recently, computed tomography (CT) is considered to be the "golden
standard" in diagnostic imaging of RCC.
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109 renal lesions in 64 patients
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Purpose:
The objective of the survey was to assess the value of
the diffusion-weighted imaging (DWI) and apparent
diffusion coefficient (ADC) in differential diagnostics
of the malignant renal lesions.
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Materials and Methods:
Study Design
25 patients with solid
form of ccRCC
(I-IV Fuhrman grades)
Retrospective study was conducted among
8 patients with cystic
form of the ccRCC
69 persons in total
54 adult patients with
RCC confirmed by
pathomorphological
examination:
(Bosniak type IV )
12 patients with
papillary RCC (pRCC)
15 healthy volunteers
(the control group)
9 patients with
chromophobe RCC
(chRCC)
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• In all patients diagnosed with RCC a consecutive partial or radical
nephrectomy was performed with subsequent pathological
verification of diagnosis.
• Anti-tumor therapy and biopsy were not performed prior to MRI
and surgery.
EXCLUSION CRITERIA
• Patients with renal insufficiency
• Multifocal RCC
• Bosniak cysts of I-III classes
• Metal objects in the body
• Low image quality and DWI with obvious artifacts
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PATIENTS GROUPS CHARACTERISTICS
Group
Number of
Sex
Age, years
patients
Men
Woman
Mean ± SD
25
17
8
59.5 ± 5.2
I Fuhrman grade
7
5
2
51.3 ± 2.1
II Fuhrman grade
5
3
2
58.4 ± 3.5
III Fuhrman grade
7
4
3
63.3 ± 3.9
IV Fuhrman grade
6
5
1
57.6 ± 4.3
6
4
2
55.3 ± 4.2
Papillary RCC
12
8
4
61.5 ± 5.1
Chromophobe RCC
9
6
3
57.8 ± 3.7
Healthy volunteers
15
9
6
41.5 ± 5.8
Solid ccRCC
Cystic ccRCC
(Bosniak type IV)
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• In all patients and healthy volunteers an MRI was performed,
which included DWI, followed by ADC measurement.
• MR imaging was performed with a 1.5 T body scanner (Signa
HDxt, General Electric, USA) using an eight-channel phased-array
body coil.
• Standard GE MRI Protocol included such series:
• Axial 2D fast imaging employing steady-state acquisition with fat
saturation (FIESTA FAT SAT);
• Axial T1-weighted fast spoiled gradient-recalled echo dual-echo
(FSPGR-DE);
• Axial 3D fat-saturated T1-weighted spoiled gradient echo liver
acquisition with volume acquisition (LAVA) with contrast;
• Axial T2-weighted fast-recovery fast spin-echo (FRFSE);
• Coronal T2-weighted single-shot fast spin-echo (SSFSE);
• Sagital T2-weighted SSFSE;
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DWI parameters
Axial DWI was conducted before contrast media
administration, using single-shot echo-planar imaging
sequence with parallel imaging technique and fat saturation
during one breath-hold.
DWI parameters: TR=12000 ms, TE=90 ms, field of
view=40×40 cm; matrix=200×192; NEX=3; bandwidth=250
kHz, diffusion direction=slice, slice thickness=6.0 mm, interscan gap=1.0 mm with b-values=0 and 800 mm2/s),
acquisition time=17 s.
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ADC measurement
• Functool software was used for ADC map
generation and measurements
• The region of interest (ROI) was placed within a
portion of the area of the lesion where the
minimum ADC value on the ADC map was
registered according to the color by visual
inspection.
• An average of two to three measurements per
lesion were performed, depending on the lesion
size.
• The mean ADC value was recorded within ROI.
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Statistical Analysis
Microsoft Excel 2013 software was used for
statistical data analysis.
Research was allowed by local Ethics Committee.
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Results
Tumors had predominantly irregular shape on MRI
images with irregular and indistinct outlines.
Tumor type
Number of
patients
Tumor diameter, cm
25
5.6 ± 2.2
I Fuhrman grade
7
4.8 ± 0.9
II Fuhrman grade
5
6.2 ± 1.1
III Fuhrman grade
7
5.2 ± 0.6
IV Fuhrman grade
6
6.3 ± 0.7
Solid ccRCC
Mean ± SD
Cystic ccRCC
(Bosniak type IV)
Papillary RCC
6
7.4 ± 1.9
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6.2 ± 1.2
Chromophobe RCC
9
6.7 ± 2.2
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MRI CHARACTERISTICS OF KIDNEY TUMORS
Tumor type
MRI features
Solid ccRCC
Intermediate to high SI on T2
Avidly enhancing
Heterogeneous with areas of necrosis
Signal loss on opposed-phase relative to in-phase
images
Intermediate to high SI on T2
Heterogeneous
Containing enhancing soft-tissue components
Signal loss on opposed-phase relative to in-phase
images
Low SI on T2
Hypoenhancing
Signal loss on in-phase relative to opposed-phase
images
Variable imaging appearance:
Low SI on T2 – 62%
Intermediate to high SI on T2 – 38%
Heterogeneous
Cystic ccRCC
(Bosniak type IV)
Papillary RCC
Chromophobe RCC
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A
D
B
C
Abdominal MRI of a 65-year-old man with pathologically
proven ccRCC, Fuhrman grade II.
