Figure 1
Cerebral MRI
Multimodality imaging in glioma recurrence
SectionNeuroradiology
Case TypeClinical Cases
AuthorsBirchall JD, Ganatra RH, Jaspan T, Smith RM, Perkins AC
Connected authors
31 years, female
Clinical History
Previous history of surgical debulking and subsequent radiotherapy for a left grade 2 fronto-parietal astrocytoma 2 years previously, represented with worsening left sided weakness and increasing tiredness.
Imaging Findings
The patient who had underwent surgical debulking and subsequent radiotherapy for a left grade 2 fronto-parietal astrocytoma 2 years previously. She represented with worsening left sided weakness and increasing tiredness. Magnetic resonance imaging (MRI ) and hydrogen 1 spectra magnetic resonance spectroscopy was performed initially (figures 1 and 2 ) with subsequent thallous 201 chloride cerebral imaging (figure 3).
MRI demonstrated hyperintense abnormality within the left posterior frontal lobe and parietal lobe with adjacent cerebral oedema on T2 weighted sequence with strong patchy enhancement following IV Gd3+ DTPA. Hydrogen 1 MRS showed an increase in the ratios of choline to creatine of greater than 1.3 and reversal of the normal choline to N acetyl aspartate within the area of morphological abnormality in the left posterior frontal lobe and parietal lobe.
Thallous 201 chloride study demonstrated intense focal uptake within the left parietal lobe corresponding to area contrast enhancement on T1 weighted MRI.
Unfortunately these finding were of recurrent glioma in this patient.
MRI demonstrated hyperintense abnormality within the left posterior frontal lobe and parietal lobe with adjacent cerebral oedema on T2 weighted sequence with strong patchy enhancement following IV Gd3+ DTPA. Hydrogen 1 MRS showed an increase in the ratios of choline to creatine of greater than 1.3 and reversal of the normal choline to N acetyl aspartate within the area of morphological abnormality in the left posterior frontal lobe and parietal lobe.
Thallous 201 chloride study demonstrated intense focal uptake within the left parietal lobe corresponding to area contrast enhancement on T1 weighted MRI.
Unfortunately these finding were of recurrent glioma in this patient.
Discussion
Imaging assessment of recurrent glioma from radiation necrosis remains a challenge for anatomical methods such as CT and MRI as the imaging characteristics of the 2 processes are similar. Both can be masses containing central cavitation with peripheral enhancement and adjacent cerebral oedema.
Hence functional assessment with radionuclide imaging is often performed. Both thallous 201 chloride and 99 m technetium labelled sestamibi are proven in the assessment of recurrent glioma and in the presurgical assessment of degree of glioma proliferation. Fluoride 18 fluorodeoxyglucose (18 FDG) PET is valuable on dedicated PET scanners but performs worse than thallous chloride on dual gamma camera coincidence imaging.
Hydrogen 1 MRS is proving valuable in the characterisation of glioma recurrence from radionecrosis on clinical 1.5 Tesla MR scanners when it can be performed. It is limited as remains currently a single slice multivoxal technique and can suffer markedly from shim artefact. However it relatively quick be adding 12 minutes to the scanning time for the long TE (135ms) and short TE (35ms )sequences. Recent reports on 3 Tesla MRS are very promising in the categorisation between recurrence and radionecrosis.
The combination of thallium cerebral imaging with MRI and MRS increases the confidence of diagnosis of cerebral gioma recurrence from radionecrosis with the potential to reduce the overall false negative rate for cerebral imaging.
Hence functional assessment with radionuclide imaging is often performed. Both thallous 201 chloride and 99 m technetium labelled sestamibi are proven in the assessment of recurrent glioma and in the presurgical assessment of degree of glioma proliferation. Fluoride 18 fluorodeoxyglucose (18 FDG) PET is valuable on dedicated PET scanners but performs worse than thallous chloride on dual gamma camera coincidence imaging.
Hydrogen 1 MRS is proving valuable in the characterisation of glioma recurrence from radionecrosis on clinical 1.5 Tesla MR scanners when it can be performed. It is limited as remains currently a single slice multivoxal technique and can suffer markedly from shim artefact. However it relatively quick be adding 12 minutes to the scanning time for the long TE (135ms) and short TE (35ms )sequences. Recent reports on 3 Tesla MRS are very promising in the categorisation between recurrence and radionecrosis.
The combination of thallium cerebral imaging with MRI and MRS increases the confidence of diagnosis of cerebral gioma recurrence from radionecrosis with the potential to reduce the overall false negative rate for cerebral imaging.
Differential Diagnosis List
Recurrent glioma
Final Diagnosis
Recurrent glioma
References
[1]
Stokkel M, Stevens H, Taphoorn M, Van Rijk PMRI
Differentiation between recurrent brain tumour and post-radiation necrosis: the value of 201Tl SPET versus 18F-FDG PET using a dual-headed coincidence camera—a pilot study
Nucl Med Commun 1999 May;20(5):411-7. (PMID: 10404525)
[2]
Nagamachi S, Jinnouchi S, Nabeshima K, Nishii R, Flores L 2nd, Kodama T, KawaiK, Tamura S, Yokogami K, Samejima T, Wakisaka S
The correlation between 99mTc-MIBI uptake and MIB-1 as a nuclear proliferationmarker in glioma--a comparative study with 201Tl
Neuroradiology 2001 Dec;43(12):1023-30. (PMID: 11792039)
[3]
Soler C, Beauchesne P, Maatougui K, Schmitt T, Barral FG, Michel D, Dubois F, Brunon J
Technetium-99m sestamibi brain single-photon emission tomography for detection of recurrent gliomas after radiation therapy
Eur J Nucl Med 1998 Dec;25(12):1649-57. (PMID: 9871097)
[4]
Kanamori M, Kumabe T, Shimizu H, Yoshimoto T
(201)Tl-SPECT, (1)H-MRS, and MIB-1 labeling index of central neurocytomas: three case reports
Acta Neurochir (Wien) 2002 Feb;144(2):157-63. (PMID: 11862516)
[5]
Rabinov JD, Lee PL, Barker FG, Louis DN, Harsh GR, Cosgrove GR, Chiocca EA, Thornton AF, Loeffler JS, Henson JW, Gonzalez RG
In vivo 3-T MR spectroscopy in the distinction of recurrent glioma versus radiation effects: initial experience
Radiology 2002 Dec;225(3):871-9. (PMID: 12461273)
Case information
| URL: | https://eurorad.org/case/2359 |
| DOI: | 10.1594/EURORAD/CASE.2359 |
| ISSN: | 1563-4086 |
Figure 2
Hydrogen 1 MRS
Hydrogen 1 MRS within mass demonstrated on contrast enchanced T1 wighted image: Elevated choline peak (3.2ppm) with reduced creatine (3.0ppm) and N acetyl aspartate (2.0)peaks.
Metabolite map projected over T2w axial image showing increased Choline to N acetyl aspartate ratio within the left posterior frontal / left partial mass.
Cerebral MRI
Hydrogen 1 MRS
Hydrogen 1 MRS within mass demonstrated on contrast enchanced T1 wighted image: Elevated choline peak (3.2ppm) with reduced creatine (3.0ppm) and N acetyl aspartate (2.0)peaks.
Metabolite map projected over T2w axial image showing increased Choline to N acetyl aspartate ratio within the left posterior frontal / left partial mass.
