1. USE OF MRI IN EVALUATING LIVER IRON LOADING (AND MONITORING THERAPY)
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2. Outline Introduction to iron and liver iron overload
Key methods for assessing liver iron
liver biopsy SF
SQUID
liver MRI
SIR method
relaxometry methods (R2 and R2*)
Clinical recommendations for measuring LIC
Summary
LIC = liver iron concentration; MRI = magnetic resonance imaging;
SF = serum ferritin; SIR = signal intensity ratio;
SQUID = superconducting quantum interface device.

3. Introduction to iron and iron overload

4. Iron overload
Iron overload is common in patients who require intermittent or regular blood transfusions to treat anaemia and associated conditions
it may be exacerbated in some conditions by excess gastrointestinal absorption of iron
Iron overload can lead to considerable morbidity and mortality1
Excess iron is deposited in major organs, resulting in organ damage
the organs that are at risk of damage due to iron overload include the liver, heart, pancreas, thyroid, pituitary gland, and other endocrine organs2,3
1Ladis V, et al. Ann NY Acad Sci. 2005;1054: Gabutti V, Piga A. Acta Haematol. 1996;95: Olivieri NF. N Engl J Med. 1999;341:

5. Importance of analysing liver iron
A patient’s LIC is the best measure of total body iron stores
Knowing the liver iron concentration helps to predict the risk of hepatic and extra-hepatic complications1–4
1Batts KP. Mod Pathol. 2007;20:S Jensen PD, et al. Blood. 2003;101: Angelucci E, et al. Blood. 2002;100: Telfer PT, et al. Br J Haematol. 2000;110:971-7.

6. Importance of analysing liver iron (cont.)5 10 15 20 25
Mean LIC + SD over previous year prior to enrolment in EPIC trial (mg Fe/g dry wt)
LIC threshold of 7 mg Fe/g dry wt
All (n = 1,744)
TM (n = 937)
TI (n = 84)
SCD (n = 80)
All transfusion-dependent patients prior to study enrolment had moderate-to-severe hepatic iron loading
Cappellini MD, et al. Blood. 2008;112:[abstract 3880].

7. Overview of LIC correlations with other measurements
Hepatocellular
injury2 and
fibrosis3
Body iron
stores1
Cardiac
iron5
DFS4
DFS = disease-free survival.
1Angelucci E, et al. N Engl J Med. 2000;343: Jensen PD, et al. Blood. 2003;101: Angelucci E, et al. Blood. 2002;100: Telfer PT, et al. Br J Haematol. 2000;110: Noetzli LJ, et al. Blood. 2008;112:

8. LIC prediction of total body iron stores
Hereditary haemochromatosis1
β-TM2
Sample > 1 mg dry wt (n = 25)
50,000
40,000
30,000
20,000
10,000 5 10 15 20 25
300
250
200
150
100 50
r = 0.98
LIC (µg/g)
Body iron stores (mg/kg) 5 10 15 20 25
Iron removed (g)
LIC (mg Fe/g dry wt)
LIC is a reliable measure of total body iron stores in hereditary haemochromatosis and β-TM
BMT = bone marrow transplantation.
1Olynyk JK, et al. Am J Gastroenterol. 1998;93: Angelucci E, et al. N Engl J Med. 2000;343:
1. Angelucci E, Brittenham GM, McLaren CE, et al. Hepatic iron concentration and total body iron stores in thalassemia major. N Engl J Med. 2000;343:

9. Serum ferritin measurement alone underestimates the body iron load
 -TM
2,000
4,000
6,000
8,000
10,000
12,000
14,000
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
-TI
-TM
SF (g/L)
SF (g/L) 5 10 15 20 25 30 35 5 10 15 20 25 30 35 40 45 50
LIC (mg Fe/g dry wt)
LIC (mg Fe/g dry wt)
SF has almost no sensitivity or specificity for iron stores in thalassaemia intermedia
Origa R, et al. Haematologica. 2007;92:583-8.
Taher A, et al. Haematologica. 2008;93:

10. Assessing liver iron overload

11. Key methods for assessing liver iron
Liver biopsy  LIC
advantages and disadvantages
correlation of LIC with other measurements
SF concentration over time
correlation of SF levels with other measurements
SQUID
Liver MRI
relaxometry methods (T2 and T2*)
SIR method
Direct method
Indirect methods
Olivieri NF, Brittenham GM. Blood. 1997;89:

