Post-treatment radiation and chemotherapy of malignant primary glial neoplasms present a wide spectrum of tumor appearances and treatment-related entities. Radiologic findings of these post-treatment effects overlap, making it difficult to distinguish treatment response and failure. The purposes of this article are to illustrate and contrast the imaging appearances of recurrent tumor from necrosis and to discuss other radiologic effects of cancer treatments. It is critical for radiologists to recognize these treatment-related effects to help direct clinical management.
BrandsmaDStalpersLTaalW. Clinical features, mechanisms, and management of pseudoprogression in malignant gliomas. Lancet Oncol. 2008; 9 (5): 453–461.
2.
ShahRVattothSJacobR. Radiation necrosis in the brain: imaging features and differentiation from tumor recurrence. RadioGraphics. 2012; 32 (5): 1343–1359.
3.
ChamberlainMCGlantzMJChalmersL. Early necrosis following concurrent Temodar and radiotherapy in patients with glioblastoma. J Neurooncol. 2007: 82 (1): 81–83.
4.
MarksJEBaglanRJPrassadSC. Cerebral radionecrosis: incidence and risk in relation to dose, time, fractionation and volume. Int J Radiat Oncol Biol Phys. 1981; 7 (2): 243–252.
5.
LeibelSAShelineGE. Radiation therapy for neoplasms of the brain. J Neurosurg. 1987; 66 (1): 1–22.
6.
RubenJDDallyMBaileyM. Cerebral radiation necrosis: incidence, outcomes, and risk factors with emphasis on radiation parameters and chemotherapy. Int J Radiat Oncol Biol Phys. 2006; 65 (2): 499–508.
7.
KumarAJLeedsNEFullerGN. Malignant gliomas: MR imaging spectrum of radiation therapy- and chemotherapy-induced necrosis of the brain after treatment. Radiology. 2000; 217 (2): 377–384.
8.
LiYQChenPHaimovitz-FriedmanA. Endothelial apoptosis initiates acute blood—brain barrier disruption after ionizing radiation. Cancer Res.2003; 63 (18): 5950–5956.
9.
MooreAHOlschowkaJAWilliamsJP. Radiation-induced edema is dependent on cyclooxygenase 2 activity in mouse brain. Radiat Res.2004; 161 (2): 153–160.
10.
MoodyDMBellMAChallaVR. Features of the cerebral vascular pattern that predict vulnerability to perfusion or oxygenation deficiency: an anatomic study. Am J Neuroradiol. 1990; 11 (3): 431–439.
11.
NelsonMDJrGonzalez-GomezIGillesFH. The search for human telencephalic ventriculofugal arteries. Am J Neuroradiol. 1991; 12 (2): 215–222.
12.
WenPYMacdonaldDRReardonDA. Updated response assessment criteria for high-grade gliomas: response assessment in neuro-oncology working group. J Clin Oncol. 2010; 28 (11): 1963–1972.
13.
MullinsMEBarestGDSchaeferPW. Radiation necrosis versus glioma recurrence: conventional MR imaging clues to diagnosis. Am J Neuroradiol. 2005; 26 (8): 1967–1972.
14.
FatterpekarGMGalheigoDNarayanaA. Treatment-related change versus tumor recurrence in high-grade gliomas: a diagnostic conundrum—use of dynamic susceptibility contrast-enhanced (DSC) perfusion MRI. Am J Roentgenol. 2012; 198 (1): 19–26.
15.
DequesadaIMQuislingRGYachnisA. Can standard magnetic resonance imaging reliably distinguish recurrent tumor from radiation necrosis after radiosurgery for brain metastases? A radiographic-pathological study. Neurosurgery. 2008; 63 (5): 898–903; discussion 904.
16.
ChaoSTSuhJHRajaS. The sensitivity and specificity of FDG PET in distinguishing recurrent brain tumor from radionecrosis in patients treated with stereotactic radiosurgery. Int J Cancer. 2001; 96 (3): 191–197.
17.
