3 Tesla proton MRI for the diagnosis of pneumonia/lung infiltrates in neutropenic patients with acute myeloid leukemia: Initial results in comparison to HRCT

doi:10.1016/j.ejrad.2013.09.002

European Journal of Radiology

Volume 83, Issue 1, January 2014, Pages e61-e66

https://doi.org/10.1016/j.ejrad.2013.09.002 Get rights and content

Abstract

Purpose

To evaluate the diagnostic accuracy of 3 Tesla proton MRI for the assessment of pneumonia/lung infiltrates in neutropenic patients with acute myeloid leukemia.

Material and methods

In a prospective study, 3 Tesla MRI was performed in 19 febrile neutropenic patients (5 women, 14 men; mean age 61 years ± 14.2; range 23–77 years). All patients underwent high-resolution CT less than 24 h prior to MRI. The MRI protocol (Magnetom Tim Trio, Siemens) included a T2-weighted HASTE sequence (TE/TR: 49 ms/∞, slice thickness 6 mm) and a high-resolution 3D VIBE sequence with an ultra-short TE < 1 ms (TE/TR 0.8/2.9 ms, slice thickness 2 mm). The VIBE sequence was examined before and after intravenous injection of 0.1 mmol/kg gadoterate meglumine (Dotarem, Guerbet). The presence of pulmonary abnormalities, their location within the lung, and lesion type (nodules, consolidations, glass opacity areas) were analyzed by one reader and compared to the findings of HRCT, which was evaluated by a second independent radiologist who served as the reference standard. The findings were compared per lobe in each patient and rated as true positive (TP) findings if all three characteristics (presence, location, and lesion type) listed above were concordant to HRCT.

Results

Pulmonary abnormalities were characterized by 3 Tesla MRI with a sensitivity of 82.3% and a specificity of 78.6%, resulting in an overall accuracy of 88% (NPV/PPV 66.7%/89.5%). In 51 lobes (19 of 19 patients), pulmonary abnormalities visualized by MR were judged to be concordant in their location and in the lesion type identified by both readers. In 22 lobes (11 of 19 patients), no abnormalities were present on either MR or HRCT (true negative). In 6 lobes (5 of 19 patients), ground glass opacity areas were detected on MRI but were not visible on HRCT (false positives). In 11 lobes (7 of 19 patients), MRI failed to detect ground glass opacity areas identified by HRCT. However, since the abnormalities were disseminated in these patients, accurate treatment decisions were possible in every case based on MRI. In one case MRI showed a central area of cavitation, which was not visualized by HRCT.

Conclusion

Infectious nodules and consolidations can be detected in neutropenic patients with acute myeloid leukemia with a sufficient diagnostic accuracy by 3 Tesla MRI. Detection of ground glass opacity areas is the main limitation of 3-Tesla MRI when compared to HRCT.

Introduction

The incidence of systemic fungal and other atypical pulmonary infections is increasing in severely immunocompromised neutropenic patients suffering from acute leukemia. Among these, invasive fungal infections such as pulmonary aspergillosis are associated with particularly high mortality [1]. Thus, early diagnosis and subsequent initiation of appropriate treatment is essential in order to improve patient outcomes. However, serological and microbiological markers are known to be of only limited sensitivity in the diagnosis of these conditions and exhibit poor specificity [1]. Thus, the mortality associated with such infections remains high. In immunocompromised patients, systemic fungal infections manifest primarily as fungal pneumonia. High-resolution computed tomography (HRCT) [2] plays a pivotal role in the diagnostic work-up due to its proven high sensitivity (∼90%) [3]. However, CT findings are often equivocal, diminishing diagnostic confidence and necessitating repetitive imaging at the expense of high cumulative radiation doses in patients who are frequently young.

Given the improved soft tissue contrast and the lack of ionizing radiation, MRI is considered a promising diagnostic alternative to HRCT [4], [5], [6], [7], [8]. Specific anatomical considerations in the lung, such as the multiple air-soft tissue interfaces, lead to greater T2* related susceptibility effects and thus present challenges to pulmonary MRI, particularly at 3 Tesla. Nevertheless, imaging at higher field-strengths may potentially improve the characterization of pulmonary infections in neutropenic patients due to high signal-to-noise and contrast-to-noise ratios at simultaneously high spatial resolutions [1], [9], [10], [11], [12], [13], [14]. These factors may prove particularly beneficial in the detection of hemorrhage which is seen characteristically in angioinvasive aspergillosis – a common infectious entity in neutropenic patients.

Thus the aim of this study was to evaluate the role of MR at 3 Tesla, in comparison to HRCT, for the assessment of pulmonary infections, especially invasive pulmonary aspergillosis in neutropenic patients with acute myeloid leukemia (AML).

Section snippets

Patient population

From 2009–2011, a total of 19 neutropenic, febrile acute myeloid leukemia (AML) patients (5 women, 14 men; mean age 61 years ± 14.2; range 23–77 years) were included in this prospective study. Institutional review board (IRB) approval was obtained, and the study followed the principles of the Declaration of Helsinki and its subsequent amendments. All patients underwent chest HRCT according to diagnostic guidelines [15], followed by MRI within 24 h. Criteria for inclusion were host factors

Results

All HRCT and MRI examinations were successfully completed without any adverse events and no study was excluded from data analysis due to insufficient image quality. A total of 95 pulmonary lobes were evaluated in terms of the presence, localization, and characteristics of abnormalities on both MRI and CT. In 51 lobes (19 of 19 patients) CT and MRI abnormalities were determined to be concordant by both readers in terms of the presence, localization, and type of abnormality (true positives). In

Discussion

The results of the present study demonstrate the promise of 3 T MRI as an alternative imaging modality to HRCT for the evaluation of acute pulmonary infections in immunocompromised patients. The comparison between HRCT and MRI in this specific patient cohort finds an overall diagnostic accuracy for MRI of 88%. Both consolidations and nodular opacities were detected accurately by MRI with good concordance to HRCT. Overall lesion localization with MRI was also comparable to that achieved by HRCT.

Conflict of interest

Ulrike Attenberger: Consultant: Research Consultant, Bayer Healthcare. Other: Institutional Research Agreement, Siemens AG.

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Thoracic 3 T MRI is an accurate and effective technique for evaluating children with pneumonia. MRI detected more pathologies than CR and had similar results to those of thorax CT.
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^☆: This work was supported by a grant (#R 08/12v), provided by the José Carreras Leukämie-Stiftung.

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3 Tesla proton MRI for the diagnosis of pneumonia/lung infiltrates in neutropenic patients with acute myeloid leukemia: Initial results in comparison to HRCT☆

Abstract

Purpose

Material and methods

Results

Conclusion

Introduction

Section snippets

Patient population

Results

Discussion

Conflict of interest

Ann Oncol

Eur J Radiol

Eur J Radiol

Eur J Cancer

Am J Med

Invasive aspergillosis: epidemiology, diagnosis and management in immunocompromised patients

Drugs

Role of helical CT in detecting right ventricular dysfunction secondary to acute pulmonary embolism

J Comput Assist Tomogr

Detection of pulmonary nodules using a 2D HASTE MR sequence: comparison with MDCT

AJR

MRI at 3.0 T: a comparison of helical CT and high-field MRI in the detection of diffuse lung disease

Eur Radiol

MR imaging of pneumonia in immunocompromised patients: comparison with helical CT

AJR

MRI of the lung: state of the art

Diagn Interv Radiol