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MultiTransmit helps expand the role of MRI in MSK oncology at Leuven

Best Practice
Dr. Pans, Steven, M.D. Leuven, University of Leuven Belgium

Leuven University Hospital's Radiology Department recently upgraded its Achieva 3.0T to TX performance which includes Philips' patient-adaptive MultiTransmit technology embodying parallel RF sources. The boost in performance this upgrade provides has led to a big expansion in the role of MRI in MSK oncology in the department, which now performs all whole body scans and almost all regional scans for bone and soft tissue lesions on its Achieva 3.0T TX.
 Steven Pans, MD Leuven University Hospital
Steven Pans, MD
Leuven University Hospital

Growing role for whole body MRI

Leuven radiologist Steven Pans, MD, specializes in MSK oncology with a particular interest in MSK interventional procedures including bone-marrow and soft-tissue biopsies. He has long considered MRI to be the preferred modality for MSK oncology because of its excellent soft tissue contrast and its absence of ionizing radiation. "The absence of ionizing radiation and the fact that you don't need to use iodized contrast agent makes MRI very interesting for staging and follow up after therapy. Patients certainly feel far more comfortable with it," he says. "And its very high sensitivity to bone-marrow pathology compared with CT means that it's an excellent tool for guiding bone-marrow biopsies."

For the past four years the department has also been engaged in whole body imaging for which Dr. Pans and his colleagues also prefer to use MRI. "This, of course, depends somewhat on the pathology. Sometimes the clinician will prefer a PET or PET/CT exam, but nowadays for multiple myeloma and lymphoma studies and staging of bone metastasis, we are seeing a general changeover from whole body CT to whole body MRI," he observes. Dr. Pans' own research interests are also directed towards combining morphological imaging with functional imaging.

MR staging benefits from MultiTransmit

Since the recent upgrade of the department's Achieva 3.0T system to TX performance, all whole body scans and almost every regional scan for bone marrow and soft tissue lesions are performed on the Achieva with, according to Dr. Pans, very impressive results.

"One of the major advantages of the new Philips scanner is that we get excellent image quality in whole body scans without the need for any covering coils. Using just the single Integrated Body coil in combination with MultiTransmit, we can perform not only whole body STIR sequences, but also whole body T1 and whole body DWI sequences in the same examination. The combination of these three sequences gives excellent information for staging of suspicious lesions," he explains. "We also now find that whereas formerly within an exam time of around 30 to 35 minutes we were only able to perform pre- and post-contrast morphological imaging, the extra time we now gain thanks to MultiTransmit enables us also to perform functional imaging with 4D THRIVE and DWI."

Dr. Pans and his colleagues have also noted a significant reduction in artifacts caused by implants. "In the past we had some problems with artifacts caused by port-a-caths - small chambers or reservoirs implanted under the skin for delivering chemo - as well as by titanium braces and screws that may have been inserted into the bones. These were particularly serious with T2 fat saturated sequences, but are now no problem at all. With the TX we get much more homogeneous images than before with better contrast and resolution," he says.

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MRI helps monitoring response to chemotherapy in adults and children

The major cancers the department encounters in its daily work include, in the adult population, lymphoma, multiple myeloma, and all types of benign and malignant bone lesions. One of Dr. Pans' particular interests within the department, however, is pediatric imaging - especially for lymphoma, bone metastasis, and lesions like Ewing sarcoma and osteosarcoma. "Previously we'd scan children at the point of diagnosis and just before surgery to have an idea of necrosis or tumor response to chemotherapy. Now on the Achieva 3.0T TX we also perform functional MRI scans at intermediate stages as well to have an idea of how the chemotherapy is progressing.

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DWI helps for staging and follow-up

Almost every patient with bone or soft tissue tumor in their department is scanned with 4D THRIVE and DWI. "We're particularly impressed with DWI and WB DWI on the Philips system," he says. "Of course, it requires some experience and you need to be careful with T2-shine-through effects when imaging abscesses and imaging hematomas. These entities can cause a hyperintense signal on the diffusion weighted images and they should be best correlated with the perfusion imaging to exclude pseudotumoral lesions or differentiate them from tumoral lesion. But now, having gotten used to it, I think it's an incredibly useful tool. We use it not only for staging and lesion detection but also in follow-up to have a good idea of tumor relapse, tumor recurrence and tumor response. Normally we use six b values - b0, b50, b100, b500, b750 and b1000 - to assure a reliable ADC calculation. We prefer to use the calculated ADC value more than the ADC map. What's more, on the Achieva TX, including DWI adds no more than about 3 minutes to the scan, rather than the 10 to 12 minutes extra on a system without MultiTransmit."

Depending upon indications, Dr. Pans and his colleagues may also combine DWI with perfusion-weighted 4D THRIVE sequences. "This adds a total of 3 minutes to the exam but provides a lot of information that can assist the oncologist or surgeon in taking a biopsy from the most viable tumoral parts, or in making a good differential diagnosis," explains Dr. Pans. Depending on the pathology, other sequences may also be included. "When scanning for multiple myeloma, for example, we add whole body STIR and whole body T1 scans in the coronal plane with 5 mm slice thickness. We also find T1-weighted VISTA sequences very useful, especially in scanning for skip-metastases in patients with Ewing and osteosarcoma. With VISTA you can perform reconstruction in a central coronal or sagittal plane with a 1 to 1.5 mm slice, which is very useful to clinicians as it enables very small skip lesions to be excluded, which can have a big influence on patient outcome."

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Future prospects

From his positive experiences with DWI on the Achieva 3.0T TX, Dr. Pans believes these sequences, especially whole body DWI, are likely to play significant roles in MSK oncology imaging in the future. "Currently all MSK oncology exams at Leuven include diffusion and perfusion weighted imaging but we're carrying out different studies in our department to determine if, for some tumor types, the perfusion phase could be omitted altogether. Preliminary results appear to confirm that at least for follow up studies on lymphoma, multiple myeloma and Ewing and osteosarcoma, we could indeed rely just on DWI."

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Jun 10, 2011

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Best Practice
Achieva 3.0T TX
Release 2.6, Release 3.2
Quasar, Quasar Dual
Abdomen, Ankle, Body, Breast, Liver, Musculoskeletal, Oncology, Pelvis

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