Diagnostic and Prognostic Potential of 18F-FET PET in the Differential Diagnosis of Glioma Recurrence and Treatment-Induced Changes After Chemoradiation Therapy

Monica Celli; Paola Caroli; Elena Amadori; Donatella Arpa; Lorena Gurrieri; Giulia Ghigi; Patrizia Cenni; Giovanni Paganelli; Federica Matteucci

doi:10.3389/fonc.2021.721821

Diagnostic and Prognostic Potential of ¹⁸F-FET PET in the Differential Diagnosis of Glioma Recurrence and Treatment-Induced Changes After Chemoradiation Therapy

Front Oncol. 2021 Oct 4:11:721821. doi: 10.3389/fonc.2021.721821. eCollection 2021.

Authors

Monica Celli¹, Paola Caroli¹, Elena Amadori², Donatella Arpa³, Lorena Gurrieri⁴, Giulia Ghigi³, Patrizia Cenni², Giovanni Paganelli¹, Federica Matteucci¹

Affiliations

¹ Diagnostic Nuclear Medicine Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy.
² Radiology MRI Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy.
³ Radiation Therapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy.
⁴ Oncology Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy.

Abstract

Background: MRI-based differential diagnosis of glioma recurrence (GR) and treatment-induced changes (TICs) remain elusive in up to 30% of treated glioma patients. We aimed to determine ¹⁸F-FET PET diagnostic performance in this clinical scenario, its outcome dependency on established prognostic factors, optimal ¹⁸F-FET semi-quantitative thresholds, and whether ¹⁸F-FET parameters may instantly predict progression-free survival (PFS) and overall survival (OS).

Methods: We retrospectively analyzed 45 glioma patients treated with chemoradiation therapy (32 males; mean age: 51 years, glioma grade: n=26 WHO4; n=15 WHO3; n=4 WHO2) who underwent ¹⁸F-FET PET to resolve differential diagnosis of GR and TICs raised by MRI performed in the preceding 2 weeks and depicting any of the following changes in their radiation field: volumetric increase of contrast-enhancing lesions; new contrast-enhancing lesion; significant increase in T2/FLAIR non-enhancing lesion without reducing corticosteroids. ¹⁸F-FET PET outcome relied on evaluation of maximum tumor-to-brain ratio (TBRmax), time-to-peak (TTP), and time-activity curve pattern (TAC). Metabolic tumor volume (MTV) and total tumor metabolism (TTM) were calculated for prognostic purposes. Standard of reference was repeat MRI performed 4-6 weeks after the previous MRI. Non-parametric statistics tested ¹⁸F-FET-based parameters for dependency on established prognostic markers. ROC curve analysis determined optimal cutoff values for ¹⁸F-FET semi-quantitative parameters. ¹⁸F-FET parameters and prognostic factors were evaluated for PFS and OS by Kaplan-Meier, univariate, and multivariate analyses.

Results: ¹⁸F-FET PET sensitivity, specificity, positive predictive value, negative predictive value were 86.2, 81.3, 89.3, 76.5%, respectively; higher diagnostic accuracy was yielded in IDH-wild-type glioma patients compared to IDH-mutant glioma patients (sensitivity: 81.8 versus 88.9%; specificity: 80.8 versus 81.8%). KPS was the only prognostic factor differing according to ¹⁸F-FET PET outcome (negative versus positive). Optimal ¹⁸F-FET cutoff values for GR were TBRmax ≥ 2.1, SUVmax ≥ 3.5, and TTP ≤ 29 min. PFS differed based on ¹⁸F-FET outcome and related metrics and according to KPS; a different OS was observed according to KPS only. On multivariate analysis, ¹⁸F-FET PET outcome was the only significant PFS factor; KPS and age the only significant OS factors.

Conclusion: ¹⁸F-FET PET demonstrated good diagnostic performance. ¹⁸F-FET PET outcome and metrics were significantly predictive only for PFS.

Keywords: 18F-FET PET; metabolic tumor volume; total tumor metabolism; treated gliomas; treatment-related changes.