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MRI Vs CT Vs Func7onal Imaging

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MRI Vs CT Vs Func7onal Imaging Staging and Following Common Pediatric Malignancies: MRI vs CT vs Func;onal Imaging Stephan D. Voss, MD, PhD Department of Radiology Boston Children’s Hospital Harvard Medical School Disclosure Statement No Disclosure Intro NeuroblastomaCancer Hepatoblastoma Wilms Tumor Surveillance Survivorship Imaging Imaging in Childhood Cancer • Detec;ng, Characterizing and Staging Disease - Generang Differen;al Diagnosis • Guiding Surgical Planning - Biopsy, resecon • Evaluang Treatment Response - Anatomic and Func;onal Imaging - Acute and Late • Predic;ng Outcome • Diagnosing & Managing Complicaons • Monitoring for Recurrence - Early and Late Intro NeuroblastomaCancer Hepatoblastoma Wilms Tumor Surveillance Survivorship Imaging The “Big Three” • Neuroblastoma • Hepatoblastoma • Wilm’s Tumor • Others: - Rhabdomyosarcoma - Germ Cell Tumors - Neurofibromatosis - Other liver, renal tumors Cases Intro NeuroblastomaNeuroblastomaCancer Hepatoblastoma WilmsImaging & Tumor Surveillance Imaging Survivorship Radiaon Risk Surveillance Imaging NBL: Previous Staging & Risk Classificaon • Major prognos;c factors • Poor prognos;c features • INSS stage of the disease include • Age, Histology and • Age >18 months molecular pathology • N-MYC gene amplificaon • 3 different risk categories • Diploid DNA content • Low, Intermediate, High • Poorly differen;ated/ undifferen;ated histology Cases Intro NeuroblastomaNeuroblastomaCancer Hepatoblastoma WilmsImaging & Tumor Surveillance Imaging Survivorship Radiaon Risk Surveillance Imaging Image Defined Risk Factors – IDRF’s • Surgical risk factors • L1: IDFR = 0 • Iden;fied by imaging, at • L2: IDRF ≥ 1 Dx, before treatment • M: Metastac disease • Based on imaging criteria • MS: 4S criteria, now age 18 mo • Internaonal consensus Ellsworth, Carroll • Goal: • Uniform reporng • Prognos;c factors Monclair T, et al. JCO 2009, Brisse H, et al. Radiology 2011 Page: 99 of 186 IM:IM: 9999 SE:SE: 400400 cmcm Page: 42 of 165 IM:IM: 4242 SE:SE: 22 cmcm Cases Intro NeuroblastomaNeuroblastomaCancer Hepatoblastoma WilmsImaging & Tumor Surveillance Imaging Survivorship Radiaon Risk Surveillance Imaging Neuroblastoma Diagnosis and Staging: MRI, CT and MIBG Cases Intro NeuroblastomaNeuroblastomaCancer Hepatoblastoma WilmsImaging & Tumor Surveillance Imaging Survivorship Radiaon Risk Surveillance Imaging Neuroblastoma Staging: MRI, CT & MIBG Cases Intro NeuroblastomaNeuroblastomaCancer Hepatoblastoma WilmsImaging & Tumor Surveillance Imaging Survivorship Radiaon Risk Surveillance Imaging Staging, IDRF’s and MRI vs CT Cases Intro NeuroblastomaNeuroblastomaCancer Hepatoblastoma WilmsImaging & Tumor Surveillance Imaging Survivorship Radiaon Risk Surveillance Imaging MRI vs sub-sec CT: decreased exposure and reduc;on in sedaon ~6 mSv Cases Intro NeuroblastomaNeuroblastomaCancer Hepatoblastoma WilmsImaging & Tumor Surveillance Imaging Survivorship Radiaon Risk Surveillance Imaging 18F-FDG PET/CT vs MIBG in NBL • MIBG: standard of care - Superior for stage 4 Dz - Superior for relapse - No quan;tave role currently (no SUV) • FDG: - Useful in MIBG (-) pts - False + BM