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Category: Volume 06 Issue 11 November 2018
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Title: Magnetic resonance spectroscopic metabolites as prognostic factors for survival and recurrence compared to anatomic MRI in grade III gliomas post adjuvant radiation: A retrospective analysis

Authors: Dr Kushal Goswami, Dr Amitabha Manna, Dr Anish Bandyopadhyay, Dr Mannavi Suman, Dr Swetha Bhukya

 DOI: https://dx.doi.org/10.18535/jmscr/v6i11.136

Abstract

Objectives: The primary objective was to assess the prognostic significance of  MR spectroscopy parameters (choline/NAA and choline/creatine ratio)both at Baseline (Pre operative MRS) and post adjuvant radiation regarding survival and its comparison with traditional anatomic MRI based grading parameters (enhancement quality, enhancement proportion, enhancement margin,T1 Flair Ratio).A secondary objective was to corelate any association between the MRS metabolic baseline and response values(cho/NAA and cho/creatine ) with Histopathologically proved recurrence.

Materials and Methods: 25 histopathologically proved Grade III gliomas (astrocytomas and mixed oligoastrocytomas),registered in our institution between 2013-2016 who had both preoperative and post radiation MRI and MRS done were included in the study.MRS metabolic parameters were graded at baseline (Pre op) into cho/Naa ratio (>3.5,<3.5)and cho/creatine ratio(>2,<2) and at response(post adjuvant radiation) into cho/Naa change(>25%,<25% of baseline) and Cho/creatine (>10%,<10% of baseline). Baseline Anatomic MRI characteristics of the tumor (pre op) was also graded into enhancement quality (mild/avid), proportional enhancement(>50%,<50%), Margin of enhancement(well defined/poorly defined) and T1/Flair Size ratio(expansive/infiltrative)based on the VASARI/REMBRANDT MR feature set. PFS was estimated from time of completion of adjuvant treatment to clinical or radiological progression or last clinical follow up. Univariate analysis using Kaplan maier survival method and Log Rank value test was done for both the metabolic MRS value groups (baseline and Response) and the anatomic MRI parameters. Univariate survival analysis was also done to assess significance of Radiation dose (>50 Gy, <50 Gy) and extent of surgery (total vs subtotal/biopsy). Any parameter with log rank p value<0.08 was deemed to be significant and was entered into multivariate cox regression analysis. Histopathologically confirmed cases of recurrence (positive HPE/negative HPE) was correlated with baseline and response MRS value groups using Paired t test to corelate any significance. All analysis were done using SPSS-V23.

Results: Median follow up period was 38 months &median pfs was 13.2 months. On univariate analysis of the baseline and response value groups of MRS, the most significant factor associated with better survival was cho/cr change greater than 10%(PFS of 22.1 months vs 9.3 months, log rank p value=0.002) followed by baseline cho/naa less than 3.5 (PFS of 21.7 months vs 12.7 months, p=0.021).Among the Anatomic MRI parameters well defined enhancement margin was associated with survival advantage(PFS 20.5 vs 12.3 months, p=0.045). Full RT dose and total excision both were individually associated with better survival (p=0.073 and p=0.002).On multivariate analysis only cho/cr change >10% was significant at p=0.144 among MRS parameters. Among the 7 patient who underwent rexcision following clinical/radiological progression,6 were HPE confirmed recurrence. On paired t test Cho/naa change>25% of baseline(post RT response value) was identified as the best predictor of HPE confirmed recurrence (p=0.008) better than radiological progression during Follow up(p=0.350)

Conclusion: MRS metabolic parameters (Lower baseline cho/naa and greater cho/cr change after treatment) are of significant survival advantage whereas lesser cho/Naa response has better specificity for HPE proved recurrence than its anatomic counterpart. Prospective studies evaluating voxel based MRS data incorporated into treatment planning systems can be an interesting way forward.

Keywords: Magnetic resonance spectroscopy, High grade gliomas, Adjuvant radiation, recurrence, progression free survival, radiotherapy planning

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Corresponding Author

Dr Amitabha Manna

Assistant Professor, Department of Radiation Oncology, Medical College, Kolkata, India

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