Thoracic James

Linda Patrick

S. Jelinek, M. Burrell, J. Peller,

Small with

Maj, MC, USA Maj, MC, USA Maj, MC, USA

Cell Lung MR Imaging’

Small cell lung cancer is an aggressive neoplasm; metastases are detected in two-thirds of patients at diagnosis with use of conventional staging, which includes bilateral bone marrow biopsy, bone scintigraphy, and computed tomography (CT) of the head and abdomen. In 25 patients, small cell lung cancer was staged prospectively with both conventional staging and a magnetic resonance (MR) imaging protocol that included 1.5-T MR imaging of the pelvis, abdomen, spine, and brain. According to conventional staging, 14 patients had extensive disease and 11 patients had limited disease;

according

to staging

with

MR, 19 patients had extensive disease and six had limited disease. All metastatic disease sites seen with conventional staging were identifled on MR images. MR images showed additional metastatic involvement in bone (four patients) and liver (three patients) not detected at conventional staging. A lowattenuation hepatic lesion on a CT scan was identified as a hemangioma on MR images. These preliminary data suggest that small cell lung cancer may be accurately staged with use of a single MR imaging study.

Radiology

Redmond III, Col, MC, USA #{149} “James J. Perry, Maj, MC, USA A. Benedikt, Capt, MC, USA #{149} Carl A. Geyer, Maj, MC, USA #{149} L. Wacks, RT #{149} Betty J. Wise, RT #{149} Victor N. Ghaed, Col, MC, USA

#{149} John

#{149} Richard #{149} Linda

Cancer:

S

Staging

cell lung cancer accounts for 20%-25% of lung cancer cases in the United States (1,2). In small cell lung cancer, the TNM staging system has not been useful, except in patients with localized disease for which surgical resection is being considered (2-4). An alternative, two-stage system based on studies of the Veterans Administration Lung Cancer Study Group is commonly used (2-4). In this system, patients arc classified as having either limited disease (ie, tumor confined to one hemithorax and to the regional lymph nodes) or extensive disease (ic, tumor beyond this area in contralatenal lung or extrathoracic sites). Extensive discase is present in 60%-80% of newly diagnosed patients with small cell lung cancer (2,4). Common sites of metastatic disease include the liver (22%-28%), bone (38%), bone marrow (17%-23%), central nervous system (CNS) (8%-15%), and nctropenitoneum (11%) (2,4-6). In patients with cxtensive disease, median survival is 71 1 months, and 2-year disease-free survival is mare; however, in patients with limited disease, median survival is 12-16 months with a 15%-20% 2year disease-free survival rate. Although both groups are treated with combination chemotherapy, patients with limited disease undergo more MALL

extensive treatment with radiation therapy to the chest and brain in an attempt to cure the disease. In addition, disease in all patients undergoing protocol treatment must be appropriately staged for immediate evaluation of its extent and for future evaluation of response to therapy. Conventional staging evaluation for extrathonacic metastases in patients with small cell lung cancer includcs computed tomography (CT) of the abdomen and head, bone scintigraphy, and bilateral bone marrow biopsies (1-7). To prospectively stage newly diagnosed small cell lung cancen, we used both conventional staging studies and a 21/2-hour magnetic resonance

(MR)

imaging

protocol

de-

signed to detect liver, adrenal, axial skeletal, bone marrow, and CNS metastases. This is a preliminary report of the first 25 patients. PATIENTS

AND

METHODS

From October 1988 to July 1990, 37 patients were evaluated for an initial diagnosis

of small

cell

lung

cancer

at Walter

Reed Army Medical Center. In all cases, the diagnosis was histologically confirmed. Eight patients were too ill to undergo either complete conventional staging

or staging

with

MR imaging

(four

of

these eight were treated with supportive care only). Four patients declined to participate in the study. The remaining 25 patients

composed

the study

group;

be-

fore therapy, each patient was evaluated for sites of metastatic disease by means From the Department of Radiology and Nuclear Medicine (J.S.J., R.A.B., C.A.G., P.J.P., I

Index

terms:

Bone

marrow,

CT,

30.1211

.

