Head Robert Sigal, MD #{149} Olivier Lorraine G. Shapeero, MD Jean-Daniel Piekarski, MD

Monnet, #{149} Morebise #{149} Bernard

Adenoid Cystic Neck: Evaluation Clinical-Pathologic

a mean

period

of 6.3 years

(range of follow-up, 3 months to 17 years); all patients underwent one to seven MR examinations. On T2weighted images, lesions with low signal intensity corresponded to highly cellular tumors (solid sub-

type)

with

a poor

with high signal sponded to less

prognosis; intensity cellular

lesions

corretumors

(crib-

riform or tubular subtype) ter prognosis. MR images

with were

specific

of ACCs

in differentiation

from suit

other

types

of tumors;

underscores

to ensure

the

correct

need

a betnot

this

re-

for biopsy

diagnosis.

Local,

Index terms:

Adenoid

#{149} Magnetic

acterization,

cystic resonance

23.3751,

264.3751,

nasal gland,

carcinoma, (MR),

264.379

tissue

1992;

184:95-101

char-

#{149} Para-

sinuses, neoplasms, 23.3751 #{149} Parotid neoplasms, 264.379 . Salivary glands, MR, 264.1214 #{149} Salivary glands, neoplasms, 264.379

Radiology

#{149} Jacques

cystic

DENOID

Masselot,

nate

carcinomas

are malignant in the major

glands.

MD

Billroth

that origisalivary

(1) first

de-

scribed these tumors and named them cyhmndroma, a benign tumor, these neoplasms were subsequently shown to recur insidiously, often many years, with eventual death the patients. The most common means of extension of these neoplasms is by local and intracranial

filtration, sheaths

particularly (2).

Among

logic

(ACCs)

tumors and minor

In 1859,

along tumors

but over of

of the

from

form:

The

worse

the

the

greater prognosis

tubular

the

to the

cellularity, (3).

solid

However,

examine

only

a single

biopsy

specimen. Whenever the entire tumor en bloc is available, staging becomes accurate but nevertheless exacting and time-consuming. Magnetic resonance (MR) imaging depicts the lesion and its extensions in their entirety. Moreover, on T2weighted images, the signal intensity of a tumor depends on the degree of cellularity and the water content, and T2 signal intensity has been proposed as a potential predictive factor of bio-

PATIENTS proved

the

Departments

of Radiology (R.S., T.d.B., LG.S., DV., J.M.) Pathology (CM., J.B.), and (M.J., B.L.), Institut Gustave Roussy, Rue Camille Desmoulins, F-94805 Villejuif, France; Department of Neuroradiology, H#{244}pitalBic#{234}tre,Le Kremlin Bic#{234}tre,France (O.M.); Department of Radiology, University of California Medical Center, San Francisco (L.G.S.); and Department of Radiology, Fondation Rothschild, Paris (J.D.P). From the 1991 RSNA scientific assembly. Received August 1, 1991; revision requested August 28; final revision received January 14, 1992; accepted February 3. Address reprint requests to R.S. 4, RSNA, 1992 See also the editorial by Yousem (pp 25-26) and the article by Meyers et al (pp 103-108) in this issue.

and Neck Surgery

of 40 patients

years [mean findings on this

patients (15 aged 16-82

age, 50 years]) with positive MR images were included

study.

cluded tumor

with

examination

were reviewed. Twenty-seven male and 12 female patients,

Thirteen

patients

were

in

ex-

had no evidence of The tumors were located in the infratemporal fossa (n = 6), parapharyngeal space (n = 4), palate (n = 4), parotid gland (n = 4) (with extension to the internal auditory canal [n = 2]), ethmoid sinus (n = 3), maxillary sinus (n 3), nasal cavity (n = 2), and retropharyngeal space (n = 1). Clinical follow-up

because they at MR imaging.

=

was

obtained

over

a mean

period

of 6.3

years (range of follow-up, 3 months to 17 years). Twenty-three patients underwent surgery and external radiation therapy.

