Relevance Of Dynamic Studies With Magnetic Resonance ... - Elsevier

Gastroenterología y Hepatología Relevance of dynamic studies with magnetic resonance enterography in Crohn's dis...

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Ver más SNIP 2024 0,357 Ver más métricas Ocultar Información de la revista Artículo anterior | Artículo siguiente Vol. 43. Núm. 4.Páginas 179-187 (Abril 2020) Exportar referencia Compartir Compartir Twitter Facebook Linkedin whatsapp E-mail Imprimir Descargar PDF Más opciones de artículo Estadísticas Apartados

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• Introduction
• Abstract
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• Introduction
• Materials and methods
• Entero magnetic resonance imaging
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Visitas 2250 Vol. 43. Núm. 4.Páginas 179-187 (Abril 2020) Original article DOI: 10.1016/j.gastrohep.2019.11.010 Acceso a texto completo Relevance of dynamic studies with magnetic resonance enterography in Crohn's disease Relevancia de los estudios dinámicos en Resonancia Entérica en la Enfermedad de Crohn Visitas 2250 Descargar PDF Salvador Pousa, Matteo Frassona, Raquel Jiméneza, José Pamiésb, Icíar Puchadesa, Margarita Llavadorc, Eduardo García-Graneroa, Pilar Nosd,e, Autor para correspondencia [email protected]Corresponding author. a Department of General Surgery, Colorectal Unit, La Fe University Hospital, University of Valencia, Spainb Department of Radiology, La Fe University Hospital, Spainc Department of Pathology, La Fe University Hospital, Spaind Department of Gastroenterology, Inflammatory Bowel Disease Unit, La Fe University Hospital, Spaine CIBEREHD (Networked Biomedical Research Center for Hepatic and Digestive Disease), Spain Este artículo ha recibido 2250 Visitas Información del artículo Resumen Texto completo Bibliografía Descargar PDF Estadísticas Figuras (2)Tablas (6)Table 1. Protocol for magnetic resonance enterography image acquisition.Table 2. Histological Chiorean classification modified by the authors.Table 3. Demographic and clinical data of patients (N=28). Age at diagnosis, disease location and behavior were defined according to the Montreal classification.19,20Table 4. Results of correlation between dynamic curve pattern with histological study.Table 5. Correlation between dynamic curve pattern with the inflammation degree in the histological study.Table 6. Correlation between the dynamic curve pattern with the fibrosis degree in the histological study.Mostrar másMostrar menos AbstractIntroduction

A proper quantification of the inflammatory activity in Crohn's disease (CD) lesions is needed to establish the appropriate management for each patient. The aim of this study is to evaluate the inflammatory activity of affected segments in small bowel lesions using dynamic studies of magnetic resonance enterography (MRE) in patients undergoing surgery, and their correlation with the level of inflammation and histological fibrosis of the surgical piece.

Methods

A prospective, consecutive, observational, clinical study was conducted that included all the patients with small bowel CD that underwent surgery in this center between March 2011 and September 2013. Diagnosis was established according to Lennard–Jones criteria and the Montreal classification. All the patients underwent MRE within three months before surgery, using a routine protocol involving Liver Acquisition with Volume Acceleration-Extended Volume (LAVA-XV) sequence for the dynamic studies before intravenous administering of gadolinium and 30, 70, 120, and 420s after administering this. The results allowed the designing of graphics with different uptake patterns. The Chiorean classification was used in the histological analysis, as well as a modified version published previously by this study group.

Results

A total of 28 patients with 47 lesions were analyzed. There was a significant correlation between both curve patterns, including the modified Chiorean classification (P<0.0001) as well as the level of inflammation (P<0.0001) and fibrosis (P<0.002). Inflammatory patterns of dynamic studies are related to histological findings with 80.9% accuracy (sensitivity=75.7%; specificity=100%).

Conclusion

There is a high correlation between dynamic enhancement studies and the level of inflammatory activity. MRE is a suitable tool to differentiate between inflammatory and fibrotic lesions, making it useful to decide the appropriate management of each patient.

