Improvement of brain tumour diagnostics is necessary because therapies are extremely expensive and their efficient use is mandatory
Both amino acid PET and advanced MRI methods (perfusion-weighted imaging, diffusion-weighted imaging and magnetic resonance spectroscopic imaging) provide substantial additional information for brain tumour diagnostics
Advanced MRI methods are readily available but interpretation is challenging and images are frequently impaired by susceptibility artefacts
Amino acid PET requires additional scanning but is a robust and attractive approach for clinicians because of easy scan reading
Information from amino acid PET and advanced MRI methods seems to be complementary but multimodal studies are scarce and urgently needed
Despite the fact that MRI has evolved to become the standard method for diagnosis and monitoring of patients with brain tumours, conventional MRI sequences have two key limitations: the inability to show the full extent of the tumour and the inability to differentiate neoplastic tissue from nonspecific, treatment-related changes after surgery, radiotherapy, chemotherapy or immunotherapy. In the past decade, PET involving the use of radiolabelled amino acids has developed into an important diagnostic tool to overcome some of the shortcomings of conventional MRI. The Response Assessment in Neuro-Oncology working group — an international effort to develop new standardized response criteria for clinical trials in brain tumours — has recommended the additional use of amino acid PET imaging for brain tumour management. Concurrently, a number of advanced MRI techniques such as magnetic resonance spectroscopic imaging and perfusion weighted imaging are under clinical evaluation to target the same diagnostic problems. This Review summarizes the clinical role of amino acid PET in relation to advanced MRI techniques for differential diagnosis of brain tumours; delineation of tumour extent for treatment planning and biopsy guidance; post-treatment differentiation between tumour progression or recurrence versus treatment-related changes; and monitoring response to therapy. An outlook for future developments in PET and MRI techniques is also presented.
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The authors declare no competing financial interests.
- Adjuvant chemotherapy
Administration of chemotherapy after surgery or radiation treatment for cancer to target remaining malignant cells.
- T1-weighted and T2-weighted sequences
Standard morphological images weighted by the longitudinal (T1) and transverse (T2) relaxation times of the protons.
- Perfusion-weighted imaging
Image acquisition techniques that highlight fluids moving through arteries, veins and capillaries.
- Diffusion-weighted imaging
Imaging technique designed to weight the MRI signal by the amount of diffusion (random thermal motion) of water molecules.
- Fluid-attenuated inversion recovery
MRI technique that uses inversion recovery, in which the signal from water is reduced by timing the delay of the inversion pulse.
- Cerebral blood flow
Flow of capillary blood per unit mass through the brain tissue (units: ml/min/100 g).
- Relative cerebral blood volume
The volume of blood in a brain lesion in relation to the normal brain tissue.
- Mean transit time
The average time, in seconds, that red blood cells spend within a given volume of capillary circulation.
- Single voxel spectroscopy
A magnetic resonance spectroscopy technique used to assess the concentration of metabolites in a defined region of interest.
- Brownian motion
Continuous random movement of particles suspended in a fluid, which arises from collisions with the fluid molecules.
- Fractional anisotropy
Fractional anisotropy (FA) is a scalar parameter (0 ≤ FA ≤1) used to quantify the degree of anisotropy of the diffusion process.
- Local maxima
Area with maximum signal of different parameters in the tumour area
Area with locally increased signal of different parameters in the corresponding image.
A phenomenon whereby tumours initially 'grow' on MRI due to immune infiltrate, but then decrease in size.
- Convection-enhanced delivery
A therapeutic strategy to facilitate delivery of pharmaceuticals. Placement of small-diameter catheters directly into the brain tumour is followed by infusion of therapeutics.
- Chemical exchange saturation transfer
An MRI technique in which exogenous or endogenous compounds containing exchangeable molecules are selectively saturated and, after transfer of this saturation, detected indirectly through the water signal with enhanced sensitivity.
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Langen, K., Galldiks, N., Hattingen, E. et al. Advances in neuro-oncology imaging. Nat Rev Neurol 13, 279–289 (2017). https://doi.org/10.1038/nrneurol.2017.44
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