From: Subject: Original article Differentiation between brain tumor recurrence and radiation injury using perfusion, diffusion-weighted imaging and MR spectroscopy Date: Thu, 29 Jul 2010 13:14:25 +0200 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0000_01CB2F1F.F76BA630" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5931 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01CB2F1F.F76BA630 Content-Type: text/html; charset="iso-8859-2" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.termedia.pl/magazine.php?magazine_id=20&article_id=15061&magazine_subpage=FULL_TEXT Original article Differentiation between brain tumor = recurrence and radiation injury using perfusion, diffusion-weighted = imaging and MR spectroscopy

 

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Folia=20 = Neuropathologica  2/2010

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full text of the=20 article:
 
Original = article
Differentiation=20 between brain tumor recurrence and radiation = injury=20 using perfusion, diffusion-weighted imaging and = MR=20 spectroscopy

Folia = Neuropathologica 2010;=20 48 (2): 81-92

authors:=20 Barbara Bobek-Billewicz, Gabriela Stasik-Pres, = Henryk=20 Majchrzak, =A3ukasz Zarudzki, =

> inform friend about the=20 article


documents in PDF=20 format:
 
> Differentiation = between.pdf=20  [0.16=20 MB]


 
Introduction

Surgery=20 and radiotherapy are the main methods of a treatment = in=20 patients with gliomas. Concomitant radiochemotherapy = followed=20 by adjuvant chemotherapy has now become the standard = of=20 treatment for patients with malignant gliomas. = Postoperative=20 radiotherapy in patients with gliomas improves the = results of=20 treatment, but it brings some side effects to the = brain=20 [8,14,35,37,39]. Three types of side effects are=20 differen-tiated taking into account the time of its=20 occurrence: acute (early), subacute (early delayed), = late=20 (late de-layed) [24,26,38].
Radionecrosis is the = end point=20 of radiation injury and the worst adverse effect of = the=20 radiotherapy. Radionecrosis generally occurs 3-12 = months after=20 radiotherapy but can occur up to years or even = deca-des=20 afterwards. Its developement depends on irra-diated = brain=20 volume, dose of the radiotherapy and concomitant = chemotherapy.=20 The incidence of radionecrosis is higher in patients = treated=20 with radiochemotherapy than patients treated with = radiotherapy=20 alone. Generally, reported incidence of radionecrosis = ranges=20 from 2 to 24% [4,12,18,26,35]. Data on the incidence = of=20 radiation necrosis are rather underestimated because = of the=20 difficulty in radiological differentiation vital tumor = tissue=20 and radionecrosis and rare surgery and biopsies in = these=20 patients.
Stereotactic biopsy, if performed, = should be=20 imaged-guided biopsy. And because of this neuroimaging = plays=20 extremely important role in monitoring the therapy and = recurrence of brain tumors. Intralesion heterogeneity = of the=20 recurrence which can consist in different proportions = from the=20 vital tumor tissue and radionerosis decreases accuracy = of=20 biopsy. Advanced MR techniques are essential for = taking a=20 representative sampling during biopsy or even it could = replace=20 this invasive technique.
Conventional MR = techniques, such=20 as T2-weighted and gadolinium-enhanced T1-weighted = imaging,=20 have limitations in discriminating tumor recurrence = and=20 treatment-induced injury. Radiological pattern of=20 radionecrosis with conventional MR techniques is = frequently=20 indistinguishable from that of tumor recurrence. Both = lesions=20 are heterogenous mainly hiperintensive on T2-weighted = images=20 and show strong, often heterogenous contrast = enhancement with=20 surrounding edema and mass effect. Standard imaging=20 recurrence/progression criteria are: increased area of = gadolinium uptake on MRI or the appearance of new = contrast=20 enhacement lesions but radiation necrosis often looks = in the=20 same way.
Advanced MRI techniques and PET = examination=20 allow the analysis of tumor or necrotic tissue = properties and=20 provide more accurate information on its nature. But=20 differentiation between tumor recurrence/vital tumor = tissue=20 and radionecrosis based on diagnostic imaging is still = very=20 difficult or sometimes impossible [4-6,18,27,43]. =
The aim=20 of our study was to evaluate the diagnostic = effectiveness of=20 perfusion-weighted imaging (PWI), diffusion-weighted = imaging=20 (DWI) and magnetic resonance spectroscopy (1HMRS) in = the=20 differentiation of the tumor recurrence from radiation = related=20 injury.

