10.1007/s00234-008-0409-3</TITLE= > <META http-equiv=3DContent-Type content=3D"text/html; = charset=3DISO-8859-1"><LINK=20 href=3D"http://www.springerlink.com/config/css/A++_common.css" = type=3Dtext/css=20 rel=3DstyleSheet><LINK=20 href=3D"http://www.springerlink.com/config/css/content_A++_SpringerLink.c= ss"=20 type=3Dtext/css rel=3DstyleSheet> <META content=3D"MSHTML 6.00.6000.16674" name=3DGENERATOR></HEAD> <BODY class=3Dfor-print> <TABLE cellPadding=3D2 border=3D1> <TBODY> <TR class=3Dheader> <TD>Neuroradiology<BR>A Journal Devoted to Neuroimagingand = Interventional=20 Neuroradiology </TD></TR> <TR> <TD>=A9 Springer-Verlag 2008</TD></TR> <TR> <TD>10.1007/s00234-008-0409-3</TD></TR></TBODY></TABLE> <H2 class=3Drubric>Diagnostic Neuroradiology</H2> <DIV class=3DHeading1><A name=3Dtitle></A>Prognostic value of choline = and creatine=20 in WHO grade II gliomas </DIV> <P class=3DAuthorGroup>Elke Hattingen<SUP>1 <A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#ContactOfAuthor1"><IMG=20 alt=3D"Contact Information"=20 src=3D"http://www.springerlink.com/content/2288165762t443qx/contact.gif" = border=3D0></A></SUP>, Peter Raab<SUP>1, 3</SUP>, = Kea Franz<SUP>2</SUP>,=20 Heiner Lanfermann<SUP>3</SUP>, Matthias Setzer<SUP>2</SUP>,=20 R=FCdiger Gerlach<SUP>2</SUP>, = Friedhelm E. Zanella<SUP>1</SUP> and=20 Ulrich Pilatus<SUP>1</SUP></P> <TABLE> <TBODY> <TR vAlign=3Dtop> <TD><SPAN class=3DAffiliation><A = name=3DAff1></A>(1) </SPAN></TD> <TD><SPAN class=3DAffiliation>Institute of Neuroradiology, Johann = Wolfgang=20 Goethe University of Frankfurt/Main, Schleusenweg 2-16,=20 60528 Frankfurt/Main, = Germany</SPAN></TD></TR></TBODY></TABLE> <TABLE> <TBODY> <TR vAlign=3Dtop> <TD><SPAN class=3DAffiliation><A = name=3DAff2></A>(2) </SPAN></TD> <TD><SPAN class=3DAffiliation>Department of Neurosurgery, Johann = Wolfgang=20 Goethe University of Frankfurt/Main, Frankfurt/Main,=20 Germany</SPAN></TD></TR></TBODY></TABLE> <TABLE> <TBODY> <TR vAlign=3Dtop> <TD><SPAN class=3DAffiliation><A = name=3DAff3></A>(3) </SPAN></TD> <TD><SPAN class=3DAffiliation>Institute of Neuroradiology, = Medizinische=20 Hochschule Hannover (MHH), Hannover, = Germany</SPAN></TD></TR></TBODY></TABLE> <P><A name=3DContactOfAuthor1></A></P> <TABLE class=3DContact> <TBODY> <TR> <TD vAlign=3Dtop><IMG alt=3D"Contact Information"=20 = src=3D"http://www.springerlink.com/content/2288165762t443qx/contact.gif" = border=3D0></TD> = <TD><STRONG>Elke </STRONG><STRONG>Hattingen</STRONG><STRONG></STRONG= ><BR><STRONG>Email:=20 </STRONG><A=20 = href=3D"mailto:elke.hattingen@kgu.de">elke.hattingen@kgu.de</A></TD></TR>= </TBODY></TABLE> <P class=3DAffiliation><STRONG>Received:=20 </STRONG>11 March 2008 <STRONG>Accepted:=20 </STRONG>30 April 2008 <STRONG>Published online:=20 </STRONG>4 June 2008 </P> <DIV class=3DAbstract><A name=3DAbs1></A><SPAN = class=3DAbstractHeading>Abstract</SPAN> <DIV class=3DAbstractSection> <DIV class=3D""><SPAN class=3DAbstractSectionHeading><A=20 name=3DASec1></A>Introduction </SPAN>The purpose of this = study was to=20 evaluate whether proton magnetic resonance spectroscopy = (<SUP>1</SUP>H-MRS)=20 predicts survival time, tumor progression, and malignant transformation = in=20 patients with WHO grade II gliomas. </DIV></DIV> <DIV class=3DAbstractSection> <DIV class=3D""><SPAN class=3DAbstractSectionHeading><A = name=3DASec2></A>Materials and=20 methods </SPAN> <SUP>1</SUP>H-MRS and MR imaging (MRI) were = performed=20 before surgery in 45 patients with histologically proven WHO grade II = gliomas.=20 Metabolite concentrations of choline-containing compounds (Cho) and=20 creatine/phosphocreatine (tCr) were normalized to contralateral brain = tissue.=20 Spectroscopic data as well as the extent of tumor resection, contrast=20 enhancement, size and histopatholocical type of the tumor, age, sex, and = first=20 neurological symptoms of the patients were analyzed for survival, tumor=20 progression, and malignant transformation for a follow-up period of 1 to = 5 years. </DIV></DIV> <DIV class=3DAbstractSection> <DIV class=3D""><SPAN class=3DAbstractSectionHeading><A=20 name=3DASec3></A>Results </SPAN>The normalized tCr of WHO = grade II=20 gliomas was a significant predictor for tumor progression = (<I>p</I> =3D 0.011) and=20 for malignant tumor transformation (<I>p</I> =3D 0.016). = Further, contrast=20 enhancement of the tumor (<I>p</I> =3D 0.014) at the time of = diagnosis was=20 significant for malignant tumor transformation and extent of tumor = resection for=20 the tumor progression (<I>p</I> =3D 0.007). All other = parameters failed to predict=20 any of the three endpoints. </DIV></DIV> <DIV class=3DAbstractSection> <DIV class=3D""><SPAN class=3DAbstractSectionHeading><A=20 name=3DASec4></A>Conclusion </SPAN>Normalized values of tCr = in WHO=20 grade II gliomas may have prognostic implications for this group of = gliomas. As=20 a rule of the thumb, low-grade gliomas with decreased tCr (relative tCr = values=20 below 1.0) may show longer progression-free times and later malignant=20 transformation than low-grade gliomas with regular or increased tCr = values.=20 </DIV></DIV></DIV> <P class=3DKeyword><SPAN = class=3DKeywordHeading>Keywords </SPAN>=20 <SUP>1</SUP>H-MR spectroscopy - WHO grade II=20 gliomas - Creatine - Choline - Progression&= nbsp;- Malignant=20 transformation </P> <DIV class=3DArticleNote><SPAN class=3D"">This study was supported by = the Federal=20 Ministry of Education and Research (Brain Imaging Center Frankfurt, DLR=20 01GO0203) and the German Research Foundation (ZA 233/1-1).</SPAN></DIV> <DIV class=3D""><A name=3DSec1></A> <HR> <DIV class=3Dheading2>Introduction</DIV> <P class=3D"">WHO grade II gliomas represent a heterogeneous group of = tumors, not=20 only regarding their histopathological differentiation, but also their = potential=20 of malignant transformation. For about 50% of all adults with WHO grade = II=20 gliomas, the tumor will progress within 5 years after surgery with = or=20 without postoperative radiation [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR1">1</A></CITE>].=20 The need for accurate recognition of a low-grade to high-grade = progression in=20 cerebral gliomas has given impetus to continuous research. </P> <P class=3D"">Proton magnetic resonance spectroscopy (<SUP>1</SUP>H-MRS) = is a=20 non-invasive method for predicting malignancy of gliomas [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR2">2</A></CITE>].=20 Studies evaluating the prognostic value of <SUP>1</SUP>H-MRS included = all WHO=20 grades of gliomas or analyzed suspected gliomas without = histopathological=20 confirmation [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR3">3</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR4">4</A></CITE>].=20 Further, studies have shown that <SUP>1</SUP>H-MRS aids in detecting the = transformation of WHO grade II gliomas towards a higher malignancy grade = [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR5">5</A></CITE>].=20 </P> <P class=3D"">A number of patient and tumor characteristics such as age = at=20 diagnosis, clinical performance status, histology subtype, tumor size, = presence=20 of seizures at diagnosis, and extent of resection have been proposed as=20 prognostic factors for the duration of the progression-free period or = overall=20 survival time [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR6">6</A></CITE>].=20 In many of these retrospective studies, patients were treated with = different=20 forms of adjuvant radiation and/or chemotherapy. This is the first study = that=20 evaluates prospectively the prognostic value of different spectroscopic = data=20 (metabolites concentrations either normalized to healthy tissue or given = as=20 ratios to reference metabolites, e.g., creatine) from = histopathologically proven=20 grade II gliomas before surgery in patients who did not receive adjuvant = radiochemotherapy in the follow-up period until tumor progression was = diagnosed.=20 </P></DIV> <DIV class=3D""><A name=3DSec2></A> <HR> <DIV class=3Dheading2>Materials and methods</DIV> <DIV class=3D""><A name=3DSec3></A> <DIV class=3DHeading3>Patients</DIV> <P class=3D"">During the period from 2002 to 2006, 50 consecutive = patients with=20 newly diagnosed low-grade gliomas WHO II and indication for surgical=20 intervention were included in the study. Tumors in close proximity to = the skull=20 base and tumors with a diameter of 1 cm or less were not included. = General=20 exclusion criteria were contraindications for MRI, e.g., the presence of = pacemakers, defibrillators, neurostimulators, prohibited medical = implants, and=20 foreign bodies, as well as agitated patients. All participants provided = informed=20 consent. Prior to surgical resection, the patients received MRI and=20 <SUP>1</SUP>H-MRS examinations. Five patients who did not keep contact = were lost=20 for additional MRI and/or clinical follow-up, leaving 45 patients for = the=20 analysis. The age ranged from 21 to 75 with a median of 41.3 years. = Twenty-eight patients were male and 17 were female. </P> <P class=3D"">All tumors were histologically confirmed according to the = WHO 2000=20 categorization standard based on samples from biopsy or surgical = resection at=20 the department of neurosurgery. Whenever tumor progression or malignant=20 transformation was diagnosed in follow-up MRIs, the patients were = treated by=20 fractionated radiation therapy or/and chemotherapy following a standard=20 protocol. </P> <P class=3D"">The follow-up examinations spanned a period of 1 to = 5 years=20 (37 months median follow-up time) with the last examination = performed in=20 July 2007. All patients were controlled clinically and by MRI 1 or = 2 days=20 after surgery, 3 and 6 months later, and then in intervals of 6 or=20 12 months, depending on the stability of the tumor or whenever = clinical=20 signs of progression were suspected. </P></DIV> <DIV class=3D""><A name=3DSec4></A> <DIV class=3DHeading3>MR examinations</DIV> <P class=3D"">All MRI and MRS data were acquired within 1 to 7 days = prior to=20 surgery. Standard MRI was performed on a 1.5-T scanner for all patients. = From=20 March 2004, spectroscopic measurements change from a 1.5-T scanner to a = 3-T=20 scanner. In the initial stage of the study (until March 2004), single = voxel=20 spectroscopy (SVS) was performed on a 1.5-T scanner (Intera; Philips = Medical=20 Systems, Best, Netherlands) using a transmit/receive quadrature head = coil. In=20 this period, 19 patients were examined. Starting from March 2004, a 3-T = head=20 scanner (Siemens Allegra, Siemens AG, Erlangen, Germany) equipped with a = transmit/receive quadrature head coil was used for the spectroscopy = examination.=20 At the higher field strength, spectroscopic imaging (MRSI) was performed = instead=20 of SVS. Voxel localization and/or slice positioning was based on = T2-weighted=20 images in three orientations. No contrast agent was applied for the = reference=20 slices prior to the spectroscopic measurement to avoid any interference = with the=20 proton relaxivities of the main metabolites [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR7">7</A></CITE>].=20 For the same reason, standard MRI was performed on a separate day. The = imaging=20 protocol was identical for all patients, including axial and coronal = T2-weighted=20 images (TR/TE 4,000/99 ms) and axial fluid-attenuated inversion = recovery=20 images (FLAIR, TR/TI/TE 10,000/2,000/120 ms). For detection of = contrast=20 enhancement, T1-weighted images (TR/TE 650/15 ms) were acquired = before and=20 after intravenous application of 0.1 mmol/kg body weight = gadolinium-DTPA.