Bone marrow, MR studies, 30.1214 #{149} Bone neoplasms. CT, 30.121 1 #{149} Bone neoplasms, metastases, 30.33 #{149} Bone neoplasms, MR studies, 30.1214 #{149} Liver neoplasms, CT, 761.1211 #{149} Liver neoplasms, MR studies, 76.1214 #{149} Liver neoplasms, secondary, 761.33 #{149} Lung neoplasms, CT, 60.1214 #{149} Lung neoplasms, metastases, 60.3213 #{149} Lung neoplasms, MR studies, 60.1214. Lung neoplasms, staging, 60.3213 #{149} Magnetic resonance (MR), comparative studies

L.L.W.,

Oncology

1990; 177:837-842

V.N.G.)

Service,

and

the

Department

Hematology-

of Medicine

(JR., J.J.P., L.M.B.), Center, Washington,

Walter Reed Army Medical DC; and the Departments

of Radiology

C.A.G.)

J.J.P.),

Uniformed

(J.S.J.,

Services

and

Medicine

University

(JR., of the

Health Sciences, Bethesda, Md. From the 1989 RSNA scientific assembly. Received October 20, 1989; revision requested December 12; revision received July 30. 1990; accepted August 2. Address reprint requests to J.S.J., Department

of Radiology, Irving

Radiology

B.J.W.,

©

Washington

St NW, Washington, RSNA, 1990

Hospital

Center,

DC 20010.

both

conventional

staging

and

of

MR imag-

ing. Institutional review board approval and informed consent were obtained for all study patients. All patients were evaluated by the hematology-oncology

service

after

patho-

logic diagnosis of small cell lung cancer. All patients had undergone standard posteroanterior and lateral chest radiography and chest CT before diagnosis. Clinical

110 Abbreviations: tern,

FOV

CNS =

field

=

central

nervous

sys-

of view.

837

evaluation for metastatic disease included history taking and physical examination, complete blood count, and biochemical profile. Conventional staging studies included CT examinations of the chest (which all patients had undergone before histologic diagnosis), head, and abdomen after the intravenous administration of contrast material. We attempted to obtain dynamic CT scans of the liver and chest by intravenously administering a 75-mL bolus of contrast material followed by rapid drip infusion of contrast material. Scan time was 2-4 seconds per section, and the contiguous sections were 8-10 mm thick. CT was performed on one of the following scanners: 1200 (Picker Intemnational, Highland Heights, Ohio),

DRH NJ),

(Siemens or 9800

Medical (GE Medical

Systems,

Iselin,

Systems,

Mil-

waukee). Three hours after injection of approximately 740 MBq of technetium-99m methylene diphosphonate, a camera (535;

GE Medical view (FOV)

Systems) with a large field was used to perform bone

of

scintigraphy of the whole body. Bilateral posterior iliac bone marrow biopsy specimens and aspirates were obtained in all patients by means of standard techniques.

MR imaging

was performed

on a 1.5-T

Signa (GE Medical Systems) MR imager. In all patients, a body coil was used to obtam Ti-weighted coronal images of the pelvis (repetition time macc/echo time msec = 300-600/20). Other parameters included a section thickness of 5 mm, a 2mm gap, and two to four repetitions. A large-FOV (40-48 cm), Ti-weighted coronal view was used to image the proximal half of the femurs and pelvis. A second set of large-FOV, Ti-weighted coronal images of the upper abdomen and mcdiastinum was obtained with use of a repetition time of 300-600 msec and an echo time of 20 msec, a 1-cm section thickness,

and

a 2-mm

gap.

