Differentiation of Glioblastoma from Brain Metastasis: Qualitative and Quantitative Analysis Using Arterial Spin Labeling MR Imaging
Differentiation of Glioblastoma from Brain Metastasis: Qualitative and Quantitative Analysis Using Arterial Spin Labeling MR Imaging
Leonard Sunwoo 0 1
Tae Jin Yun 0 1
Sung-Hye You 1
Roh-Eul Yoo 0 1
Koung Mi Kang 0 1
Seung Hong Choi 0 1
Ji-hoon Kim 0 1
Chul-Ho Sohn 0 1
Sun-Won Park 0 1
Cheolkyu Jung 0 1
Chul-Kee Park 1
0 Department of Radiology, Seoul National University College of Medicine , Seoul , Korea , 2 Department of Radiology, Seoul National University Bundang Hospital , Seongnam , Korea , 3 Department of Radiology, Seoul National University Hospital , Seoul , Korea , 4 Department of Radiology, Seoul Metropolitan GovernmentÐSeoul National University Boramae Medical Center , Seoul , Korea , 5 Department of Neurosurgery, Seoul National University Hospital , Seoul , Korea
1 Editor: Jeroen Hendrikse, Universitair Medisch Centrum Utrecht , NETHERLANDS
Data Availability Statement; Data are all contained within the Supporting Information files
Competing Interests: The authors have declared
that no competing interests exist.
(GBM) from brain metastasis.
Materials and Methods
To evaluate the diagnostic performance of cerebral blood flow (CBF) by using arterial spin
labeling (ASL) perfusion magnetic resonance (MR) imaging to differentiate glioblastoma
The institutional review board of our hospital approved this retrospective study. The study
population consisted of 128 consecutive patients who underwent surgical resection and
were diagnosed as either GBM (n = 89) or brain metastasis (n = 39). All participants
underwent preoperative MR imaging including ASL. For qualitative analysis, the tumors were
visually graded into five categories based on ASL-CBF maps by two blinded reviewers. For
quantitative analysis, the reviewers drew regions of interest (ROIs) on ASL-CBF maps upon
the most hyperperfused portion within the tumor and upon peritumoral T2 hyperintensity
area. Signal intensities of intratumoral and peritumoral ROIs for each subject were
normalized by dividing the values by those of contralateral normal gray matter (nCBFintratumoral and
nCBFperitumoral, respectively). Visual grading scales and quantitative parameters between
GBM and brain metastasis were compared. In addition, the area under the receiver-operat
ing characteristic curve was used to evaluate the diagnostic performance of ASL-driven
CBF to differentiate GBM from brain metastasis.
For qualitative analysis, GBM group showed significantly higher grade compared to metasta
sis group (p = 0.001). For quantitative analysis, both nCBFintratumoral and nCBFperitumoral in
GBM were significantly higher than those in metastasis (both p < 0.001). The areas under the
curve were 0.677, 0.714, and 0.835 for visual grading, nCBFintratumoral, and nCBFperitumoral,
respectively (all p < 0.001).
ASL perfusion MR imaging can aid in the differentiation of GBM from brain metastasis.
Differentiation of glioblastomas (GBMs) from brain metastases is clinically important, because
these two entities differ from each other in clinical course and management. The clinical
settings, particularly in patients with known primary malignancy or multiple brain lesions, often
lead to the diagnosis of brain metastasis without much difficulty. However, for patients
without proven systemic malignancy, differentiation of brain metastasis from high grade glioma
such as GBM becomes challenging because they are known to exhibit overlapping imaging
findings on conventional magnetic resonance (MR) imaging [
Both GBMs and metastatic brain tumors are known to induce angiogenesis, and thus
display increased perfusion [
]. GBM cells, in contrast to brain metastasis, tend to infiltrate into
surrounding while matter [4±7]. Therefore, many researchers have used perfusion MR
imaging techniques to discriminate GBM from brain metastasis [1, 2, 8±13]. Regarding dynamic
susceptibility contrast-enhanced (DSC) perfusion imaging, several studies have demonstrated
that relative cerebral blood volume (rCBV) in the peritumoral T2 hyperintensity area in GBM
is significantly higher than that in brain metastasis. Additionally, a histopatholgic study
revealed significantly higher microvessel density in GBMs than that in brain metastasis [
However, rCBV measurement in enhancing tumor volumes using DSC perfusion imaging has
not been shown to be helpful in the differentiation of the two [1, 2, 8±10, 12].