Keywords:MRI enterographyCalprotectinSurgeryCrohn's diseaseActivityDiagnosisResumenIntroducción

Se necesita una cuantificación adecuada de la actividad inflamatoria en las lesiones de la enfermedad de Crohn (EC) para establecer el tratamiento adecuado para cada paciente. El objetivo de este estudio es evaluar la actividad inflamatoria de los segmentos afectados en las lesiones del intestino delgado mediante estudios dinámicos de enterografía por resonancia magnética (ERM).

Métodos

Estudio prospectivo, consecutivo, observacional y clínico, que incluye a todos los pacientes con EC del intestino delgado que se sometieron a cirugía en nuestro centro entre marzo de 2011 y septiembre de 2013. El diagnóstico se estableció de acuerdo con los criterios de Lennard-Jones y la clasificación de Montreal. Todos los pacientes se sometieron a una ERM dentro de los 3 meses previos a la cirugía, aplicando el protocolo de rutina y secuencias preestablecidas. Para el estudio dinámico se empleó la secuencia Adquisición hepática con aceleración de volumen-Volumen extendido (LAVA-XV), antes de la administración intravenosa (iv) de gadolinio, y 30, 70, 120 y 420s después de esta administración. Los resultados permiten diseñar gráficos con diferentes patrones de captación. En el análisis histológico se utilizó la clasificación de Chiorean, así como una versión modificada creada por nuestro grupo de estudio.

Resultados

En total se analizaron 28 pacientes con 47 lesiones. Se detectó una correlación significativa entre ambos patrones de curva, incluyendo la clasificación de Chiorean modificada (p<0,0001), así como el grado inflamatorio (p<0,0001) y de fibrosis (p<0,002). Los patrones inflamatorios de los estudios dinámicos se relacionaron con los hallazgos histológicos con una precisión del 80,9% (S=75,7%; E=100%).

Conclusión

Existe una alta correlación entre los estudios dinámicos y el grado de actividad inflamatoria. La ERM constituye una herramienta adecuada para diferenciar entre lesiones inflamatorias y fibróticas, siendo útil para colaborar en la decisión terapéutica.

Palabras clave:Enterografía de resonancia magnéticaCalprotectinaCirugíaEnfermedad de CrohnActividadDiagnóstico Texto completo Introduction

Crohn's disease (CD) is a chronic inflammatory pathology that affects the entire digestive tract. The inflammation has a transmural character that involves the entire thickness of the intestinal wall. Despite the progress in the medical treatment of CD, there is still an increased risk of a surgical intervention.

Inflammatory activity in CD is classically measured by clinical, endoscopic and radiological indicators, and by biological markers. Dynamic studies of entero-magnetic resonance imaging (MRE) have a high sensitivity for the detection of wall and extramural lesions and constitute a well-accepted tool for diagnosis and follow-up 1in patients with CD. Some studies have attempted to relate MRI radiological findings with the severity and activity of the CD,2–5 and some have been able to validate these radiological findings with the histology of the surgical specimen.6–8 Usually, morphological changes related to CD activity are assessed, such as wall thickness, contrast uptake, stenosis, mucous membrane distortions, ulcers, cobblestone appearance, edema, hyper vascularization, pathological lymph nodes, abscess, fistulas, adipose-fibrous proliferation, layers enhancement, pre-stenosis dilation, etc. Radiological indicators based on these findings have even been described to evaluate CD activity and intensity.3,5,9 Several publications try to correlate dynamic pattern of wall enhancement with the extent of inflammation in CD, although they all present different methodology and results.10–16 In a very recent systematic review that reviews the state of the art to assess stenosis and fibrotic component in Crohn's disease, the authors conclude that more studies are needed to distinguish fibrosis from inflammation since the studies published to date are not accurate enough to be used in daily clinical practice.17

It would be interesting to know whether dynamic uptake MRI studies allow differentiating early inflammatory processes of CD, which are susceptible to pharmacological treatment, from fibrotic lesions, with low response to medication, which will probably benefit from surgical treatment.

