Clinical metric for differentiating intracranial hemangiopericytomas from meningiomas using diffusion weighted MRI

doi:10.1016/j.clinimag.2018.10.018

Clinical Imaging

Volume 54, March–April 2019, Pages 1-5

https://doi.org/10.1016/j.clinimag.2018.10.018 Get rights and content

Highlights

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Conventional MR imaging characteristics did not significantly differ between IHP and meningioma.
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IHP tumors demonstrated increased diffusivity relative to meningiomas.
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Using a simple ROI method, an ADC ratio of >1.3 was 96% specific for the diagnosis of IHP.

Abstract

Purpose

Intracranial Hemangiopericytomas (IHP) are dural based tumors that frequently recur/metastasize. Unfortunately, their imaging appearance overlaps significantly with more benign meningiomas. We evaluated the use of diffusion weighted imaging (DWI) to differentiate IHP from meningioma.

Methods

We compared MRI of IHP tumors (WHO Grades II/III) (n = 20) to meningioma (n = 48, WHO Grade I/II).

Findings

ADC values differed between IHP (1.05 × 10–3 mm2/s) and meningiomas (0.89 × 10–3 mm2/s) (p = 0.05). Normalized ADC ratios (nADC), differed between IHP and meningiomas (1.30 vs 1.07, p = 0.03).

Conclusion

Importantly, a nADC cutoff of >1.3 was specific (96%) but not sensitive (35%) for identifying IHP.

Introduction

First described in 1942, hemangiopericytomas are rare tumors that arise from the pericytes of Zimmerman, which surround capillaries [1]. Unfortunately, the early literature on mesenchymal tumors of the central nervous system was highly variable, leading to much confusion. In the most recent iteration of the World Health Organization (WHO) tumor classification, hemangiopericytomas are placed in a spectrum termed solitary fibrous tumor/hemangiopericytoma [2]. The current WHO Grade I, II, and III tumors correlate with the previously termed solitary fibrous tumor, hemangiopericytoma, and anaplastic hemangiopericytoma, respectively. In other words, solitary fibrous tumor (Grade I) are low grade tumors and hemangiopericytomas (Grade II)/anaplastic hemangiopericytomas (Grade III) represent higher grade tumors in the WHO 2016 classification.

WHO Grade II and III tumors, herein collectively termed intracranial hemangiopericytoma (IHP), are aggressive tumors that commonly recur after surgical resection (60%) and metastasize (20%) to distant organs such as lung, bone and liver [3]. Unfortunately, they are notoriously difficult to distinguish from benign dural based masses such as meningiomas using standard MRI sequences. Suggesting the diagnosis of IHP on preoperative imaging may alter surgical management as gross total resection has been shown to independently improve survival and IHPs may require preoperative embolization and/or radiation for adequate treatment [4].

Typical MR imaging features include the following: a heterogeneous dural-based mass, isointensity on T1, mild hyperintensity on T2, contrast enhancement, and prominent signal voids (i.e. ‘flow voids’) [5]. Multiple recent small series have suggested that diffusion-weighted imaging can be useful in differentiating IHP from other dural-based tumors. Liu et al. demonstrated that IHPs had significantly higher absolute ADC and ADC ratios [6]. Meng et al. demonstrated that ADC values were the sole independent predictor of HPC in their series [7].

Here, we present the findings from the largest retrospective MRI series of 20 patients with pathologically proven IHP (WHO Grade II and III) from two institutions. MRI findings, including diffusion weighted imaging (DWI) findings were compared with a control cohort of patients with WHO Grade I and II meningiomas. We hypothesize that IHPs in our series would demonstrate elevated ADC values.

Section snippets

Materials and methods

An IRB approved, retrospective review of pathology databases from two separate institutions for cases of IHP and meningioma from 2005 to 2016 was performed. Results were referenced with the PACS for preoperative MR imaging. Imaging required for inclusion consisted of the following sequences: axial fluid attenuated inversion recovery (FLAIR), pre-contrast T1-weighted image (T1WI), axial fast spin echo (FSE) T2-weighted image (T2WI), axial isotropic DWI, coronal FLAIR T2WI, sagittal FLAIR T1WI,

Demographics

Of the 26 patients identified with histology confirmed IHP, 20 had relevant preoperative MR imaging available for review. The IHP study population was 70% male (age range: 22–78) and 30% female (age range: 22–75). The average IHP patient was 53.0 years old.