Three

patients

intraorbital

with

intracranial

and/or

underwent

radia-

extension

tion therapy went surgery All patients

only, and only. underwent

examinations

(total,

one

patient one

56 MR

under-

to seven

MR

examinations).

In eight patients, MR imaging was performed during initial workup, whereas in the 19 other patients the first MR study was performed imaging was

dual From

usefulness

METHODS

at histologic

GE

for tumor recurrence. performed on a 1.5-T

Medical

MR images I

We there-

the

AND

The case histories ACC

(Signa;

Head

(6-9).

to study

of MR imaging for establishment of the prognosis of adenoid cystic carcinomas. We present the MR imaging features in 27 patients with ACCs proved at histologic examination that were evaluated in a retrospective MR imaging, histopathologic, and clinical study.

sali-

every specimen has mixed patterns and histologic grades; therefore, staging can be difficult whenever pathologists

decided

in-

the

aggressiveness

fore

nerve

vary glands, ACCs constitute a separate type because several authors have found a correlation between the morphologic characteristics of the tumor and the patient’s prognosis (3-5). Three main histologic patterns have been described: tubular, cribriform, and solid. The degree of cellularity increases

intracranial, osseous, and perineural invasion was depicted, but because of its lack of specificity, MR imaging caused overdiagnosis of tumor extension, particularly perineural spread and bone abnormalities.

264.379

Radiology

Carcinoma ofthe Head and with MR Imaging and Correlation In 27 Patients’

Twenty-seven adenoid cystic carcinomas (ACCs) of the head and neck in 27 patients were evaluated in a retrospective study based on findings at magnetic resonance (MR) imaging and pathologic and clinical examination. Clinical follow-up was obtained

over

MD

Neck

MD #{149} Christian Micheau, MD Bosq, MD #{149} Daniel Vanel, MD

MD #{149} Thierry de Baere, Julieron, MD #{149} Jacques

Luboinski,

and

Systems,

were

spin-echo

obtained

multisection,

imaging technique. Short tition time [TR] msec/echo msec = 600/20) and long (2,000/20,

Abbreviations: noma, TE

90)

=

echo

were

ACC time,

used

=

MR unit

Milwaukee).

by means

of the

multiplane sequences (repetime [TE] sequences in all patients.

adenoid cystic = repetition

TR

An

carcitime.