The aim of this study is to assess the inflammatory activity of CD affected areas in small bowel lesions through dynamic studies of entero-magnetic resonance imaging (MRE) in patients undergoing surgery and to explore their correlation with the degree of inflammation and histological fibrosis of the surgical piece.

Materials and methods

This is a consecutive, prospective, observational clinical 30-month study (March, 2011–September, 2013), carried out at a tertiary hospital. The study protocol was approved by the Hospital Ethics Committee. All the patients accepted to participate in the study by signing an informed consent form. During the study period, all the patients diagnosed with CD, who were older than 14 years old, presented small bowel affection, and needed surgery due to medical treatment failure or complications, were studied by entero-MRI (n=38). A dynamic study was performed in 28 of these patients, and they were therefore considered for this analysis.

CD diagnosis was defined according to the ECCO standard criteria18 and after excluding infectious, ischemic or vascular, malignant and actinic causes. Patients were classified by age at the moment of diagnosis, location and the disease's behavior. Harvey and Bradshaw Index was used to describe the clinical activity of the CD.19 A preoperative colonoscopy was performed in all the patients, to discard colic affection and, when possible, take a biopsy of the terminal ileum. A multidisciplinary committee discussed each case and made all the decisions related to the management of these patients.

Entero magnetic resonance imaging

Every patient underwent an MRE test during the three months prior to surgery (one month if the patient had received treatment with anti-TNF biological drugs). MRE examinations were performed using a standardized clinical protocol on a 3T magnet (GE MedicalSystems, Milwaukee, WI, USA). Patients fasted for at least 6h and then ingested 1500ml of a 5% mannitol solution over 45min immediately before MRI took place, to distend the small bowel. To reduce bowel peristalsis, 10mg of e.v. hyoscine butylbromide (Buscopan; Boehringer Ingelheim, Ingelheim, Germany) were administered prior to initiating the study, and additional 10mg were administered before administrating the contrast bolus. In case of contraindication (glaucoma, arrhythmia, benign prostatic hypertrophy), 1mg of e.v. glucagon (Glucagen; Novo Nordisk, Bagsvaerd, Denmark) was administered. For the dynamic study, a contrast injection of gadobenate dimeglumine (Multihance; Bracco Diagnostics Inc., Milan, Italy): 0.2ml/kg body weight was administered at a rate of 2ml/s. Images were obtained by placing the patient in prone position. Sequences and parameters of the MRE protocol are detailed in Table 1. Every lesion was listed and measured on a map, starting from the closest to the ileocecal valve. The distance of each lesion from the ileocecal valve, its length and morphological characteristics were precisely measured.

Table 1.

Protocol for magnetic resonance enterography image acquisition.

Sequences	Plane	Slice thickness/gap (mm)	TR/TE (ms)	FOV	Matrix	Flip angle	Receiver bandwidth
T2-SSFSE	Coronal	4/0	1500/120	440×440	384×224	90	50
FIESTA	Coronal	4/0	4.60/1.54	440×440	384×224	65	125
T2-SSFSE	Axial	5/1	1500/120	Variable	384×224	90	50
T2-SSFSE-FS	Axial	5/1	1500/120	Variable	384×224	90	50
DWI	Axial	5/1	TE minimum	Variable	132×132	90
LAVA-XV	Coronal	2/0	4.9/1.8	440×440	320×224	12	62.5
In Phase FS	Axial	5/1	185/2.1	Variable	256×180	70	31.25

SSFSE, single-shot fast spin echo; FIESTA, fast imaging employing steady state acquisition; FS, fat saturation; DWI, diffusion-weight imaging; LAVA-XV, Liver Acquisition with Volume Acceleration-Extended Volume.

