title: Diffusion-Weighted Imaging in Meningioma: Prediction of Tumor Grade and Association with Histopathological Parameters.
abstract: OBJECTIVE
  To analyze diffusion-weighted imaging (DWI) findings of meningiomas and to compare them with tumor grade, cell count, and proliferation index and to test a possibility of use of apparent diffusion coefficient (ADC) to differentiate benign from atypical/malignant tumors.
  
  
  METHODS
  Forty-nine meningiomas were analyzed. DWI was done using a multislice single-shot echo-planar imaging sequence. A polygonal region of interest was drawn on ADC maps around the margin of the lesion. In all lesions, minimal ADC values (ADCmin) and mean ADC values (ADCmean) were estimated. Normalized ADC (NADC) was calculated in every case as a ratio ADCmean meningioma/ADCmean white matter. All meningiomas were surgically resected and analyzed histopathologically. The tumor proliferation index was estimated on Ki-67 antigen-stained specimens. Cell density was calculated. Collected data were evaluated by means of descriptive statistics. Analyses of ADC/NADC values were performed by means of two-sided t tests.
  
  
  RESULTS
  The mean ADCmean value was higher in grade I meningiomas in comparison to grade II/III tumors (0.96 vs 0.80 × 10(-3) mm(2)s(-1), P = .006). Grade II/III meningiomas showed lower NADC values in comparison to grade I tumors (1.05 vs 1.26, P = .015). There was no significant difference in ADCmin values between grade I and II/III tumors (0.69 vs 0.63 × 10(-3) mm(2)s(-1), P = .539). The estimated cell count varied from 486 to 2091 (mean value, 1158.20 ± 333.74; median value, 1108). There were no significant differences in cell count between grade I and grade II/III tumors (1163.93 vs 1123.86 cells, P = .77). The mean level of the proliferation index was 4.78 ± 5.08%, the range was 1% to 18%, and the median value was 2%. The proliferation index was statistically significant higher in grade II/III meningiomas in comparison to grade I tumors (15.43% vs 3.00%, P = .001). Ki-67 was negatively associated with ADCmean (r = -0.61, P < .001) and NADC (r = -0.60, P < .001). No significant correlations between cell count and ADCmean (r = -0.20, P = .164) or NADC (r = -0.25, P = .079) were found. ADCmin correlated statistically significant with cell count (r = -0.44, P = .002) but not with Ki-67 (r = -0.22, P = .129). Furthermore, the association between ADCmin and cell count was stronger in grade II/III tumors (r = -0.79, P = .036) versus grade I meningiomas (r = -0.41, P = .008). An ADCmean value of less than 0.85 × 10(-3) mm(2)s(-1) was determined as the threshold in differentiating between grade I and grade II/III meningiomas (sensitivity 72.9%, specificity 73.1%, accuracy 73.0%). The positive and negative predictive values were 33.3% and 96.8%, respectively. The same threshold ADCmean value was used in differentiating between tumors with Ki-67 level ≥5% and meningiomas with low proliferation index (Ki-67 <5%). This threshold yielded a sensitivity of 70.6%, a specificity of 81.2%, and an accuracy of 77.6%. The positive and negative predictive values were 66.6% and 83.9%, respectively.
  
  
  CONCLUSIONS
  Grade II/III tumors had lower ADCmean values than grade I meningiomas. ADCmean correlated negatively with tumor proliferation index and ADCmin with tumor cell count. These associations were different in several meningiomas. ADCmean can be used for distinguishing between benign and atypical/malignant tumors.
authors.affiliation: Department of Radiology, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06097 Halle. Electronic address: alex.surow@medizin.uni-halle.de.
authors.forename: Alexey
authors.initials: A
authors.lastname: Surov
authors.affiliation: Department of Radiology, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06097 Halle. Electronic address: sebastian.gottschling@googlemail.com.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Gottschling
authors.affiliation: Department of Neuropathology, Otto-von-Guericke-University Magdeburg, Leipziger Str. 44, 39120 Magdeburg. Electronic address: christian.mawrin@med.ovgu.de.
authors.forename: Christian
authors.initials: C
authors.lastname: Mawrin
authors.affiliation: Department of Neurosurgery, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06097 Halle. Electronic address: julian.prell@medizin.uni-halle.de.
authors.forename: Julian
authors.initials: J
authors.lastname: Prell
authors.affiliation: Department of Radiology, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06097 Halle. Electronic address: rolf.spielmann@medizin.uni-halle.de.
authors.forename: Rolf Peter
authors.initials: RP
authors.lastname: Spielmann
authors.affiliation: Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Magdeburger Straße 8, 06112 Halle. Electronic address: andreas.wienke@medizin.uni-halle.de.
authors.forename: Andreas
authors.initials: A
authors.lastname: Wienke
authors.affiliation: Department of Dermatology (histopathological laboratory), Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06097 Halle. Electronic address: eckhard.fiedler@medizin.uni-halle.de.
authors.forename: Eckhard
authors.initials: E
authors.lastname: Fiedler