Journal OF MILITARY PHARMACO MEDICINE N02 2022 151 EVALUATION OF MAGNETIC RESONANCE IMAGING CHARACTERISTICS OF MALIGNANT GLIOMAS Pham Van Huu1, Bui Quang Tuyen2 Dong Van He3, Nguyen Thanh Bac2 SUMMARY[.]
Journal OF MILITARY PHARMACO - MEDICINE N02 - 2022 EVALUATION OF MAGNETIC RESONANCE IMAGING CHARACTERISTICS OF MALIGNANT GLIOMAS Pham Van Huu1, Bui Quang Tuyen2 Dong Van He3, Nguyen Thanh Bac2 SUMMARY Objectives: The describe MRI characters of malignant gliomas Subjects and methods: A descriptive study with no control group on 77 patients at Viet Duc University hospital from July 2015 to June 2017 Results: The medium size of tumor: 5.45, the smallest was 2.4 cm, the largest was 12cm, hyperintense on T2W was 88.3%, hypointense on T1W was high at 72.7% Unclear margin after injecting contrast made up to 49.4% heterogeneous intense was 85.7%, including calcified, necrotic, cystolic and haemorrhage tumor was 6.5%, 58.4%, 22.1%, and 13%, respectively - 10 mm midline shift was 31.2% Most patients had grade II edema with a rate of 40.3% Conclusion: The size of tumor is after the extent of malignancy Necrotic tumor, heterogeneity, and edema are the most crucial features in diagnosing malignant gliomas * Keywords: Malignant gliomas; MRI INTRODUCTION A glioma is a type of tumor that starts in the glial cells of the brain According to previous studies, gliomas were mostly malignant and comprised 80 percent of all malignant central nervous system tumors [1] In recent years, with advances in technology, many modern diagnostic imaging equipment enable the physician to easily diagnose and treat malignant gliomas Of all these facilities, MRI especially improved MRI can evaluate the extent, margin, and invasion of tumor into the adjacent brain tissue, which leads to radical surgery and enhancing treatment results SUBJECTS AND METHODS Subjects 77 patients were under diagnosis of malignant gliomas and underwent micro surgery at Viet Duc University Hospital from July 2015 to June 2017 All of these had the pathologic results of WHO grade III and grade IV Methods * Study design: A descriptive study with no control group All patients experienced MRI-SIGNA creator 1.5 Tesla, by GE Healthcare in America, with and without contrast in T1-weighted and T2-weighted Thai Binh General Hospital Military Hospital 103 Viet Duc University Hospital Corresponding author: Pham Van Huu (pham.huu30@yahoo.com) Date received: 17/01/2022 Date accepted: 25/01/2022 151 Journal OF MILITARY PHARMACO - MEDICINE N02 - 2022 * Evaluation criteria: - Location: Define the left and right hemispheres Location of lobes was defined by Orringer D if the tumor has a strong correlation with lobe, the classification will be given by the lobe in which the tumor mainly is Classification according to the frontal lobe, parietal lobe, temporal lobe, occipital lobe, internal capsule and falx cerebri - Size: The largest diameter of tumor calculated on contrast T1-weighted + Grade I: Under cm + Grade II: Between and 10 cm + Grade III: Over 10 cm - Intense on MRI: + T1W: Hyper, hypo, homogenous, heterogeneous intense + Contrast T1W: Enhancement of tumor capsule or tumor core, non-enhancement + T2W: Hyper, hypo, homogenous, heterogeneous intense + Margin: Clear or not + Intense: Heterogeneous or homogenous - Edema: On T2-weighted of MRI + Grade I: cm from the tumor margin to the outer edge of edema Heterogeneous (cystolic, necrosis and haemorrhage) + Grade II: Over cm from the tumor margin - Karnofski (KPS): I: 80 - 100; II: 60 - 70; III: 40 - 50; IV: 10 - 30 + Grade III: Edema over half of the brain hemisphere - Pathological classification by WHO 2016 - Extent of midline shift: calcified, - Data was analysed by SPSS 22.0 RESULT - Size: smallest 2.4 cm and largest 12 cm - Medium tumor size 5.45 cm, standard deviation 1.88 Table 1: Tumor size and Karnofski score Tumor size 5 n (%) n (%) n (%) 80 - 100 0 (2,4) 60 - 70 (16,7) (10,7) (9,3) 40 - 50 (66,6) 23 (82,1) 34 (79) 61 10 - 30 (16,7) (7,2) (9,3) Total (100) 28 (100) 43 (100) 77 KPS p Total 0,04 (SD = 0.733) - With the group of tumors over cm: KPS III made up to 79% and KPS IV was 9.3% - In the group of tumors under cm: KPS III was 66.6%, KPS IV was 