Diffusion MRI Outside the Brain

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2 Diffusion MRI Outside the Brain

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4 Antonio Luna Ramón Ribes Jorge A. Soto Diffusion MRI Outside the Brain A Case-Based Review and Clinical Applications

5 Authors Antonio Luna, M.D. Clinica Las Nieves Sercosa Carmelo Torres Jaén Spain aluna70@sercosa.com Jorge A. Soto, M.D. Radiology Department Boston University School of Medicine E. Newton St Boston, MA USA jorge.soto@bmc.org Ramón Ribes, M.D., Ph.D. Department of Radiology Case Western Reserve University Euclid Ave Cleveland, OH USA ribesb@gmail.com ISBN e-isbn DOI / Springer Heidelberg Dordrecht London New York Library of Congress Control Number: Springer-Verlag Berlin Heidelberg 2012 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.the use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Printed on acid-free paper Springer is part of Springer Science+Business Media (

6 To both Marias, my wife and child, for their patience Antonio Luna To Rosario, my oldest daughter, for the priceless moments we share every day Ramón Ribes I dedicate this book to my wife, Ana, and my children, Andrea and Alejandro Jorge A. Soto

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8 Foreword It is my pleasure to write the foreword for this book on Diffusion-Weighted Imaging (DWI) Outside the Brain, which we believe it is the first on this subject. This book is co-authored by three young and bright radiologists from two different continents but united by their quest for innovation in clinical Body-MRI. Drs. Luna, Ribes and Soto are practicing radiologists in different settings ranging from a large academic medical center in the USA such as in the case of Dr. Soto, to a large private practice multicenter group in Spain (Dr. Luna) and a hybrid of both in Dr. Ribes. It is remarkable how the authors have been able to recruit a very comprehensive and talented team of collaborators from multiple locations in Europe, South America and the USA. The topics addressed cover the waterfront of Diffusion-Weighted Imaging (DWI). DWI is an emerging technique currently available in the majority of clinical MRI units and starting to generate a lot of interest because of its unique properties. Although DWI images are less pleasing to the eye than conventional T1-MRI and T2-MRI weighted images, DWI outside the brain holds the promise of quantification and in-depth functional information. The contributors of this volume range from physicists and clinical scientists to practicing radiologists with obvious research tendencies including several M.D., Ph.D.s. This book contains a number of introductory chapters ranging from the physics basis for DWI to artifacts, quantification and pitfalls. A second component deals with DWI applied to different areas of the body from head to toe. Key chapters on pancreatic, hepatic, renal and adrenal; prostate, bladder and retroperitoneum; female pelvis, breast, GI tract, rectum, lung and heart; head and neck, musculoskeletal and whole body provide practical, clinical day-to-day applications for this technique. The reader will enjoy having in a single volume, a comprehensive compilation of the knowledge of DWI and its applications to all areas of the body. The volume is well illustrated and contains lessons learned from day-to-day practice. Pablo R. Ros, M.D., M.P.H., Ph.D. Theodore J. Castele University Professors and Chairman Department of Radiology Case Western Reserve University University Hospitals Case Medical Center vii