321 cases of WHO Grade I meningioma and 51 cases of WHO Grade II meningioma were identified in the above time period. 30 cases from each group were selected for inclusion in our series using a random number generator in the R software

Discussion

Generally speaking, restricted diffusion has been shown to correlate with tumor grade in numerous intracranial neoplasms. Previous work by Filippi et al. showed that DWI could differentiate low and high grade meningiomas, with higher grade meningiomas demonstrating more diffusion restriction than lower grade meningiomas [8]. While there is not a consensus on the biophysical basis of this phenomenon, it is generally thought to be the result of a combination of higher cellularity, tissue

Conclusions

IHPs are rare extra-axial neoplasms which can have a similar appearance to the more common meningiomas on conventional MR imaging. As has been described in the literature, the presence flow voids and contrast enhancement were common. Our series, the largest MRI series of IHPs to date, suggests that elevated ADC values on DWI are also a common imaging feature, 70% in our series. In fact, this finding may be distinctive enough to differentiate it from meningiomas of varying grades with high

Acknowledgements

None.

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Cited by (7)

Radiological Differentiation Between Intracranial Meningioma and Solitary Fibrous Tumor/Hemangiopericytoma: A Systematic Literature Review
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Of the 11 studies that incorporated DWI, 5 (5/11, 45%) used DWI-derived measures of ADC to distinguish between SFT and various grades/subtypes of meningioma. Four out of the 5 studies (4/5, 80%) found that those with SFT had significantly higher mean ADC values compared to those with meningioma,6,10,24,25 and the study by Ohba et al. found no statistically meaningful differences in ADC values between both tumor types.19 Four studies mentioned the types of meningioma included, which ranged from low grade (WHO grade I) to high grade meningiomas (WHO grade II–III).
Intracranial solitary fibrous tumor (SFT) is characterized by aggressive local behavior and high post-resection recurrence rates. It is difficult to distinguish between SFT and meningiomas, which are typically benign. The goal of this study was to systematically review radiological features that differentiate meningioma and SFT.
We performed a systematic review in accordance with PRISMA guidelines to identify studies that used imaging techniques to identify radiological differentiators of SFT and meningioma.
Eighteen studies with 1565 patients (SFT: 662; meningiomas: 903) were included. The most commonly used imaging modality was diffusion weighted imaging, which was reported in 11 studies. Eight studies used a combination of diffusion weighted imaging and T1- and T2-weighted sequences to distinguish between SFT and meningioma. Compared to all grades/subtypes of meningioma, SFT is associated with higher apparent diffusion coefficient, presence of narrow-based dural attachments, lack of dural tail, less peritumoral brain edema, extensive serpentine flow voids, and younger age at initial diagnosis. Tumor volume was a poor differentiator of SFT and meningioma, and overall, there were less consensus findings in studies exclusively comparing angiomatous meningiomas and SFT.
Clinicians can differentiate SFT from meningiomas on preoperative imaging by looking for higher apparent diffusion coefficient, lack of dural tail/narrow-based dural attachment, less peritumoral brain edema, and vascular flow voids on neuroimaging, in addition to younger age at diagnosis. Distinguishing between angiomatous meningioma and SFT is much more challenging, as both are highly vascular pathologies. Tumor volume has limited utility in differentiating between SFT and various grades/subtypes of meningioma.
Tumor volume and the dural tail sign enable the differentiation of intracranial solitary fibrous tumor/hemangiopericytoma from high-grade meningioma
2021, Clinical Neurology and Neurosurgery
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Finally, SFT/HPC is a rare tumor; therefore, our sample size was small, and the sample size was markedly different between the tumor groups. Hence, the established models could not be [1–48] fully validated using an internal/external validation dataset. Nevertheless, we applied rigorous and scientific data processing and statistical analysis to minimize potential errors caused by the small sample size.
