Pediatric Whole-body Mri a Review of Current Imaging Techniques and Clinical Applications
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Hyun Woo Goo, MD, PhD  | |
| Department of Radiology and Enquiry Institute of Radiology, Asan Medical Centre, University of Ulsan College of Medicine, Seoul 05505, Korea. | |
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| Received March 29, 2015; Accepted May 19, 2015. | |
| This is an Open Access article distributed under the terms of the Creative Commons Attribution Not-Commercial License (http://creativecommons.org/licenses/past- | |
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| Become to: Abstract | |
| Whole-body magnetic resonance imaging (MRI) is increasingly used in children to evaluate the extent and distribution of various neoplastic and non-neoplastic diseases. Not using ionizing radiation is a major advantage of pediatric whole-body MRI. Coronal and sagittal short tau inversion recovery imaging is most commonly used as the fundamental whole-body MRI protocol. Diffusion-weighted imaging and Dixon-based imaging, which has been recently incorporated into whole-body MRI, are promising pulse sequences, peculiarly for pediatric oncology. Other pulse sequences may be added to increase diagnostic capability of whole-trunk MRI. Of importance, the overall whole-body MRI test time should be less than 30-60 minutes in children, regardless of the imaging protocol. Established and potentially useful clinical applications of pediatric whole-body MRI are described. | |
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Whole-body magnetic resonance imaging (MRI) is useful not just for delineating the extent and distribution of a systemic or multifocal disease but also for making the diagnosis and evaluating treatment responses ( 1 , ii , 3 , 4 , 5 , 6 , 7). Compared with other whole-body imaging methods, whole-body MRI is inherently advantageous for characterizing soft tissue with skillful anatomic details. In add-on, MRI is peculiarly useful in children and young adults who require repeated whole-trunk imaging because information technology does not employ ionizing radiation. In this respect, whole-body MRI is likewise useful in genetically radiosensitive patients, such equally those with neurofibromatosis or ataxia telangiectasia. Several technical developments are worth mentioning that make a whole-body MRI examination applied, including a rolling table platform facilitating continuous acquisition of multiple whole-body MRI stations, a software package enabling seamless composited or merged whole-torso images for easier viewing and interpretation, and a dedicated multi-channel, multi-element surface whorl system optimizing image acquisition efficiency and signal-to-noise ratio (SNR). As a result, whole-body MRI is increasingly used to prototype various oncological or non-oncological diseases in children. In this article, the current status of imaging techniques, key and disease-specific imaging protocols, and clinical applications of whole-body MRI in children will exist reviewed to boost its widespread use for better patient care.
Imaging Techniques
Whole-torso MRI imaging techniques are influenced by magnetic field strength, gyre system, and pulse sequence. In full general, the SNR and the contrast-to-noise ratio are greater at 3T than at one.5T. In dissimilarity, susceptibility artifacts and dielectric shading oftentimes dethrone whole-body MRI image quality, requiring a big field-of-view at 3T, which can be reduced by using a recently introduced multi-transmit technology (Fig. ane) ( 5 , viii , 9). Furthermore, motion artifacts at thoracoabdominal body parts tend to be more pronounced at 3T. Whole-torso MRI signals are received by several coil types, including a quadrature body gyre or a multi-channel surface coil. Additional surface coils are not necessary when a quadrature body coil is used, simply whole-body MRI image quality improves considerably using a multi-aqueduct surface gyre, which allows a higher SNR and spatial resolution. Moreover, scan time can be reduced using a parallel imaging technique with a multi-channel surface whorl. A sliding surface coil approach can be used to gain these benefits by using a single conventional torso phased array coil (Fig. 2) ( 7 , ten). A combination of neurovascular and spine coils tin be used for whole-body MRI of small children (Fig. 3) ( seven). Longitudinal coverage for whole-trunk MRI is shorter, by up to 95 and 125 cm, respectively when using these two approaches ( vii). Nevertheless, whole-body MRI using a dedicated multi-aqueduct, multi-element surface coil arrangement is the electric current technical standard. Any trunk part tin can be imaged at any fourth dimension during a whole-body MRI examination without moving this curl system. Whatever pulse sequences can exist used for whole-body MRI, and some play a major office due to their ability to cover the whole-body inside a short menses of fourth dimension, whereas others play a supplementary part for a specific body part. Curt tau inversion recovery (STIR) and T1-weighted sequences are two key pulse sequences used for whole-body MRI.