=20 </P></DIV> <DIV class=3D""><A name=3DSec5></A> <DIV class=3DHeading3>Spectroscopic data acquisition</DIV> <P class=3D"">Single voxel <SUP>1</SUP>H MR spectroscopy was performed = using=20 point-resolved spectroscopy (PRESS) volume selection with an echo time = of=20 135 ms, a repetition time of 1,500 ms, and chemical shift = selective=20 saturation (CHESS) for suppression of the water signal. The voxel was = positioned=20 within the tumor. To exclude the influence of metabolite variability in=20 different brain regions, a reference voxel was measured, which was = located in=20 normal (healthy) appearing brain tissue in the same anatomic area of the = contralateral hemisphere excluding gray matter. Quantitative values were = obtained by comparing the signal intensities to a calibration = measurement with a=20 phantom containing a solution of 20 mmol/l NAA (phantom replacement = method). </P> <P class=3D"">Starting in 2004, magnetic resonance data were acquired = with a 3-T=20 head scanner (Siemens Allegra, Siemens AG, Erlangen, Germany) using a = protocol=20 described in Hattingen et al. [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR8">8</A></CITE>].=20 Briefly, two-dimensional <SUP>1</SUP>H-MR spectroscopic imaging=20 (<SUP>1</SUP>H-MRSI) was performed with TR of 1,500 ms and TE of=20 144 ms (<I>n</I> =3D 24) or TE of 30 ms = (<I>n</I> =3D 5). The slice was=20 positioned in the center of the tumor. The VOI (selected by PRESS) was = adjusted=20 to contain pathological tissue and contralateral healthy tissue, while = lipid=20 from the skull was excluded. Slice thickness was 10 mm and the FOV = was=20 240 =D7 240 mm<SUP>2</SUP> acquired with a circular = phase encoding scheme on=20 a 28 =D7 28 matrix, extrapolated to 32 =D7 32. = The resulting nominal spectroscopic=20 voxels measured = 7.5 =D7 7.5 =D7 10 mm<SUP>3</SUP>. Typical = VOIs were=20 80 =D7 80 =D7 10 mm<SUP>3</SUP> of size, = but, whenever required, the size was=20 adjusted according to the lesion=92s and head=92s geometry. Axial slice = orientation=20 was preferred, but some tumors near the skull base were measured in = coronal=20 orientation (typical VOI of = 60 =D7 80 =D7 10 mm<SUP>3</SUP>) in order = to=20 minimize artefacts. </P> <DIV class=3DPara> <DIV class=3D"">For postprocessing, the reference images and = spectroscopic data=20 were transferred to a workstation for offline analysis. Spectra were = fitted in=20 the frequency domain by a linear combination of a set of model spectra = including=20 the main metabolites choline-containing compounds (Cho),=20 creatine/phosphocreatine (tCr), and <I>N</I>-acetyl-aspartate (NAA) = using the=20 commercially available software tool LCModel (Provencher, downloadable = test=20 version at: <A = href=3D"http://s-provencher.com/">http://s-provencher.com/</A>)=20 [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR9">9</A></CITE>].=20 Baseline correction was performed including macromolecules. Quantitative = values=20 were obtained by phantom replacement method applying correction terms as = described by Michaelis et al. [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR10">10</A></CITE>].=20 Partial saturation and dephasing of in vivo metabolites were corrected = for by=20 assuming T1 and T2 relaxation times as described by Hattingen et al. = [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR8">8</A></CITE>].=20 Concentrations were estimated as millimole per voxel volume, which may = be=20 considered as absolute concentrations, and plotted as metabolite maps = for Cho,=20 tCr, and NAA. Cho and tCr metabolite maps as well as representative = spectra from=20 tumor and contralateral tissue are shown in Fig. <A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#Fig1">1</A>.=20 For each tumor, experienced neuroradiologists (E.H., P.R.) delineated a=20 two-dimensional region of interest (ROI) by manually tracing the border = of tumor=20 tissue on the corresponding T2-weighted slices (ROI of the tumor =3D=20 ROI<SUB>tu</SUB>). Further, for tumor tissue the value of the voxel with = the=20 maximum concentration of Cho (Cho<SUB>max</SUB>) was determined = according to=20 Tedeschi et al. [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR5">5</A></CITE>].=20 The Cho<SUB>max</SUB> was identified on gray-scaled concentration = images. To=20 validate the results, the maximum values were compared to all other=20 concentrations in the ROI<SUB>tu</SUB>. Analogous to the SVS, the=20 ROI<SUB>tu</SUB>=92s mean concentrations of Cho and tCr were normalized = by=20 calculating the ratios between the values of ROI<SUB>tu</SUB> to a = reference=20 ROI, which was located in normal (healthy) appearing brain tissue in the = same=20 anatomic area of the contralateral hemisphere (e.g.,=20 Cho<SUB>tumor</SUB>/Cho<SUB>normal</SUB>,=20 tCr<SUB>tumor</SUB>/tCr<SUB>normal</SUB>). Further, the increase of = normalized=20 Cho of the tumor at the time of progression = (<I>n</I> =3D 13) compared to the=20 preoperative value of normalized Cho was calculated.=20 <DIV class=3DFigure><A name=3DFig1></A><IMG=20 alt=3DMediaObjects/234_2008_409_Fig1_HTML.gif=20 src=3D"http://www.springerlink.com/content/2288165762t443qx/MediaObjects/= 234_2008_409_Fig1_HTML.gif"></DIV> <DIV class=3DCapt><SPAN = class=3DCaptNr>Fig. 1 </SPAN>Metabolite maps and=20 representative long TE (144 ms) spectra from control (<I>upper = right</I>)=20 and tumor tissue for an LGG. The <I>red line</I> shows the result of the = LCModel=20 fit </DIV> <HR> </DIV></DIV></DIV> <DIV class=3D""><A name=3DSec6></A> <DIV class=3DHeading3>Clinical features</DIV> <P class=3D"">Besides age and sex of the patients, the first = neurological symptoms=20 at time of diagnosis were analyzed by categorizing them into four = different=20 groups: patients with no symptoms, patients with seizures, patients with = neurological deficits, and patients with other symptoms like headache or = vertigo. </P></DIV> <DIV class=3D""><A name=3DSec7></A> <DIV class=3DHeading3>Tumor features</DIV> <P class=3D"">The size of the tumor was indicated by the largest = diameter and was=20 categorized in tumors smaller than 6 cm, larger than 6 cm, and = gliomatosis. Further, the presence or absence of contrast enhancement of = the=20 tumor at time of diagnosis and the differentiation of tumor with or = without=20 oligodendroglial components were analyzed. The extent of tumor resection = was=20 assessed on MRI, which was performed within 48 h after surgery. No=20 detectable tumor tissue was categorized as total resection, less than = 10% of=20 remaining tumor tissue as subtotal resection, and more than 10% tumor = tissue as=20 partial resection. A fourth group implied the tumor biopsy. </P></DIV> <DIV class=3D""><A name=3DSec8></A> <DIV class=3DHeading3>Target variables</DIV> <P class=3D"">The prognosis of WHO grade II gliomas was determined by = analyzing=20 the data with respect to three endpoints: tumor progression, malignant = tumor=20 transformation, and survival time. Tumor progression was defined by new = contrast=20 enhancement and/or volume progression of more than 25% or recurrence of = a=20 previously completely resected tumor. Among tumors with progression, = malignant=20 transformation of the tumor was defined as biopsy-proven grade III or IV = gliomas=20 and/or new enhancement of contrast medium (CM) of the untreated tumors. = Thus,=20 gliomas with malignant transformation represent a subgroup of gliomas = with tumor=20 progression, whereas in reverse, tumor progression does not imply = malignant=20 transformation. </P></DIV> <DIV class=3D""><A name=3DSec9></A> <DIV class=3DHeading3>Statistical methods</DIV> <DIV class=3DPara> <DIV class=3D"">Statistical analyses were performed with STATISTICA 7.1 = (StatSoft,=20 Tulsa, OK, USA). Significance level was set = <I>p</I> < 0.05 for all tests.=20 Categorical variables were analyzed using the chi-square test to = determine the=20 predictive values of tumor features and clinical data and for tumor = progression=20 and malignant transformation. Unifactorial analysis of variance (ANOVA), = followed by Scheff=E9 post hoc test was performed to analyze the = predictive value=20 of normalized tCr, Cho, and Cho<SUB>max</SUB> on survival, tumor = progression,=20 and malignant transformation, respectively. The median progression-free = survival=20 was estimated with the Kaplan=96Meier method. Time until tumor = progression was=20 expressed in months while categorical groups were formed for the = normalized=20 values of Cho and tCr (Table <A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#Tab1">1</A>).=20 <A name=3DTab1></A> <DIV class=3DCapt><SPAN = class=3DCaptNr>Table 1 </SPAN>Normalized values of=20 Cho (Cho<SUB>tumor</SUB>/Cho<SUB>normal</SUB>) and tCr=20 (tCr<SUB>tumor</SUB>/tCr<SUB>normal</SUB>) grouped for categories to = analyze the=20 time-dependent variable =93tumor progression=94 with the Kaplan=96Meier = method and=20 further to compare metabolite data with other categorial variables = (tumor=20 features, clinical data). </DIV> <TABLE border=3D1> <COLGROUP> <COL align=3Dleft> <COL align=3Dleft> <COL align=3Dleft> <COL align=3Dleft> <COL align=3Dleft> <COL align=3Dleft></COLGROUP> <THEAD> <TR class=3Dheader> <TH align=3Dleft> <P class=3D""> </P></TH> <TH align=3Dleft> <P class=3D""><1.0 (<I>N</I>) </P></TH> <TH align=3Dleft> <P class=3D"">1.0=961.19 (<I>N</I>) </P></TH> <TH align=3Dleft> <P class=3D"">1.2=961.59 (<I>N</I>) </P></TH> <TH align=3Dleft> <P class=3D"">1.6=962.0 (<I>N</I>) </P></TH> <TH align=3Dleft> <P class=3D"">>2.0 (<I>N</I>) </P></TH></TR></THEAD> <TBODY> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Normalized Cho = (Cho<SUB>tumor</SUB>/Cho<SUB>normal</SUB>)=20 </P></TD> <TD align=3Dleft> <P class=3D"">(1)</P></TD> <TD align=3Dleft> <P class=3D"">7 + 1</P></TD> <TD align=3Dleft> <P class=3D"">22</P></TD> <TD align=3Dleft> <P class=3D"">8</P></TD> <TD align=3Dleft> <P class=3D"">7</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Normalized tCr = (tCr<SUB>tumor</SUB>/tCr<SUB>normal</SUB>)=20 </P></TD> <TD align=3Dleft> <P class=3D"">27</P></TD> <TD align=3Dleft> <P class=3D"">9</P></TD> <TD align=3Dleft> <P class=3D"">7 + 2</P></TD> <TD align=3Dleft> <P class=3D"">(2)</P></TD> <TD align=3Dleft> <P class=3D"">0</P></TD></TR></TBODY></TABLE> <DIV class=3DCapt> <DIV class=3DCaptCont> <DIV class=3D"">Numbers of cases (<I>N</I>) for each category are = indicated.=20 Categories in parenthesis did not include enough cases. Patients with = too small=20 samples were expressed (+) in the groups they were included.=20 </DIV></DIV></DIV></DIV></DIV></DIV></DIV> <DIV class=3D""><A name=3DSec10></A> <HR> <DIV class=3Dheading2>Results</DIV> <P class=3D"">Twenty-eight males and 17 females with a mean age of=20 41 =B1 13 years were included in the study. Symptoms at = admission were=20 seizures (<I>n</I> =3D 29), neurological deficits = (<I>n</I> =3D 7; two of them also=20 had seizures), and others (<I>n</I> =3D 7). Two patients = were asymptomatic. </P> <DIV class=3DPara> <DIV class=3D"">Features of the tumor at time of diagnosis and extent of = resection=20 are shown in Table <A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#Tab2">2</A>.=20 <A name=3DTab2></A> <DIV class=3DCapt><SPAN class=3DCaptNr>Table 2 </SPAN>The = features of the=20 tumor at time of diagnosis and extent of resection. </DIV> <TABLE border=3D1> <COLGROUP> <COL align=3Dleft> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."></COLGROUP> <THEAD> <TR class=3Dheader> <TH align=3Dleft rowSpan=3D2> <P class=3D""> </P></TH> <TH align=3Dchar colSpan=3D2 char=3D"."> <P class=3D"">CM enhancement</P></TH> <TH align=3Dchar colSpan=3D3 char=3D"."> <P class=3D"">Largest diameter (cm)</P></TH> <TH align=3Dchar colSpan=3D2 char=3D"."> <P class=3D"">Histopathology</P></TH> <TH align=3Dchar char=3D"."> <P class=3D"">Extent of resection</P></TH> <TD class=3Dauto-generated> </TD> <TD class=3Dauto-generated> </TD> <TD class=3Dauto-generated> </TD> <TD class=3Dauto-generated> </TD></TR> <TR class=3Dheader> <TH align=3Dleft char=3D"."> <P class=3D"">Yes</P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">No</P></TH> <TH align=3Dleft char=3D"."