Arterial spin labeling (ASL), a perfusion imaging technique that utilizes electromagnetically
labeled arterial blood water as an intrinsic tracer, could be used to assess cerebral blood flow
(CBF) in tumor [12, 14±20]. Despite its clinical usefulness and applicability for the
characterization of brain tumors, to the best of our knowledge, only a few studies have investigated the
clinical utility of ASL to differentiate GBM from brain metastasis [
The aim of this study was to compare CBF values in GBM and brain metastasis by using
ASL perfusion MR imaging and to assess the diagnostic performance of CBF on ASL for differ
entiation of GBM from brain metastasis. More specifically, we aimed to evaluate whether
peritumoral hyperperfusion is better able to differentiate between GBM and metastasis than
intratumoral hyperperfusion. To this end, we applied quantitative measurements of
peritumoral and intratumoral CBF and visual assessment of intratumoral hyperperfusion.
Materials and Methods
The institutional review board waived the need for written informed consent from the partici
pants because this was a retrospective study and the patient records and information was
anonymized and de-identified prior to analysis. From January 2012 through December 2014,
298 consecutive patients who satisfied the following inclusion criteria were included in this
retrospective study: (a) patients whose histopathologic diagnoses were confirmed either as GBM
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or as brain metastasis, and (b) patients whose preoperative MR imagings were performed
within 3 months prior to surgery. Of these, 170 patients were excluded for the following
reasons: (a) lack of ASL images in the preoperative MR imaging (n = 164), and (b) skull or dural
metastasis without evidence of parenchymal metastasis (n = 6). The remaining 128 subjects
were finally enrolled for the study, including 89 GBMs and 39 metastases (primary
malignancy: lung cancer (n = 9), breast cancer (n = 8), hepatocellular carcinoma (n = 5), colorectal
cancer (n = 5), melanoma (n = 4), mixed hepatocellular cholangiocarcinoma (n = 1), papillary
thyroid carcinoma (n = 1), esophageal cancer (n = 1), renal cell carcinoma (n = 1), bladder
cancer (n = 1), prostate cancer (n = 1), leiomyosarcoma (n = 1), and mediastinal
choriocarcinoma (n = 1)). Patients with GBM consisted of 56 men (mean age, 58.7 years, range, 24±84
years) and 33 women (mean age, 56.3 years, range, 29±79 years). In patients with brain
metastases, there were 20 men (mean age, 59.9 years, range, 19±79 years) and 19 women (mean age,
52.1 years, range, 23±69 years). Four patients with brain metastasis (10.3%) initially presented
with symptoms related to brain lesion before the diagnosis of primary malignancy.
MR images were obtained with a 1.5 T (Signa HDxt; GE Healthcare, Milwaukee, WI) or a 3 T
(Verio; Siemens Healthcare, Erlangen, Germany, or Discovery 750w; GE Healthcare) MR
scanner with an 8- or 32- channel head coil. Imaging sequences included fast spin-echo
T2-weigthed images (T2WI), contrast-enhanced spin-echo T1-weighted images (T1WI) with
gadobutrol (Gadovist; Bayer Schering Pharma, Berlin, Germany), and ASL images. ASL
images were acquired before the administration of the contrast agent. MR imaging parameters
were as follows: 467±567/8±9 ms/90Ê/320 × 192 (TR/TE/flip angle/matrix) for spin-echo
T1WI; 4850±5330/92±127 ms/90±142Ê/448 × 256 (TR/TE/flip angle/matrix) for fast spin-echo
T2-weighted images (T2WI); section thickness, 5 mm with a 1 mm gap; field-of-view,
240 × 240 mm.
The ASL perfusion imaging was performed using a pseudo-continuous ASL pulse sequence.
