Raphael Calmon1,2,3,4, Stephanie Puget5, Pascale Varlet3,6, Volodia Dangouloff-Ros1,2,3,4, Thomas Blauwblomme5, Kevin Beccaria5, David Grevent1,2,3,4, Christian Sainte-Rose5, David Castel7, Marie-Anne Debily7,8, Christelle Dufour9, Stéphanie Bolle10, Frederic Dhermain9,10, Ana Saitovitch2,3, Monica Zilbovicius3, Francis Brunelle1,2,3,4, Jacques Grill7,9, Nathalie Boddaert1,2,3,4. 1. Hôpital Necker Enfants Malades, Pediatric Radiology Department, Paris, France. 2. Imagine: Institut de Maladies Génétiques, Paris, France. 3. INSERM, Paris, France. 4. Université Paris Descartes, ComUE Sorbonne Paris Cité, Paris, France. 5. Hôpital Necker Enfants Malades, Pediatric Neurosurgery Department, Paris, France. 6. Centre Hospitalier Sainte-Anne, Laboratoire de Neuropathologie, Paris, France. 7. Centre National de la Recherche Scientifique, Unité Mixte de Recherche 8203 et Universite Paris Saclay, Villejuif, France. 8. Université Evry Val-d'Essonne, Département de Biologie, Evry, France. 9. Gustave Roussy, Département de Cancerologie de l'Enfant et de l'Adolescent, Villejuif, France. 10. Gustave Roussy, Département de Radiothérapie, Villejuif, France.
Abstract
Background: The interval between progression and death in diffuse intrinsic pontine glioma (DIPG) is usually <6 months. However, reports of longer patient survival following radiotherapy, in the presence of radiological signs of progression, suggest that these cases may be comparable to pseudoprogression observed in adult glioblastoma. Our aim was to identify such cases and compare their multimodal MRI features with those of patients who did not present the same evolution. Methods: Multimodal MRIs of 43 children treated for DIPG were retrospectively selected at 4 timepoints: baseline, after radiotherapy, during true progression, and at the last visit. The patients were divided into 2 groups depending on whether they presented conventional MRI changes that mimicked progression. The apparent diffusion coefficient, arterial spin labeling cerebral blood flow (ASL-CBF), and dynamic susceptibility contrast perfusion relative cerebral blood volume (DSCrCBV) and flow (DSCrCBF) values were recorded for each tumor voxel, avoiding necrotic areas. Results: After radiotherapy, 19 patients (44%) showed radiological signs that mimicked progression: 16 survived >6 months following so-called pseudoprogression, with a median of 8.9 months and a maximum of 35.6 months. All 43 patients exhibited increased blood volume and flow after radiotherapy, but the 90th percentile of those with signs of pseudoprogression had a greater increase of ASL-CBF (P < 0.001). Survival between the 2 groups did not differ significantly. During true progression, DSCrCBF and DSCrCBV values increased only in patients who had not experienced pseudoprogression. Conclusions: Pseudoprogression is a frequent phenomenon in DIPG patients. This condition needs to be recognized before considering treatment discontinuation. In this study, the larger increase of the ASL-CBF ratio after radiotherapy accurately distinguished pseudoprogression from true progression.
Background: The interval between progression and death in diffuse intrinsic pontine glioma (DIPG) is usually <6 months. However, reports of longer patient survival following radiotherapy, in the presence of radiological signs of progression, suggest that these cases may be comparable to pseudoprogression observed in adult glioblastoma. Our aim was to identify such cases and compare their multimodal MRI features with those of patients who did not present the same evolution. Methods: Multimodal MRIs of 43 children treated for DIPG were retrospectively selected at 4 timepoints: baseline, after radiotherapy, during true progression, and at the last visit. The patients were divided into 2 groups depending on whether they presented conventional MRI changes that mimicked progression. The apparent diffusion coefficient, arterial spin labeling cerebral blood flow (ASL-CBF), and dynamic susceptibility contrast perfusion relative cerebral blood volume (DSCrCBV) and flow (DSCrCBF) values were recorded for each tumor voxel, avoiding necrotic areas. Results: After radiotherapy, 19 patients (44%) showed radiological signs that mimicked progression: 16 survived >6 months following so-called pseudoprogression, with a median of 8.9 months and a maximum of 35.6 months. All 43 patients exhibited increased blood volume and flow after radiotherapy, but the 90th percentile of those with signs of pseudoprogression had a greater increase of ASL-CBF (P < 0.001). Survival between the 2 groups did not differ significantly. During true progression, DSCrCBF and DSCrCBV values increased only in patients who had not experienced pseudoprogression. Conclusions: Pseudoprogression is a frequent phenomenon in DIPGpatients. This condition needs to be recognized before considering treatment discontinuation. In this study, the larger increase of the ASL-CBF ratio after radiotherapy accurately distinguished pseudoprogression from true progression.
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