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Jiun-Lin Yan, Anouk van der Hoorn, Timothy J. Larkin, Natalie R. Boonzaier, Tomasz Matys and Stephen J. Price

OBJECTIVE

Diffusion tensor imaging (DTI) has been shown to detect tumor invasion in glioblastoma patients and has been applied in surgical planning. However, the clinical value of the extent of resection based on DTI is unclear. Therefore, the correlation between the extent of resection of DTI abnormalities and patients' outcome was retrospectively reviewed.

METHODS

A review was conducted of 31 patients with newly diagnosed supratentorial glioblastoma who underwent standard 5-aminolevulinic acid–aided surgery with the aim of maximal resection of the enhancing tumor component. All patients underwent presurgical MRI, including volumetric postcontrast T1-weighted imaging, DTI, and FLAIR. Postsurgical anatomical MR images were obtained within 72 hours of resection. The diffusion tensor was split into an isotropic (p) and anisotropic (q) component. The extent of resection was measured for the abnormal area on the p, q, FLAIR, and postcontrast T1-weighted images. Data were analyzed in relation to patients' outcome using univariate and multivariate Cox regression models controlling for possible confounding factors including age, O6-methylguanine-DNA-methyltrans-ferase methylation status, and isocitrate dehydrogenase–1 mutation.

RESULTS

Complete resection of the enhanced tumor shown on the postcontrast T1-weighted images was achieved in 24 of 31 patients (77%). The mean extent of resection of the abnormal p, q, and FLAIR areas was 57%, 83%, and 59%, respectively. Increased resection of the abnormal p and q areas correlated positively with progression-free survival (p = 0.009 and p = 0.006, respectively). Additionally, a larger, residual, abnormal q volume predicted significantly shorter time to progression (p = 0.008). More extensive resection of the abnormal q and contrast-enhanced area improved overall survival (p = 0.041 and 0.050, respectively).

CONCLUSIONS

Longer progression-free survival and overall survival were seen in glioblastoma patients in whom more DTI-documented abnormality was resected, which was previously shown to represent infiltrative tumor. This highlights the potential usefulness and the importance of an extended resection based on DTI-derived maps.

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Tomasz Matys, Tariq Ali, Fulvio Zaccagna, Damiano G. Barone, Ramez W. Kirollos and Tarik F. Massoud

OBJECTIVE

Ossification of pterygoalar and pterygospinous ligaments traversing the superior aspect of the infratemporal fossa results in formation of osseous bars that can obstruct percutaneous needle access to the trigeminal ganglion through the foramen ovale (FO), interfere with lateral mandibular nerve block, and impede transzygomatic surgical approaches. Presence of these ligaments has been studied on dry skulls, but description of their radiological anatomy is scarce, in particular on cross-sectional imaging. The aim of this study was to describe visualization of pterygoalar and pterygospinous bars on computed tomography (CT) and to review their prevalence and clinical significance.

METHODS

The authors retrospectively reviewed 200 helical sinonasal CT scans by analyzing 0.75- to 1.0-mm axial images, maximum intensity projection (MIP) reconstructions, and volume rendered (VR) images, including views along the anticipated axis of the needle in percutaneous Hartel and submandibular approaches to the FO.

RESULTS

Ossified pterygoalar and pterygospinous ligaments were readily identifiable on CT scans. An ossified pterygoalar ligament was demonstrated in 10 patients, including 1 individual with bilateral complete ossification (0.5%), 4 patients with unilateral complete ossification (2.0%), and 5 with incomplete unilateral ossification (2.5%). Nearly all patients with pterygoalar bars were male (90%, p < 0.01). An ossified pterygospinous ligament was seen in 35 patients, including 2 individuals with bilateral complete (1.0%), 8 with unilateral complete (4%), 8 with bilateral incomplete (4.0%), 12 with bilateral incomplete (6.0%) ossification, and 5 (2.5%) with mixed ossification (complete on one side and incomplete on the contralateral side). All pterygoalar bars interfered with a hypothetical needle access to the FO using the Hartel approach but not the submandibular approach. In contrast, 54% of complete and 24% of incomplete pterygospinous bars impeded the submandibular approach to the FO, without affecting the Hartel approach.

CONCLUSIONS

This study provides the first detailed description of cross-sectional radiological and applied surgical anatomy of pterygoalar and pterygospinous bars. Our data are clinically useful during skull base imaging to predict potential obstacles to percutaneous cannulation of the FO and assist in the choice of approach, as these two variants differentially impede the Hartel and submandibular access routes. Our results can also be useful in planning surgical approaches to the skull base through the infratemporal fossa.

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Chao Li, Shuo Wang, Jiun-Lin Yan, Turid Torheim, Natalie R. Boonzaier, Rohitashwa Sinha, Tomasz Matys, Florian Markowetz and Stephen J. Price

OBJECTIVE

The objective of this study was to characterize the abnormalities revealed by diffusion tensor imaging (DTI) using MR spectroscopy (MRS) and perfusion imaging, and to evaluate the prognostic value of a proposed quantitative measure of tumor invasiveness by combining contrast-enhancing (CE) and DTI abnormalities in patients with glioblastoma.

METHODS

Eighty-four patients with glioblastoma were recruited preoperatively. DTI was decomposed into isotropic (p) and anisotropic (q) components. The relative cerebral blood volume (rCBV) was calculated from the dynamic susceptibility contrast imaging. Values of N-acetylaspartate, myoinositol, choline (Cho), lactate (Lac), and glutamate + glutamine (Glx) were measured from multivoxel MRS and normalized as ratios to creatine (Cr). Tumor regions of interest (ROIs) were manually segmented from the CE T1-weighted (CE-ROI) and DTI-q (q-ROI) maps. Perfusion and metabolic characteristics of these ROIs were measured and compared. The relative invasiveness coefficient (RIC) was calculated as a ratio of the characteristic radii of CE-ROI and q-ROI. The prognostic significance of RIC was tested using Kaplan-Meier and multivariate Cox regression analyses.

RESULTS

The Cho/Cr, Lac/Cr, and Glx/Cr in q-ROI were significantly higher than CE-ROI (p = 0.004, p = 0.005, and p = 0.007, respectively). CE-ROI had significantly higher rCBV values than q-ROI (p < 0.001). A higher RIC was associated with worse survival in a multivariate overall survival (OS) model (hazard ratio [HR] 1.40, 95% confidence interval [CI] 1.06–1.85, p = 0.016) and progression-free survival (PFS) model (HR 1.55, 95% CI 1.16–2.07, p = 0.003). An RIC cutoff value of 0.89 significantly predicted shorter OS (median 384 vs 605 days, p = 0.002) and PFS (median 244 vs 406 days, p = 0.001).

CONCLUSIONS

DTI-q abnormalities displayed higher tumor load and hypoxic signatures compared with CE abnormalities, whereas CE regions potentially represented the tumor proliferation edge. Integrating the extents of invasion visualized by DTI-q and CE images into clinical practice may lead to improved treatment efficacy.