Journal of Neuro-Oncology

https://doi.org/10.1007/s11060-019-03205-z

CLINICAL STUDY

Comparison of ABC/2 estimation and a volumetric computerized

method for measurement of meningiomas using magnetic resonance
imaging
Charles F. Opalak1 · Matthew Parry1 · Andrew K. Rock1 · Adam P. Sima2 · Matthew T. Carr1 · Vyshak Chandra1 ·
Kathryn G. Workman1 · Aravind Somasundaram1 · William C. Broaddus1 

Received: 9 March 2019 / Accepted: 4 June 2019

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Introduction  Measurement of tumor growth rates over time for patients with meningiomas has important prognostic and
therapeutic implications. Our objective was to compare two methods of measuring meningioma volume: (1) the simplified
ellipsoid (ABC/2) method; and (2) perimetric volume measurements using imaging software modules.
Methods  Patients with conservatively managed meningiomas for at least 1.5 years were retrospectively identified from the
VCU Brain and Spine Tumor Registry over a 10-year period (2005–2015). Tumor volumes were independently measured
using the simplified ellipsoid and computerized perimetric methods. Intra class correlations (CC) and Bland–Altman analyses
were performed.
Results  A total of 26 patients representing 29 tumors were identified. Across 146 images, there were 24 (16%) images that
were non-measurable using standard application commands with the computerized perimetric method. The mean volume
obtained using the ABC/2 and computerized perimetric methods were 3.2 ± 3.4 cm3 and 3.4 ± 3.5 cm3, respectively. The
mean volume difference was 0.2 cm3 (SE = 0.12; p = 0.10) across measurement methods. The concordance correlation coef-
ficient (CCC) between methods was 0.95 (95% CI 0.91, 0.98).
Conclusions  There is excellent correlation between the simplified ellipsoid and computerized perimetric methods of volu-
metric analysis for conservatively managed meningiomas. The simplified ellipsoid method remains an excellent method for
meningioma volume assessment and had an advantage over the perimetric method which failed to allow measurement of
roughly one in six tumors on imaging.

Keywords  Comparative studies · Meningioma · ABC/2 · Tumor volume · Tumor burden · Magnetic resonance imaging

Introduction discovery of incidental asymptomatic meningiomas [4].

Meningiomas account for 35% of all intracranial tumors
within the Central Brain Tumor Registry [1]. The estimated
prevalence within the general population and from autopsy
studies ranges from 0.9 to 2.8% [2, 3]. Increasing use of
neuroimaging for other conditions has led to more frequent
* William C. Broaddus
wbroaddus@vcu.edu
1
Department of Neurosurgery, Virginia Commonwealth
University, 417 North 11th Street, Sixth Floor, P.O.
Box 980631, Richmond, VA 23219‑0631, USA
2 and computerized volumetric analysis [8]. Chang et al. [9]
Department of Biostatistics, Virginia Commonwealth
University, 830 East Main Street, Seventh Floor,
P.O. Box 980032, Richmond, VA 23298‑0032, USA
Current expert opinion is that asymptomatic meningiomas
can be safely managed conservatively with serial imaging
until there is obvious mass effect with attributable neuro-
logic symptoms, documented increase in size, and/or reason-
able suspicion of malignancy [5, 6]. In general, close initial
imaging at 6 months followed by repeat imaging at intervals
of 1–2 years is considered adequate for assessing growth [7].
There is, however, no consensus in the literature on the most
appropriate method for defining growth of meningiomas on
imaging.
Previous studies for assessing meningioma volume on
imaging have used the simplified ellipsoid formula (ABC/2)
and Zeidman et al. [10] are the only studies that have directly
compared meningioma volumes calculated across these two

