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Pseudoprogression, radionecrosis, inflammation or true tumor progression? challenges associated with glioblastoma
Benjamin M Ellingson1,2,3, Caroline Chung4, Whitney B Pope5
1UCLA Brain Tumor Imaging Laboratory (BTIL), David Geffen School of Medicine, Center for Computer Vision and Imaging, University of California Los Angeles, 924 Westwood Blvd., Suite 615, Los Angeles, CA, 90024, USA. bellingson@mednet.ucla.edu.
Abstract:
The wide variety of treatment options that exist for glioblastoma, including surgery, ionizing radiation, anti-neoplastic chemotherapies, anti-angiogenic therapies, and active or passive immunotherapies, all may alter aspects of vascular permeability within the tumor and/or normal parenchyma. These alterations manifest as changes in the degree of contrast enhancement or T2-weighted signal hyperintensity on standard anatomic MRI scans, posing a potential challenge for accurate radiographic response assessment for identifying anti-tumor effects. The current review highlights the challenges that remain in differentiating true disease progression from changes due to radiation therapy, including pseudoprogression and radionecrosis, as well as immune or inflammatory changes that may occur as either an undesired result of cytotoxic therapy or as a desired consequence of immunotherapies.
Insights
Assessing glioblastoma treatment response is challenging due to therapy-induced changes in MRI scans. Differentiating true tumor progression from treatment effects like pseudoprogression is crucial for effective patient management.
Area of Science:
- Neuro-oncology
- Radiology
- Immunotherapy
Background:
- Glioblastoma treatments (surgery, radiation, chemotherapy, immunotherapy) can alter tumor vascular permeability.
- These alterations affect MRI findings like contrast enhancement and T2 signal intensity.
- Accurate assessment of treatment response is complicated by these therapy-induced changes.
Purpose of the Study:
- To review the challenges in differentiating true glioblastoma progression from treatment-related imaging changes.
- To highlight the impact of various therapies on radiographic assessment.
- To discuss pseudoprogression, radionecrosis, and immune/inflammatory changes.
Main Methods:
- Literature review of studies on glioblastoma treatment response assessment.
- Analysis of imaging findings in response to diverse therapeutic modalities.
- Discussion of differential diagnostic criteria for treatment effects versus tumor progression.
Main Results:
- Treatment modalities significantly alter vascular permeability, mimicking tumor progression on MRI.
- Pseudoprogression and radionecrosis are common challenges after radiation therapy.
- Immune and inflammatory changes can also complicate response evaluation.
Conclusions:
- Distinguishing true disease progression from treatment-induced changes in glioblastoma remains a significant challenge.
- Careful interpretation of MRI findings in the context of therapy is essential.
- Further research is needed to refine response assessment criteria.