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Salans M, Houri J, Karunamuni R, Hopper A, Delfanti R, Seibert TM, Bahrami N, Sharifzadeh Y, McDonald C, Dale A, Moiseenko V, Farid N, Hattangadi-Gluth JA. The relationship between radiation dose and bevacizumab-related imaging abnormality in patients with brain tumors: A voxel-wise normal tissue complication probability (NTCP) analysis. PLoS One 2023; 18:e0279812. [PMID: 36800342 PMCID: PMC9937457 DOI: 10.1371/journal.pone.0279812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 12/15/2022] [Indexed: 02/18/2023] Open
Abstract
PURPOSE Bevacizumab-related imaging abnormality (BRIA), appearing as areas of restricted diffusion on magnetic resonance imaging (MRI) and representing atypical coagulative necrosis pathologically, has been observed in patients with brain tumors receiving radiotherapy and bevacizumab. We investigated the role of cumulative radiation dose in BRIA development in a voxel-wise analysis. METHODS Patients (n = 18) with BRIA were identified. All had high-grade gliomas or brain metastases treated with radiotherapy and bevacizumab. Areas of BRIA were segmented semi-automatically on diffusion-weighted MRI with apparent diffusion coefficient (ADC) images. To avoid confounding by possible tumor, hypoperfusion was confirmed with perfusion imaging. ADC images and radiation dose maps were co-registered to a high-resolution T1-weighted MRI and registration accuracy was verified. Voxel-wise normal tissue complication probability analyses were performed using a logistic model analyzing the relationship between cumulative voxel equivalent total dose in 2 Gy fractions (EQD2) and BRIA development at each voxel. Confidence intervals for regression model predictions were estimated with bootstrapping. RESULTS Among 18 patients, 39 brain tumors were treated. Patients received a median of 4.5 cycles of bevacizumab and 1-4 radiation courses prior to BRIA appearance. Most (64%) treated tumors overlapped with areas of BRIA. The median proportion of each BRIA region of interest volume overlapping with tumor was 98%. We found a dose-dependent association between cumulative voxel EQD2 and the relative probability of BRIA (β0 = -5.1, β1 = 0.03 Gy-1, γ = 1.3). CONCLUSIONS BRIA is likely a radiation dose-dependent phenomenon in patients with brain tumors receiving bevacizumab and radiotherapy. The combination of radiation effects and tumor microenvironmental factors in potentiating BRIA in this population should be further investigated.
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Affiliation(s)
- Mia Salans
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, United States of America
| | - Jordan Houri
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, United States of America
- Carl E. Ravin Advanced Imaging Laboratories, Duke University, Durham, North Carolina, United States of America
| | - Roshan Karunamuni
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, United States of America
| | - Austin Hopper
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, United States of America
| | - Rachel Delfanti
- Department of Radiology, University of California San Diego, La Jolla, California, United States of America
| | - Tyler M. Seibert
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, United States of America
- Department of Bioengineering, University of California San Diego, La Jolla, California, United States of America
| | - Naeim Bahrami
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, United States of America
| | - Yasamin Sharifzadeh
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, United States of America
| | - Carrie McDonald
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, United States of America
- Department of Psychiatry, University of California San Diego, La Jolla, California, United States of America
| | - Anders Dale
- Department of Radiology, University of California San Diego, La Jolla, California, United States of America
- Department of Psychiatry, University of California San Diego, La Jolla, California, United States of America
| | - Vitali Moiseenko
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, United States of America
| | - Nikdokht Farid
- Department of Radiology, University of California San Diego, La Jolla, California, United States of America
| | - Jona A. Hattangadi-Gluth
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, United States of America
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Zhang M, Gulotta B, Thomas A, Kaley T, Karimi S, Gavrilovic I, Woo KM, Zhang Z, Arevalo-Perez J, Holodny AI, Rosenblum M, Young RJ. Large-volume low apparent diffusion coefficient lesions predict poor survival in bevacizumab-treated glioblastoma patients. Neuro Oncol 2015; 18:735-43. [PMID: 26538618 DOI: 10.1093/neuonc/nov268] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 10/01/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Glioblastomas treated with bevacizumab may develop low-signal apparent diffusion coefficient (low-ADC) lesions, which may reflect increased tumor cellularity or atypical necrosis. The purpose of this study was to examine the relationship between low-ADC lesions and overall survival (OS). We hypothesized that growing low-ADC lesions would be associated with shorter OS. METHODS We retrospectively identified 52 patients treated with bevacizumab for the first (n = 42, 81%) or later recurrence of primary glioblastoma, who had low-ADC lesions and 2 post-bevacizumab scans ≤90 days apart. Low-ADC lesion volumes were measured, and normalized 5th percentile histogram low-ADC values were recorded. Using OS as the primary endpoint, semiparametric Cox models were fitted to ascertain univariate and multivariate hazard ratios (HRs) with significance at P = .05. RESULTS Median OS was 9.1 months (95% CI = 7.2-14.3). At the second post-bevacizumab scan, the volume of the low-ADC lesion (median: 12.94 cm(3)) was inversely associated with OS, with larger volumes predicting shorter OS (HR = 1.014 [95% CI = 1.003-1.025], P = .009). The percent change in low-ADC volume (median: 6.8%) trended toward increased risk of death with growing volumes (P = .08). Normalized 5th percentile low-ADC value and its percent change were not associated with OS (P > .51). Also correlated with shorter OS were the pre-bevacizumab nonenhancing volume (P = .025), the first post-bevacizumab enhancing volume (P = .040), and the second post-bevacizumab enhancing volume (P = .004). CONCLUSIONS The volume of low-ADC lesions at the second post-bevacizumab scan predicted shorter OS. This suggests that low-ADC lesions may be considered important imaging markers and included in treatment decision algorithms.