Material and=20 methods
Material
The retrospective = analysis=20 comprised 11 contrast-enhancing lesions observed in 8 = patients=20 (5 females, 3 males, range of age 23-68 years) treated = for=20 gliomas with radiotherapy (6/8 patients) or=20 radiochemo­thera-py with Temozolomide (2/8 = patients).=20
In 2 patients contrast-enhancing lesions were = multifocal=20 and appeared in different time during follow-up. All = patients=20 had undergone surgical excision of the tumor which=20 histological examination results were as follows: = Glioblastoma=20 multiforme WHO IV – 2, Astrocytoma anaplasticum = WHO III – 5,=20 Astrocytoma diffusum WHO II/III – 1 (Table I). = The time from=20 the end of radiation therapy to appearance of=20 contrast-enhancing lesions ranged from 3 to 70 months = (Table=20 I). 5 out of 11 contrast-enhancing lesions were tumor=20 recurrences (those results were histopatho-logically=20 verified). 6 out of 11 contrast-enhancing lesions were = radiation-related injuries (3/6 were = histopathologically=20 verified as radionecrosis and 3/6 disappeared = completely=20 during follow-up without any treatment and were = classified as=20 non-neoplastic lesion/radiation-related injury). The = clinical=20 characteri-sation of the analysed group is presented = in Table=20 I.
Methods
The MR examinations were = performed on=20 1.5T (Avanto, Siemens) or 3.0T (Achieva, Philips) = scanner with=20 the standard head coil.

Conventional MR=20 imaging
Conventional MR imaging consisted of=20 T2-weigh-ted images, FLAIR (fluid-attenuated inversion = reco-very), T1-weighted images before and after CE = (con-trast=20 enhancement).
1.5T: T1-SE (TR/TE 458/14 ms, = Thk/gap=20 5.0/1.5 mm, FOV 207 =D7 230 mm, matrix 288 =D7 320), = T1-MPRAGE=20 with CE (TR/TE 1160/4.2 ms, Thk/gap 0.9/0.0 mm, FOV = 230 =D7 230=20 mm, matrix 256 =D7 256), T2-TSE (TR/TE 4240/92 ms, = Thk/gap=20 5.0/1.0 mm, FOV 234 =D7 250 mm, matrix 360 =D7 512), = T2-FLAIR (TI=20 =3D 2371 ms, TR/TE 8000/89 ms, Thk/gap 5.0/1.0 mm, FOV = 199 =D7 250=20 mm, matrix 204 =D7 256).
3.0T: T1-SE (TR/TE = 450/13=20 ms, Thk/gap 5.0/1.0 mm, FOV 230 =D7 230 mm, matrix = 256/512,=20 T1-3D TFE with CE (TR/TE 6.4/2.3 ms, Thk/gap 1.0/0.0 = mm, FOV=20 256 =D7 256 mm, matrix 256/256), T2-TSE (TR/TE 3000/80 = ms,=20 Thk/gap 5.0/1.0 mm, FOV 230 =D7 184 mm, matrix = 306/512),=20 T2-FLAIR (TI =3D 2500 ms, TR/TE 9000/125 ms, Thk/gap = 5.0/1.0 mm,=20 FOV 230 =D7 182 mm, matrix 217/512).=20

Perfusion-Weighted Imaging (PWI)=20

1.5T: EPI spin echo (TR/TE 1400/30 = ms,=20 Thk/gap 5.0/1.5 mm, FOV 230 =D7 230 mm, matrix 128 =D7 = 128). 60=20 data sets were acquired with a time resolution 1 per = data set.=20
3.0T: EPI gradient echo (TR/TE 16/24 ms, = flip 7=B0=20 slice thickness 4.0 mm, intersection gap 0.0 mm, = matrix 64 =D7=20 128 pixels). 60 data sets were acquired with a time = resolution=20 1 per data set.
Paramagnetic gadolinium based = contrast=20 medium (0.1 mmoL/kg) was injected at with a rate 6.0 = mL/sec,=20 followed by administration of 20 mL bolus of saline. =
rCBV=20 (relative cerebral blood volume) maps were calculated = by=20 postprocessing software delivered by MR systems = producer.=20
Mean and maximum rCBV values of each = contrast-enhancing=20 lesion were calculated. rCBV was calcula-ted as = follows:=20
rCBVmean – region of interest (ROI) = covered the=20 contrast-enhancing lesion except necrotic part;=20
rCBVmax – ROI in contrast-enhancing = lesion was=20 placed within the highest rCBV after visual = asses-sment of the=20 color map.
These values were normalized to normal=20 appearing white matter.
rCBVnawm – = ROI in normal=20 appearing white matter (nawm) was placed within normal = appearing white matter in the contralateral = hemisphere.=20
Mean normalized rCBVmax =3D rCBVmax/rCBVnawm and = mean=20 normalized rCBVmean =3D rCBVmean/ rCBVnawm were = analysed. ROIs=20 area ranged from 0.2 to 0.4 cm2.=20

