European Radiology

, Volume 24, Issue 2, pp 531–541 | Cite as

Characterisation of solitary pulmonary lesions combining visual perfusion and quantitative diffusion MR imaging

  • Johan CoolenEmail author
  • Johan Vansteenkiste
  • Frederik De Keyzer
  • Herbert Decaluwé
  • Walter De Wever
  • Christophe Deroose
  • Christophe Dooms
  • Eric Verbeken
  • Paul De Leyn
  • Vincent Vandecaveye
  • Dirk Van Raemdonck
  • Kristiaan Nackaerts
  • Steven Dymarkowski
  • Johny Verschakelen



To evaluate the diagnostic accuracy of dynamic contrast-enhanced (DCE) magnetic resonance (MR) and diffusion-weighted imaging (DWI) sequences for defining benignity or malignancy of solitary pulmonary lesions (SPL).


First, 54 consecutive patients with SPL, clinically staged (CT and PET or integrated PET-CT) as N0M0, were included in this prospective study. An additional 3-Tesla MR examination including DCE and DWI was performed 1 day before the surgical procedure. Histopathology of the surgical specimen served as the standard of reference. Subsequently, this functional method of SPL characterisation was validated with a second cohort of 54 patients.


In the feasibility group, 11 benign and 43 malignant SPL were included. Using the combination of conventional MR sequences with visual interpretation of DCE-MR curves resulted in a sensitivity, specificity and accuracy of 100 %, 55 % and 91 %, respectively. These results can be improved by DWI (with a cut-off value of 1.52 × 10−3 mm2/s for ADChigh) leading to a sensitivity, specificity and accuracy of 98 %, 82 % and 94 %, respectively. In the validation group these results were confirmed.


Visual DCE-MR-based curve interpretation can be used for initial differentiation of benign from malignant SPL, while additional quantitative DWI-based interpretation can further improve the specificity.

Key Points

• Magnetic resonance imaging is increasingly being used to help differentiate lung lesions.

• Solitary pulmonary lesions (SPL) are accurately characterised by combining DCE-MRI and DWI.

• Visual DCE-MRI assessment facilitates the diagnostic throughput in patients with SPL.

• DWI provides additional information in inconclusive DCE-MRI (type B pattern).


Single pulmonary lesion Magnetic resonance imaging Diffusion-weighted imaging Dynamic contrast-enhanced MR imaging Characterisation of lung nodule or mass 


