Abstract
PET/CT and PET/MR can be used with various radiopharmaceuticals to assess the mechanisms underlying biochemical changes and pathophysiologic changes of brain tumors.
Amino acid tracers are frequently used for most clinical issues. These tracers include, among others, [11C]methionine ([11C]MET), l-3,4-dihydroxyphenylalanine ([18F]fluorodopa), and O-(2-18F-fluoroethyl)-l-tyrosine. Amino acid tracers are particularly accurate to distinguish between tumor recurrence and radiation necrosis, which represents the single most common question in the clinical management of brain tumor patients. The role of [18F]FDG, the earliest PET tracer used for diagnosis and monitoring of brain tumors, is today much reduced after the introduction of amino acid tracers. However, for in vivo prediction of tumor grading, which represents a very important prognostic factor, [18F]FDG still remains more accurate than most amino acid tracers.
It has been shown with different tracers that higher baseline values of tracer uptake as well as lower percent changes after therapy in treated patients predict shorter survival.
PET/CT and PET/MR can be used also after surgery to assess the presence of residual tumor. Currently, PET, in combination with MR, is increasingly used for the definition of the tumor volume that has to be irradiated. Identification of the part of the tumor that displays highest metabolic activity can also be used to direct stereotaxic biopsy.
Other tracers have been developed to explore different biochemical processes, for example, hypoxia (e.g., 18F-fluoromisonidazole), DNA synthesis (3-deoxy-3-18F-fluorothymidine), and membrane proliferation (radiolabeled choline). However, at the moment all these tracers have a less established role in the clinical practice, even though some interesting results are emerging from clinical studies.
The hybrid PET/MR scanners developed over the last decade are still mainly restricted to selected university or research centers, although their availability is increasing. They represent a technological breakthrough with immediate impact on research as well as on diagnostic capabilities. The patient, for example, can perform simultaneously (“one-stop-shop”) an examination that provides information that would otherwise require two different examinations performed often in two different institutes and in different days. Several studies have shown indeed that the combination of the two modalities provides a synergistic effect. In the research setting, PET/MR scanners are of particular value since they allow accurate registration and anatomic fusion, as well segmentation and partial volume correction. The widespread use of PET/MR scanners is limited by high costs, sufficient research funds availability, high clinical demand, and highly qualified interdisciplinary personnel, but further growth is expected in the near future.
The most promising perspective for future investigations is probably represented by the development of software enabling radiomics analysis of brain tumors. Radiomics extracts large amounts of features from either PET or MR images using data characterization algorithms. These features, termed radiomic features, have the potential to uncover disease characteristics that fail to be appreciated by visual or semiquantitative analysis. The hypothesis of radiomics is that the distinctive imaging features between disease forms may be useful for predicting prognosis and therapeutic response for various conditions, thus providing valuable information for personalized therapy. Radiomics has already been successfully employed in pilot studies in brain tumor patients with either [11C]MET or [18F]FDG.
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Abbreviations
- ADC:
-
Apparent diffusion coefficient, a parameter of MR imaging
- AJCC:
-
American Joint Committee on Cancer
- BBB:
-
Blood–brain barrier
- BTV:
-
Biological tumor volume (the extent of tumor based on PET imaging); the combination of GTV and BTV provides the planning target volume for radiation therapy
- CBF:
-
Cerebral blood flow