16.7% - There was one patient having over-5 cm tumor with KPS I The larger the tumor was, the lower KPS was (p < 0.05) 152 Journal OF MILITARY PHARMACO - MEDICINE N02 - 2022 Table 2: Tumor features on non-contrast MRI T1W Intense T2W Number of patients Rate (%) Number of patients Rate (%) Hyper 2.6 68 88.3 Homogenous 7.8 0 Hypo 56 72.7 2.6 Mixed signal 13 16.9 9.1 Total 77 100 77 100 - Patients mainly had hyperintense on T2W, accounting for 88.3% - Hypointense on T1W was major with 72.7% Table 3: Tumor features on contrast MRI Features Margin Homogenous Heterogenous Number of patients Rate (%) Clear 39 50.6 Unclear 38 49.4 Yes 11 14.3 No 66 85.7 Cystolic 17 22.1 Calcified 6.5 Necrotic 45 58.4 Haemorrhage 10 13 - Unclear margin on contrast MRI amounted to 49.4% - Heterogenous tumor was 85.7% including calcified 6.5%, necrosis 58.4%, cystolic 22.1% and haemorrhage 13% Table 4: Pathological classification and tumor features on MRI Pathology Cystolic Calcified Necrosis Haemorrhage Grade III (41,2) (80) 19 (42,2) (60) Grade IV 10 (58,8) (20) 26 (57,8) (40) Total 17 (100) (100) 45 (100) 10 (100) Grade p 0,042 Cystolic and necrosis tumors are the majority in grade IV gliomas with the percentage of 58.8% and 57.8%, respectively With grade III malignant gliomas, calcified and haemorrhage tumors are more common with the rate of 80% and 60% This difference has statistical significance with p < 0.05 153 Journal OF MILITARY PHARMACO - MEDICINE N02 - 2022 Table 5: Pathological classification and enhancement on MRI Enhancement on MRI Enhancement n = 74 (%) Malignant extent Non-enhancement n = (%) Cortex Core Grade III 13 (39,4) 20 (60,6) (100) Grade IV 34 (82,9) (17,1) 47 (63,5) 27 (36,5) Total (100) - There were 74 out of 77 patients having enhancement MRI after injection - Grade IV malignant gliomas mainly enhanced contrast in the cortex with 82.9%, while in grade III, this rate was 39.4% Table 6: Pathological classification and Brain edema Edema extent Pathology Total Grade III Grade IV (%) Non-edema (3.9) Grade I 13 18 31 (40.3) Grade II 17 17 34 (44.1) Grade III (16.7) Total 36 41 77 (100) p 0,003 - 44.1% of all patients had grade II edema - 3.9% of patients had no edema - Severe edema appeared when the tumor had great extent of malignancy with p = 0.003 DISCUSSION The smallest tumor was 2.4 cm, and the largest was 12 cm Medium tumor size was 5.45 cm In our study, tumor was mainly over cm, amounting to 55.8% Tumor over cm in the temporal lobe was at the highest rate of 37.2% This can be explained by a tumor in this area having the highest rate of grade IV and rapid growth, representing when tumors turn into big size Our study has shown that 154 tumor size is related to neurofunction at the time of admission The bigger tumor was, the lower KPS was, with p < 0.05 our study is similar to the results of Lê Văn Phước when investigating gliomas on MRI, with an average tumor size of 5.28 cm In that research, gliomas tumor size was 5.48 ± 1.88 cm, and the author reported that the tumor size rose after the extent of malignancy [2] According to the research of Chaichana, K.L (2014) about Journal OF MILITARY PHARMACO - MEDICINE N02 - 2022 surgery on glioblastoma, the medium tumor size was 27 cm3, smallest 13.8 and largest 54.4 [3] The tumor size in this study is smaller than in ours This can result from the consciousness and living conditions in our country, patients only represented to the hospital when the tumor was large Besides, gliomas had no tendency of invading the brain tissue, only localizing partly in the brain, isolating in these areas, presenting with minimal symptoms, sporadic and sometimes no clinical symptoms Some kinds of gliomas had no symptoms even the tumor is huge, accidentlly detected by MRI when investigating other diseases in the head and neck In our study, hypointense was common on T1W with 71.7%, while the mixed signal was 16.9% Authors believed that gliomas at low grade are almost hypointense on T1W However, gliomas at high grade had mixed signals because of calcification, necrosis and haemorrhage Hypointense of tumor is heterogeneous due to necrosis and old haemorrhage resulting in cysts, which is most evident in gliomas By