title: Prognostic value of combined visualization of MR diffusion and perfusion maps in glioblastoma.
abstract: We analyzed whether the combined visualization of decreased apparent diffusion coefficient (ADC) values and increased cerebral blood volume (CBV) in perfusion imaging can identify prognosis-related growth patterns in patients with newly diagnosed glioblastoma. Sixty-five consecutive patients were examined with diffusion and dynamic susceptibility-weighted contrast-enhanced perfusion weighted MRI. ADC and CBV maps were co-registered on the T1-w image and a region of interest (ROI) was manually delineated encompassing the enhancing lesion. Within this ROI pixels with ADC values <the 30th percentile (ADCmin), pixels with CBV values >the 70th percentile (CBVmax) and the intersection of pixels with ADCmin and CBVmax were automatically calculated and visualized. Initially, all tumors with a mean intersection greater than the upper quartile of the normally distributed mean intersection of all patients were subsumed to the first growth pattern termed big intersection (BI). Subsequently, the remaining tumors' growth patterns were categorized depending on the qualitative representation of ADCmin, CBVmax and their intersection. Log-rank test exposed a significantly longer overall survival of BI (n = 16) compared to non-BI group (n = 49) (p = 0.0057). Thirty-one, four and 14 patients of the non-BI group were classified as predominant ADC-, CBV- and mixed growth group, respectively. In a multivariate Cox regression model, the BI-, CBV- and mixed groups had significantly lower adjusted hazard ratios (p-value, α(Bonferroni) < 0.006) when compared to the reference group ADC: 0.29 (0.0027), 0.11 (0.038) and 0.33 (0.0059). Our study provides evidence that the combination of diffusion and perfusion imaging allows visualization of different glioblastoma growth patterns that are associated with prognosis. A possible biological hypothesis for this finding could be the interpretation of the ADCmin fraction as the invasion-front of tumor cells while the CBVmax fraction might represent the vascular rich tumor border that is "trailing behind" the invasion-front in the ADC group.
authors.affiliation: Neurological University Clinic, Department of Neuroradiology, University of Heidelberg Medical Center, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. Deike@stud.uni-heidelberg.de.
authors.forename: Katerina
authors.initials: K
authors.lastname: Deike
authors.affiliation: Department of Neurooncology, University of Heidelberg Medical Center, Heidelberg, Germany. benedikt_wiestler@med.uni-heidelberg.de.|DKTK, Clinical Cooperation Unit Neurooncology, German Cancer Research Center, DKFZ, Heidelberg, Germany. benedikt_wiestler@med.uni-heidelberg.de.
authors.forename: Benedikt
authors.initials: B
authors.lastname: Wiestler
authors.affiliation: Department of Radiology, German Cancer Research Center, DKFZ, Heidelberg, Germany. m.graf@dkfz.de.
authors.forename: Markus
authors.initials: M
authors.lastname: Graf
authors.affiliation: Neurological University Clinic, Department of Neuroradiology, University of Heidelberg Medical Center, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. Reimer@stud.uni-heidelberg.de.
authors.forename: Caroline
authors.initials: C
authors.lastname: Reimer
authors.affiliation: Department of Radiology, German Cancer Research Center, DKFZ, Heidelberg, Germany. r.floca@dkfz.de.
authors.forename: Ralf O
authors.initials: RO
authors.lastname: Floca
authors.affiliation: Neurological University Clinic, Department of Neuroradiology, University of Heidelberg Medical Center, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. philipp_baeumer@med.uni-heidelberg.de.
authors.forename: Philipp
authors.initials: P
authors.lastname: Bäumer
authors.affiliation: Neurological University Clinic, Department of Neuroradiology, University of Heidelberg Medical Center, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. philipp_kickingereder@med.uni-heidelberg.de.
authors.forename: Philipp
authors.initials: P
authors.lastname: Kickingereder
authors.affiliation: Neurological University Clinic, Department of Neuroradiology, University of Heidelberg Medical Center, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. sabine_heiland@med.uni-heidelberg.de.
authors.forename: Sabine
authors.initials: S
authors.lastname: Heiland
authors.affiliation: Department of Radiology, German Cancer Research Center, DKFZ, Heidelberg, Germany. h.schlemmer@dkfz.de.
authors.forename: Heinz-Peter
authors.initials: HP
authors.lastname: Schlemmer
authors.affiliation: Department of Neurooncology, University of Heidelberg Medical Center, Heidelberg, Germany. wolfgang.wick@med.uni-heidelberg.de.|DKTK, Clinical Cooperation Unit Neurooncology, German Cancer Research Center, DKFZ, Heidelberg, Germany. wolfgang.wick@med.uni-heidelberg.de.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Wick
authors.affiliation: Neurological University Clinic, Department of Neuroradiology, University of Heidelberg Medical Center, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. martin_bendszus@med.uni-heidelberg.de.
authors.forename: Martin
authors.initials: M
authors.lastname: Bendszus
authors.affiliation: Neurological University Clinic, Department of Neuroradiology, University of Heidelberg Medical Center, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. a.radbruch@dkfz.de.|Neurooncologic Imaging (E012), Department of Radiology, German Cancer Research Center, DKFZ, Heidelberg, Germany. a.radbruch@dkfz.de.
authors.forename: Alexander
authors.initials: A
authors.lastname: Radbruch
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001932:Brain Neoplasms / Q000473:pathology* / Q000628:therapy; D003131:Combined Modality Therapy; D038524:Diffusion Magnetic Resonance Imaging / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005909:Glioblastoma / Q000473:pathology* / Q000628:therapy; D006801:Humans; D007090:Image Interpretation, Computer-Assisted / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate
keywords: DWI (128); Glioblastoma; MRI (120); Primary brain tumor (214)