12. Liver biopsy

13. Technique for taking a percutaneous liver biopsy
Patient preparation: Blood tests are done shortly before the biopsy to check blood clotting time, to exclude risk of bleeding following the biopsy. The biopsy is commonly preceded by an ultrasound examination of the liver to determine the best and safest biopsy site
Liver biopsy
A tiny incision is made between the ribs, and a needle is inserted to reach the area of the liver where a tissue sample is taken. The procedure requires local anaesthesia
Step 1. The patient lies on his back, or his left side
Area where a tissue sample is taken from
Step 2. The place for the biopsy is cleaned with antiseptic and local anaesthesia is provided (s.c. on the right hand side)
Step 3. A special hollow needle is inserted into the liver, usually between the 2 lower ribs on the right hand side
Step 4. The patient must hold breath for 5-10 seconds when the needle is quickly pushed in and out. As the needle comes out it brings with it a small sample of liver tissue
Overall: The procedure is carried out by a qualified physician or surgeon in an outpatient care centre or hospital. It is fast (not longer than 5 min) and the patient is discharged shortly after
adam.com

14. Processing the liver biopsy sample
Gross histopathological examination
reveals presence of abnormal cells or liver tissue
used to determine presence and degree of cirrhosis and fibrosis
LIC measurement
by iron staining
by atomic absorption spectroscopy: the current gold standard!
Who does the test?
preparation of the samples might be by a trained technician
the analysis requires a qualified pathologist
Angelucci E, et al. Haematologica. 2008;93:
Image from:

15. LIC threshold (mol Fe/g dry wt)
Liver biopsy
Liver biopsy with iron measurement by atomic absorption spectroscopy is the gold standard for measuring LIC1
LIC threshold (mg Fe/g dry wt)2
LIC threshold (mol Fe/g dry wt)
Clinical relevance
1.8 32
Upper 95% of normal
 15.0
269
Greatly increased risk of cardiac disease and early death
1Angelucci E, et al. Haematologica. 2008;93: St Pierre TG, et al. Blood. 2005;105:

16. Liver biopsy: pros and cons
Direct measurement of LIC
Validated reference standard
Quantitative, specific, and sensitive
Allows for measurement of non-haem storage iron
Provides information on liver histology/pathology
Correlates with morbidity and mortality
Invasive and painful procedure with risk of potentially serious complications1
May involve sampling errors, especially in patients with cirrhosis1
Requires skilled physicians1
Laboratory techniques not standardized1
iron measurement by atomic absorption spectroscopy2 or chemical determination3
wet or dry weight quoted
iron concentration varies throughout the liver,4 sample size often insufficient (requires ≥ 1 mg dry weight, or > 4 mg wet weight)
1TIF. Guidelines for the Clinical Management of Thalassemia. 2nd rev. ed. Cyprus: TIF; Available from:
Accessed December Angelucci E, et al. Haematologica. 2008;93: Wood JC. Blood Rev. 2008;22 Suppl 2:S Ambu R, et al. J Hepatol. 1995;23:544-9.

17. Heterogeneity of iron concentration throughout the liver
0–20%
20–40%
40–60%
60–80%
80–100%
Iron is unevenly distributed in the liver; therefore, a small sample may not give an absolutely representative mean LIC
From autopsy of a patient with beta-zero-thalassaemia.
Ambu R, et al. J Hepatol. 1995;23:544-9.

18. SF Concentration

19. SF > 1,000 µg/L is a marker of excess body iron
Ferritin and SF
Ferritin is primarily an intracellular protein that
stores iron in a form readily accessible to cells
releases iron in a controlled fashion
The molecule is shaped like a hollow sphere and it stores ferric (Fe3+) iron in its central cavity
the storage capacity of ferritin is approximately 4,500 Fe3+ ions per molecule
Ferritin is found in all tissues, though primarily in the liver, spleen, and bone marrow
A small amount is also found in the blood as serum ferritin
SF > 1,000 µg/L is a marker of excess body iron
Harrison PM, Arosio P. Biochim Biophys Acta. 1996;1275:

20. SF: pros and cons SF levels from a blood sample are measured Pros Cons
Easy to assess
Inexpensive
Positive correlation with morbidity and mortality
Allows longitudinal follow-up of patients
Indirect measurement of iron burden
Fluctuates in response to inflammation, abnormal liver function, ascorbate deficiencies
TIF. Guidelines for the Clinical Management of Thalassaemia. 2nd rev. ed. Cyprus: TIF; Available from:
Accessed December 2010.

