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Diagnostic Applications of Nuclear Medicine: Brain Tumors

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Nuclear Oncology

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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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  1. Nuclear Medicine Department, S. Andrea Hospital, La Spezia, Italy

    Giampiero Giovacchini, Sara Pastorino, Mattia Riondato, Elisabetta Giovannini & Andrea Ciarmiello

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  1. Giampiero Giovacchini
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  2. Sara Pastorino
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  3. Mattia Riondato
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  4. Elisabetta Giovannini
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  5. Andrea Ciarmiello
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Correspondence to Andrea Ciarmiello .

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Editors and Affiliations

  1. Associate Professor and Director of Nuclear Medicine, University of Pisa, Pisa, Italy

    Duccio Volterrani

  2. Translational Research, Pisa University, PISA, Pisa, Italy

    Paola A. Erba

  3. Attending Emeritus, Memorial Sloan-Kettering Cancer Center Dept. Radiology, New York, NY, USA

    H. William Strauss

  4. Professor Emeritus, University of Pisa, Pisa, Italy

    Giuliano Mariani

  5. Attending Physician, Memorial Sloan-Kettering Cancer Center, New York, NY, USA

    Steven M. Larson

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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/10.1007/978-3-319-26067-9_9-2

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  1. Latest

    Diagnostic Applications of Nuclear Medicine: Brain Tumors
    Published:
    23 April 2022

    DOI: https://doi.org/10.1007/978-3-319-26067-9_9-2

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    Diagnostic Applications of Nuclear Medicine: Brain Tumors
    Published:
    07 October 2016

    DOI: https://doi.org/10.1007/978-3-319-26067-9_9-1

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