> <P class=3D""><6</P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">≥6</P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">Gliomatosis</P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">Astrocytoma</P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">LGGs with oligodendroglial components</P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">Total</P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">Subtotal</P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">Partial</P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">Biopsy</P></TH></TR></THEAD> <TBODY> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Number (<I>n</I>) </P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">7</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">38</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">23</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">16</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">6</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">37</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">8</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">5</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">3</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">20</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">17</P></TD></TR></TBODY></TABLE> <DIV class=3DCapt> <DIV class=3DCaptCont> <DIV class=3D"">Numbers of each group are = indicated.</DIV></DIV></DIV></DIV></DIV> <DIV class=3D""><A name=3DSec11></A> <DIV class=3DHeading3>Target values</DIV> <P class=3D"">In 12 patients, no tumor progression occurred during = follow-up. In=20 33 cases, the tumor progressed. The mean time for detection of = progression was=20 8 months. Twenty-six of the progressive cases (12 of these were=20 biopsy-proven) showed malignant transformation, diagnosed with a mean = time of=20 15 months. Ten patients died in the follow-up after a mean time of=20 38 months. </P></DIV> <DIV class=3D""><A name=3DSec12></A> <DIV class=3DHeading3>Statistical results</DIV> <DIV class=3DPara> <DIV class=3D"">The median and ranges of normalized tCr and Cho for the = three=20 endpoints are indicated in Table <A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#Tab3">3</A>.=20 Chi-square tests revealed that categorial groups of normalized tCr=20 (<I>p</I> =3D 0.017) as well as contrast enhancement at the = time of the diagnosis=20 (<I>p</I> =3D 0.014) were significant for the endpoint = malignant transformation of=20 the WHO grade II gliomas. The extent of resection was the only = significant=20 categorial variable for the endpoint tumor progression = (<I>p</I> =3D 0.007). All=20 other categorial parameters failed significance level. <A = name=3DTab3></A> <DIV class=3DCapt><SPAN = class=3DCaptNr>Table 3 </SPAN>Concentrations of=20 tCr and Cho (median and range), which were normalized by calculating = ratios=20 between the values of the tumor (Cho<SUB>tu</SUB>, tCr<SUB>tu</SUB>) and = values=20 of normal appearing brain tissue in the same anatomic area of the = contralateral=20 hemisphere (Cho<SUB>no</SUB>, tCr<SUB>no</SUB>). </DIV> <TABLE border=3D1> <COLGROUP> <COL align=3Dleft> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"("> <COL align=3Dchar char=3D"("></COLGROUP> <THEAD> <TR class=3Dheader> <TH align=3Dleft> <P class=3D""> </P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">Number of tumors (<I>N</I>) </P></TH> <TH align=3Dleft char=3D"("> <P class=3D"">Cho<SUB>tu</SUB>/Cho<SUB>n</SUB> median (range) = </P></TH> <TH align=3Dleft char=3D"("> <P class=3D"">tCr<SUB>tu</SUB>/tCr<SUB>n</SUB> median (range)=20 </P></TH></TR></THEAD> <TBODY> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Tumor progression</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">33</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">1.33 (0.75=963.23)</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">1.00 (0.55=961.94)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">No tumor progression</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">12</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">1.31 (0.41=961.65)</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">0.80 (0.27=961.36)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Malignant tumor transformation</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">26</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">1.50 (0.75=963.23)</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">1.03 (0.6=961.94)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">No malignant transformation</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">19</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">1.24 (0.41=961.65)</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">0.79 (0.27=961.26)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Death</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">10</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">1.83 (1.16=963.23)</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">1.04 (0.79=961.94)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">No death</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">35</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">1.27 (0.41=961.74)</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">0.94 (0.27=961.43)</P></TD></TR></TBODY></TABLE> <DIV class=3DCapt> <DIV class=3DCaptCont> <DIV class=3D"">The values are indicated for WHO grade II gliomas with = and without=20 progression, WHO grade II gliomas with and without malignant = transformation, and=20 for patients with WHO grade II gliomas who died or survived during the = follow-up=20 period. </DIV></DIV></DIV></DIV></DIV> <DIV class=3DPara> <DIV class=3D"">In the ANOVA analysis of continuous data, the normalized = tCr was=20 significant for each of the two endpoints tumor progression = (<I>p</I> =3D 0.011)=20 and malignant transformation (<I>p</I> =3D 0.016; = Fig. <A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#Fig2">2</A>).=20 Normalized Cho and Cho<SUB>max</SUB> failed significance level for both=20 endpoints. No significances were found for the endpoint survival/death.=20 <DIV class=3DFigure><A name=3DFig2></A><IMG=20 alt=3DMediaObjects/234_2008_409_Fig2_HTML.gif=20 src=3D"http://www.springerlink.com/content/2288165762t443qx/MediaObjects/= 234_2008_409_Fig2_HTML.gif"></DIV> <DIV class=3DCapt><SPAN class=3DCaptNr>Fig. 2 </SPAN> = <B>a</B>, <B>b</B>=20 The predictive values of normalized tCr=20 (tCr<SUB>tumor</SUB>/tCr<SUB>normal</SUB>) and normalized Cho=20 (Cho<SUB>tumor</SUB>/Cho<SUB>normal</SUB>) were analyzed for progression = (<B>a</B>) and malignant transformation (<B>b</B>) of histopathological = proven=20 gliomas WHO grade II using the unifactorial analysis of variance = (ANOVA).=20 <SUP>*</SUP>indicates significant change </DIV> <HR> </DIV></DIV> <DIV class=3DPara> <DIV class=3D"">Results from the Kaplan=96Meier method are shown in = Table <A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#Tab4">4</A>=20 with illustration of progression-free survival for the normalized tCr=20 (Fig. <A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#Fig3">3</A>).=20 <DIV class=3DFigure><A name=3DFig3></A><IMG=20 alt=3DMediaObjects/234_2008_409_Fig3_HTML.gif=20 src=3D"http://www.springerlink.com/content/2288165762t443qx/MediaObjects/= 234_2008_409_Fig3_HTML.gif"></DIV> <DIV class=3DCapt><SPAN class=3DCaptNr>Fig. 3 </SPAN>The = Kaplan=96Meier=20 graph shows the median progression-free intervals for categorized = concentrations=20 of tCr<SUB>tumor</SUB>/tCr<SUB>normal</SUB> </DIV> <HR> <A name=3DTab4></A> <DIV class=3DCapt><SPAN class=3DCaptNr>Table 4 </SPAN>Results = from=20 Kaplan=96Meier method for the median progression-free interval are = indicated for=20 the different categorized groups of normalized tCr and Cho. </DIV> <TABLE border=3D1> <COLGROUP> <COL align=3Dleft> <COL align=3Dleft> <COL align=3Dleft> <COL align=3Dleft> <COL align=3Dleft></COLGROUP> <THEAD> <TR class=3Dheader> <TH align=3Dleft rowSpan=3D2> <P class=3D""> </P></TH> <TH align=3Dleft> <P class=3D"">All patients</P></TH> <TH align=3Dleft> <P class=3D"">Patients with LGG progression</P></TH> <TH align=3Dleft colSpan=3D2> <P class=3D"">Progression-free interval (months)</P></TH></TR> <TR class=3Dheader> <TH align=3Dleft> <P class=3D"">Number</P></TH> <TH align=3Dleft> <P class=3D"">Number</P></TH> <TH align=3Dleft> <P class=3D"">Median</P></TH> <TH align=3Dleft> <P class=3D"">Mean (95% CI)</P></TH></TR></THEAD> <TBODY> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">tCr <1.0</P></TD> <TD align=3Dleft> <P class=3D"">27</P></TD> <TD align=3Dleft> <P class=3D"">17</P></TD> <TD align=3Dleft> <P class=3D"">12</P></TD> <TD align=3Dleft> <P class=3D"">20 (13=9627)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">tCr =3D 1.0=961.19</P></TD> <TD align=3Dleft> <P class=3D"">9</P></TD> <TD align=3Dleft> <P class=3D"">8</P></TD> <TD align=3Dleft> <P class=3D"">7</P></TD> <TD align=3Dleft> <P class=3D"">8 (6=9610)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">tCr >1.19</P></TD> <TD align=3Dleft> <P class=3D"">9</P></TD> <TD align=3Dleft> <P class=3D"">8</P></TD> <TD align=3Dleft> <P class=3D"">4</P></TD> <TD align=3Dleft> <P class=3D"">7 (2=9613)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Cho <1.19</P></TD> <TD align=3Dleft> <P class=3D"">8</P></TD> <TD align=3Dleft> <P class=3D"">5</P></TD> <TD align=3Dleft> <P class=3D"">26</P></TD> <TD align=3Dleft> <P class=3D"">25 (15=9635)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Cho =3D 1.2=961.59</P></TD> <TD align=3Dleft> <P class=3D"">22</P></TD> <TD align=3Dleft> <P class=3D"">16</P></TD> <TD align=3Dleft> <P class=3D"">6</P></TD> <TD align=3Dleft> <P class=3D"">11 (7=9616)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Cho =3D 1.6=962.0</P></TD> <TD align=3Dleft> <P class=3D"">8</P></TD> <TD align=3Dleft> <P class=3D"">5</P></TD> <TD align=3Dleft> <P class=3D"">7</P></TD> <TD align=3Dleft> <P class=3D"">19 (8=9631)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Cho >2.0</P></TD> <TD align=3Dleft> <P class=3D"">7</P></TD> <TD align=3Dleft> <P class=3D"">7</P></TD> <TD align=3Dleft> <P class=3D"">5</P></TD> <TD align=3Dleft> <P class=3D"">5 (1=969)</P></TD></TR></TBODY></TABLE> <DIV class=3DCapt> <DIV class=3DCaptCont> <DIV class=3D""><I>LGG</I> Low-grade gliomas WHO II, <I>CI</I> = confidence interval=20 </DIV></DIV></DIV></DIV></DIV></DIV></DIV> <DIV class=3D""><A name=3DSec13></A> <HR> <DIV class=3Dheading2>Discussion</DIV> <P class=3D"">This is the first study group which investigates the role = of Cho and=20 tCr concentrations for predicting the progression-free survival of WHO = grade II=20 gliomas and the time until these low-grade gliomas (LGG) show malignant=20 transformation. </P> <P class=3D"">In a prospective study monitoring suspected but = histopathologically=20 unproven WHO grade II gliomas, Reijneveld et al. did not find clear = evidence=20 that <SUP>1</SUP>H-MRSI improves the prediction regarding malignant=20 transformation [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR4">4</A></CITE>].=20 However, their study was based on the within-voxel NAA/Cho ratio of the = lesion.=20 A strong decrease in tNAA may mask changes in the Cho concentration = concealing=20 their significance. A retrospective study by Kuznetsov was designed to = evaluate=20 the accuracy of survival predictions on the basis of <SUP>1</SUP>H-MRSI = features=20 for all grades of gliomas including glioblastomas [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR3">3</A></CITE>].=20 They found that the ratio between the maximum values of Cho normalized = to tCr of=20 normal appearing brain tissue of the same patient could predict survival = in=20 patients with supratentorial gliomas with accuracy comparable to = invasive=20 methods. However, since higher tumor grades correspond to higher Cho, it = remains=20 disputable whether Cho is a spectroscopic predictor of survival = independent from=20 tumor grade or whether Cho reflects the well-known correlation between=20 histopathological tumor grade and survival. Tedeschi et al. could show = that an=20 increase of Cho<SUB>max</SUB> during <SUP>1</SUP>H-MRSI monitoring of = WHO grade=20 II gliomas detects the shift towards a higher malignancy grade [<CITE><A = href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR5">5</A></CITE>].