Diffusion-Weighted Imaging (DWI)=20

1.5T: EPI spin-echo (TR/TE 3100/99 = ms, β =3D=20 0.1000 mm2/s, FOV 230 =D7 230 mm; matrix = 192 =D7 192=20 pixels, slice thickness 5.0 mm, intersection gap 1.0 = mm).=20
3.0T: EPI spin-echo (TR/TE, 3080/70 ms, = β =3D 0.1000=20 mm2/s, matrix 112 =D7 256 pixels, slice = thickness 4.0=20 mm, intersection gap 1.0 mm).
ADC (Apparent = Diffusion=20 Coefficient) maps were calculated by postprocessing = software=20 delivered by MR systems producer.
ADCce = – ROI in=20 contrast-enhancing lesion was placed within solid part = of the=20 lesion, within the lowest signal intensity after = visual=20 assessment of the ADC map.
ADCnawm – = ROI in normal=20 appearing white matter was placed within normal = appearing=20 white matter in the contralateral hemisphere.
ROIs = area=20 ranged from 0.2-0.4 cm2. Mean norma-lized = ADC =3D=20 ADCce/ADCnawm ratio and mean ADCce were analysed.=20

Proton MR spectroscopy (1HMRS) =

1.5T:=20 3D CSI SE: long TE (TR/TE 1300/135 ms), short TE = (TR/TE=20 1300/30 ms), voxel size 10 =D7 15 =D7 10 mm, and SVS = SE: long TE=20 (TR/TE 1500/135 ms), short TE (TR/TE 1300/30 ms), = voxel size=20 15 =D7 15 =D7 15 mm.
3.0T: 3D CSI PRESS: = long TE (TR/TE=20 1083/288 ms), short TE (TR/TE 1083/35 ms), voxel size = 15 =D7 15=20 =D7 12 mm, SVS SE: long TE (TR/TE 1083/288 ms), short = TE (TR/TE=20 1083/35 ms), voxel size 10 =D7 10 =D7 10 mm.
Only = those voxels=20 which were in solid part of the contrast-enhancing = lesion were=20 analysed. MR spectroscopy data were evaluated using LC = Model=20 version 6.1-4F. Cho/Cr, Cho/NAA ratios were = calculated, Lac=20 and Lip were marked as “+” or = “–”, if standard deviation of=20 their concentrations were less than 20%. Two=20 contrast-enhancing lesions (number I.2 and II.4) = lacked of MR=20 spectroscopy.

Statistical=20 analysis

Continuous parameters with normal=20 distribution were presented as mean ± standard = deviation (SD).=20 The normal distribution of parameters was tested with=20 Shapiro-Wilk test. Mean differences were tested = between two=20 groups (Group I – contrast-enhancing lesions = which were=20 recurrent gliomas, Group II – contrast-enhancing = lesions which=20 were radiation injuries). The significance of mean=20 dif-ferences was tested with a t-Student test. = Con-tinuous=20 parameters which were located into groups smaller than = 5 were=20 compared with the 2 test. Statistically = significant p-levels=20 were assumed as < 0.05 (two-sided). Statistical=20 calculations and analyses were performed with = Statistical PL=20 software version 6.1 by StatSoft, Inc.=20

Results

Mean normalized rCBV = values are=20 presented in Table II. Mean normalized rCBVmax and = rCBVmean=20 normalized rCBVmean were significantly higher in the = recurrent=20 gliomas group than in the radiation injury one. = Normalized=20 rCBVmax: 2.44 ± 0.73 for tumor rec-curence vs. = 0.78 ± 0.46 for=20 radiation injury; p < 0.001 (Fig. 1), and = normalized=20 rCVBmean: 1.46 ± 0.49 for tumor reccurence vs. = 0.49 ± 0.38 for=20 radiation injury; p < 0.004 (Fig. 2). It was = observed that=20 normalized rCBVmax higher than 1.7 and normalized = rCBVmean=20 higher than 1.25 is highly indicative for recurrent = glioma=20 whereas normalized rCBVmax lower than 1.0 and = normalized=20 rCBVmean lower than 0.5 is highly indicative for = radiation=20 injury.
Neither mean ADCce: 1.06 ± 0.18 =D7 = 10-3=20 mm2/s for tumor recurrence vs. 1.13 = ± 0.13 =D7 10-3=20 mm2/s for radiation injury; p =3D 0.51 nor = mean=20 normalized ADC: 1.55 ± 0.39 =D7 10-3 = mm2/s for tumor=20 reccurence vs. 1.55 ± 0.18 =D7 10-3 = mm2/s for=20 radiation injury; p =3D 0.98) were not statistically = significant=20 different between two analysed groups. Mean ADC values = are=20 presented in Table III and Figs. 3 and 4.
Results = of MR=20 spectroscopy are presented in Table IV. Neither median = Cho/Cr=20 ratio (2.16 min/max [1.67-3.15] for tumor recurrence = vs. 1.34=20 min/max [1.13-2.37] for radiation injury; p =3D 0.15) = nor median=20 Cho/NAA ratio (1.9 min/max [0.86-2.36] for tumor = rec-curence=20 vs. 2.11 min/max [0.97 vs. 2.87] for radiation injury; = p =3D=20 0.51) were not statistically significant dif-ferent = between=20 two analysed groups (Figs. 5-6).=20