Using one MR scanner (Verio; Siemens Healthcare), ASL images were acquired with a back
ground-suppressed 3-dimensional gradient and spin echo single-shot readout (labeling pulse
duration = 1.5 s, post-labeling delay = 1.6 s, no flow crushing gradient, TR = 3660 ms, TE = 14
ms, field-of-view = 240 × 240 × 96 mm, matrix = 64 × 64 × 11, 60 pairs of tags and controls,
acquired in 4 minutes, whole brain coverage). For the other MR scanners (Signa HDxt and
Discovery 750w; GE Healthcare), the ASL parameters were as follows: labeling pulse dura
tion = 1.5 s, post-labeling delay = 1.5 s, TR = 4446±4564 ms, TE = 9.4±9.9 ms,
field-ofview = 240 × 240 mm, number of excitations = 3, number of interleaved slices = 32, and slice
thickness = 5 mm. The signal intensity change between labeled image and control image was
fitted to a model, from which a quantitative perfusion map of CBF was obtained.
Qualitative and quantitative analyses of CBF maps using ASL
Three qualified neuroradiologists (with 6 years, 12 years, and 5 years of clinical experiences,
respectively) who were blinded to patient history and pathologic data independently reviewed
MR image sets in random order. In case of multiple lesions, the largest one on axial images was selected for the review because the largest one was always removed on surgery in this study.
For qualitative analysis, the reviewers were asked to grade the lesions on ASL images based on the following criteria: 1) no demonstrable hyperpefusion; 2) minimal hyperpefusion or only scattered hyperperfused spots; 3) diffuse mild hyperpefusion or moderate-to-strong hyperpefusionarea occupying 1/3 of enhancing area on contrast-enhanced T1WI; 4) diffuse
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moderate hyperpefusion or strong hyperpefusion area occupying > 1/3 and 2/3 of
enhancing portion on contrast-enhanced T1WI; and 5) strong hyperpefusion area occupying > 2/3 of
enhancing portion on contrast-enhanced T1WI (Fig 1). Before the image interpretation, the
reviewers were asked to adjust the window width and level appropriately in reference to the
Fig 1. Representative MR images including ASL for each visual grade. Grade 1, no demonstrable hyperpefusion; Grade 2,
minimal hyperpefusion or only scattered hyperperfused spots; Grade 3, diffuse mild hyperpefusion or moderate-to-strong
hyperpefusion area occupying 1/3 of enhancing portion on CE T1WI; Grade 4, diffuse moderate hyperpefusion or strong
hyperpefusion area occupying > 1/3 and 2/3 of enhancing portion on T1WI; and Grade 5, strong hyperpefusion area
occupying > 2/3 of enhancing portion on T1WI. T1WI = T1-weighted images, T2WI = T2-weighted images, CE =
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With regard to quantitative analysis, the reviewers were asked to place circular regions of
interest (ROIs) on ASL images at 1) the most hyperperfused portion within the tumor
(intratumoral ROI), 2) peritumoral T2 hyperintensity area (peritumoral ROI), and 3) contralateral
normal gray matter, respectively. At least two ROIs for each region were drawn and the
average of the mean of each ROI was recorded.
To minimize inter-individual differences in perfusion, signal intensities of intratumoral and
peritumoral ROIs for each subject were normalized by dividing the values by those of
contralateral normal gray matter (nCBFintratumoral and nCBFperitumoral, respectively) [16, 20±22]. A
Mann-Whitney test was used to compare parameters from GBMs with those from metastases.
We used intraclass correlation coefficient (ICC) to assess interobserver agreement between the
three reviewers [
]. The ICC values of less than 0, 0±0.20, 0.21±0.40, 0.41±0.60, 0.61±0.80, or
greater than 0.81 indicated negative, positive but poor, fair, moderate, good, or excellent
agreement, respectively. Demographic information was analyzed using student's t-test and Fisher's
exact test. The area under the curve (AUC) from receiver operating characteristic (ROC)
analysis was used to evaluate the diagnostic performance of the ASL-determined CBF for
differentiating GBM from brain metastasis. To assess the association between visual grading and
nCBFintratumoral, an analysis of variance (ANOVA) followed by post-hoc test using ScheffeÂ's
method was used. Statistical analyses were performed with SPSS (version 12.0 for Windows,
SPSS, Chicago, Ill, USA) and MedCalc (version 15.11.4, MedCalc Software, Mariakerke, Belgium). P values of less than 0.05 were considered to be statistically significant.