For the dynamic study, Liver Acquisition with Volume Acceleration-Extended Volume (LAVA-XV) sequences prior to contrast administration were used, and also 30, 70, 120 and 420s after the gadolinium administration. In this study, the area of radiological interest (ARI) was placed in the wall section with maximum initial contrast uptake. Enhancement curves were obtained using FuncTool® in the Windows platform version4.8 (GE Medical Systems, Milwaukee, WI, USA) for the analysis of the dynamic pattern of wall enhancement.

The curves were classified as inflammatory pattern when a steep ascending slope in the early phases of contrast uptake in the dynamic study (above 200%), and a decreasing grade of enhancement at the end of the curve was presented. A fibrosis type pattern was determined when the curve displayed a slowly rising slope during the early phases (always below 200%), reaching a plateau or keeping a progressive increase until the end of the curve with no decrease at the end. The decrease in the parietal enhancement degree at the end of the uptake curve was considered distinctive of the inflammatory pattern (Fig. 1). All the images were evaluated by two radiologists experienced in abdominal imaging who reached a consensus regarding any doubts about the interpretation of the images. Both radiologists were blinded to the clinical and laboratory data.

Figure 1.

Magnetic resonance enterography and pattern curves. Image A represents inflamed bowel area and its corresponding inflammatory enhancement curve. Image B represents a fibrotic stenosis and its corresponding enhancement curve.

Surgery

All the patients were operated on by members of the Colorectal Surgery Unit, under homogenous surgical criteria and applying the same perioperative protocol. Elective laparoscopic ileocaecal or ileocolonic resection with latero-lateral anastomoses was the most common procedure (n=20 patients). All the resected bowel segments were remitted for pathological examination, indicating whether one or more lesions were included, its number and location, specifying its distance from the ileocecal valve. When necessary, a picture describing the location of the resected segments was sent along with the specimens. When a strictureplasty was performed, complete wall samples were obtained for histological study.

Pathology report

The freshly excised specimen was photographed before fixation in 10% formaldehyde solution during 24h. Fibrosis and inflammation of the lesions were defined according to the Chiorean criteria.20 A lesion presenting moderate or severe inflammation and none, mild or moderate fibrosis was defined as “Inflammatory”. A lesion displaying severe fibrotic component and none or mild inflammation was defined as “Fibrotic”. In all the other cases lesions were defined as “Mixed”. In this manuscript, a modification of the Chiorean Classification was used dividing the mixed group in mild mixed (no or mild inflammation and mild or moderate fibrosis) and severe mixed (moderate or severe inflammation and severe fibrosis) (Table 2). Two experienced Pathologists, specialized in digestive diseases and part of the multidisciplinary team, evaluated all the specimens. In case of discrepancies, data interpretation was made by consensus.

Table 2.

Histological Chiorean classification modified by the authors.

Inflammation score (0=none; 1=mild; 2=moderate; 3=severe)	Fibrosis score (0=none; 1=mild or moderate; 2=severe)	Lesion with predominant component:
>1	≤1	Inflammatory
≤1	>1	Fibrotic
	Difference ≤1	Mixed
1 or 0	1	Mild mixed
3 or 2	2	Severe mixed

Statistical analysis

Data was analyzed by patients and by lesions. Lesion analysis was accomplished by correlating pathologically assessed surgical specimen's lesions, with the ones identified on the MRE. Unconfirmed lesions during surgery, have been excluded from the analysis.

The Variable Statistics were attained by using the IBM® SPSS® Statistical Program for Social Science version 22.0. In the univariate analysis, continuous variables were expressed using the mean and the standard deviation, while categorical variables were expressed using frequencies and percentages (number of patients, number of lesions, and the percentage). When a non-parametric analysis of categorical variables was necessary, the Pearson's Chi-square test was applied. For the analysis of dichotomous MRI results, a 2×2 table was used and, values of sensitivity, specificity, diagnostic accuracy, positive predictive value (PPV) and negative predictive value (NPV) were obtained by calculating 95% confidence intervals for all estimates. P value of