title: Associations among magnetic resonance spectroscopy, apparent diffusion coefficients, and image-guided histopathology with special attention to radiation necrosis.
abstract: OBJECTIVE
  In patients with malignant glioma previously treated with surgery, radiation, and chemotherapy, clinical and radiographic signs of recurrent disease often require differentiation between radiation necrosis and recurrent tumor. Published work suggests that although magnetic resonance spectroscopy (MRS) can reliably differentiate pure tumor, pure necrosis, and spectroscopically normal tissues, it may not be particularly helpful because most patients have mixed histological findings comprised of necrosis and tumor. To improve our clinical ability to discriminate among these histological entities, we have analyzed MRS in conjunction with apparent diffusion coefficient (ADC) sequences derived from magnetic resonance imaging.
  
  
  METHODS
  In 18 patients, spectroscopic and diffusion-weighted images were obtained before surgery for suspected recurrent neoplastic disease. Spectral data for pure tumor, pure necrosis, and mixed tumor and necrosis were derived from 65 spectroscopic observations in patients with previously treated gliomas (n = 16) and metastatic tumors (n = 2). Spectral data for choline (Cho), N-acetylaspartate (NAA), creatine (Cr), and lipid-lactate were analyzed separately and in conjunction with ADCs in all patients (15 observations of pure tumor, 33 observations of pure necrosis, and 13 observations of mixed tumor and necrosis). Histological specimens were obtained stereotactically at the time of surgery (<48 h after image acquisition) for recurrent disease and digitally co-registered with MRS data.
  
  
  RESULTS
  ADC values for pure tumor, pure necrosis, and mixed tumor and necrosis were 1.30, 1.60, and 1.42, respectively. Cho/NAA less than 0.20, NAA/normal Cr greater than 1.56, and NAA/Cho greater than 1.32 increase the odds that a tissue biopsy will be pure necrosis versus mixed tumor and necrosis. Although various values of all MRS ratios analyzed may provide positive correlations for histopathological differentiation of tissue between that of pure tumor and that of pure necrosis, the addition of ADC values to only NAA/Cho and NAA/normal Cr increases the odds of correct differentiation between pure tumor and pure necrosis. The addition of ADC values does not provide additional information beyond that of MRS in distinguishing specimens of mixed tumor and necrosis from either pure tumor or pure necrosis.
  
  
  CONCLUSIONS
  It has been demonstrated that MRS ratio analysis may allow for the clinical discrimination between specimens of pure tumor and pure necrosis, and the addition of ADC data into this analysis may enhance this specific differentiation. However, although a trend toward correlation between ADC values and the various histopathological features was noted, the direct addition of ADC data does not seem to allow further discrimination, beyond that provided by MRS, among specimens of mixed tumor and necrosis and either pure tumor or pure necrosis.
authors.affiliation: Hermelin Brain Tumor Center, Henry Ford Hospital, Detroit, Michigan 48202, USA. nsjar@neuro.hfh.edu
authors.forename: Jack P
authors.initials: JP
authors.lastname: Rock
authors.forename: Lisa
authors.initials: L
authors.lastname: Scarpace
authors.forename: David
authors.initials: D
authors.lastname: Hearshen
authors.forename: Jorge
authors.initials: J
authors.lastname: Gutierrez
authors.forename: James L
authors.initials: JL
authors.lastname: Fisher
authors.forename: Mark
authors.initials: M
authors.lastname: Rosenblum
authors.forename: Tom
authors.initials: T
authors.lastname: Mikkelsen
mesh_terms: D000328:Adult; D001921:Brain / Q000473:pathology*; D001932:Brain Neoplasms / Q000175:diagnosis*; D003937:Diagnosis, Differential; D038524:Diffusion Magnetic Resonance Imaging; D006801:Humans; D009682:Magnetic Resonance Spectroscopy; D009336:Necrosis; D009364:Neoplasm Recurrence, Local / Q000175:diagnosis*; D011832:Radiation Injuries / Q000175:diagnosis*