The use of hyperpolarised (13)C-MRI in clinical body imaging to probe cancer metabolism

Metabolic reprogramming is one of the hallmarks of cancer and includes the Warburg effect, which is exhibited by many tumours. This can be exploited by positron emission tomography (PET) as part of routine clinical cancer imaging. However, an emerging and alternative method to detect altered metabolism is carbon-13 magnetic resonance imaging (MRI) following injection of hyperpolarised [1-(13)C]pyruvate. The technique increases the signal-to-noise ratio for the detection of hyperpolarised (13)C-labelled metabolites by several orders of magnitude and facilitates the dynamic, noninvasive imaging of the exchange of (13)C-pyruvate to (13)C-lactate over time. The method has produced promising preclinical results in the area of oncology and is currently being explored in human imaging studies. The first translational studies have demonstrated the safety and feasibility of the technique in patients with prostate, renal, breast and pancreatic cancer, as well as revealing a successful response to treatment in breast and prostate cancer patients at an earlier stage than multiparametric MRI. This review will focus on the strengths of the technique and its applications in the area of oncological body MRI including noninvasive characterisation of disease aggressiveness, mapping of tumour heterogeneity, and early response assessment. A comparison of hyperpolarised (13)C-MRI with state-of-the-art multiparametric MRI is likely to reveal the unique additional information and applications offered by the technique.