(A) Definite heterogeneous lesion of the anterior part of the
right kidney (arrow) on axial FIESTA scan with fat saturation
with areas of hyper- and hypointensity;
(B) On sagital T2-weighted SSFSE hyperintence lesion of the
medium renal segment with well-defined hypointense
pseudocapsule (arrows) and central zone;
(C) Diffusion-weighted MR, b-value=0 and 800 mm2/s,
inhomogeneous area with peripheral zone of hyperintesity
(arrow);
(D) ADC map with hypointense area in the right kidney (left
arrow) corresponding to the hyperintese zone on DWI
image, ADC=1.84×10−3 mm2/s. The right arrow is pointing on
ROI with normal left kidney parenchyma, ADC=2.16×10−3
mm2/s.
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A
B
C
Abdominal MRI of a 62-year-old woman with pathologically proven ccRCC,
Fuhrman grade III.
(A) Axial T2-weighted FRFSE, large inhomogeneous lesion of the right kidney
with area of hyperintensity in posterior segment (arrow).
(B) Diffusion-weighted MR, b-value=0 and 800 s/mm2, area of defined
hyperintesity in the posterior segment of the right kidney (arrows).
(C) ADC map with ROI over the hypointense area in the posterior segment of
the right kidney (arrow) corresponding to hyperintese zone on DWI image, in
given area ADC had the lowest value: 1.79×10−3 mm2/s.
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A
B
C
D
E
F
MRI of the patient, 68 y.o., pathologically proven chRCC of the left kidney.
(A) on sagittal T2-weighted SSFSE large tumor 68×75×55 mm with zones of iso- and
hyperintensity and without infiltration into surrounding tissues.
(B) on axial T2-weighted FIESTA with fat saturation tumor is presented by regions of
iso- and hyperintensity.
(E) on axial DWI tumor presented as hyperintense region.
(F) ADC-map with b values 0 and 800, ROI1 and ROI2 over the tumor region
showed highest ADC values (1.52 × 10– 3 mm2/s and 1.53 × 10– 3 mm2/s) in
comparison to ROI3 over the normal renal parenchyma of contralateral kidney
(2.15 × 10– 3 mm2/s).
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In the result of the performed analysis it was found that the average
ADC value of the malignant tumors was significantly different between
the histological subtypes of RCC:
Group
Number of
patients
ADC value, ×10−3mm2/s
25
Mean ± SD
1,81±0.24
I Fuhrman grade
7
1,89±0.18
II Fuhrman grade
5
1,80±0.17
III Fuhrman grade
7
1,74±0.16
IV Fuhrman grade
6
1,70±0.17
Cystic ccRCC (Bosniak type IV)
6
2,08±0.25
Papillary RCC
12
1,61±0.19
Chromophobe RCC
9
1,53±0.21
Healthy volunteers
15
2,18±0.18
Solid ccRCC
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DIFFERENCE BETWEEN THE HISTOLOGICAL SUBTYPES OF RCC
AND NORMAL RENAL PARENCHYMA
2.73
2.53
2.33
ADC value
2.13
1.93
1.73
1.53
1.33
1.13
0.93
Healthy
ccRCC
Grade I
Grade II Grade III Grade IV
Cystic
ccRCC
pRCC
chRCC
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Comparisons of Renal Lesion ADCs
Comparison
P Value
Solid tumors
ccRCC vs pRCC
<0.05
ccRCC vs chRCC
<0.05
pRCC vs chRCC
<0.05
ccRCC grade I vs ccRCC grade II
>0.05
ccRCC grade I vs ccRCC grade III
>0.05
ccRCC grade I vs ccRCC grade IV
<0.05
ccRCC grade II vs ccRCC grade III
>0.05
ccRCC grade II vs ccRCC grade IV
>0.05
ccRCC grade III vs ccRCC grade IV
>0.05
Cystic RCC
Cystic ccRCC vs solid ccRCC
<0.05
Cystic ccRCC vs pRCC
<0.05
Cystic ccRCC vs chRCC
Cystic ccRCC grades vs each other
<0.05
>0.05
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Conclusions
• We observed a statistically significant difference
(P<0.05) in a mean ADC values of solid forms of
RCC: ccRCC, pRCC and chRCC 1,81±0.24×10−3mm2/s vs 1,61±0.19×10−3mm2/s vs
1,53±0.21×10−3mm2/s respectively;
• The cystic form of ccRCC had significantly higher
mean ADC value than the solid forms of RCC 2,08±0.25×10−3mm2/s (P<0.05);
• The method of the diffusion-weighted imaging
along with ADC measurement gives valuable
information for the differential diagnostics of the
malignant renal lesions but have limitations in
differentiating between the grades of the solid and
cystic forms of ccRCC: statistically reliable
difference (P<0.05) was observed only between the
ccRCC lesions with I and IV Fuhrman grades of
differentiation.
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