These

images

helped

to

locate areas for axial liver and adrenal images and to define the mediastinal adenopathy. Respiratory-gated, axial 12weighted images (1,800-2,500/30, 80)

were

obtained

with

use of a section

thick-

ness of 8-10 mm, a 2-mm gap, and four repetitions. Sagittal Ti-weighted (400600/20) MR imaging of the vertebral bodies and spinal cord was performed (section thickness, 3-5 mm) both before and after administration of gadopentetate dimeglumine (0.i mmol/kg) (Magnevist;

Berlex Imaging, Wayne, NJ). The spine was imaged with use of a 5 X 1 1-inch (13 x 28-cm) flat surface coil. Before gadopentetate dimeglumine was administered, spinal images were obtained in this order: cervical, thoracic, and lumbar. Repositioning of the surface coil was required each time. The FOVs used were 30, 35, and 35 cm for each part of the spine, respectively. After administration of gadopentetate dimeglumine, spinal images

were

obtained

in the opposite

order

(lum-

bar, thoracic, and cervical); the same imaging parameters were used as before. Gadopentetate dimeglumine was also used to image the brain and cranium; a head

838

Radiology

#{149}

I

b’

$

,

4-

-“r

‘ a. Figure

!

‘C

-,

b. 1. Patient 14. Liver gland shows diffuse

adrenal

and adrenal imaging. (a) Axial CT scan through hepatic metastases (black arrows) and a 1 .8-cm

left adrenal mass (white arrow). (b) Axial as CT scan in a shows diffuse involvement well as hyperintense adrenal gland mass

T2-weighted of both compatible

the liver

and

homogeneous (1,900/80) MR image at similar lobes of liver by metastases (arrows) with metastasis (arrowheads).

level as

coil was used for Ti-weighted (600/20) sagittal and axial imaging after administration of contrast material. The total amount of time needed for the entire examination was approximately 21/2 hours; actual scanning time was approximately i’/4 hours.

Bone marrow aspirates and biopsy specimens were interpreted by medical oncology and hematopathology staff. All bone scintigrams were interpreted by nuclear medicine physicians. All CT scans were interpreted by CT radiology and neuroradiology staff. All MR images were interpreted by a radiologist trained in CT and MR imaging who did not have any knowledge of the results of conventional staging. Results of MR imaging of bone

were considered positive if focal, nal-intensity lesions were present the

medullary

from from

the the

tween

bone

at locations

subchondral disk spaces.

conventional

staging

complete

data were conventional standard

small

tional

staging

Figure

staging

and

ret-

with and

and

the results of staging with

were

treated

lung MR

liver

with reg-

cancer.

Conven-

imaging

protocol

studies were repeated in 14 patients after three to four courses of induction chemotherapy, and these results were compared with the results of initial staging studies. Four patients died before follow-up studies could be performed; seven patients are still

receiving

induction

A cost analysis

staging

and the MR imaging formed by surveying

protocol was perboth private and

university groups

and

in

cost

conventional

for

the

3.

Characterization

imaging.

(not shown)

demonstrated

Axial through

demonstrates

of a

Contrast-enhanced

a region

proton-weighted the dome of the

a hyperintense

lesion

(ar-

row) just anterior to the right hepatic vein. On a T2-weighted MR image, the lesion was even more hyperintense. US and dynamic delayed CT helped confirm diagnosis of hemangioma.

agnosis

in

most

cases

and

jective of our protocol extrathoracic metastasis. study,

was

because

was

for

1 hour

contrast examinations and postcontrast

study

obfor

The cost of the

assessed

including

the

to evaluate

of

pre-

a 2’/2-hour and

of the spinal of the brain.

post-

cord

oncology

Washington,

DC, area. staging

was

The

RESULTS

based

on the sum of the average cost of each individual study: CT examinations (head and abdomen), bone scintigrams, and bilateral bone examinations. The cost of the CT scan of the chest was not used because

According ventional had limited

this study

aging,

had been

MR

MR imaging

chemotherapy.

