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Wang P, Zhang H, Chen P, Sun Z, Zhang Z, Yin Q, Sun H, Yu J. The Presence of Genomic Instability in Cerebrospinal Fluid in Patients with Meningeal Metastasis. Cancer Manag Res 2021; 13:4853-4863. [PMID: 34188538 PMCID: PMC8232886 DOI: 10.2147/cmar.s295368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 05/17/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose This study aimed to explore the genomic instability in cerebrospinal fluid (CSF) in patients with meningeal metastasis (MM). Material and Methods We collected the blood and CSF samples of 15 MM patients and one brain parenchymal metastasis (BPM) patient. A panel of 543 cancer-related genes was conducted to analyze the status of genomic instability in CSF and plasma cell-free DNA (cfDNA) of all patients. Subsequently, nine patients underwent low-depth whole-genome sequencing (WGS) analysis to verify the existence of genomic instability, followed by genomic scoring by the application of aneuploidy scores. Diagnosis-specific graded prognostic assessment (DS-GPA) score was utilized to assess the clinical status of MM patients. Results There was significant difference in gene mutation between CSF cfDNA and plasma cfDNA in MM patients. Among them, 12 MM patients developed genomic instability in their CSF cfDNA, while the remaining 3 had stable genetic profile. Besides, BPM patients showed genomic stability in his CSF and paraffin-embedded tissue sections. No genomic instability was noticed in plasma cfDNA of all patients. Sensitive mutations on EGFR, ERBB2, ALK and KRAS genes and increased gene copy numbers of MET and ERBB2 were detected in 10 MM patients with genomic instability, as well as the EGFR gene mutation in one MM case with genomic stability. Additionally, MM patients with genomic instability had lower overall survival and higher aneuploidy scores and tumor mutation burden compared with those with genomic stability. Moreover, MM patients with higher DS-GPA scores benefited from better survival. Conclusion Genomic instability existed in the CSF cfDNA rather than plasma cfDNA of MM patients, which might be the underlying cause of the differences in MM.
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Affiliation(s)
- Peng Wang
- Department of Neuro-Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin's Clinical Research Center for Cancer, Tianjin, 300060, People's Republic of China.,Key Laboratory of Cancer Prevention and Therapy, Key Laboratory of Cancer Immunology and Biotherapy, Tianjin, 300060, People's Republic of China
| | - Henghui Zhang
- Genecast Biotechnology Co., Ltd, Wuxi, 214000, People's Republic of China
| | - Peng Chen
- Genecast Biotechnology Co., Ltd, Wuxi, 214000, People's Republic of China
| | - Zengfeng Sun
- Department of Neuro-Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin's Clinical Research Center for Cancer, Tianjin, 300060, People's Republic of China.,Key Laboratory of Cancer Prevention and Therapy, Key Laboratory of Cancer Immunology and Biotherapy, Tianjin, 300060, People's Republic of China
| | - Zhen Zhang
- Department of Neuro-Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin's Clinical Research Center for Cancer, Tianjin, 300060, People's Republic of China.,Key Laboratory of Cancer Prevention and Therapy, Key Laboratory of Cancer Immunology and Biotherapy, Tianjin, 300060, People's Republic of China
| | - Qiang Yin
- Department of Neuro-Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin's Clinical Research Center for Cancer, Tianjin, 300060, People's Republic of China.,Key Laboratory of Cancer Prevention and Therapy, Key Laboratory of Cancer Immunology and Biotherapy, Tianjin, 300060, People's Republic of China
| | - Huaibo Sun
- Genecast Biotechnology Co., Ltd, Wuxi, 214000, People's Republic of China
| | - Jinpu Yu
- Key Laboratory of Cancer Prevention and Therapy, Key Laboratory of Cancer Immunology and Biotherapy, Tianjin, 300060, People's Republic of China.,Cancer Molecular Diagnostics Core, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin's Clinical Research Center for Cancer, Tianjin, 300060, People's Republic of China