- CI:
-
Confidence interval
- CMRglc:
-
Cerebral metabolic rate for glucose
- CNS:
-
Central nervous system
- CSF:
-
Cerebrospinal fluid
- CT:
-
X-ray computed tomography
- 64Cu-ATSM:
-
64Cu-diacetyl-bis(N4-methylsemicarbazone)
- DG:
-
2-Deoxyglucose
- DOTA:
-
1,4,7,10-Tetraazacyclododecane-1,4,7,10-tetraacetic acid
- DOTANOC:
-
DOTA-1-Nal3-octreotide
- DOTATATE:
-
DOTA- Tyr3-octreotate
- DOTATOC:
-
DOTA-octreotate
- DWI:
-
Diffusion-weighted imaging, an MR imaging technique
- EGFR:
-
Epidermal growth factor receptor; the mutated form EGFRvIII plays a prominent role in tumorigenesis and proangiogenic signaling
- 18F-FAZA:
-
18F-azomycin arabinoside
- 18F-FES:
-
16α-18F-fluoro-17β-oestradiol
- 18F-FET:
-
O-(2-18F-Fluoroethyl)-l-Tyrosine, a tyrosine analog
- 18F-FLT:
-
18F-fluorothymidine
- 18F-FMAU:
-
18F-2-fluoro-5-methyl-1-beta-d-arabinofuranosyluracil
- 18F-MISO:
-
18F-fluoromisonidazole
- [18F]FDOPA:
-
l-3,4-dihydroxy-6-[18F]fluorophenylalanine
- [18F]FDG:
-
2-Deoxy-2-[18F]fluoro-d-glucose
- FLAIR:
-
Fluid-attenuated inversion recovery, an MR imaging technique
- GBM:
-
Glioblastoma multiforme
- GTV:
-
Gross tumor volume (the extent of the tumor on morphologic imaging)
- [123I]IAZA:
-
[123I]iodoazomycin arabinoside
- IDH:
-
Isocitrate dehydrogenase; mutations of this enzyme occur more frequently in oligodendroglial and astrocytic tumors
- 123I-IMT:
-
[123I]alpha-methyltyrosine, a tyrosine analog transported as l-tyrosine by the neutral amino acid transporter
- KPS:
-
Karnofsky performance score
- LAT1:
-
l-type amino acid transporter 1
- M:
-
Metastasis status according to the AJCC/UICC TNM staging system
- MDR1:
-
Multidrug resistance gene 1, a characteristic associated with aggressive tumors; this gene encodes for P-glyoprotein
- [11C]MET:
-
[11C]methionine
- MGMT:
-
Methyl guanine DNA methyl transferase, a DNA repair enzyme; methylation of MGMT promoter is associated with increased overall survival
- MIB-1:
-
Marker of cell proliferation used for stratification of grades of brain tumors
- MoAb:
-
Monoclonal antibody
- MPNST:
-
Malignant peripheral nerve sheath tumor
- MR:
-
Magnetic resonance
- MRI:
-
Magnetic resonance imaging
- N:
-
Lymph node status according to the AJCC/UICC TNM staging system
- PET:
-
Positron emission tomography
- PET/CT:
-
Positron emission tomography/Computed tomography
- PET/MR:
-
Positron emission tomography/Magnetic resonance
- PI3K:
-
Phosphatidylinositol 3-kinase
- PNET:
-
Primitive neuroectodermic tumor
- pRIT:
-
Pretargeting radioimmunotherapy
- PTEN:
-
Phosphatase and tensin homolog is a tumor suppressor; PTEN deletions indicate a poor prognosis
- RIT:
-
Radioimmunotherapy
- ROC:
-
Receiver operating characteristic, a statistical analysis to assess the performance of a binary classifier
- ROI:
-
Region of interest
- SPECT:
-
Single-photon emission computed tomography
- SPECT/CT:
-
Single-photon emission computed tomography/Computed tomography
- SST:
-
Somatostatin
- SSTR:
-
Somatostatin receptors
- SUV:
-
Standardized uptake value
- T:
-
Tumor status according to the AJCC/UICC TNM staging system
- T/N:
-
Ratio of tumor uptake to normal brain uptake
- TBR:
-
Tumor-to-background ratio
- TNM:
-
AJCC/UICC staging system based on parameters “T” (tumor status), “N” (lymph node status), and “M” (distant metastasis status)
- TP53:
-
Tumor protein p53, also known as cellular tumor antigen p53, phosphoprotein p53, tumor suppressor p53, antigen NY-CO-13, or transformation-related protein 53 (TRP53)
- UICC:
-
Union Internationale Contre le Cancer (International Union Against Cancer)
- VEGF:
-
Vascular endothelial growth factor
- VOI:
-
Volume of interest
- WHO:
-
World Health Organization
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Giovacchini, G., Pastorino, S., Riondato, M., Giovannini, E., Ciarmiello, A. (2022). Diagnostic Applications of Nuclear Medicine: Brain Tumors. In: Volterrani, D., Erba, P.A., Strauss, H.W., Mariani, G., Larson, S.M. (eds) Nuclear Oncology. Springer, Cham. https://doi.org/10.1007/978-3-031-05494-5_9
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