RicciPEKarisJPHeisermanJE. Differentiating recurrent tumor from radiation necrosis: time for re-evaluation of positron emission tomography?Am J Neuroradiol. 1998; 19 (3): 407–413.
18.
HazleJDJacksonEFSchomerDF. Dynamic imaging of intracranial lesions using fast spin-echo imaging: differentiation of brain tumors and treatment effects. J Magn Reson Imaging. 1997; 7 (6): 1084–1093.
19.
FinkJRCarrRBMatsusueE. Comparison of 3 Tesla proton MR spectroscopy, MR perfusion and MR diffusion for distinguishing glioma recurrence from posttreatment effects. J Magn Reson Imaging. 2012: 35 (1): 56–63.
20.
BarajasRFJrChangJSSegalM. Differentiation of recurrent glioblastoma multiforme from radiation necrosis after external beam radiation therapy with dynamic susceptibility-weighted contrast-enhanced perfusion MR imaging. Radiology. 2009; 253 (2): 486–496.
21.
BarajasRFChangJSSneedPK. Distinguishing recurrent intra-axial metastatic tumor from radiation necrosis following gamma knife radiosurgery using dynamic susceptibility-weighted contrast-enhanced perfusion MR imaging. Am J Neuroradiol. 2009; 30 (2): 367–372.
22.
SugaharaTKorogiYTomiguchiS. Posttherapeutic intraaxial brain tumor: the value of perfusion-sensitive contrast-enhanced MR imaging for differentiating tumor recurrence from nonneoplastic contrast-enhancing tissue. Am J Neuroradiol. 2000; 21 (5): 901–909.
23.
HuLSBaxterLCSmithKA. Relative cerebral blood volume values to differentiate highgrade glioma recurrence from posttreatment radiation effect: direct correlation between image-guided tissue histopathology and localized dynamic susceptibility-weighted contrast-enhanced perfusion MR imaging measurements. Am J Neuroradiol. 2009; 30 (3): 552–558.
24.
WarmuthCGuntherMZimmerC. Quantification of blood flow in brain tumors: comparison of arterial spin labeling and dynamic susceptibility-weighted contrast-enhanced MR imaging. Radiology. 2003; 228 (2): 523–532.
25.
SundgrenPC. MR spectroscopy in radiation injury. Am J Neuroradiol. 2009; 30 (8): 1469–1476.
26.
ZengQSLiCFZhangK. Multivoxel 3D proton MR spectroscopy in the distinction of recurrent glioma from radiation injury. J Neurooncol. 2007; 84 (1): 63–69.
27.
HeinPAEskeyCJDunnJF. Diffusion-weighted imaging in the follow up of treated high-grade gliomas: tumor recurrence versus radiation injury. Am J Neuroradiol. 2004; 25 (2): 201–209.
28.
SundgrenPCFanXWeybrightP. Differentiation of recurrent brain tumor versus radiation injury using diffusion tensor imaging in patients with new contrast. Magn Reson Imaging. 2006; 24 (9): 1131–1142.
MacdonaldDRCascinoTLScholdSCJr. Response criteria for phase II studies of supratentorial malignant glioma. J Clin Oncol. 1990; 8 (7): 1277–1280.
31.
TaalWBrandsmaDde BruinHG. Incidence of early pseudo-progression in a cohort of malignant glioma patients treated with chemoirradiation with temozolomide. Cancer. 2008; 113 (2): 405–410.
32.
BrandesAAFranceschiETosoniA. MGMT promoter methylation status can predict the incidence and outcome of pseudoprogression after concomitant radiochemotherapy in newly diagnosed glioblastoma patients. J Clin Oncol. 2008; 26 (13): 2192–2197.
33.
ClarkeJLChangS. Pseudoprogression and pseudoresponse: challenges in brain tumor imaging. Curr Neurol Neurosci Rep.2009; 9 (3): 241–246.
34.
Hygino da CruzLCJrRodriguezIDominguesRC. Pseudoprogression and pseudoresponse: imaging challenges in the assessment of posttreatment glioma. Am J Neuroradiol. 2011; 32 (11): 1978–1985.