=20 </P> <P class=3D"">None of the spectroscopic studies evaluated the prognostic = significance of tCr in WHO grade II gliomas. In this study, the average = tCr=20 concentration of the entire tumor tissue, delineated on the T2-weighted=20 reference slices, divided by the tCr concentration of the same = anatomical area=20 in the contralateral hemisphere turned out to be an important predictive = value=20 for tumor progression and malignant transformation. As a rule of thumb, = WHO=20 grade II gliomas with decreased tCr (relative tCr values below 1.0) may = show=20 longer progression-free times and later malignant transformation than = LGGs with=20 regular or increased tCr values. There was no significant correlation = between=20 values of normalized tCr and survival time, possibly due to the low = number of=20 patients who died in the follow-up time. Further, survival not only = depends on=20 the progression-free interval, but also on the efficiency of the applied = tumor=20 therapy. In this study, most of the patients with progressive disease = received=20 radiation with or without chemotherapy. Therefore, the tumor = concentration of=20 tCr might rather correlate with longer progression-free survival of = patients=20 without adjuvant therapy than it provides information on the = susceptibility of=20 tumor tissue for therapy. </P> <P class=3D"">Many studies evaluate metabolite levels in brain tumors = expressed as=20 ratio to tCr. The denominator is explicitly assumed to be stable in = normal as=20 well as in many pathologic states. The use of this ratio misses the = importance=20 of tCr for WHO grade II gliomas and thus, our results should have = implication on=20 spectroscopic studies of glial tumors. Further, Li et al. could show = high=20 coefficients of variations for metabolite ratios NAA/Cr and Cho/Cr in = normal=20 brains [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR11">11</A></CITE>].=20 Reports of absolute concentrations of creatine in tumor tissue are = limited to=20 few publications. Some authors found significant changes of tCr in = gliomas=20 observing both increased and decreased tCr levels in different brain = tumors and=20 even in different tumor regions [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR12">12</A></CITE>=96<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR14">14</A></CITE>].=20 In gliomas, it is still unclear whether there is another biochemical = role for=20 creatine besides the well-established function of phosphocreatine as = short-term=20 energy reservoir. Highest tCr concentrations were found in astrocytes = and=20 oligodendrocytes [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR15">15</A></CITE>].=20 Astroglial cells of the brain are able to synthesize creatine and to = release=20 guanidinoacetate as intermediate of creatine synthesis, whereas tumor = cells seem=20 to synthesize a lower amount of tCr [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR16">16</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR17">17</A></CITE>].=20 Previous results indicate that increased tCr may be the reaction of = astroglial=20 cells to infiltrative growth of tumor cells [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR8">8</A></CITE>].=20 In this context, tCr reveals the infiltrative activity of the tumor = cells which=20 explains that gliomas with higher tCr progress faster. </P> <P class=3D"">In contrast to tCr, many studies have investigated the = role of Cho=20 in glial tumors. Increased Cho levels are attributed to cell = proliferation or=20 growth stimulation, and increased phosphocholine is associated with = oncogenic=20 and malignant transformation [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR18">18</A></CITE>=96<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR21">21</A></CITE>].=20 The Cho signal also reflects levels of local cellularity [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR22">22</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR23">23</A></CITE>],=20 the invasiveness as well as the malignancy of gliomas [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR24">24</A></CITE>=96<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR26">26</A></CITE>].=20 In our study, the normalized Cho failed significance level for malignant = transformation (<I>p</I> =3D 0.07); however, there was a = trend toward earlier=20 malignant transformation for higher Cho values including the = Cho<SUB>max</SUB>=20 values. </P> <P class=3D"">It has to be considered that the differentiation between = tumor=20 progression with or without malignant transformation is limited because=20 interobserver variability and other sources of errors like tumor = heterogeneity=20 and variability of contrast enhancement have to be considered. The same = is true=20 for the grading of gliomas. Therefore, choline might be a good indicator = for=20 tumor progression and survival when all grades of gliomas are = considered.=20 Regarding the subgroup of grade II gliomas, normalized tCr might be a = more=20 reliable indicator for progression-free survival. Considering the = limitations of=20 correct tumor grading, both metabolites complement each other as = predictive=20 values for patients with gliomas. </P> <P class=3D"">Besides the spectroscopic data, there were only two other=20 significant prognostic parameters in the presented study: the CE = enhancement of=20 WHO grade II gliomas at the time of diagnosis in predicting the endpoint = of=20 malignant transformation and the extent of tumor resection in predicting = the=20 endpoint tumor progression. Grade II gliomas might enhance to a = considerable=20 degree [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR27">27</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR28">28</A></CITE>].=20 The prognostic value on survival regarding CM enhancement of the gliomas = is=20 controversial [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR28">28</A></CITE>=96<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR30">30</A></CITE>].=20 The quantitative method for analyzing CM enhancement in WHO grade II = gliomas=20 shows a clear difference between tumors with and without progression = [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR30">30</A></CITE>].=20 Concordant with our data, the grade of tumor resection in LGGs turned = out as=20 important predictive factor for the prognosis in previous studies = [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR6">6</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR31">31</A></CITE>=96<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR6">34</A></CITE>].=20 </P> <P class=3D"">In contrast to previous studies, especially in contrast to = trials=20 from the European Organization for Research and Treatment of Cancer = Radiotherapy=20 Cooperative Group, patient=92s age, neurological symptoms, and = histopathological=20 type of LGG failed to be significant to predict the prognosis of the = patients=20 with LGG [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR6">6</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR29">29</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR35">35</A></CITE>=96<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR40">40</A></CITE>].=20 Different reasons for the discrepancies between the multicenter studies = and our=20 collective might be their higher patient numbers, longer follow-up = times, and=20 their higher statistical power for LGGs with oligodendroglial = components.=20 Further, most of the patients in the multicenter trials received = postoperative=20 adjuvant therapy (radiation/chemotherapy), and postoperative tumor = imaging was=20 not mandatory. </P> <DIV class=3D""><A name=3DSec14></A> <DIV class=3DHeading3>Limitations of the study</DIV> <P class=3D"">High percentage of our patients had gliomas in eloquent = brain areas,=20 and therefore, they underwent tumor biopsy instead of tumor resection. = Even=20 though total tumor resection was the first aim of surgical therapy, = eloquent=20 localization and/or large size of the low-grade gliomas indicated a more = conservative procedure in order to prevent neurological deficits. Apart = from the=20 larger remaining tumor volume, tumor biopsy might implicate sampling = errors and=20 the intrinsic heterogeneity of cerebral gliomas may confound = histopathological=20 diagnoses that are made on the basis of small biopsy specimens. These = facts=20 might also explain the short progression-free survival of our patient = group=20 compared to others [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR40">40</A></CITE>].=20 </P> <P class=3D"">Further, two different methods were employed for the = spectroscopic=20 measurements with a change from SVS at 1.5 T to MRSI at 3 T. = However,=20 metabolite concentrations from the tumor were normalized for each = patient using=20 values from normal appearing contralateral white matter area that = corresponded=20 anatomically to the tumor area. This method calibrates the metabolite=20 concentrations to an internal reference minimizing the influence of = different=20 spectroscopic parameters, different brain areas, and individuals = [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR41">41</A></CITE>].=20 The use of this method of normalization is validated by a previous study = [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR5">5</A></CITE>].=20 </P></DIV></DIV> <DIV class=3D""><A name=3DSec15></A> <HR> <DIV class=3Dheading2>Conclusion</DIV> <P class=3D"">Normalized tCr of the WHO grade II gliomas proved to be a=20 significant prognostic factor concerning progression-free survival and = for the=20 time until these LGGs show malignant transformation. WHO grade II = gliomas with=20 decreased tCr showed longer time intervals until the gliomas progressed. = Contrast enhancement of the WHO grade II gliomas at time of diagnosis = was the=20 second significant factor correlating positively with the malignant=20 transformation of these LGGs. The grade of tumor resection correlated=20 significantly with tumor progression, but not with the malignant = transformation.=20 Thus, normalized tCr may be an important prognostic predictor for = untreated WHO=20 grade II gliomas, implicating that the group without decreased values = might=20 profit from more aggressive therapeutic strategies. Considering that = choline=20 might be a good indicator for tumor progression and survival with regard = to all=20 grades of gliomas, both metabolites complement each other as predictive = values=20 for patients with gliomas. </P></DIV> <DIV class=3DAcknowledgments> <DIV class=3DFormalPara> <DIV class=3D""><SPAN style=3D"FONT-STYLE: italic; TEXT-DECORATION: = none">Conflict=20 of interest statement</SPAN> The authors declare that they = have no=20 conflict of interest. </DIV></DIV></DIV> <P></P> <HR> <H2><A name=3DBib1></A>References </H2> <TABLE> <TBODY class=3DCitation> <TR vAlign=3Dtop> <TD>1.</TD> <TD><A name=3DCR1></A>Karim AB, Afra D, Cornu P, Bleehan N, Schraub = S, De=20 Witte O, Darcel F, Stenning S, Pierart M, Van Glabbeke M (2002) = Randomized=20 trial on the efficacy of radiotherapy for cerebral low-grade = glioma in the=20 adult: European Organization for Research and Treatment of Cancer = Study=20 22845 with the Medical Research Council study BRO4: an interim = analysis.=20 Int J Radiat Oncol Biol Phys 52:316=96324<BR><A=20 = href=3D"http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=3DRetrieve&= db=3DPubMed&dopt=3DAbstract&list_uids=3D11872276"=20 target=3D_blank><IMG height=3D20 alt=3DPubMed=20 = src=3D"http://www.springerlink.com/content/2288165762t443qx/pubmed_link.g= if"=20 width=3D65 border=3D0></A> </TD></TR> <TR> <TD> </TD></TR> <TR vAlign=3Dtop> <TD>2.</TD> <TD><A name=3DCR2></A>Shimizu H, Kumabe T, Tominaga T, Kayama T, = Hara K, Ono=20 Y, Sato K, Arai N, Fujiwara S, Yoshimoto T (1996) Noninvasive = evaluation=20 of malignancy of brain tumors with proton MR spectroscopy. 