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10 Preface In 1827, the botanist Robert Brown described the presumably random drifting of particles suspended in a fluid. Nowadays, it is known as Brownian motion, which is a probabilistic process. In biological tissues, the extracellular water follows a Brownian motion, which is directly related to the tissue composition. Technological advances in magnetic resonance imaging (MRI) have made possible the detection of this microscopic motion by means of diffusion-weighted imaging (DWI). First used to detect brain ischemia, in the last decade, DWI has established as a robust imaging oncological biomarker with applications from head to toe. Its use outside the brain has been specially challenging due to the higher sensitivity of this technique to motion and susceptibility artifacts. However, the maturity of MRI technology has allowed its widespread use. Moreover, DWI forms part of today s clinical MR protocol in areas such as body, musculoskeletal, breast, or head and neck. This technique adds functional information about tissue composition to the conventional morphological sequences, with the advantage of need neither for intravenous contrast injection nor ionizing radiation. Besides, DWI is fast and reproducible, showing a superb sensitivity to detect areas of high cellular content due to the restriction of extracellular water motion at this level. DWI is also a flexible technique that allows visual or quantitative assessment. Furthermore, the information of DWI may be added to vascular or metabolic information obtained by means of MR perfusion or MR spectroscopy. Therefore, in the era of functional imaging, DWI is one of the pillar which has converted MRI in a leading technique in this field. Conversely, DWI has not still exploded its full potential. Available studies are still limited. At first, DWI was used as a detector of pathology, but now new oncological applications, as prediction of tumor response or early postreatment monitorization, have to be completely explored. Besides, new groundbreaking applications of DWI are developing as whole-body DWI or DWI neurography. Other areas of work and cooperation are the need of standardization of protocols and to discover the most appropriate model of diffusion signal decay and parameter of quantification according to the explored system and clinical use. The idea to write this book was to summarize the author s experience dealing in a daily clinical environment with DWI. We intend to transmit the pros and cons of this technique in a case-based format in order to be easy and fast reading. We have enjoyed and learned a lot during this process, and we hope the readers may share some of our experiences working with DWI outside the brain. Antonio Luna ix

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12 Contents 1 Diffusion-Weighted Imaging: Acquisition and Biophysical Basis Javier Sánchez-González and Javier Lafuente-Martínez 1.1 Diffusion-Weighted Imaging: Physical Basis and Types of Acquisition Fat Suppression Techniques Advanced Fat Suppression Techniques Motion Control Non-Single-Shot EPI Acquisition Further Reading How to Identify and Avoid Artifacts on DWI Javier Sánchez-González 2.1 Optimization of Signal to Noise Ratio Geometrical Distortion Artifacts Motion Artifacts Eddy Currents Artifacts Fat Suppression Artifacts Dielectric Shielding Artifacts Tips in DWI Sequence Design for Body Applications Further Reading Quantification and Postprocessing of DWI Javier Sánchez-González and Antonio Luna 3.1 Biophysical Basis Estimation of Quantitative Data ADC and eadc Estimation with Two and Multiple b-values Multiexponential Modeling of Diffusion Diffusion Tensor Imaging DWI Analysis and Postprocessing Diffusion Registration DWI Analysis and Postprocessing ADC Analysis Further Reading xi

13 xii Contents 4 DWI at 3 T: Advantages, Disadvantages, Pitfalls, and Advanced Clinical Applications Javier Sánchez-González and Antonio Luna 4.1 DWI at 3 T Advanced Clinical Applications at 3 T Magnets Pitfalls in DWI T2 Shine-Through T2 Dark-Through Restriction of Normal Structures Iron Overload Nonmalignant Lesions with Apparent Restrictions on DWI Tumors with Low Cellular Density Conclusions Further Reading DWI of the Liver Antonio Luna and Luis Luna 5.1 Background DWI: Basic Concepts DWI: Basic Sequence Design Quantification Other Techniques Clinical Applications in Liver Disease Focal Liver Lesion Detection Characterization of Focal Liver Lesions Benign Focal Liver Lesions Malignant Focal Liver Lesions Focal Liver Lesions in the Cirrhotic Liver Monitoring Response to Treatment Diffuse Liver Disease Conclusions Further Reading Diffusion-Weighted MR Imaging of the Pancreas Jorge A. Soto, German A. Castrillon, Stephan Anderson, and Nagaraj Holalkere 6.1 Introduction Pancreatic Cancer Cystic Masses Other Applications Biliary Tract Case 6.1: Mass-Forming Focal Pancreatitis Case 6.2: Pancreatic Ductal Adenocarcinoma Case 6.3: Serous Cystadenoma Case 6.4: Pancreatic Pseudocyst Case 6.5: Von Hippel Lindau Disease with Simple Pancreatic Cysts

