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ECR 2019 / C-0185
Certificate of Merit
Neurooncology pending battles: is it possible to differentiate true progression from pseudoprogression?
Congress: ECR 2019
Poster No.: C-0185
Type: Educational Exhibit
Keywords: Neoplasia, Multidisciplinary cancer care, Radiation effects, Diagnostic procedure, MR-Diffusion/Perfusion, MR, Neuroradiology brain
Authors: A. Hilario Barrio, P. Martín Medina, E. Salvador, G. Ayala, L. Koren, A. Martinez de Aragon, F. Ballenilla, J. M. Millan, A. Ramos Gonzalez; Madrid/ES
DOI:10.26044/ecr2019/C-0185

Findings and procedure details

Problematic analysis of pseudoprogressions:

 

Fig. 10: Problematic analysis of pseudoprogressions
References: Radiology, Hospital Universitario 12 de Octubre, 12 Octubre - Madrid/ES

 

 

At conventional imaging:

 

Pseudoprogression: self-limited enhancing lesions that spontaneously stabilize and resolve without treatment.

 

True progression. During the first 12 weeks after RT+QT or RT alone:

  • New enhancement outside radiation field
  • Pathologic confirmations of progressive disease
  • Subependymal enhancement

With conventional techniques, in most cases it is not possible to differentiate pseudoprogression and true progression.

 

Fig. 11: At conventional imaging
References: Radiology, Hospital Universitario 12 de Octubre, 12 Octubre - Madrid/ES

 

 

At DWI:

 

Pseudoprogression: higher ADC values in treatment related changes

 

True progression: lower ADC values

 

Fig. 12: DWI differentiating pseudoprogression and true progression
References: Radiology, Hospital Universitario 12 de Octubre, 12 Octubre - Madrid/ES

 

ADC values may differentiate between true progression and pseudoprogression. Tumor recurrence usually presents with lower ADC values (mean & minimum).

Due to tumor heterogeneity, DWI as a single ROI measure is inadequate.

Articles applied Voxel-wise analysis with ADC histograms analysis or parametric response. However, this advances analysis are NOT incorporated into clinical practice.

 

IMPORTANT!!! New enhancing lesion with DWI restriction... think true progression.

 

Fig. 13: New enhancing lesion with DWI restriction ... think true progression
References: Radiology, Hospital Universitario 12 de Octubre, 12 Octubre - Madrid/ES

 

 

At DSC perfusion MRI:

 

Cerebral blodd volume (rCBV) elevated in malignant gliomas and relatively low in pseudoprogression.

Some estudies conclude that speficific relative thresholds are helpful:

  • rCBV ratio thresholds ranging from 1.2 to 2.0 for pseudoprogression (low rCBV)
  • rCBV>2.5 for recurrent disease (high rCBV)
Fig. 14: rCBV threshold values for pseudoprogression and recurrent disease
References: Radiology, Hospital Universitario 12 de Octubre, 12 Octubre - Madrid/ES

 

Variations in rCBV in respect to previous tumor:

  • ⇓ 41% pseudoprogression
  • ⇑ 21% disease progression

Hence, >5% ⇑ in rCBV after treatment predicts poor survival

 

There is a conflicting evidence for the ability of rCBV to distinguish pseudoprogression from true progression. Overlap results derived from coexistence of tumor with treatment-related enhancement.

 

Fig. 15: Variations of rCBV in respecto to previous tumor
References: Radiology, Hospital Universitario 12 de Octubre, 12 Octubre - Madrid/ES
Fig. 16: Importance of rCBV distinguishing pseudoprogression and true progression
References: Radiology, Hospital Universitario 12 de Octubre, 12 Octubre - Madrid/ES

 

 

At DCE perfusion MRI:

 

This perfusion technique allows "quantitative" and "semiquantitative" evaluation of enhancing tumor.

Ktrans and iAUC are better imaging markers than Ve and Kep, and are significantly higher in the recurrent group.

 

Fig. 17: Ktrans and iAUC relatively higher in recurrent tumors
References: Radiology, Hospital Universitario 12 de Octubre, 12 Octubre - Madrid/ES

 

 

Semiquantitative analysis: curves of enhancing SI(signal intensity)/time

 

iAUC: reflects the degree of early leakage of contrast agent into the EES. Depends on the hypervascularity and neoangiogenesis. INCREASES IN TUMORS.

 

fAUC: HIGHER IN PSEUDOPROGRESSION. A measure of contrast retention within EES. Reflecfs increased EES associated with  cellularity and more tissue damage.

 

Fig. 18: Semiquantitative analysis: curves of enhancing SI/time
References: Radiology, Hospital Universitario 12 de Octubre, 12 Octubre - Madrid/ES

 

Fig. 19: Different curves of enhancing SI/time in pseudoprogression and recurrent disease
References: Radiology, Hospital Universitario 12 de Octubre, 12 Octubre - Madrid/ES
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