Methionine positron emission tomography of recurrent metastatic brain tumor and radiation necrosis after stereotactic radiosurgery: is a differential diagnosis possible?

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Object. In this study the authors examined how to differentiate radiation necrosis from recurrent metastatic brain tumor following stereotactic radiosurgery by using positron emission tomography (PET) with l-[methyl-11C]methionine (MET).

Methods. In 21 adult patients with suspected recurrent metastatic brain tumor or radiation injury, MET-PET scans were obtained. These patients had previously undergone stereotactic radiosurgery and subsequent contrast-enhanced magnetic resonance (MR) examinations before nuclear medicine imaging. Positron emission tomography images were obtained as a static scan of 10 minutes performed 20 minutes after injection of 370 MBq of MET. On MET-PET scans, the portion of the tumor with the highest accumulation of MET was selected as the region of interest (ROI), and the ratio of tumor tissue to normal tissue (T/N) was defined as the mean counts of radioisotope per pixel in the tumor divided by the mean counts per pixel in normal gray matter. The standardized uptake value (SUV) was calculated using the same ROI in the tumor. The accuracy of the MET-PET scan was evaluated by correlating findings with results of subsequent histological analysis (11 cases) or, in cases in which surgery or biopsy was not performed, with subsequent clinical course and MR imaging findings (10 cases).

Histological examinations performed in 11 cases showed viable tumor cells with necrosis in nine and necrosis with no viable tumor cells in two. Another 10 cases were characterized as radiation necrosis because the patients exhibited stable neurological symptoms with no sign of massive enlargement of the lesion on follow-up MR images after 5 months. The mean T/N was 1.15 in the radiation necrosis group (12 cases) and 1.62 in the tumor recurrence group (nine cases). The mean SUV was 1.78 in the necrosis group and 2.5 in the recurrence group. There were statistically significant differences between the recurrence and necrosis groups in T/N and SUV. Furthermore, the borderline T/N value was 1.42 according to a 2 × 2 factorial table (high T/N or low T/N, recurrence or necrosis). From this result, the sensitivity and specificity of MET-PET scanning in detecting tumor recurrence were determined to be 77.8 and 100%, respectively.

Conclusions. The use of MET-PET scanning is a sensitive and accurate technique for differentiating between metastatic brain tumor recurrence and radiation necrosis following stereotactic radiosurgery. This study reveals important information for creating strategies to treat postradiation reactions.

Article Information

Address reprint requests to: Naohiro Tsuyuguchi, M.D., Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1–4–3 Asahimachi, Abeno, Osaka 545–8585, Japan. email: nao@med.osaka-cu.ac.jp.

© AANS, except where prohibited by US copyright law.

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Figures

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    Bar graph illustrating the distribution of T/N (TN) in the necrosis and recurrence groups. There was a significant difference between the two groups. Error bars show the standard error of the mean (SEM). The T/N value was 1.15 ± 0.22 (SEM 0.06) in the radiation necrosis group (12 patients), and 1.62 ± 0.28 (SEM 0.09) in tumor recurrence group (nine patients).

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    Case 1. Left: An MR image demonstrating an enhanced lesion around the left basal ganglion. Center: An MET-PET scan revealing slight accumulation in the lesion, similar to the gray matter. The T/N was 1.29. Right: A 201Tl-SPECT scan exhibiting this lesion as a high-uptake area.

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    Case 1. Photomicrograph of a tissue section displaying a small tumorous lesion within the necrosis. H & E, original magnification × 100.

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    Case 2. Left: An MR image demonstrating an abnormal enhanced lesion in the left parietal lobe. Center: An MET-PET scan exhibiting accumulation in the lesion (T/N 1.95). Right: A 201Tl-SPECT scan revealing slight accumulation in the lesion (201Tl index 1.46).

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    Case 2. Photomicrograph of a tissue section showing viable tumor cells. H & E, original magnification × 125.

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    Case 10. Left: An MR image revealing an enhanced lesion in the right frontal lobe. Center: An MET-PET scan revealing increased uptake in the lesion and a high T/N ratio (1.41). Right: A 201Tl-SPECT scan demonstrating this lesion to be a high-uptake area.

