Outline of the module
Since its inception in the 1980’s, MRI has quickly become indispensable for clinical imaging. MRI can image different biological processes due to the fact that the transverse and longitudinal magnetisations of the protons (and other nuclei) are sensitive to the local biological environment. In addition, applying radiofrequency pulses and MR gradients, the MRI signal can be made sensitive to moving spins probing diffusion and perfusion of the tissue. Thus, MRI is a versatile technique which can be used to evaluate the status of biological tissues.
This module will introduce the applications of MRI to oncology and cardiology. It will provide the necessary basic knowledge on the aetiology and phenomenology of tumour types, causes and clinical therapies. For the characterisation of the tumour status, perfusion, diffusion, vascular density, metabolite concentrations have to be assessed, which all can be provided by various MRI techniques. In the second part of the module, MRI in cardiology will be taught. As the heart is a relatively small organ and fast moving, MRI of the heart is particularly challenging. In addition to the above mentioned MRI techniques, MRI approaches specific to cardiology will be part of the module, e.g. acquisition of MR images gated by the cardiac cycle (i.e. CINE imaging, SSFP MRI sequence). The students will learn to diagnose diseases in the field of oncology and cardiology using MRI images. Finally, the participants will – in the practical sessions – acquire MR images on both types of clinical populations and interpret them accordingly.
Learning objectives
At the end of the module, students will have expert knowledge about the following topics:
• Aetiology and phenomenology and tumour types
• MRI sequences to assess tumour status, in particular perfusion and diffusion MRI
• Aetiology and phenomenology of cardiac diseases
• MRI approaches in cardiology, in particular CINE imaging
• Scanning at the MRI instruments available at the UM on patients with tumor and/or cardiac diseases
• Functional MRI for presurgical planning in brain tumours
• Processing of MR images to delineate and quantify diseases
• Differential diagnosis on diseases with similar clinical symptoms and/or MR image contrasts
• Magnetic field strength dependency of MRI contrasts and their advantages and disadvantages in diagnosis
• Clinical benefits of MRI for patients and comparison with other approaches (e.g. CT)
Content
This module deals with the application of MRI in the clinical fields of oncology and cardiology. Cardiac magnetic resonance imaging has become a routinely used imaging modality for the diagnosis of ischemic heart disease and non-ischaemic cardiomyopathies and can provide non-invasive evaluation of reperfusion therapy through comprehensive evaluation of wall motion, global function, perfusion and viability due to its excellent spatial resolution, reproducibility and safety.
Cardiac wall motion and ventricular function are commonly assessed using SSFP sequences. This technique provides an optimal contrast-to-noise ratio (CNR) between the myocardium and blood pool at a high SNR and is obtained in a relatively short breath-hold, allowing its practical application in the clinical setting. The most commonly used sequence for myocardial viability imaging and morphological assessment of the heart is an inversion recovery prepared spoiled gradient echo (IR-SGE) technique. Myocardial perfusion MR imaging during the administration of a contrast bolus is commonly utilised for assessment of myocardial ischemia. Finally, phase-contrast MR imaging at 1.5 T is an accurate method of quantifying blood flow velocity but it has been predominantly limited to large structures such as the ventricles, valves, or great vessels. In this module, all of these MRI techniques will be introduced, discussed and – in some exemplary cases – applied in patients.
MRI also plays an important role in the diagnosis and management of cancer. Currently, approximately one in three people in the industrialised countries will develop cancer in their lifetime and one in four will die of the disease. MRI is non-invasively used to obtain information on the location and extent of cancer, as well as assessments of tissue characteristics (e.g. hypoxia, apoptosis, necrosis, and tumour vasculature) that can monitor and predict treatment response. MRI methods, that are sensitive to the diffusion of water molecules (DWI), can provide novel information on tissue cellularity that is not obtainable by other means. Many tumours can rapidly outgrow their vascular and nutrient supply (e.g. in high-grade gliomas), and often new vasculature develops in order for the tumour to continue to thrive (angiogenesis). Dynamic contrast-enhanced (DCE) and dynamic susceptibility contrast (DSC) MRI using intra-venously administered contrast agents measures the density, integrity and leakiness of tissue vasculature by measuring T1 and T2*, respectively. The acquired DSC-MRI data are then fit to an appropriate pharmacokinetic model to extract parameters relating to blood volume, blood flow and mean transit time. Finally, functional MRI is used to test whether brain tissue close or within a tumour is still functionally responsive and this information is used for presurgical planning. In this module, the use of MRI in oncology will be demonstrated and the techniques described and used in selective patient populations.
Overview of tasks and lectures
There will be 10 lectures of 2 hours distributed over 5 days.
• Introduction into Cardiology and Oncology
• Overview of MRI sequences and contrasts relevant to oncology
• Oncology: Tumours in the body (e.g. breast, prostate)
• Oncology: Tumours in the neck/head/brain
• Oncology: Novel molecular imaging methods and other imaging techniques
• Overview of MRI sequences and contrasts relevant to cardiology
• Cardiology: Ischaemic heart disease
• Cardiology: Non-ischaemic cardiomyopathies
• Cardiology: Novel approaches and comparison with other imaging techniques
• Summary and Introduction of post-module assignments
Position within the programme
This module is one of the two modules on clinical MRI (see module on neurology and musculoskeletal imaging). In addition, knowledge of other modules (MR physics I, MR spectroscopy, Sequences for MR physics, Pharmacological MRI, Anatomical and function Image basics) will deepen the understanding of background knowledge for clinical practice.
Teaching format
Structure
The module is a one week-long residential module consisting of 10 lectures of 2 hours. Each day, the students will in addition perform data acquisition on the UHF scanners located at the UM (7 and 9.4 Tesla), subsequent data analysis and/or implementation of computer algorithms relevant to one the lecture topics guided by tutors. Furthermore, the residential part is combined with a preparatory reading phase and post-module marked assignments.
Grading
Passing the module requires an 85% attendance to the lectures and practical sessions, and a satisfactory completion of the practical sessions and the module assignments. The module assignments will be summarised by the students in a written form which will be evaluated by the module coordinator(s).