A 73 year old right-handed man sought medical attention because of a grand mal seizure
and progressive difficulty with speech. Brain biopsy in 3/95 revealed grade II
astrocytoma; however, because of his age and speed of progression, the
pathological result was thought to be artifactually benign and due to sampling error.
He underwent conventional whole brain radiation consisting of 6440 cGys given
in 35 treatments. He tolerated his radiation therapy well, but attempts to wean
his steroids resulted in prompt seizure recurrence. Concern of tumor recurrence
vs. radiation necrosis prompted evaluation with PET.
The T1-weighted precontrast MR (not shown) demonstrated an area of low signal intensity throughout the left parietal-occipital area which was new. A previous study had shown only postoperative changes. Following the administration of contrast material (gadolinium-DTPA), signal intensity was much enhanced, as seen in image 59 and surronding slices, suggesting either tumor recurrence or radiation necrosis. This finding also represented a change when compared to the previous contrast enhanced MR. The PET scan demonstrated high activity in this region, suggestive of tumor recurrence, and effectively ruling out radiation necrosis.
Treatment options included surgical resection of the area of increased metabolic activity consistent with tumor recurrence or stereotactic radiosurgery to that same area, either as a primary treatment or for palliation, if follow-up MR again revealed contrast enhancement.
Like Thallium SPECT, the PET scan has been very useful in differentiating tumor recurrence and radiation necrosis. It also allows specific targeting of the area of recurrence, which may be surrounded by radiation necrosis in those patients who have received radiation.
Case contributed by Drs. C. D. Sturm and R. Bucholz, St. Louis University.