95

Table

1

Findings

on MR

Images

with

and Pathologic

Clinical

Findings

Location

of ACC

gland

4

Maxillary

5

Infratemporal

fossa

Low

6

Retropharyngeal

7 8

Infratemporal Palate

space fossa

Low High

9

Palate

+ + + + + + +

Low

Low

10

Maxillary

sinus

11 12 14

Nasalcavity Infratemporal Nasal cavity Parapharyngeal

15

Ethmoid

16 17 18 19

Infratemporal fossa Infratemporal fossa Parotid gland Ethmoid sinus

20

Infratemporal

21

Maxillary

22

Parapharyngeal

23

High

space

Pathologic

Clinical

Good

-

Good

-

Good

Good Good Good

+

Poor

Poor

Good Good Poor

+ +

Poor

Poor

Poor

Poor

Poor Poor Poor Poor

Poor Poor Poor Poor Intermediate Good Intermediate

Poor Poor Poor Intermediate

Good

-

Intermediate

-

Intermediate

-

Intermediate Intermediate

Good Good Good Intermediate Poor

+ +

Poor Poor

Poor

Intermediate

Intermediate

Poor Poor

Intermediate Intermediate

Poor Poor

Poor Poor Poor

Intermediate Poor Poor Poor

Poor Intermediate

Intermediate

+ + + + + + + + +

space

Intermediate

+ +

Poor

Poor

Good

Poor

Poor

Normal

space

Low Low

-

24

Ethmoid sinus Parapharyngeal

Poor

NA

Intermediate

25

Parapharyngeal

space

Intermediate

+ +

26

Parotid

gland

and

27

Parotid

gland

and

Poor Poor Poor

NA Poor Poor

Intermediate NA NAt

sinus

Low

Intermediate Intermediate

Intermediate Low Low

fossa

sinus

LAC IAC

=

t The

specimen

injection

of the

initial

of a gadolinium

parotid

acid

raazacyclododecanetetraacetic 0.1 mmoh/kg) was performed examinations thickness

was

Low Low

(12 patients). 5 mm, with

(dior tet-

acid) (dose, in 23 MR The

section

an intersection

gap of 1 mm. The acquisition matrix was either 256 x 256 or 192 x 256. All studies

were performed dicular imaging

with at least planes.

To compare MR

the respective

imaging,

and

establish decided groups

the prognosis to categorize of prognoses

mainly

to parallel

previously

two perpenhistopatho-

clinical

findings

to

in each patient, we the patients in three for each set of data,

three

described

prognostic

+ + + +

groups

in histopathologic

analyzed

with

of data: signal intensity of the tumor and tumor extension. For evaluation of signal intensity, the long TR/TE images (T2weighted sequences) were believed to contribute the most information because signal intensity parallels the degree of cel-

of the tumor.

However,

signal

in-

glandlike

spaces,

extension. Good prognosis was associated with tumor with signal intensity nearly as high as that of cerebrospinal fluid, with no tumor extension. Intermediate prognosis

nosis was cellularity.

attributed Whenever

was

24 of 27 patients, the mean interval between examination with MR imaging and pathologic biopsy was 49 days. In two of 27 patients, this interval was longer than 1

on

T2-weighted

images

associated

with

Poor prognosis mors

that

pattern

specimens

or solid

with

tumor

ment

of the facial bone

skull

base.

96 #{149} Radiology

extension

was

of four criteria: inintraorbital invasion, and osseous involve-

structures

and

(3).

of small,

little

mucinous

manner this

only

we

the cellularity

based

and

lumen

a

and

Bondi

(5).

of

before

In

are

interpretation. staging

and

the prog-

next

patients

category.

had

a

an

In

in-

on

were

not

of 27 patients

avail-

underwent

for longer

25 patients

were

than

placed

2

in

three prognostic groups according to the following criteria: (a) survival less than 5 years, (b) two or more recurrences of ACC, (c) metastasis, and/or (d) nerve palsies or Patients

with

of these

prognosis

The For

relapse,

examinations

These

none

the rela-

histologic

the

Twenty-five years.

on the

histologic

Three

of these

follow-up

tive proportion of tumoral cells and glandlike spaces by adapting the criteria of Santucci

present,

to the

dense pen-

able.

depends

of the lesion

was

lowered

One

paresis.

subjective

reason,

was

with and

of

prog-

years

however, all three patare interleaved in such

that diagnosis

to lesions osseous

infiltration

nosis

the worst

tubular

materials.

a few

neural

whereas

catego-

prognosis number

tubular

of cells

or hyalinized

for

The

inten-

central lumen. In the cribriform pattern, the most classical feature of ACC, nests tumor cells have a sievelike or “Swisscheese” appearance with spaces filled

with

used

of extension. classified tu-

one or more

slender

stratification

were

of 26 patients: The best associated with the greater

year.

inter-

signal

criteria were

tu-

of prognosis

tracranial relapse, but the specimen from the original parotid ACC removed 7 years before the relapse was examined. In one of 27 patients who had a purely intracranial relapse, the original specimens, removed 3

with

or high

two or more

consists

with

intensity,

intensity

cribriform,

units

signal

of extension,

with

bular,

low

signal

criteria

and no tu-

was associated

had

mediate

intensity

was

with

or (b) tumor with high sigand one criteria of extension.

pathologist’s

The

(a) tumor

signal

also

by means extension, spread,

either

rization

tumor

mor extension nal intensity

the solid pattern, seen. In most ACCs, terns coexist and

analyzed.

and

intermediate

tensity on the short TR/TE images (Tiweighted sequences), homogeneity of signal intensity on Ti- and T2-weighted images, and contrast enhancement after injection of gadolinium in the tumor were assessed tracranial perineural

prognosis.

sity

sity

two sets

Good

classes

Histologic

were

with a good

Good

The three classes of prognoses established with MR imaging were based on the two previous sets of data: signal inten-

(3,4).