The clinical characteristics of subjects are summarized in Table 1. There was no statistical dif
ference in male-to-female ratio or age between the two groups. While the majority of patients
with brain metastasis underwent MR imaging at a 1.5 T scanner, the majority of patients with
GBM underwent MR imaging at a 3 T scanner (p < 0.001). Among the 39 patients with brain metastasis, 11 patients (28.2%) had more than one nodule: four patients had two nodules, one patient had three nodules, and six patients had more than three nodules.
Qualitative analysis of CBF maps using ASL
The ICCs for qualitative and quantitative parameters are shown in S1 Table. The interobserver agreement of visual grading was excellent (ICC = 0.763). Results of qualitative analysis are shown in Fig 2. The GBM group showed significantly higher grade compared to the metastasis group according to both reviewers (p = 0.001 and p = 0.005, respectively). By using grade 5 as
GBM (n = 89)
57.8 ± 15.1
Brain metastasis (n = 39)
56.1 ± 12.7
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Fig 2. A bar chart of relative frequency of each visual grade in GBM and brain metastasis. GBM occupies a larger proportion of grade 5
tumors than brain metastasis, whereas brain metastasis occupies a larger proportion of grade 1 tumors than GBM.
a cut-off value, the ROC analysis revealed a sensitivity of 42.7% and a specificity of 84.6% with
an AUC of 0.677 (p < 0.001, Fig 3).
Quantitative analyses of CBF maps using ASL
The interobserver agreements for nCBFintratumoral and nCBFperitumoral were good (ICC = 0.630)
and moderate (ICC = 0.421), respectively (S1 Table). Results of quantitative analyses are
summarized in Table 2. nCBFintratumoral was significantly higher in patients with GBM than in
those with metastasis (p < 0.001). As expected, patients with GBM also showed significantly
higher nCBFperitumoral than those with metastasis (p < 0.001). Representative MR images
including ASL perfusion MR images are shown in Fig 4.
The ROC analysis for nCBFintratumoral showed an AUC of 0.714 with a sensitivity of 92.1%
and a specificity of 43.6% when nCBFintratumoral > 1.04 was used as the cut-off value
(p < 0.001). The AUC for nCBFperitumoral was 0.835 with a sensitivity of 64.0% and a specificity
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Fig 3. Receiver operating characteristic curves for (A) visual grading, (B) nCBFintratumoral, and (C) nCBFperitumoral. AUC = area under the
receiver operating characteristic curve, nCBFintratumoral = maximum value of normalized intratumoral blood flow, nCBFperitumoral = maximum value of
normalized peritumoral blood flow.
of 89.7% using a criterion of nCBFperitumoral > 0.40 (p < 0.001). The AUC for nCBFperitumoral
was significantly higher than that for visual grading (p = 0.011, Fig 3).
There was a positive relationship between visual grade and nCBFintratumoral (Fig 5).
nCBFintratumoral significantly differed among visual grades based on one-way ANOVA
(p < 0.001). Post-hoc test revealed that grade 5 tumors were distinctive from all other
grades, whereas grade 1±4 tumors showed some overlap with each other. Subgroup analysis
in the metastasis group according to the primary sites showed no significant difference
between any of the two in either qualitative or quantitative analyses (p > 0.05 for all). The
results of comparative analyses with regard to magnetic strength are described in S1
In the present study, GBMs exhibited higher CBF values based on ASL perfusion MR imaging
using both qualitative and quantitative approaches. The ROC analysis for these parameters
suggested that they could aid the differentiation of GBM from brain metastasis. Particularly,
peritumoral perfusion was more useful in differentiating between tumor types than visual
grading based on intratumoral perfusion.