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    Case 10. Photomicrographs of tissue sections demonstrating necrosis with vascular proliferation and no viable tumor cells (left) and many LCA-positive cells (right, arrows). H & E, original magnification × 100 (left); LCA, original magnification × 100 (right).

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    Case 12. Left: An MR image revealing a ringlike enhanced lesion in the left parietal region. Center: An MET-PET scan demonstrating no accumulation in the lesion and a low T/N ratio (0.98). Right: A 201Tl-SPECT scan exhibiting the lesion as a high-uptake area (201Tl index 5.2).

References

  • 1.

    Black KLHawkins RAKim KTet al: Use of thallium-201 SPECT to quantitate malignancy grade of gliomas. J Neurosurg 71:3423461989Black KL Hawkins RA Kim KT et al: Use of thallium-201 SPECT to quantitate malignancy grade of gliomas. J Neurosurg 71:342–346 1989

    • Search Google Scholar
    • Export Citation
  • 2.

    Buchpiguel CAAlavi JBAlavi Aet al: PET versus SPECT in distinguishing radiation necrosis from tumor recurrence in the brain. J Nucl Med 36:1591641995Buchpiguel CA Alavi JB Alavi A et al: PET versus SPECT in distinguishing radiation necrosis from tumor recurrence in the brain. J Nucl Med 36:159–164 1995

    • Search Google Scholar
    • Export Citation
  • 3.

    Chiang CSMcBride WHWithers HR: Radiation-induced astrocytic and microglial responses in mouse brain. Radiother Oncol 29:60681993Chiang CS McBride WH Withers HR: Radiation-induced astrocytic and microglial responses in mouse brain. Radiother Oncol 29:60–68 1993

    • Search Google Scholar
    • Export Citation
  • 4.

    De Witte OGoldberg IWikler Det al: Positron emission tomography with injection of methionine as a prognostic factor in glioma. J Neurosurg 95:7467502001De Witte O Goldberg I Wikler D et al: Positron emission tomography with injection of methionine as a prognostic factor in glioma. J Neurosurg 95:746–750 2001

    • Search Google Scholar
    • Export Citation
  • 5.

    Dethy SGoldman SBlecic Set al: Carbon-11-methionine and fluorine-18-fDG PET study in brain hematoma. J Nucl Med 35:116211661994Dethy S Goldman S Blecic S et al: Carbon-11-methionine and fluorine-18-fDG PET study in brain hematoma. J Nucl Med 35:1162–1166 1994

    • Search Google Scholar
    • Export Citation
  • 6.

    Di Chiro G: Positron emission tomography using [18F] fluorodeoxyglucose in brain tumors. A powerful diagnostic and prognostic tool. Invest Radiol 22:3603711987Di Chiro G: Positron emission tomography using [18F] fluorodeoxyglucose in brain tumors. A powerful diagnostic and prognostic tool. Invest Radiol 22:360–371 1987

    • Search Google Scholar
    • Export Citation
  • 7.

    Di Chiro GOldfield EWright DCet al: Cerebral necrosis after radiotherapy and/or intraarterial chemotherapy for brain tumors: PET and neuropathologic studies. AJR 150:1891971988Di Chiro G Oldfield E Wright DC et al: Cerebral necrosis after radiotherapy and/or intraarterial chemotherapy for brain tumors: PET and neuropathologic studies. AJR 150:189–197 1988

    • Search Google Scholar
    • Export Citation
  • 8.

    Dooms GCHecht SBrant-Zawadzki Met al: Brain radiation lesions: MR imaging. Radiology 158:1491551986Dooms GC Hecht S Brant-Zawadzki M et al: Brain radiation lesions: MR imaging. Radiology 158:149–155 1986

    • Search Google Scholar
    • Export Citation
  • 9.

    Ishii KOgawa THatazawa Jet al: High L-methyl-[11C]methionine uptake in brain abscess: a PET study. J Comput Assist Tomogr 17:6606611993Ishii K Ogawa T Hatazawa J et al: High L-methyl-[11C]methionine uptake in brain abscess: a PET study. J Comput Assist Tomogr 17:660–661 1993

    • Search Google Scholar
    • Export Citation
  • 10.

