Discrimination of Different Brain Metastases and Primary CNS Lymphomas Using Morphologic Criteria and Diffusion Tensor Imaging

Abstract

Purpose: Brain metastases are a common complication of cancer and occur in about 15 – 40 % of patients with malignancies. The aim of this retrospective study was to differentiate between metastases from different primary tumors/CNS lymphyomas using morphologic criteria, fractional anisotropy (FA) and apparent diffusion coefficient (ADC).

Materials and Methods: Morphologic criteria such as hemorrhage, cysts, pattern of contrast enhancement and location were reported in 200 consecutive patients with brain metastases/primary CNS lymphomas. FA and ADC values were measured in regions of interest (ROIs) placed in the contrast-enhancing tumor part, the necrosis and the non-enhancing peritumoral region (NEPTR). Differences between histopathological subtypes of metastases were analyzed using non-parametric tests, decision trees and hierarchical clustering analysis.

Results: Significant differences were found in morphologic criteria such as hemorrhage or pattern of contrast enhancement. In diffusion measurements, significant differences between the different tumor entities were only found in ADC analyzed in the contrast-enhancing tumor part. Among single tumor entities, primary CNS lymphomas showed significantly lower median ADC values in the contrast-enhancing tumor part (ADC_lymphoma 0.92 [0.83 – 1.07] vs. ADC_{no_lymphoma} 1.35 [1.10 – 1.64] P = 0.001). Further differentiation between types of metastases was not possible using FA and ADC.

Conclusion: There were morphologic differences among the main subtypes of brain metastases/CNS lymphomas. However, due to a high variability of common types of metastases and low specificity, prospective differentiation remained challenging. DTI including FA and ADC was not a reliable tool for differentiation between different histopathological subtypes of brain metastases except for CNS lymphomas showing lower ADC values. Biopsy, surgery and staging remain essential for diagnosis.

Key Points:

• Histopathological subtypes of brain metastases/CNS lymphomas show different morphologic features on MRI

• Primary CNS lymphomas show significantly reduced ADC values

• DTI is not a reliable tool for differentiation between brain metastases

Citation Format:

• Bette S, Wiestler B, Delbridge C et al. Discrimination of Different Brain Metastases and Primary CNS Lymphomas Using Morphologic Criteria and Diffusion Tensor Imaging. Fortschr Röntgenstr 2016; 188: 1134 – 1143

Zusammenfassung

Ziel: Hirnmetastasen treten in ca. 15 – 40 % der Patienten mit malignen Grunderkrankungen auf. Ziel dieser Studie war es, zwischen Hirnmetastasen unterschiedlicher Primärtumore/ZNS-Lymphomen bildgebend anhand morphologischer Kriterien sowie der Fraktionalen Anisotropie (FA) und dem „apparent diffusion coefficient“ (ADC) der Diffusions-Tensor-Bildgebung (DTI) zu differenzieren.

Material und Methoden: 200 Patienten mit zerebralen Hirnmetastasen/primären ZNS-Lymphomen wurden retrospektiv eingeschlossen. Morphologische Kriterien wie Blutung, Zysten, Art der Kontrastmittelanreicherung sowie Lokalisation wurden untersucht. Die FA- und ADC-Werte wurden mithilfe von regions of interest (ROIs) im Kontrastmittelanreichernden Tumoranteil, der Nekrose sowie der peritumoralen Region untersucht. Unterschiede wurde anhand von nicht-parametrischen Tests, Entscheidungsbäumen sowie Clusteranalysen statistisch analysiert.

Ergebnisse: Signifikante Unterschiede zwischen den Hirnmetastasen verschiedener Primärtumoren zeigten sich bei den morphologischen Kriterien wie Blutung und Art der Kontrastmittelanreicherung. Zudem zeigten sich signifikante Unterschiede für die ADC-Werte im Kontrastmittelanreichernden Tumoranteil. Primäre ZNS-Lymphome zeigten signifikant niedrigere mediane ADC-Werte im Kontrastmittelanreichernden Tumoranteil (ADC_lymphom 0,92 [0,83 – 1,07] vs ADC_{kein_lymphom} 1,35 [1,10 – 1,64] P = 0,001). Eine weitere Differenzierung anhand von FA- und ADC-Werten war nicht möglich.

Schlussfolgerung: Hirnmetastasen unterschiedlicher Primärtumoren/primärer ZNS-Lymphome unterscheiden sich hinsichtlich morphologischer Kriterien. Jedoch zeigt sich aufgrund der hohen Variabilität eine niedrige Spezifität. Anhand von FA und ADC ist keine verlässliche Differenzierung unterschiedlicher Hirnmetastasen möglich mit Ausnahme von ZNS-Lymphomen, die niedrigere ADC-Werte zeigen. Somit bleiben die Operation, Biopsie oder das Staging weiterhin notwendig für die Diagnosestellung.

Kernaussagen:

• Histopathologische Subtypen von Hirnmetastasen/ZNS-Lymphomen unterscheiden sich hinsichtlich der Morphologie im MRT

• Primäre ZNS-Lymphome zeigen signifikant niedrigere ADC-Werte

• DTI kann nicht zwischen Subtypen von Hirnmetastasen differenzieren

Key words

brain metastases - diffusion tensor imaging - fractional anisotropy - apparent diffusion coefficient

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