MR images

Poor

NA = not applicable, T2-weighted = long TR/TE. of extension, + + = two or more criteria of extension. lesion sampled 7 years prior to this study was associated

compound

ethylenetriaminepentaacetic

lularity

Imaging

-

Intermediate Intermediate Intermediate High

fossa

Note.-IAC = internal auditory canal, * no extension, + = one criterion

studies

Extension*

High High High Low

sinus

Neck

MR

Tumor

Parotid

Palate Palate

ACC of the Head and

with

Prognosis

1 2 3

13

logic,

in 27 Patients

Images

MR

Signal Intensity on T2-weighted Images

Patient No.

on

Correlation

poor

group

had

prognostic

two of these

good

criteria.

prognosis

had

The intermediate one

of these

group

had

criteria.

at least

criteria.

In 23 of 27 patients, MR imaging, histopathologic, and clinical data were correlated. Correlation between clinical findings

and

performed

findings

on

MR

in 25 patients.

images

was

The

MR signal

July

1992

b.

Figure

1.

ACC

of the left deep

parotid

examination. (a) Axial 600/20 MR image shows to that of muscles. The patient had previously mogeneous high signal intensity characteristics

ACC, which tumor cells.

has a Swiss-cheese (Hematoxylin-eosin

C.

lobe in a patient

with

a good

prognosis

based

on findings

at MR imaging

an ovoid lesion with regular margins (arrowheads). The signal undergone a partial parotidectomy (arrow). (b) Axial 2,000/100 of the tumor. (c) Photomicrograph of biopsy specimen shows

appearance. The glandlike stain; original magnification,

spaces, which x 100.)

contain

mucinous

and

hyalinized

I Figure

and

clinical

intensity MR image the classic

materials,

2

and

clearly

outnumber

ACC of the palate

prognosis

based

on

pathologic

of the lesion is similar demonstrates the hocribriform pattern of

with

findings

the

a poor

at MR

imaging

and clinical and pathologic examination. (a) Axial 600/20 MR image does not enable one to differentiate between tumor and inflammatory tissues. (b) Axial 2,000/100 MR image

reveals

a lesion

low signal intensity areas of high signal that

correspond

with

predominantly

(arrowhead), with focal intensity (straight arrow)

to necrosis,

edema,

or areas

with many glandlike spaces. Inflammatory secretions (curved arrow) are depicted as areas of high signal intensity. (c) Axial MR image

obtained

after

administration

of gado-

linium demonstrates an inhomogeneous enhancement of the lesion. (d) Photomicrograph of biopsy specimen shows the highly cellular, solid pattern of ACC, with interspersed areas stain; original

b.

sponding

fined

strength

with was

.00-20

of edema. magnification,

of agreement

the Landis rated

moderate;

.60,

(Hematoxylin-eosin x iOO.)

slight;

.61-80,

was

and Koch

de-

scale (10):

.21-40,

fair;

substantial;

.41-

and .81-

1.0, perfect.

RESULTS On MR images, ACCs appeared as poorly defined neoplasms with infiltrative margins in 23 patients (Table 1). The diameter was greater than 2 cm d.

lar data

intensity

the MR tumor were correlated tion

between

Volume

184

were

then

separated

from

extension data, and both with clinical data. Correlapathologic

findings

#{149} Number

1

and

din-

ical

in 21 patients.

weighted images, a homogeneous

findings

alone

was

performed

in 24

patients. To determine intertest agreement, a K test was applied in all cases. value of the K statistic with the corre-

The

to that

On

the

Ti-

all of the ACCs had signal intensity simi-

of muscles.