of conventional

radiology

with

of low attenuation. (2,500/30) image

laboratory

chemotherapy

cell

2. Patient

lesion

CT scan

combination for

and

and

Patients

imens

or away be-

reviewed

clinical

correlated staging

MR imaging.

away

joint space Discrepancies

with MR imaging were rospectively evaluated. The

low-sigwithin

performed

before

di-

sive

disease. six

to evaluation with constaging, 1 1 of 25 patients disease and 14 had exten-

At staging

with

MR

of 25 patients

had

limited

December

im-

1990

Table 1 Abdominal

Imaging:

MR and CT Results Adrenal

Liver Patient

No.

ative bone scintigrams. Retrospective evaluation of these initially negative bone scintigrams with review of the companion MR images showed that four of the eight scintigrams could

CT

CT

Comments

MR Imaging

Gland MR Imaging

have

been

interpreted

initially

as

positive. 2 3 4

-

-

+

-

-

5

6 7 8

9 10 11 12 13 14 15 16

+

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

+

+

-

-

+ + + +

Metastases

+ + +

at follow-up

-

#{247}

Metastases

+ + +

+ + +

+

+

-

-

-

-

at follow-up

-

-

-

-

-

-

-

-

-

-

-

-

-

-

18 19 20 21 22 23

+

+

+

+

-

-

-

-

-

-

-

-

24

+ +

+ + +

-

-

-

-

-

-

+ +

+ +

+

+

-

-

-

25 Note.--

absence

=

and

Of the

-

+

-

17

disease

-

Hemangioma

of metastatic

19 had

five

Awaiting

disease,

extensive

+

disease.

discrepancies,

three

pa-

tients (patients 1, 19, and 23) had positive bone involvement at MR imaging but not at prospective conventional staging with bone marrow biopsy and bone scintigraphy. Retrospective evaluation of these patients’ bone scintigrams after review of the

presence

follow-up

of metastatic

Imaging

MR imaging brain

3). These

disease.

crepancies in liver imaging. In patient 3, a region of low attenuation was seen in the upper dome of the liver on a contrast-enhanced CT scan;

MR

with

that

three

MR

bone

patients

scm-

could

imaging;

results

of

CT had been negative. Patient 13 underwent follow-up MR imaging and CT after four courses of chemotherapy, and these showed enlargement of the previously identified hepatic lesions and multiple new lesions in the liver, which indicated progressive disease. Patient 20 has not yet undergone

follow-up

Liver ing

and

studies.

Adrenal

Imaging

imaging

and

CT were

in agree-

ment in 21 of 25 and 25 of 25 patients for the liver and adrenal gland, mespectively. In only four patients were adrenal metastases identified on both

CT scans nine mal

ages; ease types

and

patients, on both

MR

images

in 12 patients, of the liver of images.

Volume

177

(Fig

the liver appeared CT scans and MR

metastatic was detected There were

Number

#{149}

3

1). In norim-

dison four

both dis-

After

three

progression was shown

cycles

on

of che-

of disease MR images

in

and CT scans. Patient 20 had a single metastasis seen only on MR images and is awaiting follow-up examinations after three to four cycles of chemotherapy.

Bone

Results of liver and adrenal imagare shown in Table 1. Results of

MR

images.

motherapy, the liver

Evaluation

As shown in Table 2, results of MR imaging were positive for metastatic disease in 14 of 25 patients. In 10 of these patients, bone scmntigraphy, bone marrow biopsy, or both provided further evidence of bone disease (Fig 3). Every patient who had positive row

bone biopsy

scintigraphy results

MR imaging

or bone marhad positive

also

results.

In four

patients

with both

positive the bone

MR imaging scintigram

results, and the

bone

marrow

study

negative.

Positive found

three

been evaluated because they neurologically demonstrated

staging

suggested

of all

were

studies.

