J Korean Soc Magn Reson Med.  2014 Jun;18(2):120-132. 10.13104/jksmrm.2014.18.2.120.

Differentiation of True Recurrence from Delayed Radiation Therapy-related Changes in Primary Brain Tumors Using Diffusion-weighted Imaging, Dynamic Susceptibility Contrast Perfusion Imaging, and Susceptibility-weighted Imaging

• Kim DH
• Choi SH
• Ryoo I
• Yoon TJ
• Kim TM
• Lee SH
• Park CK
• Kim JH
• Sohn CH
• Park SH
• Kim IH

• KMID: 2099888
• DOI: http://doi.org/10.13104/jksmrm.2014.18.2.120

Abstract

PURPOSE
To compare dynamic susceptibility contrast imaging, diffusion-weighted imaging, and susceptibility-weighted imaging (SWI) for the differentiation of tumor recurrence and delayed radiation therapy (RT)-related changes in patients treated with RT for primary brain tumors.
MATERIALS AND METHODS
We enrolled 24 patients treated with RT for various primary brain tumors, who showed newly appearing enhancing lesions more than one year after completion of RT on follow-up MRI. The enhancing-lesions were confirmed as recurrences (n=14) or RT-changes (n=10). We calculated the mean values of normalized cerebral blood volume (nCBV), apparent diffusion coefficient (ADC), and proportion of dark signal intensity on SWI (proSWI) for the enhancing-lesions. All the values between the two groups were compared using t-test. A multivariable logistic regression model was used to determine the best predictor of differential diagnosis. The cutoff value of the best predictor obtained from receiver-operating characteristic curve analysis was applied to calculate the sensitivity, specificity, and accuracy for the diagnosis.
RESULTS
The mean nCBV value was significantly higher in the recurrence group than in the RT-change group (P=.004), and the mean proSWI was significantly lower in the recurrence group (P<.001). However, no significant difference was observed in the mean ADC values between the two groups. A multivariable logistic regression analysis showed that proSWI was the only independent variable for the differentiation; the sensitivity, specificity, and accuracy were 78.6% (11 of 14), 100% (10 of 10), and 87.5% (21 of 24), respectively.
CONCLUSION
The proSWI was the most promising parameter for the differentiation of newly developed enhancing-lesions more than one year after RT completion in brain tumor patients.

Keyword

Tumor recurrence; Radiation therapy-related change; Diffusion-weighted imaging; Perfusion imaging Susceptibility-weighted imaging

MeSH Terms

Blood Volume
Brain Neoplasms*
Diagnosis
Diagnosis, Differential
Diffusion
Follow-Up Studies
Humans
Logistic Models
Magnetic Resonance Imaging
Perfusion Imaging*
Recurrence*
Sensitivity and Specificity

Figure

• 

  Fig. 1 Flow diagram of patient selection with inclusion and exclusion criteria. Note.- DWI = diffusion-weighted imaging, DSC PWI = dynamic susceptibility contrast perfusion-weighted imaging, SWI = susceptibility-weighted imaging

• 

  Fig. 2 Flow chart of quantitative image analysis. Region of interest (ROI) was manually selected in each section of the enhancing lesions, and was semi-automatically co-registered with the apparent diffusion coefficient and relative cerebral blood volume maps. Volume of interest was determined by the summation of each slice, and final ADC and normalized CBV values were obtained. In cases of susceptibility-weighted imaging, the binary scale was adjusted to measure the area of dark signal intensity (SI) in the ROI (red spots show transformed dark SI). All the areas from each slice were also totaled for volumetric data. Note.- ROI = region of interest, SWI = susceptibility-weighted imaging, ADC = apparent diffusion coefficient, CBV = cerebral blood volume

• 

  Fig. 3 Box-and-whisker plots. The distributions of (a) ADC, (b) nCBV, and (c) proSWI between two groups are displayed. Outliers are plotted as individual points. Note.- RT = radiation therapy, ADC = apparent diffusion coefficient, nCBV = normalized cerebral blood volume, proSWI = proportion of dark signal intensity on susceptibility-weighted imaging

• 

  Fig. 4 True recurrence. A 57-year-old woman who underwent gross total resection and concomitant chemoradiotherapy (CCRT) with temozolomide for glioblastoma in the left parietal lobe. (a) Contrast-enhanced T1-weighted (CET1) magnetic resonance (MR) image obtained 11 months after CCRT completion shows no abnormal enhancing lesion in the left parietal surgical bed. (b) 4 months follow-up CET1 MR image demonstrates newly developed enhancing lesion (arrow) in the left parietal tumor resection site. (c) Serial follow-up MR image obtained one month later shows an increase in the enhancement extent (arrow). (d) The mean apparent diffusion coefficient (ADC) value of the enhancing lesion from ADC map was 1130 × 10-6 mm2/s (b = 1000 sec/mm2) (arrow). (e) Relative cerebral blood volume (CBV) map from dynamic susceptibility contrast perfusion-weighted imaging shows increased blood flow in the corresponding enhancing lesion (normalized relative CBV = 3.7). (f) Susceptibility-weighted imaging demonstrates nearly no dark spot in the enhancing lesion, and the proportion of dark signal intensity was 0.44%.

• 

  Fig. 5 Radiation therapy (RT)-related change. A 44-year-old woman who underwent gross total resection and concomitant chemoradiotherapy (CCRT) for anaplastic oligoastrocytoma in bilateral frontal lobes. (a) Contrast-enhanced T1-weighted (CET1) magnetic resonance (MR) image obtained 15 months after CCRT completion shows postoperative surgical bed enhancements (arrows) in the bilateral frontal areas without evidence of tumor recurrence. 90 months after CCRT follow-up (b) precontrast T1-weighted image and (c) CET1 image demonstrate a newly noted large hemorrhagic mass (arrow), with peripheral enhancement in the right frontal lobe. After the surgical resection, pathology revealed this lesion to be an RT-related change. (d) The mean apparent diffusion coefficient (ADC) value of the enhancing lesion from ADC map was 1230 × 10-6 mm2/s (b = 1000 sec/mm2) (arrow). (e) Relative cerebral blood volume map (CBV) from dynamic susceptibility contrast perfusion-weighted imaging shows nearly an absence of blood flow (arrow) in the corresponding enhancing area (normalized relative CBV = 0.3). (f) Susceptibility-weighted imaging demonstrates significant dark spots in the inner hemorrhage (asterisk) and peripheral enhancing portion (arrowheads) of the mass; the calculated proportion of dark signal intensity (proSWI) was 80.53%.

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