Accuracy of High-Field Intraoperative MRI in the Detectability of Residual Tumor in Glioma Grade IV Resections

Abstract

Objective To assess the sensitivity/specificity of tumor detection by T1 contrast enhancement in intraoperative MRI (ioMRI) in comparison to histopathological assessment as the gold standard in patients receiving surgical resection of grade IV glioblastoma.

Materials and Methods 68 patients with a primary or a recurrent glioblastoma scheduled for surgery including fluorescence guidance and neuronavigation were included (mean age: 59 years, 26 female, 42 male patients). The ioMRI after the first resection included transverse FLAIR, DWI, T2-FFE and T1 – 3 d FFE +/- GD-DPTA. The second resection was performed whenever residual contrast-enhancing tissue was detected on ioMRI. Resected tissue samples were histopathologically evaluated (gold standard). Additionally, we evaluated the early postoperative MRI scan acquired within 48 h post-OP for remaining enhancing tissue and compared them with the ioMRI scan.

Results In 43 patients ioMRI indicated residual tumorous tissue, which could be confirmed in the histological specimens of the second resection. In 16 (4 with recurrent, 12 with primary glioblastoma) cases, ioMRI revealed truly negative results without residual tumor and follow-up MRI confirmed complete resection. In 7 cases (3 with recurrent, 4 with primary glioblastoma) ioMRI revealed a suspicious result without tumorous tissue in the histopathological workup. In 2 (1 for each group) patients, residual tumorous tissue was detected in spite of negative ioMRI. IoMRI had a sensitivity of 95 % (94 % recurrent and 96 % for primary glioblastoma) and a specificity of 69.5 % (57 % and 75 %, respectively). The positive predictive value was 86 % (84 % for recurrent and 87 % for primary glioblastoma), and the negative predictive value was 88 % (80 % and 92 %, respectively).

Conclusion ioMRI is effective for detecting remaining tumorous tissue after glioma resection. However, scars and leakage of contrast agent can be misleading and limit specificity.

Key points 

• Intraoperative MRI (ioMRI) presents with a high sensitivity for residual contrast-enhancing tumorous tissue during glioma resection.

• Contrast leakage due to bleeding and scars with reactive contrast enhancement can cause possible misleading artifacts in ioMRI, leading to a limited specificity of ioMRI.

• Bleeding control in glioma resection is crucial for successful usage of ioMRO for glioma resection.

Citation Format

• Heßelmann V, Mager A, Goetz C et al. Accuracy of High-Field Intraoperative MRI in the Detectability of Residual Tumor in Glioma Grade IV Resections. Fortschr Röntgenstr 2017; 189: 519 – 526

Zusammenfassung

Einleitung Ziel der Studie ist die Untersuchung der Sensitivität und Spezifität der intraoperativen MRT (ioMRI) zum Nachweis von Resttumorgewebe auf der Basis der T1-Wichtung nach GD-DPTA im Vergleich zur Histopathologie (Goldstandard) bei neurochirurgischen Operationen von WHO Grad IV Gliomen.

Material und Methoden 68 Patienten (Durchschnittsalter 59 Jahre, 26 weiblich, 42 männlich mit primären oder rezidivierenden WHO Grad IV Gliomen erhielten gleichzeitig eine floureszenz-, eine neuronavigations- und ein ioMRI-gestützte Resektion. Bei Nachweis von KM-Anreicherungen in T1-Wichtung in der ioMRI erfolgte eine Nachresektion, deren histopathologischen Proben (Goldstandard) von einem Neuropathologen bewertet wurde. Nach kompletter Entfernung des flouresziierenden oder MR-tomografisch nachweisbaren Resttumorgewebes wurde die OP beendet. Zusätzlich wurde die postoperative MRT zum Nachweis residueller KM-Anreicherungen mit der ioMRI verglichen und als in die Auswertung mit einbezogen.

Ergebnisse Bei 43 Patienten wurde in der ioMRI Resttumorgewebe nachgewiesen und histopathologisch bestätigt. In 16 Fällen war die zweite ioMRI ohne histopathologischen Nachweis von Resttumor richtig negativ (4 Rezidive, 12 Primärtumore). In 7 Fällen (3 Rezidive, 4 Primärtumore) war der ioMRT Befund falsch positiv, in zwei Patienten (1 Rezidiv, 1 Primärtumor) falsch negativ. Für alle Patienten betrug die Sensitivität 95 %, die Spezifität 69,5 %, für die Rezidive 94 % und 57 % und für die Primärtumore 96 % und 75 %. Der positive Vorhersagewert war 86 %, der negative Vorhersagewert 88 % für alle Patienten, 84 % und 80 % für die Rezidive und 87 und 92 % für die Primärtumore.

Schlussfolgerung Die ioMRI ist sensitiv im Nachweis von kontrastmittelanreicherndem Resttumorgewebes nach Gliomresektion. Narbengewebe und Kontrastmittelleckagen durch Blutaustritt führen zu Fehlinterpretationen und reduzieren die Spezifität.

Kernaussagen 

• Die ioMRI ist hochsensitiv im Nachweis residueller, kontrastmittelanreichender Resttumoranteile in der Gliomresektion

• Artefakte durch blutungsbedingte Kontrastmittelaustritte und reaktive Kontrastmittelanreicherungen durch Narbengewebe limitieren die Spezifität der ioMRI

• Eine suffiziente Blutungsstillung ist entscheidend für eine hohe Aussagekraft der ioMRI

Key words

intraoperative - treatment planning - gadolinium - aminolaevolinic acid - mr imaging - high-grade glioma

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