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Qie S, Li Y, Shi HY, Yuan L, Su L, Zhang X. Stereotactic radiosurgery (SRS) alone versus whole brain radiotherapy plus SRS in patients with 1 to 4 brain metastases from non-small cell lung cancer stratified by the graded prognostic assessment: A meta-analysis (PRISMA) of randomized control trials. Medicine (Baltimore) 2018; 97:e11777. [PMID: 30113464 PMCID: PMC6113005 DOI: 10.1097/md.0000000000011777] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The present study aims to assess the therapeutic effect of whole brain radiotherapy (WBRT) for brain metastases from non-small cell lung cancer stratified by graded prognostic assessment (GPA) through meta-analysis. METHODS The Cochrane Library, PubMed, Ovid (Elsevier) were retrieved. The included randomized controlled trials (RCT) were evaluated, and the statistical analysis was performed using RevMan 5.3 software. Cochrane handbook was applied to evaluate the methodological quality. Statistical significance was considered as P < .05. RESULTS There were 2 randomized control trials identified eligible for the meta-analysis. Stereotactic radiosurgery (SRS)+WBRT did not significantly improved overall survival (OS) in 2 subgroups. (GPA <2: HR, 0.93; 95% confidence interval [CI], 0.61-1.40; P = .71), (GPA ≥2: HR, 1.28; 95% CI, 0.58-2.80; P = .54). The use of SRS+WBRT significantly extended brain tumor recurrence (BTR) free time in both subgroups (GPA <2: HR, 5.46; 95% CI: 2.09-14.22; P = .0005), (GPA ≥2: HR, 4.24; 95% CI: 2.24-8.04; P < .00001). The meta-analysis showed salvage therapy was more frequent among the SRS-alone in 2 subgroups (GPA <2: RR, 5.83; 95% CI: 1.47-23.06; P = .01), (GPA ≥2: RR, 2.53; 95% CI: 1.30-4.93; P = .006). The rate of grade 3 or 4 late radiation toxic effects was similar in 2 subgroups between SRS and SRS+WBRT CONCLUSIONS:: Because there are few studies to meet inclusion criteria, we cannot include more researches. The results of this analysis must be carefully interpreted in view of the unclear risk of bias in inclusion in the study. This meta-analysis of 2 randomized trails indicated that the combined treatment group did not show a survival benefit over SRS alone. However, SRS+WBRT improved BTR free time in the subgroup both GPA <2 and GPA ≥2 with the similar grade 3 or 4 late radiation toxicities.
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Li H, Wang W, Jia H, Lian J, Cao J, Zhang X, Song X, Jia S, Li Z, Cao X, Zhou W, Han S, Yang W, Xi Y, Lian S. Prognostic model for brain metastases from lung adenocarcinoma identified with epidermal growth factor receptor mutation status. Thorac Cancer 2017; 8:436-442. [PMID: 28597503 PMCID: PMC5582515 DOI: 10.1111/1759-7714.12460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 05/03/2017] [Accepted: 05/08/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Several indices have been developed to predict survival of brain metastases (BM) based on prognostic factors. However, such models were designed for general brain metastases from different kinds of cancers, and prognostic factors vary between cancers and histological subtypes. Recently, studies have indicated that epidermal growth factor receptor (EGFR) mutation status may be a potential prognostic biological factor in BM from lung adenocarcinoma. Thus, we sought to define the role of EGFR mutation in prognoses and introduce a prognostic model specific for BM from lung adenocarcinoma. METHODS Data of 256 patients with BM from lung adenocarcinoma identified with EGFR mutations were collected. Independent prognostic factors were confirmed using a Cox regression model. The new prognostic model was developed based on the results of multivariable analyses. The score of each factor was calculated by six-month survival. Prognostic groups were divided into low, medium, and high risk based on the total scores. The prediction ability of the new model was compared to the three existing models. RESULTS EGFR mutation and Karnofsky performance status were independent prognostic factors and were thus integrated into the new prognostic model. The new model was superior to the three other scoring systems regarding the prediction of three, six, and 12-month survival by pairwise comparison of the area under the curve. CONCLUSION Our proposed prognostic model specific for BM from lung adenocarcinoma incorporating EGFR mutation status was valid in predicting patient survival. Further verification is warranted, with prospective testing using large sample sizes.