contrast to hypointense on T1W, T2W images serve to supply the extent of perfusion and edema There were 88.3% heterogeneous hypointense images resulting from necrotic and cystolic tumor in high grade gliomas, which is similar to the research of other authors Studying on T1W and T2W in brain tumors, Just M (1988) [4] learnt that gliomas often had isointense and hyperintense on T1W and T2W compared with the brain tissue However, there are light hyperintense and heterogeneous enhancement after injecting contrast Necrosis and cysts even having hyperintense on T2W, hypointense on T1W, and FLAIR, higher intensity than CSF In our research, there were 58.4% of necrosis and 22.1% of cysts These forms are more common in grade IV gliomas with p = 0.042 Authors believed that cysts and necrosis rarely appear in low grade gliomas, but are the characters of high grade gliomas The rate of necrosis in the study of Nguyen Duy Hung (2018) [5] was 77.5%, of Le Van Phuoc (2012) [2] was 51.4% in high grade gliomas And Dean confirmed that internal necrosis of tumors had value in diagnosing high grade gliomas [6] The contrast enhancement on MRI serves as the extent of malignancy of tumors In our research, 96.1% of the tumor had contrast enhancement after injecting the contrast agent Heterogenous enhancement generally appeared in grade III gliomas and edge enhancement in grade IV gliomas (34/41 patients) Nguyen Duy Hung (2018) [5] reported that divergent from low grade gliomas, high grade tumors often enhanced strongly after injecting the contrast agent Grade III tumor had heterogeneous enhancement, and grade IV got edge enhancement Le Van Phuoc (2012) [2], there were 98.3% of low grade tumors having nonenhancement and 89.8% high grade tumors having enhancement Tynninen O’s research (1999) proved that there was arelation between enhancement area on MRI and extent of mitosis and vascular density on pathology [7] 155 Journal OF MILITARY PHARMACO - MEDICINE N02 - 2022 In our research, grade I edema was 40.3%, which is similar to the study of Le Van Phuoc (2012) [2] that malignant gliomas had a percentage of 33.9% edema Ishtiaq A (2012) [8] reported that the extent of edema had a correlation with the extent of malignancy of gliomas CONCLUSION By this study, we come to the conclusion that malignant gliomas had the salient characteristics, including: Internal necrosis, the large hyperintense area around the tumor, shape effect, vivid enhancement REFERENCE Burton, E.C and M.D Prados, Malignant gliomas Curr Treat Options Oncol 2000; 1(5):459-468 Le Van Phuoc Vai trò cộng hưởng từ phổ cộng hưởng từ khuếch tán chẩn đoán u bào trước phẫu thuật Ho Chi Minh City University of Medicine and 156 Pharmacy: Ho Chi Minh City University of Medicine and Pharmacy 2012 Chaichana, K.L., et al., When gross total resection of a glioblastoma is possible, how much resection should be achieved? World Neurosurg 2014; 82(1-2):e257-265 Just, M and M Thelen, Tissue characterization with T1, T2, and proton density values: Results in 160 patients with brain tumors Radiology 1988; 169(3):779-785 Nguyen Duy Hung Nghiên cứu giá trị cộng hưởng từ tưới máu cộng hưởng từ phổ chẩn đoán số u thần kinh đệm lều người lớn Ha Noi Medical University 2018 Dean, B.L., et al Gliomas: Classification with MR imaging Radiology 1990; 174(2): 411-415 Tynninen, O., et al MRI enhancement and microvascular density in gliomas Correlation with tumor cell proliferation Invest Radiol 1999; 34(6):427-434 Ishtiaq A.C., el at MRI characterization and histopathological correlation of primary intra-axial brain glioma JLUMHS 2010; 09(02) ... Phuoc (2012) [2] that malignant gliomas had a percentage of 33.9% edema Ishtiaq A (2012) [8] reported that the extent of edema had a correlation with the extent of malignancy of gliomas CONCLUSION... but are the characters of high grade gliomas The rate of necrosis in the study of Nguyen Duy Hung (2018) [5] was 77.5%, of Le Van Phuoc (2012) [2] was 51.4% in high grade gliomas And Dean confirmed... internal necrosis of tumors had value in diagnosing high grade gliomas [6] The contrast enhancement on MRI serves as the extent of malignancy of tumors In our research, 96.1% of the tumor had