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Affiliation(s)
- Myron Zhang
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York (M.Z., B.G., S.K., J.A.-P., A.I.H., R.J.Y.); Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.T., T.K., I.G.); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York (K.M.W., Z.Z.); Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York (M.R.); Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York (T.K., S.K., I.G., A.I.H., M.R., R.J.Y.)
| | - Bryanna Gulotta
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York (M.Z., B.G., S.K., J.A.-P., A.I.H., R.J.Y.); Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.T., T.K., I.G.); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York (K.M.W., Z.Z.); Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York (M.R.); Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York (T.K., S.K., I.G., A.I.H., M.R., R.J.Y.)
| | - Alissa Thomas
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York (M.Z., B.G., S.K., J.A.-P., A.I.H., R.J.Y.); Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.T., T.K., I.G.); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York (K.M.W., Z.Z.); Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York (M.R.); Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York (T.K., S.K., I.G., A.I.H., M.R., R.J.Y.)
| | - Thomas Kaley
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York (M.Z., B.G., S.K., J.A.-P., A.I.H., R.J.Y.); Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.T., T.K., I.G.); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York (K.M.W., Z.Z.); Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York (M.R.); Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York (T.K., S.K., I.G., A.I.H., M.R., R.J.Y.)
| | - Sasan Karimi
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York (M.Z., B.G., S.K., J.A.-P., A.I.H., R.J.Y.); Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.T., T.K., I.G.); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York (K.M.W., Z.Z.); Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York (M.R.); Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York (T.K., S.K., I.G., A.I.H., M.R., R.J.Y.)
| | - Igor Gavrilovic
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York (M.Z., B.G., S.K., J.A.-P., A.I.H., R.J.Y.); Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.T., T.K., I.G.); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York (K.M.W., Z.Z.); Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York (M.R.); Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York (T.K., S.K., I.G., A.I.H., M.R., R.J.Y.)
| | - Kaitlin M Woo
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York (M.Z., B.G., S.K., J.A.-P., A.I.H., R.J.Y.); Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.T., T.K., I.G.); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York (K.M.W., Z.Z.); Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York (M.R.); Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York (T.K., S.K., I.G., A.I.H., M.R., R.J.Y.)
| | - Zhigang Zhang
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York (M.Z., B.G., S.K., J.A.-P., A.I.H., R.J.Y.); Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.T., T.K., I.G.); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York (K.M.W., Z.Z.); Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York (M.R.); Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York (T.K., S.K., I.G., A.I.H., M.R., R.J.Y.)
| | - Julio Arevalo-Perez
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York (M.Z., B.G., S.K., J.A.-P., A.I.H., R.J.Y.); Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.T., T.K., I.G.); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York (K.M.W., Z.Z.); Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York (M.R.); Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York (T.K., S.K., I.G., A.I.H., M.R., R.J.Y.)
| | - Andrei I Holodny
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York (M.Z., B.G., S.K., J.A.-P., A.I.H., R.J.Y.); Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.T., T.K., I.G.); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York (K.M.W., Z.Z.); Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York (M.R.); Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York (T.K., S.K., I.G., A.I.H., M.R., R.J.Y.)
| | - Marc Rosenblum
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York (M.Z., B.G., S.K., J.A.-P., A.I.H., R.J.Y.); Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.T., T.K., I.G.); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York (K.M.W., Z.Z.); Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York (M.R.); Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York (T.K., S.K., I.G., A.I.H., M.R., R.J.Y.)
| | - Robert J Young
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York (M.Z., B.G., S.K., J.A.-P., A.I.H., R.J.Y.); Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.T., T.K., I.G.); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York (K.M.W., Z.Z.); Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York (M.R.); Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York (T.K., S.K., I.G., A.I.H., M.R., R.J.Y.)
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