Abstract
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Objectives: The currently available PET tracers i.e. 18F-FET and 11C-methionine have proven high diagnostic efficacy in GBM. However, the development of SPECT based tracers is always viewed as a cost-effective alternate to PET imaging. The aim of the present study was to determine the diagnostic efficacy of 99mTc-labelled MDM (bis-methionine) SPECT in the diagnostic work up in glioma.
Methods: The present study was conducted in 143 glioma patients (101M: 42F; mean age 41.97±11.9 years; range 18-71 years) who were newly diagnosed or previously treated or who were recruited for post-surgical radiotherapy/chemotherapy treatment from December 2014 to August 2018. Amongst, 143 patients, 29/143 (20.0%) were freshly diagnosed patients of glioma and the remaining 114/143 (80.0%) patients were on post-surgery follow-up (radiological/clinical) with chemotherapy/radiotherapy interventions. The patients were subjected to a detailed histopathological tumor analysis (including Ki-67 index), 99mTc-MDM-SPECT, conventional MRI, DSCE-MRI and MR spectroscopy for the disease evaluation at presentation and during the course of follow-up after surgery/chemo/radiotherapy. A total of 227 brain scans (99mTc-MDM-SPECT) and an equal number of conventional MRI scans were performed in 143 patients. The results of the two imaging modalities were compared and correlated with the clinical findings. In a sub-set of patients (n=43), a quantitative DSCE-MRI and MR spectroscopy analysis was done. The results of the later were compared with the 99mTc-MDM-SPECT quantitative results for validation of this technique for accuracy in the glioma detection and characterization.
Results: On histopathological analysis, 26/29 patients (pre-surgery group) were diagnosed to have glioma ( G IV-13; G III-04; G II-09) and the remaining 3/29 patients were found to be meningioma. The mean target to non-target (T/NT) ratios of 99mTc-MDM in glioma grade II, grade III, and grade IV patients were estimated to be 2.46±2.3, 7.13±2.2 and 5.16±1.2 respectively. This ratio was much higher (15.9 ±6.8) in meningioma. The ROC curve analysis derived cut-off value of T/NT ratio of greater than 3.08 when used to discriminate low grade from high grade glioma provided 100% sensitivity, 87.5% specificity. In the post-surgery group, the final diagnosis could be made in 72/114 patients. Out of these, 47/72 showed tumor recurrent (Fig.1) or residual disease and the remaining 25 patients showed necrosis. The ROC curve analysis derived cut-off value of T/NT ratio of greater than 1.90 used to discriminate tumor recurrence from necrosis offered sensitivity and specificity of 97.9 % and 92.0% respectively. A similar analysis on DSCE-MRI quantitative data with derived nCBV cut of value of greater than 3.32 for discriminating tumor recurrence versus necrosis provided sensitivity and specificity of 84.6% and 93.0% respectively. MR spectroscopy data analysis estimated the cut-of ratios; sensitivity/specificity of different metabolites i.e. Cho/NAA, Cho/Cr, Cr/NAA, Cr/Cho and Cho/LL to be >1.57, 81.0%/73.0%; >1.64, 85.3%/73.7%; >1.06. 57.1%/ 63.6%; ≤ 0.60, 72.3%/81.0% and >0.90, 71.4%, /50% respectively. T/NT ratio showed a strongest linear correlation with nCBV(r = 0.775, P <0.00001) followed by Cho/NAA(r = 0.467, P = 0.007).
Conclusions: 99mTc-MDM uptake was significantly higher in HGG than in LGG. The derived cut-of-values of T/NT ratios and nCBV values could accurately discriminate between tumor recurrence and necrosis and both (MDM-SPECT & DSCE-MRI) the techniques have comparable sensitivity and specificity. It is thus concluded that quantitative 99mTc-MDM-SPECT and DCSE-MRI derived parameters have the similar diagnostic efficacy and when combined provides a comprehensive disease characterization in the post-surgery/RT follow up period which may impact the, management of gliomas significantly.
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