Differentiating glioblastoma from primary central nervous system lymphoma of atypical manifestation using multiparametric magnetic resonance imaging: A comparative study

Abstract

Background: The aim of this study is to evaluate the diagnostic efficiency of magnetic resonance imaging (MRI) of single parameters, unimodality, and bimodality in distinguishing glioblastoma (GBM) from atypical primary central nervous system lymphoma (PCNSL) based on diffusion-weighted imaging (DWI), dynamic susceptibility contrast (DSC) enhancement, diffusion tensor imaging (DTI), and proton magnetic resonance spectroscopy (¹H-MRS) findings.

Methods: The cohort included 108 patients pathologically diagnosed with GBM and 54 patients pathologically diagnosed with PCNSL. Pretreatment morphological MRI, DWI, DSC, DTI and MRS were all performed on each patient. The quantitative parameters of multimodal MRI were measured and compared between the patients in the GBM and atypical PCNSL groups, and those parameters showing a significant difference (p < 0.05) between patients in the GBM and atypical PCNSL groups were used to develop one-parameters, unimodality, and bimodality models. We evaluated the efficiency of different models in distinguishing GBM from atypical PCNSL by performing receiver operating characteristic analysis (ROC).

Results: Atypical PCNSL had lower minimum apparent diffusion coefficient (ADC_min), mean ADC (ADC_mean), relative ADC (rADC), mean relative cerebral blood volume (rCBV_mean), maximum rCBV (rCBV_max), fractional anisotropy (FA), axial diffusion coefficient (DA) and radial diffusion coefficient (DR) values and higher choline/creatine (Cho/Cr) and lipid/creatine (Lip/Cr) ratios than GBM (all p < 0.05). The rCBV_max, DTI and DSC + DTI data were optimal models of single-parameter, unimodality and bimodality for differentiation of GBM from atypical PCNSL, yielding areas under the curves (AUCs) of 0.905, 0.954, and 0.992, respectively.

Conclusions: Models of single-parameter, unimodality and bimodality based on muti multiparameter functional MRI may help to discriminate GBM from atypical PCNSL.

Keywords: Advanced MR Imaging; Atypical primary central nervous system lymphomas; Diffusion tensor imaging; Glioblastoma; Multiparametric MRI.

Fig. 1

Flowchart of the study population. PCNSL, primary central nervous system lymphoma; MRI, magnetic resonance imaging; DWI, diffusion-weighted imaging; DSC, dynamic susceptibility contrast enhancement-perfusion weighted imaging; DTI, diffusion tensor imaging; MRS, magnetic resonance spectroscopy.

Fig. 2

Images acquired from a 50-year-old female pathologically diagnosed with GBM. (a and b) Axial and sagittal contrast-enhanced T1WI present relatively strong peripheral enhancement of the lesion in the right temporal lobe. (c) Axial T2WI demonstrating that a substantial area of the lesion has an equal/slightly increased signal and that the cystic and necrotic regions exhibit hyperintensity; hyperintense edema associated with the mass can be seen around the lesion. (d) Axial FLAIR showing that a substantial area of the lesion is slightly hyperintense and that the cystic and necrotic regions exhibit hypointensity; hyperintense edema associated with the mass can be seen around the lesion. (e) DWI demonstrating a hyperintense tumor mass of substantial size, central hypointense tumor necrosis, and isointense peritumoral edema. (f) ADC map with mild hypointensity of the lesion to measure ADC_mean values of 0.938 × 10⁻³ mm²/s at substantial areas. (g) rCBV map showing hyperperfusion in a substantial area with an rCBV_mean value of 6.06 at the region of the lesion; (h) FA map showing FA values of 0.22 at the area of the lesion; (i) color-coded map generated based on DTI data; (j) spectroscopy analysis revealed choline (Cho)/N-acetylaspartate (NAA), Cho/creatine (Cr), NAA/Cr, lipid (Lip)/Cr and lactate (Lac)/Cr ratios of 1.76, 1.48, 0.83, 3.12 and 1.28, respectively. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

Fig. 3

Images acquired from a 48-year-old female pathologically diagnosed with PCNSL. (a and b) Axial and coronal contrast-enhanced T1WI presents a relatively strong enhanced lesion in the right basal ganglia. (c) Axial T2WI shows that a substantial area of the lesion has an equal/slightly increased signal but no obvious cystic or necrotic regions; hyperintense edema associated with the mass can be seen around the lesion. (d) Axial FLAIR demonstrates that a substantial area of the lesion presents as slightly hyperintense, and hyperintense edema associated with the mass can be seen. (e) DWI shows a hyperintense tumor mass in a substantial region as well as isointense peritumoral edema. (f) ADC map with mild hypointensity/hypointensity of the lesion and the ADC_mean values of a substantial region of 0.632 × 10⁻³ mm²/s (g) rCBV map showing scattered areas with substantial hypoperfusion and an rCBV_mean value of 2.94; (h) FA map showing FA values of 0.14 at the region of the lesion; (i) color-coded map to be generated based on DTI data; (j) spectroscopy analysis revealed ratios of choline (Cho)/N-acetylaspartate (NAA), Cho/creatine (Cr), NAA/Cr, lipids (Lip)/Cr and lactate (Lac)/Cr of 2.14, 1.60, 0.74, 5.44 and 1.39, respectively. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

Fig. 4

Box scatter plots of ADC_min (a), ADC_mean (b), rADC (c), rCBV_mean (d), rCBV_max (e), FA (f), DA (g), DR (h), Cho/Cr (i), and Lip/Cr (j). Abbreviations: ADC_min, minimum apparent diffusion coefficient values; ADC_max, maximum ADC values; rADC, relative ADC; rCBV_mean, mean relative cerebral blood volume; rCBV_max, maximum relative cerebral blood volume; FA, fractional anisotropy; DA, axial diffusion coefficient; DR, radial diffusion coefficient; Cho, choline; Cr, creatine; Lip, lipids.

Fig. 5

The ROC curves based on the single-parameter (a–d), unimodality (e) and bimodality (f) models. Abbreviations: ADC_min, minimum apparent diffusion coefficient values; ADC_max, maximum ADC values; rADC, relative ADC; rCBV_mean, mean relative cerebral blood volume; rCBV_max, maximum relative cerebral blood volume; FA, fractional anisotropy; DA, axial diffusion coefficient; DR, radial diffusion coefficient; Cho, choline; Cr, creatine; Lip, lipids; DWI, diffusion-weighted imaging; DSC, dynamic susceptibility contrast enhancement; DTI, diffusion tensor imaging; MRS, magnetic resonance spectroscopy. Notes: DWI comprises the metrics ADC_min, ADC_mean and rADC; DSC includes the metrics rCBV_mean and rCBV_max; DTI comprises the parameters FA, DA and DR; and MRS contains ratios of Cho/Cr and Lip/Cr.