21. SQUID

22. SQUID: superconducting quantum interference device
Principle of the technique: Normal tissue is diamagnetic and has a magnetic susceptibility similar to that of water. In the presence of iron, tissue susceptibility is changed proportional to the amount of iron present. This alteration is detected, allowing non-invasive measurement of LIC
Magnetizing coil
Dewar
Liquid helium
SQUID
Pick to coil
Water bag
Patient
Mattress
Bed
Piston
H2O
Patient preparation: No special patient preparation is required. Ultrasound is used to evaluate the depth and size of the liver. The patient lies on their back with their torso surrounded by a 5-L water bag to minimize contributions from other tissues
Step 1. The susceptometer applies a low-power (114 T and 7.7 Hz) homogeneous magnetizing field in the hepatic region. Sensitive detectors measure the interference of tissue iron vs the water reference medium within the field
Step 2. LIC corresponds to the variation of magnetization detected and is calculated using custom-made Matlab 6.5 software
Overall: The procedure is carried out by a qualified radiologist in a hospital. It is fast (not longer than 5 min) and the patient is discharged immediately after. Processing could be done on the spot and is faster then LIC histopathological examination
Carneiro AA, et al. Reson Med. 2005;43:122-8.

23. Hepatic iron (magnetic) (mol Fe/g wet wt)
SQUID: pros and cons
Pros
Cons
Non-invasive1
Wide linear range1
Good correlation with LIC by biopsy2
Requires expensive, specialized equipment and expertise1
Not widely available1
Each machine should be individually calibrated1
SQUID can underestimate LIC3
250
200
150
100 50
Hepatic iron (magnetic) (mol Fe/g wet wt)
Hepatic iron (biopsy)
(mol Fe/g wet wt)
R = 0.99
p < 0.001
SQUID is a non-invasive method that has been calibrated, validated, and used in clinical studies, but the complexity, cost and technical demands limit its use
1TIF. Guidelines for the Clinical Management of Thalassaemia. 2nd rev. ed. Cyprus: TIF; Available from:
Accessed December Sheth S. Pediatr Radiol. 2003;33: Piga A, et al. Blood. 2005;106:[abstract 2689].

24. Liver MRI

25. MRI
Principle of the technique: A strong magnetic field is used to organize the protons in the tissue in 1 direction. Then radiofrequency is used to “knock” them off. The time for them to re-align with the magnetic field and the energy they release during the process depend on the interactions of the proton with other ions, notably iron ions. These events could be measured at various TEs and then analysed to reveal the iron content in the tissue
Main magnet coils
x,y,z gradient coils
Patient preparation: All infusion and medication pumps should be removed. The scan does not require contrast agent, and so no peripheral vein access is needed
Integral radiofrequency transmitter (body) coil
Step 1. Image acquisition: Images are taken at various TEs
Patient table
Step 2. Post-processing: As TE increases, the image’s SI decreases. The relationship between TE and SI in a selected part of the image (i.e. ROI) is analysed with specialized software or manually. Data are reported as relaxation times (T2 or T2*), depending on the acquisition method
T1 - LONGITUDINAL RELAXATION TIME - determines the rate at which excited protons return to equilibrium within the lattice. A measure of the time taken for spinning protons to re-align with the external magnetic field. The magnetization will grow after excitation from zero to a value of about 63% of its final value in a time of T1.
T2 - spin-spin or transverse relaxation time. The time constant for loss of phase coherence among spins oriented at an angle to the static magnetic field due to interactions between the spins. Results in a loss of transverse magnetization and the MRI signal.
T2* ("T-two-star") - the time constant for loss of phase coherence among spins oriented at an angle to the static magnetic field due to a combination of magnetic field inhomogeneities and the spin-spin relaxation. Results in a rapid loss of transverse magnetization and the MRI signal.T2* < T2.
TE (Echo Time) - represents the time in milliseconds between the application of the 90° pulse and the peak of the echo signal in Spin Echo and Inversion Recovery pulse sequences.
Main magnet coils
Overall: The procedure is carried out by a qualified radiologist in a hospital. Acquisition is fast (approx. 5 min), and the patient is discharged immediately after. Processing may require specialized software and is done afterwards
ROI = region of interest; SI = signal intensity; TE = echo time.
Brittenham GM, Badman DG. Blood. 2003;101:15-9. Ridgway JP. J Cardiovasc Magn Reson. 2010;12:71.