Discussion

Differentiating vital = tumor=20 tissue (tumor regrowth/ recurrence) from radiation = injury=20 remains an impor-tant and common issue in = neurooncology.=20 Surgery and radiotherapy are the main methods of a = treatment=20 in patients with gliomas. Concomitant = radiochemo-therapy=20 followed by adjuvant chemotherapy has now become the = standard=20 of treatment for patients with malignant gliomas.=20 Postoperative radiotherapy in patients with gliomas = improves=20 the results of treatment, but it brings some side = effects to=20 the brain [8,14,35,37,39]. Among those radionecrosis = – as the=20 end point of radiation injury is the worst. Its = developement=20 depends on irradiated brain volume, dose of the = radiotherapy=20 and concomitant chemo-therapy.
Although = radiological=20 features commonly seen in radionecrosis has been = described=20 (location in periventricular white matter, corpus = callosum and=20 distant from the site of primary tumor, soap bubble, = Swiss=20 cheese pattern), differential diagnosis from tumor = recurrence=20 based on conventional MR is still impossible = [10,18,19],=20 because of the likeness of the images. = Contrast-enhancing=20 lesions occur within residual tumor or tumor = recurrence and=20 also within radiation injuries with or without = necrosis=20 [18,25,48]. Both lesions (tumor and radionecrosis) are = hete-rogenous, mainly hiperintensive on T2-weighted = images and=20 show strong, often heterogenous contrast enhancement = with=20 surrounding edema and mass effect. Both entities can = increase=20 in size or be stable over serial examinations. It is = essential=20 to remember that from clinical point of view the=20 differentiation between tumor recurrence and = radionecrosis has=20 a pivotal role, because of the further treatment = implications=20 [4,18].
18 FDG PET/CT (18F-Fluorodeoxyglucose = PET/CT) is=20 not a guarantee for reliable diagnosis either. Because = of the=20 high physiologic glucose metabolism in normal brain, = one faces=20 difficulties in detecting tumor and tumor recurrence.=20 Radiation injuries (especially radionecrosis) are=20 characterized with low FDG uptake. On the other hand = small=20 tumor size or its low metabolic activity can be a = reason for=20 false negative results. Further, increased FDG uptake = in the=20 area of radiation injury can be due to inflammatory = processes,=20 seizure activity, healing processes up to 3 months = after=20 surgery (false positive results). 18FDG PET/CT has = sensitivity=20 81-86% and specificity 40-94% in differentiation = between tumor=20 recurrence and radiation injury [6]. Amino-acid PET = e.c.=20 18F-FET PET (18F(fluoroethyl)-L-tyrosine) seems to be = more=20 useful in differential diagnosis. Popperl et al. = proved that=20 18F-FET PET was able to distinguish between recurrent = tumor=20 and therapy-induced benign changes with 100% accuracy=20 [6,27,43]. In such circumstances advanced MRI = techniques (PWI,=20 DWI, 1H-MRS) seem to be helpful in vital tumor tissue = vs.=20 benign radiation induced injury/radionecrosis = defferentiation.=20
Dynamic Susceptibility Contrast Enhanced = Perfu-sion MRI=20 (DSCE-MRI, PWI) is based on rapid T2 or T2*-weighted = imaging=20 of the first pass of gadolinium-based contrast = material. It=20 gives access to information on the capillary = microcirculation=20 of tissue and reflects tissue microvascular density = (MVD) by=20 measuring relative cerebral blood volume [28,34,46]. = The most=20 efficacies, among parametres obtained in PWI, in = assessing=20 brain tumors or treatment effectiveness has rCBV = [10,19].=20 Angiogenesis in recurrence/growth tumor lead to raise=20 capillary perfusion and MVD what is seen as an = increase of=20 rCBV [16,29]. Tumor’s vessels in comparison to = normal ones are=20 characterized by increased tortuosity, lack of = maturity and=20 increased permeability. MVD and rCBV are decreased in=20 radiation necrosis which mainly consists of ischemic = changes=20 because radiotherapy induces endothelial cell damage = and small=20 vessel injury [16,29]. Assuming that contrast- = enhancing=20 lesion contain pure neoplastic tissue or pure necrotic = one,=20 these two entities should be distinguishable by using = PWI. But=20 such situation is extremely rare. The areas of = recurrence=20 tumor comprised of mixture of neoplastic and necrotic = tissue=20 in at least 33% cases [12,26,28]. Because of this = overlap of=20 the rCBV between tumor recurrence and radiation injury = is=20 predictable. Not only irradiated brain tissue but also = irradiated tumor is not the same as before treatment. = It was=20 stated [11,42] that normalized rCBV ratios=20 (rCBV[tumor]/rCBV[contralateral tissue]) in the = recurrent=20 glioblastoma were significantly lower than those in = the=20 initial glioblastoma in the same patients. The = usefulness of=20 rCBV in discrimination between tumor reccurence and = radiation=20 injury has been evaluated by the same authors. They = analysed=20 contrast-enhancing lesions in 20 patients treated with = postoperative radiochemotherapy or chemotherapy for = gliomas.