Enhanced MRI - "Searching Radar" in Brain Glioma Diagnosis and Treatment!

*Only for medical professionals to read and refer to the series of reports of "Precise Plus - Imaging and Clinical Diagnosis and Treatment Cases Symposium" (1) In order to strengthen the communication and collaboration between imaging departments and clinical departments, the China Association for Health Promotion and Education specially initiated and hosted the "Precision Youjia - Imaging and Clinical Diagnosis and Treatment Case Symposium project helps to promote the intersection and integration of disciplines at all levels, and to improve the whole-process management of diseases from precise diagnosis to precise treatment
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The "medical community" has sorted out the wonderful content of this project, and will reproduce the wonderful content of the conference one by one in the form of a series of reports for readers
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In this issue, we will show you the important role of enhanced MRI in the diagnosis and treatment of glioma
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The following four cases are from the neurosurgery Gong Jin and other doctors of the Third Affiliated Hospital of Sun Yat-sen University, the radiology department of Ningbo Medical Center Li Huili Hospital Wang Chaochao and other doctors, and the neurosurgery Huang Xin of the First Affiliated Hospital of Zhejiang University School of Medicine and other doctors.
The application and significance of MRI in the whole management of gliomas are described from the perspectives of diagnosis, treatment and follow-up of gliomas
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Cases 1 and 2: How to ensure the "safety" of patients with near-total tumor resection? Case 3: How to locate and qualitatively judge glioma patients? Case 4: How to simultaneously identify tumor recurrence and pseudoprogression? Enhanced MRI throughout the whole process of glioma treatment, Dr.
Gong Jin and others summarized the role of multimodal MRI in diagnosis, preoperative planning, and prognosis evaluation and analysis
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Dr.
Gong said that MRI detection can assist clinicians in judging the pathological classification of the patient's tumor and the anatomical relationship around the lesion, and then predict or guide the patient's postoperative treatment effect, quality of life, and follow-up treatment
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Subsequently, Dr.
Gong shared two classic cases of glioma: although the first patient did not show any symptoms of neurological dysfunction, it could be preliminarily judged to be a low-grade glioma based on the patient's imaging features (LGG, Figure 1)
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The biggest difficulty in the surgical treatment of this patient was that the lesion was located in the anterior central gyrus of the patient and adjacent to the activation area of ​​the hands and feet when making a preoperative plan for the patient based on the preoperative images and 3D imaging technology
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Through imaging detection techniques including enhanced MRI, clinicians have made more precise localization of the patient's lesions, thereby assisting doctors in performing surgical treatment for the patient more smoothly.
Postoperative enhanced MRI detection and evaluation showed that the tumor was nearly completely removed (Figure 2).
, 3)
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Figures 1-5 The application of MRI in the whole process of the first and second diagnosis and treatment of patients (swipe left and right to view all) The second patient was admitted to the hospital because of "headache with disturbance of consciousness for more than 3 months, and double vision for 18 days", and the head MRI showed that the left side The temporal lobe, insula, suprasellar cistern, and corpus callosum were frequently occupied, and EEG showed abnormal EEG (Figure 4)
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Enhanced MRI showed that the patient had extensive lesions that had involved the corpus callosum, and necrotic tissue could be observed in the lesions.
Combined with the characteristics of the patient’s MRI detection, it was considered as a high-grade glioma (HGG)
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The patient's lesions were multiple diffuse and rich in blood supply, which was the biggest difficulty in the surgical treatment of this patient
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Dr.
Gong pointed out that the biggest difficulty and principle in the clinical treatment of such patients is to ensure the "safety" of the patients.
After surgical treatment, this patient has clear consciousness, normal language and normal limb muscle strength.
The postoperative CT showed that the tumor was large.
Partial excision (Figure 5)
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These two cases clearly show that multimodal magnetic resonance imaging plays an important role in the diagnosis, preoperative planning and prognosis evaluation of brain tumors, and is an indispensable and important method in the diagnosis and treatment of brain gliomas
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Enhanced MRI can assist doctors in locating and qualitatively judging the lesions of patients.
At present, the clinical treatment of gliomas is mainly surgical resection, and postoperative radiotherapy, chemotherapy and other comprehensive treatment methods are combined for further comprehensive treatment of tumors.
Therefore, it is necessary to ensure safety.
Under the premise, the maximum range of resection of the lesion is the top priority of glioma treatment
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Through the above two cases, we also have a preliminary understanding of how MRI plays an important role in the treatment of glioma
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Next, the cases brought by experts such as Dr.
Wang Chaochao, Department of Radiology, Li Huili Hospital, Ningbo Medical Center, explained the positive role of MRI detection in the diagnosis of glioma disease more clearly and concretely
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The patient came to the hospital for "sudden involuntary shaking of both upper limbs after drinking for more than 7 hours".
No obvious abnormality was found in the nervous system examination and laboratory examination.
With massive edema
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Figures 6-9 MRI T1-weighted imaging (T1WI) showed that the right basal ganglia of the patient had cystic mass and massive edema, and the right lateral ventricle was compressed
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Fluid-attenuated inversion recovery (FLAIR) sequence images showed a large area of ​​edema, and T1WI-enhanced scans showed that the patient's lesion wall was uneven
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At the same time, combined with the patient's sagittal and coronal MRI images, the patient's lesions can be initially located (Figures 6-9) (swipe left and right to view all)
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Subsequently, a magnetic resonance spectroscopy (MRS) scan was performed for the patient, and the results showed that the choline (Cho) peak decreased, the N-acetylaspartate (NAA) peak was significantly increased, and the Cho/NAA value was about 2.