recovery - Accurate where MIBG and CIM are discrepant MIBG - / FDG + MIBG + / FDG - Sharp S. et al. J. Nucl Med, 2009 Taggart et al. JCO, 2001 Melzer et al, EJNMMI, 2011 Intro NeuroblastomaNeuroblastomaCancer Hepatoblastoma Wilms Tumor Surveillance Survivorship Imaging Response Assessment: Primary site criteria • 229 HR NBL paents • Internaonal group • Compared volumetric measurement with RECIST - 30% decrease in LD (RECIST) - 50% (INRC) or 65% decrease in volume • Conclusion: None of the methods of primary site assessment predicted outcome. Bagatell R. et al. JCO 2016 Intro NeuroblastomaNeuroblastomaCancer Hepatoblastoma Wilms Tumor Surveillance Survivorship Imaging Response Assessment: MIBG & Curie scoring • MIBG scoring: predicts outcome for paents with MIBG-avid, stage 4 neuroblastoma • No correlaon between Curie score at diagnosis and subsequent treatment outcome • Post-induc;on Curie scores > 2: – poor prognosis – alternave therapeu;c opons Yanik G, et al. J Nucl Med 2013 Intro NeuroblastomaNeuroblastomaCancer Hepatoblastoma Wilms Tumor Surveillance Survivorship Imaging Neuroblastoma: Predictors of Outcome • High Stage at Dx • IDRF > 2, impac;ng surgical resectability • Presence of MIBG avid disease - Independent predictor of outcome (Dubois, 2017) - MIBG (-) pts have fewer mets and increased EFS • Extent of surgical resec;on: gross total > 90% (La Quaglia et al, JCO 2017; Fischer et al, BMC Cancer 2017) • MIBG+ residual disease aer induc;on Rx Intro NeuroblastomaCancer Hepatoblastoma Wilms Tumor Surveillance Survivorship Imaging Hepatoblastoma: Imaging • Establishing the presence of a liver lesion • Characterizing the lesion (focal vs mul;-focal) - Primary vs metastasis from elsewhere - Local / regional spread (lymph nodes, adjacent structures) • Determining surgical resectability (PRETEXT) • Contraindicaons to surgery or transplant • Presence of metastac disease (lungs): CT Intro NeuroblastomaCancer Hepatoblastoma Wilms Tumor Surveillance Survivorship Imaging Goals of Imaging and Therapy • Surgical resec;on mainstay of curave Rx - Only ⅓ - ½ are resectable at diagnosis - Complete resec;on of primary: 90% EFS • Un-resectable tumors: neoadjuvant chemoRx - Large, PRETEXT III and IV - Portal or HV invasion - Lung metastases at Dx • OLTX for paents unresponsive to chemoRx - POSTTEXT IV (III with major vascular invasion) - Should have drop in AFP and response to ChemoRx Intro NeuroblastomaCancer Hepatoblastoma Wilms Tumor Surveillance Survivorship Imaging PRETEXT Staging System • I One sec;on involved; three adjoining sec;ons are free • II One or two sec;ons involved, two adjoining sec;ons are free • III Two or three sec;ons involved; no two adjoining sec;ons are free • IV All four sec;ons are involved • Addi;onal consideraons - Mets, vascular invasion, rupture Roebuck et al. Pediatr Radiol. 