Magnetic resonance imaging of the chest in the evaluation of cancer patients: state of the art

Magnetic resonance imaging (MRI) has several advantages in the evaluation of cancer patients with thoracic lesions, including involvement of the chest wall, pleura, lungs, mediastinum, esophagus and heart. It is a quite useful tool in the diagnosis, staging, surgical planning, treatment response evaluation and follow-up of these patients. In the present review, the authors contextualize the relevance of MRI in the evaluation of thoracic lesions in cancer patients. Considering that MRI is a widely available method with high contrast and spatial resolution and without the risks associated with the use of ionizing radiation, its use combined with new techniques such as cine-MRI and functional methods such as perfusion- and diffusion-weighted imaging may be useful as an alternative tool with performance comparable or complementary to conventional radiological methods such as radiography, computed tomography and PET/CT imaging in the evaluation of patients with thoracic neoplasias.

Magnetic resonance imaging; Diffusion-weighted imaging; Chest; Thoracic lesions; Oncology

Authorship

Marcos Duarte Guimaraes Mailing Address: Dr. Marcos Duarte Guimaraes. Rua Paulo Orozimbo, 726, Aclimação. São Paulo, SP, Brazil, 01535-001. E-mail: marcosduarte500@yahoo.com.br.

PhD, Radiologist, Specialist in Internal Medicine, Responsible for Chest Imaging Units at Hospital Heliópolis and A.C.Camargo Cancer Center, São Paulo, SP, BrazilHospital HeliópolisBrazilSão Paulo, SP, BrazilPhD, Radiologist, Specialist in Internal Medicine, Responsible for Chest Imaging Units at Hospital Heliópolis and A.C.Camargo Cancer Center, São Paulo, SP, Brazil

Bruno Hochhegger

PhD, Associate Professor at Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, BrazilUniversidade Federal de Ciências da Saúde de Porto AlegreBrazilPorto Alegre, RS, BrazilPhD, Associate Professor at Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil

Marcel Koenigkam Santos

PhD, Radiologist at Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, BrazilUniversidade de São PauloBrazilRibeirão Preto, SP, BrazilPhD, Radiologist at Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil

Pablo Rydz Pinheiro Santana

MD, Member of Colégio Brasileiro de Radiologia e Diagnóstico por Imagem (CBR), Thoracic Radiologist at Beneficência Portuguesa de São Paulo, São Paulo, SP, BrazilColégio Brasileiro de Radiologia e Diagnóstico por ImagemBrazilSão Paulo, SP, BrazilMD, Member of Colégio Brasileiro de Radiologia e Diagnóstico por Imagem (CBR), Thoracic Radiologist at Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil

Arthur Soares Sousa Júnior

PhD, Professor and Post-graduation Advisor, Faculdade de Medicina de São José do Rio Preto (Famerp), São José do Rio Preto, SP, BrazilFaculdade de Medicina de São José do Rio Preto (Famerp)BrazilSão José do Rio Preto, SP, BrazilPhD, Professor and Post-graduation Advisor, Faculdade de Medicina de São José do Rio Preto (Famerp), São José do Rio Preto, SP, Brazil

Luciana Soares Souza

MD, Radiologist, Faculdade de Medicina São José do Rio Preto (Famerp), São José do Rio Preto, SP, BrazilFaculdade de Medicina São José do Rio PretoBrazilSão José do Rio Preto, SP, BrazilMD, Radiologist, Faculdade de Medicina São José do Rio Preto (Famerp), São José do Rio Preto, SP, Brazil

Edson Marchiori

PhD, Adjunct Coordinator of Post-Graduation, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, BrazilUniversidade Federal do Rio de JaneiroBrazilRio de Janeiro, RJ, BrazilPhD, Adjunct Coordinator of Post-Graduation, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil

Mailing Address: Dr. Marcos Duarte Guimaraes. Rua Paulo Orozimbo, 726, Aclimação. São Paulo, SP, Brazil, 01535-001. E-mail: marcosduarte500@yahoo.com.br.