MR imaging in eight patients

were

results who

in agreement

In two

in all

patients

(pa-

tients 7 and 9), MR images showed impression of the thecal sac by a cervical disk without adjacent metastatic bone disease. MR images of patient 15 showed a metastatic bone lesion of the posterior vertebral body with minimal thecal sac impression (Fig

have been interpreted as positive. Two patients (patients 13 and 20) had a single hepatic metastasis at initial

images

tigrams

CNS

One patient had intracranial metastases. MR imaging showed no intradural spinal metastatic disease in our study group. Results of CT and

this anomaly was interpreted as a hemangioma based on results of MR imaging, ultrasound (US), and follow-up MR imaging and delayed-bolus CT examinations (Fig 2). Results of MR imaging were positive in three patients who had negative CT mesuits. Two patients (patients 9 and 13) had normal CT scans of the liver, but hepatic lesions were seen on initial

MR

of the

were had neg-

ullary

lipoma

patients

have

not

with myelography are free of pain and intact. MR imaging an extensive intramed-

from

T-4 to T-9 in pa-

tient 6; this patient was asymptomatic initially but later presented with symptoms of myelopathy while being treated with prednisone. This patient underwent lammnectomy and debulking of the lipoma. No cvidence of metastatic disease was present in the surgical specimen.

Cost

Analysis

Three university hospitals, a large medical center, and two private-practice radiology groups were surveyed for the cost of various CT studies. The average cost was $511 per contrast material-enhanced head CT scan, $713 for a contrast-enhanced chest CT scan, and $739 for an abdominal CT scan. The average cost for a whole-body bone scintigram was $444. Costs for bilateral bone marrow examination were obtained from two university hospitals and a private-practice oncology and pathology group. The average cost (including the hematologist’s and pathologist’s fees) was $558. Thus, the total cost for conventional staging (excluding the cost of the chest CT) was $2,252. The average cost per hour for MR imaging, based on survey prices of three university hospitals and three private-practice radiology groups, was $800. Most groups charge approximately $200 for the injection of gadopentetate dimeglummne and approximately 166% more for both preD..,1

1-.

and postcontrast studies. V!2 hours of MR imaging hour studies

for

The cost for time plus 1

both pre- and postcontrast was estimated to be $2,733.

Table 2 Bone Metastasis: Biopsy Patient

cell

lung

aggressive detectable

I

cancer

neoplasm metastases

with clinically in 60%-80%

patients at diagnosis rent therapy, patients disease rarely remain yond 2 years, whereas patients with limited

achieve

possible

exists

evaluation small

No consensus

the

needed

cell

lung

of

(2,4). With curwith extensive disease free be10%-15% of disease can

cure.

concerning

2 3 4 5

is a highly

extent

of the

to accurately

cancer

stage

(1-7).

The

irradiation,

pears

which

at this

to be beneficial

time

only

patients with limited identify reasonable cols, which currently

for

disease; treatment differ

of metastasis

uated ment.

that

be

protolimit-

reeval-

later to assess response to treatAlthough there are other pa-

rameters

for

measuring

extent

of dis-

ease (eg, performance status, nutrition, and weight loss), here we primanly address the ability of imaging studies thoracic

to allow metastatic

detection disease.

The cost of staging ing is slightly more complete

if the

dines may

in the become

gamd

the

time,

cost

single,

21/2-hour

of extra-

staging.

How-

of MR imaging

future, equal.

then Many

MR

preferable to three ments for bilateral

de-

the costs would re-

noninvasive, imaging

onestudy

as

separate appointbone marrow bi-

opsy and aspiration, phy, and CT studies. results of MR imaging

bone scintigraIn addition, the would be im-

mediately

because

available,

not require specimen pathologic review. party reimbursement

analyze tients

until from

demonstrate tocol and those

a large multiple

The

institutions

Qgn

#{149} Ra1jn1oQv

prowith

staging.

