Advances in Evaluation of Primary Brain Tumors

The evaluation of primary brain tumor is challenging. Neuroimaging plays a significant role. At diagnosis, imaging is needed to establish a differential diagnosis, provide prognostic information, as well as direct biopsy. After the initial treatment, imaging is needed to distinguish recurrent disease from treatment-related changes such as radiation necrosis. In low-grade gliomas, this also includes monitoring anaplastic transformation into high-grade tumors. Recently, targeted treatments have been an extremely active area of research. Evaluation in clinical trials of such targeted treatments demands advanced roles of imaging such as treatment planning, monitoring response, and predicting treatment outcomes. Current clinical gold standard magnetic resonance imaging provides superior structural detail but poor specificity in identifying viable tumors in treated brain with surgery/radiation/chemotherapy. ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET) is capable of identifying anaplastic transformation and has prognostic value. The sensitivity and specificity of FDG in evaluating recurrent tumor and treatment-induced changes can be significantly improved by coregistration with magnetic resonance imaging and potentially by delayed imaging 3 to 8 hours after injection. Amino acid PET tracers can be more sensitive than FDG in imaging some recurrent tumors, in particular recurrent low-grade tumors. They are also promising for differentiating between recurrent tumors and treatment-induced changes. Newer PET tracers to image important aspects of tumor biology have been actively studied. Tracers for imaging membrane transport such as ¹⁸F-choline have shown promise in differential diagnosis. ¹⁸F-labeled nucleotide analogs such as 3′-deoxy-3′-[¹⁸F]-fluorothymidine (FLT) and ¹⁸F-FMAU have been developed to image proliferation. The use of FLT has demonstrated prognostic power in predicting treatment response in patients treated with an antiangiogenic agent. Tracers for imaging hypoxia such as ¹⁸F-FMISO have been studied and appear promising in providing prognostic information as well as planning treatment.