26. MRI is increasingly being used as a non-invasive method to measure LIC
Pros
Cons
Non-invasive1,2
Assesses iron content throughout the liver2
Increasingly and widely available worldwide2
Pathological status of liver and heart can be assessed in parallel2
Validated relationship with biopsy LIC3‒6
Indirect measurement of LIC2
Requires MRI with dedicated imaging method2
Sensitivity depends on type of scanner, degree of iron overload, presence of fibrosis, and inflammation7
1Chavhan GB, et al. Radiographics. 2009;29: TIF. Guidelines for the Clinical Management of Thalassaemia. 2nd rev. ed. Cyprus: TIF; Available from: revised_edition_EN.pdf. Accessed December Christoforidis A, et al. Eur J Haematol. 2009;82: St Pierre TG, et al. Blood. 2005;105: Wood JC, et al. Blood. 2005;106: Hankins JS, et al. Blood. 2009;113: Sirlin CB, Reeder SB. Magn Reson Imaging Clin N Am. 2010;18:

27. MRI scanners Manufacturers
Siemens Healthcare (Erlangen, Germany;
GE Healthcare (Milwaukee, WI, USA;
Philips Healthcare (Best, the Netherlands;
Magnetic field strength
most imaging is done on 1.5 T machines
3 T machines give
better signal:noise ratio1
worse susceptibility artefacts1
The upper detection limit is halved, therefore it is too low for many patients1
lower T2 and T2* values than 1.5 T machines2
Liver package (including standard sequences and analysis of the data) is included in the software provided together with the MRI machine
specialized LIC analysis software can be bought separately
1Wood JC, Ghugre N. Hemoglobin. 2008;32: Storey P, et al. J Magn Reson Imaging. 2007;25:540-7.

28. Overview of MRI techniques used to measure LIC
DATA ACQUISITION
DATA ANALYSIS
MAJOR PROS AND CONS
A combination of
gradient and spin
echos
Free website
Fast acquisition Simple data analysis
Limited sensitivity Reproducibility
Gradient echo (same technique as cardiac iron measurement) (1 min)
Manually (free xls sheet) or with dedicated software (e.g CMR tool 3,000 GBP per year)
Fast acquisition Correlates well with LIC
Susceptible to artefacts Training needs
Spin echo (15min)
Done centrally by Resonance Health (300 USD per scan)
Gold Standard Little training need
Longer data acquisition time Cost of analysis
Signal Intensity Ratio (SIR) method (Gandon/Ernst)
Liver MRI Technique
R2*(T2*)
Relaxometry method
R2(T2)
(Ferriscan®)

29. MRI measurement of LIC: techniques
There are 2 broad groups of techniques
SIR methods (Gandon et al. methods)
relaxometry methods (FerriScan® and T2* (R2*) methods)
Pros
Cons
SIR
method
Fast data acquisition
Relatively simple algorithms and data analysis
Can be used in scanners with different magnetic strengths (0.5, 1.0, 1.5 T)
Limited range of sensitivity (upper limit is 21 mg Fe/g dry wt [380 mol/L])
Assumptions on reference tissue
Not reliable in cirrhosis
Smaller reproducibility
Relaxometry method
Greater range of sensitivity
Does not rely on reference tissue assumptions
T2* (or R2*) is very quick (requires a single breath-hold)
Has only been calibrated at 1.5 T
Takes longer to acquire data, when done as T2 (or R2)
Argyropoulou MI, Astrakas L. Pediatr Radiol. 2007;37: Gandon Y, et al. Lancet. 2004;363: St Pierre TG, et al. Ann N Y Acad Sci. 2005;1054: Wood JC. Curr Opin Hematol. 2007;14: Wood JC, et al. Blood. 2005;106:

30. (depends on experience)
SIR methods
1. Patient preparation
(5 min)
2. Image acquisition
(approx min)
3. Data analysis
(depends on experience)
Most common protocol includes
4-gradient echo sequences with different TEs
1 spin-echo sequence
100
300
400
200
Study group
Validation group
MRI LIC (µmol Fe/g dry wt)
100
200
400
300
Biopsy LIC (µmol Fe/g dry wt)
Gandon Y, et al. Lancet. 2004;363:

31. SIR methods (cont.)
1. Patient preparation
(5 min)
2. Image acquisition
(approx min)
3. Data analysis
(relatively fast)
The ROI is selected in the liver and the reference tissue (muscle or fat), in each image
The SI of the liver region is divided by that of the reference tissue
A calculation algorithm to assist has been developed for 0.5, 1.0, and 1.5 T MRI machines1
1Gandon Y. Available from: Accessed December 2010.