Note.ÐValues are medians with interquartile ranges in the parentheses. nCBFintratumoral = maximum value of normalized intratumoral blood ¯ow,
nCBFperitumoral = maximum value of normalized peritumoral blood ¯ow
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Fig 4. Comparison between GBM and brain metastasis. Axial T2WI (A and E), pre- (B and F),
postcontrast (C and G) T1WI images, and ASL images (D and H, both acquired from a 1.5 T scanner (Signa HDxt;
GE Healthcare)). A±D: A 66-year-old male patient with GBM. ASL images reveal strong hyperperfusion along
the rim-enhancing tumor margin at the left frontal lobe. Note that apparent perfusion in the left hemisphere is
lower compared to the contralateral side, suggesting a labeling artifact arising from different labeling efficiency
(D). Despite this labeling variability, the peritumoral hyperperfusion is clearly seen. E±H: A 59-year-old male
patient with metastatic lung cancer. No significant hyperperfusion was noted within the left temporal mass.
While glioma cells tend to infiltrate into the surrounding brain tissues, tumor cells in the
metastatic brain tumors are seldom found in the peritumoral areas [4±7]. In addition, a recent
animal study has revealed that the so-called perifocal edema of glioma not only contains
invading tumor cells, but also includes glial alterations of surrounding normal tissue such as
astrocytic swelling, microglial accumulation, and microglial activation [
]. Elevated peritumoral
perfusion of GBMs in contrast to brain metastasis in our data as well as in other studies [1, 2,
8±13] could be explained by these histopathologic findings.
One focus of this study was to explore the utility of intratumoral perfusion on ASL. To date,
only a few studies using DSC method have found significantly higher cerebral blood volume in
the enhancing portion of GBM than that of brain metastasis [
]. In the present study, we
demonstrated that GBMs had significantly higher intratumoral perfusion than brain
metastases using ASL. In addition, interobserver agreement for visual grading or nCBFintratumoral was
relatively higher than that for nCBFperitumoral. Therefore, although the discriminative power as
presented by AUC values is higher for the peritumoral perfusion than for the intratumoral
perfusion parameters, we believe that nCBFintratumoral or visual grading may have implications
because they are more convenient and reproducible. Of note, grade 5 lesions on visual grading
revealed a specificity of 84.6% and a positive predictive value of 86.4% for diagnosing GBM in
our cohort, suggesting that strongly hyperperfused tumors on ASL have a significantly higher
chance to be GBMs rather than metastases. In addition, there was a positive correlation
between visual grading and nCBFintratumoral.
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Fig 5. Correlation plot between visual grade and nCBFintratumoral using one-way analysis of variance. Horizontal lines at
the top of the graph indicate the relationship between corresponding visual grades. A horizontal line with an asterisk (*)
indicates that nCBFintratumoral values between the corresponding visual grades are significantly different.
To our knowledge, only a few studies have been conducted for histopathologic comparison
of tumor vascularity between GBM and metastatic brain tumors. Weber et al. have observed
that the microvessel density of GBM is significantly higher than that of brain metastasis [
On the other hand, Noguchi et al. have proposed that ASL-driven CBF may predict histopath
ologic vascular densities of brain tumors [
]. Recently, Yoo et al. have demonstrated that ASL
may predict the angiographic vascularity of meningiomas [
]. Thus, elevated intratumoral
CBF in GBM compared to brain metastasis in our study may reflect the difference in vascular
density, although the exact pathologic mechanisms remain unclear.
One possible explanation for the different trends in results of intratumoral perfusion
between DSC-driven CBV and ASL-driven CBF is that hemodynamic parameters such as CBF
and CBV derived from DSC may be influenced by vascular permeability and leakage of
contrast agent. In cases of enhancing tumors, in particular, rCBV tends to be underestimated due
to T1 effects of extravasated contrast agents into the interstitial space [
]. A few studies have
attempted to make corrections or modifications for the possible leakage effects [
], but such
efforts might not have been sufficient. On the other hand, ASL is relatively free from this issue
because it uses labeled water proton in the arterial blood which acts as a diffusible tracer,
hence it is less affected by a disrupted blood-brain barrier . In addition, several
comparative studies of DSC-CBV and ASL-CBF for evaluation of brain tumors have reported good
correlations between the two methods [
12, 14, 21, 26
]. In one of these studies, it was noted that
the susceptibility artifact in the tumor region or peritumoral area is smaller on ASL images
compared to that on DSC images .