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From: Subject: 10.1007/s00234-008-0409-3 Date: Sat, 28 Jun 2008 11:17:54 +0200 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0000_01C8D910.9C6FDCE0" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5512 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01C8D910.9C6FDCE0 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.springerlink.com/content/2288165762t443qx/fulltext.html 10.1007/s00234-008-0409-3</TITLE= > <META http-equiv=3DContent-Type content=3D"text/html; = charset=3DISO-8859-1"><LINK=20 href=3D"http://www.springerlink.com/config/css/A++_common.css" = type=3Dtext/css=20 rel=3DstyleSheet><LINK=20 href=3D"http://www.springerlink.com/config/css/content_A++_SpringerLink.c= ss"=20 type=3Dtext/css rel=3DstyleSheet> <META content=3D"MSHTML 6.00.6000.16674" name=3DGENERATOR></HEAD> <BODY class=3Dfor-print> <TABLE cellPadding=3D2 border=3D1> <TBODY> <TR class=3Dheader> <TD>Neuroradiology<BR>A Journal Devoted to Neuroimagingand = Interventional=20 Neuroradiology </TD></TR> <TR> <TD>=A9 Springer-Verlag 2008</TD></TR> <TR> <TD>10.1007/s00234-008-0409-3</TD></TR></TBODY></TABLE> <H2 class=3Drubric>Diagnostic Neuroradiology</H2> <DIV class=3DHeading1><A name=3Dtitle></A>Prognostic value of choline = and creatine=20 in WHO grade II gliomas </DIV> <P class=3DAuthorGroup>Elke Hattingen<SUP>1 <A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#ContactOfAuthor1"><IMG=20 alt=3D"Contact Information"=20 src=3D"http://www.springerlink.com/content/2288165762t443qx/contact.gif" = border=3D0></A></SUP>, Peter Raab<SUP>1, 3</SUP>, = Kea Franz<SUP>2</SUP>,=20 Heiner Lanfermann<SUP>3</SUP>, Matthias Setzer<SUP>2</SUP>,=20 R=FCdiger Gerlach<SUP>2</SUP>, = Friedhelm E. Zanella<SUP>1</SUP> and=20 Ulrich Pilatus<SUP>1</SUP></P> <TABLE> <TBODY> <TR vAlign=3Dtop> <TD><SPAN class=3DAffiliation><A = name=3DAff1></A>(1) </SPAN></TD> <TD><SPAN class=3DAffiliation>Institute of Neuroradiology, Johann = Wolfgang=20 Goethe University of Frankfurt/Main, Schleusenweg 2-16,=20 60528 Frankfurt/Main, = Germany</SPAN></TD></TR></TBODY></TABLE> <TABLE> <TBODY> <TR vAlign=3Dtop> <TD><SPAN class=3DAffiliation><A = name=3DAff2></A>(2) </SPAN></TD> <TD><SPAN class=3DAffiliation>Department of Neurosurgery, Johann = Wolfgang=20 Goethe University of Frankfurt/Main, Frankfurt/Main,=20 Germany</SPAN></TD></TR></TBODY></TABLE> <TABLE> <TBODY> <TR vAlign=3Dtop> <TD><SPAN class=3DAffiliation><A = name=3DAff3></A>(3) </SPAN></TD> <TD><SPAN class=3DAffiliation>Institute of Neuroradiology, = Medizinische=20 Hochschule Hannover (MHH), Hannover, = Germany</SPAN></TD></TR></TBODY></TABLE> <P><A name=3DContactOfAuthor1></A></P> <TABLE class=3DContact> <TBODY> <TR> <TD vAlign=3Dtop><IMG alt=3D"Contact Information"=20 = src=3D"http://www.springerlink.com/content/2288165762t443qx/contact.gif" = border=3D0></TD> = <TD><STRONG>Elke </STRONG><STRONG>Hattingen</STRONG><STRONG></STRONG= ><BR><STRONG>Email:=20 </STRONG><A=20 = href=3D"mailto:elke.hattingen@kgu.de">elke.hattingen@kgu.de</A></TD></TR>= </TBODY></TABLE> <P class=3DAffiliation><STRONG>Received:=20 </STRONG>11 March 2008 <STRONG>Accepted:=20 </STRONG>30 April 2008 <STRONG>Published online:=20 </STRONG>4 June 2008 </P> <DIV class=3DAbstract><A name=3DAbs1></A><SPAN = class=3DAbstractHeading>Abstract</SPAN> <DIV class=3DAbstractSection> <DIV class=3D""><SPAN class=3DAbstractSectionHeading><A=20 name=3DASec1></A>Introduction </SPAN>The purpose of this = study was to=20 evaluate whether proton magnetic resonance spectroscopy = (<SUP>1</SUP>H-MRS)=20 predicts survival time, tumor progression, and malignant transformation = in=20 patients with WHO grade II gliomas. </DIV></DIV> <DIV class=3DAbstractSection> <DIV class=3D""><SPAN class=3DAbstractSectionHeading><A = name=3DASec2></A>Materials and=20 methods </SPAN> <SUP>1</SUP>H-MRS and MR imaging (MRI) were = performed=20 before surgery in 45 patients with histologically proven WHO grade II = gliomas.=20 Metabolite concentrations of choline-containing compounds (Cho) and=20 creatine/phosphocreatine (tCr) were normalized to contralateral brain = tissue.=20 Spectroscopic data as well as the extent of tumor resection, contrast=20 enhancement, size and histopatholocical type of the tumor, age, sex, and = first=20 neurological symptoms of the patients were analyzed for survival, tumor=20 progression, and malignant transformation for a follow-up period of 1 to = 5 years. </DIV></DIV> <DIV class=3DAbstractSection> <DIV class=3D""><SPAN class=3DAbstractSectionHeading><A=20 name=3DASec3></A>Results </SPAN>The normalized tCr of WHO = grade II=20 gliomas was a significant predictor for tumor progression = (<I>p</I> =3D 0.011) and=20 for malignant tumor transformation (<I>p</I> =3D 0.016). = Further, contrast=20 enhancement of the tumor (<I>p</I> =3D 0.014) at the time of = diagnosis was=20 significant for malignant tumor transformation and extent of tumor = resection for=20 the tumor progression (<I>p</I> =3D 0.007). All other = parameters failed to predict=20 any of the three endpoints. </DIV></DIV> <DIV class=3DAbstractSection> <DIV class=3D""><SPAN class=3DAbstractSectionHeading><A=20 name=3DASec4></A>Conclusion </SPAN>Normalized values of tCr = in WHO=20 grade II gliomas may have prognostic implications for this group of = gliomas. As=20 a rule of the thumb, low-grade gliomas with decreased tCr (relative tCr = values=20 below 1.0) may show longer progression-free times and later malignant=20 transformation than low-grade gliomas with regular or increased tCr = values.=20 </DIV></DIV></DIV> <P class=3DKeyword><SPAN = class=3DKeywordHeading>Keywords </SPAN>=20 <SUP>1</SUP>H-MR spectroscopy - WHO grade II=20 gliomas - Creatine - Choline - Progression&= nbsp;- Malignant=20 transformation </P> <DIV class=3DArticleNote><SPAN class=3D"">This study was supported by = the Federal=20 Ministry of Education and Research (Brain Imaging Center Frankfurt, DLR=20 01GO0203) and the German Research Foundation (ZA 233/1-1).</SPAN></DIV> <DIV class=3D""><A name=3DSec1></A> <HR> <DIV class=3Dheading2>Introduction</DIV> <P class=3D"">WHO grade II gliomas represent a heterogeneous group of = tumors, not=20 only regarding their histopathological differentiation, but also their = potential=20 of malignant transformation. For about 50% of all adults with WHO grade = II=20 gliomas, the tumor will progress within 5 years after surgery with = or=20 without postoperative radiation [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR1">1</A></CITE>].=20 The need for accurate recognition of a low-grade to high-grade = progression in=20 cerebral gliomas has given impetus to continuous research. </P> <P class=3D"">Proton magnetic resonance spectroscopy (<SUP>1</SUP>H-MRS) = is a=20 non-invasive method for predicting malignancy of gliomas [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR2">2</A></CITE>].=20 Studies evaluating the prognostic value of <SUP>1</SUP>H-MRS included = all WHO=20 grades of gliomas or analyzed suspected gliomas without = histopathological=20 confirmation [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR3">3</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR4">4</A></CITE>].=20 Further, studies have shown that <SUP>1</SUP>H-MRS aids in detecting the = transformation of WHO grade II gliomas towards a higher malignancy grade = [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR5">5</A></CITE>].=20 </P> <P class=3D"">A number of patient and tumor characteristics such as age = at=20 diagnosis, clinical performance status, histology subtype, tumor size, = presence=20 of seizures at diagnosis, and extent of resection have been proposed as=20 prognostic factors for the duration of the progression-free period or = overall=20 survival time [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR6">6</A></CITE>].=20 In many of these retrospective studies, patients were treated with = different=20 forms of adjuvant radiation and/or chemotherapy. This is the first study = that=20 evaluates prospectively the prognostic value of different spectroscopic = data=20 (metabolites concentrations either normalized to healthy tissue or given = as=20 ratios to reference metabolites, e.g., creatine) from = histopathologically proven=20 grade II gliomas before surgery in patients who did not receive adjuvant = radiochemotherapy in the follow-up period until tumor progression was = diagnosed.=20 </P></DIV> <DIV class=3D""><A name=3DSec2></A> <HR> <DIV class=3Dheading2>Materials and methods</DIV> <DIV class=3D""><A name=3DSec3></A> <DIV class=3DHeading3>Patients</DIV> <P class=3D"">During the period from 2002 to 2006, 50 consecutive = patients with=20 newly diagnosed low-grade gliomas WHO II and indication for surgical=20 intervention were included in the study. Tumors in close proximity to = the skull=20 base and tumors with a diameter of 1 cm or less were not included. = General=20 exclusion criteria were contraindications for MRI, e.g., the presence of = pacemakers, defibrillators, neurostimulators, prohibited medical = implants, and=20 foreign bodies, as well as agitated patients. All participants provided = informed=20 consent. Prior to surgical resection, the patients received MRI and=20 <SUP>1</SUP>H-MRS examinations. Five patients who did not keep contact = were lost=20 for additional MRI and/or clinical follow-up, leaving 45 patients for = the=20 analysis. The age ranged from 21 to 75 with a median of 41.3 years. = Twenty-eight patients were male and 17 were female. </P> <P class=3D"">All tumors were histologically confirmed according to the = WHO 2000=20 categorization standard based on samples from biopsy or surgical = resection at=20 the department of neurosurgery. Whenever tumor progression or malignant=20 transformation was diagnosed in follow-up MRIs, the patients were = treated by=20 fractionated radiation therapy or/and chemotherapy following a standard=20 protocol. </P> <P class=3D"">The follow-up examinations spanned a period of 1 to = 5 years=20 (37 months median follow-up time) with the last examination = performed in=20 July 2007. All patients were controlled clinically and by MRI 1 or = 2 days=20 after surgery, 3 and 6 months later, and then in intervals of 6 or=20 12 months, depending on the stability of the tumor or whenever = clinical=20 signs of progression were suspected. </P></DIV> <DIV class=3D""><A name=3DSec4></A> <DIV class=3DHeading3>MR examinations</DIV> <P class=3D"">All MRI and MRS data were acquired within 1 to 7 days = prior to=20 surgery. Standard MRI was performed on a 1.5-T scanner for all patients. = From=20 March 2004, spectroscopic measurements change from a 1.5-T scanner to a = 3-T=20 scanner. In the initial stage of the study (until March 2004), single = voxel=20 spectroscopy (SVS) was performed on a 1.5-T scanner (Intera; Philips = Medical=20 Systems, Best, Netherlands) using a transmit/receive quadrature head = coil. In=20 this period, 19 patients were examined. Starting from March 2004, a 3-T = head=20 scanner (Siemens Allegra, Siemens AG, Erlangen, Germany) equipped with a = transmit/receive quadrature head coil was used for the spectroscopy = examination.=20 At the higher field strength, spectroscopic imaging (MRSI) was performed = instead=20 of SVS. Voxel localization and/or slice positioning was based on = T2-weighted=20 images in three orientations. No contrast agent was applied for the = reference=20 slices prior to the spectroscopic measurement to avoid any interference = with the=20 proton relaxivities of the main metabolites [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR7">7</A></CITE>].=20 For the same reason, standard MRI was performed on a separate day. The = imaging=20 protocol was identical for all patients, including axial and coronal = T2-weighted=20 images (TR/TE 4,000/99 ms) and axial fluid-attenuated inversion = recovery=20 images (FLAIR, TR/TI/TE 10,000/2,000/120 ms). For detection of = contrast=20 enhancement, T1-weighted images (TR/TE 650/15 ms) were acquired = before and=20 after intravenous application of 0.1 mmol/kg body weight = gadolinium-DTPA.