2007 17 Intro Neuroblastoma Hepatoblastoma Wilms Tumor Surveillance Imaging • PRETEXT Stage and Risk Determinaon • Accurate preoperave imaging is cri;cal to management - Low risk vs High Risk Aronson & Meyers (2016) Seminars in Ped Surg 25: 265-75 Cases Intro NeuroblastomaCancer Hepatoblastoma WilmsImaging & Tumor Surveillance Imaging Survivorship Radiaon Risk Surveillance Imaging Hepatoblastoma and EOVIST: Upstaging Cases Intro NeuroblastomaCancer Hepatoblastoma WilmsImaging & Tumor Surveillance Imaging Survivorship Radiaon Risk Surveillance Imaging Hepatoblastoma and EOVIST: Characterizing Indeterminate Lesions 5 yo with incidental mass on appy CT CT: reported c/w FNH MRI/EOVIST: No uptake on hepatocyte phase Bx: HBL, PRETEXT III Intro Neuroblastoma Hepatoblastoma Wilms Tumor Surveillance Imaging Hepatoblastoma: Other Modali;es/Strategies • No role for rou;ne FDG PET/CT in HBL - May be useful for detec;ng relapse • MRI of lungs not yet accepted for assessing pulmonary mets • TACE, HIFU: Exploratory to reduce tumor size Small nodules ≤ 5 mm: CT Intro NeuroblastomaCancer Hepatoblastoma Wilms Tumor Surveillance Survivorship Imaging Hepatoblastoma: Predictors of Outcome • High Stage at Dx (PRETEXT III, IV) • Residual disease aer induc;on Rx • Surgical Resectability • Metastac disease (pulmonary) - Response of mets to induc;on chemoRx Intro NeuroblastomaCancer Hepatoblastoma Wilms Tumor Surveillance Survivorship Imaging Wilm’s Tumor Imaging • Establish the stage of tumor - Local, locoregional, or metastac • MRI and CT comparable for tumor rupture • Vascular invasion: renal vein, IVC • MRI: superior for detec;ng bilateral disease • Chest CT for pulmonary metastac disease • Treatment response: - USA: upfront surgical resec;on, unless bilateral - Europe: inducon chemoRx, response eval, surgery Cases Intro NeuroblastomaCancer Hepatoblastoma WilmsImaging & Tumor Surveillance Imaging Survivorship Radiaon Risk Surveillance Imaging Wilm’s Tumor – NWTS Staging I Limited to kidney and completely excised. No rupture II Extends through renal capsule but completely excised. May be local vascular invasion and/or local spillage/rupture. III Unresectable primary tumor. Residual local disease. Lymph node metastasis. Extension beyond surgical margins. IV Hematogenous metastasis: lung, brain, liver V Bilateral Prognosis: 4 years DFS > 90% Cases Intro NeuroblastomaCancer Hepatoblastoma WilmsImaging & Tumor Surveillance Imaging Survivorship Radiaon Risk Surveillance Imaging Wilm’s Tumor: Predictors of Outcome Stage, Histology, LOH Intro Neuroblastoma Hepatoblastoma Wilms Tumor Surveillance Imaging Wilms: US vs CT vs MRI • US screening for syndromes - Abnormali;es -> MRI • CT: osen the ini;al study - If unilateral, localized -> OR • MRI: Bilateral Disease - Response assessment - Characterize lesions in each kidney (20% different path) • CT: pulmonary metastases - Debate re: CT only lung mets • MRI: surveillance, with US Intro Neuroblastoma Hepatoblastoma Wilms Tumor Surveillance Imaging Wilms: CT vs MRI • MRI: - Mul;-sequence/mul;-plane - Superior to CT for subtle lesions in contrateral kidney - Vascular invasion • Not contrast phase dependent • MRI/DWI: - Improved sensi;vity for malignant lesions - ADC change correlates with histopathology post chemo Servaes et al. (2016) • MRI ≈ CT Pediatr Radiol. 45:166-72 - Lymph node invasion Liooij et al. (2017) - Capsular penetraon Pediatr Radiol. July 1 • MRI: pulmonary metastases Olsen et al. (2017) - CT remains standard JMRI. 45: 1316-24 Intro NeuroblastomaCancer Hepatoblastoma Wilms Tumor Surveillance Survivorship Imaging Wilm’s Imaging : High Impact Opportuni;es • Chest
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