  1. 1.
    MacMahon H, Austin JH, Gamsu G et al (2005) Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology 237:395–400PubMedCrossRefGoogle Scholar
  2. 2.
    Gould MK, Fletcher J, Iannettoni MD et al (2007) Evaluation of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 132:108S–130SPubMedCrossRefGoogle Scholar
  3. 3.
    Eisenberg RL, Bankier AA, Boiselle PM (2010) Compliance with Fleischner Society guidelines for management of small lung nodules: a survey of 834 radiologists. Radiology 255:218–224PubMedCrossRefGoogle Scholar
  4. 4.
    Dewan NA, Shehan CJ, Reeb SD, Gobar LS, Scott WJ, Ryschon K (1997) Likelihood of malignancy in a solitary pulmonary nodule: comparison of Bayesian analysis and results of FDG-PET scan. Chest 112:416–422PubMedCrossRefGoogle Scholar
  5. 5.
    Libby DM, Smith JP, Altorki NK, Pasmantier MW, Yankelevitz D, Henschke CI (2004) Managing the small pulmonary nodule discovered by CT. Chest 125:1522–1529PubMedCrossRefGoogle Scholar
  6. 6.
    Erasmus JJ, Connolly JE, McAdams HP, Roggli VL (2000) Solitary pulmonary nodules: Part I. Morphologic evaluation for differentiation of benign and malignant lesions. Radiographics 20:43–58PubMedCrossRefGoogle Scholar
  7. 7.
    Erasmus JJ, McAdams HP, Connolly JE (2000) Solitary pulmonary nodules: Part II. Evaluation of the indeterminate nodule. Radiographics 20:59–66PubMedCrossRefGoogle Scholar
  8. 8.
    Wormanns D, Diederich S (2004) Characterization of small pulmonary nodules by CT. Eur Radiol 14:1380–1391PubMedGoogle Scholar
  9. 9.
    Winer-Muram HT (2006) The solitary pulmonary nodule. Radiology 239:34–49PubMedCrossRefGoogle Scholar
  10. 10.
    Swensen SJ, Viggiano RW, Midthun DE et al (2000) Lung nodule enhancement at CT: multicenter study. Radiology 214:73–80PubMedCrossRefGoogle Scholar
  11. 11.
    Gupta NC, Maloof J, Gunel E (1996) Probability of malignancy in solitary pulmonary nodules using fluorine-18-FDG and PET. J Nucl Med 37:943–948PubMedGoogle Scholar
  12. 12.
    Ohno Y, Koyama H, Matsumoto K et al (2011) Differentiation of malignant and benign pulmonary nodules with quantitative first-pass 320-detector row perfusion CT versus FDG PET/CT. Radiology 258:599–609PubMedCrossRefGoogle Scholar
  13. 13.
    Yi CA, Lee KS, Kim BT et al (2006) Tissue characterization of solitary pulmonary nodule: comparative study between helical dynamic CT and integrated PET/CT. J Nucl Med 47:443–450PubMedGoogle Scholar
  14. 14.
    Cronin P, Dwamena BA, Kelly AM, Carlos RC (2008) Solitary pulmonary nodules: meta-analytic comparison of cross-sectional imaging modalities for diagnosis of malignancy. Radiology 246:772–782PubMedCrossRefGoogle Scholar
  15. 15.
    Yi CA, Jeon TY, Lee KS et al (2007) 3-T MRI: usefulness for evaluating primary lung cancer and small nodules in lobes not containing primary tumors. AJR Am J Roentgenol 189:386–392PubMedCrossRefGoogle Scholar
  16. 16.
    Regier M, Kandel S, Kaul MG et al (2007) Detection of small pulmonary nodules in high-field MR at 3 T: evaluation of different pulse sequences using porcine lung explants. Eur Radiol 17:1341–1351PubMedCrossRefGoogle Scholar
  17. 17.
    Ohno Y, Hatabu H, Takenaka D, Adachi S, Kono M, Sugimura K (2002) Solitary pulmonary nodules: potential role of dynamic MR imaging in management initial experience. Radiology 224:503–511PubMedCrossRefGoogle Scholar
  18. 18.
    Kono R, Fujimoto K, Terasaki H et al (2007) Dynamic MRI of solitary pulmonary nodules: comparison of enhancement patterns of malignant and benign small peripheral lung lesions. AJR Am J Roentgenol 188:26–36PubMedCrossRefGoogle Scholar
  19. 19.
    Fujimoto K (2008) Usefulness of contrast-enhanced magnetic resonance imaging for evaluating solitary pulmonary nodules. Cancer Imaging 8:36–44PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    Tanaka R, Horikoshi H, Nakazato Y et al (2009) Magnetic resonance imaging in peripheral lung adenocarcinoma: correlation with histopathologic features. J Thorac Imaging 24:4–9PubMedCrossRefGoogle Scholar
  21. 21.
    Kono M, Adachi S, Kusumoto M, Sakai E (1993) Clinical utility of Gd-DTPA-enhanced magnetic resonance imaging in lung cancer. J Thorac Imaging 8:18–26PubMedGoogle Scholar
  22. 22.
    Schaefer JF, Vollmar J, Schick F et al (2004) Solitary pulmonary nodules: dynamic contrast-enhanced MR imaging–perfusion differences in malignant and benign lesions. Radiology 232:544–553PubMedCrossRefGoogle Scholar
  23. 23.
    Tozaki M, Ichiba N, Fukuda K (2005) Dynamic magnetic resonance imaging of solitary pulmonary nodules: utility of kinetic patterns in differential diagnosis. J Comput Assist Tomogr 29:13–19PubMedCrossRefGoogle Scholar
  24. 24.
    Zou Y, Zhang M, Wang Q, Shang D, Wang L, Yu G (2008) Quantitative investigation of solitary pulmonary nodules: dynamic contrast-enhanced MRI and histopathologic analysis. AJR Am J Roentgenol 191:252–259PubMedCrossRefGoogle Scholar
  25. 25.
    Mori T, Nomori H, Ikeda K et al (2008) Diffusion-weighted magnetic resonance imaging for diagnosing malignant pulmonary nodules/masses: comparison with positron emission tomography. J Thorac Oncol 3:358–364PubMedCrossRefGoogle Scholar
  26. 26.