=20 Estimation showed two thresholds for normalized rCBV = ratios –=20 2.6 and 0.6, respectively. rCBV higher than 2.6 within = contrast-enhancing lesions was highly indicative for = tumor=20 recurrence, whereas threshold lower than 0.6 was = highly=20 indicative for radiation injury. Values between those = two=20 thresholds might have indicated mixture of = pathological=20 processes and for better assessment other = exa-minations should=20 have been performed [41,42]. Recently Hu et all. = presented a=20 threshold of 0.71 of rCBV with a sensitivity of 91.7% = and a=20 specificity of 100% for the best differential = diagnosis [16].=20 Authors of these analysis observed very small overlap = between=20 two discussed pathological processes only two tumors = rCBV=20 values (8.3% of all investigated samples) fell within = the=20 posttreatment radiation effect group range. Authors = suggested=20 that such efficient results may be due to preload = contrast=20 medium bolus for correctin T1-weighted errors and=20 normalization rCBV to average grey matter and white = matter and=20 not only to white matter [16]. Barajas et al. found = that the=20 mean and maximum rCBV values were significantly higher = in the=20 recurrent metastatic tumor group than radiation = necrosis [3].=20 Noteworthy fact is that cutoff for rCBV value of 1.52 = with a=20 sensitivity of 91.30% and a spe-cificity of 72.73% was = characteristic for recurrent metastatic tumor whereas. = rCBV=20 values < 1.35 were only observed in enhancing = regions,=20 consistent with radiation necrosis. Our results show=20 statistically significant difference in terms of rCBV = between=20 the tumor recurrence and the radiation injury group = (nrCBVmax=20 p < 0.001, nrCBVmean p < 0.005). Lesion no VIII = 11 in=20 our group was histopahologically verified as recurrent = Anaplastic Astrocytoma (Fig. 7). In our group = normalized=20 rCBVmax over 1.7 and normalized rCBVmean over 1.25=20 characterized regrowth/recurrence, whereas normalized = rCBVmax=20 below 1.0 and nor-malized rCBVmean below 0.5 = characterized=20 radiation injury. Like in other authors’ = results, the overlap=20 between the two groups considering rCBV was also = observed.=20 Considering that the overlap is not high this method = might be=20 highly indicative for differential diagnosis. Further = the=20 overlap of the normalized rCBV between these two = groups could=20 have a few reasons, as it was stressed above the most=20 important of these is heterogeneity of the recurrence = tumor=20 which often consist of tumor cells and necrosis. = Additionally=20 petechial hemorrhage induced by radiation may produce=20 susceptibility artifacts and decrease the rCBV ratios = if it=20 occures within tumor recurrence [41,42]. False = negative=20 results considering PWI can be similar to problems in = FDG=20 PET/CT – small size of tumor and its low = metabolic activity.=20 It was observed that within irradiated brain tissue = many=20 vessels are occluded but there are aneurysmal = formation,=20 teleangiectasias and profliferation of endothelial = cells=20 [13,17] what can lead to high perfusion within = radiation=20 induced injury/ radionecrosis and false positive = results.=20
Extracellular water is the main object of = investigation in=20 diffusion imaging. Diffusion data provides indirect=20 information about the structure surrounding these = water=20 molecules and is sensitive to microenvironment changes = in the=20 tumor and tissue. Quantitative assessment is expressed = as ADC=20 maps, which value gets higher if the ability of motion = increases. In the opposite if the ability of the water = molecules motion is decreased by e.c. the higher = cellularity=20 or cytotoxic edema existence, what is called diffusion = restriction and what causes diminishing the ADC = values. The=20 validity of DWI has been already established in such = disorders=20 as acute brain ischemia or differentiation epidermoid = vs.=20 arachnoid cyst [33], tumor necrosis vs. abscess and = others.