Most studies demonstrate aging to be as sensitive as-or than

do

of pa-

the benefits of this the costs are compared

of conventional

sensitive

they

fixation or issue of thirdis difficult to

number

-contrast-enhanced

+

-

-

-

-

+

-

-

-

-

-

-

-

7

-

-

-

8

+

-

9

+

+

10

+

11

-

+ +

12 13

+

-

+ + + + +

-

-

-

14

+

-

15 16 17 18

+ +

+ -

+ + +

-

-

-

-

-

-

-

-

+

-

-

-

-

-

-

+

+

-

-

24

+

+

+ + +

25

-

-

-

absence of metastatic femur, C cranium.

CT (with

disease,

+

presence

MR immore

or without

use

of a bolus

of

contrast material) in detecting metastatic liver disease (8-12). However, the increased sensitivity has not been

sufficient to offset the added expense of MR imaging and its more limited availability. CT with arterial portography may be even more sensitive than MR imaging, but it is more invasive and still misses sites of metastasis

with MR imagthan the cost of

conventional

ever,

-

-

and Bone

Comment Multiple Negative Solitary Negative Negative Negative Negative Multiple Multiple Multiple Multiple Multiple Negative Multiple Multiple Multiple Negative

Marrow

(MR lesions:

lesion:

Image) 5, P

right

ischium

lesions: lesions: lesions: lesions: lesions:

5, S. 5, S. S.

P. P. P. P. P.

lesions: lesions: lesions:

5, P. F 5, P. F, C 5, P. F

Solitary

lesion:

Multiple Solitary Multiple

lesions: 5, P. F lesion: T-10 lesions: S. P. F, C

of metastatic

disease,

S

-

right

F F F F F

spine,

ilium

P

=

pelvis,

F

those (b) to

for

can

-

-

Note.-(proximal)

ed and extensive disease because of the poor long-term disease-free survival prospects for patients with cxtensive disease; and (c) to identify sites

MR Image

-

20 21 2.2 23

ap-

Scintigram

Bone Scintigraphy,

6

19

three general clinical purposes for complete staging of small cell lung cancer are (a) to identify patients who would benefit from combinedmodality therapy with consolidated chest and prophylactic whole-brain

of MR Imaging,

Marrow Biopsy

No.

DISCUSSION Small

Results

shown

on

MR

images

(9).

For

routine enhanced

screening, traditional bolusCT is probably adequate,

but

imaging

MR

may

be preferred

when other organ systems currently being evaluated,

are conwhen an

optimal bolus dynamic CT scan cannot be obtained, or when the patient has allergies to iodinated contrast

material. quence

It is unclear and contrast

pulse seare op-

timal

for

tases; field

the answer may depend on the strength used (13-17). At 1.5 T,

the the

detection

which medium

T2-weighted most sensitivity

of hepatic

pulse

metas-

sequence (13,15,17).

has T2-

of MR imaging were similar to mesults of CT in detection of adrenal disease (Fig 1). The role of MR imaging in bone and bone marrow imaging is evolving (24-27). MR imaging can enable detection of both diffuse and focal Icsions when bone scintigrams are negative, and a recent study showed that MR imaging was more sensitive than bone scintigraphy in the evaluation of vertebral body metastasis (28). Rarely, bone scintigraphy results can be normal in patients with disseminated bone metastasis (29). Traditional evaluation of bone and bone marrow in patients with small cell lung cancer

uses

bone

marrow

bone

scintigraphy

biopsies.

in all patients scintigrams examinations; ing showed

with

metastases

bone disease than and bone marrow

as in one

of our

patients)

tases,

MR

imaging

of adrenal may

be

more

metasaccu-

rate than CT for tissue discrimination (19-23). Prospective studies comparing CT with MR imaging in evaluating adrenal metastases have not yet been performed. In this study, results

that tive

MR include

spine

MR imaging in the detection

findings report reasons would findings

positive

bone

or positive bone marrow in addition, MR imagmultiple focal defects in

the pelvis and bone scintigrams.

