Sequential implementation of DSC-MR perfusion and dynamic [18F]FET PET allows efficient differentiation of glioma progression from treatment-related changes

Purpose Perfusion-weighted MRI (PWI) and O-(2-[F-18]fluoroethyl-)-l-tyrosine ([F-18]FET) PET are both applied to discriminate tumor progression (TP) from treatment-related changes (TRC) in patients with suspected recurrent glioma. While the combination of both methods has been reported to improve the diagnostic accuracy, the performance of a sequential implementation has not been further investigated. Therefore, we retrospectively analyzed the diagnostic value of consecutive PWI and [F-18]FET PET. Methods We evaluated 104 patients with WHO grade II-IV glioma and suspected TP on conventional MRI using PWI and dynamic [F-18]FET PET. Leakage corrected maximum relative cerebral blood volumes (rCBV(max)) were obtained from dynamic susceptibility contrast PWI. Furthermore, we calculated static (i.e., maximum tumor to brain ratios; TBRmax) and dynamic [F-18]FET PET parameters (i.e., Slope). Definitive diagnoses were based on histopathology (n = 42) or clinico-radiological follow-up (n = 62). The diagnostic performance of PWI and [F-18]FET PET parameters to differentiate TP from TRC was evaluated by analyzing receiver operating characteristic and area under the curve (AUC). Results Across all patients, the differentiation of TP from TRC using rCBV(max) or [F-18]FET PET parameters was moderate (AUC = 0.69-0.75; p <0.01). A rCBV(max) cutoff > 2.85 had a positive predictive value for TP of 100%, enabling a correct TP diagnosis in 44 patients. In the remaining 60 patients, combined static and dynamic [F-18]FET PET parameters (TBRmax, Slope) correctly discriminated TP and TRC in a significant 78% of patients, increasing the overall accuracy to 87%. A subgroup analysis of isocitrate dehydrogenase (IDH) mutant tumors indicated a superior performance of PWI to [F-18]FET PET (AUC = 0.8/<0.62, p <0.01/>= 0.3). Conclusion While marked hyperperfusion on PWI indicated TP, [F-18]FET PET proved beneficial to discriminate TP from TRC when PWI remained inconclusive. Thus, our results highlight the clinical value of sequential use of PWI and [F-18]FET PET, allowing an economical use of diagnostic methods. The impact of an IDH mutation needs further investigation.