    Ishiwata KKubota KMurakami Met al: Re-evaluation of amino acid PET studies: can the protein synthesis rates in brain and tumor tissues be measured in vivo? J Nucl Med 34:193619431993Ishiwata K Kubota K Murakami M et al: Re-evaluation of amino acid PET studies: can the protein synthesis rates in brain and tumor tissues be measured in vivo? J Nucl Med 34:1936–1943 1993

    • Search Google Scholar
    • Export Citation
  • 11.

    Iwai YYamanaka KOda Jet al: Tracer accumulation in radiation necrosis of the brain after thallium-201 SPECT and [11C] methionine PET—case report. Neurol Med Chir 41:4154182001Iwai Y Yamanaka K Oda J et al: Tracer accumulation in radiation necrosis of the brain after thallium-201 SPECT and [11C] methionine PET—case report. Neurol Med Chir 41:415–418 2001

    • Search Google Scholar
    • Export Citation
  • 12.

    Kline JLNoto RBGlantz M: Single-photon emission CT in the evaluation of recurrent brain tumor in patients treated with gamma knife radiosurgery or conventional radiation therapy. AJNR 17:168116861996Kline JL Noto RB Glantz M: Single-photon emission CT in the evaluation of recurrent brain tumor in patients treated with gamma knife radiosurgery or conventional radiation therapy. AJNR 17:1681–1686 1996

    • Search Google Scholar
    • Export Citation
  • 13.

    Kubota KMatsuzawa TFuziwara Tet al: [An experimental study on differential diagnosis of cancer from inflammation using 11C-L-methionine.] ??Kaku Igaku 22:132713321985 (Jpn)Kubota K Matsuzawa T Fuziwara T et al: [An experimental study on differential diagnosis of cancer from inflammation using 11C-L-methionine.] ??Kaku Igaku 22:1327–1332 1985 (Jpn)

    • Search Google Scholar
    • Export Citation
  • 14.

    Kureshi SAHofman FMSchneider JHet al: Cytokine expression in radiation-induced delayed cerebral injury. Neurosurgery 35:8228301994Kureshi SA Hofman FM Schneider JH et al: Cytokine expression in radiation-induced delayed cerebral injury. Neurosurgery 35:822–830 1994

    • Search Google Scholar
    • Export Citation
  • 15.

    Lilja ALundqvist HOlsson Yet al: Positron emission tomography and computed tomography in differential diagnosis between recurrent or residual glioma and treatment-induced brain lesions. Acta Radiol 30:1211281989Lilja A Lundqvist H Olsson Y et al: Positron emission tomography and computed tomography in differential diagnosis between recurrent or residual glioma and treatment-induced brain lesions. Acta Radiol 30:121–128 1989

    • Search Google Scholar
    • Export Citation
  • 16.

    Loeffler JSSiddon RLWen PYet al: Stereotactic radiosurgery of the brain using a standard linear accelerator: a study of early and late effects. Radiother Oncol 17:3113211997Loeffler JS Siddon RL Wen PY et al: Stereotactic radiosurgery of the brain using a standard linear accelerator: a study of early and late effects. Radiother Oncol 17:311–321 1997

    • Search Google Scholar
    • Export Citation
  • 17.

    Matheja PRickert CWeckesser Met al: Scintigraphic pitfall: delayed radionecrosis. Case illustration. J Neurosurg 92:7322000Matheja P Rickert C Weckesser M et al: Scintigraphic pitfall: delayed radionecrosis. Case illustration. J Neurosurg 92:732 2000

    • Search Google Scholar
    • Export Citation
  • 18.

    Nakamura OKosuda SOkamoto Ket al: [Differential diagnosis between recurrence of gliomas and radiation necrosis by 201TlCl SPECT.] ??No To Shinkei 46:105110571994 (Jpn)Nakamura O Kosuda S Okamoto K et al: [Differential diagnosis between recurrence of gliomas and radiation necrosis by 201TlCl SPECT.] ??No To Shinkei 46:1051–1057 1994 (Jpn)

    • Search Google Scholar
    • Export Citation
  • 19.

    Nishimura RTakahashi MMorishita Set al: MR imaging of late radiation brain injury. Radiat Med 10:1011081992Nishimura R Takahashi M Morishita S et al: MR imaging of late radiation brain injury. Radiat Med 10:101–108 1992

    • Search Google Scholar
    • Export Citation
  • 20.