5
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Figure 10-12 Magnetic resonance diffusion tensor imaging (DTI) scans showed significant damage to peripheral nerve fiber bundles, and three-dimensional arterial spin labeling (3D-ASL) results showed that the cerebral blood flow (CBF) in the solid area of ​​the lesion was significantly higher than that in the contralateral side , Dynamic susceptibility contrast enhancement (DSC)-perfusion-weighted imaging (PWI) results showed that CBF and cerebral blood volume (CBV) in the lesion area were significantly increased (Figure 10-12) (swipe left and right to view all)
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Dr.
Wang Chaochao said that based on the above image information, it was initially considered that the patient was a malignant brain tumor
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After chest and abdomen CT, stomach, colonoscopy and tumor markers and other laboratory tests were performed for the patient, no obvious tumor synergy was found, and brain metastases were excluded from most tumors, suggesting a primary malignant tumor in the brain, and further differential diagnosis was made.
Comprehensive analysis, the patient was considered to be glioma
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Through this case, we can see the important role of imaging detection, especially MRI detection, in locating and qualitatively judging patients with glioma
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This also provides a number of important information for the surgeon to perform subsequent surgical treatment on the patient, and provides more guarantees for the surgeon to "remove the lesion to the maximum extent under the premise of ensuring safety"
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guide radiotherapy? Small point! Identifying tumor pseudoprogression is the key! A case of "left facial numbness for 1 week" shared by experts such as Huang Xin and Xu Jingfeng will lead us to understand the key role of MRI in the treatment of glioma patients and after treatment
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The patient was diagnosed as (right frontal lobe) glioblastoma (WHO grade IV, IDH wild type) after imaging and pathological examination
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In June 2020, after surgical treatment, the patient recovered well without neurological deficit, and was transferred to the radiotherapy department for concurrent chemoradiotherapy treatment
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At this time, the guiding significance of MRI detection in the process of glioma radiotherapy is reflected.
Dr.
Huang Xin introduced that the patient received postoperative radiotherapy and intensity-modulated radiation therapy (IMRT) from July 7 to August 18, 2020.
), and the delineation of the patient’s radiotherapy target needs to be guided by MRI-CT images (Fig.
13)
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Figure 13 The patient's radiotherapy and chemotherapy plan Unfortunately, the patient found an enhancement focus in the frontal horn of the left lateral ventricle in the patient's left lateral ventricle, which was considered to be a multicentric glioma.
After consultation, enter the clinical trial to receive anlotinib combination therapy
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Follow-up MRI 4 months after operation showed that the intracranial enhancement foci were significantly reduced and reduced
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However, the re-examination of PET/CT in April 2021 indicated that the tumor bed recurred, and he received wave radiosurgery outside the hospital
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On July 14, 2021, the patient's re-examination of MRI found that a thin cloud-like enhancement signal was seen around the right frontal lobe lesion, and the range was larger than before.
It was considered that some of them were false reactions and radiotherapy necrosis, but the possibility of tumor recurrence could not be ruled out
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On August 7, a DWI scan showed that there was a little diffusion restriction at the top of the lesion, and no obvious restriction at the rest of the site
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Susceptibility-weighted imaging (SWI) showed a few spots or streaks of low signal in the lesion, which were considered to be intratumoral venules
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Cerebral artery spin labeling (ASL) perfusion scan revealed localized hyperintensity at the tumor site
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Based on the imaging results, the patient's intracranial tumor showed local progression (Fig.
14)
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Dr.
Xu Jingfeng pointed out that ASL perfusion scan can be used to judge the growth rate of tumor lesions, and can judge the aggressiveness of tumors by observing the density of new blood vessels, vascular permeability and normal vascular expansion in the lesions, and at the same time, it can distinguish tumor recurrence and pseudo-progression.
It can be used for preoperative assessment of surgical risks and the formulation of risk prevention plans
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In September of the same year, the patient's re-examination MRI showed that the tumor in the right frontal lobe and basal ganglia recurred with extensive surrounding edema, so the patient was treated with bevacizumab combined with chemotherapy
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MRI examination in November showed improvement in his condition (Figs.
15, 16)
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 Figures 14-16 MRI image results of the patient at 7, 8, 9, and 11 months after operation (swipe left and right to view all) From this case, it is not difficult to see that MRI can not only assist clinicians in locating and locating glioma patients, Qualitative
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It also plays a key role during treatment and subsequent follow-up
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Combining SWI and ASL sequence scanning detection can identify patients with tumor recurrence or pseudoprogression
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Summary From the above cases, it can be seen that MRI detection, especially enhanced MRI detection, has a crucial and irreplaceable role in the diagnosis, treatment, and follow-up of gliomas.
Selecting an appropriate contrast agent can more effectively help the precise diagnosis of the disease.
diagnosis
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Gadobutrol (Galoxian) is currently the only high-concentration high-relaxation rate MRI contrast agent, whose concentration is twice that of other contrast agents, and is suitable for systemic examinations of all ages (including term neonates)
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Several studies have confirmed that due to the advantages of high concentration and high relaxation rate of gadobutrol, it can significantly improve the display of lesion details in the detection of primary and metastatic tumors in the central nervous system, multiple sclerosis, etc.
Routine concentration contrast medium can find more tiny lesions, which is helpful for more accurate diagnosis and treatment plan formulation
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In recent years, relevant reviews have reported the value and potential of enhanced MRI in tumor diagnosis and treatment.
As a new quantitative diagnostic method, it has brought new options for precise diagnosis, efficacy evaluation, and prognosis prediction of glioma
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With the continuous development of enhanced MRI, it is believed that enhanced MRI will play an increasingly important role in the whole management of patients with glioma in the future, assisting clinical decision-making and benefiting patients! *This article is only used to provide scientific information to medical and health professionals and does not represent the views of the platform