Diffusion-weighted MR imaging for the differentiation of true progression from pseudoprogression following concomitant radiotherapy with temozolomide in patients with newly diagnosed high-grade gliomas

Acad Radiol. 2012 Nov;19(11):1353-61. doi: 10.1016/j.acra.2012.06.011. Epub 2012 Aug 11.


Rationale and objectives: The assessment of the therapeutic response of high-grade gliomas treated with concomitant chemoradiotherapy (CCRT) using temozolomide is difficult because of the frequent occurrence of early imaging changes that are indistinguishable from tumor progression, termed pseudoprogression. The purpose of this study was to determine whether diffusion-weighted imaging could be used to differentiate true progression and pseudoprogression.

Materials and methods: Magnetic resonance images and diffusion-weighted images obtained within 2 months of CCRT completion in patients with high-grade gliomas were retrospectively reviewed. A total of 22 patients with increases in measurable enhancing regions were identified and classified into true progression and pseudoprogression groups on the basis of contrast-enhanced magnetic resonance images obtained 12 weeks after CCRT. Qualitative and quantitative analysis of diffusion-weighted images and apparent diffusion coefficient maps, respectively, was performed to discriminate true progression and pseudoprogression. Statistical analyses were performed using Fisher's exact test, unpaired t tests, and receiver-operating characteristic analysis.

Results: The true progression group showed a higher incidence of homogeneous or multifocal high signal intensity on diffusion-weighted images (seven of 10 patients [70%]), whereas rim high or no high signal intensity (10 of 12 [83%]) was observed in the pseudoprogression group (P = .027). True progression was defined by newly appearing or enlarged enhancing lesions with mean apparent diffusion coefficient values of 1200 × 10(-6) mm(2)/s inside the radiation field after CCRT; the sensitivity, specificity, and accuracy were 80% (eight of 10), 83.3% (10 of 12), and 81.2% (18 of 22), respectively.

Conclusions: The assessment of diffusion-weighted images for patients with increases of measurable enhancing regions 2 months after CCRT completion is useful for differentiating true progression from pseudoprogression.

Publication types

  • Clinical Trial

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Antineoplastic Agents, Alkylating / therapeutic use
  • Artifacts*
  • Brain Neoplasms / pathology*
  • Brain Neoplasms / therapy*
  • Chemoradiotherapy / methods*
  • Dacarbazine / analogs & derivatives
  • Dacarbazine / therapeutic use
  • Diagnosis, Differential
  • Diffusion Magnetic Resonance Imaging / methods*
  • Female
  • Glioma / pathology*
  • Glioma / therapy*
  • Humans
  • Male
  • Reproducibility of Results
  • Sensitivity and Specificity
  • Temozolomide
  • Treatment Outcome
  • Young Adult


  • Antineoplastic Agents, Alkylating
  • Dacarbazine
  • Temozolomide