    Uto T, Takehara Y, Nakamura Y et al (2009) Higher sensitivity and specificity for diffusion-weighted imaging of malignant lung lesions without apparent diffusion coefficient quantification. Radiology 252:247–254PubMedCrossRefGoogle Scholar
  27. 27.
    Ohba Y, Nomori H, Mori T, Shiraishi K, Namimoto T, Katahira K (2011) Diffusion-weighted magnetic resonance for pulmonary nodules: 1.5 vs. 3 Tesla. Asian Cardiovasc Thorac Ann 19:108–114PubMedCrossRefGoogle Scholar
  28. 28.
    Matoba M, Tonami H, Kondou T et al (2007) Lung carcinoma: diffusion-weighted MR imaging–preliminary evaluation with apparent diffusion coefficient. Radiology 243:570–577PubMedCrossRefGoogle Scholar
  29. 29.
    Liu H, Liu Y, Yu T, Ye N (2010) Usefulness of diffusion-weighted MR imaging in the evaluation of pulmonary lesions. Eur Radiol 20:807–815PubMedCrossRefGoogle Scholar
  30. 30.
    Regier M, Schwarz D, Henes FO et al (2011) Diffusion-weighted MR-imaging for the detection of pulmonary nodules at 1.5 Tesla: intraindividual comparison with multidetector computed tomography. J Med Imaging Radiat Oncol 55:266–274PubMedCrossRefGoogle Scholar
  31. 31.
    González Hernando C, Esteban L, Cañas T, Van den Brule E, Pastrana M (2010) The role of magnetic resonance imaging in oncology. Clin Transl Oncol 12:606–613PubMedCrossRefGoogle Scholar
  32. 32.
    Henzler T, Schmid-Bindert G, Schoenberg SO, Fink C (2010) Diffusion and perfusion MRI of the lung and mediastinum. Eur J Radiol 76:329–336PubMedCrossRefGoogle Scholar
  33. 33.
    Loh SE, Wu DD, Venkatesh SK et al (2013) CT-guided thoracic biopsy: evaluating diagnostic yield and complications. Ann Acad Med Singapore 42:285–290PubMedGoogle Scholar
  34. 34.
    UyBico SJ, Wu CC, Suh RD, Le NH, Brown K, Krishnam MS (2010) Lung cancer staging essentials: the new TNM staging system and potential imaging pitfalls. Radiographics 30:1163–1181PubMedCrossRefGoogle Scholar
  35. 35.
    Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A (2010) In: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A (eds) AJCC cancer staging manual, 7th edn. Springer, New York, pp 232–250Google Scholar
  36. 36.
    Beasley MB (2008) Immunohistochemistry of pulmonary and pleural neoplasia. Arch Pathol Lab Med 132:1062–1072PubMedGoogle Scholar
  37. 37.
    El Khouli RH, Macura KJ, Jacobs MA et al (2009) Dynamic contrast-enhanced MRI of the breast: quantitative method for kinetic curve type assessment. AJR Am J Roentgenol 193:W295–W300PubMedCentralPubMedCrossRefGoogle Scholar
  38. 38.
    Matsuoka S, Hunsaker AR, Gill RR et al (2008) Functional MR imaging of the lung. Magn Reson Imaging Clin N Am 16:275–289PubMedCrossRefGoogle Scholar
  39. 39.
    Li SP, Padhani AR (2012) Tumor response assessments with diffusion and perfusion MRI. J Magn Reson Imaging 35:745–763PubMedCrossRefGoogle Scholar
  40. 40.
    Coolen J, De Keyzer F, Nafteux P et al (2012) Malignant pleural disease: diagnosis by using diffusion-weighted and dynamic contrast-enhanced MR imaging–initial experience. Radiology 263:884–892PubMedCrossRefGoogle Scholar
  41. 41.
    Koh DM, Collins DJ (2007) Diffusion-weighted MRI in the body: applications and challenges in oncology. AJR Am J Roentgenol 188:1622–1635PubMedCrossRefGoogle Scholar
  42. 42.
    Matsuoka S, Uchiyama K, Shima H et al (2002) Effect of the rate of gadolinium injection on magnetic resonance pulmonary perfusion imaging. J Magn Reson Imaging 15:108–113PubMedCrossRefGoogle Scholar
  43. 43.
    Eiber M, Martinez-Möller A, Souvatzoglou M et al (2011) Value of a Dixon-based MR/PET attenuation correction sequence for the localization and evaluation of PET-positive lesions. Eur J Nucl Med Mol Imaging 38:1691–1701PubMedCrossRefGoogle Scholar
  44. 44.
    Sauter AW, Wehrl HF, Kolb A, Judenhofer MS, Pichler BJ (2010) Combined PET/MRI: one step further in multimodality imaging. Trends Mol Med 16:508–515PubMedCrossRefGoogle Scholar
  45. 45.
    Yankeelov TE, Peterson TE, Abramson RG et al (2012) Simultaneous PET-MRI in oncology: a solution looking for a problem? Magn Reson Imaging 30:1342–1356PubMedCentralPubMedCrossRefGoogle Scholar
  46. 46.
    Jerome NP, Orton MR, d’Arcy JA, Collins DJ, Koh DM, Leach MO (2013) Comparison of free-breathing with navigator-controlled acquisition regimes in abdominal diffusion-weighted magnetic resonance images: effect on ADC and IVIM statistics. J Magn Reson Imaging. doi: 10.1002/jmri.24140 Google Scholar

Copyright information

© European Society of Radiology 2013

Authors and Affiliations

  • Johan Coolen
    • 1
    Email author
  • Johan Vansteenkiste
    • 2
  • Frederik De Keyzer
    • 1
  • Herbert Decaluwé
    • 3
  • Walter De Wever
    • 1
  • Christophe Deroose
    • 4
  • Christophe Dooms
    • 2
  • Eric Verbeken
    • 5
  • Paul De Leyn
    • 3
  • Vincent Vandecaveye
    • 1
  • Dirk Van Raemdonck
    • 3
  • Kristiaan Nackaerts
    • 2
  • Steven Dymarkowski
    • 1
  • Johny Verschakelen
    • 1
  1. 1.Department of RadiologyUniversity Hospitals LeuvenLeuvenBelgium
  2. 2.Department of PneumologyUniversity Hospitals LeuvenLeuvenBelgium
  3. 3.Department of Thoracic SurgeryUniversity Hospitals LeuvenLeuvenBelgium
  4. 4.Department of Nuclear MedicineUniversity Hospitals LeuvenLeuvenBelgium
  5. 5.Department of PathologyUniversity Hospitals LeuvenLeuvenBelgium

Personalised recommendations