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Differentiation Between Glioblastoma and Solitary Metastasis: Morphologic Assessment by Conventional Brain MR Imaging and Diffusion-Weighted Imaging

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Differentiation Between Glioblastoma and Solitary Metastasis: Morphologic Assessment by Conventional Brain MR Imaging and Diffusion-Weighted Imaging pISSN 2384-1095 iMRI 2021;25:23-34 https://doi.org/10.13104/imri.2021.25.1.23 eISSN 2384-1109 Differentiation between Glioblastoma and Solitary Metastasis: Morphologic Assessment by Conventional Brain MR Imaging and Diffusion-Weighted Imaging Bo Young Jung1, Eun Ja Lee1, Jong Myon Bae2, Young Jae Choi1, Eun Kyoung Lee1, Dae Bong Kim1 1Department of Radiology, Dongguk University Ilsan Hospital, Goyang-si, Korea 2Department of Preventive Medicine, Jeju National University School of Medicine, Jeju, Korea Original Article Purpose: Differentiating between glioblastoma and solitary metastasis is very important for the planning of further workup and treatment. We assessed the ability Received: December 8, 2019 of various morphological parameters using conventional MRI and diffusion-based Revised: January 3, 2021 Accepted: January 4, 2021 techniques to distinguish between glioblastomas and solitary metastases in tumoral and peritumoral regions. Correspondence to: Materials and Methods: We included 38 patients with solitary brain tumors (21 Eun Ja Lee, M.D. glioblastomas, 17 solitary metastases). To find out if there were differences in the Department of Radiology, morphologic parameters of enhancing tumors, we analyzed their shape, margins, Dongguk University Ilsan Hospital, 814, Siksa-dong, Ilsandong-gu, and enhancement patterns on postcontrast T1-weighted images. During analyses of Goyang-si, Gyeonggi-do 10326, peritumoral regions, we assessed the extent of peritumoral non-enhancing lesion Korea. on T2- and postcontrast T1-weighted images. We also aimed to detect peritumoral Tel. +82-31-961-7836 neoplastic cell infiltration by visual assessment of T2-weighted and diffusion- Fax. +82-31-961-8281 based images, including DWI, ADC maps, and exponential DWI, and evaluated which E-mail: [email protected] sequence depicted peritumoral neoplastic cell infiltration most clearly. Results: The shapes, margins, and enhancement patterns of tumors all significantly differentiated glioblastomas from metastases. Glioblastomas had an irregular shape, ill-defined margins, and a heterogeneous enhancement pattern; on the other hand, metastases had an ovoid or round shape, well-defined margins, and homogeneous This is an Open Access article distributed under the terms of the Creative Commons enhancement. Metastases had significantly more extensive peritumoral T2 high signal Attribution Non-Commercial License intensity than glioblastomas had. In visual assessment of peritumoral neoplastic cell (http://creativecommons.org/licenses/ infiltration using T2-weighted and diffusion-based images, all sequences differed by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and significantly between the two groups. Exponential DWI had the highest sensitivity for reproduction in any medium, provided the diagnosis of both glioblastoma (100%) and metastasis (70.6%). A combination the original work is properly cited. of exponential DWI and ADC maps was optimal for the depiction of peritumoral neoplastic cell infiltration in glioblastoma. Conclusion: In the differentiation of glioblastoma from solitary metastatic lesions, visual morphologic assessment of tumoral and peritumoral regions using conventional Copyright © 2021 Korean Society MRI and diffusion-based techniques can also offer diagnostic information. of Magnetic Resonance in Medicine (KSMRM) Keywords: Glioblastoma; Intracranial metastasis; MR imaging; Diffusion weighted imaging www.i-mri.org 23 Morphologic Assessment for Glioblastoma and Solitary Metastasis | Bo Young Jung, et al. INTRODUCTION of MRI sequences that are easier to implement, such as conventional MRI, diffusion-weighted imaging (DWI), ADC Glioblastomas and metastases represent the most- maps, and exponential DWI for the differentiation of these common malignant brain tumors in adults (1). When tumors. Previous study has indicated that exponential DWI, intracranial tumors are encountered, a history of primary which represents the negative exponential of ADC maps and malignancy or the presence of multifocal lesions may assist depicts diffusion effects more accurately by removing the in the diagnosis of metastasis, but differentiation is often T2 shine-through effect, is useful for distinguishing tumors difficult when patients present with a solitary enhancing (11); therefore, we included this sequence in this study, in mass of unknown primary malignancy. which we individually evaluated whether morphological Because the clinical management of these two types of parameters of enhancing tumors can distinguish between tumor is radically different, it is