SCIMAGO INSTITUTIONS RANKINGS

Figures

Figures (12)

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Figure 1
Female, 64-year-old patient with diagnosis of pulmonary adenocarcinoma in the right upper lobe. Intense radiopharmaceutical FDG uptake (hypersignal) is observed in the right lung lesion and contralateral para-aortic lymph nodes, the latter with standard uptake value (SUV) of 5.1, corresponding to clinical stage N3.

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Figure 2
Female, 23-year-old patient with neurofibromatosis, presenting with left paravertebral lesion in close contact with the neural foramen. On A, high signal intensity is observed on the diffusion-weighted image (arrow). On B, the same lesion is observed (arrow) on the ADC map, presenting values > 1 mm²/s (not demonstrated), corresponding to lower cellularity and little water molecules diffusion restriction. This lesion was considered as little aggressive, a probable schwannoma corroborated by the findings on the other sequences. Considering the age of the patient as well as the benign appearance/low aggressiveness of the lesion, one has opted for semestral follow-up of the lesions by means of MRI.

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Figure 3
Male, 54-year-old with colon adenocarcinoma progressing with pulmonary nodule suggestive of metastasis. Chest MRI demonstrates a solid nodule in the right upper lobe. On A, the nodule presents heterogeneous hyperintensity (arrow) of the signal on the diffusion-weighted sequence. On B, ADC map demonstrates values < 1 mm²/s within the lesion, corresponding to high cellularity and water molecules diffusion restriction suggesting malignancy. The nodule was biopsied and the diagnosis of metastasis was confirmed.

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Figure 4
Male, 75-year-old patient with chronic obstructive pulmonary disease and previous history of lung cancer resection for two years. Currently, there is a suspicion of recurrence. On A, MRI T2-weighted fatsat sequence could detect the presence os a central nodule at left (long arrow) in the area of post-obstructive pneumonitis (short arrows). On B, pulmonary perfusion-weighted sequence demonstrates absence of perfusion in the remnant left lung.

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Figure 5
Male, 22-year-old patient with a malignant nonseminomatous germ cell tumor. On A and B, an anterior, heterogeneous mediastinal nodule with areas of necrosis is observed extending toward the right atrium and superior vena cava, with signs of invasion of these structures (arrows), contraindicating surgical resection. Complementary cine-MRI was performed, confirming the fixation/infiltration of the superior vena cava and right atrium by the nodule.

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Figure 6
Patient 49-year-old with renal tumor progressing with bilateral chest pain. MRI T1-weighted sequence with fat suppression demonstrates coastal lesions with signal intensity of soft parts and intense paramagnetic contrast enhancement (arrows) suggestive of metastasis. Later, the diagnosis was histopathologically confirmed.

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Figure 7
Male, 71-year-old patient with spinocellular carcinoma of the lung. On A, chest CT demonstrates lytic lesion with soft parts component in the left vertebral hemibody (arrow) of an inferior thoracic vertebra. On B, fusion of a background anatomical T2-weighted image superimposed by the diffusion-weighted sequence, demonstrating marked hypersignal in the thoracic vertebral lesion (long arrow) and also on the anterior wall of the right ventricle (short arrow) compatible with areas of intense cellularity, suggestive of malignancy.

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Figure 8
Female, 21-year-old, with voluminous anterior expansile mediastinal lesion. On A, T2-weighted image demonstrating well-defined lesion (arrows) with regular contours, and with finely heterogeneous, slightly increased signal intensity on this sequence. Homogeneous and diffuse increase in signal is observed on the diffusionweighted sequence, and the ADC map demonstrated values > 1 mm²/s (not available) within the lesion, corresponding to low cellularity and little water molecules diffusion restriction. On B, the surgical specimen can be observed. The histopathological result confirmed the diagnosis of a well differentiated tumor: thymoma B1.

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Figure 9
Male, 71-year-old patient with long history of smoking and alcoholism, developed esophageal spinocellular carcinoma. On this figure, there was a fusion of the background anatomical T2-weighted image with the diffusion-weighted image. Observe that the esophageal expansile lesion (arrow) and the left paratracheal lymph node enlargement (asterisk) present hypersignal on the diffusion-weighted sequence compatible with high cellularity. The diagnosis of malignancy was later confirmed by histopathological analysis.

