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Spectroscopic Window on Tumor Metabolism Michael Garwood, Ph.D. Univ. of Minnesota Role of MRS in the Clinical Management of Cancer • Diagnosis: guide biopsy avoid unnecessary/risky biopsies ascertain aggressiveness/stage/prognosis • Treatment: guide choice of treatment identify non-responders early → alter treatment regime tool for follow up High Res 1H MRS of Cells Non-Malignant cells Malignant cells extract in vitro Ackerstaff et al., J Cell Biochem 2003 GPC → PCho switch Aboagye et al., Cancer Res 1999 Choline-containing compounds H H C H + R-CH2-CH2-N -C H C H H H H - - H In vivo 1H MRS of breast cancer First reported studies: Roebuck et al, Radiol 1998; Gribbestad et al, JMRI 1998 1H MRI MRS suppressed water invasive ductal carcinoma lipid Choline compounds (tCho) lipids Frequency (ppm) CMRR 4 Tesla Infiltrating ductal carcinoma P < 0.0008 Benign Focal Fibrosis Jacobs MA, Barker PB, et al. Proton magnetic resonance spectroscopic imaging of human breast cancer: a preliminary study. J Magn. Reson Imaging. 2004 Jan;19(1):68-75 Membrane Choline Phospholipid Metabolism Lysophosphatidic acid Adapted from Aboagye EO, Bhujwalla ZM. Cancer Res 59:80-84 1999 Mechanisms of increased PC in cancer: • Increased expression and activity of choline kinase [Ramirez de Molina et al., Oncogene 2002] • Higher rate of choline transport [Katz-Brull & Degani, AntiCancer Res. 1996] • Increased PLD activity [Noh et al., Cancer Lett. 2000] • Increased PLA2 activity [Guthridge et al., Cancer Lett. 1994] Glioblastoma Multiforme (High Grade Tumor) FLAIR Cho Right T1 Cho Cr NAA NAA Lac Left PPM 4.0 3.0 2.0 1.0 slide courtesy of Peter Barker, Johns Hopkins U Prostate Cancer Cheng LL, FEBS Lett. 2001 Normal human prostate Tumor-bearing prostate MRI/MRSI Targeted, TRUS-Guided Biopsies courtesy of J.Kurhanewicz, UCSF MR targeted TRUS guided biopsy positive 5 PSA - 12 ng/ml Two prior negative biopsies The accuracy of cancer detection of MRI/MRSI targeted biopsy in men with prior negative biopsy ≈80%. (Yuen et al, J. Urol. 2004; Prando et al, Radiology 2005) 5 5 5 5 The sensitivity of TRUS guided biopsy is reduced in large prostates and when the cancer is located in difficult locations such as the apex or in the anterior or lateral aspects of the prostate. Journal Urology 2000, 164(2) 400-404 Chemical Shift: Minimized with higher BW pulses Standard pulses Broadband pulses Spectrum 900 DF DF DF Gradients RF 1800 90 180 180 Center Frequency (-235 Hz) %CS : DF / BWRF X Courtesy of: G. Metzger Y Z 13 OVS with over-prescription Courtesy of: G. Metzger 14 Prostate Spectroscopy at 3T: Single Voxel Echo Time, Coupling and SNR TE = 260 ms TE = 100 ms Courtesy of: P. Choyke & G. Metzger 15 Case Study: Slice 5 Cho Cre Cit Sp Courtesy of: P. Choyke & G. Metzger 16 Quantification • Metabolite ratios (eg, tCho/NAA, (tCho+Cr)/Cit) • External reference (eg, phantom of known conc) • Reference to tissue water signal 3 Tesla Normal breast MRI Devices 4-ch coil 3x3x3 cm voxel LASER Localization a) TE Averaging (60-300ms in 128 increments) NEX=2 tCho b) 6 5 4 3 2 1 0 Breast Anatomy Lobules Adipose tissue Fibroglandular tissue Stroma Fat Tavassoli, 1999 • Anatomy varies greatly • Tissues are distributed heterogeneously Intravoxel lipids are inevitable Netter, 1997 Internal Referencing with Water • NOT assuming constant water concentration • Assuming a two-compartment model (water & fat) and all tCho is in the aqueous compartment f gain fT1 fT2 AtCho [tCho] Awater f gain fT1 fT2 [tCho] expressed in molal units (mmol tCho/kg water) No assumptions about volume or density water tCho water 1 tCho MWwater A Time