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CC BY-NC-ND 4.0 · Indian J Radiol Imaging 2015; 25(02): 102-108
DOI: 10.4103/0971-3026.155829
Imaging in Oncology: Recent Advances

Post-treatment imaging of high-grade gliomas

Darshana Sanghvi
Department of Radiology, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India
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Abstract

Current standard of care for treatment of newly diagnosed high grade gliomas is surgery followed by concomitant radiotherapy (RT) and chemotherapy (CT) with temozolomide (TMZ). Recently, bevacizumab, an anti - angiogenic agent has also been approved for treatment of recurrent gliomas. Baseline imaging after excision is optimally obtained in the first 24 hours. When baseline postoperative imaging is delayed beyond 24 hours, subacute hemorrhage, subacute ischemia and inflammation at the resection margins render differentiation from residual tumor challenging. Radiation necrosis is a well recognized entity and is differentiated from recurrence based on morphology on structural imaging, presence of lipid - lactate complexes with lack of choline on spectroscopy and low normalized cerebral blood volume (CBV) ratios at perfusion imaging. Novel chemotherapies have lead to the occurrence of interesting but sometimes confusing post treatment imaging appearances including the phenomena of ′pseudoprogression′ and ′pseudoresponse′. Pseudoprogression refers to transient, self resolving focal enhancement mediated by TMZ-induced increased vascular permeability and local inflammatory response. Pathologically, these lesions do not have viable tumor. The lesions stabilize or regress without further treatment and are usually clinically asymptomatic. Pseudoresponse refers to rapid regression of enhancement, perfusion, mass effect and midline shift caused by the anti - angiogenic effect of bevacizumab. It is termed pseudoresponse since biological tumor persists as non-enhancing altered signal. It is important for radiologists to be aware of these entities seen on post treatment imaging of gliomas, as misinterpretation may lead to inappropriate management decisions and prognostication.

Keywords

Glioma - post treatment - pseudoprogression - pseudoresponse - radiation necrosis


Publication History

Article published online:
30 July 2021

© 2015. Indian Radiological Association. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

