Role of magnetic resonance spectroscopy for the differentiation of recurrent glioma from radiation necrosis: A systematic review and meta-analysis

doi:10.1016/j.ejrad.2014.09.018

European Journal of Radiology

Volume 83, Issue 12, December 2014, Pages 2181-2189

https://doi.org/10.1016/j.ejrad.2014.09.018 Get rights and content

Abstract

Purpose

Differentiating glioma recurrence from radiation necrosis remains a great challenge. We conducted a meta-analysis to evaluate the diagnostic quality of magnetic resonance spectroscopy (MRS) in differentiating glioma recurrence from radiation necrosis.

Methods

Studies about evaluation of MRS for the differential diagnosis of glioma recurrence from radiation necrosis were systematically searched in PubMed, Embase and Chinese Biomedical databases up to May 4, 2014. The data were extracted to perform heterogeneity test, threshold effect test and to calculate sensitivity (SEN), specificity (SPE) and areas under summary receiver operating characteristic curve (SROC).

Results

Eighteen articles comprising a total sample size of 455 patients (447 lesions) with suspected glioma recurrence after radiotherapy, met all inclusion and exclusion criteria, and were included in our meta-analysis. Quantitative synthesis of studies showed that the pooled SEN and SPE for Cho/Cr ratio were 0.83 (95% CI: 0.77, 0.89) and 0.83 (95% CI: 0.74, 0.90). The area under the curve (AUC) under the SROC was 0.9001. The pooled SEN and SPE for Cho/NAA ratio were 0.88 (95% CI: 0.81, 0.93) and 0.86 (95% CI: 0.76, 0.93). The AUC under the SROC was 0.9185.

Conclusion

This meta-analysis shows that MRS alone has moderate diagnostic performance in differentiating glioma recurrence from radiation necrosis using metabolite ratios like Cho/Cr and Cho/NAA ratio. It is strongly recommended that MRS should combine other advanced imaging technologies to improve diagnostic accuracy. This article underlines the importance of implementing multimodal imaging trials and multicentre trials in the future.

Introduction

Differentiating glioma recurrence from radiation necrosis remains a great challenge. The two entities have totally different prognosis, however often share the same symptoms and the same features in conventional morphologic imaging like computerized tomography (CT) and magnetic resonance imaging (MRI) [1]. To solve the problem, numerous innovative imaging technologies focusing on metabolism or blood flow have been introduced, like positron-emission tomography (PET) with different tracers, single photon emission computed tomography (SPECT), and some advanced MRI techniques (diffusion-weighted imaging [DWI], dynamic susceptibility contrast-enhanced perfusion imaging, and magnetic resonance spectroscopy [MRS], etc.) [1], [2], [3], [4]. They are believed to contribute a lot to the distinction and the clinical decision-making in the absence of histopathologic confirmation. Some of them are very promising with high sensitivity (SEN) and specificity (SPE). However, MRS might be the most suited noninvasive tool when a new enhancing lesion is first identified since it is an adjunct to MRI and it only requires the imaging time is extended for 15–30 min [5].

MRS provides information about metabolic tissue composition, advanced spectroscopic methods have been used to quantify markers of tumor metabolism (e.g. glucose), membrane turnover and proliferation (e.g. choline [Cho]), energy homoeostasis (e.g. creatine [Cr]), intact glioneural structures (e.g. N-acetyl-aspartate [NAA]), and necrosis (e.g. lactate [Lac] or lipids) [5]. Results are usually expressed as ratios between cerebral metabolites, rather than absolute concentrations. Numerous studies have evaluated the diagnostic role of MRS for distinguishing glioma recurrence from radiation necrosis. However, the sample size in each study is relatively small, which may compromise the credibility of results. Thus, we performed the present meta-analysis to evaluate the diagnostic accuracy of MRS for differentiating recurrent glioma from radiation necrosis.

Section snippets

Search strategy

A comprehensive computer literature search of the PubMed, Embase and Chinese Biomedical databases was conducted to find relevant published articles (up to May 4, 2014). The search terms were as follows: (“Magnetic resonance spectroscopy” or “MR spectroscopy” or “MRS”) AND (glioma or brain neoplasm) AND recurrence. The equivalent Chinese terms were used in the Chinese databases. Additionally, the reference lists of all retrieved articles were checked for other eligible reports that have not been

Study selection and characteristics

The study selection process is detailed in Fig. 1. Eighteen articles [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30] comprising a total sample size of 455 patients (447 lesions) with suspected glioma recurrence after radiotherapy, met all inclusion and exclusion criteria, and were included in our meta-analysis. The characteristics of the included studies are presented in Table 1.

Fifteen studies were retrospective cohort studies, and

Discussion

When new contrast-enhancing lesions are discovered at or near the site of previously treated glioma, contrast-enhanced anatomic MRI usually can’t reliably discriminate between radiation change and recurrent tumor, which requires new imaging techniques [1], [2], [3], [4]. MRS is a non-invasive and non-ionizing technique based on fundamental nuclear magnetic resonance principles, which is used to gain metabolic information from tissues of interest. It can detect a large number of endogenous

Conclusion

This meta-analysis provides evidence that MRS alone has moderate diagnostic performance in differentiating glioma recurrence from radiation necrosis using metabolite ratios like Cho/Cr and Cho/NAA ratios. It is strongly recommended that MRS should combine other advanced imaging technologies to improve diagnostic accuracy. This article also underlines the importance of implementing multimodal imaging trials and multicentre trials in the future. In the interpretation of our results, the

Conflicts of interest

The authors declare that they have no conflict of interest.

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¹: These authors are first authors and they are contributed equally to this work.

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ReviewRole of magnetic resonance spectroscopy for the differentiation of recurrent glioma from radiation necrosis: A systematic review and meta-analysis

Abstract

Purpose

Methods

Results

Conclusion

Introduction

Section snippets

Search strategy

Study selection and characteristics

Discussion

Conclusion

Conflicts of interest

Int J Radiat Oncol Biol Phys

J Clin Neurosci

Lancet Neurol

J Clin Epidemiol

Acad Radiol

Acad Radiol

J Clin Neurosci

Int J Radiat Oncol Biol Phys

J Clin Epidemiol

Glioma recurrence versus radiation necrosis: accuracy of current imaging modalities

J Neurooncol

Differentiating tumor recurrence from treatment necrosis: a review of neuro-oncologic imaging strategies

Neuro Oncol

QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies

Ann Intern Med

Conducting systematic reviews of diagnostic studies: didactic guidelines

BMC Med Res Methodol

Meta-DiSc: a software for meta-analysis of test accuracy data

BMC Med Res Methodol

Measuring inconsistency in meta-analyses

Br Med J

Systematic reviews of diagnostic test accuracy

Ann Intern Med

Review
Role of magnetic resonance spectroscopy for the differentiation of recurrent glioma from radiation necrosis: A systematic review and meta-analysis