domain amplitude f gain receiver gain correction fT1 fT2 relaxation correction water ,tCho # nuclei / molecule MWwater molecular wt Bolan et al., MRM 2003 Spectral Fitting Adapted TDFDFit (Slotboom et al., MRM 1998) Time-Domain Model: s(t ) A exp(it i t 2t 2 ) Minimize residuals in frequency-domain over narrow (0.4 ppm) band model • Fit 3 peaks independently: tCho, water, 1.3 ppm lipid data • Errors from Cramer-Rao Minimum Variance Bound; used for detection threshold residual 6 4 ppm 2 0 Bolan et al., MRM 2003 Normal gland (Presumed) [tCho] = 0.75 ± 0.07 mmol/kg volume = 13.0 mL lipid fraction = 3.5% Invasive Ductal Carcinoma [tCho] = 6.8 ± 0.1 mmol/kg volume = 6.8 mL lipid fraction = 8% Atypical Hyperplasia [[tCho] = 1.5 ± 0.8 mmol/kg volume = 1.1 mL lipid fraction = 15% Bolan et al., MRM 2003 no Cho invasive ductal carcinoma 6 5 4 3 2 1 0 -1 -2 Frequency (ppm) Reason for false negative? Spurious lipid sideband peaks! invasive ductal carcinoma 6 5 4 3 2 1 0 -1 -2 Frequency (ppm) Sideband Artifacts water sidebands sidebands • Antisymmetric side peaks TE (ms) 57 • Amplitude >1% • Caused by B0 oscillation 45 -500 -300 -100 Hz Sidebands have coherent, TE-dependent phase 100 300 -500 Averaging causes destructive interference Bolan et al., MRM 2002 Echo-time Averaging tCho? NEX=64 TE=45ms Conventional single TE No tCho TE=45-196ms 64 increments TE averaging 8 6 2 4 ppm 0 -2 Bolan et al., MRM 2002 In vivo 1H spectrum of a voxel containing mainly adipose tissue Day 127 (AC x 4 followed by Taxotere x 3) size = 3.0 x 2.7 x 3.0 cm3 [Cho] = 0.642 mmol/kg [Cho] = 0.910 mmol/kg [Cho] = 0 mmol/kg Invasive Ductal Carcinoma Precontrast Postcontrast Subtraction 4 H2O Lipid 3 Lipid Lipid SI 2 tCho 1 0 0 1 2 3 time (min) (sec) 4 All 4 readers maintained their decision to biopsy 5 7 6 5 4 3 2 ppm 1 0 -1 [tCho] = 0 ± 1.73 Meisamy et al, Radiology 2005 Conclusions about MRS for breast cancer diagnosis: Adding quantitative 1H MRS to breast MRI improves sensitivity, specificity, and accuracy, over MRI alone Quantitative 1H MRS is particularly useful in cases where lesion morphology and time-intensity curves are indeterminate Meisamy et al, Radiology 2005 Treatment Planning and Monitoring MRSI for Radiation Treatment Planning of Brain Tumor MRSI-based radiation dose painting using the IMRT method Cho/Cr Grade Dose painting <1 0 ≥1-2 1 5040 ≥2-3 2 5940 ≥3 3 7020 Thakur, Chang, Huang, Koutcher, Narayana Memorial Sloan-Kettering Cancer Center Models of tCho response Jordan et al., NMR Biomed 2006 Al-Safar et al., Cancer Res 2006 cell density PCho CK Measured acute response to PX-478 (inhibits HIF1-alpha production) in mouse xenografts of HT-29 (colon) Measured acute response to MN58b (inhibits CK) in mouse xenografts of MDAMB-231 (breast) and HT-29 (colon) Methods: in vivo MRS at 4.7T, ex vivo validation Methods: in vivo MRS at 4.7T, ex vivo validation Results: tCho dropped significantly at 12 and 24 hrs Results: tCho dropped significantly at 48hrs in both models Treatment Monitoring in Breast Cancer Neoadjuvant chemotherapy (primary systemic therapy, PST) is the preferred treatment for locally advanced breast cancer (Fisher et al. J Clin Oncol 1997, 1998) Advantages: Tumor shrinkage; possible breast conserving procedures In vivo monitoring of chemo-sensitivity (customize Tx complete pathologic response) 4T Tx Monitoring in Breast Cancer: Results to Date Non-Responders 9 9 8 8 7 7 [tCho] (mmol/kg) [tCho] (mmol/kg) Responders 6 5 4 3 5 4 3 2 1 1 0 0 Day 1 • 9/10 Nonresponders had a increase in [tCho] at Day 1 6 2 Baseline • 14/18 Responders had a decrease in [tCho] at Day 1 • Day 1 Rule: 82% accuracy in 28 subjects Baseline Day 1 Meisamy et