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1404.full Espectroscopia en Tumores
1404.full Espectroscopia en Tumores
ORIGINAL
Resonance Spectroscopy for the Characterization
RESEARCH of Brain Tumors
W. Hollingworth BACKGROUND AND PURPOSE: Proton MR spectroscopy (1H-MR spectroscopy) is a potentially useful
L.S. Medina adjunct to anatomic MR imaging in the characterization of brain tumors. We performed an updated
systematic review of the evidence.
R.E. Lenkinski
D.K. Shibata METHODS: We employed a standardized search strategy to find studies published during 20022004.
We reviewed studies measuring diagnostic accuracy and diagnostic, therapeutic, or health impact of
B. Bernal 1
H-MR spectroscopy. We abstracted information on study design, 1H-MR spectroscopy technique, and
D. Zurakowski methodologic quality. We categorized studies into 5 subgroups: (1) metastasis versus high-grade
B. Comstock tumor; (2) high-versus low-grade tumor; (3) recurrent tumor versus radiation necrosis; (4) tumor extent;
J.G. Jarvik and (5) tumor versus non-neoplastic lesion.
CONCLUSION: The current evidence on the accuracy of 1H-MR spectroscopy in the characterization of
brain tumors is promising. However, additional high-quality studies are needed to convince policy
makers. We present guidelines to help focus future research in this area.
Received September 22, 2005; accepted after revision December 2. Defining Study Type and Clinical Subgroups
From the Departments of Radiology (W.H., D.K.S., J.G.J.) and General Internal Medicine In this systematic review, we elected to include all studies that assessed
(B.C.), University of Washington, Seattle, Wash; Department of Radiology (L.S.M., B.B.), the diagnostic performance (eg, sensitivity, specificity) or the impact
Miami Childrens Hospital, Miami, Fla; Department of Radiology (R.E.L.), Beth Israel
of 1H-MR spectroscopy on subsequent diagnostic testing, treatment
Deaconess Medical Center, Boston, Mass; and Departments of Orthopaedic Surgery and
Biostatistics (D.Z.), Harvard Medical School, Boston, Mass. choices, patient health, or cost effectiveness of care. It would be inap-
This research was funded by a grant from the Neuroradiology Education and Research propriate to combine diagnostic accuracy results from diverse clinical
Foundation. applications of 1H-MR spectroscopy. Therefore, we categorized pub-
A preliminary summary of these data were presented at the American Society of lications according to the following 5 main clinical subgroups: 1)
Neuroradiology conference, Toronto, Canada, May 2005. Some of the data contained within
metastasis versus high-grade astrocytoma; 2) high- versus low-grade
this paper were also discussed at the American College of Radiology Imaging Network
meeting, Washington, DC, September 2005. astrocytoma; 3) tumor extent before treatment; 4) neoplastic versus
Address correspondence to William Hollingworth, PhD, Department of Radiology, Box non-neoplastic lesions; 5) recurrent or residual tumor versus treat-
359960, 325 Ninth Ave, Seattle, WA 98104-2499; e-mail: willh@u.washington.edu ment-related change.
Search Strategy ences between the 2 reviewers were resolved by a third reviewer
We searched Medline via the Pubmed interface, Embase via the Dia- through recourse to the original text.
log interface, and the Cochrane Library data bases for relevant articles.
Because the primary focus of this project was to update previous tech- Study Quality
nology assessments,4,5 we limited our search strategy to articles pub- We used the Quality Assessment of Diagnostic Accuracy Studies
lished between January 1, 2002, and December 31, 2004. The search (QUADAS)6 tool to measure methodologic quality. QUADAS con-
strategy was tailored for each data base. The Medline search strategy is
BRAIN
tains 14 items, including questions about the spectrum of patients, the
presented in Appendix 1. We excluded all Embase titles already iden- validity of the reference standard, and the potential existence of dis-
tified by the Medline search. Two authors (J.G.J. and W.H.) then ease progression, verification, review, and incorporation biases.7 We
reviewed each Embase title to reach consensus on whether to pur- added 1 item to the standard QUADAS tool: Was the reproducibility
chase the abstract. The Cochrane library data base was searched by (inter-radiologist or intertechnologist) of MR spectroscopy de-
ORIGINAL RESEARCH
using the Brain neoplasms and Magnetic Resonance Spectros- scribed? The reviewers coded each item as yes, no, or unclear.
copy medical subject headings. In our analysis, we interpreted both no and unclear responses as
All selected abstracts were independently screened by 2 authors indicating that the quality criterion was not met.