STIR Imaging
Curt tau inversion recovery imaging is nigh commonly used for pediatric whole-body MRI because the pulse sequence allows lesions to be identified even in the hypercellular ruby bone marrow common in young children ( 2 , 3 , 4 , 5 , half dozen , 7 , 8). Such a lesion tends to exist less distinguishable from the red marrow on T1-weighted imaging. STIR imaging provides more homogeneous fat suppression compared to that of fat-saturated T2-weighted imaging, leading to an first-class lesion-to-groundwork contrast ratio but its shortcomings include a lower SNR and a longer scan time. The inversion-preparatory pulse should exist adjusted to 150-160 msec at ane.5T and 210-230 msec at 3T to reach optimal fat saturation on STIR imaging ( 5 , vii , viii). It is noteworthy that osteoblastic or calcified lesions may be barely discernible on STIR images ( 5 , 6).
T2-Weighted Imaging
Frequency-selective fat saturation on T2-weighted images usually results in imperfect fat suppression in trunk parts showing main static magnetic field (B0) inhomogeneity, such as the neck, lungs, and calves. More uniform fat suppression than that obtained with STIR imaging can be accomplished using the recently introduced T2-weighted three-point Dixon technique, which maintains a higher SNR and a shorter scan time (Fig. iv) ( 11 , 12). Moreover, T2-weighted Dixon in-phase images demonstrate anatomic details and fat marrow changes. It remains to be determined whether this promising new T2-weighted imaging technique will become a mainstay in pediatric whole-body MRI beyond STIR imaging. Fat-water separation or swapping fault tin rarely occur in one leg or effectually the thorax ( 13) regardless of whether two- or three-point Dixon technique and T1 or T2 weighting are used (Figs. 4 , 5).
T1-Weighted Imaging
Focal or lengthened bone marrow lesions stand out against fatty bone marrow on T1-weighted fast spin echo imaging (Fig. vi). Thus, T1-weighted imaging has been ordinarily included in whole-torso MRI examinations of adolescents and adults. One study demonstrated that whole-body three-dimensional (3D) T1-weighted MRI showed as good or better diagnostic functioning for metastatic disease screening than that of whole-body two-dimensional (2D) T1-weighted MRI in 30 adult patients with prostate cancer ( 14). In improver, localized fat marrow changes later on radiations therapy are well-delineated. Lesion enhancement is evaluated using post-dissimilarity fatty-saturated 3D T1-weighted gradient echo imaging (Fig. half dozen). The curt scan time of this pulse sequence allows acquiring images during breath-holding. This pulse sequence is often problematic for obtaining compatible fat suppression. The Dixon technique generates 4 sets of images with different image contrasts, i.e., fat-only, water-only, in-phase, and opposed-stage images, from a single acquisition (Fig. 7). In contrast to fat-saturated 3D T1-weighted gradient repeat imaging, water-but images offer most perfect fat suppression. In addition, marrow-replacing lesions can be distinguished from non-marrow-replacing conditions, including the red marrow, by detecting the absence of pregnant signal drop on opposed-phase images compared with in-phase images ( xv). As a result, this pulse sequence with multiple paradigm dissimilarity tin can be used to enhance lesion detectability on pre- and post-contrast whole-body MRI T1-weighted images ( 12).
Diffusion-Weighted Imaging (DWI)
Signal intensities (Sis) on diffusion-weighted imaging (DWI) and an apparent diffusion coefficient (ADC) map depend on water diffusion in tissues and, therefore, reflect tumor cellularity. In addition to regional DWI, whole-body DWI is technically feasible and useful for evaluating lymphoma and other small round prison cell tumors in children ( 5 , half-dozen , 7 , sixteen). In addition to staging malignant tumors, whole-body DWI tin can be used to monitor therapy, e.m., a favorable handling response is normally accompanied by an increased ADC (Fig. 8) ( sixteen , 17).