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Figure 10
Patient 14-year-old, asymptomatic patient presenting with anterior mediastinal nodule detected at imaging study. On A, MRI ADC mapping performed to support biopsy planning, definition of needle pathway (long arrow) and selection of the area for sample collection, indicating the region with values < 1 mm²/s within the lesion (short arrow). On B, the gross needle pathway is seen at CT image. Note that, at CT, the needle pathway (arrow) coincides with the MRI planned pathway. Five biopsy specimens were collected and the anatomopathological analysis confirmed the diagnosis of thymoma B3.

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Figure 11
Male, 73-year-old patient with a central nodule at left in association with secondary atelectasis. Transbronchial biopsy confirmed the diagnosis of clinical stage IIIa pulmonary adenocarcinoma. Chest MRI including ADC mapping was performed. ADC values were measured within the region of interest (circle). On A, the ADC mapping (arrow) performed before the neoadjuvant chemotherapy, and on B, ADC mapping (arrow) performed after neoadjuvant chemotherapy. Note the increase in ADC values (a sign of good response, cell necrosis), even without significant change in the nodule dimensions. The lesion was uneventfully resected and the diagnosis of predominantly micropapillary adenocarcinoma (tumor T3N2) was confirmed.

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Figure 12
Male, 68-year-old patient with diagnosis of adenocarcinoma in the right upper lobe. On A, chest MRI including fusion between anatomical (T2-weighted) image and functional (diffusion-weighted) image, similarly to PET/CT imaging. Observe the central lesion in association with intense brightness (arrow) leading to post-obstructive pneumonitis characterized by the area of atelectasis with lower brightness (asterisk). On B, PET/CT image demonstrates central lesion in association with intense contrast uptake (arrow) corresponding to post-obstructive pneumonitis characterized by the area of atelectasis, without contrast uptake (asterisk).

Figure 1 Female, 64-year-old patient with diagnosis of pulmonary adenocarcinoma in the right upper lobe. Intense radiopharmaceutical FDG uptake (hypersignal) is observed in the right lung lesion and contralateral para-aortic lymph nodes, the latter with standard uptake value (SUV) of 5.1, corresponding to clinical stage N3.

Figure 2 Female, 23-year-old patient with neurofibromatosis, presenting with left paravertebral lesion in close contact with the neural foramen. On A, high signal intensity is observed on the diffusion-weighted image (arrow). On B, the same lesion is observed (arrow) on the ADC map, presenting values > 1 mm²/s (not demonstrated), corresponding to lower cellularity and little water molecules diffusion restriction. This lesion was considered as little aggressive, a probable schwannoma corroborated by the findings on the other sequences. Considering the age of the patient as well as the benign appearance/low aggressiveness of the lesion, one has opted for semestral follow-up of the lesions by means of MRI.

Figure 3 Male, 54-year-old with colon adenocarcinoma progressing with pulmonary nodule suggestive of metastasis. Chest MRI demonstrates a solid nodule in the right upper lobe. On A, the nodule presents heterogeneous hyperintensity (arrow) of the signal on the diffusion-weighted sequence. On B, ADC map demonstrates values < 1 mm²/s within the lesion, corresponding to high cellularity and water molecules diffusion restriction suggesting malignancy. The nodule was biopsied and the diagnosis of metastasis was confirmed.

Figure 4 Male, 75-year-old patient with chronic obstructive pulmonary disease and previous history of lung cancer resection for two years. Currently, there is a suspicion of recurrence. On A, MRI T2-weighted fatsat sequence could detect the presence os a central nodule at left (long arrow) in the area of post-obstructive pneumonitis (short arrows). On B, pulmonary perfusion-weighted sequence demonstrates absence of perfusion in the remnant left lung.

