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Whole-Body Magnetic Resonance Imaging: Technique, Guidelines and Key Applications

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Whole-Body Magnetic Resonance Imaging: Technique, Guidelines and Key Applications Whole-body magnetic resonance imaging: technique, guidelines and key applications Paul Summers1, Giulia Saia1,2, Alberto Colombo1, Paola Pricolo1, Fabio Zugni1, Sarah Alessi1, Giulia Marvaso3,4, Barbara Alicja Jereczek-Fossa3,4, Massimo Bellomi1,4 and Giuseppe Petralia4,5 1Division of Radiology, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy 2Advanced Screening Centers, ASC Italia, 24060 Castelli Calepio, Bergamo, Italy 3Division of Radiotherapy, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy 4Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy 5 Precision Imaging and Research Unit, Department of Medical Imaging and Radiation Sciences, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy Abstract Whole-body magnetic resonance imaging (WB-MRI) is an imaging method without ion- ising radiation that can provide WB coverage with a core protocol of essential imaging contrasts in less than 40 minutes, and it can be complemented with sequences to evalu- ate specific body regions as needed. In many cases, WB-MRI surpasses bone scintigra- phy and computed tomography in detecting and characterising lesions, evaluating their Review response to therapy and in screening of high-risk patients. Consequently, international guidelines now recommend the use of WB-MRI in the management of patients with mul- tiple myeloma, prostate cancer, melanoma and individuals with certain cancer predisposi- tion syndromes. The use of WB-MRI is also growing for metastatic breast cancer, ovarian cancer and lymphoma as well as for cancer screening amongst the general population. In light of the increasing interest from clinicians and patients in WB-MRI as a radiation-free technique for guiding the management of cancer and for cancer screening, we review its technical basis, current international guidelines for its use and key applications. Keywords: magnetic resonance imaging, whole-body, diffusion-weighted imaging, oncology Background Correspondence to: Paul Summers The introduction of multiple receiver coils and table movement for multi-station scanning Email: [email protected] in the late 1990s transformed magnetic resonance imaging (MRI) from a segmental to a ecancer 2021, 15:1164 whole-body (WB) imaging modality [1–3]. Progressive improvements in scanner homo- https://doi.org/10.3332/ecancer.2021.1164 geneity and gradient systems facilitated the introduction of diffusion-weighted imaging Published: 07/01/2021 (DWI) [4] WB examinations by Takahara et al [5]. Evidence that DWI provides good diag- Received: 04/05/2020 nostic performance in the detection, characterisation and monitoring of therapy of many Copyright: © the authors; licensee cancers, consolidated in a first consensus meeting of experts in 2009 [6], has led to DWI ecancermedicalscience. This is an Open Access having a central role in WB-MRI. Further developments, including accelerated imaging and article distributed under the terms of the improved sequence design, have brought improvements in image quality and rendered Creative Commons Attribution License (http:// WB-MRI feasible in a clinically acceptable scan-time of under 40 minutes, opening further creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and opportunities for clinical use [7–9]. In the course of this progression, WB-MRI has become reproduction in any medium, provided the original an established part of the management of several cancer histotypes [10–15]. In light of the work is properly cited. ecancer 2021, 15:1164; www.ecancer.org; DOI: https://doi.org/10.3332/ecancer.2021.1164 1 increasing interest from clinicians and patients in WB-MRI as a radiation-free technique for guiding the management of cancer and for cancer screening, we review its technical basis, current international guidelines for its use and key applications. Technical considerations Sequences and image acquisition WB-MRI imaging protocols generally include morphological T1- and T2-weighted sequences along with DWI (Table 1). T1-weighted images are usually obtained with gradient-echo (GRE) Dixon acquisitions [16], producing in- and opposed-phase images that allow the calculation of fat-only and water-only images. These are useful in the detection, characterisation and response assessment of bone metastases. As an alternative, a T1-weighted 3D turbo spin echo (TSE) sequence could be performed [17], but this typically results in a longer acquisition and foregoes the discrimination of water and fat components. T2-weighted images, acquired using single-shot or half-acquisition turbo spin echo (HASTE) sequences without fat suppression, can be used for the evaluation of disease in organs