Diffusion-weighted imaging with background body signal suppression (DWIBS) is commonly used for whole-body DWI considering better fatty suppression and less prototype distortion can be achieved throughout the entire body with DWIBS using STIR than DWI using a chemical shift selective pulse ( 18). Single-shot echo-planar imaging is by and large used in clinical practice to minimize motion artifacts on DWI. Multi-shot DWI with or without the use of navigator echoes has recently become available and improves spatial resolution and reduces prototype distortion at the expense of longer acquisition fourth dimension ( 19). Notably, DWI acquisition in the axial aeroplane with coronal and sagittal reformations is less vulnerable to image baloney than that of directly coronal or sagittal acquisition. Because of time constraints, the number of b-values for whole-body DWI is usually express to two. DWI should exist acquired over longer times with more than b-values. Therefore, it is very difficult to obtain whole-body intravoxel incoherent motility (IVIM) imaging requiring 8-10 b-values inside a clinically acceptable time period. However, i report demonstrated the technical feasibility of whole-trunk IVIM imaging in developed volunteers in 72 minutes at 3T ( 20). Yet, it remains to be determined whether whole-torso IVIM imaging providing diffusion, pseudodiffusion, and perfusion fraction maps has added clinical benefits over whole-torso DWI.
Klenk et al. ( 21) reported that ferumoxytol-enhanced whole-body DWI has equivalent sensitivity and specificity to those of positron emission tomography/computed tomography (PET/CT) for staging 22 young patients with lymphomas and sarcomas. The tumor-to-background contrast is improved finer with this new imaging technique by point drop in normal reticuloendothelial system organs, such as the liver, spleen, and bone marrow, after intravenous assistants of iron oxide nanoparticles. Moreover, information technology probably resolves diagnostic pitfalls of whole-body MRI resulting from hypercellular red marrow, which is described in detail later on in this commodity.
Continuously Moving Table MRI
The continuously moving table imaging technique with whole-body coverage tin be used for whole-body MRI (Fig. ix) ( 22) and MR angiography ( 23). A principal advantage of this technique over the conventional multi-station technique is that the whole-torso MRI information are acquired at the isocenter of the magnet where magnetic field inhomogeneity is minimal. Loftier-throughput whole-torso MRI examinations can too be achieved with this technique. However, the drawbacks of this technique include numerous axial images resulting in lengthy interpretation and limited longitudinal spatial resolution leading to stair-footstep artifacts on reformatted images. The latter shortcoming tin can exist ameliorated by using gilt angle radial sampling ( 22). The depression-resolution continuously moving table imaging technique tin can exist used to generate a watch view for whole-body MRI or MR/PET.
MR Angiography
Several 3D T1-weighted slope repeat sequence imaging stations adjusted to cover the entire torso are used after intravenous assistants of a gadolinium-based contrast amanuensis for whole-trunk MR angiography ( 24). Instead of the multi-station technique, the continuously moving table imaging technique tin exist used for whole-body MR angiography, which avoids the stepping artifacts frequently seen with the multi-station technique ( 23). The imaging parameters and intravenous injection protocol should be optimized for whole-trunk MR angiography to minimize the venous contagion frequently seen in the lower extremities. Image quality of whole-body MR angiography may be compromised past motility and susceptibility artifacts and modest vessel size. Systemic vasculopathy in children, such every bit Marfan syndrome, Loeys-Dietz syndrome, Kawasaki disease, or Takayasu arteritis, can be evaluated using whole-body MR angiography.
Miscellaneous Pulse Sequences
The balanced-steady country free procession sequence has been infrequently used for whole-body MRI ( 6). This pulse sequence has several merits, including fast scan speed, high SNR, and uniformly loftier blood pool SI, but it is often limited past off-resonance banding artifacts and high specific absorption rate, particularly at 3T. Pulse sequences dedicated to specific body regions, such as dynamic contrast-enhanced imaging (DCE) and fluid attenuation inversion recovery imaging (Fig. x), can be added to whole-trunk MRI examinations as needed.
