Impact of Resecting Radiation Necrosis and Pseudoprogression on Survival of Patients with Glioblastoma

Grossman, Rachel; Shimony, Nir; Hadelsberg, Uri; Soffer, Dov; Sitt, R.; Strauss, Natan; Corn, Benjamin W.; Ram, Zvi

doi:10.1016/j.wneu.2016.01.020

Cited by 20 publications

(9 citation statements)

References 19 publications

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“…However, pseudoprogression also occurs in MGMT promotor unmethylated cases. Another series reported 18 cases of radiation necrosis in a series of 159 patients undergoing second surgery for a glioblastoma, in which survival was not improved in patients who suffered from radiation necrosis compared to patients undergoing surgery for PD …”

Section: Incidence and Outcomementioning

confidence: 99%

Pseudoprogression of brain tumors

Thust

Bent

Smits

2018

Magnetic Resonance Imaging

238

194

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This review describes the definition, incidence, clinical implications, and magnetic resonance imaging (MRI) findings of pseudoprogression of brain tumors, in particular, but not limited to, high‐grade glioma. Pseudoprogression is an important clinical problem after brain tumor treatment, interfering not only with day‐to‐day patient care but also the execution and interpretation of clinical trials. Radiologically, pseudoprogression is defined as a new or enlarging area(s) of contrast agent enhancement, in the absence of true tumor growth, which subsides or stabilizes without a change in therapy. The clinical definitions of pseudoprogression have been quite variable, which may explain some of the differences in reported incidences, which range from 9–30%. Conventional structural MRI is insufficient for distinguishing pseudoprogression from true progressive disease, and advanced imaging is needed to obtain higher levels of diagnostic certainty. Perfusion MRI is the most widely used imaging technique to diagnose pseudoprogression and has high reported diagnostic accuracy. Diagnostic performance of MR spectroscopy (MRS) appears to be somewhat higher, but MRS is less suitable for the routine and universal application in brain tumor follow‐up. The combination of MRS and diffusion‐weighted imaging and/or perfusion MRI seems to be particularly powerful, with diagnostic accuracy reaching up to or even greater than 90%. While diagnostic performance can be high with appropriate implementation and interpretation, even a combination of techniques, however, does not provide 100% accuracy. It should also be noted that most studies to date are small, heterogeneous, and retrospective in nature. Future improvements in diagnostic accuracy can be expected with harmonization of acquisition and postprocessing, quantitative MRI and computer‐aided diagnostic technology, and meticulous evaluation with clinical and pathological data. Level of Evidence: 3 Technical Efficacy: Stage 2J. Magn. Reson. Imaging 2018;48:571–589.

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Section: Incidence and Outcomementioning

confidence: 99%

Pseudoprogression of brain tumors

Thust

Bent

Smits

2018

Magnetic Resonance Imaging

238

194

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“…However, the current literature surrounding the safety and efficacy of surgical resection is limited to smaller case series and case studies, and direct comparison is difficult because of a lack of consistency in histopathology and reporting outcomes. [13][14][15][16][17][18] The goal of this study is therefore to assess a single institution's experience with craniotomy for confirmed treatment-refractory symptomatic radiation. To our knowledge, this remains the largest study to date assessing the utility of craniotomies for this indication.…”

Section: Shah Et Al Craniotomy For Refractory Radiation Necrosismentioning

confidence: 99%

Salvage craniotomy for treatment-refractory symptomatic cerebral radiation necrosis

