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Case Reports
. 2020 Mar;7(2):152-157.
doi: 10.1093/nop/npz068. Epub 2019 Dec 8.

18 F-Fluciclovine PET to Distinguish Treatment-Related Effects From Disease Progression in Recurrent Glioblastoma: PET Fusion With MRI Guides Neurosurgical Sampling

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Case Reports

18 F-Fluciclovine PET to Distinguish Treatment-Related Effects From Disease Progression in Recurrent Glioblastoma: PET Fusion With MRI Guides Neurosurgical Sampling

Fraser Henderson Jr et al. Neurooncol Pract. .
Free PMC article

Abstract

Differentiation of true tumor progression from treatment-related effects remains a major unmet need in caring for patients with glioblastoma. Here, we report how the intraoperative combination of MRI with18F-fluciclovine PET guided surgical sampling in 2 patients with recurrent glioblastoma.18F-Fluciclovine PET is FDA approved for use in prostate cancer and carries an orphan drug designation in glioma. To investigate its utility in recurrent glioblastoma, we fused PET and MRI images using 2 different surgical navigation systems and performed targeted stereotactic biopsies from the areas of high ("hot") and low ("cold") radiotracer uptake. Concordant histopathologic and imaging findings suggest that a combined18F-fluciclovine PET-MRI-guided approach can guide neurosurgical resection of viable recurrent glioblastoma in the background of treatment-related effects, which can otherwise look similar on MRI.

Keywords: 18F-fluciclovine; glioblastoma; positron emission tomography (PET); pseudoprogression.

Figures

Fig. 1
Fig. 1
Case A. At 16 months after initial resection, A, T1 postcontrast MRI shows gradual progression of nodular enhancement around the surgical cavity with a satellite nodule anteriorly, and surrounding hyperintensity on B, fluid-attenuated inversion recovery. C, Source perfusion images demonstrate marked susceptibility artifact due to blood products at the resection site, making the D relative cerebral blood volume perfusion map nondiagnostic. E and F, Two 18F-fluciclovine PET–avid sites (biopsy 1 and biopsy 2) and G, 1 non–PET-avid site (biopsy 3), were sampled (white arrows). Intraoperative navigation was used to stereotactically identify the sites after registration of the images to the navigation software. E, F, and G, Orange navigation cross-hairs are faintly visible.
Fig. 2
Fig. 2
Case A. Images stained with hematoxylin and eosin compare A, biopsy 2, a “hot” PET-avid site, vs B, biopsy 3, a “cold” site, contrasting predominant findings of A, tumor recurrence vs B, treatment effect. Malignant cells with hyperchromatic chromatin and abundant mitotic activity are noted in A, whereas a high macrophage population is seen in B. Images taken at 20× objective (with a 10× eye piece, total magnification 200×). The scale bar in Figure 2A is 100 μm.
Fig. 3
Fig. 3
Case B. Nodular enhancement posterior to the resection cavity in left parietal lobe on A, T1 postcontrast, and with adjacent hyperintensity on B, fluid-attenuated inversion recovery images. C, Source perfusion image and relative cerebral blood volume (rCBV) map demonstrate D, elevated rCBV corresponding to the nodular and rim enhancement at A, left parietal surgical cavity. E and F, Three 18F-fluciclovine PET-avid biopsy sites are shown (E, small arrow, biopsy 1; larger arrow, biopsy 2; F, arrow, biopsy 3).

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