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  • References

  • 1 Macdonald DR, Cascino TL, Schold SC Jr, Cairncross JG. Response criteria for phase II studies of supratentorial malignant glioma. J Clin Oncol 1990;8:1277-80.
  • 2 Stupp R, Mason WP, van den Bent MJ, Weller M, Fisher B, Taphoorn MJ, et al.; European Organisation for Research and Treatment of Cancer Brain Tumor and Radiotherapy Groups; National Cancer Institute of Canada Clinical Trials Group. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 2005;352:987-96.
  • 3 Cloughesy TF, Prados MD, Wen PY, Mikkelsen T, Abrey LE, Schiff D, et al. A phase II, randomized, non-comparative clinical trial of the effect of bevacizumab (BV) alone or in combination with irinotecan (CPT) on 6-month progression free survival (PFS6) in recurrent, treatment-refractory glioblastoma (GBM). J Clin Otol 2008;26(Suppl 15):2010b.
  • 4 Hygino da Cruz LC Jr, Rodriguez I, Domingues RC, Gasparetto EL, Sorensen AG. Pseudoprogression and pseudoresponse: Imaging challenges in the assessment of posttreatment glioma. AJNR Am J Neuroradiol 2011;32:1978-85.
  • 5 Wen PY, Macdonald DR, Reardon DA, Cloughesy TF, Sorensen AG, Galanis E, et al. Updated response assessment criteria for high-grade gliomas: Response assessment in neuro-oncology working group. J Clin Oncol 2010;28:1963-72.
  • 6 Oser AB, Moran CJ, Kaufman BA, Park TS. Intracranial tumor in children: MR imaging findings within 24 hours of craniotomy. Radiology 1997;205:807-12.
  • 7 Wang LL, Leach JL, Breneman JC, McPherson CM, Gaskill-Shipley MF. Critical role of imaging in the neurosurgical and radiotherapeutic management of brain tumors. Radiographics 2014;34:702-21.
  • 8 Farace P, Amelio D, Ricciardi GK, Zoccatelli G, Magon S, Pizzini F, et al. Early MRI changes in glioblastoma in the period between surgery and adjuvant therapy. J Neurooncol 2013;111:177-85.
  • 9 Winterstein M, Münter MW, Burkholder I, Essig M, Kauczor HU, Weber MA. Partially resected gliomas: Diagnostic performance of fluid-attenuated inversion recovery MR imaging for detection of progression. Radiology 2010;254:907-16.
  • 10 Kumar AJ, Leeds NE, Fuller GN, Van Tassel P, Maor MH, Sawaya RE, et al. Malignant gliomas: MR imaging spectrum of radiation therapy- and chemotherapy-induced necrosis of the brain after treatment. Radiology 2000;217:377-84.
  • 11 Fatterpekar GM, Galheigo D, Narayana A, Johnson G, Knopp E. Treatment-related change versus tumor recurrence in high-grade gliomas: A diagnostic conundrum-use of dynamic susceptibility contrast-enhanced (DSC) perfusion MRI. AJR Am J Roentgenol 2012;198:19-26.
  • 12 Barajas RF Jr, Chang JS, Segal MR, Parsa AT, McDermott MW, Berger MS, et al. Differentiation of recurrent glioblastoma multiforme from radiation necrosis after external beam radiation therapy with dynamic susceptibility-weighted contrast-enhanced perfusion MR imaging. Radiology 2009;253:486-96.
  • 13 Rock JP, Hearshen D, Scarpace L, Croteau D, Gutierrez J, Fisher JL, et al. Correlations between magnetic resonance spectroscopy and image-guided histopathology, with special attention to radiation necrosis. Neurosurgery 2002;51: 912-20.
  • 14 Alexiou GA, Tsiouris S, Kyritsis AP, Voulgaris S, Argyropoulou MI, Fotopoulos AD. Glioma recurrence versus radiation necrosis: Accuracy of current imaging modalities. J Neurooncol 2009;95:1-11.
  • 15 Plotkin M, Eisenacher J, Bruhn H, Wurm R, Michel R, Stockhammer F, et al. 123I-IMT SPECT and 1H MR-spectroscopy at 3.0 T in the differential diagnosis of recurrent or residual gliomas: A comparative study. J Neurooncol 2004;70:49-58.
  • 16 Sugahara T, Korogi Y, Tomiguchi S, Shigematsu Y, Ikushima I, Kira T, et al. Posttherapeutic intraaxial brain tumor: The value of perfusion-sensitive contrast-enhanced MR imaging for differentiating tumor recurrence from nonneoplastic contrast-enhancing tissue. AJNR Am J Neuroradiol 2000;21:901-9.
  • 17 Tsien C, Galbán CJ, Chenevert TL, Johnson TD, Hamstra DA, Sundgren PC, et al. Parametric response map as an imaging biomarker to distinguish progression from pseudoprogression in high-gradeglioma. J Clin Oncol 2010;28:2293-9.
  • 18 Zeng QS, Li CF, Liu H, Zhen JH, Feng DC. Distinction between recurrent glioma and radiation injury using magnetic resonance spectroscopy in combination with diffusion-weighted imaging. Int J Radiat Oncol Biol Phys 2007;68:151-8.
  • 19 Sundgren PC, Fan X, Weybright P, Welsh RC, Carlos RC, Petrou M, et al. Differentiation of recurrent brain tumor versus radiation injury using diffusion tensor imaging in patients with new contrast-enhancing lesions. Magn Reson Imaging 2006;24:1131-42.
  • 20 Chamberlain MC, Glantz MJ, Chalmers L, Van Horn A, Sloan AE. Early necrosis following concurrent Temodar and radiotherapy in patients with glioblastoma. J Neurooncol 2007;82:81-3.
  • 21 Brandes AA, Tosoni A, Spagnolli F, Frezza G, Leonardi M, Calbucci F, et al. Disease progression or pseudoprogression after concomitant radiochemotherapy treatment: Pitfalls in neurooncology. Neuro Oncol 2008;10:361-7.
  • 22 Taal W, Brandsma D, de Bruin HG, Bromberg JE, Swaak-Kragten AT, Smitt PA, et al. Incidence of early pseudo-progression in a cohort of malignant glioma patients treated with chemoirradiation with temozolomide. Cancer 2008;113:405-10.
  • 23 Young RJ, Gupta A, Shah AD, Graber JJ, Zhang Z, Shi W, et al. Potential utility of conventional MRI signs in diagnosing pseudoprogression in glioblastoma. Neurology 2011;76:1918-24.
  • 24 Mangla R, Singh G, Ziegelitz D, Milano MT, Korones DN, Zhong J, et al. Changes in relative cerebral blood volume 1 month after radiation-temozolomide therapy can help predict overall survival in patients with glioblastoma. Radiology 2010;256:575-84.
  • 25 Cha J, Kim ST, Kim HJ, Kim BJ, Kim YK, Lee JY, et al. Differentiation of tumor progression from pseudoprogression in patients with posttreatment glioblastoma using multiparametric histogram analysis. AJNR Am J Neuroradiol 2014;35:1309-17.
  • 26 Laymon CM, Oborski MJ, Lee VK, Davis DK, Wiener EC, Lieberman FS, et al. Combined imaging biomarkers for therapy evaluation in glioblastoma multiforme: Correlating sodium MRI and F-18 FLT PET on a voxel-wise basis. Magn Reson Imaging 2012;30:1268-78.
  • 27 Götz I, Grosu AL. [(18) F] FET-PET imaging for treatment and response monitoring of radiation therapy in malignant glioma patients-A review. Front Oncol 2013;3:104.
  • 28 Brandsma D, van den Bent MJ. Pseudoprogression and pseudoresponse in the treatment of gliomas. Curr Opin Neurol 2009;22:633-8.
  • 29 Clarke JL, Chang S. Pseudoprogression and pseudoresponse: Challenges in brain tumor imaging. Curr Neurol Neurosci Rep 2009;9:241-6.
  • 30 Kreisl TN, Kim L, Moore K, Duic P, Royce C, Stroud I, et al. Phase II trial of single-agent bevacizumab followed by bevacizumab plus irinotecan at tumor progression in recurrent glioblastoma. J Clin Oncol 2009;27:740-5.
  • 31 Vredenburgh JJ, Desjardins A, Herndon JE 2 nd , Marcello J, Reardon DA, Quinn JA, et al. Bevacizumab plus irinotecan in recurrent glioblastoma multiforme. J Clin Oncol 2007;25:4722-9.
  • 32 Pàez-Ribes M, Allen E, Hudock J, Takeda T, Okuyama H, Viñals F, et al. Antiangiogenic therapy elicits malignant progression of tumors to increased local invasion and distant metastasis. Cancer Cell 2009;15:220-31.