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J 201Thallium SPECT; Accuracy in Astrocytoma Diagnosis and Treatment Evaluation SE9900361 J 201Thallium SPECT; accuracy in astrocytoma diagnosis and treatment evaluation Kristina Kallen, M.D. LUND UNIVERSITY 3 1-04 201Thallium SPECT; accuracy in astrocytoma diagnosis and treatment evaluation Akademisk avhandling Som med vederborligt tillstand av medicinska fakulteten vid Lunds Universitet for avlaggande av medicine doktorsexamen kommer att forsvaras i Segerfalksalen Wallenberg Neurocentrum, centralblocket, Universitetssjukhuset i Lund, lordagen den 16 oktober 1999 Id. 9.00 av Kristina Kallen leg. lakare Institutionen for Klinisk Neurovetenskap Avdelningen for Neurologi Lunds Universitet Fakultetsopponent: Docent Carsten Wikkelso Institutionen for Klinisk Neurovetenskap Universitetssjukhuset Sahlgrenska GSteborgs Universitet Organization Document name LUND UNIVERSITY DOCTORAL DISSERTATION Dept. of Clinical Neuroscience Dateofissue ^^ ^ ^ University Hospital S-221 B5 LUND, Sweden CODEN: ISRN LUMEDW/MENL_1016_SE Autlior(s) Sponsoring organization KRISHNA KAlLEN Title and subtitle ^Thallium SPECT, accuracy in astrocytoma diagnosis and treatment evaluation Abstract The aims of the studies included in this thesis were: • to investigate the reliability of M'thallium single photon emission computed tomography (2O1T1 SPECT) for preoperative diagnosis and histological staging of malignant astrocytomas in comparison with CT; • to develop a method for quantification of cerebral thallium uptake, and to evaluate the quantitative measurement in comparison with CT, for astrocytoma treatment follow-up purposes; • to compare quantitative MITI SPECT and proton magnetic resonance spectroscopy ('H-MRS) with conventional MR imaging for astrocytoma monitoring, and to evaluate associations between change of morphological tumour characteristics during treatment and changes of cerebral thallium uptake and metabolic ratios. Results and conclusions: • High wlTl-index, calculated as a ratio comparing tumour uptake to uptake in the contralateral hemisphere, is an indicator of highly malignant astrocytoma. Differentiation between the high-grade astrocytomas, the low-grade astrocytomas, and infectious lesions is only partial, with an overlap of TI- indexes between these groups. High-grade astrocytomas that do not show contrast enhancement on CT, and astrocytomas with central necrosis and moderate ring-enhancement, tend to be underestimated when evaluated by M1Tl-index calculation. MITI SPECT is not a reliable method for non-invasive tumour staging among the group of highly malignant astrocytomas. • Quantification of cerebral 2olTl-uptake, defining the volume of viable tumour tissue, is a new method for astrocytoma chemotherapy monitoring. Results suggest that the method provides prognostic information, and information of treatment efficacy, at an earlier stage than CT. • We did not find a higher accuracy of quantitative "'Tl SPECT than of MR for h monitoring purposes and our results indicated that treatment induced MR changes were interrelated with UJ ^"Tl-uptake variations. • Multi-voxel 'H-MRS was difficult to apply for astrocytoma treatment monitoring, due to the anatomical and histological heterogeneity of astrocytomas. gg 2u1 cywor s. astroCytoma, abscess, thallium, single-photon emission computed tomography, computed tomography, magnetic resonance imaging, protonmagnetic resonance SDectroscopy, chemntrmrany Classification system and/or index termes (if any): Supplementary bibliographical information: Language Eno]i sh ISSN and key title: ISBN 91-628-3684-6 Recipient's notes Number of pages Price Security classification Distribution by (name and address) Kristina Kalian, Dept. of Neurology, University Hospital, 221 85 LUND, Sweden I. the undersigned, being the copyright owner or the abstract of the above-mentioned dissertation, hereby grant to all reference sources permission to publish and disseminate the abstract of the above-mentioned dissertation. Signature Date ^ OJ 201Thallium SPECT; accuracy in astrocytoma diagnosis and treatment evaluation Kristina Kdllen, M.D. Department of Clinical Neuroscience Division of Neurology Lund University Hospital S-221 85 Sweden 1999 Academic dissertation ISBN 91-628-3684-6 © Kristina Kallen 1999 (pages 1-74, and paper V) Printed by Studentlitteratur Lund, Sweden Contents List of papers 1 Abbreviations 2 Introduction 3 Clinical background 4 Diagnostic procedures 4 Treatment 5 Low grade astrocytomas 5 High grade astrocytomas 6 Treatment response assessment 11 Clinical parameters 11 Neuro-imaging methods for diagnosis and treatment follow-up 13 CT and MR imaging 13 20lThallium SPECT 15 Historical background 15 Diagnosis and staging 17 Comparison with anatomic imaging 18 Treatment evaluation 19 'H-MR spectroscopy 21 Metabolite characterisation 