32. Relaxometry methods: T2, T2*, T2′, R2, and R2*
If a spin-echo sequence is used, the relaxation time is T2
If a gradient-echo sequence is used, it is T2*
These are related by the equation1
1/T2* = 1/T2 + 1/T2′
T2′ is the magnetic field inhomogeneity of the tissue
To attain a positive linear relationship with HIC
T2* can be transformed into reciprocal R2*: R2* [Hz] = 1,000/T2* [ms]
T2 can be transformed into reciprocal R2: R2 [Hz] = 1,000/T2 [ms]
1Anderson LJ, et al. Eur Heart J. 2001;22: Wood JC, Ghugre N. Hemoglobin. 2008;32:85-96.

33. Relaxometry methods: R2 and R2*
Several pulse sequences are included in the MRI software package
Parameters
R2 (for FerriScan®) spin echo sequence
T2* (and R2*) gradient echo sequence
FOV (mm)
300 x 225
350 x 300
Matrix (lines)
256 x 176
128 x 80
Resolution (mm)
1.17 x 1.28 x 5.0
2.73 x 3.75 x 10.0
TR (ms)
2500
200
TE (ms)
6, 9, 12, 15, 18
Minimum possible (ideally < 2.0 ms)
NEX (n) 1
Flip angle (°) 90 20
BW (Hz/px)
300
1,950
Segments (n) – 8
FatSat On
Wood JC, Ghugre N. Hemoglobin. 2008;32:85-96.

34. Correlation between R2-estimated LIC and LIC by biopsy
R2-LIC calibration curve by Wood et al
R2-LIC calibration curve by St Pierre et al
300
250
200
150
100 50
350
300
250
200
R2 (Hz)
Mean R2 (Hz)
150
-thalassaemia/Hb E
100
LIC by biopsy, R = 0.98
-thalassaemia
Hepatitis
Linear fit using biopsy data 50
Hereditary haemochromatosis
Controls, LIC by norms alone 10 20 30 40 50 60 10 20 30 40
Biopsy LIC (mg Fe/g dry wt)
Biopsy LIC (mg Fe/g dry wt)
1Wood JC, et al. Blood. 2005;106: St Pierre TG, et al. Blood. 2005;105:

35. Correlation between R2*-estimated LIC and LIC by biopsy
R2*-LIC calibration curve by Wood et al.1
R2*-LIC calibration curve by Hankins et al.2
Patients
Controls
Fit
200
400
600
800
1,000
1,200
1,400
1,600
1,800
2,000 30 25 20 15 10 5
Correlation coefficient = 0.98
p < 0.001
R2* (Hz)
LIC (mg Fe/g dry wt)
R = 0.97 10 20 30 40 50 60
200
400
600
800
1000
Biopsy LIC (mg Fe/g dry wt)
R2*MRI (Hz)
1Wood JC, et al. Blood. 2005;106: Hankins JS, et al. Blood. 2009;113:

36. LIC estimated with R2 and R2* MRI correlate well with each other10 20 30 40 50
Estimated HIC (mg/dry) by R2-SP
Patient data
Linear fit, R=0.94
Estimated HIC (mg/dry) by R2*
Wood JC, et al. Blood. 2005;106:

37. Gradient relaxometry (T2. , R2
Gradient relaxometry (T2*, R2*) can conveniently measure cardiac and liver iron
Cardiac MRI
Liver MRI 30 2 4 6 8 10 12 14
Hankins, et al. 25 20
Wood, et al.
HIC (mg Fe/g of dry weight liver) 15
[Fe] (mg/g dry wt) 10
Anderson, et al.
R2 = 5
100
200
300
400
200
400
600
800
1000
Cardiac R2* (Hz)
Liver R2* (Hz)
Cardiac and liver iron can be assessed together conveniently by gradient echo during a single MRI measurement.
HIC = hepatic iron concentration
Carpenter JP, et al. J Cardiovasc Magn Reson. 2009;11 Suppl 1:P224. Hankins et al Blood. 2009;113:

38. Relaxometry methods: pros and cons
Correlate well to biopsy LIC1–4
Greater sensitivity to iron deposits5
Faster (images can be obtained in a single breath-hold) and easier6
Can perform cardiac and liver iron assessment at the same time
More susceptible to artefacts
Requires expert training of a technician/ radiologist for data acquisition and data analysis
R2 (Ferriscan®)
Less affected by susceptibility artefacts6
Highly sensitive and specific over a large range of LIC, including patients with severe haemosiderosis7
The gold standard method in clinical trials
Requires no training for data analysis (done centralized by Resonance Health)
Multiple breath-holds required which increases MRI time
Cost of analysis (300 USD per scan)
1Christoforidis A, et al. Eur J Haematol. 2009;82: St Pierre TG, et al. Blood. 2005;105: Wood JC, et al. Blood. 2005;106: Hankins JS, et al. Blood. 2009;113: Anderson LJ, et al. Eur Heart J. 2001;22: Wood JC, Ghugre N. Hemoglobin. 2008;32: Papakonstantinou, O, et al. J Magn Reson Imaging. 2009;29:853-9.

39. Relaxometry methods: R2 and R2* (cont.)
1. Patient preparation
(5 min)
2. Image acquisition
(approx min)
3. Data analysis
(depends on experience)
Correct position is important so that the LIC across the whole liver can be measured
Images are taken at various TEs
Red line indicates correct position of the slice

40. Liver R2* MRI Liver with normal iron levels
TE=1.3ms
TE=3.6ms
TE=7.1ms
T2* = 15.7 ms or R2* = 63.7 Hz or LIC = 1.3mg/g
Liver with severe iron overload
TE=1.3ms
TE=3.6ms
TE=7.1ms
T2* = 1.1 ms or R2* = 909 Hz or LIC = 25.0 mg/g
Images courtesy of Dr J. de Lara Fernandes.

41. FAQ: artefacts How frequent are artefacts in liver MRI?
In contrast to cardiac MRI, the risk for motion artefacts (e.g. due to breathing) or susceptibility artefacts is much lower when performing liver MRI. As in cardiac MRI, if artefacts are present and too severe, scans may have to be repeated
How can I avoid artefacts when assessing LIC by MRI?
When assessing LIC, one thing that is really important is to use fat saturation (usually automatically included in all the sequences). This is especially important if a patient has steatosis (e.g. adults with haemochromatosis)
Questions and answers were prepared under the review of Dr J. de Lara Fernandes, University of Campinas, Brazil.

42. Relaxometry methods: R2 and R2* (cont.)
1. Patient preparation
(5 min)
2. Image acquisition
(approx min)
3. Data analysis
(depends on experience)
Determine ROI
entire liver boundary, excluding obvious hilar vessels1
Slice thickness
varies, generally 5–15 mm1–4
Number of slices
anything from about 1 to 20 slices can be studied1–4
Red outline shows position of ROI
1Wood JC, et al. Blood. 2005;106: St Pierre TG, et al. Blood. 2005;105:
3Papakonstantinou O, et al. J Magn Reson Imaging. 2009;29: Hankins JS, et al. Blood. 2009;113:

43. Relaxometry methods: R2 and R2* (cont.)
1. Patient preparation
(5 min)
2. Image acquisition
(approx min)
3. Data analysis
(depends on experience)
As TE increases, SI should decrease
When plotted on a graph
as iron load increases, the curve gets steeper
T2 or T2* can be calculated from the curve
R2 and R2* can also be calculated
Calculations are done
manually, or
by specific licensed software (e.g. CMRtools®), or
images could be directly sent to a validated centre performing FerriScan® for analysis
100 80 60 40 20 15 5 10 SI
TE (ms)
Typical non-iron-loaded tissue
Increasing iron loading

44. Analysis of the data
The data can be analysed manually or using post-processing software
Manually
Post-processing software
Excel spreadsheet
ThalassaemiaTools (CMRtools)
cmr42
FerriScan
MRmap
MATLAB