Shah

Mahavadi

Morell

et al. 2019

Neuro-Oncology Practice

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Background The incidence of symptomatic radiation necrosis (RN) has risen as radiotherapy is increasingly used to control brain tumor progression. Traditionally managed with steroids, symptomatic RN can remain refractory to medical treatment, requiring surgical intervention for control. The purpose of our study was to assess a single institution’s experience with craniotomy for steroid-refractory pure RN. Methods The medical records of all tumor patients who underwent craniotomies at our institution from 2011 to 2016 were retrospectively reviewed for a history of preoperative radiotherapy or radiosurgery. RN was confirmed histopathologically and patients with active tumor were excluded. Preoperative, intraoperative, and outcome information was collected. Primary outcomes measured were postoperative KPS and time to steroid freedom. Results Twenty-four patients with symptomatic RN were identified. Gross total resection was achieved for all patients. Patients with metastases experienced an increase in KPS (80 vs 100, P < .001) and required a shortened course of dexamethasone vs patients with high-grade gliomas (3.4 vs 22.2 weeks, P = .003). RN control and neurological improvement at 13.3 months’ follow-up were 100% and 66.7%, respectively. Adrenal insufficiency after rapidly tapering dexamethasone was the only morbidity (n = 1). Overall survival was 93.3% (14/15) at 1 year. Conclusion In cases of treatment-refractory symptomatic RN, resection can lead to an overall improvement in postoperative health status and neurological outcomes with minimal RN recurrence. Craniotomy for surgically accessible RN can safely manage symptomatic patients, and future studies assessing the efficacy of resection vs bevacizumab may be warranted.

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“…Although histologic and follow-up MR imaging findings have been used for this purpose, histologic evaluation is invasive and frequently standard treatment and may eventually be a clinically relevant tool to help guide treatment in patients with glioblastoma with imaging findings of deterioration during standard therapy. Calculation of relative standardized uptake values in the residual tumor with PET may enable identification of patients with a worse prognosis who may benefit from further therapeutic interventions (20). Note.-Data in parentheses are 95% CIs, and data in brackets are P values.…”

Section: Neuroradiology: Fdg Pet/mr Imaging Coregistration To Predictmentioning

confidence: 99%

FDG PET/MR Imaging Coregistration Helps Predict Survival in Patients with Glioblastoma and Radiologic Progression after Standard of Care Treatment

et al. 2017

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Purpose To determine the correlation between metabolic activity at fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) and survival in patients with glioblastoma and suspected progression at posttherapy magnetic resonance (MR) imaging. Materials and Methods The authors retrospectively examined the relationship between metabolic activity at FDG PET in the residual lesion identified at brain MR imaging and survival time in 56 patients with glioblastoma who were treated with postoperative concurrent radiation and temozolomide therapy and who underwent FDG PET/computed tomography because of radiologic deterioration at follow-up MR imaging between 2006 and 2015. A normalized metric of metabolic activity in the residual lesion (standardized uptake value ratio [SUV]) was calculated as the maximum standardized uptake value (SUV) in the tumor relative to that in healthy white matter. The primary end point of the study was survival time from PET. Patients were stratified according to SUV. Comparisons of risk for death between subgroups were made with the log-hazard ratio of the Cox proportional hazard model. Results There was a significant association between overall survival and SUV in the residual lesion (P = .006), and a survival benefit was observed in patients with SUV of less than 1.7, who had a median survival time of 23.1 months (95% confidence interval [CI]: 12.7, 38.9), which was significantly longer than that in patients with an SUV of 2.0 to less than 2.5 and those with an SUV of at least 2.5, who had a median survival time of 10.1 (95% CI: 2.4, 15.9; P = .008) and 7.5 (95% CI: 3.9, 9.7; P < .001) months, respectively. Conclusion Patients with glioblastoma whose posttherapy MR images showed a residual lesion with high relative metabolic activity at FDG PET had a shorter survival time than did those with low activity at FDG PET. RSNA, 2016.

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Impact of Resecting Radiation Necrosis and Pseudoprogression on Survival of Patients with Glioblastoma

Cited by 20 publications

References 19 publications

Pseudoprogression of brain tumors

Pseudoprogression of brain tumors

Salvage craniotomy for treatment-refractory symptomatic cerebral radiation necrosis

FDG PET/MR Imaging Coregistration Helps Predict Survival in Patients with Glioblastoma and Radiologic Progression after Standard of Care Treatment

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