21 Diagnosis and staging 22 Treatment evaluation 23 Aims of the study 24 Materials and methods 25 Patient selection and follow-up 25 Techniques 27 CT 27 2OIThallium SPECT 27 MR imaging and 'H-MR spectroscopy 28 Data acquisition for therapy monitoring 29 Data analysis 29 Results 35 Pre-operative studies; Papers I and II 35 Quantification of cerebral 2o'thallium-uptake; Paper III 38 Post-operative studies; Papers IV and V 40 General Discussion 43 Diagnosis and staging 43 Treatment monitoring 45 Conclusions 51 Figures in colour 53 Acknowledgements 58 Summary in Swedish 60 References 64 List of papers I. K. Kallen, A-M. Andersson, M. Heiling, S. Holtas, A. Brun, E. Ryding. Preoperative grading of glioma malignancy with thallium-201 single-photon emission CT: Comparison with conventional CT. AJNR Am JNeuroradiol 1996;17:925-932 II. K. Kallen, A-M. Andersson, M. Heiling, S. Holtas, A. Brun, E. Ryding, I. Rosen. Evaluation of malignancy in ring enhancing brain lesions on CT by thallium-201 SPECT. J Neurol Neurosurg Psychiatry 1997;63:569-574 III. K. Kallen, B. Geijer, A-M. Andersson, S. Holtas, E. Ryding, I. Rosen. Assessment of glioma viability by estimating 20;Tl SPET •tumour uptake volume. Nucl Med Comm 1999; 20:837-844 IV. K. Kallen, B. Geijer, P. Malmstrom, A-M. Andersson, S. Holtas, E. Ryding, I. Rosen. Quantitative Tl-201 SPECT imaging in brain tumour treatment follow-up. A sensitive tool for early identification of chemotherapy response? Accepted for publication in Nucl Med Comm V. K. Kallen, I.M. Burtscher, S. Holtas, E. Ryding, I. Rosen. 201 Thallium SPECT and 'H-MRS compared to MRI in chemotherapy monitoring of high-grade malignant astrocytomas. Submitted Papers I-III are reprinted by permission of the copyright owners. Abbreviations AA anaplastic astrocytoma ATPase adenosine triphosphatase BBB blood-brain barrier Cho choline Cr creatine CT computed tomography 2DCSI two dimensional chemical shift imaging GBM glioblastoma multiforme 'H-MRS proton magnetic resonance spectroscopy Lac lactate Lip lipids MRI magnetic resonance imaging NAA N-acetyl aspartate PCV procarbazine, CCNU, vincristine PET positron emission tomography PRESS point-resolved spectroscopy ROI region of interest SE spin echo ST survival time TI 20lthallium index 201Tl SPECT 2O'thallium single-photon emission comp TTD time to treatment discontinuation TTP time to tumour progression TUV tumour uptake volume Introduction Primary highly malignant brain tumours in adults comprise of astroglial cell neoplasms or astrocytomas. The astrocytomas represent a challenge to neurologists, oncologist and neurosurgeons responsible for patient management and tumour treatment, as patients often present with disabling neurological symptoms, respond poorly to therapy and undergo rapid clinical deterioration. Highly malignant astrocytomas are the fourth leading cause of cancer mortality in men and women between 15-34 years of age, and the fifth leading cause in men between 35-54 years of age ]'2. The patients are often in their most productive age; in the middle of their career, they are parents of young children and have extensive economic responsibilities. It is a demanding responsibility for all physicians engaged in astrocytoma management to offer these patients the best possible treatment and care. The effort to enhance the accuracy of preoperative diagnosis work up, and the reliability of treatment efficacy monitoring, is part of the challenge to improve the outcome of astrocytoma patients. This thesis addresses the question of diagnostic precision and treatment evaluation by functional brain investigation tools, focusing on 2O'thallium single- photon computed tomography (201Tl SPECT) assessment for astrocytoma diagnosis, tumour staging and treatment monitoring. Additionally, chemical brain analysis by proton magnetic resonance spectroscopy ('H-MRS) is evaluated during treatment follow-up. Clinical background Diagnostic procedures Neurological signs suggestive of brain tumour disease are; adult onset of seizures, development of increasing focal deficits, and general symptoms of elevated intracranial pressure such as headache or decline of cognitive functions. Characteristic features for astrocytomas are seen with computed tomography (CT) and magnetic resonance imaging (MRI), and a probable diagnosis can be provided by structural imaging in most cases. An experienced neuroradiologist will correctly diagnose 95% of malignant brain tumours 3. However, a proportion of the patients diagnosed to have a low-grade astrocytoma by CT or MRI, will harbour a highly malignant tumour within the lesion when histological diagnosis is obtained <l;3. As the imaging characteristics only enable tumour staging to a limited extent, diagnostic procedures also include histo- pathologic examination to define the grade of
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