=20 </P></DIV> <DIV class=3D""><A name=3DSec5></A> <DIV class=3DHeading3>Spectroscopic data acquisition</DIV> <P class=3D"">Single voxel <SUP>1</SUP>H MR spectroscopy was performed = using=20 point-resolved spectroscopy (PRESS) volume selection with an echo time = of=20 135 ms, a repetition time of 1,500 ms, and chemical shift = selective=20 saturation (CHESS) for suppression of the water signal. The voxel was = positioned=20 within the tumor. To exclude the influence of metabolite variability in=20 different brain regions, a reference voxel was measured, which was = located in=20 normal (healthy) appearing brain tissue in the same anatomic area of the = contralateral hemisphere excluding gray matter. Quantitative values were = obtained by comparing the signal intensities to a calibration = measurement with a=20 phantom containing a solution of 20 mmol/l NAA (phantom replacement = method). </P> <P class=3D"">Starting in 2004, magnetic resonance data were acquired = with a 3-T=20 head scanner (Siemens Allegra, Siemens AG, Erlangen, Germany) using a = protocol=20 described in Hattingen et al. [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR8">8</A></CITE>].=20 Briefly, two-dimensional <SUP>1</SUP>H-MR spectroscopic imaging=20 (<SUP>1</SUP>H-MRSI) was performed with TR of 1,500 ms and TE of=20 144 ms (<I>n</I> =3D 24) or TE of 30 ms = (<I>n</I> =3D 5). The slice was=20 positioned in the center of the tumor. The VOI (selected by PRESS) was = adjusted=20 to contain pathological tissue and contralateral healthy tissue, while = lipid=20 from the skull was excluded. Slice thickness was 10 mm and the FOV = was=20 240 =D7 240 mm<SUP>2</SUP> acquired with a circular = phase encoding scheme on=20 a 28 =D7 28 matrix, extrapolated to 32 =D7 32. = The resulting nominal spectroscopic=20 voxels measured = 7.5 =D7 7.5 =D7 10 mm<SUP>3</SUP>. Typical = VOIs were=20 80 =D7 80 =D7 10 mm<SUP>3</SUP> of size, = but, whenever required, the size was=20 adjusted according to the lesion=92s and head=92s geometry. Axial slice = orientation=20 was preferred, but some tumors near the skull base were measured in = coronal=20 orientation (typical VOI of = 60 =D7 80 =D7 10 mm<SUP>3</SUP>) in order = to=20 minimize artefacts. </P> <DIV class=3DPara> <DIV class=3D"">For postprocessing, the reference images and = spectroscopic data=20 were transferred to a workstation for offline analysis. Spectra were = fitted in=20 the frequency domain by a linear combination of a set of model spectra = including=20 the main metabolites choline-containing compounds (Cho),=20 creatine/phosphocreatine (tCr), and <I>N</I>-acetyl-aspartate (NAA) = using the=20 commercially available software tool LCModel (Provencher, downloadable = test=20 version at: <A = href=3D"http://s-provencher.com/">http://s-provencher.com/</A>)=20 [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR9">9</A></CITE>].=20 Baseline correction was performed including macromolecules. Quantitative = values=20 were obtained by phantom replacement method applying correction terms as = described by Michaelis et al. [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR10">10</A></CITE>].=20 Partial saturation and dephasing of in vivo metabolites were corrected = for by=20 assuming T1 and T2 relaxation times as described by Hattingen et al. = [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR8">8</A></CITE>].=20 Concentrations were estimated as millimole per voxel volume, which may = be=20 considered as absolute concentrations, and plotted as metabolite maps = for Cho,=20 tCr, and NAA. Cho and tCr metabolite maps as well as representative = spectra from=20 tumor and contralateral tissue are shown in Fig. <A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#Fig1">1</A>.=20 For each tumor, experienced neuroradiologists (E.H., P.R.) delineated a=20 two-dimensional region of interest (ROI) by manually tracing the border = of tumor=20 tissue on the corresponding T2-weighted slices (ROI of the tumor =3D=20 ROI<SUB>tu</SUB>). Further, for tumor tissue the value of the voxel with = the=20 maximum concentration of Cho (Cho<SUB>max</SUB>) was determined = according to=20 Tedeschi et al. [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR5">5</A></CITE>].=20 The Cho<SUB>max</SUB> was identified on gray-scaled concentration = images. To=20 validate the results, the maximum values were compared to all other=20 concentrations in the ROI<SUB>tu</SUB>. Analogous to the SVS, the=20 ROI<SUB>tu</SUB>=92s mean concentrations of Cho and tCr were normalized = by=20 calculating the ratios between the values of ROI<SUB>tu</SUB> to a = reference=20 ROI, which was located in normal (healthy) appearing brain tissue in the = same=20 anatomic area of the contralateral hemisphere (e.g.,=20 Cho<SUB>tumor</SUB>/Cho<SUB>normal</SUB>,=20 tCr<SUB>tumor</SUB>/tCr<SUB>normal</SUB>). Further, the increase of = normalized=20 Cho of the tumor at the time of progression = (<I>n</I> =3D 13) compared to the=20 preoperative value of normalized Cho was calculated.=20 <DIV class=3DFigure><A name=3DFig1></A><IMG=20 alt=3DMediaObjects/234_2008_409_Fig1_HTML.gif=20 src=3D"http://www.springerlink.com/content/2288165762t443qx/MediaObjects/= 234_2008_409_Fig1_HTML.gif"></DIV> <DIV class=3DCapt><SPAN = class=3DCaptNr>Fig. 1 </SPAN>Metabolite maps and=20 representative long TE (144 ms) spectra from control (<I>upper = right</I>)=20 and tumor tissue for an LGG. The <I>red line</I> shows the result of the = LCModel=20 fit </DIV> <HR> </DIV></DIV></DIV> <DIV class=3D""><A name=3DSec6></A> <DIV class=3DHeading3>Clinical features</DIV> <P class=3D"">Besides age and sex of the patients, the first = neurological symptoms=20 at time of diagnosis were analyzed by categorizing them into four = different=20 groups: patients with no symptoms, patients with seizures, patients with = neurological deficits, and patients with other symptoms like headache or = vertigo. </P></DIV> <DIV class=3D""><A name=3DSec7></A> <DIV class=3DHeading3>Tumor features</DIV> <P class=3D"">The size of the tumor was indicated by the largest = diameter and was=20 categorized in tumors smaller than 6 cm, larger than 6 cm, and = gliomatosis. Further, the presence or absence of contrast enhancement of = the=20 tumor at time of diagnosis and the differentiation of tumor with or = without=20 oligodendroglial components were analyzed. The extent of tumor resection = was=20 assessed on MRI, which was performed within 48 h after surgery. No=20 detectable tumor tissue was categorized as total resection, less than = 10% of=20 remaining tumor tissue as subtotal resection, and more than 10% tumor = tissue as=20 partial resection. A fourth group implied the tumor biopsy. </P></DIV> <DIV class=3D""><A name=3DSec8></A> <DIV class=3DHeading3>Target variables</DIV> <P class=3D"">The prognosis of WHO grade II gliomas was determined by = analyzing=20 the data with respect to three endpoints: tumor progression, malignant = tumor=20 transformation, and survival time. Tumor progression was defined by new = contrast=20 enhancement and/or volume progression of more than 25% or recurrence of = a=20 previously completely resected tumor. Among tumors with progression, = malignant=20 transformation of the tumor was defined as biopsy-proven grade III or IV = gliomas=20 and/or new enhancement of contrast medium (CM) of the untreated tumors. = Thus,=20 gliomas with malignant transformation represent a subgroup of gliomas = with tumor=20 progression, whereas in reverse, tumor progression does not imply = malignant=20 transformation. </P></DIV> <DIV class=3D""><A name=3DSec9></A> <DIV class=3DHeading3>Statistical methods</DIV> <DIV class=3DPara> <DIV class=3D"">Statistical analyses were performed with STATISTICA 7.1 = (StatSoft,=20 Tulsa, OK, USA). Significance level was set = <I>p</I> < 0.05 for all tests.=20 Categorical variables were analyzed using the chi-square test to = determine the=20 predictive values of tumor features and clinical data and for tumor = progression=20 and malignant transformation. Unifactorial analysis of variance (ANOVA), = followed by Scheff=E9 post hoc test was performed to analyze the = predictive value=20 of normalized tCr, Cho, and Cho<SUB>max</SUB> on survival, tumor = progression,=20 and malignant transformation, respectively. The median progression-free = survival=20 was estimated with the Kaplan=96Meier method. Time until tumor = progression was=20 expressed in months while categorical groups were formed for the = normalized=20 values of Cho and tCr (Table <A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#Tab1">1</A>).=20 <A name=3DTab1></A> <DIV class=3DCapt><SPAN = class=3DCaptNr>Table 1 </SPAN>Normalized values of=20 Cho (Cho<SUB>tumor</SUB>/Cho<SUB>normal</SUB>) and tCr=20 (tCr<SUB>tumor</SUB>/tCr<SUB>normal</SUB>) grouped for categories to = analyze the=20 time-dependent variable =93tumor progression=94 with the Kaplan=96Meier = method and=20 further to compare metabolite data with other categorial variables = (tumor=20 features, clinical data). </DIV> <TABLE border=3D1> <COLGROUP> <COL align=3Dleft> <COL align=3Dleft> <COL align=3Dleft> <COL align=3Dleft> <COL align=3Dleft> <COL align=3Dleft></COLGROUP> <THEAD> <TR class=3Dheader> <TH align=3Dleft> <P class=3D""> </P></TH> <TH align=3Dleft> <P class=3D""><1.0 (<I>N</I>) </P></TH> <TH align=3Dleft> <P class=3D"">1.0=961.19 (<I>N</I>) </P></TH> <TH align=3Dleft> <P class=3D"">1.2=961.59 (<I>N</I>) </P></TH> <TH align=3Dleft> <P class=3D"">1.6=962.0 (<I>N</I>) </P></TH> <TH align=3Dleft> <P class=3D"">>2.0 (<I>N</I>) </P></TH></TR></THEAD> <TBODY> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Normalized Cho = (Cho<SUB>tumor</SUB>/Cho<SUB>normal</SUB>)=20 </P></TD> <TD align=3Dleft> <P class=3D"">(1)</P></TD> <TD align=3Dleft> <P class=3D"">7 + 1</P></TD> <TD align=3Dleft> <P class=3D"">22</P></TD> <TD align=3Dleft> <P class=3D"">8</P></TD> <TD align=3Dleft> <P class=3D"">7</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Normalized tCr = (tCr<SUB>tumor</SUB>/tCr<SUB>normal</SUB>)=20 </P></TD> <TD align=3Dleft> <P class=3D"">27</P></TD> <TD align=3Dleft> <P class=3D"">9</P></TD> <TD align=3Dleft> <P class=3D"">7 + 2</P></TD> <TD align=3Dleft> <P class=3D"">(2)</P></TD> <TD align=3Dleft> <P class=3D"">0</P></TD></TR></TBODY></TABLE> <DIV class=3DCapt> <DIV class=3DCaptCont> <DIV class=3D"">Numbers of cases (<I>N</I>) for each category are = indicated.=20 Categories in parenthesis did not include enough cases. Patients with = too small=20 samples were expressed (+) in the groups they were included.=20 </DIV></DIV></DIV></DIV></DIV></DIV></DIV> <DIV class=3D""><A name=3DSec10></A> <HR> <DIV class=3Dheading2>Results</DIV> <P class=3D"">Twenty-eight males and 17 females with a mean age of=20 41 =B1 13 years were included in the study. Symptoms at = admission were=20 seizures (<I>n</I> =3D 29), neurological deficits = (<I>n</I> =3D 7; two of them also=20 had seizures), and others (<I>n</I> =3D 7). Two patients = were asymptomatic. </P> <DIV class=3DPara> <DIV class=3D"">Features of the tumor at time of diagnosis and extent of = resection=20 are shown in Table <A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#Tab2">2</A>.=20 <A name=3DTab2></A> <DIV class=3DCapt><SPAN class=3DCaptNr>Table 2 </SPAN>The = features of the=20 tumor at time of diagnosis and extent of resection. </DIV> <TABLE border=3D1> <COLGROUP> <COL align=3Dleft> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"."></COLGROUP> <THEAD> <TR class=3Dheader> <TH align=3Dleft rowSpan=3D2> <P class=3D""> </P></TH> <TH align=3Dchar colSpan=3D2 char=3D"."> <P class=3D"">CM enhancement</P></TH> <TH align=3Dchar colSpan=3D3 char=3D"."> <P class=3D"">Largest diameter (cm)</P></TH> <TH align=3Dchar colSpan=3D2 char=3D"."> <P class=3D"">Histopathology</P></TH> <TH align=3Dchar char=3D"."> <P class=3D"">Extent of resection</P></TH> <TD class=3Dauto-generated> </TD> <TD class=3Dauto-generated> </TD> <TD class=3Dauto-generated> </TD> <TD class=3Dauto-generated> </TD></TR> <TR class=3Dheader> <TH align=3Dleft char=3D"."> <P class=3D"">Yes</P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">No</P></TH> <TH align=3Dleft char=3D"."