important to differentiate glioblastomas and solitary metastases and assessed T2- them. Patients with glioblastomas do not typically require weighted and diffusion-based images for visual analysis of systemic work-up, because tumor invasion outside of the peritumoral neoplastic cell infiltration in the peritumoral central nervous system is very rare. However, any patient region. We also identified the sequence that depicts with suspected brain metastasis and no previous history of peritumoral neoplastic cell infiltration most clearly. To the primary cancer should undergo systemic staging to detect best of our knowledge, no previous study has considered all its origin, and any evidence of distant metastasis, before these factors. treatment. Standard treatment of glioblastoma consists of maximal surgical resection, radiotherapy, and concomitant and adjuvant chemotherapy. In patients with metastasis, MATERIALS AND METHODS more conservative management (usually a nonsurgical approach) should be considered (2-5). This retrospective study was approved by our Institutional Conventional magnetic resonance imaging (MRI) is of Review Board. limited value for the differentiation of glioblastoma from metastasis, because of these tumors’ similar imaging Patients appearances (6-8). Therefore, numerous studies have used We retrospectively reviewed the MRI examinations of advanced MRI techniques, such as MR spectroscopy (MRS), 38 patients with a diagnosis of glioblastoma or solitary perfusion-weighted imaging (PWI), diffusion tensor imaging metastasis between February 2006 and May 2014. The (DTI), and measurement of the absolute apparent diffusion patients ranged in age from 41 to 87 years (mean age, coefficient (ADC) in an attempt to differentiate them (2, 3, 62 ± 8.6 years); there were 20 males and 18 females. All 9-12). The key to differentiating the two neoplasms lies in patients had a previously untreated solitary enhancing the peritumoral region. In glioblastomas, peritumoral non- brain tumor and peritumoral non-enhancing lesion and had enhancing T2 high signal intensity is the result of both undergone conventional brain MRI and DWI before surgical neoplastic cell infiltration and vasogenic edema, whereas in intervention. Patients with infratentorial lesion were metastases it results from pure vasogenic edema (12-15). excluded, as were those with a previous history of surgery The continued development of advanced MRI techniques or whose peritumoral T2 high-signal lesion was not large has allowed for some success in the differentiation of enough to evaluate on T2-weighted imaging. Patients with peritumoral neoplastic cell infiltration from pure vasogenic obvious movement artifacts were also excluded. In total, 10 edema, in the peritumoral region using quantitative patients were excluded. methods. However, most investigators have found no Of the 38 patients, WHO grade IV glioblastoma was significant differences in intratumoral areas using these diagnosed in 21 cases and solitary metastasis in 17. new techniques (2, 3, 9-12, 16). Furthermore, advanced Metastatic brain tumors included lung carcinoma (n = MRI is not available in all centers and requires more time 8), anorectal carcinoma (n = 2), breast carcinoma (n = 1), and expense; this can put great pressure on patients. thyroid carcinoma (n = 1), hepatic cellular carcinoma (n = Quantitative evaluation is not easy, even using advanced 1), gall bladder cancer (n = 1), and carcinoma of unknown MRI techniques, and differential diagnosis remains a origin (n = 3). Diagnosis of glioblastoma was made by challenge with a reported accuracy of < 65% (8, 17). For means of pathology in all patients; diagnosis of solitary these reasons, we attempted to assess the diagnostic utility metastasis was confirmed pathologically in 13 patients and 24 www.i-mri.org https://doi.org/10.13104/imri.2021.25.1.23 was made clinically in the remaining four patients based 0.1 mmol/kg of body weight. on their history, MRI findings, and response to palliative Of the patients, 33 underwent T2* gradient-echo chemotherapy and/or radiation therapy. (GRE) images. For the MRI examinations of 29 patients (14 glioblastomas, 15 metastases), T2* gradient-echo MRI Techniques (GRE) images were evaluated to assess the presence of All MRI examinations were done using a 1.5 T MRI intratumoral hemorrhage. The remaining 4 patients were scanner (Avanto, Siemens Healthcare, Erlangen, Germany) excluded because of severe motion artifacts. with a standard head coil. Standard T1- and T2-weighted images, fluid attenuated inversion recovery (FLAIR) images, Image Analysis contrast-enhanced T1 weighted images and DWI were All MRIs were analyzed in consensus by a staff obtained for all patients. The following pulse sequences neuroradiologist (with 20 years of clinical experience) and were acquired. a fourth-year radiology resident; the two observers were • For precontrast and contrast-enhanced axial
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