2) (18). In the evaluation

scintig-

raphy can be useful in evaluating the response to chemotherapy (30). In our study, MR images were positive

weighted images may also yield greater tissue characterization so that specific lesions can be differentiated (eg, to separate hemangiomas and (Fig

and

Bone

not These

may

seen data

on suggest

be more of metastatic

sensi-

bone scintigraphy examination; these

are consistent with a recent on this subject (28). Possible why bone scintigraphy show only subtle or negative (Fig 3) when the results of

imaging the

are obviously following:

positive First,

small

December

1990

.

‘i’:

b.

a.

Figure

3. Patient

15.

Results

of MR imaging

compared

with

results

of bone

scintigraphy.

(a) Technetium-99m

methylene

diphosphonate

bone scan shows subtle increased uptake in lumbar spine and pelvis, which is consistent with metastasis. (b) Bone scintigram of thoracic spine shows minimal increase in uptake. Rib uptake is present (arrow). (c) Coronal Ti-weighted MR image (400/20) of the pelvis shows cxtensive metastases (arrows), which were not as well seen on bone scintigram shown in a. (d) Coronal Ti-weighted (400/20) MR image of the upper abdomen and lower chest helps locate areas for axial imaging and demonstrates a right parenchymal nodule, right hilar adenopathy (arrows), large subcarinal adenopathy, and thoracic and lumbar vertebral body metastases (arrowheads). Liver metastases are shown poorly. (e) Sagittal Ti-weighted (600/20) MR image of the spine and spinal cord after injection of gadopentetate dimeglumine shows multiple vertebral body metastases; lesion at the T-5 level has minimal thecal sac impression (arrow). No intradural metastases are present. (f) Sagittal Tiweighted (600/20) MR image of the head after injection of gadopentetate dimeglumine demonstrates multiple calvarial bone metastases (arrows). No parenchymal metastases are seen.

bone metastases may be difficult to detect due to an insufficient targetto-background ratio. Second, a rapidly growing tumor may quickly that it does not

progress cause

remodeling

and

appears

photopenic

lesion

ial skeletal row

hence against

infiltrative

so

as a

Third,

process

is unlikely

positive

bone

scintigmams.

Our

MR

imaging

protocol

able

detection

cancer, study

away rib

and had

either

from

the

177

patient

isolated

metastasis.

Volume

one

such lung

or me-

in our disease

axial

skeleton

Since

pathologic

Number

#{149}

en-

to ribs

However, in small cell

not

to

cannot

of metastases

extremities. are rare

ax-

a mar-

produce

distal tastases

3

on MR results

bone

a “hot”

background.

firmation

dence

or only con-

is not

for metastatic images of MR

feasible,

the

disease

only is indirect, imaging were

cvi-

studied disease

detected

and

but support-

size of metastases, photopenic and marrow infiltration).

format

routine

ed by follow-up examinations. The retrospective review of the initial bone scintigrams after review with the companion MR imaging studies, however, suggests that in small cell lung cancer, bone scmntigraphy may be less sensitive than MR imaging for the three reasons previously listed (small lesions,

for detection to the CNS

We

are continuing MR imaging of these patients after chemotherapy to evaluate their response to treatment. MR imaging has been extensively

hanced mine,

for MR imaging

evaluation

ses have (33-35,37). only

of metastatic (31-40). The

not

of brain

metasta-

yet been determined In this study, we used

Ti-weighted

MR

by gadopentetate on which cerebral

ter changes tases may

role

in the

be

images

en-

dimegluwhite mat-

and possibly some missed; however,

metasgado-

pentetate dimeglumine-enhanced MR imaging probably is at least equal to contrast-enhanced CT of the brain.

The

aging

modalities

limited Little

accuracies

series can

of the

were of cerebral

be concluded

two

equal

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