=20 Published data regarding ADC changes during the = radiotherapy=20 are ambiguous [7,22]. Hein et al. showed that ADC = ratios (1.43=20 vs. 1.82*10-3 mm2/s) and mean ADC values = (1.18 vs.=20 1.4*10-3 mm2/s) in the recurrence group is=20 significantly lower than those of the nonrecurrence = group=20 [17]. Similar results presented Zeng et al. Authors = stated=20 that recurrence group showed mean ADC value and ADC = ratio=20 significantly lower than radiation injury group = – 1.2 vs.=20 1.39*10-3 mm2/s, 1.42 vs. 1.69*10-3=20 mm2/s, respec-tively [49]. Interesting = analysis=20 presented Asao et al. Authors investigated 20 = enhancing=20 lesions in which 12 were recurrent tumors and 8 = radiation=20 injuries. The minimal, maximal, and mean values of = each lesion=20 were compared between these 2 groups. What is = noteworthy only=20 the maximal ADC values within each lesion were = significantly=20 lower for the recurrence group than for the necrosis = one [2].=20 Our analysis revealed similar tendency to those = results but=20 without statistical significance. Contrary results = presented=20 Sundgren et al. [38] In their group, mean ADC values = in the=20 contrast-enhancing lesions were significantly higher = for=20 recurrent tumors in compa-rison with radiation = injuries (1.27=20 vs. 1.12*10-3 mm2/s) [47]. It is considered = that=20 low ADC values in re-growth/recurrent tumor are the = result of=20 high-cell density, but microangiogenesis in the = recurrent=20 tumor can elevate ADC values [40]. On the other hand = low ADC=20 values in radiation injury could be a result of = gliosis,=20 fibrosis, macrophage invasion, de-myeliation, = coagulative=20 necrosis, but simple acellular necrosis, cystic = necrosis,=20 liquefactive necrosis elevate ADC values [49]. Lesion = no II.5=20 in our group was histopahologically verified as = coagulative=20 necrosis (Fig. 8). Also, a great deal of recurrent = tumors=20 contains areas of necrosis. To sum up, pathological = processes=20 within recurrent tumor and radiation injury might lead = to=20 similar changes in diffusivity.
MR spectroscopy=20 characterizes tissue in terms of chemical = constitution. Taking=20 into account different published reports one may = suggest that=20 tumor recurrence may be characterized by high Cho and = low NAA=20 levels, whereas radiation injury by low levels of all=20 metabolites, except for lipids [1,9,13,20,23,32,36,=20 42,45,47,49]. Weybright et al. [47] in the group of 29 = patients with gliomas treated with surgery and RT = noted the=20 highest mean Cho/Cr, Cho/NAA ratios for recurrent = tumor, next=20 radiation injury and normal-appearing white matter. = Mean=20 NAA/Cr ratio was the highest in normal-appearing white = matter,=20 followed by radiation injury, and recurrent tumor = respectively=20 [47]. Taylor et al. compared absolute concentrations = of Cho,=20 NAA and Cr in areas suspected for tumor regrowth or=20 radionecrosis. Authors stated that although for = recurrent=20 tumor Cho increase and NAA decrease is highly = characteristic,=20 and in radioinjury low levels all these metabolites = are seen,=20 discriminant analysis suggested that the primary = diagnostic=20 information for differentiating radionecrosis from = tumor lay=20 in the normalized MRS peak areas for choline and = creatine=20 compounds [44]. According to Zeng et al. [49], = Weybright et=20 al. [47] and Schlemmer et al. [36] Cho/Cr ratio > 2 = and=20 Cho/NAA ratio > 2.5 in the contrast-enhancing = lesions=20 strongly indicate tumor regrowth or recurrence. = Rabinov et al.=20 [30] stated that the level of Cho at the biopsy site = (within=20 contrast-enhancing lesion) to normal creatine level = with the=20 treshold greater than 1.3 is the criterion for tumor. = Lipids=20 correspond to necrosis which is often visible either = within=20 tumor or radiation injury/ necrosis. That is the cause = that=20 lipids can be detected either in tumor recurrence or = radiation=20 injury [31]. Rock et al. [32]. Indicated Lac + Lip/Cho = ratio =3D=20 0.75 as threshold characteristic for tumor recurrence = 7 times=20 more often than in radiation injur. Our analysis did = not=20 reveal any statistically significant difference = between the=20 recurrent gliomas group and radiation injury one in = terms of=20 Cho/Cr and Cho/NAA, which can be caused by the small = group of=20 analyzed patients. As it has been stated already in = many of=20 the enhancing lesions, often both tumor cells and = radiation=20 injury are present the results of spectroscopy in = these cases=20 are much less clear than those observed in cases of = pure tumor=20 or pure radiation necrosis.=20