Intracranial solitary fibrous tumor/hemangiopericytoma (SFT/HPC) is a rare mesenchymal neoplasm with imaging features mimicking high-grade meningioma (HGM) and can easily be misdiagnosed. We sought to determine the value of routine preoperative data in differentiating these tumors.
Patients with confirmed SFT/HPC or HGM between January 2012 and June 2020 were identified. A total of 28 preoperative variables (including age, sex, tumor location, tumor volume, 10 traditional MRI features, and 14 peripheral blood indices) were collected for each patient. The top features were selected sequentially based on the least absolute shrinkage and selection operator (LASSO) and support vector machines-recursive feature elimination (SVM-RFE) methods. Differentiation and calibration of the classifiers were assessed by receiver operating characteristic (ROC) curves and calibration curves, respectively. Nomograms were constructed based on multivariate analysis.
A total of 127 patients, including 29 with SFT/HPC and 98 with HGM, were analyzed. Three features were first selected using the LASSO and SVM-RFE methods, and corresponding models were developed. Although the area under the curve (AUC) of model 1 was the highest, a comprehensive analysis suggested the superiority of model 2, which consisted only of the features tumor volume (TV) and dural tail sign (DTS) (AUC: 0.942, sensitivity: 93.10%, p-value of H-L test: 0.734, Brier score: 0.07). A risk score formula and a nomogram were constructed.
TV can be used to effectively identify SFT/HPC and HGM, whereas adding DTS can improve the overall prediction accuracy. As these two variables are routinely available and are easy for clinicians to master, they can provide a powerful reference for clinical decision-making.
Whole-tumor histogram analysis of apparent diffusion coefficient in differentiating intracranial solitary fibrous tumor/hemangiopericytoma from angiomatous meningioma
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Advanced MRI techniques, such as diffusion weighted imaging (DWI), can provide information on the tissue microstructural characteristics and may be valuable in this regard. Some researchers have studied the role of apparent diffusion coefficient (ADC) measurements in differentiation of these two but with no agreement obtained [4,5,13,14]. This may be mainly due to the research methods they used.
To assess the role of histogram analysis of apparent diffusion coefficient (ADC) maps based on whole-tumor in differentiating intracranial solitary fibrous tumor/hemangiopericytoma (SFT/HPC) from angiomatous meningioma (AM).
Pathologically confirmed intracranial SFT/HPC (n = 15) and AM (n = 20) were retrospectively collected and their clinical and conventional MRI features were analyzed. Diffusion-weighted (DW) images (b = 0 and 1000 s/mm²) were processed with the mono-exponential model. Regions of interest covering the whole tumor were drawn on all slices of the ADC maps to obtain histogram parameters, including mean ADC (ADCmean), median ADC (ADCmedian), maximum ADC (ADCmax), minimum ADC (ADCmin), skewness and kurtosis, as well as the 5th, 10th, 25th, 75th, 90th and 95th percentile ADC (ADC5, ADC10, ADC25, ADC75, ADC90 and ADC95). Differences of histogram parameters between SFT/HPC and AM were compared using Mann-Whitney U test. Receiver operating characteristic (ROC) curve was used to determine the diagnostic performance.
The ADCmin (P = 0.001) and ADC5 (P = 0.045) were significantly lower in SFT/HPCs than in AMs, while no significant difference was found in sex, age, conventional MRI features or any other histogram parameters between the two entities (P = 0.051−1.000). ADCmin showed the best diagnostic performance (area under curve [AUC], 0.86; sensitivity, 81.3%; specificity, 83.3%) in differentiating SFT/HPC from AM with optimal cutoff value being 569.00 × 10⁻⁶ mm²/s, followed by ADC5 (AUC, 0.72; sensitivity, 68.8%; specificity, 75%) with optimal cutoff value being 781.97 × 10⁻⁶ mm²/s.
SFT/HPC and AM share similar conventional MR appearances. Whole-tumor histogram analysis of ADC maps may be a useful tool for differential diagnosis, with ADCmin and ADC5 being potential parameters.
T1 and ADC histogram parameters may be an in vivo biomarker for predicting the grade, subtype, and proliferative activity of meningioma
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NeuroradiologyClinical metric for differentiating intracranial hemangiopericytomas from meningiomas using diffusion weighted MRI