Improved detection of diffuse glioma infiltration with imaging combinations: a diagnostic accuracy study

Abstract

Background Surgical resection and irradiation of diffuse glioma are guided by standard MRI: T2/fluid attenuated inversion recovery (FLAIR)–weighted MRI for non-enhancing and T1-weighted gadolinium-enhanced (T1G) MRI for enhancing gliomas. Amino acid PET has been suggested as the new standard. Imaging combinations may improve standard MRI and amino acid PET. The aim of the study was to determine the accuracy of imaging combinations to detect glioma infiltration. Methods We included 20 consecutive adults with newly diagnosed non-enhancing glioma (7 diffuse astrocytomas, isocitrate dehydrogenase [IDH] mutant; 1 oligodendroglioma, IDH mutant and 1p/19q codeleted; 1 glioblastoma IDH wildtype) or enhancing glioma (glioblastoma, 9 IDH wildtype and 2 IDH mutant). Standardized preoperative imaging (T1-, T2-, FLAIR-weighted, and T1G MRI, perfusion and diffusion MRI, MR spectroscopy and O-(2-[18F]-fluoroethyl)-L-tyrosine ([18F]FET) PET) was co-localized with multiregion stereotactic biopsies preceding resection. Tumor presence in the biopsies was assessed by 2 neuropathologists. Diagnostic accuracy was determined using receiver operating characteristic analysis. Results A total of 174 biopsies were obtained (63 from 9 non-enhancing and 111 from 11 enhancing gliomas), of which 129 contained tumor (50 from non-enhancing and 79 from enhancing gliomas). In enhancing gliomas, the combination of apparent diffusion coefficient (ADC) with [18F]FET PET (area under the curve [AUC], 95% CI: 0.89, 0.79‒0.99) detected tumor better than T1G MRI (0.56, 0.39‒0.72; P < 0.001) and [18F]FET PET (0.76, 0.66‒0.86; P = 0.001). In non-enhancing gliomas, no imaging combination detected tumor significantly better than standard MRI. FLAIR-weighted MRI had an AUC of 0.81 (0.65–0.98) compared with 0.69 (0.56–0.81; P = 0.019) for [18F]FET PET. Conclusion Combining ADC and [18F]FET PET detects glioma infiltration better than standard MRI and [18F]FET PET in enhancing gliomas, potentially enabling better guidance of local therapy.

The Association Between the Extent of Glioblastoma Resection and Survival in Light of MGMT Promoter Methylation in 326 Patients With Newly Diagnosed IDH-Wildtype Glioblastoma

“…It can be hypothesized that the direct peritumoral NCE area reflects a higher degree of tumor infiltration than the NCE area further away from the CE tumor, which is presumably more dominated by edema than tumor infiltration (4). In future research, a combination of physiological imaging modalities (such as MR spectroscopy, diffusion and perfusion imaging or positron-emission tomography) may be used to more accurately detect tumor infiltrated portions in NCE and to tailor surgical planning (21).…”

Voxelwise and Patientwise Correlation of 18F-FDOPA PET, Relative Cerebral Blood Volume, and Apparent Diffusion Coefficient in Treatment-Naïve Diffuse Gliomas with Different Molecular Subtypes

“…Amino acid positron emission tomography (PET), such as 18 F-fluorodihydroxyphenylalanine (FDOPA) and 18 F-fluorethyltyrosine (FET), is often used in neuro-oncological practices to identify metabolically active tumor tissues. These amino acid PETs provide information that complement MRI, and the combination of PET and MRI metrics were reported to be useful for clinical management of gliomas (1,2). Hybrid examinations of PET and MRI have recently been performed for evaluating gliomas in clinical practice (3).…”

Visualizing Glioma Infiltration by the Combination of Multimodality Imaging and Artificial Intelligence, a Systematic Review of the Literature

“…Eight of these were retrospective studies [ 21 , 22 , 23 , 27 , 30 , 31 , 32 , 37 ] and six were prospective [ 24 , 25 , 26 , 28 , 29 , 38 ]. Two of the reported six prospective studies had clear specification of being consecutive [ 24 , 29 ]. The focus of all studies was high-grade glioma, with two studies including also low-grade glioma [ 24 , 29 ].…”

“…Two of the reported six prospective studies had clear specification of being consecutive [ 24 , 29 ]. The focus of all studies was high-grade glioma, with two studies including also low-grade glioma [ 24 , 29 ]. All studies except Durst et al [ 24 ] incorporated two or more conventional MRI sequences (T1, T1ce, T2, FLAIR) in their final model.…”

“…However, single imaging modalities have only achieved moderate accuracy for the detection of infiltration [ 20 ]. In acknowledgement of this, various groups have focused their attention on an integration of multiple imaging modalities in a predictive model showing the probability of tumor presence or later tumor recurrence in glioma patients [ 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ]. By the aid of artificial intelligence (AI) methods a variety of imaging parameters can be considered simultaneously as opposed to a manual visual assessment of tumor extent during treatment planning.…”