On

the

T2-

weighted images, six lesions were depicted with high signal intensity (Fig 1), nine lesions with intermediate signal intensity, and 12 lesions with low signal

intensity

(Fig

2). Among Radiology

the

21 #{149} 97

tumors

with

low

or intermediate

sig-

one patient, the biopsy specimens were negative for tumor. In 25 of 27 patients, clinical follow-up lasted longer than 24 months.

nal intensity on the T2-weighted images, 10 were homogeneous lesions; the i 1 others were heterogeneous lesions with areas of predominantly low or intermediate signal intensity, which were consistent with tumorous tissues, tensity,

either areas

Nine

with

of necrosis a greater

or edema number

was

third

patient

had

Clinical

of gland-

patients,

of the

medullary

cranial

than

nerve

developed of ACC

5 years

prognosis

pal-

patients.

good

in six

intermediate

on MR images and between

survival

in two

was

in five

patients,

poor in i4 patients. The prognoses established with MR imaging and histologic examination were correlated with the clinical prognosis

(Table

2). Correlation

prognosis.

superior

to correlation

pathologic (K

clinical findings alone Signal intensity on correlated better with din.56, P < .0001) than did

(K

findings

of tumor

extension

on

in four

prognoses images

between

.007).

Correlation

and =

clinical findings intensity on MR

and

was Three and

observed in patients six, a poor

discordance

patients

was

in whom

based on findings clinical findings

the

on MR were

poor, but either the prognosis based on pathologic findings was good

= .04).

MR images icah data

Complete

found

and

.27, P

and signal

related. Concordance nine patients (39%): had a good prognosis

between

on MR images and clinical alone (K = .42, P = .002) was

=

images and clinical findings, but the rest of the analyses showed only fair strength of agreement. In 23 of 27 patients, the three sets of data were cor-

and

findings findings

P

findings on MR images findings was fair (K

.3i, P = .01). Thus, according to the Landis and Koch scale (10), moderate agreement existed between findings

two and six

metastases;

.33,

=

(K

(n

=

3) or no

abnormal

tissue

was

found (n = I). In one of the patients who had ACC of the masticator space

MR

antegrade

extension of the tumor along the third extracranial portion of the facial nerve. Seventeen patients had bone abnormalities: enlargement of the foramen ovale (n = 4), focal defect in the cortical bone with low signal intensity (n = 4), and decreased signal intensity

lung

less

or

like spaces. On the T2-weighted images, differentiation between tumors with high signal intensity and inflammatory tissues was impossible in one patient with ACC of the maxillary sinus. In all other sinonasal ACCs, accurate distinction between inflammatory tissue and tumorous tissue was possible because the tumor appeared to have low signal intensity compared with that of inflammatory tissue. Gadolinium was injected in 23 patients, and a diffuse contrast enhancement was noted in the tumor in all of them. Perineural infiltration with nerve enlargement, contrast enhancement, or both was noted on MR images in nine patients. Six cases of retrograde and antegrade invasion of the trigeminal nerve were seen. The maxillary nerve (V3) was most often affected (Figs 3, 4). Invasion of the facial nerve was seen in three of the four patients with parotid ACC: Two patients had a retrograde extension of the tumor along the facial nerve that was confined to the internal auditory canal and the cerebellopontine angle (Fig 5). The

had

developed

and foci with high signal inwhich were consistent with

areas

patients

sies. Fifteen patients or more recurrences

images

between pathologic

bone

a.

b.

on

the Ti-weighted images (n = ii). Intracranial extension, intraorbital extension, or both were seen in eight cases. signal

The prognosis intensity and

based tumor

on data extension

of

on MR images was good in three patients, intermediate in five patients, and poor in i9 patients. Of the 26 available histologic specimens, seven had a low proportion of tumor cells with concomitant large glandlike spaces; 12 had a balanced proportion of tumoral nests and glandlike spaces; and six had a dense cellularity. Perineural spread occurred in six patients and bone extension in six patients. The prognosis at histopathologic examination was good in eight patients, intermediate in six patients, and poor in eleven patients. In 98 #{149} Radiology

d.