45. Analysis of the data (cont.)
Method
Pros
Cons
Excel spreadsheet
Low cost
Time-consuming
Tedious
ThalassaemiaTools (CMRtools)1
Fast (1 min)2
Easy to use
FDA approved
GBP 3,000 per year
cmr42(3)
FDA approved3
Can generate T2*/R2* and T2/R2 maps with same software
Allows different forms of analysis
Generates pixel-wise fitting with colour maps
40,000 USD first year costs
12,000 USD per year after
FDA = Food and Drug Administration.
1www.cmrtools.com/cmrweb/ThalassaemiaToolsIntroduction.htm. Accessed Dec 2010.
2Pennell DJ. JACC Cardiovasc Imaging. 2008;1:
3www.circlecvi.com. Accessed Dec 2010.

46. Analysis of the data (cont.)
Method
Pros
Cons
FerriScan1
Centralized analysis of locally acquired data (206 active sites across 25 countries)
Easy set-up on most MRI machines
EU approved
Validated on GE, Philips, and Siemens scanners
USD 300 per scan
Patients data are sent to reference centre
MRmap2
Uses IDL runtime, which is a commercial software (less expensive than cmr42/CMRtools)
Can quantify T1 and T2 map with the same software
Purely a research tool
Not intended for diagnostic or clinical use
MATLAB3
Low cost
Available only locally
Physicists or engineers need to write a MATLAB program for display and T2* measurement
1www.resonancehealth.com/resonance/ferriscan. Accessed Dec 2010.
2www.cmr-berlin.org/forschung/mrmapengl/index.html. Accessed Dec 2010.
3Wood JC, Noetzli L. Ann N Y Acad Sci. 2010;1202:173-9.

47. FAQ: mistakes in manual analysis of liver MRI data
What is truncation?
After the selection of the ROI, the signal decay can be fitted using different models. In the truncation model, the late points in the curve (the plateau) are subjectively discarded to obtain a curve with an R2 > A new single exponential curve is made by fitting the remaining signals.
What is the most frequent mistake made when interpreting the data from an MRI scan?
Interpreting a liver MRI is more challenging than for a cardiac MRI, especially in patients with severe liver iron overload. Correcting the data using truncation analysis is very important (done automatically by some software). The example (see following slide) clearly shows what happens, if the truncation is not done correctly
Questions and answers were prepared under the review of Dr J. de Lara Fernandes, University of Campinas, Brazil.

48. FAQ: mistakes in manual analysis of liver MRI data (cont.)
Analysis without truncation of the data
Analysis with truncation of the data
Non-truncated analysis with results with a poor R2 (< 0.995). The apparent LIC of 4.65 suggests mild LICs. Observe the flat plateau of the data points after a TE of 3.62 ms
The same patient, but analysing the data with only the 3 first data points results in a better (although not perfect) R2. The LIC results in severe iron overload, reflecting the real concentrations of iron

49. FAQ: how to start measuring liver iron loading?
How to start measuring liver iron loading in a hospital? What steps need to be taken?
To start assessing liver iron loading by MRI, these steps can be followed
Check MRI machine requirements
0.5–1.5 T (1.5 T is highly recommended for T2* and T2 calculations; 0.5 T only for SIR)
calibrated
includes a liver package
Optional: buy software for analysing the data (otherwise, Excel spreadsheet can be used)
Optional: training of personnel for acquiring MRI images
Optional: training of personnel on how to analyse the data
Questions and answers were prepared under the review of Dr J. de Lara Fernandes, University of Campinas, Brazil.

50. LIC: interpretation of results
LIC threshold values for classification of iron overload
Iron levels
LIC (mg Fe per g dry weight)
LIC (µmol Fe per g dry wt)
R2 (s−1)†
R2* (s−1)
T2* (ms)
Normal
< 2
< 35.6
< 50
< 88
> 11.4
Mild overload
≥ 2−7
≥ 35.6 − 125.0
≥ 50 – 100
≥ 88 – 263
> 3.8 – 11.4
Moderate overload
≥ 7−15
≥ 125 − 269
≥ 100 – 155
≥ 263 – 555
> 1.8 – 3.8
Severe overload
≥ 15
≥ 269
≥ 155
≥ 555
≤ 1.8
†Values estimated based on R2 LIC calibration curve; R2, R2* and T2* values valid for MRI machines with 1.5T only.
St Pierre TG, et al. Blood 2005;105:855–861; Wood JC, et al. Blood 2005;106:1460–1465.

