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Page 1 of 18
Aims and objectives
Diffusion weighted sequences are now routine in MR imaging [1]. In fact several studies
have emphasized its role in the detection and characterization of abdominal parenchymal
organ lesions [2-4], in the assessment of hepatic fibrosis [5-7], and in the evaluation of
response to therapy in oncological patients [8, 9].
In clinical practice most patients are not able to hold their breath for up to 20 seconds,
so that the triggered sequences or free-breathing sequences are mostly used.
Different studies have pointed out that ADC values have different repeatability and
reproducibility. Therefore, several methods have been proposed in order to standardize
the technique of measurement especially in the evaluation of hepatic disease [11].
Page 2 of 18
Fig. 1: Axial diffusion-weighted single-shot echo-planar images with parallel imaging and
fat saturation illustrating possible artifacts in DW imaging. In figure a, respiratory artifact is
demonstrated by double-edged liver and spleen (arrows), due to misregistration. In figure
1b, cardiac pulsation artifact is showed, with consequent left liver signal loss (arrows)
and cardiac ghost outside the abdomen (arrowheads).
Page 3 of 18
Methods and materials
This study was approved by our internal institutional committee. From April to August
2014, twenty-seven patients (15 men and 12 women; mean age 59 years; range 21-82
years) were enrolled for abdominal MR examination. Written informed consent was
obtained from all patients.
13 patients were studied for chronic liver disease or hepatocellular carcinoma (HCC), 10
patients underwent MRI to characterize focal liver lesions, one patient was analyzed to
stage renal cancer, 3 patients were scanned for metastatic cancer staging.
Patients were examined with a 1.5 Tesla (T) MR scanner (Signa HDxt; GE Healthcare,
Milwaukee), with an eight channel dedicated phased-array coil.
Study protocol
Images were retrospectively evaluated for ADC assessment in both sequences. Namely,
ADC values were obtained placing ROI of 1 cm in the following anatomical regions (Fig.
3 on page 6): left liver lobe, right liver lobe, spleen and right kidney.
Page 4 of 18
Wilcoxon matched pairs signed rank test was performed to compare ADC measurements
obtained with both techniques. Pearson ADC correlation was also assessed.
Page 5 of 18
Fig. 2: The table illustrates parameters used in b500 and b800 diffusion-weighted single-
shot echo-planar sequences acquired with triggered and free-breathing techniques.
Page 6 of 18
Fig. 3: ADC maps obtained from diffusion-weighted single-shot echo-planar images.
Figures show examples of ROI (Region of Interest) placed in left liver (II-III segment on
figure a and IV segment on figure b), in right liver (c), in anterior (d) and posterior (e)
portions of spleen and in right kidney (f).
Page 7 of 18
Results
Using Wilcoxon test, no statistically significant difference (p= 0.76) was reported between
free breathing and respiratory triggered techniques, in diffusion MR sequences acquired
with b=0-500 (Fig. 4 on page 8).
High Pearson correlations (Fig. 6 on page 10; Fig. 7 on page 11) between
sequences in both modalities were also found (0.76 for b-500 values and 0.90 for b-800
values).
For the qualitative assessment (Fig. 8 on page 12), a statistically significant better
performance was found for free-breathing images (p<0.05) for both b=500 and b=800,
using Student's t-test.
High interobserver agreement (k>0.85) was found adopting Cohen's kappa coefficient.
Page 8 of 18
Fig. 4: Graphic representation of Wilcoxon for b=500 DW sequences. Wilcoxon test
reported no statistically significant difference (p= 0.76) for ADC measurements between
free breathing and respiratory-triggered techniques.
Page 9 of 18
Fig. 5: Graphic representation of Wilcoxon test for b=800 DW sequences. The test
reported no statistically significant difference (p= 0.79) for ADC measurements between
free breathing and respiratory-triggered techniques.
Page 10 of 18
Fig. 6: Scatter plot of ADC values obtained with b=500 DW sequences. Graphic shows
high correlation between ADC values obtained through the two techniques.
Page 11 of 18
Fig. 7: Scatter plot of ADC values in b=800 DW sequences. Graphic indicates high
correlation between ADC values obtained through the two techniques.
Page 12 of 18
Fig. 8: Qualitative assessment of the two techniques analyzed by two separated
operators (first operator in a and b; second operator in c and d). Both operators found
a statistically significant better performance for free-breathing images for both b=500 (a,
c) and b=800 (b, d) DW sequences.
Page 13 of 18
Conclusion
Free-breathing echo-planar sequences do not have this limit and can also be used in
patients with irregular breathing, using some expedients that permit improved image
quality. High signal averages or number of excitations are generally able to increase
the signal-to-noise ratio and reduce motion artifacts on images [15]. In addition, an
incremented number of excitations (NEX) increase the possibility of data acquisition
during diastole, reducing pulsation artifacts using only respiratory trigger [16].
In our study, quantitative analysis of ADC values did not show any significant difference
between acquisition techniques. Free breathing technique reported high image quality
score and therefore could be used in patients with irregular respiratory gating.
Results of our study agree with the experience reported by Choi et al [18], although
they used 3T scanner for their study. No statistical difference was reported between
the different techniques for ADC measurements, even though our qualitative analysis
significantly favors free-breathing sequences.
Unfortunately, number of enrolled patients in our study is quite low. Therefore further
patients are needed in order to obtain a more reliable statistical analysis.
Personal information
Giuseppina Cappello, MD
Page 14 of 18
giuseppina.cappello@gmail.com
Stefano Palmucci, MD
spalmucci@sirm.org
ritasi84@hotmail.it
Giancarlo Attinà, MD
gianco82t@hotmail.it
Federica Roccasalva, MD
f.roccasalva@gmail.com
Page 15 of 18
Via Santa Sofia 78 - 95123, Catania - Italy
Marina Piccoli, MD
p.mari4@hotmail.it
marialuisagiunta@gmail.com
pucciopetrillo@hotmail.com
References
Page 16 of 18
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