C.

Figure

3.

ACC

based

on

MR

lesion

with

low

vades

the

cavernous

with

imaging, signal

intracranial clinical,

and and

intensity

sinus

that

(arrow).

intraorbital

pathologic extends

(b) Sagittal

extension findings.

through

600/20

in a patient (a) Coronal

the

MR

600/20

foramen

ovale

image

confirms

with

a poor MR

image

(arrowhead)

extension

prognosis shows and

a in-

through

the foramen ovale (arrow) and displays intraorbital extension along the branches of the thalmic nerve (arrowheads). (c) Coronal 600/20 MR image reveals intraorbital extension. evidence of previous surgery in the palate, site of origin of the tumor (arrow). (d) Coronal 2,000/100 MR image, which corresponds to c, shows the low signal intensity characteristics the tumor.

July

ophNote of

1992

that invaded the skull base at presentation, examination of a biopsy specimen from the superficial part of the

gland found where

tumor

hignant common

revealed

a cribriform

ACC,

with a good prognosis. MR imaging revealed an invading tumor with markedly low signal intensity on the T2-weighted image (Fig 4). This patient died within i year of MR imaging. In another patient, the biopsy findings in a recurrence of a tumor of the ethmoid sinus were negative, but MR images showed evidence of relapse,

which

was

confirmed

at sur-

gery. DISCUSSION ACC

is a relatively

constitutes

4%-15%

rare

tumor

of all salivary

that

ACC

tumors (ii,i2). in the minor it constitutes neoplasms malignant

It is usually salivary glands, 25%-3i% of ma-

i5%

submandibular

of tumors

gland

of tumors

of the

(i2,15,i6).

It occurs

but

parotid

2%-6%

bones, years,

3rd

peat

gland

between

the

and the 9th decades of life, with a maximum incidence between ages 40 and 70 years (2). Clinical features at presentation (nasal obstruction, swelling,

and

and had

more than symptoms

facial

pain)

are

nonspecific,

50% of patients have for 1-5 years before

presentation (2,17). Paresthesia trigeminal nerve, particularly nals the onset of perineural Despite the relatively benign

the

of the V3. sigextension. histo-

slow

malignant and

lungs,

growth

course. distant

cervical

surgical

Repeat

metastases

lymph

excision

are

mean

the

and

however,

many Re-

radiation of choice.

rate

is 60%-69%

5 years and approximately years (4,i2,17,i8). Success

ment,

(to

nodes,

treatment

survival

of

carcire-

and liver [i4]) occur over finally killing the patient.

therapy

The

and

the natural history of this is characterized by a slow

recurrences

of the

only

appearance

ACC, noma lentlessly

and is the most tumor (13,14).

constitutes

logic

at

40% at iO of treat-

is never

certain

and

should be evaluated in terms of 15-20 years (4,12,15). Therefore, a follow-up of 6.3 years, as in our study, is relatively short. Many studies have addressed the prognosis of ACC. Different factors

have

been

prognosis: (3,4,11,18),

reported

to influence

primary site of the size of the neoplasm

the tumor (3,4),

bone and nerve invasion (4,15,19,20), quality of surgical margins (3,4), and clinical stage of disease (11,18). However, the factor that appears to be most closely correlated with the prognosis

of ACC

is its predominant

logic

pattern

(tubular,

histo-

cribriform,

solid) (3,11) and its degree ity, which increases from

or

of cellularthe tubular

to the solid form. The greater the cellularity, the worse the prognosis (4,5). The transformation of ACC from the

b.

d.

e.