    Ogawa THatazawa JInugami Aet al: Carbon-11-methionine PET evaluation of intracerebral hematoma: distinguishing neoplastic from non-neoplastic hematoma. J Nucl Med 36:217521791995Ogawa T Hatazawa J Inugami A et al: Carbon-11-methionine PET evaluation of intracerebral hematoma: distinguishing neoplastic from non-neoplastic hematoma. J Nucl Med 36:2175–2179 1995

    • Search Google Scholar
    • Export Citation
  • 21.

    Ogawa TInugami AHatazawa Jet al: Clinical positron emission tomography for brain tumors: comparison of fludeoxyglucose F18 and L-methyl-11C-methionine. AJNR 17:3453531996Ogawa T Inugami A Hatazawa J et al: Clinical positron emission tomography for brain tumors: comparison of fludeoxyglucose F18 and L-methyl-11C-methionine. AJNR 17:345–353 1996

    • Search Google Scholar
    • Export Citation
  • 22.

    Ogawa TKanno IShishido Fet al: Clinical value of PET with 8F-fluorodeoxyglucose and L-methyl-11C-methionine for diagnosis of recurrent brain tumor and radiation injury. Acta Radiol 32:1972021991Ogawa T Kanno I Shishido F et al: Clinical value of PET with 8F-fluorodeoxyglucose and L-methyl-11C-methionine for diagnosis of recurrent brain tumor and radiation injury. Acta Radiol 32:197–202 1991

    • Search Google Scholar
    • Export Citation
  • 23.

    Patronas NJDi Chiro GBrooks RAet al: Work in progress: [18F] fluorodeoxyglucose and positron emission tomography in the evaluation of radiation necrosis of the brain. Radiology 144:8858891982Patronas NJ Di Chiro G Brooks RA et al: Work in progress: [18F] fluorodeoxyglucose and positron emission tomography in the evaluation of radiation necrosis of the brain. Radiology 144:885–889 1982

    • Search Google Scholar
    • Export Citation
  • 24.

    Plowman PN: Stereotactic radiosurgery. VIII. The classification of postradiation reactions. Br J Neurosurg 13:2562641999Plowman PN: Stereotactic radiosurgery. VIII. The classification of postradiation reactions. Br J Neurosurg 13:256–264 1999

    • Search Google Scholar
    • Export Citation
  • 25.

    Schwartz RBCarvalho PAAlexander E IIIet al: Radiation necrosis vs high-grade recurrent glioma: differentiation by using dual-isotope SPECT with 201TI and 99mTc-HMPAO. AJNR 12:118711921991Schwartz RB Carvalho PA Alexander E III et al: Radiation necrosis vs high-grade recurrent glioma: differentiation by using dual-isotope SPECT with 201TI and 99mTc-HMPAO. AJNR 12:1187–1192 1991

    • Search Google Scholar
    • Export Citation
  • 26.

    Sonoda YKumabe TTakahashi Tet al: Clinical usefulness of 11C-MET PET and 201T1 SPECT for differentiation of recurrent glioma from radiation necrosis. Neurol Med Chir 38:3423481998Sonoda Y Kumabe T Takahashi T et al: Clinical usefulness of 11C-MET PET and 201T1 SPECT for differentiation of recurrent glioma from radiation necrosis. Neurol Med Chir 38:342–348 1998

    • Search Google Scholar
    • Export Citation
  • 27.

    Valk PEBudinger TFLevin VAet al: PET of malignant cerebral tumors after interstitial brachytherapy. Demonstration of metabolic activity and correlation with clinical outcome. J Neurosurg 69:8308381988Valk PE Budinger TF Levin VA et al: PET of malignant cerebral tumors after interstitial brachytherapy. Demonstration of metabolic activity and correlation with clinical outcome. J Neurosurg 69:830–838 1988

    • Search Google Scholar
    • Export Citation
  • 28.

    Yang TWu SLLiang JCet al: Time-dependent astroglial changes after gamma knife radiosurgery in the rat forebrain. Neurosurgery 47:4074162000Yang T Wu SL Liang JC et al: Time-dependent astroglial changes after gamma knife radiosurgery in the rat forebrain. Neurosurgery 47:407–416 2000

    • Search Google Scholar
    • Export Citation

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