51. Implementation of liver and cardiac MRI
1.5T MRI Scanner
US$
Yes
½ day training
Liver
Analysis
Experienced radiologist No
1 day training
Post-processing analysis
US$ or US$4.000/y
or in-house or outsource
Cardiac acquisition package
US$50.000
Yes
1-2 day training
Heart
Analysis
Routine cardiac MR exams No
4 day training
Slide presented at Global Iron Summit With the permission of Juliano de Lara Fernandes

52. Summary

53. Summary
Iron overload is a serious problem among patients who require blood transfusions to treat anaemia and associated conditions
Analysing liver iron overload is important
to predict risk of hepatic and extra-hepatic complications
The extent of iron accumulation in the liver is a key prognostic indicator for morbidity and mortality
MRI has the added advantage that iron levels throughout the liver can be analysed, rather than just the biopsied section (iron levels throughout the liver can vary)
R2 is the most commonly used technique in clinical practice, although R2* is a comparable alternative across most ranges of iron overload and is faster

54. GLOSSARY OF TERMS

55. GLOSSARY AML = acute myeloid leukemia APFR = Atrialp peak filling rate
BA = basilar artery
ß-TM = Beta Thalassemia Major
ß-TI = Beta Thalassemia Intermedia
BM = bone marrow
BTM = bone marrow transplantation
BW = bandwidth
CFU = colony-forming unit
CMML = chronic myelomonocytic leukemia
CT2 = cardiac T2*.
DAPI = 4',6-diamidino-2-phenylindole
References
Kassab MY et al. J Am Board Fam Med 2007;20:65–71.
Krejza J et al. AJR Am J Roentgenol 2000;174:1297–1303.

56. GLOSSARY DFS = = disease-free survival. DysE = dyserythropoiesis
ECG = electrocardiography
EDV = end-diastolic velocity
EF = ejection fraction
EPFR = early peak filling rate
FatSat = fat saturation
FAQ = frequently asked questions
FDA = Food and Drug Administration
FISH = fluorescence in situ hybridization.
FOV = field of view
GBP = Currency, pound sterling (£)

57. GLOSSARY Hb = hemoglobin HbE = hemoglobin E HbF = fetal hemoglobin
HbS = sickle cell hemoglobin.
HbSS = sickle cell anemia.
HIC = hepatic iron concentration
HU = hydroxyurea
ICA = internal carotid artery.
ICT = iron chelation therapy
IDL = interface description language
IPSS = International Prognostic Scoring System
iso = isochromosome

58. GLOSSARY LIC = liver iron concentration
LVEF = left-ventricular ejection fraction
MCA = middle cerebral artery
MDS = Myelodysplastic syndromes
MDS-U = myelodysplastic syndrome, unclassified
MRA = magnetic resonance angiography
MRI = magnetic resonance imaging
MV = mean velocity.
N = neutropenia
NEX = number of excitations
NIH = National Institute of Health
OS = overall survival

59. GLOSSARY pB = peripheral blood PI = pulsatility index
PSV = peak systolic Velocity
RA =refractory anemia
RAEB = refractory anemia with excess blasts
RAEB -T = refractory anemia with excess blasts in transformation
RARS = refractory anemia with ringed sideroblasts
RBC = red blood cells
RF = radio-frequency
RCMD = refractory cytopenia with multilineage dysplasia
RCMD-RS = refractory cytopenia with multilineage dysplasia with ringed sideroblasts
RCUD = refractory cytopenia with unilineage dysplasia

60. GLOSSARY RN = refractory neutropenia ROI = region of interest
RT = refractory thrombocytopenia
SCD = sickle cell disease
SD = standard deviation
SI = signal intensity
SIR = signal intensity ratio
SF = serum ferritin
SNP-a = single-nucleotide polymorphism
SQUID = superconducting quantum interface device.
STOP = = Stroke Prevention Trial in Sickle Cell Anemia
STOP II = Optimizing Primary Stroke Prevention in Sickle Cell Anemia

61. GLOSSARY T = thrombocytopenia
TAMMV = time-averaged mean of the maximum velocity.
TCCS = transcranial colour-coded sonography
TCD = transcranial doppler ultrasonography
TCDI = duplex (imaging TCD)
TE = echo time
TR = repetition time
WHO = World Health Organization
WPSS = WHO classification-based Prognostic Scoring System