14 Contents xiii Case 6.6: Mucinous Cystadenoma Case 6.7: Intraductal Papillary Mucinous Neoplasm Case 6.8: Sclerosing Pancreatitis and Peripancreatic Collection Case 6.9: Hilar Cholangiocarcinoma Case 6.10: Acute Cholecystitis Further Reading Diffusion-Weighted MR Imaging of the Renal and Adrenal Glands Nagaraj Holalkere, Stephan Anderson, and Jorge A. Soto 7.1 Introduction Technique Renal DWI Adrenal DWI Case 7.1: Papillary Cell Carcinoma Case 7.2: Cystic Clear Cell Carcinoma Case 7.3: Hemorrhagic Renal Cyst Case 7.4: Lymph Node Metastasis Case 7.5: Alternative to Contrast-Enhanced MR Imaging Case 7.6: Recurrent Renal Cancer Case 7.7: Adrenal Metastatic Lesion Case 7.8: Lipid Rich Adrenal Adenoma Case 7.9: Adrenal Hematoma Case 7.10: Collision Tumor Further Reading Diffusion-Weighted Imaging of Prostate, Bladder, and Retroperitoneum Joan C. Vilanova, Roberto García-Figueiras, Joaquim Barceló, and Antonio Luna 8.1 DWI of Prostate Biophysical Basis Technical Adjustments DWI of the Prostate at 3 T Benign Conditions Cancer Detection Cancer Localization Tumoral Grading and Local Staging (T-Staging) N and M Staging Posttreatment Monitorization, Detection of Recurrence, and Prediction of Response to Treatment Diffusion Tensor Imaging (DTI) Applications of DWI in Bladder Cancer Assessment of the Retroperitoneum with DWI Case 8.1: Evaluation of Prostatic Cancer with DWI at 3 T Magnet Case 8.2: Chronic Prostatitis

15 xiv Contents Case 8.3: Central Gland Prostate Cancer Case 8.4: Bilateral Peripheral Prostate Cancer Case 8.5: Seminal Vesicles Infiltration Case 8.6: Monitorization of Response to Hormonal Therapy in a Patient with Prostate Cancer and Metastatic Pelvic Lymph Nodes Case 8.7: Local Recurrence After Brachytherapy Case 8.8: Local Recurrence After Radical Prostatectomy Case 8.9: Bladder Carcinoma Case 8.10: Recurrent Retroperitoneal Leiomyosarcoma Further Reading Use of DWI in Female Pelvis German A. Castrillon, Stephan Anderson, Nagaraj Holalkere, and Jorge A. Soto 9.1 Introduction Normal Appearance of Uterus and Cervix on DWI Clinical Applications Cervical Carcinoma Endometrial Cancer Myometrium Characterization of Ovarian Masses Assessment of Peritoneal Spread of Ovarian Carcinoma Vagina and Vulva Case 9.1: Residual Cervical Carcinoma Case 9.2: Characterization of Endometrial Adenocarcinoma Case 9.3: Early Endometrial Adenocarcinoma Case 9.4: Adenomyosis Case 9.5: Uterine Leiomyoma Case 9.6: Adnexal Endometrioma Case 9.7: Ovarian Fibroma Case 9.8: Didelphus Uterus and Ovarian Dermoid Tumor Case 9.9: Ovarian Carcinoma Case 9.10: Vulvar Sarcoma Further Reading DWI of the Breast Joaquim Barceló, Joan C. Vilanova, and Antonio Luna 10.1 Introduction Quantification in Breast DWI Assessment of Breast Lesions Technical Considerations of Breast DWI Breast Cancer: Monitorization and Prediction of Response to Treatment with DWI Breast Cancer: Screening and Staging with DWI Case 10.1: Invasive Ductal Carcinoma Case 10.2: Pure Mucinous Carcinoma Case 10.3: Ductal Carcinoma In Situ Case 10.4: Fibroadenoma Case 10.5: Borderline Phyllodes Tumor Case 10.6: Infiltrating Lobulillar Carcinoma