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Affiliation(s)
- Hongwei Li
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Weili Wang
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Haixia Jia
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Jianhong Lian
- Department of Surgery, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Jianzhong Cao
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Xiaqin Zhang
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Xing Song
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Sufang Jia
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Zhengran Li
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Xing Cao
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Wei Zhou
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Songye Han
- Department of Chemotherapy, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Weihua Yang
- Department of Chemotherapy, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Yanfen Xi
- Department of Pathology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Shenming Lian
- Department of Radiation Oncology, Shanxi Provincial Cancer Hospital, Shanxi Medical University, Taiyuan, China
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Genre L, Roché H, Varela L, Kanoun D, Ouali M, Filleron T, Dalenc F. External validation of a published nomogram for prediction of brain metastasis in patients with extra-cerebral metastatic breast cancer and risk regression analysis. Eur J Cancer 2016; 72:200-209. [PMID: 28042991 DOI: 10.1016/j.ejca.2016.10.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 10/04/2016] [Accepted: 10/21/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Survival of patients with metastatic breast cancer (MBC) suffering from brain metastasis (BM) is limited and this event is usually fatal. In 2010, the Graesslin's nomogram was published in order to predict subsequent BM in patients with breast cancer (BC) with extra-cerebral metastatic disease. This model aims to select a patient population at high risk for BM and thus will facilitate the design of prevention strategies and/or the impact of early treatment of BM in prospective clinical studies. PATIENTS AND METHODS Nomogram external validation was retrospectively applied to patients with BC and later BM between January 2005 and December 2012, treated in our institution. Moreover, risk factors of BM appearance were studied by Fine and Gray's competing risk analysis. RESULTS Among 492 patients with MBC, 116 developed subsequent BM. Seventy of them were included for the nomogram validation. The discrimination is good (area under curve = 0.695 [95% confidence interval, 0.61-0.77]). Risk factors of BM appearance are: human epidermal growth factor receptor 2 (HER2) overexpression/amplification, triple-negative BC and number of extra-cerebral metastatic sites (>1). With a competing risk model, we highlight the nomogram interest for HER2+ tumour subgroup exclusively. CONCLUSION Graesslin's nomogram external validation demonstrates exportability and reproducibility. Importantly, the competing risk model analysis provides additional information for the design of prospective trials concerning the early diagnosis of BM and/or preventive treatment on high risk patients with extra-cerebral metastatic BC.
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Affiliation(s)
- Ludivine Genre
- Department of Gynecologic Surgery, IUCT-O, Toulouse, France
| | - Henri Roché
- Department of Medical Oncology, Institut Claudius Regaud, IUCT-O, Toulouse, France
| | - Léonel Varela
- Department of Radiotherapy, Institut Claudius Regaud, IUCT-O, Toulouse, France
| | - Dorra Kanoun
- Department of Medical Oncology, Institut Claudius Regaud, IUCT-O, Toulouse, France
| | - Monia Ouali
- Department of Biostatistics, Institut Claudius Regaud, IUCT-O, Toulouse, France
| | - Thomas Filleron
- Department of Biostatistics, Institut Claudius Regaud, IUCT-O, Toulouse, France
| | - Florence Dalenc
- Department of Medical Oncology, Institut Claudius Regaud, IUCT-O, Toulouse, France.
