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Harat M, Miechowicz I, Rakowska J, Zarębska I, Małkowski B. A Biopsy-Controlled Prospective Study of Contrast-Enhancing Diffuse Glioma Infiltration Based on FET-PET and FLAIR. Cancers (Basel) 2024; 16:1265. [PMID: 38610944 PMCID: PMC11010945 DOI: 10.3390/cancers16071265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/15/2024] [Accepted: 03/16/2024] [Indexed: 04/14/2024] Open
Abstract
Accurately defining glioma infiltration is crucial for optimizing radiotherapy and surgery, but glioma infiltration is heterogeneous and MRI imperfectly defines the tumor extent. Currently, it is impossible to determine the tumor infiltration gradient within a FLAIR signal. O-(2-[18F]fluoroethyl)-L-tyrosine (FET)-PET often reveals high-grade glioma infiltration beyond contrast-enhancing areas on MRI. Here, we studied FET uptake dynamics in tumor and normal brain structures by dual-timepoint (10 min and 40-60 min post-injection) acquisition to optimize analysis protocols for defining glioma infiltration. Over 300 serial stereotactic biopsies from 23 patients (mean age 47, 12 female/11 male) of diffuse contrast-enhancing gliomas were taken from areas inside and outside contrast enhancement or outside the FET hotspot but inside FLAIR. The final diagnosis was G4 in 11, grade 3 in 10, and grade 2 in 2 patients. The target-to-background (TBRs) ratios and standardized uptake values (SUVs) were calculated in areas used for biopsy planning and in background structures. The optimal method and threshold values were determined to find a preferred strategy for defining glioma infiltration. Standard thresholding (1.6× uptake in the contralateral brain) in standard acquisition PET images differentiated a tumor of any grade from astrogliosis, although the uptake in astrogliosis and grade 2 glioma was similar. Analyzing an optimal strategy for infiltration volume definition astrogliosis could be accurately differentiated from tumor samples using a choroid plexus as a background. Early acquisition improved the AUC in many cases, especially within FLAIR, from 56% to 90% sensitivity and 41% to 61% specificity (standard TBR 1.6 vs. early TBR plexus). The current FET-PET evaluation protocols for contrast-enhancing gliomas are limited, especially at the tumor border where grade 2 tumor and astrogliosis have similar uptake, but using choroid plexus uptake in early acquisitions as a background, we can precisely define a tumor within FLAIR that was outside of the scope of current FET-PET protocols.
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Affiliation(s)
- Maciej Harat
- Department of Neurooncology and Radiosurgery, Franciszek Lukaszczyk Oncology Center, 85-796 Bydgoszcz, Poland
- Department of Clinical Medicine, Faculty of Medicine, University of Science and Technology, 85-796 Bydgoszcz, Poland
| | - Izabela Miechowicz
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, 61-701 Poznań, Poland;
| | - Józefina Rakowska
- Department of Neurosurgery, 10th Military Research Hospital, 85-681 Bydgoszcz, Poland;
| | - Izabela Zarębska
- Department of Radiotherapy, Franciszek Lukaszczyk Oncology Center, 85-796 Bydgoszcz, Poland;
| | - Bogdan Małkowski
- Department of Nuclear Medicine, Franciszek Lukaszczyk Oncology Center, 85-796 Bydgoszcz, Poland
- Department of Diagnostic Imaging, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, 85-067 Bydgoszcz, Poland
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Prather KY, O’Neal CM, Westrup AM, Tullos HJ, Hughes KL, Conner AK, Glenn CA, Battiste JD. A systematic review of amino acid PET in assessing treatment response to temozolomide in glioma. Neurooncol Adv 2022; 4:vdac008. [PMID: 35300149 PMCID: PMC8923003 DOI: 10.1093/noajnl/vdac008] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The response assessment in neuro-oncology (RANO) criteria have been the gold standard for monitoring treatment response in glioblastoma (GBM) and differentiating tumor progression from pseudoprogression. While the RANO criteria have played a key role in detecting early tumor progression, their ability to identify pseudoprogression is limited by post-treatment damage to the blood-brain barrier (BBB), which often leads to contrast enhancement on MRI and correlates poorly to tumor status. Amino acid positron emission tomography (AA PET) is a rapidly growing imaging modality in neuro-oncology. While contrast-enhanced MRI relies on leaky vascularity or a compromised BBB for delivery of contrast agents, amino acid tracers can cross the BBB, making AA PET particularly well-suited for monitoring treatment response and diagnosing pseudoprogression. The authors performed a systematic review of PubMed, MEDLINE, and Embase through December 2021 with the search terms “temozolomide” OR “Temodar,” “glioma” OR “glioblastoma,” “PET,” and “amino acid.” There were 19 studies meeting inclusion criteria. Thirteen studies utilized [18F]FET, five utilized [11C]MET, and one utilized both. All studies used static AA PET parameters to evaluate TMZ treatment in glioma patients, with nine using dynamic tracer parameters in addition. Throughout these studies, AA PET demonstrated utility in TMZ treatment monitoring and predicting patient survival.
