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Combined Use of Diffusion-Weighted MRI and 1H MR Spectroscopy to Increase Accuracy in Prostate Cancer Detection

Stefan A. Reinsberg1, Geoffrey S. Payne1, Sophie F. Riches1, Sue Ashley2, Jonathan M. Brewster3, Veronica A. Morgan1 and Nandita M. deSouza1,3

1 Clinical Magnetic Resonance Group, Royal Marsden NHS Foundation Trust, Royal Marsden Hospital, Downs Rd., Sutton, Surrey SM2 5PT, United Kingdom.
2 Department of Statistics, Royal Marsden NHS Foundation Trust, Sutton, Surrey, United Kingdom.
3 Institute of Cancer Research, Royal Marsden NHS Foundation Trust, Sutton, Surrey, United Kingdom.


Figure 1
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  		Fig. 1A —75-year-old man with prostate cancer. Endorectal T2-weighted transverse image through mid prostate shows well-defined low-signal-intensity region in peripheral zone on left (arrows), within sextant that was positive for tumor on biopsy.

 

Figure 2
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  		Fig. 1B —75-year-old man with prostate cancer. Radiologist-determined region of interest around tumor and overlay of voxels for MR spectroscopy acquisition are seen.

 

Figure 3
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  		Fig. 1C —75-year-old man with prostate cancer. Hydrogen-1 MR spectroscopy from a voxel of nonmalignant peripheral zone on right (signal-to-noise ratio [SNR] = 4) (C) is compared with a spectrum from malignant peripheral zone nodule on left (SNR = 3) (D). Gray line shows data and black line represents fit using LCModel (Stephen Provencher, Inc.) (both smoothed for display using 5-point weighted average). Increase in choline (Cho) (3.2 ppm) and decrease in citrate (Cit) (2.6 ppm) are seen in D compared with C. In C, Cho/Cit ratio is 0.31; in D, 0.45. AU = arbitrary units.

 

Figure 4
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  		Fig. 1D —75-year-old man with prostate cancer. Hydrogen-1 MR spectroscopy from a voxel of nonmalignant peripheral zone on right (signal-to-noise ratio [SNR] = 4) (C) is compared with a spectrum from malignant peripheral zone nodule on left (SNR = 3) (D). Gray line shows data and black line represents fit using LCModel (Stephen Provencher, Inc.) (both smoothed for display using 5-point weighted average). Increase in choline (Cho) (3.2 ppm) and decrease in citrate (Cit) (2.6 ppm) are seen in D compared with C. In C, Cho/Cit ratio is 0.31; in D, 0.45. AU = arbitrary units.

 

Figure 5
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  		Fig. 1E —75-year-old man with prostate cancer. Apparent diffusion coefficient (ADC) map at native resolution (E) and ADC map resampled to match MR spectroscopy resolution (F) show restricted diffusion in left peripheral zone (mean ADC: tumor-containing voxel, 0.8 x 10-3 mm2/s; non-tumor-containing voxel, 1.24 x 10-3 mm2/s).

 

Figure 6
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  		Fig. 1F —75-year-old man with prostate cancer. Apparent diffusion coefficient (ADC) map at native resolution (E) and ADC map resampled to match MR spectroscopy resolution (F) show restricted diffusion in left peripheral zone (mean ADC: tumor-containing voxel, 0.8 x 10-3 mm2/s; non-tumor-containing voxel, 1.24 x 10-3 mm2/s).

 

Figure 7
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  		Fig. 2 —Scatterplot of choline-citrate (Cho/Cit) ratio versus apparent diffusion coefficient (ADC) for MR spectroscopy voxels with minimum signal-to-noise ratio of 2. Tumor voxels (...) were those that contained 70% or more tumor, as outlined on T2-weighted images. Peripheral zone voxels (x) are non-tumor-containing voxels with at least 70% peripheral zone, and central gland voxels (+) are non-tumor-containing voxels with 70% or more central gland. Non-tumor-containing voxels, which do not reach either of these classification thresholds, are labeled peripheral zone, central gland, or central gland-peripheral zone mixed ({blacksquare}). Line optimally separating tumor from nontumor voxels is shown.

 

Figure 8
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  		Fig. 3A —Receiver operating characteristic (ROC) curves. ROC curves show power of choline-citrate (Cho/Cit) ratio alone (dashed line), apparent diffusion coefficient (ADC) alone (dotted line), and combination of the two (solid line) as predictors of tumor at histology when voxels containing ≥ 30% tumor as defined by tumor regions of interest on T2-weighted images are considered positive (A) and when voxels containing ≥ 70% tumor are considered positive (B).

 

Figure 9
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  		Fig. 3B —Receiver operating characteristic (ROC) curves. ROC curves show power of choline-citrate (Cho/Cit) ratio alone (dashed line), apparent diffusion coefficient (ADC) alone (dotted line), and combination of the two (solid line) as predictors of tumor at histology when voxels containing ≥ 30% tumor as defined by tumor regions of interest on T2-weighted images are considered positive (A) and when voxels containing ≥ 70% tumor are considered positive (B).

 

Figure 10
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  		Fig. 4 —Quality of receiver operating characteristic curves as measured by area under curve (AUC) as function of tumor fraction in voxel. As expected, there is increase in AUC with increasing tumor fraction for all parameters measured due to reduction of normal tissue in tumor voxel. Choline-citrate ratio alone (dashed line), apparent diffusion coefficient alone (dotted line), and combination of the two (solid line) are shown.

 

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