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[Imaging methods used in the differential diagnosis between brain tumour relapse and radiation necrosis after stereotactic radiosurgery of brain metastases: Literature review]. Cancer Radiother 2016; 20:837-845. [PMID: 28270324 DOI: 10.1016/j.canrad.2016.07.098] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 06/22/2016] [Accepted: 07/01/2016] [Indexed: 11/20/2022]
Abstract
After stereotactic radiosurgery for a cerebral metastasis, one of the dreaded toxicities is radionecrosis. In the follow-up of these patients, it is impossible to distinguish radiation necrosis from tumour relapse either clinically or with MRI. In current practice, many imaging methods are designed such as special sequences of MRI (dynamic susceptibility contrast perfusion and susceptibility-weighted imaging, diffusion), proton magnetic resonance spectroscopy, positron emission tomography, or more seldom 201-thallium single-photon emission computerized tomography. This article is a required literature analysis in order to establish a decision tree with the analysis of retrospective and prospective data.
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Cho KR, Lee MH, Kong DS, Seol HJ, Nam DH, Sun JM, Ahn JS, Ahn MJ, Park K, Kim ST, Lim DH, Lee JI. Outcome of gamma knife radiosurgery for metastatic brain tumors derived from non-small cell lung cancer. J Neurooncol 2015; 125:331-8. [PMID: 26373297 DOI: 10.1007/s11060-015-1915-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 08/29/2015] [Indexed: 11/24/2022]
Abstract
The purpose of this study was to analyze outcomes in patients treated with gamma knife radiosurgery (GKS) for brain metastases from non-small cell lung cancer (NSCLC). We retrospectively reviewed the medical records of 817 patients who underwent GKS for brain metastases from NSCLC between January 2002 and December 2012. A total of 1363 GKS procedures were performed for 2970 lesions. The median overall survival time from the initial GKS was 13 months and the salvage treatment-free survival from the first GKS was 6.5 months. Younger age (≤65 years), female sex, better RPA class, higher DS-GPA score, adenocarcinoma, synchronous onset, and lower integrated value of the "numbers and cumulative volume of tumors" were associated with better outcomes. Among the 601 patients with an available follow up image, the pattern of the first progression after initial GKS was the development of new lesions in 356 patients (59.2 %), regrowth of treated lesions in 106 patients (17.6 %), and leptomeningeal seeding (LMS) in 51 patients (8.5 %). Among the deceased, the last MRI performed prior to death was evaluated in 409 patients and showed progression in 263 patients (64.3 %), despite multiple salvage treatments. LMS was identified in 63 patients (15.4 %); a rate much higher than the incidence at first progression. Intracranial tumor burden, defined as the integrated value of the "number of the lesions and cumulative tumor volume", is a new prognostic factor of greater significance than tumor volume or number alone when analyzed as separate factors. Although the cause of death was not progression of brain lesions in the majority of patients, the brain lesions tended to have been persistently progressive in most patients, despite repeated salvage treatment. LMS is an important pattern of treatment failure, in addition to local progression or development of new lesions, particularly in the terminal phase of the disease.
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Affiliation(s)
- Kyung Rae Cho
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam Gu, Seoul, 135-710, Korea
| | - Min Ho Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam Gu, Seoul, 135-710, Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam Gu, Seoul, 135-710, Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam Gu, Seoul, 135-710, Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam Gu, Seoul, 135-710, Korea
| | - Jong-Mu Sun
- Division of Hematology Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Seok Ahn
- Division of Hematology Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myung-Ju Ahn
- Division of Hematology Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keunchil Park
- Division of Hematology Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Tae Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do Hun Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam Gu, Seoul, 135-710, Korea.