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Affiliation(s)
- Kiana Y Prather
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Christen M O’Neal
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Alison M Westrup
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Hurtis J Tullos
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Kendall L Hughes
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Andrew K Conner
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Chad A Glenn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - James D Battiste
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Furtak J, Rakowska J, Szylberg T, Harat M, Małkowski B, Harat M. Glioma Biopsy Based on Hybrid Dual Time-Point FET-PET/MRI-A Proof of Concept Study. Front Neurol 2021; 12:634609. [PMID: 34046002 PMCID: PMC8144440 DOI: 10.3389/fneur.2021.634609] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 03/15/2021] [Indexed: 11/13/2022] Open
Abstract
Neuroimaging based on O-[2-(18F)fluoroethyl]-l-tyrosine (FET)-PET provides additional information on tumor grade and extent compared with MRI. Dynamic PET for biopsy target selection further improves results but is often clinically impractical. Static FET-PET performed at two time-points may be a good compromise, but data on this approach are limited. The aim of this study was to compare the histology of lesions obtained from two challenging glioma patients with targets selected based on hybrid dual time-point FET-PET/MRI. Five neuronavigated tumor biopsies were performed in two difficult cases of suspected glioma. Lesions with (T1-CE) and without contrast enhancement (T1 and T2-FLAIR) on MRI were selected. Dual time-point FET-PET imaging was performed 5–15 min (PET10) and 45–60 min (PET60) after radionuclide injection. The most informative FET-PET/MRI images were coregistered with MRI in time of biopsy planning. Five biopsy targets (three from high uptake and two from moderate uptake FET areas) thought to represent the most malignant sites and tumor extent were selected. Histopathological findings were compared with FET-PET and MRI images. Increased FET uptake in the area of non-CE locations on MRI correlated well with high-grade gliomas localized as far as 3 cm from T1-CE foci. Selecting a target in the motor cortex based on FET kinetics defined by dual time-point PET resulted in a grade IV diagnosis after previous negative biopsies based on MRI. An additional grade III diagnosis was obtained from an area of glioma infiltration with moderate FET uptake (between 1 and 1.25 SUV). These findings seem to show that dual time-point FET-PET-based biopsies can provide additional and clinically useful information for glioma diagnosis. Selection of targets based on dual time-point images may be useful for determining the most malignant tumor areas and may therefore be useful for resection and radiotherapy planning.
