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Pseudoprogression in high-grade glioma
K M Knudsen-Baas1, G Moen, Ø Fluge
1Department of Neurology, Haukeland University Hospital, Bergen, Norway. kristin.marie.knudsen-baas@helse-bergen.no
Abstract:
Pseudoprogression is a treatment-related effect seen on imaging in high-grade glioma. Enhancement of gadolinium contrast on control MRI can be misinterpreted as tumor recurrence and is also difficult to distinguish from radiation necrosis. Pseudoprogression is seen in up to 30% after standard treatment for glioblastoma multiforme (GBM), which is radiotherapy concurrent with chemotherapy with temozolomide (TMZ) and adjuvant cycles of TMZ. In this article, the current literature on pseudoprogression in high-grade glioma is reviewed by searches in PubMed. We also present two clinical cases, one of which had medullary pseudoprogression. No articles on this subentity of pseudoprogression were found in PubMed. Standard MRI with gadolinium contrast cannot differentiate between pseudoprogression, tumor recurrence and radiation necrosis. More advanced imaging techniques are often not available. Pseudoprogression seems to be related to methylated promoter of the O(6)--methyl-guanine methyl transferase (MGMT) gene, which is associated with improved treatment effect. Discontinuation or change of therapy on the basis of misinterpretation of MRI as disease progression is thus unfortunate. MRI should be interpreted with caution the first 6 months after standard treatment of high-grade glioma. In a GBM patient with contrast enhancement on MRI but few or no new symptoms and/or stable steroid doses, treatment should be continued and control imaging performed after 2-3 months.
Insights
Pseudoprogression, a common imaging effect in high-grade glioma, can mimic tumor recurrence. Careful MRI interpretation is crucial in the first six months post-treatment to avoid unnecessary therapy changes.
Area of Science:
- Neuro-oncology
- Radiology
- Oncologic Imaging
Background:
- Pseudoprogression is a treatment effect in high-grade glioma, often seen after radiotherapy with temozolomide (TMZ) for glioblastoma multiforme (GBM).
- It presents as contrast enhancement on MRI, mimicking tumor recurrence or radiation necrosis.
Observation:
- Standard MRI with gadolinium contrast cannot reliably differentiate pseudoprogression from true tumor progression or radiation necrosis.
- Medullary pseudoprogression is a rare subentity with limited reported literature.
- Pseudoprogression may be linked to the methylated O(6)-methyl-guanine methyl transferase (MGMT) gene promoter, indicating a positive treatment response.
Findings:
- Misinterpreting pseudoprogression as disease progression can lead to premature discontinuation or alteration of effective therapy.
- Advanced imaging techniques for differentiation are not always accessible.
Implications:
- MRI interpretation in high-grade glioma patients requires caution during the initial six months post-treatment.
- For GBM patients with contrast enhancement but stable clinical status, continuing treatment and scheduling follow-up imaging in 2-3 months is recommended.
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