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. 2023 Jul;163(3):647-655.
doi: 10.1007/s11060-023-04377-5. Epub 2023 Jun 21.

18F-fluciclovine PET/CT to distinguish radiation necrosis from tumor progression for brain metastases treated with radiosurgery: results of a prospective pilot study

Martin C Tom  1 , Frank P DiFilippo  2 , Stephen E Jones  3 , John H Suh  4   5 , Nancy A Obuchowski  6 , Timothy D Smile  4 , Erin S Murphy  4   5 , Jennifer S Yu  4   5 , Gene H Barnett  5   7 , Lilyana Angelov  5   7 , Alireza M Mohammadi  5   7 , Steve S Huang  2 , Guiyun Wu  2 , Scott Johnson  3 , David M Peereboom  5   8 , Glen H J Stevens  5   9 , Manmeet S Ahluwalia  5   8 , Samuel T Chao  4   5
Affiliations

18F-fluciclovine PET/CT to distinguish radiation necrosis from tumor progression for brain metastases treated with radiosurgery: results of a prospective pilot study

Martin C Tom et al. J Neurooncol. 2023 Jul.

Abstract

Purpose: Distinguishing radiation necrosis from tumor progression among patients with brain metastases previously treated with stereotactic radiosurgery represents a common diagnostic challenge. We performed a prospective pilot study to determine whether PET/CT with 18F-fluciclovine, a widely available amino acid PET radiotracer, repurposed intracranially, can accurately diagnose equivocal lesions.

Methods: Adults with brain metastases previously treated with radiosurgery presenting with a follow-up tumor-protocol MRI brain equivocal for radiation necrosis versus tumor progression underwent an 18F-fluciclovine PET/CT of the brain within 30 days. The reference standard for final diagnosis consisted of clinical follow-up until multidisciplinary consensus or tissue confirmation.

Results: Of 16 patients imaged from 7/2019 to 11/2020, 15 subjects were evaluable with 20 lesions (radiation necrosis, n = 16; tumor progression, n = 4). Higher SUVmax statistically significantly predicted tumor progression (AUC = 0.875; p = 0.011). Lesion SUVmean (AUC = 0.875; p = 0.018), SUVpeak (AUC = 0.813; p = 0.007), and SUVpeak-to-normal-brain (AUC = 0.859; p = 0.002) also predicted tumor progression, whereas SUVmax-to-normal-brain (p = 0.1) and SUVmean-to-normal-brain (p = 0.5) did not. Qualitative visual scores were significant predictors for readers 1 (AUC = 0.750; p < 0.001) and 3 (AUC = 0.781; p = 0.045), but not for reader 2 (p = 0.3). Visual interpretations were significant predictors for reader 1 (AUC = 0.898; p = 0.012) but not for reader 2 (p = 0.3) or 3 (p = 0.2).

Conclusions: In this prospective pilot study of patients with brain metastases previously treated with radiosurgery presenting with a contemporary MRI brain with a lesion equivocal for radiation necrosis versus tumor progression, 18F-fluciclovine PET/CT repurposed intracranially demonstrated encouraging diagnostic accuracy, supporting the pursuit of larger clinical trials which will be necessary to establish diagnostic criteria and performance.

Keywords: 18F-fluciclovine PET/CT; Brain metastases; Radiation necrosis; Stereotactic radiosurgery; Tumor progression.

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References

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