Tumour Progression or radionecrosis?

The role of
molecular imaging

Gliomas: The basics

Arises from glial cells

The most common site of gliomas is the brain

Make up ~30% of all brain and central nervous

system tumors and 80% of all malignant brain
tumors
Low-grade gliomas [WHO grade II] are welldifferentiated (not anaplastic); these are benign
and portend a better prognosis for the patient
High-grade [WHO grade IIIIV] gliomas are
undifferentiated or anaplastic; these are
malignant and carry a worse prognosis

Prognosis

Prognosis largely determined by grade

For low grade gliomas, median survival is 12-17
years
Anaplastic astrocytoma (Grade III), median
survival 3 years
Glioblastoma Multiforme (Grade IV), median
survival 14 months (without treatment, 4
months)

Treatment

Grade IV debulking with concurrent irradiation

and temozolomide, then 6 months of
temozolomide
Grade III debulking with irradiation.
Temozolomide if recurrence
Low grade controversial. Debulking.
Irradiation if progression? Temozolomide?
Despite treatment, high grade gliomas often
recur

Recurrence or radionecrosis?

Due to the high risk of recurrence, posttreatment imaging must be able to distinguish
between recurrence, pseudo-progression, and
radiation necrosis
Imaging options include MR, PET, and SPECT

MRI

PET

Case Report: 17M with headache, blurred vision, left

upper limb weakness

Dx: GBM, 5 months post chemo-rads

FDG-PET/CT

FCH-PET/CT

Sestamibi-SPECT/CT

Sestamibi

Monovalent lipophilic cation

No tissue specificity

Doesn't cross the BBB

No contrast nephropathy, no NSF, no

significant anaphylaxis risk

Single Photon Emission Computed Tomography

(SPECT)

3D imaging using a gamma camera

Many different possible radiotracers depending
on the application
For glioma imaging, perfusion agents are
generally used e.g. Sestamibi, Tetrofosmin,
Thallium

SPECT

LeJeune et al

Largest (N=201) MIBI study to date

For all grades, Sn 90%, Sp 91.5%, Accy 90.5%

Path/clinical follow-up as gold standard

False positives in 3 patients - 2 inflammation (?)

1 unknown

False negatives in 5 intact BBB (?)

SPECT positive earlier than MR

Interpretation

Advantages

Accuracy comparable to MR Spectroscopy

No risk to the patient (besides radiation)

High inter-observer agreement

Positive earlier than MR

No patient restrictions

Cost ($215.95)

Disadvantages

Radiation exposure (~4.5 mSv < 2 yrs

background radiation)

Fusion Imaging