Radiation necrosis versus glioma recurrence: conventional MR imaging clues to diagnosis

Abstract

Background and purpose: Conventional MR imaging findings are considered to be inadequate for reliably distinguishing radiation necrosis from tumor recurrence in patients with glioma. Despite this belief, we hypothesized that certain conventional MR imaging findings, alone or in combination, though not definitive, may favor one or another of these diagnoses in proton beam-treated patients with new enhancing lesions on serial scanning.

Methods: MR imaging findings (axial T1-, T2-, and post-gadolinium T1-weighted) of 27 proton beam radiation therapy patients with high-grade gliomas were retrospectively reviewed. Entry criteria included new MR imaging enhancing lesions after treatment and histologically unequivocal biopsy proof of diagnosis. Readers rated corpus callosum involvement, midline spread, subependymal spread, new discrete multiple enhancing foci, a "spreading wavefront" appearance, and septum pellucidum involvement. Statistical analysis was by the Fisher exact test.

Results: Corpus callosum involvement in combination with multiple other findings was highly associated with progressive glioma. These combinations included involvement of the corpus callosum with multiple enhancing foci (P = .02), involvement of the corpus callosum with crossing the midline and multiple enhancing lesions (P = .04), and involvement of the corpus callosum with subependymal spread and multiple enhancing lesions (P = .01).

Conclusions: In proton beam-treated patients with glioma, corpus callosum involvement, in conjunction with multiple enhancing lesions with or without crossing of the midline and subependymal spread, favors predominant glioma progression. Overall, combinations of enhancement patterns were more likely than individual patterns to distinguish necrosis from predominant tumor progression. Together with clinical and functional imaging findings, these results may assist in determining the need for biopsy.

Fig 1.

60-year-old woman with a history of left parietal anaplastic astrocytoma and new abnormal enhancement on follow-up imaging after surgery and proton beam irradiation therapy. Arrows on this postcontrast axial T1-weighted image illustrate the “spreading wavefront” appearance. Biopsy of this lesion yielded radiation necrosis.

Fig 2.

50-year-old woman with history of left parieto-temporo-occipital glioblastoma multiforme and new abnormal enhancement on follow-up imaging after surgery and proton beam irradiation therapy. A, Arrows on this precontrast axial T1-weighted image illustrate the location of abnormal enhancement. B, Arrows on this postcontrast axial T1-weighted image illustrate the spreading wavefront appearance along one of the dominant borders of the lesion; subependymal involvement that extended up to involve the corpus callosum is also observed. Biopsy of a portion of the abnormality yielded recurrent tumor.

Fig 3.

57-year-old woman with history of right frontal glioblastoma multiforme and new abnormal enhancement on follow-up imaging after surgery and proton beam irradiation therapy. A, Arrows on this postcontrast axial T1-weighted image illustrate multiple enhancing lesions and spread to the contralateral hemisphere. B, Arrows on this postcontrast axial T2-weighted image illustrate the location of abnormal enhancement on the axial T1-weighted images, as well as associated vasogenic or tumor edema. Biopsy of a portion of the abnormality yielded recurrent tumor.

Fig 4.

68-year-old man with history of left parietooccipital glioblastoma multiforme has new abnormal enhancement on follow-up imaging after surgery and proton beam irradiation therapy. Arrows on this postcontrast axial T1-weighted image illustrate enhancement and thickening of the septum pellucidum. Arrowhead points to involvement of the corpus callosum. Open arrow points to subependymal spread. Multiple new lesions were identified. Biopsy of a portion of the corpus callosum abnormality (arrowhead) yielded recurrent tumor.