Conclusions

Among the analyzed = advanced=20 neuroimaging methods PWI seems to be most reliable in=20 diffe-rentiation between tumor regrowth/recurrence and = radiation necrosis. In these results mean rCBV is a = better=20 differing factor than max rCBV. Proton MR spectroscopy = and DWI=20 do not differentiate analyzed groups with statistical=20 significance, despite tendency to lower ADC values in=20 recurrence group than in radiation injury one.=20

References

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11px; COLOR: #404040; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif } .inputButton { BORDER-RIGHT: #bbbbbb 1px solid; BORDER-TOP: #bbbbbb 1px solid; = FONT-SIZE: 10px; BORDER-LEFT: #bbbbbb 1px solid; COLOR: #ffffff; = BORDER-BOTTOM: #bbbbbb 1px solid; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif; BACKGROUND-COLOR: #777 } .inputButtonBig { BORDER-RIGHT: #bbbbbb 1px solid; BORDER-TOP: #bbbbbb 1px solid; = FONT-SIZE: 11px; BORDER-LEFT: #bbbbbb 1px solid; COLOR: #ffffff; = BORDER-BOTTOM: #bbbbbb 1px solid; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif; BACKGROUND-COLOR: #777 } .inputText { BORDER-RIGHT: #dddddd 1px solid; BORDER-TOP: #dddddd 1px solid; = FONT-SIZE: 10px; BORDER-LEFT: #dddddd 1px solid; COLOR: #656565; = BORDER-BOTTOM: #dddddd 1px solid; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif; BACKGROUND-COLOR: #ffffff } .inputTextBig { BORDER-RIGHT: #aaaaaa 1px solid; BORDER-TOP: #aaaaaa 1px solid; = FONT-SIZE: 11px; BORDER-LEFT: #aaaaaa 1px solid; COLOR: #656565; = BORDER-BOTTOM: #aaaaaa 1px solid; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif; BACKGROUND-COLOR: #ffffff } .inputTextSurveyBig { BORDER-RIGHT: #cccccc 1px solid; BORDER-TOP: #cccccc 1px solid; = FONT-SIZE: 11px; BORDER-LEFT: #cccccc 1px solid; COLOR: #656565; = BORDER-BOTTOM: #cccccc 1px solid; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif; BACKGROUND-COLOR: #ffffff } .volumeInfo { FONT-WEIGHT: bold; FONT-SIZE: 14px; COLOR: #4a5364; FONT-FAMILY: Arial, = Verdana, Helvetica, sans-serif } .menuPositionPadding { PADDING-RIGHT: 10px; PADDING-LEFT: 10px; PADDING-BOTTOM: 3px; = PADDING-TOP: 3px } .menuPositionPadding1 { PADDING-RIGHT: 10px; PADDING-LEFT: 10px; PADDING-BOTTOM: 3px; = PADDING-TOP: 3px } .conference { FONT-SIZE: 12px; COLOR: #d35c15 } .conferenceMP { COLOR: #990000 } .bLine { BORDER-BOTTOM: #ccc 1px solid } .lineSolid { MARGIN-TOP: 10px; BORDER-BOTTOM: #d1d1d1 1px solid } TD.adv750x100 { PADDING-RIGHT: 0px; PADDING-LEFT: 15px; BACKGROUND: #f7f7f7; = PADDING-BOTTOM: 5px; PADDING-TOP: 5px; HEIGHT: 7px } TD.adv120x600 { PADDING-LEFT: 15px; VERTICAL-ALIGN: top } DIV.folder { PADDING-RIGHT: 0px; PADDING-LEFT: 23px; BACKGROUND-IMAGE: = url(../graphics/files/folder.gif); PADDING-BOTTOM: 0px; MARGIN: 0px 0px = 8px; PADDING-TOP: 1px; BACKGROUND-REPEAT: no-repeat } DIV.pdf { PADDING-RIGHT: 0px; PADDING-LEFT: 23px; BACKGROUND-IMAGE: = url(../graphics/files/pdf.gif); PADDING-BOTTOM: 0px; MARGIN: 0px 0px = 8px; PADDING-TOP: 1px; BACKGROUND-REPEAT: no-repeat } DIV.backFile { PADDING-RIGHT: 0px; PADDING-LEFT: 23px; BACKGROUND-IMAGE: = url(../graphics/files/back.gif); PADDING-BOTTOM: 0px; MARGIN: 0px 0px = 8px; PADDING-TOP: 1px; BACKGROUND-REPEAT: no-repeat } A.link { FONT-SIZE: 11px; COLOR: #990000; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif } LABEL { CURSOR: pointer } DIV.surveyQuestion { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; FONT-WEIGHT: bold; FONT-SIZE: = 11px; PADDING-BOTTOM: 5px; WIDTH: 160px; COLOR: #990000; PADDING-TOP: = 6px; FONT-FAMILY: tahoma,arial } DIV.surveyLogin { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 5px; = PADDING-TOP: 5px } DIV.surveyResults { PADDING-RIGHT: 0px; BORDER-TOP: #d1d1d1 1px solid; MARGIN-TOP: 6px; = PADDING-LEFT: 0px; PADDING-BOTTOM: 2px; LINE-HEIGHT: 16px; PADDING-TOP: = 5px } INPUT.surveyBut { MARGIN: 5px 0px 2px } DIV.surveyAnswer { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 3px; = PADDING-TOP: 13px } DIV.surveysList { LINE-HEIGHT: 20px } DIV.pointsFrTL { BACKGROUND: url(../graphics/pointsfr/tl.gif) #999999 no-repeat left = top; WIDTH: 110px } DIV.pointsFrTR { BACKGROUND: url(../graphics/pointsfr/tr.gif) no-repeat right top } DIV.pointsFrBR { BACKGROUND: url(../graphics/pointsfr/br.gif) no-repeat right bottom } DIV.pointsFrBL { PADDING-RIGHT: 2px; PADDING-LEFT: 2px; FONT-WEIGHT: bold; FONT-SIZE: = 11px; BACKGROUND: url(../graphics/pointsfr/bl.gif) no-repeat left = bottom; PADDING-BOTTOM: 2px; COLOR: #f3f3f3; PADDING-TOP: 2px; = FONT-FAMILY: Arial,tahoma; TEXT-ALIGN: center } DIV.pointsFrBL SPAN { FONT-SIZE: 15px; COLOR: #fff } SPAN.advertLabel { FONT-WEIGHT: bold } DIV.green { BORDER-RIGHT: #ccc 1px solid; PADDING-RIGHT: 9px; BORDER-TOP: #ccc 1px = solid; PADDING-LEFT: 9px; FONT-WEIGHT: bold; FONT-SIZE: 13px; = MARGIN-BOTTOM: 25px; PADDING-BOTTOM: 4px; BORDER-LEFT: #ccc 1px solid; = COLOR: #00860d; PADDING-TOP: 4px; BORDER-BOTTOM: #ccc 1px solid; = BACKGROUND-COLOR: #e9e9e9 } DIV.advBox { BORDER-RIGHT: #bbcce3 1px solid; BORDER-TOP: #bbcce3 1px solid; = BORDER-LEFT: #bbcce3 1px solid; BORDER-BOTTOM: #bbcce3 1px solid; = BACKGROUND-COLOR: #e7edf5 } DIV.advBoxTitle { PADDING-RIGHT: 5px; PADDING-LEFT: 5px; FONT-WEIGHT: bold; FONT-SIZE: = 14px; PADDING-BOTTOM: 0px; COLOR: #990000; PADDING-TOP: 5px; = FONT-FAMILY: arial,verdana } DIV.advBoxSectionTitle { PADDING-RIGHT: 7px; PADDING-LEFT: 7px; FONT-WEIGHT: bold; FONT-SIZE: = 11px; PADDING-BOTTOM: 3px; MARGIN: 10px 0px 0px; COLOR: #436ba7; = PADDING-TOP: 3px; FONT-FAMILY: tahoma,verdana; BACKGROUND-COLOR: #f5f7fa } DIV.advBoxSection { PADDING-RIGHT: 7px; PADDING-LEFT: 7px; PADDING-BOTTOM: 2px; = PADDING-TOP: 3px } DIV.advBoxSectionPos { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 5px; = PADDING-TOP: 5px; BORDER-BOTTOM: #d1dbe7 1px solid } DIV.right { FLOAT: right } DIV.clearAll { CLEAR: both; DISPLAY: block; FONT-SIZE: 0px; LINE-HEIGHT: 0%; HEIGHT: = 0px } ------=_NextPart_000_0000_01CB2F1F.F76BA630 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://www.termedia.pl/js/scripts.js // JavaScript Document function newSurvey(surveyId) { = newWindow('surveys/survey.php?subpage=3DsendSurvey&surveyId=3D'+surveyId,= 'Ranking', 700, 600, 'YES'); } function newWindow(src, title ,w,h,r) { var t =3D (screen.availHeight-h)/2; var l =3D (screen.availWidth-w)/2; var popup=3D = window.open(src,title,"TOOLBAR=3DNULL,RESIZABLE=3D"+r+",STATUS=3DYES,SCRO= LLBARS=3DYES, WIDTH=3D"+w+",HEIGHT=3D"+h+",LEFT=3D"+l+",TOP=3D"+t+""); popup.focus(); } function getElem(id) { return document.getElementById(id); } function showDiv(divId){ var divToShow =3D getElem(divId); if(divToShow){ divToShow.style.display =3D "block"; } } function = rewrite(sourceFormName,sourceFieldName,destFormName,destFieldName) { document.forms[destFormName].elements[destFieldName].value =3D = document.forms[sourceFormName].elements[sourceFieldName].value; } =20 function add_to_cart_pop_up(url) { nowe =3D = window.open(url,'window','width=3D380,height=3D270,toolbar=3Dno,scrollbar= s=3Dyes,menubar=3Dno'); } function promotion_pop_up(url) { nowe =3D = window.open(url,'window','width=3D460,height=3D439,toolbar=3Dno,scrollbar= s=3Dno,menubar=3Dno'); } =20 function help_popup(url) { nowe =3D = window.open(url,'window','width=3D380,height=3D270,toolbar=3Dno,scrollbar= s=3Dyes,menubar=3Dno'); } function pic_popup(url) { nowe =3D = window.open(url,'window','width=3D538,height=3D405,toolbar=3Dno,scrollbar= s=3Dyes,menubar=3Dno'); } =20 function inform_friend(url) { nowe =3D = window.open(url,'window','width=3D645,height=3D385,toolbar=3Dno,scrollbar= s=3Dyes,menubar=3Dno'); } ------=_NextPart_000_0000_01CB2F1F.F76BA630 Content-Type: application/octet-stream Content-Transfer-Encoding: 7bit Content-Location: http://www.termedia.pl/show_ad.php ------=_NextPart_000_0000_01CB2F1F.F76BA630--