The whole-body MRI protocol should exist tailored to fit the diagnostic purpose and the patient's condition. In addition to pulse sequences, imagers should determine the scan airplane and the necessity for post-dissimilarity imaging. A combination of the coronal and sagittal scan planes is well-nigh commonly used. A unmarried coronal browse aeroplane, compared with these two scan planes, may considerably shorten the exam time of whole body MRI at the expense of diagnostic performance ( 25). The centric plane is the to the lowest degree oftentimes used scan plane due to lengthy browse and interpretation times. Examination time is also influenced by patient meridian and scanned longitudinal coverage, i.e., ordinarily from head to toe or infrequently from head to thigh. The second scan mode has been usually used for whole-body MRI but the 3D scan mode with isotropic loftier spatial resolution and multiplanar reformation is now existence increasingly used due to improved browse efficiency and paradigm quality, virtually ofttimes for post-dissimilarity T1-weighted imaging. Post-contrast imaging demanding additional examination time is oftentimes included in the initial exam and intermittently during follow-up examinations. Therefore, a routine whole-torso MRI surveillance protocol is usually comprised of pre-contrast coronal and sagittal STIR images only. Overall examination time of whole-body MRI should be less than 30-threescore minutes in children because a protracted exam ofttimes ends in unsuccessful imaging in these patients. As for other pediatric imaging procedures, sedation or general anesthesia is required for whole-body MRI in immature or uncooperative children. A small overlap of 3-5 cm, between adjacent stations during a multi-station imaging protocol, is ofttimes placed to create seamless whole-torso MRI mainly by compensating for signal loss at the periphery. In addition to the multi-purpose protocol, imagers may develop a dedicated whole-trunk MRI protocol tailored to a specific affliction.
In a recently introduced integrated whole-trunk MR/PET arrangement, whole-body MRI provided an important anatomic backbone for localizing metabolic abnormalities as well as a Dixon MRI-based attenuation map for correcting the attenuation of PET images ( 26 , 27 , 28). Approximately 73-80% of the radiation dose tin can be reduced during MR/PET compared with that during PET/CT, which is of disquisitional importance in children ( 26 , 27). In addition, this hybrid system saves full exam time compared with two separate whole-body MRI and whole-body PET examinations. MR/PET offers equivalent lesion detection rates and advantages during a soft tissue evaluation compared with those of PET/CT ( 27). However, PET standardized uptake values should exist carefully compared between MR/PET and PET/CT because an MRI-based PET attenuation correction may event in discrepant values, particularly for bone marrow (13.1%) ( 27).
Clinical Applications
Whole-torso MRI was initially applied to diverse malignant tumors, except encephalon tumors, in adults and children ( 1 , 2 , four , five , seven , 25). Its clinical applications have subsequently expanded to not-oncological diseases. In this section, established and ongoing clinical applications of whole-body MRI and their key results in children are described.
Pediatric Oncology
As mentioned previously, initial tumor staging and the treatment response of pediatric malignant tumors are the virtually common established clinical applications for whole-body MRI ( 29). The indisputable reward of whole-torso MRI in pediatric oncology is its lack of ionizing radiation because the high cumulative radiation dose from medical imaging is a major business organization in this accomplice ( 30). In general, whole-body MRI is superior to bone scintigraphy for detecting skeletal lesions and exclusively for identifying extraskeletal lesions. Additional DWI and DCE imaging may help improve the limited capability of whole-body MRI for distinguishing feasible or recurrent tumors from residual lesions and for evaluating the handling response (Fig. eight). Given its excellent soft-tissue contrast, whole-body MRI is usually ameliorate for evaluating the brain, liver, and bone marrow, whereas PET/CT is relatively superior for assessing the lungs and lymph nodes. Information technology should be recognized that normal bone marrow in children shows a region-specific dynamic blueprint of conversion from red (hypercellular hematopoietic) to fatty marrow to avoid potential misinterpretation of pediatric whole-trunk MRI ( 31). Conversely, marrow reconversion or hyperplasia may occur in severe anemia or after granulocyte-colony stimulating factor therapy ( 32). The reddish marrow tends to be symmetrically distributed and poorly marginated, but it may mimic pathology on T1-, T2-weighted, and STIR sequences. In these cases, opposed-phase imaging helps differentiate marrow lesions from the crimson marrow.
Several studies have consistently demonstrated that whole-trunk MRI with or without whole-body DWI offers comparable diagnostic performance to that of PET/CT and, therefore, may be a radiation-free imaging alternative for initial staging of pediatric lymphoma ( 4 , 33). Another study suggested that positive os marrow lesions on whole-body MRI including whole-body DWI and with a negative blind bone marrow biopsy may accept prognostic implications in patients with diffuse big B-jail cell lymphoma ( 34). Similar to lymphoma, pediatric modest circular cell tumors, including neuroblastoma (Fig. 5), Ewing sarcoma (Fig. 2), and rhabdomyosarcoma (Fig. 1), testify mutual histological features, i.e., hypercellularity and a high nucleocytoplasmic ratio. As such, DWI is useful to detect lesions and monitor therapy in patients with these tumors. In contrast, this is not truthful for carcinomas and Langerhans cell histiocytosis (LCH) with arable cytoplasm. DCE imaging is peculiarly useful to assess lesion activity in patients with LCH ( 3). Because PET is also useful to identify active LCH lesions, a combined analysis with PET and whole-torso MRI improves diagnostic accurateness ( 35). Because most whole-body MRI studies on pediatric small round cell tumors and LCH have been conducted in a small number of patients, farther larger studies comparing whole-body MRI with PET/CT and conventional imaging methods are necessary to obtain more than conclusive results.