13
Vol.:(0123456789)

modalities. Chang et al. [9] used volumetric analysis to iden-
tify undetected growth in 17 of 29 meningiomas previously
measured using the simplified ellipsoid formula. They con-
cluded volumetric analysis was more accurate and superior
for detecting tumor progression as compared to the simpli-
fied ellipsoid method, which underestimated growth rates.
Similarly, Zeidman et al. [10] observed higher growth rate
by volume using computerized methods than the simplified
ellipsoid formula and concluded computerized measure-
ments were more informative. Xue et al. however, compared
manual with computerized methods in intracerebral hemor-
rhages and found that manual estimation tended to overesti-
mate volume in comparison to computerized measurement
in 45% of cases [11].
The objective of the current study was to further examine
whether volumetric analysis of meningiomas from perimet-
ric measurements are superior to measurements performed
using the simplified ellipsoid volume calculated from
orthogonal diameters.
Methods
Study overview and patient selection
Data was collected from a single academic medical center
between January 2005 and February 2015 from the retro-
spective VCU Brain and Spine Tumor Registry. Within the
sample of patients with brain tumors, those with tumors
diagnosed as meningioma were considered for inclusion
in this study. The following inclusion criteria were used to
further define the sample: (1) conservatively managed with
serial imaging alone; (2) at least three MRI scans; (3) at least
eighteen months of follow-up; and (4) assessment by both
methods of volume analysis. Criteria for exclusion were: (1)
any patient treated non-conservatively (surgery, radiation,
chemotherapy); and (2) age less than 18 years old. Patient
demographics (age at initial imaging, sex), tumor charac-
teristics (months of follow-up, number of images, number
of tumors, location), and MRI scans were collected for each
patient. Our institutional review board approved the study
protocol.
Image review and analysis
Tumor volume was determined from T1-weighted post-gad-
olinium MRI images with 1 mm slice thickness. The MRI
machines used Siemens magnets with field strengths 1.5 and
3T. One observer (C.O.) measured three orthogonal perpen-
dicular axes (A, B, C), as demonstrated in Fig. 1. These
measurements were used to calculate the simplified ellip-
soid volume for each tumor based on the equation (ABC/2).
Additionally, a separate researcher (M.P.) calculated the
13
Journal of Neuro-Oncology
perimetric volume for each corresponding image using the
VitreaWorkstation™ (Vital Images Inc, Plymouth, MN,
USA). This software has not been previously validated in
the literature for measurement of meningiomas. Tri-plane
(axial, sagittal, coronal) T1-weighted post-contrast images
were analyzed by using a computer-assisted, hand-drawn
technique to outline regions of interest for each tumor. The
software segmentation process was thus semi-automatic.
The software then applied computer-detected perimeters
within the defined region of interest to estimate the tumor
volume. The software’s computer-detected perimeters could
be further defined through user interaction and user edit-
ing to adjust for non-tumor anatomical findings within the
region of interest. The time required for the software to
measure each meningioma was approximately 10 min per
imaging study. Figure 2 provides a representative image of
the tumor segmentation process using VitreaWorkstation™.
Statistical analysis
Demographic and tumor variables, including: sex, number of
tumors, location, age at initial imaging, years of follow-up,
and number of images for patients fulfilling inclusion crite-
ria were summarized using means and standard deviations
or frequencies and percentages. The average and difference
between each volume dyad were calculated and used to cre-
ate Bland–Altman plots [12]. A repeated measures ANOVA
was used to compare the mean difference of the volume
measurements. This model was used to estimate the intra-
class correlation (ICC) between measurements on a same
individual. Large positive values of this statistic indicate
that the differences between the imaging modalities favor a
single method as being larger than the other within an indi-
vidual. Negative binomial regression was used to estimate
the number of times that one method resulted in higher val-
ues compared to the other. The agreement between continu-
ous measurements was assessed using Lin’s concordance
correlation coefficient (CCC) [13]. Carrasco et al. extended
this statistic for longitudinal measurements [14]. This sta-
tistic was calculated using a SAS macro published by Car-
rasco et al. using an auto-regressive error structure [15].
Estimates and 95% confidence intervals were calculated
when applicable.
Results
Study sample
A total of 2344 patients presented with brain tumors to VCU
between January 2005 and February 2015. Of these, there
were 657 (28%) who were diagnosed with at least one pre-
sumptive meningioma. A total of 26 (4%) patients with 29
Journal of Neuro-Oncology
Fig. 1  T1-weighted post gadolinium contrast images demonstrate
how to measure the “A”, “B”, and “C” dimensions. “A” is the longest
dimension measured in the axial plane, with “B” being the longest
unique meningiomas met inclusion criteria for this study.
The mean age at initial MRI imaging was 61.3 ranging from
36 to 92 years with a median of 62 years. There were 25
(96%) females and one (4%) male. Twenty-four patients
(88%) had a single meningioma and three (12%) patients
had two meningiomas. The mean duration of follow-up was
5.7 ± 2.6 years (range 1.8–12.0). The study cohort yielded
a total of 146 MRI images with 28 baseline images and
118 follow-up images. The mean number of image sets per
patient was 5.6 ± 1.8 (range 3–10). The most common tumor
location was the convexity (41%) followed by falcine (14%)
and sphenoid wing (14%). This demographic information is
summarized in Table 1.
perpendicular dimension to “A” in the same axial cut. “C” is longest
dimension orthogonal to “A” in the sagittal plane
Correlation between measurement modalities
A total of 122 of the 146 (84%) scans yielded volume meas-
urements using both the perimeter and ellipsoid modalities
with subjects contributing between 1 and 8 dyads per tumor.
The VitreaWorkstation™ was unable to measure tumor vol-
umes for 24 (16%) of the images available using standard
application commands. The mean volume obtained using the
ABC/2 method for calculating the simplified ellipsoid vol-
ume was 3.2 ± 3.4 cm3, while the mean volume from com-
puterized perimetric methods was 3.4 ± 3.5 cm3. Adjusting
for repeated observations within a patient, the mean vol-
ume difference between methods was 0.2 cm3 (SE = 0.12;
13