35.
ManglaRSinghGZiegelitzD. Changes in relative cerebral blood volume 1 month after radiation-temozolomide therapy can help predict overall survival in patients with glioblastoma. Radiology. 2010; 256 (2): 575–584.
36.
YamasakiFKurisuKAokiT. Advantages of high b-value diffusion-weighted imaging to diagnose pseudo-responses in patients with recurrent glioma after bevacizumab treatment. Eur J Radiol. 2012; 81 (10): 2805–2810.
37.
ThompsonEMFrenkelEPNeuweltEA. The paradoxical effect of bevacizumab in the therapy of malignant gliomas. Neurology. 2011; 76 (1): 87–93.
38.
JainRKDudaDGWillettCG. Biomarkers of response and resistance to antiangiogenic therapy. Nat Rev Clin Oncol. 2009; 6 (6): 327–338.
39.
CahanWGWoodardHQHiginbothamNL. Sarcoma arising in irradiated bone: report of eleven cases. Cancer. 1948; 1 (1): 3–29.
40.
YangSYWangKCChoBK. Radiation-induced cerebellar glioblastoma at the site of a treated medulloblastoma: case report. J Neurosurg. 2005; 102 (Suppl 4): 417–422.
41.
Wu-ChenWYJacobsDAVolpeNJ. Intracranial malignancies occurring more than 20 years after radiation therapy for pituitary adenoma. J Neuroophthalmol. 2009; 29 (4): 289–295.
42.
RabinBMMeyerJRBerlinJW. Radiation-induced changes in the central nervous system and head and neck. RadioGraphics. 1996; 16 (5): 1055–1072.
43.
BradaMFordDAshleyS. Risk of second brain tumour after conservative surgery and radiotherapy for pituitary adenoma. BMJ. 1992; 304 (6838): 1343–1346.
44.
PerryASchmidtRE. Cancer therapy-associated CNS neuropathology: An update and review of the literature. Acta Neuropathol. 2006; 111 (3): 197–212.
45.
ChanYLLeungSFKingAD. Late radiation injury to the temporal lobes: morphologic evaluation at MR imaging. Radiology. 1999; 213 (3): 800–807.
WuQMarescauxCWolffV. Tacrolimus-associated posterior reversible encephalopathy syndrome after solid organ transplantation. Eur Neurol. 2010; 64 (3): 169–177.
50.
McKinneyAMShortJTruwitCL. Posterior reversible encephalopathy syndrome: incidence of atypical regions of involvement and imaging findings. Am J Roentgenol. 2007; 189 (4): 904–912.
51.
PruzincováLStenoJSrbeckýM. MR imaging of late radiation therapy- and chemotherapy-induced injury: a pictorial essay. Eur Radiol. 2009; 19 (11): 2716–2727.
52.
ValkPEDillonWP. Radiation injury of the brain. Am J Neuroradiol. 1991; 12 (1): 45–62.
53.
LarsonJJBallWSBoveKE. Formation of intracerebral cavernous malformations after radiation treatment for central nervous system neoplasia in children. J Neurosurg. 1998; 88 (1): 51–56.
54.
RigamontiDDrayerBPJohnsonPC. The MRI appearance of cavernous malformations (angiomas). J Neurosurg. 1987; 67 (4): 518–524.
55.
KoikeSAidaNHataM. Asymptomatic radiation-induced telangiectasia in children after cranial irradiation: frequency, latency, and dose relation. Radiology. 2004; 230 (1): 93–99.
56.
GaenslerEHLDillonWPEdwardsMS. Radiation-induced telangiectasia in the brain simulates cryptic vascular malformations at MR imaging. Radiology. 1994; 193 (3): 629–636.
57.
OiSKokunaiTIjichiA. Radiation induced brain damage in children: histologic analysis of sequential tissue changes in 34 autopsies. Neurol Med Chir (Tokyo). 1990; 30 (1): 36–42.