based on the following 6 exclusion criteria: (1) does not use 1H-MR
spectroscopy; (2) not focused on brain tumors; (3) less than 10 pa- Data Analysis
tients with suspected tumors get 1H-MR spectroscopy; (4) uses For each clinical subgroup, we tabulated estimates of sensitivity, spec-
1
H-MR spectroscopy to study the effect of therapy on normal brain ificity, percentage of correct diagnoses, and area under the receiver
tissue; (5) includes only patients with HIV/AIDS; and (6) a review
operating characteristic (ROC) curve. If data on statistical uncertainty
paper reporting no new data. We obtained the full text of each article
were missing or incorrect, we calculated confidence intervals from the
when one or both reviewers were unsure or recommended full text
raw data. We plotted sensitivity, specificity, and ROC curve results to
review. Two additional exclusion criteria were applied on reviewing
aid interstudy comparisons. ROC curves were calculated from the
the full text: (1) duplicate publications and (2) articles not published
published area under the curve estimates by using PlotROC software.8
in English, French, Spanish, German, or Japanese. We hand-searched
This method assumes a bi-normal model for sensitivity and specificity
citations of all eligible articles and sent e-mails to corresponding au-
and produces an ROC curve that is an approximation, though not
thors to identify additional articles initially overlooked.
identical, to the original data.
Diagnostic performance studies were distributed to 2 reviewers
(B.B., D.K.S., J.G.J., R.E.L., L.S.M., or W.H.) for independent review.
Non-English language articles were reviewed by one reviewer fluent Results
in that languageFrench (J.G.J.), Spanish (L.S.M.), German (K.F.L.), The Medline search strategy identified 323 abstracts. After ex-
and Japanese (Y.A.). Each reviewer abstracted study information on a clusion of duplicate and irrelevant Embase titles, 37 Embase
standardized Microsoft Excel spreadsheet. Reviewers recorded details abstracts were obtained for review. The search of the Cochrane
about the dates of patient recruitment, sample size, other imaging library data base revealed no additional abstracts. The hand
tests used, reference standard, and the 1H-MR spectroscopy tech- search of the citations and request to corresponding authors
nique. In particular, we recorded the metabolites evaluated, spectral revealed 6 additional abstracts. Therefore, a total of 366 ab-
analysis methods, single or multivoxel spectroscopy, imaging field stracts were reviewed. Reviewers agreed on the eligibility of the
strength, repetition time, echo time, and pulse sequence. Any differ- abstract in 323 of 366 cases (88%) (Figure 1).
1407
* Authors who made diagnostic classifications based on visualizing the spectra are categorized as qualitative; authors who present specific ratios or threshold values for distinguishing lesions are categorized as quantitative; authors who used statistical modeling,
such as linear discriminant analysis, are categorized as automated.
Table 2: Methodologic quality
Quality item %*
Is the reference standard likely to correctly classify the target condition? 90
Did the whole sample or a random selection of the sample receive verification using a reference standard? 90
Did patients receive the same reference standard regardless of the index test result? 80
Were selection criteria clearly described? 76
Was the spectrum of patients representative of the patients who will receive the test in practice? 73
Were the MRS results interpreted without knowledge of the results of the reference standard? 71
Was the execution of MRS described in sufficient detail to permit replication of the test? 68
Was the reference standard independent of the MRS (ie, MRS did not contribute to the reference standard)? 66
Was the execution of the reference standard described in sufficient detail to permit its replication? 63
Were uninterpretable/intermediate test results reported? 59
Were the same clinical data available when test results were interpreted as would be available when the test is used in practice? 49
Were withdrawals from the study explained? 49
Were the reference test results interpreted without knowledge of the results of MRS? 41
Is the time period between MRS and the reference standard short enough to be reasonably sure that the target condition did not change between 34
the 2 tests?
Was the reproducibility of (inter-radiologist or inter-technologist) MRS described? 12
Note:MRS indicates magnetic resonance spectroscopy.
* Each of the quality items were assessed by 2 reviewers for English language articles and by one reviewer for the foreign language articles. Percentages represent the proportion of these
assessments which judged the article to have met the quality criterion.
Fig 3. Receiver operating characteristic (ROC) curves and point estimates of sensitivity and
specificity of 1H-MR spectroscopy for distinguishing high- and low-grade astrocytomas. The
ROC curves are back-calculated from the area-under-the-curve figures provided by the
authors. They approximate, but are not perfect matches, for the ROC curves based on the Fig 4. Sensitivity and specificity of 1H-MR spectroscopy for differentiating recurrent or
individual patient data. residual tumor from treatment-related changes.