Fig. 2  T1-weighted post gadolinium contrast images demonstrating tumor measurement using the VitreaWorkstation™
p = 0.10). Although the CCC was 0.95 (95% CI 0.91, 0.98)
between the two methods, the ABC/2 method resulted in a
higher estimate of the volume in 76% (95% CI 0.62–0.95)
of the images (Fig. 3). The difference in the volume meas-
urements tended to be clustered together, so that if one
method was found to produce a larger value than the other,
future observations would have the same trend (ICC = 0.58,
p = 0.002). The Bland Altman plot comparing the ABC/2 to
the perimetric method is presented in Fig. 4.
Discussion
In this study, we examined whether perimetric measure-
ments of meningiomas using the VitreaWorkstation™ are
as accurate as measurements using the simplified ellipsoid
method. Based on our results, there is a clear correlation
between the two methods of volumetric analysis.
The measurements with the VitreaWorkstation™ rely
upon user-defined perimeters of regions of interest to derive
automated calculations of volume, while the simplified ellip-
soid volume is calculated directly from three orthogonal
perpendicular axes (A, B, C). Traditionally, the ellipsoid
formula has been used by clinicians for measuring volume
of intracerebral hemorrhage [16–19], but has been expanded
to the measurement of gliomas [20], acoustic neuromas
13
Journal of Neuro-Oncology
[21], and meningiomas [9, 10, 22, 23]. Meanwhile, the Vit-
reaWorkstation™ has largely been used in CT applications
[24–38] with limited use in MRI for tumor response in high
grade gliomas [39] and meningiomas [9]. The VitreaWork-
station™ perimetric method was successful in calculating
volumes for 84% of images but was unable to provide volu-
metric data for 16% of images.
For the images that could not be measured using the
VitreaWorkstation™, attempts were made to redefine the
perimeters and recalibrate the windowing, but no automated
volume was produced. It remains unclear why the software
was unable to calculate these tumor volumes. There may
have been insufficient contrast between the tumor and sur-
rounding parenchyma for the software to appropriately dis-
tinguish the tumor from adjacent tissue within the region
of interest. When reviewing the literature, only one article
addressed the potential drawback of semi-automatic soft-
ware tools as compared to manually derived measurements.
De Jonge et al. [30] compared semi-automatic and manually
adjusted left ventricular functional measurements derived
from ECG-gated dual-source CT for three separate CT
analysis software packages. They acknowledged good cor-
relation between methods but recognized largely different
outliers with automatic measurements which were suspected
to be due to the inability to detect the heart valve when it
is open. Further research will be necessary to clarify why
Journal of Neuro-Oncology