Although whole-body MRI is infrequently used in patients with leukemia, the abnormal marrow replaced by leukemic cells or chloroma can be identified on whole-torso MRI (Fig. half dozen). Furthermore, widespread osteonecrosis in children with leukemia can be detected early whole-torso MRI earlier articular collapse, which indicates an unfavorable outcome ( 36). Whole-trunk tumor burden in patients with neurofibromatosis can be calculated with whole-body MRI-based 3D segmentation and volumetry (Fig. 10) ( 37). Whole-body MRI may exist useful for early detection of associated tumors in cancer predisposition syndromes in children, such every bit neurofibromatosis type 1, Beckwith-Wiedemann syndrome, multiple endocrine neoplasia, Li-Fraumeni syndrome, von Hippel-Lindau syndrome, and familial adenomatous polyposis ( 38). In add-on, whole-torso MRI tin can be used to find the primary site of an unknown primary tumor.
Pediatric Non-Oncological Diseases or Conditions
The extent and distribution of generalized lymphatic/vascular malformations involving multiple organs or tissues tin be evaluated with whole-body MRI. Whole-body MRI is particularly helpful to predict clinical outcome by identifying findings indicating a poor prognosis, such equally chylous pleural effusion, mediastinal interest, and laryngeal involvement in patients with generalized lymphangiomatosis ( 39).
Whole-torso MRI is useful to evaluate disease extent and activeness equally well as treatment response in patients with juvenile dermatomyositis (Fig. eleven) ( 40). One study ( 41) reported that whole-body MRI helps recognize characteristic patterns of muscular abnormalities in patients with early on onset neuromuscular disorders. Axelsen et al. ( 42) reported that whole-body MRI is a promising tool for evaluating disease activity and structural impairment and is more ofttimes identified than by clinical test in patients with rheumatoid arthritis. Synovitis indicating active inflammation in patients with juvenile rheumatoid arthritis can be identified as periarticular soft tissue T2 hyperintensity and enhancement on whole-body MRI (Fig. 12). In improver, whole-torso MRI may be useful to quantify changes in adipose tissue distribution during medical therapy that coincides with biochemical improvement in patients with familial partial lipodystrophy ( 43).
Whole-body MRI is useful for detecting chronic recurrent multifocal osteomyelitis, peculiarly in indeterminate cases, as it shows subclinical edema ( 44 , 45). Whole-body MRI also may exist useful to detect an infection focus in children with fever of unknown origin.
In cases with suspected child abuse, whole-trunk MRI is helpful to identify soft-tissue injuries simply insensitive for detecting classic metaphyseal lesions or rib fractures specific to child abuse ( 46). Of interest, initial experiences of postmortem whole-body MRI have been reported to be a noninvasive complimentary virtual autopsy prior to archetype dissection ( 47 , 48).
Whole-trunk MRI has been rarely used to appraise the extent and distribution of multiple benign bone and soft tissue lesions, such every bit polyostotic fibrous dysplasia in patients with McCune-Albright syndrome ( 49), hypophosphatasia ( 50), Rsai-Dorfman illness ( 51), and disseminated cysticercosis ( 52).
Whole-trunk MRI is a useful radiations-free imaging method for evaluating the whole-body extent and distribution of various neoplastic and non-neoplastic diseases in children. Its diagnostic value in children is likely to increase with combined apply of functional or metabolic imaging, such every bit PET, and expanded clinical implications, which remains to be proven by time to come studies. Pediatric whole-body MRI protocols evidently demand to be further optimized towards shorter exam times with ameliorate image quality using innovative MRI technologies.
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Source: https://www.kjronline.org/DOIx.php?id=10.3348%2Fkjr.2015.16.5.973
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