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Taillibert S, Le Rhun É. Épidémiologie des lésions métastatiques cérébrales. Cancer Radiother 2015; 19:3-9. [DOI: 10.1016/j.canrad.2014.11.001] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 11/26/2014] [Indexed: 01/29/2023]
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Radiothérapie encéphalique en totalité des métastases cérébrales : intérêts et controverses dans le cadre d’un référentiel. Cancer Radiother 2015; 19:30-5. [DOI: 10.1016/j.canrad.2014.12.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 12/08/2014] [Indexed: 11/18/2022]
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Place de l’association radiothérapie encéphalique et thérapies systémiques dans le traitement des métastases cérébrales d’un cancer du sein. Cancer Radiother 2014; 18:235-42; quiz 246, 249. [DOI: 10.1016/j.canrad.2014.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Revised: 02/15/2014] [Accepted: 02/19/2014] [Indexed: 11/20/2022]
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Patsouris A, Augereau P, Tanguy JY, Morel O, Menei P, Rousseau A, Paumier A. [Differential diagnosis of local tumor recurrence or radionecrosis after stereotactic radiosurgery for treatment of brain metastasis]. Cancer Radiother 2014; 18:142-6. [PMID: 24433952 DOI: 10.1016/j.canrad.2013.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 10/16/2013] [Accepted: 10/23/2013] [Indexed: 10/25/2022]
Abstract
Magnetic resonance imaging (MRI) is a method of choice for follow-up of irradiated brain metastasis. It is difficult to differentiate local tumour recurrences from radiation induced-changes in case of suspicious contrast enhancement. New advanced MRI techniques (perfusion and spectrometry) and amino acid positron-emission tomography (PET) allow to be more accurate and could avoid a stereotactic biopsy for histological assessment, the only reliable but invasive method. We report the case of a patient who underwent surgery for a single, left frontal brain metastasis of a breast carcinoma, followed by adjuvant stereotactic radiotherapy in the operative bed. Seven months after, she presented a local change in the irradiated area on the perfusion-weighted MRI, for which the differentiation between a local tumour recurrence and radionecrosis was not possible. PET with 2-deoxy-((18)F)-fluoro-D-glucose (FDG) revealed a hypermetabolic lesion. After surgical resection, the histological assessment has mainly recovered radionecrosis with few carcinoma cells. The multimodal MRI has greatly contributed to refine the differential diagnosis between tumour recurrence and radionecrosis, which remains difficult. The FDG PET is helpful, in favour of the diagnosis of local tumour recurrence when a hypermetabolic lesion is found. Others tracers (such as carbon 11 or a fluoride isotope) deserve interest but are not available in all centres. Stereotactic biopsy should be discussed if any doubt remains.
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Affiliation(s)
- A Patsouris
- Service d'oncologie médicale, institut de cancérologie de l'Ouest Paul-Papin, 2, rue Moll, 49000 Angers, France
| | - P Augereau
- Service d'oncologie médicale, institut de cancérologie de l'Ouest Paul-Papin, 2, rue Moll, 49000 Angers, France
| | - J-Y Tanguy
- Service de radiologie, centre hospitalier universitaire, université d'Angers, 4, rue Larrey, 49933 Angers cedex 9, France; Université Nantes Angers Le Mans (Unam), 4, rue Larrey, 49933 Angers cedex 9, France
| | - O Morel
- Service de médecine nucléaire, institut de cancérologie de l'Ouest Paul-Papin, 2, rue Moll, 49000 Angers, France
| | - P Menei
- Université Nantes Angers Le Mans (Unam), 4, rue Larrey, 49933 Angers cedex 9, France; Service de neurochirurgie, centre hospitalier universitaire, université d'Angers, 4, rue Larrey, 49933 Angers cedex 9, France
| | - A Rousseau
- Université Nantes Angers Le Mans (Unam), 4, rue Larrey, 49933 Angers cedex 9, France; Service d'anatomopathologie, centre hospitalier universitaire, université d'Angers, 4, rue Larrey, 49933 Angers cedex 9, France
| | - A Paumier
- Service d'oncologie radiothérapie, institut de cancérologie de l'Ouest Paul-Papin, 2, rue Moll, 49000 Angers, France.
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