Table 1  Characteristics of 26 patients with conservatively managed method would be expected to be less accurate for irregu-
meningiomas larly shaped tumors, we note that the volume obtained by
Variable Study cohort (n = 26) the measurement of an irregularly shaped tumor would
be expected to be representative of the tumor volume at a
Female 25 (96.2%)
particular time, and should be comparable to subsequent
Age at initial imaging (years) 61.3 ± 13.7
measurements of the same tumor over time, allowing for an
Years of follow-up 5.7 ± 2.6
assessment of stability or growth over time by comparing
Number of images 146
the volumes represented by the ABC/2 method.
Mean number of images 6.2 ± 1.9
Locations in our tumor sample primarily consisted of
Number of tumors
convexity (41.4%), falcine (13.8%) and sphenoid wing
 1 26 (88%)
(13.8%). This is comparable to prior estimates of 60–70%
 2 3 (12%)
arising along the falx, sphenoid bone, or convexity [40].
Tumor location
The sample may over-represent convexity meningiomas,
 Convexity 12 (41.4%)
and these are likely slightly overrepresented due to the con-
 Falcine 4 (13.8%)
servatively managed nature of this series.
 Sphenoid wing 4 (13.8%)
The measurements reported herein were carried out by
 Planum sphenoide 2 (6.9%)
one individual, and subsequent studies of tumor growth
 Tentorial 2 (6.9%)
(to be reported separately) confirm reproducibility of these
 Anterior fossa 1 (3.5%)
measurements. Future studies of interuser reliability of the
 Cavernous sinus 1 (3.5%)
measurement methods would also be valuable. A major
 Intraventricular 1 (3.5%)
strength of the current study is the potential generalizability
 Middle fossa 1 (3.5%)
to the broader population. The data is drawn from a retro-
 Posterior fossa 1 (3.5%)
spective sample of all patients with brain tumors presenting
to a large academic institution over a 10-year time period
there are circumstances where the software cannot accu- (2005–2015). Each patient had on average at least 6 sepa-
rately identify the anatomy of interest. rate imaging studies over an average of 5.6 years of follow-
When comparing the methods of meningioma measure- up. This allowed for analysis across a substantial number
ment, there was a clear correlation (CCC: 0.95; 95% CI 0.91, of images for both modalities, albeit from a smaller num-
0.98) between measurements using the VitreaWorkstation™ ber of actual individual tumors. While this does introduce
and simplified ellipsoid methods. This helps demonstrate bias related to repeated measurements of tumors, it was felt
that both methods may be effective for the clinical assess- that the increased sample size available by comparing all
ment of meningioma growth and volume changes over time, independently performed measurements from both methods
as monitoring meningiomas for growth is an important was more valuable than the potential bias noted. The non-
aspect of non-operative management of these tumors. The operative nature of this sample provides no way of histo-
results from the current study cannot directly distinguish logically confirming the diagnosis as a meningioma, so it
which method is more accurate for measuring actual tumor strictly relies upon tumor characteristics from imaging alone
volume. The ease, reliability and reproducibility of the vol- for diagnosis. Despite this limitation, this study supports the
umes produced by the ABC/2 method make this an attrac- widely-practiced extrapolation of volume from diameters as
tive method for general clinical use. Indeed, the authors are a reliable and accurate method for the measurement of men-
preparing to submit results of monitoring the same patient ingiomas. Additionally, ABC/2 is easily performed in clini-
cohort for growth of their tumors over time using the ABC/2 cal settings, even without access to electronic methods. Vit-
method and related measurements. reaWorkstation™ is not routinely used in the measurement
None of the tumors exhibited bony invasion or meningi- of meningiomas as it requires a specialized workstation.
omatosis, and all were homogeneously enhancing on imag- Other limitations of the software include time necessary to
ing. Any evidence of calcification or necrosis would have measure tumor volumes, the level of resources required to
shown non-enhancement and be contained within the tumor. have the software readily available, and the personnel skill
This study demonstrates the equivalence of the simplified and training required to use the software. We note also that
ellipsoid method and VitreaWorkstation™ in measuring a there are other software products available for volumetric
variety of meningiomas, but was not powered adequately to analysis of MRI scan data, which could have other features,
determine whether these methods are equivalent in meas- benefits or potential drawbacks relative to the system used
uring irregularly shaped meningiomas. While the ABC/2 in the current study.

13
 Journal of Neuro-Oncology

Fig. 3  Comparisons of ABC/2
and perimetric methods of
tumor volume measurement.
A line of accuracy is superim-
posed on the plot. The symbols
indicate unique dyads

Fig. 4  Bland Altman plots

comparing the ABC/2 to the
perimetric method. A moving
average line and correspond-
ing 95% confidence interval is
superimposed on the plot. The
symbols indicate unique dyads

Conclusion performed using the simplified ellipsoid volume calcu-

lated from diameters (ABC/2). The perimetric method for
The objective of the current study was to further exam- measuring meningioma tumor volume showed excellent
ine whether volumetric analysis of meningiomas from correlation with the simplified ellipsoid method of meas-
perimetric measurements are superior to measurements urement but was unable to detect the tumor of interest in

13
Journal of Neuro-Oncology
16% of images. While other investigators suggest perimet-
ric methods are preferable, these results demonstrate that
the simplified ellipsoid method (ABC/2) maintains inter-
nal consistency and allows for measurement of all scans.
Acknowledgements  Services in support of the research project were
generated by the VCU Massey Cancer Center Biostatistics Shared
Resource, supported, in part, with funding from NIH-NCI Cancer
Center Support Grant P30 CA016059.
Data availability  The datasets generated during and/or analyzed dur-
ing the current study are available from the corresponding author on
reasonable request.
Compliance with ethical standards  ance components. J Biopharm Stat 19(1):90–105. https​://doi.
Conflict of interest  The authors declare that they have no conflict of
interest.
Ethical approval  All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
This article does not contain any studies with animals performed by
any of the authors.
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