Roberta Cianci1, Andrea Delli Pizzi2, Guido Patriarca3, Renato Massari4, Raffaella Basilico1, Daniela Gabrielli1, Antonella Filippone1. 1. Department of Neuroscience Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti, Italy. 2. Department of Neuroscience Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti, Italy; ITAB Institute for Advanced Biomedical Technologies, "G. d'Annunzio" University, Chieti, Italy. Electronic address: andreadellipizzi@gmail.com. 3. ASL Pescara, Presidio Ospedaliero "Santo Spirito", Unità Operativa Complessa di Diagnostica per Immagini, Pescara, Italy. 4. Dipartimento di Scienze Chirurgiche, U.O. Clinica Chirurgica-Chirurgia Toracica, Università degli Studi G. D'Annunzio, Chieti, Italy.
Abstract
PURPOSE: To assess the added value of diffusion weighted imaging (DWI) with intermediate (500 s/mm2) and high (1000 s/mm2) b values when combined to conventional contrast-enhanced magnetic resonance imaging (MRI) in identifying peritoneal neoplastic involvement. METHODS: Twenty-four patients with peritoneal carcinomatosis from gastrointestinal or gynecological tumors were retrospectively evaluated. All patients underwent peritonectomy with hyperthermic intraoperative chemotherapy and 1.5 T MRI including DWI with 500 s/mm2 and 1000 s/mm2 b values within 1 month from surgery. Images were independently reviewed by 2 radiologists with different experience in abdominal MRI in 3 separate reading sessions, the first including conventional MR images alone (T2-weighted, T1-weighted pre- and post gadolinium injection), the second conventional MRI and DWI with a b value of 500 s/mm2 (b 500-DWI), and the third conventional MRI and DWI with a b value of 1000 s/mm2 (b 1000-DWI). Apparent diffusion coefficient maps were included in the DWI analyses. Peritoneal dissemination was assessed in 9 anatomical sites, including right and left subphrenic space, paracolic gutters, small bowel mesentery, greater omentum, gastric-bowel serosa, free peritoneal surfaces, rectosigmoid-colon mesentery, and pelvis. The presence or absence of peritoneal dissemination for each patient and for each site was scored using a 5-point confidence scale. Sensitivity, specificity, and area under the curve (AUC) for identifying per-site peritoneal implants were calculated for each reader at each reading session. Interobserver agreement was evaluated using kappa statistics. RESULTS: For both readers, the sensitivity and AUC values resulting from combined interpretation of conventional MRI and DWI (both b500-DWI and b1000-DWI) were significantly higher than those of conventional MRI alone (P < 0.001). The added value of DWI was greater for the less experienced reader (sensitivity 0.55, specificity 0.73, AUC 0.64 on conventional MRI; sensitivity 0.75, specificity 0.72, AUC 0.74 on b500-DWI; sensitivity 0.87, specificity 0.72, AUC 0.80 on b1000-DWI) than for the more experienced reader (sensitivity 0.63, specificity 0.75, AUC 0.70 on conventional MRI; sensitivity 0.76, specificity 0.77, AUC 0.77 on b500-DWI; sensitivity 0.85, specificity 0.72, AUC 0.79 on b1000-DWI), although the differences between the 2 observers were not statistically significant. Interobserver agreement resulted to be fair (κ = 0.30) when dealing with conventional MRI alone. The addition of b500-DWI and b1000-DWI to conventional MRI allowed to reach a substantial agreement (κ = 0.75). CONCLUSIONS: The combined interpretation of high b value DWI and conventional MRI provides increased sensitivity and diagnostic performance in detection of peritoneal carcinomatosis in oncologic patients.
PURPOSE: To assess the added value of diffusion weighted imaging (DWI) with intermediate (500 s/mm2) and high (1000 s/mm2) b values when combined to conventional contrast-enhanced magnetic resonance imaging (MRI) in identifying peritoneal neoplastic involvement. METHODS: Twenty-four patients with peritoneal carcinomatosis from gastrointestinal or gynecological tumors were retrospectively evaluated. All patients underwent peritonectomy with hyperthermic intraoperative chemotherapy and 1.5 T MRI including DWI with 500 s/mm2 and 1000 s/mm2 b values within 1 month from surgery. Images were independently reviewed by 2 radiologists with different experience in abdominal MRI in 3 separate reading sessions, the first including conventional MR images alone (T2-weighted, T1-weighted pre- and post gadolinium injection), the second conventional MRI and DWI with a b value of 500 s/mm2 (b 500-DWI), and the third conventional MRI and DWI with a b value of 1000 s/mm2 (b 1000-DWI). Apparent diffusion coefficient maps were included in the DWI analyses. Peritoneal dissemination was assessed in 9 anatomical sites, including right and left subphrenic space, paracolic gutters, small bowel mesentery, greater omentum, gastric-bowel serosa, free peritoneal surfaces, rectosigmoid-colon mesentery, and pelvis. The presence or absence of peritoneal dissemination for each patient and for each site was scored using a 5-point confidence scale. Sensitivity, specificity, and area under the curve (AUC) for identifying per-site peritoneal implants were calculated for each reader at each reading session. Interobserver agreement was evaluated using kappa statistics. RESULTS: For both readers, the sensitivity and AUC values resulting from combined interpretation of conventional MRI and DWI (both b500-DWI and b1000-DWI) were significantly higher than those of conventional MRI alone (P < 0.001). The added value of DWI was greater for the less experienced reader (sensitivity 0.55, specificity 0.73, AUC 0.64 on conventional MRI; sensitivity 0.75, specificity 0.72, AUC 0.74 on b500-DWI; sensitivity 0.87, specificity 0.72, AUC 0.80 on b1000-DWI) than for the more experienced reader (sensitivity 0.63, specificity 0.75, AUC 0.70 on conventional MRI; sensitivity 0.76, specificity 0.77, AUC 0.77 on b500-DWI; sensitivity 0.85, specificity 0.72, AUC 0.79 on b1000-DWI), although the differences between the 2 observers were not statistically significant. Interobserver agreement resulted to be fair (κ = 0.30) when dealing with conventional MRI alone. The addition of b500-DWI and b1000-DWI to conventional MRI allowed to reach a substantial agreement (κ = 0.75). CONCLUSIONS: The combined interpretation of high b value DWI and conventional MRI provides increased sensitivity and diagnostic performance in detection of peritoneal carcinomatosis in oncologic patients.