other than bone [18] with a good trade-off between duration and signal to noise ratio (SNR) [19], and can be helpful in confirming the presence of spinal cord compression [20]. Sagittal T1-weighted TSE and fat-saturated (short tau inversion recovery—STIR) T2-weighted TSE images of the whole spine are used for the detection of vertebral metastases, fractures and spinal cord compression [11, 13]. The final essential component of a WB-MRI protocol is a single-shot diffusion-weighted echo-planar imaging sequence. DWI has become central to WB-MRI due to its ability to detect malignant lesions characterised by high cellularity. Acquiring multiple averages of the DWI data during free-breathing is recommended in order to reduce motion artefacts and increase SNR [21]. At least two b-values are needed in order Review to calculate the corresponding apparent diffusion coefficient (ADC) map for image interpretation and disease response assessment [22]. The lowest b-value should be at least 50 s/mm2 in order to reduce perfusion-related signals, while a high b-value in the range between 800 and 1,000 s/mm2 is recommended [13, 21, 22]. The use of a single diffusion encoding direction with simultaneous application of gradients from all three axes can provide higher SNR by reducing echo times. It may also reduce the blurring that can arise when averaging across images acquired with multiple diffusion encoded directions that are prone to different eddy current induced distortions [23]. The values of ADC in tissues that have anisotropic diffusion (kidneys, and white matter) may, however, be biased with such diffusion encoding, though this is usually of secondary importance for WB-MRI examinations. WB DWI requires a relatively long (10–15 minutes) acquisition time [24, 25]. Obtaining fewer averages of the low b-value images, that have intrinsically higher SNR, is one measure for minimising acquisition times. Coverage of the lung and brain can be incorporated with less than 2 minutes of scanning by using a single breath-hold, short echo-time GRE sequence for evaluation of lung parenchyma [26], and a fluid-attenuated inversion recovery TSE sequence for detection of focal brain lesions or brain oedema. While contrast media is not routinely used in WB-MRI studies, it may be useful for detecting brain metastases or meningeal disease [27]. Depending on clinical context, sequences to evaluate specific body regions can be added to a basic WB-MRI protocol [13]. For example, a post-contrast T1-weighted brain scan is recommended in Li–Fraumeni syndrome (LFS) [28]. For men, axial T2-weighted and DWI sequences targeted to the prostate can be added to provide an all-in-one prostate cancer (PC) staging examination [17, 29]. Following well-established practices for WB positron emission tomography (PET) and computed tomography (CT), WB-MRI acquisitions span from the vertex to mid-thigh. A distinction is that with the patient lying supine, the arms remain adducted. The acquisition should be extended to the feet when performed for diseases that frequently involve the extremities, such as neurofibromatosis [30], or as part of surveillance in cancer predisposition syndromes that favour soft-tissue tumours, such as LFS [31]. The acquisition of WB-MRI in patients affected by multiple myeloma should, instead, span from vertex to knees [11]. Both coronal and axial acquisitions have been used in WB-MRI [11, 17, 18]. The coronal orientation may permit the acquisition of fewer sta- tions and thus reduce scan time. Coronal DWI scans are more likely, however, to suffer from distortion than axial DWI with the same field of view (FOV) and number of slices [32]. Axial acquisition has a further advantage in providing images that can be directly correlated with the conventional cross-sectional anatomy of other modalities. Slice thickness (SLT) should remain consistent across the different sequences to allow efficient image comparison and improve the readability of the examination. The choice of SLT remains somewhat variable; recom- mendations are for the use of contiguous slices with a thickness between 5 and 7 mm [11, 13]. ecancer 2021, 15:1164; www.ecancer.org; DOI: https://doi.org/10.3332/ecancer.2021.1164 2 Table 1. Sequence components for WB-MRI examinations. Sequence description Metastatic Suggested protocols Multiple prostate myeloma [11] cancer [13] (MY-RADS) Breast cancer Ovarian cancer Lymphoma Screening (MET-RADS-P) 1 Whole spine—sagittal, T1W TSEc, 4–5 mm Core Core Yes Yes No No SLT 2 Whole spine—sagittal T2W TSE STIR Core Core Yes Yes Yes Yes (preferred) or fat suppressed, 4–5 mm SLT 3 WB—axial, T1W GRE Dixonc, 5 mm SLTdFat Core Coreb Yes Yes Yes Yes image reconstructions mandatory vertex to vertex to vertex to vertex to vertex to vertex to knees mid-thighs mid-thighs mid-thighs mid-thighs mid-thighs 4 WB—axial, diffusion
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