====== Brain metastases recurrence diagnosis ====== It is difficult to differentiate local [[brain metastases recurrence]] from radiation induced-changes in case of suspicious contrast enhancement. New advanced MRI techniques ([[perfusion]] and [[spectrometry]]) and [[Amino Acid Positron Emission tomography]] allow to be more accurate and could avoid a [[stereotactic biopsy]] for histological assessment, the only reliable but invasive method. ===== PET ===== Whereas [[positron emission tomography]] (PET) with the widely used [[18F]]-2-deoxy-2-fluoro-D-glucose ([[18F-FDG]]) has low diagnostic accuracy after [[SRS]], the use of radiolabelled amino acids or amino acid analogues such as L-methyl-11C-methionine (11C-MET) and O-(2-18F-[[Fluoroethyl]])-L-Tyrosine (18F-FET) reaches sensitivity and specificity values in the range of 78 and 100 % rendering especially 18F-FET a highly reliable tracer in glioma imaging. ---- In patients with MRI-suspected tumor recurrence after focused high dose radiotherapy, 18F-[[FET]] PET has a high sensitivity and specificity for the differentiation of vital tumor tissue and radiation-induced lesions ((Romagna A, Unterrainer M, Schmid-Tannwald C, Brendel M, Tonn JC, Nachbichler SB, Muacevic A, Bartenstein P, Kreth FW, Albert NL. Suspected recurrence of brain metastases after focused high dose radiotherapy: can [18F]FET- PET overcome diagnostic uncertainties? Radiat Oncol. 2016 Oct 21;11(1):139. doi: 10.1186/s13014-016-0713-8. PMID: 27769279; PMCID: PMC5073742.)). ---- Tran et al. performed a feasibility study to prospectively evaluate [[11C methionine positron emission tomography]] and[[ 11C PBR28 positron emission tomography]] in 5 patients with 7 previously SRS-treated [[brain metastases]] demonstrating regrowth to differentiate [[tumor regrowth]] (TR) from [[radiation necrosis]] (RN). Sequential imaging with dual tracers was well-tolerated. [11C]methionine was accurate for detecting pathologically confirmed TR in 7/7 lesions, whereas [11C]PBR28 was only accurate in 3/7 lesions. Tumor [[PBR]]-[[TSPO]] expression was elevated in both [[melanoma]] and [[lung cancer]] cells, contributing to lack of [[specificity]] of [11C]PBR28-PET. Sequential use of PET tracers is safe and effective. [11C]Methionine was a reliable TR marker, but [11C]PBR28 was not a reliable marker of RN. Studies are needed to determine the causes of post-radiation inflammation and identify specific markers of RN to improve diagnostic imaging ((Tran TT, Gallezot JD, Jilaveanu LB, Zito C, Turcu G, Lim K, Nabulsi N, Huang H, Huttner A, Kluger HM, Chiang VL, Carson R. [11C]Methionine and [11C]PBR28 as PET Imaging Tracers to Differentiate Metastatic Tumor Recurrence or Radiation Necrosis. Mol Imaging. 2020 Jan-Dec;19:1536012120968669. doi: 10.1177/1536012120968669. PMID: 33147119.)). ===== MRI ===== The multimodal MRI has greatly contributed to refine the differential diagnosis between tumour recurrence and radionecrosis, which remains difficult. The FDG PET is helpful, in favour of the diagnosis of local tumour recurrence when a hypermetabolic lesion is found. Others tracers (such as carbon 11 or a fluoride isotope) deserve interest but are not available in all centres. Stereotactic biopsy should be discussed if any doubt remains ((Patsouris A, Augereau P, Tanguy JY, Morel O, Menei P, Rousseau A, Paumier A. [Differentiation from local tumour recurrence and radionecrosis after stereotactic radiosurgery for treatment of brain metastases.]. Cancer Radiother. 2014 Jan 13. pii: S1278-3218(13)00444-7. doi: 10.1016/j.canrad.2013.10.013. [Epub ahead of print] French. PubMed PMID: 24433952. )). An increase in [[FLAIR]] signal of the fluid within the resection cavity might be a highly specific and early sign of local [[tumor recurrence]]/[[tumor progression]] also for [[brain metastases]]. ((Bette S, Gempt J, Wiestler B, Huber T, Specht H, Meyer B, Zimmer C, Kirschke JS, Boeckh-Behrens T. Increase in FLAIR Signal of the Fluid Within the Resection Cavity as Early Recurrence Marker: Also Valid for Brain Metastases? Rofo. 2017 Jan;189(1):63-70. doi: 10.1055/s-0042-119686. PubMed PMID: 28002859. )). ===== References =====