¹¹C-Methionine Positron Emission Tomography for Preoperative Evaluation of Suggestive Low-Grade Gliomas

Abstract

Objective: The treatment regimen for cerebral gliomas is different, depending on the histological grade of the lesion. The therapeutic strategy for anaplastic gliomas and glioblastomas is more aggressive, including microsurgical removal, radiation and chemotherapy. The management for low-grade gliomas is still under discussion, operation or “wait and see” tactics are possible options. Therefore the diagnostic imaging procedures are crucial for further treatment planning. Although most of the low-grade gliomas appear as hypointense lesions without contrast medium (CM) enhancement on magnetic resonance images, in some cases lesions without CM enhancement can be anaplastic tumours as well. ¹¹C-Methionine positron emission tomography (MET-PET) was performed for preoperative evaluation of non or low CM enhancing intracerebral lesions, so-called suggestive low-grade gliomas.

Method: 20 patients harbouring suggestive low-grade gliomas were included. Seventeen patients were found to be candidates for open surgery and 3 patients were planned for stereotactic biopsy due to the localisation of the lesions. MET-PET studies were performed a few days prior to surgery. On the day of surgery MRI sequences for neuronavigation planning were carried out (MPRAGE and FLAIR sequences). All image data were fused for operation with neuronavigation-guided microsurgery or stereotactic biopsy (BrainLAB Neuronavigation system, VectorVision 6.1). Biopsies were taken from the MET uptake areas as well as from areas without MET uptake.

Results: 2/20 patients showed sparse CM enhancement on MRI T₁ images, 18/20 patients had lesions without CM enhancement. MET uptake was found in 16/20 cases (T/N ratio 1.5 or more) and no MET uptake was documented in 4/20 cases (T/N ratio <1.5). Histologically the 2 patients with sparse CM enhancement and MET uptake were glioblastoma multiforme, 10/14 patients with MET uptake and without CM enhancement had an anaplastic astrocytoma WHO III, 3/14 with MET uptake and no CM enhancement had an anaplastic oligoastrocytoma WHO III, and 1/14 had an oligoastrocytoma grade II. The lesions of the 4 patients without MET uptake and without CM enhancement were classified as astrocytoma grade II in 2 cases, as astrocytoma grade I in 1 case and as astrocytoma III in one case.

Conclusion: According to the results of this study, we find MET-PET to be a helpful tool for pretreatment evaluation of non-CM enhancing, suggestive low-grade intracerebral lesions. MET-PET adds valuable information for the decision-making for surgery or stereotactic biopsy.

Zusammenfassung

Ziel: Im Gegensatz zu dem therapeutischen Management hochmaligner Gliome sind die Therapieverfahren bei den niedrig malignen Gliomen weiterhin in der Diskussion. Die präoperative Bildgebung ist mit entscheidend für die weitere Therapie. Ziel dieser Untersuchung ist, den Stellenwert der Methionin PET Unter-suchung in der präoperativen Diagnostik von Gliomen festzustellen.

Methode: Zusätzlich zu MRT-Untersuchungen wurden bei 20 Patienten mit potentiell niedrig malignen Gliomen Methionin-Positron-Emissionstomographien durchgeführt. Bei 17 Patienten erfolgte die offene operative Entfernung des Tumors, bei 3 Patienten nur eine stereotaktische Biopsie. Für die Neuronavigationsplanung wurden alle Bilddaten (MRT Sequenzen und PET) fusioniert.

Ergebnisse: Die Tumore von 20 Patienten wurden aufgrund der fehlenden oder sehr geringen Kontrastmittelaufnahme im MRT als potentiell niedrig maligne gewertet. Bei 16/20 Fällen wurde eine Methioninaufnahme festgestellt (T/N ratio 1,5 oder mehr), in 4/20 Fällen reicherte kein Methionin im Tumor an (T/N ratio <1,5). Histologisch wurde bei Patienten mit MET-Aufnahme und ohne KM-Aufnahme 10 mal ein anaplastisches Astrozytom WHO Grad III diagnostiziert, bei 3 Patienten ein Oligoastrozytom WHO Grad III, bei einem Patienten handelte es sich um ein Oligoastrozytom WHO Grad II. Die beiden Tumore mit geringer KM-Aufnahme und deutlicher MET-Aufnahme wurden als Glioblastome WHO IV klassifiziert. Die nicht Methionin aufneh-menden Tumoren waren in 2 Fällen Astrozytome Grad II und in einem Fall ein Astrozytom Grad I, in einem Fall handelte es sich um ein Astrozytom Grad III.

Schlussfolgerung: Da die Therapie der Wahl bei malignen Gliomen die Operation, gefolgt von Bestrahlung und ggf. Chemotherapie ist, kommt der präoperativen Diagnostik eine entscheidende Bedeutung zu. Bei potentiell niedrigmalignen Gliomen aufgrund fehlender Kontrastmittelaufnahme könnte die Methionin PET zusätzliche Informationen zur Entscheidungsfindung bezüglich der weiteren Therapie liefern.

methionine PET - low-grade glioma - neuronavigation - image-guided surgery

Methionin PET - niedriggradige Gliome - Neuronavigation - computer assistierte Neurochirurgie

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