> <P class=3D""><6</P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">≥6</P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">Gliomatosis</P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">Astrocytoma</P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">LGGs with oligodendroglial components</P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">Total</P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">Subtotal</P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">Partial</P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">Biopsy</P></TH></TR></THEAD> <TBODY> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Number (<I>n</I>) </P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">7</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">38</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">23</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">16</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">6</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">37</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">8</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">5</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">3</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">20</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">17</P></TD></TR></TBODY></TABLE> <DIV class=3DCapt> <DIV class=3DCaptCont> <DIV class=3D"">Numbers of each group are = indicated.</DIV></DIV></DIV></DIV></DIV> <DIV class=3D""><A name=3DSec11></A> <DIV class=3DHeading3>Target values</DIV> <P class=3D"">In 12 patients, no tumor progression occurred during = follow-up. In=20 33 cases, the tumor progressed. The mean time for detection of = progression was=20 8 months. Twenty-six of the progressive cases (12 of these were=20 biopsy-proven) showed malignant transformation, diagnosed with a mean = time of=20 15 months. Ten patients died in the follow-up after a mean time of=20 38 months. </P></DIV> <DIV class=3D""><A name=3DSec12></A> <DIV class=3DHeading3>Statistical results</DIV> <DIV class=3DPara> <DIV class=3D"">The median and ranges of normalized tCr and Cho for the = three=20 endpoints are indicated in Table <A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#Tab3">3</A>.=20 Chi-square tests revealed that categorial groups of normalized tCr=20 (<I>p</I> =3D 0.017) as well as contrast enhancement at the = time of the diagnosis=20 (<I>p</I> =3D 0.014) were significant for the endpoint = malignant transformation of=20 the WHO grade II gliomas. The extent of resection was the only = significant=20 categorial variable for the endpoint tumor progression = (<I>p</I> =3D 0.007). All=20 other categorial parameters failed significance level. <A = name=3DTab3></A> <DIV class=3DCapt><SPAN = class=3DCaptNr>Table 3 </SPAN>Concentrations of=20 tCr and Cho (median and range), which were normalized by calculating = ratios=20 between the values of the tumor (Cho<SUB>tu</SUB>, tCr<SUB>tu</SUB>) and = values=20 of normal appearing brain tissue in the same anatomic area of the = contralateral=20 hemisphere (Cho<SUB>no</SUB>, tCr<SUB>no</SUB>). </DIV> <TABLE border=3D1> <COLGROUP> <COL align=3Dleft> <COL align=3Dchar char=3D"."> <COL align=3Dchar char=3D"("> <COL align=3Dchar char=3D"("></COLGROUP> <THEAD> <TR class=3Dheader> <TH align=3Dleft> <P class=3D""> </P></TH> <TH align=3Dleft char=3D"."> <P class=3D"">Number of tumors (<I>N</I>) </P></TH> <TH align=3Dleft char=3D"("> <P class=3D"">Cho<SUB>tu</SUB>/Cho<SUB>n</SUB> median (range) = </P></TH> <TH align=3Dleft char=3D"("> <P class=3D"">tCr<SUB>tu</SUB>/tCr<SUB>n</SUB> median (range)=20 </P></TH></TR></THEAD> <TBODY> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Tumor progression</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">33</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">1.33 (0.75=963.23)</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">1.00 (0.55=961.94)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">No tumor progression</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">12</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">1.31 (0.41=961.65)</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">0.80 (0.27=961.36)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Malignant tumor transformation</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">26</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">1.50 (0.75=963.23)</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">1.03 (0.6=961.94)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">No malignant transformation</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">19</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">1.24 (0.41=961.65)</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">0.79 (0.27=961.26)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Death</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">10</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">1.83 (1.16=963.23)</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">1.04 (0.79=961.94)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">No death</P></TD> <TD align=3Dchar char=3D"."> <P class=3D"">35</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">1.27 (0.41=961.74)</P></TD> <TD align=3Dchar char=3D"("> <P class=3D"">0.94 (0.27=961.43)</P></TD></TR></TBODY></TABLE> <DIV class=3DCapt> <DIV class=3DCaptCont> <DIV class=3D"">The values are indicated for WHO grade II gliomas with = and without=20 progression, WHO grade II gliomas with and without malignant = transformation, and=20 for patients with WHO grade II gliomas who died or survived during the = follow-up=20 period. </DIV></DIV></DIV></DIV></DIV> <DIV class=3DPara> <DIV class=3D"">In the ANOVA analysis of continuous data, the normalized = tCr was=20 significant for each of the two endpoints tumor progression = (<I>p</I> =3D 0.011)=20 and malignant transformation (<I>p</I> =3D 0.016; = Fig. <A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#Fig2">2</A>).=20 Normalized Cho and Cho<SUB>max</SUB> failed significance level for both=20 endpoints. No significances were found for the endpoint survival/death.=20 <DIV class=3DFigure><A name=3DFig2></A><IMG=20 alt=3DMediaObjects/234_2008_409_Fig2_HTML.gif=20 src=3D"http://www.springerlink.com/content/2288165762t443qx/MediaObjects/= 234_2008_409_Fig2_HTML.gif"></DIV> <DIV class=3DCapt><SPAN class=3DCaptNr>Fig. 2 </SPAN> = <B>a</B>, <B>b</B>=20 The predictive values of normalized tCr=20 (tCr<SUB>tumor</SUB>/tCr<SUB>normal</SUB>) and normalized Cho=20 (Cho<SUB>tumor</SUB>/Cho<SUB>normal</SUB>) were analyzed for progression = (<B>a</B>) and malignant transformation (<B>b</B>) of histopathological = proven=20 gliomas WHO grade II using the unifactorial analysis of variance = (ANOVA).=20 <SUP>*</SUP>indicates significant change </DIV> <HR> </DIV></DIV> <DIV class=3DPara> <DIV class=3D"">Results from the Kaplan=96Meier method are shown in = Table <A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#Tab4">4</A>=20 with illustration of progression-free survival for the normalized tCr=20 (Fig. <A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#Fig3">3</A>).=20 <DIV class=3DFigure><A name=3DFig3></A><IMG=20 alt=3DMediaObjects/234_2008_409_Fig3_HTML.gif=20 src=3D"http://www.springerlink.com/content/2288165762t443qx/MediaObjects/= 234_2008_409_Fig3_HTML.gif"></DIV> <DIV class=3DCapt><SPAN class=3DCaptNr>Fig. 3 </SPAN>The = Kaplan=96Meier=20 graph shows the median progression-free intervals for categorized = concentrations=20 of tCr<SUB>tumor</SUB>/tCr<SUB>normal</SUB> </DIV> <HR> <A name=3DTab4></A> <DIV class=3DCapt><SPAN class=3DCaptNr>Table 4 </SPAN>Results = from=20 Kaplan=96Meier method for the median progression-free interval are = indicated for=20 the different categorized groups of normalized tCr and Cho. </DIV> <TABLE border=3D1> <COLGROUP> <COL align=3Dleft> <COL align=3Dleft> <COL align=3Dleft> <COL align=3Dleft> <COL align=3Dleft></COLGROUP> <THEAD> <TR class=3Dheader> <TH align=3Dleft rowSpan=3D2> <P class=3D""> </P></TH> <TH align=3Dleft> <P class=3D"">All patients</P></TH> <TH align=3Dleft> <P class=3D"">Patients with LGG progression</P></TH> <TH align=3Dleft colSpan=3D2> <P class=3D"">Progression-free interval (months)</P></TH></TR> <TR class=3Dheader> <TH align=3Dleft> <P class=3D"">Number</P></TH> <TH align=3Dleft> <P class=3D"">Number</P></TH> <TH align=3Dleft> <P class=3D"">Median</P></TH> <TH align=3Dleft> <P class=3D"">Mean (95% CI)</P></TH></TR></THEAD> <TBODY> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">tCr <1.0</P></TD> <TD align=3Dleft> <P class=3D"">27</P></TD> <TD align=3Dleft> <P class=3D"">17</P></TD> <TD align=3Dleft> <P class=3D"">12</P></TD> <TD align=3Dleft> <P class=3D"">20 (13=9627)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">tCr =3D 1.0=961.19</P></TD> <TD align=3Dleft> <P class=3D"">9</P></TD> <TD align=3Dleft> <P class=3D"">8</P></TD> <TD align=3Dleft> <P class=3D"">7</P></TD> <TD align=3Dleft> <P class=3D"">8 (6=9610)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">tCr >1.19</P></TD> <TD align=3Dleft> <P class=3D"">9</P></TD> <TD align=3Dleft> <P class=3D"">8</P></TD> <TD align=3Dleft> <P class=3D"">4</P></TD> <TD align=3Dleft> <P class=3D"">7 (2=9613)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Cho <1.19</P></TD> <TD align=3Dleft> <P class=3D"">8</P></TD> <TD align=3Dleft> <P class=3D"">5</P></TD> <TD align=3Dleft> <P class=3D"">26</P></TD> <TD align=3Dleft> <P class=3D"">25 (15=9635)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Cho =3D 1.2=961.59</P></TD> <TD align=3Dleft> <P class=3D"">22</P></TD> <TD align=3Dleft> <P class=3D"">16</P></TD> <TD align=3Dleft> <P class=3D"">6</P></TD> <TD align=3Dleft> <P class=3D"">11 (7=9616)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Cho =3D 1.6=962.0</P></TD> <TD align=3Dleft> <P class=3D"">8</P></TD> <TD align=3Dleft> <P class=3D"">5</P></TD> <TD align=3Dleft> <P class=3D"">7</P></TD> <TD align=3Dleft> <P class=3D"">19 (8=9631)</P></TD></TR> <TR class=3Dnoclass> <TD align=3Dleft> <P class=3D"">Cho >2.0</P></TD> <TD align=3Dleft> <P class=3D"">7</P></TD> <TD align=3Dleft> <P class=3D"">7</P></TD> <TD align=3Dleft> <P class=3D"">5</P></TD> <TD align=3Dleft> <P class=3D"">5 (1=969)</P></TD></TR></TBODY></TABLE> <DIV class=3DCapt> <DIV class=3DCaptCont> <DIV class=3D""><I>LGG</I> Low-grade gliomas WHO II, <I>CI</I> = confidence interval=20 </DIV></DIV></DIV></DIV></DIV></DIV></DIV> <DIV class=3D""><A name=3DSec13></A> <HR> <DIV class=3Dheading2>Discussion</DIV> <P class=3D"">This is the first study group which investigates the role = of Cho and=20 tCr concentrations for predicting the progression-free survival of WHO = grade II=20 gliomas and the time until these low-grade gliomas (LGG) show malignant=20 transformation. </P> <P class=3D"">In a prospective study monitoring suspected but = histopathologically=20 unproven WHO grade II gliomas, Reijneveld et al. did not find clear = evidence=20 that <SUP>1</SUP>H-MRSI improves the prediction regarding malignant=20 transformation [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR4">4</A></CITE>].=20 However, their study was based on the within-voxel NAA/Cho ratio of the = lesion.=20 A strong decrease in tNAA may mask changes in the Cho concentration = concealing=20 their significance. A retrospective study by Kuznetsov was designed to = evaluate=20 the accuracy of survival predictions on the basis of <SUP>1</SUP>H-MRSI = features=20 for all grades of gliomas including glioblastomas [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR3">3</A></CITE>].=20 They found that the ratio between the maximum values of Cho normalized = to tCr of=20 normal appearing brain tissue of the same patient could predict survival = in=20 patients with supratentorial gliomas with accuracy comparable to = invasive=20 methods. However, since higher tumor grades correspond to higher Cho, it = remains=20 disputable whether Cho is a spectroscopic predictor of survival = independent from=20 tumor grade or whether Cho reflects the well-known correlation between=20 histopathological tumor grade and survival. Tedeschi et al. could show = that an=20 increase of Cho<SUB>max</SUB> during <SUP>1</SUP>H-MRSI monitoring of = WHO grade=20 II gliomas detects the shift towards a higher malignancy grade [<CITE><A = href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR5">5</A></CITE>].