Reproducibility of 3 T APT-CEST in Healthy Volunteers and Patients With Brain Glioma

BACKGROUND: Amide proton transfer (APT) imaging is a chemical exchange saturation transfer (CEST) technique offering potential clinical applications such as diagnosis, characterization, and treatment planning and monitoring in glioma patients. While APT-CEST has demonstrated high potential, reproducibility remains underexplored. PURPOSE: To investigate whether cerebral APT-CEST with clinically feasible scan time is reproducible in healthy tissue and glioma for clinical use at 3 T. STUDY TYPE: Prospective, longitudinal. SUBJECTS: Twenty-one healthy volunteers (11 females; mean age ± SD: 39 ± 11 years) and 6 glioma patients (3 females; 50 ± 17 years: 4 glioblastomas, 1 oligodendroglioma, 1 radiologically suspected low-grade glioma). FIELD STRENGTH/SEQUENCE: 3 T, Turbo Spin Echo - ampling perfection with application optimized contrasts using different flip angle evolution - chemical exchange saturation transfer (TSE SPACE-CEST). ASSESSMENT: APT-CEST measurement reproducibility was assessed within-session (glioma patients, scan session 1; healthy volunteers scan sessions 1, 2, and 3), between-sessions (healthy volunteers scan sessions 1 and 2), and between-days (healthy volunteers, scan sessions 1 and 3). The mean APTCEST values and standard deviation of the within-subject difference (SDdiff ) were calculated in whole tumor enclosed by regions of interest (ROIs) in patients, and eight ROIs in healthy volunteers-whole-brain, cortical gray matter, putamen, thalami, orbitofrontal gyri, occipital lobes, central brain-and compared. STATISTICAL TESTS: Brown-Forsythe tests and variance component analysis (VCA) were used to assess the reproducibility of ROIs for the three time intervals. Significance was set at P  P > 0.22). The within-session SDdiff of whole-brain was 0.2% in both healthy volunteers and patients, and 0.21% in the segmented tumor. VCA showed that within-session factors were the most important (60%) for scanning variance. DATA CONCLUSION: Cerebral APT-CEST imaging may show good scan-rescan reproducibility in healthy tissue and tumors with clinically feasible scan times at 3 T. Short-term measurement effects may be the dominant components for reproducibility. LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY: Stage 2

Review and consensus recommendations on clinical APT-weighted imaging approaches at 3T: Application to brain tumors

Amide proton transfer-weighted (APTw) MR imaging shows promise as a biomarker of brain tumor status. Currently used APTw MRI pulse sequences and protocols vary substantially among different institutes, and there are no agreed-on standards in the imaging community. Therefore, the results acquired from different research centers are difficult to compare, which hampers uniform clinical application and interpretation. This paper reviews current clinical APTw imaging approaches and provides a rationale for optimized APTw brain tumor imaging at 3T, including specific recommendations for pulse sequences, acquisition protocols, and data processing methods. We expect that these consensus recommendations will become the first broadly accepted guidelines for APTw imaging of brain tumors on 3 T MRI systems from different vendors. This will allow more medical centers to use the same or comparable APTw MRI techniques for the detection, characterization, and monitoring of brain tumors, enabling multi-center trials in larger patient cohorts and, ultimately, routine clinical use

Review and consensus recommendations on clinical APT-weighted imaging approaches at 3T: Application to brain tumors

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What do we know about dynamic glucose-enhanced (DGE) MRI and how close is it to the clinics? Horizon 2020 GLINT consortium report

Cancer is one of the most devastating diseases that the world is currently facing, accounting for 10 million deaths in 2020 (WHO). In the last two decades, advanced medical imaging has played an ever more important role in the early detection of the disease, as it increases the chances of survival and the potential for full recovery. To date, dynamic glucose-enhanced (DGE) MRI using glucose-based chemical exchange saturation transfer (glucoCEST) has demonstrated the sensitivity to detect both D-glucose and glucose analogs, such as 3-oxy-methyl-D-glucose (3OMG) uptake in tumors. As one of the recent international efforts aiming at pushing the boundaries of translation of the DGE MRI technique into clinical practice, a multidisciplinary team of eight partners came together to form the "glucoCEST Imaging of Neoplastic Tumors (GLINT)" consortium, funded by the Horizon 2020 European Commission. This paper summarizes the progress made to date both by these groups and others in increasing our knowledge of the underlying mechanisms related to this technique as well as translating it into clinical practice

Mapping tumour heterogeneity with pulsed 3D CEST MRI in non-enhancing glioma at 3 T

Objective: Amide proton transfer (APT) weighted chemical exchange saturation transfer (CEST) imaging is increasingly used to investigate high-grade, enhancing brain tumours. Non-enhancing glioma is currently less studied, but shows heterogeneous pathophysiology with subtypes having equally poor prognosis as enhancing glioma. Here, we investigate the use of CEST MRI to best differentiate non-enhancing glioma from healthy tissue and image tumour heterogeneity. Materials & Methods: A 3D pulsed CEST sequence was applied at 3 Tesla with whole tumour coverage and 31 off-resonance frequencies (+6 to -6 ppm) in 18 patients with non-enhancing glioma. Magnetisation transfer ratio asymmetry (MTRasym)

