Post-treatment Glioma Imaging - South West...Post-treatment Glioma Imaging MANAS SHARMA MD...
Transcript of Post-treatment Glioma Imaging - South West...Post-treatment Glioma Imaging MANAS SHARMA MD...
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Post-treatment Glioma
Imaging
MANAS SHARMA MD
Neuroradiologist, LHSC Asst Prof, Western University
South-West Regional Cancer Program Oncology
Imaging Update Day
Mark Landis Memorial Lecture Series in
Oncologic Imaging
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Disclosures
None
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Objectives
Post treatment imaging – When? How?
Imaging patterns :
Tumor progression
Pseudoprogression
Pseudoresponse
Possible to differentiate?
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Introduction
GBM is the MC primary malignant type of brain
neoplasm
Best imaging tool – MRI with gad
Current standard of care is surgery followed by
RT and concomitant and adjuvant TMZ
chemotherapy (2005) - increases overall survival
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Introduction
Surgery and RT affect brain imaging appearances
With newer treatments – TMZ, Bevacizumab, etc – newer patterns recognized on imaging
Macdonald criteria – tumor progression > 25 % in 2D size of the contrast enhancing lesion
Newer RANO criteria – accounts for non-enhancing component
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Post surgery FU
Recurrence
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First FU - 20 day post surgery
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Enhancement ..
Is it tumor residual ?
Is it tumor re-growing ?
OR
Is it something else happening ?
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Imaging - salient points
Contrast enhancement reflects status of BBB
Surrounding non-enhancing T2 hyperintensity is not all
edema !
Contrast enhancement in post treatment tumors is rather
non-specific and can be due to many reasons – not only
tumor progression !
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Increased contrast enhancement
Non-tumoral processes
Treatment related inflammation
Post-surgical changes
Ischemia
Subacute radiation effects
Radiation necrosis
Microischemic lesions after surgery / RT can cause BBB disruption – can enhance for weeks to months after
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Of infarctions and enhancements
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Radiation injury
Acute = during and immediate
Sub-acute / Early delayed = up to 12 weeks after RT ends
Vasodilation / BBB injury / edema
Late delayed = within few months to years
Blood vessel damage – ischemia – necrosis
Increased capillary permeability - edema
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When to image ?
First scan post ttm will be baseline for future
comparisons
Within first 48 hours (at the most 72 hours) – the
ttm effect enhancements have not set in and is
good for residual tumor assessment
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First follow up scan – new baseline
Ideally within 48 hours, not more than 72
Looking for:
Surgery bordering changes – ‘expected’ surgical changes or more ? - ischemia, hemorrhage,
Any other adverse findings – distant effects – ischemia, hemorrhage
Residual tumor
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How to image ?
CT – post – quick check for adverse findings – hemorr, infarction
MRI
DWI
GRE/MPGR/SWI
Pre and post T1 images – 3D / 2D
T2
FLAIR
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Case 1 pre-surgery
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Case 1: post-surgery baseline
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Case 1: post-surgery baseline
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Case 1: post-surgery baseline
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Case 1: post-surgery baseline
Checking DWI beyond stroke is important
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Case 2: GBM, Surgery in Jan 2018, TMZ + RT
March 2018 June 2018 Aug 2018
Pseudoprogression
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Pseudo-progression
Subacute ttm-related reaction +/- clinical deterioration
First few weeks- 6 month / 60 % within 3 months
Increase in CE lesion size shortly after completion of RT – stabilizes
and decreases over time without further ttm
Mimics tumor progression
Pronounced local tissue reaction + inflammatory component,
edema, increased vessel permeability – enhancement
Represents active ‘inflammatory’ reaction against tumor!
Pts with methyl-MGMT-prom show more pseudo-progression
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Pseudo-progression
Clinical dilemma is :
Continue same ?
Change to second line ttm ?
Attempts to differentiate are important !
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Differentiation techniques -
Diffusion – a) DWI b) DTI
MR Spectrocopy – low NAA, high cho, lipid-lactate
Perfusion – DSC surrogate marker for neoangiogeneis
PsP – decrease in rCBV vs Tumor – increase in rCBV
Permeability DSC – still being evaluated
PET sensitivity / specificity also remains low
Follow up still remains the most practical / Bx may be needed!
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GBM, resected → recurrent
Bevacizumab
Cediranib
Aug Sep
No real overall survival benefits !
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Pseudo-response!
Anti-angiogenic agents
Produce a rapid decrease in enhancement by restoring BBB
Imaging improvement is fast – CAUTION !
With or without clinical improvement
High response rate / 6-month progression free survival
Tumor finds a way to expand without angiogenesis – vessel
co-option
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Treated with antiangiogens Recurrent tumor
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Of Diffusion and Perfusion
Restricted diffusion reflects cellularity and may
show infiltrative tumor tissue in the edema
Increased blood volume seen in tumor as versus
edema
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Summary: Glioma post treatment MRI
Careful interpretation – enhancements can be tricky !
Awareness of :
Pseudo-progression and pseudo-response imaging signs
Pseudo-progression vs progression techniques available
Limitations of techniques
Follow up is the best answer yet
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Case 3 : GBM, Surgery - apr 10, 2018
April 10 April 13
August 03
Pseudoprogression or tumor growth ?
Follow-up imaging
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Delayed radiation injury
Few months to several years after radiation
Necrosis triggered by ischemia secondary to blood vessel
damage and increased permeability - edema