=20 </P> <P class=3D"">None of the spectroscopic studies evaluated the prognostic = significance of tCr in WHO grade II gliomas. In this study, the average = tCr=20 concentration of the entire tumor tissue, delineated on the T2-weighted=20 reference slices, divided by the tCr concentration of the same = anatomical area=20 in the contralateral hemisphere turned out to be an important predictive = value=20 for tumor progression and malignant transformation. As a rule of thumb, = WHO=20 grade II gliomas with decreased tCr (relative tCr values below 1.0) may = show=20 longer progression-free times and later malignant transformation than = LGGs with=20 regular or increased tCr values. There was no significant correlation = between=20 values of normalized tCr and survival time, possibly due to the low = number of=20 patients who died in the follow-up time. Further, survival not only = depends on=20 the progression-free interval, but also on the efficiency of the applied = tumor=20 therapy. In this study, most of the patients with progressive disease = received=20 radiation with or without chemotherapy. Therefore, the tumor = concentration of=20 tCr might rather correlate with longer progression-free survival of = patients=20 without adjuvant therapy than it provides information on the = susceptibility of=20 tumor tissue for therapy. </P> <P class=3D"">Many studies evaluate metabolite levels in brain tumors = expressed as=20 ratio to tCr. The denominator is explicitly assumed to be stable in = normal as=20 well as in many pathologic states. The use of this ratio misses the = importance=20 of tCr for WHO grade II gliomas and thus, our results should have = implication on=20 spectroscopic studies of glial tumors. Further, Li et al. could show = high=20 coefficients of variations for metabolite ratios NAA/Cr and Cho/Cr in = normal=20 brains [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR11">11</A></CITE>].=20 Reports of absolute concentrations of creatine in tumor tissue are = limited to=20 few publications. Some authors found significant changes of tCr in = gliomas=20 observing both increased and decreased tCr levels in different brain = tumors and=20 even in different tumor regions [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR12">12</A></CITE>=96<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR14">14</A></CITE>].=20 In gliomas, it is still unclear whether there is another biochemical = role for=20 creatine besides the well-established function of phosphocreatine as = short-term=20 energy reservoir. Highest tCr concentrations were found in astrocytes = and=20 oligodendrocytes [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR15">15</A></CITE>].=20 Astroglial cells of the brain are able to synthesize creatine and to = release=20 guanidinoacetate as intermediate of creatine synthesis, whereas tumor = cells seem=20 to synthesize a lower amount of tCr [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR16">16</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR17">17</A></CITE>].=20 Previous results indicate that increased tCr may be the reaction of = astroglial=20 cells to infiltrative growth of tumor cells [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR8">8</A></CITE>].=20 In this context, tCr reveals the infiltrative activity of the tumor = cells which=20 explains that gliomas with higher tCr progress faster. </P> <P class=3D"">In contrast to tCr, many studies have investigated the = role of Cho=20 in glial tumors. Increased Cho levels are attributed to cell = proliferation or=20 growth stimulation, and increased phosphocholine is associated with = oncogenic=20 and malignant transformation [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR18">18</A></CITE>=96<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR21">21</A></CITE>].=20 The Cho signal also reflects levels of local cellularity [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR22">22</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR23">23</A></CITE>],=20 the invasiveness as well as the malignancy of gliomas [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR24">24</A></CITE>=96<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR26">26</A></CITE>].=20 In our study, the normalized Cho failed significance level for malignant = transformation (<I>p</I> =3D 0.07); however, there was a = trend toward earlier=20 malignant transformation for higher Cho values including the = Cho<SUB>max</SUB>=20 values. </P> <P class=3D"">It has to be considered that the differentiation between = tumor=20 progression with or without malignant transformation is limited because=20 interobserver variability and other sources of errors like tumor = heterogeneity=20 and variability of contrast enhancement have to be considered. The same = is true=20 for the grading of gliomas. Therefore, choline might be a good indicator = for=20 tumor progression and survival when all grades of gliomas are = considered.=20 Regarding the subgroup of grade II gliomas, normalized tCr might be a = more=20 reliable indicator for progression-free survival. Considering the = limitations of=20 correct tumor grading, both metabolites complement each other as = predictive=20 values for patients with gliomas. </P> <P class=3D"">Besides the spectroscopic data, there were only two other=20 significant prognostic parameters in the presented study: the CE = enhancement of=20 WHO grade II gliomas at the time of diagnosis in predicting the endpoint = of=20 malignant transformation and the extent of tumor resection in predicting = the=20 endpoint tumor progression. Grade II gliomas might enhance to a = considerable=20 degree [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR27">27</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR28">28</A></CITE>].=20 The prognostic value on survival regarding CM enhancement of the gliomas = is=20 controversial [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR28">28</A></CITE>=96<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR30">30</A></CITE>].=20 The quantitative method for analyzing CM enhancement in WHO grade II = gliomas=20 shows a clear difference between tumors with and without progression = [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR30">30</A></CITE>].=20 Concordant with our data, the grade of tumor resection in LGGs turned = out as=20 important predictive factor for the prognosis in previous studies = [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR6">6</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR31">31</A></CITE>=96<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR6">34</A></CITE>].=20 </P> <P class=3D"">In contrast to previous studies, especially in contrast to = trials=20 from the European Organization for Research and Treatment of Cancer = Radiotherapy=20 Cooperative Group, patient=92s age, neurological symptoms, and = histopathological=20 type of LGG failed to be significant to predict the prognosis of the = patients=20 with LGG [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR6">6</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR29">29</A></CITE>,=20 <CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR35">35</A></CITE>=96<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR40">40</A></CITE>].=20 Different reasons for the discrepancies between the multicenter studies = and our=20 collective might be their higher patient numbers, longer follow-up = times, and=20 their higher statistical power for LGGs with oligodendroglial = components.=20 Further, most of the patients in the multicenter trials received = postoperative=20 adjuvant therapy (radiation/chemotherapy), and postoperative tumor = imaging was=20 not mandatory. </P> <DIV class=3D""><A name=3DSec14></A> <DIV class=3DHeading3>Limitations of the study</DIV> <P class=3D"">High percentage of our patients had gliomas in eloquent = brain areas,=20 and therefore, they underwent tumor biopsy instead of tumor resection. = Even=20 though total tumor resection was the first aim of surgical therapy, = eloquent=20 localization and/or large size of the low-grade gliomas indicated a more = conservative procedure in order to prevent neurological deficits. Apart = from the=20 larger remaining tumor volume, tumor biopsy might implicate sampling = errors and=20 the intrinsic heterogeneity of cerebral gliomas may confound = histopathological=20 diagnoses that are made on the basis of small biopsy specimens. These = facts=20 might also explain the short progression-free survival of our patient = group=20 compared to others [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR40">40</A></CITE>].=20 </P> <P class=3D"">Further, two different methods were employed for the = spectroscopic=20 measurements with a change from SVS at 1.5 T to MRSI at 3 T. = However,=20 metabolite concentrations from the tumor were normalized for each = patient using=20 values from normal appearing contralateral white matter area that = corresponded=20 anatomically to the tumor area. This method calibrates the metabolite=20 concentrations to an internal reference minimizing the influence of = different=20 spectroscopic parameters, different brain areas, and individuals = [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR41">41</A></CITE>].=20 The use of this method of normalization is validated by a previous study = [<CITE><A=20 href=3D"http://www.springerlink.com/content/2288165762t443qx/fulltext.htm= l#CR5">5</A></CITE>].=20 </P></DIV></DIV> <DIV class=3D""><A name=3DSec15></A> <HR> <DIV class=3Dheading2>Conclusion</DIV> <P class=3D"">Normalized tCr of the WHO grade II gliomas proved to be a=20 significant prognostic factor concerning progression-free survival and = for the=20 time until these LGGs show malignant transformation. WHO grade II = gliomas with=20 decreased tCr showed longer time intervals until the gliomas progressed. = Contrast enhancement of the WHO grade II gliomas at time of diagnosis = was the=20 second significant factor correlating positively with the malignant=20 transformation of these LGGs. The grade of tumor resection correlated=20 significantly with tumor progression, but not with the malignant = transformation.=20 Thus, normalized tCr may be an important prognostic predictor for = untreated WHO=20 grade II gliomas, implicating that the group without decreased values = might=20 profit from more aggressive therapeutic strategies. Considering that = choline=20 might be a good indicator for tumor progression and survival with regard = to all=20 grades of gliomas, both metabolites complement each other as predictive = values=20 for patients with gliomas. </P></DIV> <DIV class=3DAcknowledgments> <DIV class=3DFormalPara> <DIV class=3D""><SPAN style=3D"FONT-STYLE: italic; TEXT-DECORATION: = none">Conflict=20 of interest statement</SPAN> The authors declare that they = have no=20 conflict of interest. </DIV></DIV></DIV> <P></P> <HR> <H2><A name=3DBib1></A>References </H2> <TABLE> <TBODY class=3DCitation> <TR vAlign=3Dtop> <TD>1.</TD> <TD><A name=3DCR1></A>Karim AB, Afra D, Cornu P, Bleehan N, Schraub = S, De=20 Witte O, Darcel F, Stenning S, Pierart M, Van Glabbeke M (2002) = Randomized=20 trial on the efficacy of radiotherapy for cerebral low-grade = glioma in the=20 adult: European Organization for Research and Treatment of Cancer = Study=20 22845 with the Medical Research Council study BRO4: an interim = analysis.=20 Int J Radiat Oncol Biol Phys 52:316=96324<BR><A=20 = href=3D"http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=3DRetrieve&= db=3DPubMed&dopt=3DAbstract&list_uids=3D11872276"=20 target=3D_blank><IMG height=3D20 alt=3DPubMed=20 = src=3D"http://www.springerlink.com/content/2288165762t443qx/pubmed_link.g= if"=20 width=3D65 border=3D0></A> </TD></TR> <TR> <TD> </TD></TR> <TR vAlign=3Dtop> <TD>2.</TD> <TD><A name=3DCR2></A>Shimizu H, Kumabe T, Tominaga T, Kayama T, = Hara K, Ono=20 Y, Sato K, Arai N, Fujiwara S, Yoshimoto T (1996) Noninvasive = evaluation=20 of malignancy of brain tumors with proton MR spectroscopy. 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