Figure 4. ACC developed in the parapharyngeal mucosal space with intracranial extension in a patient with a poor prognosis based on findings at MR imaging and clinical examination and a good prognosis based on pathologic findings. (a) Coronal 600/20 MR image reveals a tumor with low signal intensity that invades the skull base with extension into the sphenoid sinus (curved arrow) and cavernous sinus (straight arrow). Note destruction of the greater wing of the sphenoid bone with decreased signal intensity of the medullary bone (arrowhead). (b) Coronal 2,000/100 MR image demonstrates the homogeneous low signal intensity characteristics of the lesion. (c) Axial 600/20 MR image obtained after administration of gadolinium shows contrast enhancement of the lesion with extension in the sphenoid sinus (curved arrow) and ethmoid sinus (straight solid arrow). The cavernous sinus is invaded with a retrograde extension along the cisternal portion of the trigeminal nerve (arrowhead) and an antegrade extension along V1 (open arrow). (d) Postgadolinium axial MR image, obtained 5 mm inferior to c, reveals invasion of the Meckel cavity (arrow) and antegrade extension along the infraorbital nerve (arrowhead). (e) Photomicrograph of biopsy specimen shows a cribriform ACC (arrowheads). It is apparent that this specimen was from a superficial part of the lesion because seromucinous glands (arrow) are present. (Hematoxylin-eosin stain; original magnification, x 100.)

Volume

184

#{149} Number

1

Radiology

#{149} 99

Figure

5. Intracranial recurrence of a paACC in which surgery had been performed 7 years before this study. The patient had a poor prognosis on the basis of findings at MR imaging and clinical examination. No biopsy was performed at MR imaging. (a) Coronal 600/20 MR image reveals invasion of the internal auditory canal (arrowhead) with spreading of the lesion in the cerebellopontine angle (arrow) and moderate mass effect on the pons. (b) On the coronal 2,000/100 image, the lesion is depicted with low signal intensity, which indicates a highly cellular lesion. (c) On the postgadolinium coronal 600/20 MR image, contrast enhancement is seen in the tumor and also along the origin of the trigeminal nerve (arrow). (d) A postgadolinium coronal 600/20 view, 15 mm more anterior than c, confirms invasion of the trigeminal nerve with invasion of the Meckel cavity (arrow) and mandibular nerve extending through the foramen ovale (arrowhead). rotid

tubular

pattern

nant

pattern,

thors

(3,5),

to the

solid

described suggests

b.

predomi-

by several

au-

tumor may represent a morphologic continuum demonstrated by histologic, ultrastructural, and immunohistochemical studies (5). Most tumors manifest

with mixed rate staging acting becomes

and

In our

this

patterns; therefore, of an entire tumor time-consuming, difficult in focal

study,

findings

ages appeared clinical findings findings (Table

enabled However,

that

a.

and biopsies.

better with pathologic MR images

of the entire we performed

d.

C.

it

on MR im-

to correlate than did 2) because

staging since

accuis ex-

Table

signal

intensity

correlated

tion

therapy,

signal

intensity

on MR

more

abundant

rosis at histologic It is impossible, 100

#{149} Radiology

than

fibrosis

examination. however,

and

scle-

on MR Imaging,

Data

Histologic,

Histologic

Data

I

P

G

I

P

3 3 0

0 1 4

0 1 13

3 1 3

0 2 4

0 2 9

4 2 0

0 4 1

2 2 10

5 1 0

1 2 2

1 6 7

I

4 2

P

0

0 1 4

3 1 7

I P Signal

intensityt

G I

P Tumor G I

...

...

...

...

...

...

. . .

. . .

...

...

...

...

...

...

...

...

...

...

extensiont

P Histologic1

G

Note-Numbers are number of patients. prognosis. * In the concordance with clinical data, .31,P= .01.

G = good K =

.42, P

prognosis, =

I

=

...

...

...

...

...

...

...

...

...

intermediate

.002; in the concordance

P

prognosis,

with

histologic

=

poor

data,

K =

tK.5f,P