Patients with suspected brain metastasis should undergo comprehensive systemic work up
to detect the site of primary malignancy before the initiation of surgical or medical therapy.
The need for repetitive contrast-enhanced studies raises the issues of complications such as
contrast-induced nephropathy or nephrogenic systemic fibrosis, in particularly for patients
with poor renal function. As a completely non-invasive MR imaging technique, ASL perfusion
imaging can aid in the differentiation between GBM and brain metastasis, even for patients in
whom contrast injection is contraindicated.
Still, a considerable overlap exists between GBM and brain metastasis in terms of qualitative
and quantitative parameters of ASL. To overcome this problem, a multiparametric approach
including ASL findings might be useful. Recently, Bauer et al. have shown that the
combination of diffusion-weighted imaging, DSC perfusion, and dynamic contrast-enhanced perfusion
MR metrics in peritumoral T2 hyperintensity area can help the differentiation of GBM from
solitary brain metastasis with an accuracy of 98% [
]. In addition, although AUC of ROC
curve for nCBFperitumoral is relatively high, because of the limitations of ASL and the relatively
low interobserver agreement, this should be used with caution. A further work to explore
where this interobserver variability originates from and how could this be improved would be
Several MR machines were used to acquire MR images and the frequency ratio of 1.5 T and
3 T studies across the tumor types was significantly different. Because it is very hard to desig
nate a specific MR scanner for certain target patients before knowing their diagnosis in clinical
practice, it may be reasonable to find a way to handle such inter-scanner variation. To
minimize possible bias associated with different magnetic strengths, we analyzed the data with a
normalized CBF [16, 20±22]. The effect of different magnetic strengths to perfusion
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parameters was not significant, except for nCBFperitumoral in brain metastasis group. In
addition, subgroup analysis in 1.5 T studies still revealed significant difference in all parameters
between GBM and brain metastasis groups, although nCBFperitumoral was the only significantly
different parameter in 3 T studies, possibly due to small sample size in metastasis group (n = 7)
(S1 Appendix). With regard to visual grading, applying the same window width and level
across the reviewers (e.g. with appropriate corticomedullary differentiation in the contralateral
normal cortex) might reduce the possible influence of different magnetic strengths. Whether
this has an added value or not could be tested in the future studies.
In addition to the inter-scanner variability issues, our study has several limitations. First,
this was a retrospective study. However, we enrolled a relatively large number of patients in a
consecutive manner. Second, we did not perform a histopathologic correlation in terms of
tumor vascularity. Considering the scarcity of such pathologic reports to date, a validation
study to confirm our findings would be valuable.
In conclusion, both intratumoral and peritumoral perfusion on ASL perfusion MR imaging can aid in the differentiation of GBM from brain metastasis. Particularly, peritumoral perfusion provides stronger differentiation power.
S1 Appendix. Supplemental Results.
S1 Dataset. Dataset for ASL perfusion parameters.
S1 Table. Interobserver agreement for the two reviewers.
S2 Table. Comparison of ASL perfusion parameters between GBM and brain metastasis
according to the magnetic strength.
S3 Table. Comparison of ASL perfusion parameters between 1.5 T and 3 T studies in each
Formal analysis: LS TJY S-HY.
Funding acquisition: TJY.
Methodology: LS TJY.
Project administration: TJY.
Resources: LS TJY CKP.
Investigation: LS TJY S-HY R-EY KMK SHC JK C-HS C-KP.
Supervision: TJY R-EY KMK SHC JK C-HS S-WP CJ C-KP.
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Validation: LS TJY S-HY.
Visualization: LS TJY.
Writing ± original draft: LS.
Writing ± review & editing: TJY.
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