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Affiliation(s)
- Jacek Furtak
- Department of Neurosurgery, 10th Military Research Hospital, Bydgoszcz, Poland
| | - Józefina Rakowska
- Department of Neurosurgery, 10th Military Research Hospital, Bydgoszcz, Poland
| | - Tadeusz Szylberg
- Department of Pathomorphology, 10th Military Research Hospital, Bydgoszcz, Poland
| | - Marek Harat
- Department of Neurosurgery, 10th Military Research Hospital, Bydgoszcz, Poland.,Department of Neurosurgery and Neurology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Bogdan Małkowski
- Department of Positron Emission Tomography and Molecular Imaging, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.,Department of Nuclear Medicine, Franciszek Lukaszczyk Oncology Center, Bydgoszcz, Poland
| | - Maciej Harat
- Department of Oncology and Brachytherapy, Faculty of Medicine, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.,Department of Neurooncology and Radiosurgery, Franciszek Lukaszczyk Oncology Center, Bydgoszcz, Poland
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Renard D, Collombier L, Laurent-Chabalier S, Mura T, Le Floch A, Fertit HE, Thouvenot E, Guillamo JS. 18F-FDOPA-PET in pseudotumoral brain lesions. J Neurol 2020; 268:1266-1275. [PMID: 33084938 DOI: 10.1007/s00415-020-10269-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/08/2020] [Accepted: 10/10/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION 3,4-Dihydroxy-6-[18F]-fluoro-L-phenylalanine (FDOPA) positron emission tomography (PET) is sensitive for identifying primary brain tumors. However, increased FDOPA uptake has been reported in pseudotumoral brain lesions. Our aim was to analyse FDOPA-PET in patients with pseudotumoral brain lesions and to compare them with patients with brain tumors. METHODS We retrospectively analysed consecutively recruited patients with suspected primary brain tumor (based on clinical and magnetic resonance imaging findings) referred for FDOPA-PET in our centre between November 2013 and June 2019 (n = 74). FDOPA-PET parameters (maximum and mean lesion standardised uptake values [SUV] and ratios comparing lesion with different background uptake SUV) and thresholds were evaluated to determine which offered optimal discrimination between pseudotumoral and tumoral lesions. RESULTS Overlapping PET values were observed between pseudotumoral (n = 26) and tumoral (n = 48) lesion, particularly for low-grade tumors. Based on receiver operating characteristic (ROC) analyses, the optimal PET parameters to discriminate pseudotumoral from tumoral lesions were SUVmax lesion/basal ganglia, SUVmax lesion/grey matter, SUVmean lesion/grey matter, and SUVmax lesion/mirror area in contralateral hemisphere (all ratios showing area under the curve [AUC] 0.85, 95% CI). The narrowest 95% sensitivity-95% specificity window was observed for SUVmax lesion/basal ganglia ratio, with ratio values of 0.79 and 1.35 corresponding to 95% sensitivity and 95% specificity, respectively. CONCLUSION FDOPA-PET uptake should be interpreted with caution in patients with suspected primary brain tumor, especially in patients showing low or intermediate SUV values and ratios. CLINICAL TRIAL REGISTRATION-URL: https://www.clinicaltrials.gov . Unique identifier: NCT04306484.
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Affiliation(s)
- Dimitri Renard
- Department of Neurology, CHU Nîmes, University Montpellier, Nîmes, France.
| | - Laurent Collombier
- Department of Nuclear Medicine, CHU Nîmes, University Montpellier, Nîmes, France
| | - Sabine Laurent-Chabalier
- Department of Biostatistics, Clinical Epidemiology, Public Health, and Innovation in Methodology, CHU Nîmes, University Montpellier, Nîmes, France
| | - Thibault Mura
- Department of Biostatistics, Clinical Epidemiology, Public Health, and Innovation in Methodology, CHU Nîmes, University Montpellier, Nîmes, France
| | - Anne Le Floch
- Department of Neurology, CHU Nîmes, University Montpellier, Nîmes, France
| | - Hassan El Fertit
- Department of Neurosurgery, CHU Nîmes, University Montpellier, Nîmes, France
| | - Eric Thouvenot
- Department of Neurology, CHU Nîmes, University Montpellier, Nîmes, France.,Institut de Génomique Fonctionnelle, UMR5203, INSERM 1191, University Montpellier, Montpellier, France
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