Figure 5 Male, 22-year-old patient with a malignant nonseminomatous germ cell tumor. On A and B, an anterior, heterogeneous mediastinal nodule with areas of necrosis is observed extending toward the right atrium and superior vena cava, with signs of invasion of these structures (arrows), contraindicating surgical resection. Complementary cine-MRI was performed, confirming the fixation/infiltration of the superior vena cava and right atrium by the nodule.

Figure 6 Patient 49-year-old with renal tumor progressing with bilateral chest pain. MRI T1-weighted sequence with fat suppression demonstrates coastal lesions with signal intensity of soft parts and intense paramagnetic contrast enhancement (arrows) suggestive of metastasis. Later, the diagnosis was histopathologically confirmed.

Figure 7 Male, 71-year-old patient with spinocellular carcinoma of the lung. On A, chest CT demonstrates lytic lesion with soft parts component in the left vertebral hemibody (arrow) of an inferior thoracic vertebra. On B, fusion of a background anatomical T2-weighted image superimposed by the diffusion-weighted sequence, demonstrating marked hypersignal in the thoracic vertebral lesion (long arrow) and also on the anterior wall of the right ventricle (short arrow) compatible with areas of intense cellularity, suggestive of malignancy.

Figure 8 Female, 21-year-old, with voluminous anterior expansile mediastinal lesion. On A, T2-weighted image demonstrating well-defined lesion (arrows) with regular contours, and with finely heterogeneous, slightly increased signal intensity on this sequence. Homogeneous and diffuse increase in signal is observed on the diffusionweighted sequence, and the ADC map demonstrated values > 1 mm²/s (not available) within the lesion, corresponding to low cellularity and little water molecules diffusion restriction. On B, the surgical specimen can be observed. The histopathological result confirmed the diagnosis of a well differentiated tumor: thymoma B1.

Figure 9 Male, 71-year-old patient with long history of smoking and alcoholism, developed esophageal spinocellular carcinoma. On this figure, there was a fusion of the background anatomical T2-weighted image with the diffusion-weighted image. Observe that the esophageal expansile lesion (arrow) and the left paratracheal lymph node enlargement (asterisk) present hypersignal on the diffusion-weighted sequence compatible with high cellularity. The diagnosis of malignancy was later confirmed by histopathological analysis.

Figure 10 Patient 14-year-old, asymptomatic patient presenting with anterior mediastinal nodule detected at imaging study. On A, MRI ADC mapping performed to support biopsy planning, definition of needle pathway (long arrow) and selection of the area for sample collection, indicating the region with values < 1 mm²/s within the lesion (short arrow). On B, the gross needle pathway is seen at CT image. Note that, at CT, the needle pathway (arrow) coincides with the MRI planned pathway. Five biopsy specimens were collected and the anatomopathological analysis confirmed the diagnosis of thymoma B3.

Figure 11 Male, 73-year-old patient with a central nodule at left in association with secondary atelectasis. Transbronchial biopsy confirmed the diagnosis of clinical stage IIIa pulmonary adenocarcinoma. Chest MRI including ADC mapping was performed. ADC values were measured within the region of interest (circle). On A, the ADC mapping (arrow) performed before the neoadjuvant chemotherapy, and on B, ADC mapping (arrow) performed after neoadjuvant chemotherapy. Note the increase in ADC values (a sign of good response, cell necrosis), even without significant change in the nodule dimensions. The lesion was uneventfully resected and the diagnosis of predominantly micropapillary adenocarcinoma (tumor T3N2) was confirmed.

Figure 12 Male, 68-year-old patient with diagnosis of adenocarcinoma in the right upper lobe. On A, chest MRI including fusion between anatomical (T2-weighted) image and functional (diffusion-weighted) image, similarly to PET/CT imaging. Observe the central lesion in association with intense brightness (arrow) leading to post-obstructive pneumonitis characterized by the area of atelectasis with lower brightness (asterisk). On B, PET/CT image demonstrates central lesion in association with intense contrast uptake (arrow) corresponding to post-obstructive pneumonitis characterized by the area of atelectasis, without contrast uptake (asterisk).

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