Abstract
Simple SummaryTumor recurrence is common among World Health Organization (WHO) grade II to IV gliomas. Magnetic resonance imaging (MRI) including fluid attenuated inversion recovery (FLAIR) sequences is key to detection of recurrence. This study used subtraction maps (SMs) derived from serial FLAIR imaging in 100 patients with glioma to facilitate detection of progressive disease, compared to conventional (CONV) visual reading. Reading of SMs revealed FLAIR signal increases in a larger proportion of patients and with higher diagnostic confidence according to evaluations of two readers. Correspondingly, an improved sensitivity (99.9% vs. 73.3%) was observed for SM reading when compared to CONV reading.Progression of glioma is frequently characterized by increases or enhanced spread of a hyperintensity in fluid attenuated inversion recovery (FLAIR) sequences. However, changes in FLAIR signal over time can be subtle, and conventional (CONV) visual reading is time-consuming. The purpose of this monocentric, retrospective study was to compare CONV reading to reading of subtraction maps (SMs) for serial FLAIR imaging. FLAIR datasets of cranial 3-Tesla magnetic resonance imaging (MRI), acquired at two different time points (mean inter-scan interval: 5.4 ± 1.9 months), were considered per patient in a consecutive series of 100 patients (mean age: 49.0 ± 13.7 years) diagnosed with glioma (19 glioma World Health Organization [WHO] grade I and II, 81 glioma WHO grade III and IV). Two readers (R1 and R2) performed CONV and SM reading by assessing overall image quality and artifacts, alterations in tumor-associated FLAIR signal over time (stable/unchanged or progressive) including diagnostic confidence (1—very high to 5—very low diagnostic confidence), and time needed for reading. Gold-standard (GS) reading, including all available clinical and imaging information, was performed by a senior reader, revealing progressive FLAIR signal in 61 patients (tumor progression or recurrence in 38 patients, pseudoprogression in 10 patients, and unclear in the remaining 13 patients). SM reading used an officially certified and commercially available algorithm performing semi-automatic coregistration, intensity normalization, and color-coding to generate individual SMs. The approach of SM reading revealed FLAIR signal increases in a larger proportion of patients according to evaluations of both readers (R1: 61 patients/R2: 60 patients identified with FLAIR signal increase vs. R1: 45 patients/R2: 44 patients for CONV reading) with significantly higher diagnostic confidence (R1: 1.29 ± 0.48, R2: 1.26 ± 0.44 vs. R1: 1.73 ± 0.80, R2: 1.82 ± 0.85; p < 0.0001). This resulted in increased sensitivity (99.9% vs. 73.3%) with maintained high specificity (98.1% vs. 98.8%) for SM reading when compared to CONV reading. Furthermore, the time needed for SM reading was significantly lower compared to CONV assessments (p < 0.0001). In conclusion, SM reading may improve diagnostic accuracy and sensitivity while reducing reading time, thus potentially enabling earlier detection of disease progression.
Highlights
Gliomas arise in the glial tissue and represent the most common malignant brain tumor type in adults, with an average annual age-adjusted incidence rate of approximately 4.67 to 5.73 per100,000 population [1,2]
The following criteria led to exclusion of patients: (1) tumor resection or biopsy performed within the inter-scan interval between MRI_1 and MRI_2, (2) non-diagnostic image quality of magnetic resonance imaging (MRI) datasets according to visual assessment, (3) artifacts due to foreign bodies or motion artifacts in imaging data, (4) other coexisting intracranial structural pathologies, and (5) pregnancy
This study investigated a commercially available, Conformité Européenne (CE)-certified and Food and Drug Administration (FDA)-approved software application for subtraction map (SM) generation and reading for longitudinal glioma imaging based on fluid attenuated inversion recovery (FLAIR) image pairs
Summary
Gliomas arise in the glial tissue and represent the most common malignant brain tumor type in adults, with an average annual age-adjusted incidence rate of approximately 4.67 to 5.73 per100,000 population [1,2]. Gliomas arise in the glial tissue and represent the most common malignant brain tumor type in adults, with an average annual age-adjusted incidence rate of approximately 4.67 to 5.73 per. III) and glioblastoma (WHO grade IV) are considered the major representatives of high-grade glioma and have shown increases in incidence with age, peaking in elderly subjects [1,2,5]. Oligodendroglioma (WHO grade II) and diffuse astrocytoma (WHO grade II) are common low-grade glioma entities that typically occur earlier in adulthood [1,2,5]. WHO grade II to IV gliomas are considered chronic progressive diseases related to their diffuse and infiltrative growth patterns, making curative treatment mostly impossible [5,6].
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