MR-based protein imaging of the human brain by means of dualCEST

Chemical exchange saturation transfer (CEST) is an emerging magnetic resonance imaging (MRI) technique enabling indirect detection of low-concentration cellular compounds in living tissue by their magnetization transfer with water. In particular, protein-attributed CEST signals have been shown to provide valuable diagnostic information for various diseases. While conventional CEST approaches suffer from confounding signals from metabolites and macromolecules, the novel dual-frequency irradiation CEST (dualCEST) technique enables increased protein specificity by selectively detecting the intramolecular spin-diffusion. However, application of this technique has so far been limited to spectroscopic investigations of model solutions at ultrahigh magnetic field strengths. In this thesis, dualCEST was translated to a clinical whole-body MR scanner, enabling protein imaging of the human brain. To this end, several methodological developments were implemented and optimized: (i) improved dual-frequency pulses for signal preparation, (ii) a fast and robust volumetric image readout, (iii) a weighted acquisition scheme, and (iv) an adaptive denoising technique. The resulting improvements are not limited to dualCEST but are relevant for the research field of CEST-MRI in general. Extensive measurements of biochemical model solutions and volunteers demonstrated the protein specificity and reproducibility of dualCEST-MRI. The clinical applicability was verified in pilot studies with tumor and Alzheimer’s patients

Optimisation and applications of chemical exchange saturation transfer MRI techniques for cancer imaging on clinical scanners

Chemical Exchange Saturation Transfer (CEST) is receiving growing attention in the field of cancer imaging due to its ability to provide molecular information with good spatial resolution within clinically acceptable scan-times. Translation to the clinic requires a solid evidence-base demonstrating the clinical utility and a range of anatomical regions and pathologies have already been studied. These have traditionally been evaluated in terms of asymmetry-based metrics, the most common of which is the magnetization transfer ratio. However, alternative and potentially more informative metrics are also possible. Investigation of fitting metrics has not been reported at clinical field strengths and there is currently no standard approach for optimising the acquisition and post-processing protocols. The work described in this thesis focuses on the practical development and implementation of z-spectrum fitting methods in vivo at 3.0T. After the technical and clinical introductory chapters, chapter three describes the evaluation and comparison of the use of two different lineshapes for modelling the water direct saturation effect. Chapter four describes the optimization of an acquisition and post-processing protocol suitable for CEST imaging of the human prostate at 3.0T. The repeatability of the method is evaluated and in chapter five the optimized protocol is applied in two cancer patients. In chapter six a method is proposed for identification of CEST and NOE resonances in z- spectra acquired at low-field strengths. Chapter seven describes a pre-clinical study of healthy rat brains at 9.4T highlighting the need to consider the interplay between CEST and perfusion effects. In chapter eight the effects of gadolinium administration on CEST signal and contrast in glioma patients is investigated. I hope that the work described herein and the contributions stemming from it will be of some practical benefit to scientists and clinicians interested in exploring the future potential of the growing field of CEST imaging

Pulse sequences for measuring exchange rates between proton species: From unlocalised NMR spectroscopy to chemical exchange saturation transfer imaging

Within the field of NMR spectroscopy, the study of chemical exchange processes through saturation transfer techniques has a long history. In the context of MRI, chemical exchange techniques have been adapted to increase the sensitivity of imaging to small fractions of exchangeable protons, including the labile protons of amines, amides and hydroxyls. The MR contrast is generated by frequency-selective irradiation of the labile protons, which results in a reduction of the water signal associated with transfer of the labile protons’ saturated magnetization to the protons of the surrounding free water. The signal intensity depends on the rate of chemical exchange and the concentration of labile protons as well as on the properties of the irradiation field. This methodology is referred to as CEST (chemical exchange saturation transfer) imaging. Applications of CEST include imaging of molecules with short transverse relaxation times and mapping of physiological parameters such as pH, temperature, buffer concentration and chemical composition due to the dependency of this chemical exchange effect on all these parameters. This article aims to describe these effects both theoretically and experimentally. In depth analysis and mathematical modelling are provided for all pulse sequences designed to date to measure the chemical exchange rate. Importantly, it has become clear that the background signal from semi-solid protons and the presence of the Nuclear Overhauser Effect (NOE), either through direct dipole-dipole mechanisms or through exchange-relayed signals, complicates the analysis of CEST effects. Therefore, advanced methods to suppress these confounding factors have been developed, and these are also reviewed. Finally, the experimental work conducted both in vitro and in vivo is discussed and the progress of CEST imaging towards clinical practice is presented

Amide proton transfer imaging in stroke

Amide proton transfer (APT) imaging, a variant of chemical exchange saturation transfer MRI, has shown promise in detecting ischemic tissue acidosis following impaired aerobic metabolism in animal models and in human stroke patients due to the sensitivity of the amide proton exchange rate to changes in pH within the physiological range. Recent studies have demonstrated the possibility of using APT-MRI to detect acidosis of the ischemic penumbra, enabling the assessment of stroke severity and risk of progression, monitoring of treatment progress, and prognostication of clinical outcome. This paper reviews current APT imaging methods actively used in ischemic stroke research and explores the clinical aspects of ischemic stroke and future applications for these methods