al, Radiology 2004 Responder to AC Pre PST 24 hrs AC X 1 AC X 4 [tCho] = 4.6 LD = 4.0 cm [tCho] = 3.7 LD = 4.0 cm [tCho] = 0.9 LD = 1.7 cm Meisamy et al, Radiology 2004 Responder to AC, but not Taxol Pre PST 24 hrs AC X 1 AC X 4 Taxol X 2 [tCho] = 4.6 LD = 4.0 cm [tCho] = 3.7 LD = 4.0 cm [tCho] = 0.9 LD = 1.7 cm [tCho] = 4.1 LD = 1.7 cm Meisamy et al, Radiology 2004 Therapeutic Selection and Monitoring Baseline 1 year 5 years courtesy of J.Kurhanewicz, UCSF citrate choline Metabolic Atrophy Metabolic Atrophy Is it possible to predict response from baseline MRS data? Treatment Prediction / Phenotyping Non-Responders 9 8 8 7 7 [tCho] (mmol/kg) [tCho] (mmol/kg) Responders 9 6 6 5 5 4 4 3 3 2 2 1 1 0 0 Baseline Baseline [tCho] was higher in responders than in non-responders (p=0.03) Day 1 Baseline Day 1 Inconsistent findings in brain MRS: Tzika, Neuroradiology 2001 – responders had lower tCho Preul, Neurosurgery 2000 – no difference Lazareff, J Neurooncol 1999 – no difference Higher [tCho] @ baseline associated with higher grade & positive nodes Can MRS identify responders before starting treatment? Pretreatment PME/NTP ratio Preliminary results with 31P MRSI Pretreatment 31P spectrum from nodal disease of a HNSCC patient who experienced partial response Pretreatment PME/NTP ratios from tumors; complete responders were different from incomplete response group P<0.001 A. Shukla-Dave, et. al. Acad Radiol, 9:688-694, 2002 31P MRS in Bone Sarcoma Baseline spectrum Zakian, et. al., Cancer Research 2003 Dec 15;63(24):9042-7 Baseline Energetics Predicts Outcome in Bone Sarcoma NTP/Pi predicts longer survival Zakian, et. al., Cancer Research 2003 Dec 15;63(24):9042-7 Future: • More studies correlating with pathology, immunohistochemistry, and outcomes • Further studies to assess reliability/reproducibility • Results of multi-center trials • Combine with other metrics (DCE-MRI, ADC,…) → multiparametric analyses • 3T (and higher?) IMAPS (1.5T) Data example A Prostate spectroscopy at 1.5T with endorectal coil C The axial T2-weighted image (A) is used for matching voxel locations to histopathological specimens (D). One of the spectral maps (B), partially expanded in (E), reflects the quality of the MRSI data throughout the slice. Deviations in the (Cho + Cr)/Ci metabolite ratio map in (C) largely correspond to the tumor location indicated with the blue line in (D). D B Cho+Cr Ci Cho Ci Courtesy of T. Scheenen and Prof. A. Heerschap, Radboud University Nijmegen E Medical Center, Dept. of Radiology Figure 3. The axial T2-weighted image (A) is used for matching The IMAPS community voxel locations to histopathological specimens (D). One of the Slide courtesy of Michael Jacobs, JHU Current Multiparametric (MRI/DTI/MRSI) Prostate Imaging Exam Slide courtesy J. Kurhanewicz UCSF MRSI (0.3 cc) Decreased Signal Intensity on T2 weighted Imaging Reduced water diffusion T2 weighted MRI Healthy Cancer Citrate Elevated choline Reduced citrate Reduced polyamines Lipid Choline Creatine Creatine Polyamines Choline Diffusion weighted MRI ADC Map PPM 3.0 2.5 2.0 3.0 2.5 2.0 3T MRSI vs 1.5T MRSI: Improved Detection of Residual Cancer 3T 1.5T Choline Creatine 0.16 cc 0.34 cc Cho Cho Cho Cho Cho Acknowledgements Thanks for Sending Slides Arend Heerschap Jason Koutcher John Kurhanewicz Michael Jacobs Peter Barker Wei Huang U of Minn Researchers Patrick Bolan Greg Metzger Sina Meisamy Adeka McIntosh Curt Corum Angela Styczynski Nate Powell Djaudat Idiyatullin Jang-Yeon Park Carl Snyder James Boyum Doug Yee Michael Nelson Tim Emory Lenore Everson Todd Tuttle Evin Gulbahce Tommy Vaughan Funding Sources National Institutes of Health (CA92004, RR08079)