Abstract
Introduction
The aim of the narrative review was to analyse the applications of nuclear medicine (NM) techniques such as PET/CT with different tracers in combination with radiotherapy for the clinical management of glioblastoma patients.
Materials and methods
Key references were derived from a PubMed query. Hand searching and clinicaltrials.gov were also used.
Results
This paper contains a narrative report and a critical discussion of NM approaches in combination with radiotherapy in glioma patients.
Conclusions
NM can provide the Radiation Oncologist several aids that can be useful in the clinical management of glioblastoma patients. At the same, these results need to be validated in prospective and multicenter trials.
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Introduction
Glioblastoma (GBM) incidence is about 2–3 cases per 100,000 people [1], and its prognosis is extremely poor with a median survival time of only 14.5 months from diagnosis in clinical trials [2]. Despite that the 3-year survival rates rarely reach 5% [3], in clinical practice a great variability in terms of prognosis exists in unselected patients.
Extensive characterisation by multiple omic platforms is improving our knowledge of the molecular bases underlying the nature of GBM aggressiveness [4,113].
The role of PET with radiolabelled aminoacids has also been evaluated for what concerns re-irradiation in glioma relapse. A small number of clinical trials have utilized PET for target volume delineation. Re-irradiation of recurrent glioblastoma multiforme using 11C-methionine PET/CT/MRI image fusion for hypofractionated stereotactic radiotherapy by intensity-modulated radiation therapy has recently been explored with good tolerance and a median survival time of 11 months after treatment completion [64]. A randomized phase II trial compared MRI-guided and 18F-FET PET-guided reirradiation in patients with recurrent GBM with the result that stereotactic fractionated RT is associated with improved survival when aminoacid-PET is integrated in tumour target delineation [114].
In summary, we report a table comparing diagnostic value of new AA tracers with standard MRI-scan (see Table 2).
The future role of NM in glioblastoma radiotherapy: trials in progress
Several trials are currently evaluating different approaches of nuclear medicine in the field of GBM research (see Table 3).
Some trials are investigating the differential diagnosis of GBM, with the use of PSMA PET (NCT04588454) in the visualisation of GBM, the use of 18F-FDG PET for the diagnosis of GBM, the use of 18F-FDOPA PET for the demonstration of functional brain abnormalities and the 18F-DASA-23 and PET Scan in the evaluation of Pyruvate Kinase M2 Expression in patients with intracranial tumours. Other trials in this context are evaluating Tryptophan Metabolism in Human Brain Tumours, the use of [68 Ga]-FF58 in Patients with selected solid tumours expected to overexpress selective Integrins, the assessment of Brain Tumour Hypoxia With Fluoromisonidazole, FDG and Water, the use of mpMRI/Fluorine-18 Fluciclovine PET-CT in GBM and the use of 11C-MET PET as a Post-surgery Baseline Scan for GBM.
Other trials are currently investigating the role of nuclear medicine in the response assessment after standard therapies for GBM, in order to differentiate pseudoprogression with 11C-MET PET or with different tracers, such as 68 Ga-PSMA PET-CT and 18F-FDOPA PET-CT, 18F-FDG PET/CT. Several trials are currently investigating F18 Fluciclovine PET/CT, either alone or in combination with mpMRI.
In the context of radiotherapy planning, other Investigators are enrolling patients for different protocols, such as Fluciclovine or 18F-FET PET guided radiotherapy, or the use of 18F-FDOPA PET/MRI scan for the investigation of proton beam therapy for elderly GBM patients. Other Investigators are currently enrolling GBP patients for TTFields and radiosurgery based on 18F-FET PET for recurrent glioblastoma, or for amino-acid PET guided reirradiation.
Finally, several other trials are currently evaluating different endpoints, such as the PARP-1 expression with 18F-FluorThanatrace PET, the predictive role of PET and perfusion CT in GBM patients undergoing anti-angiogenics, the role of 18F-FDG PET in EGFR positive GBM patients undergoing osimertinib, or laser interstitial thermal therapy treatment response assessment with Fluciclovine PET.
Future directions and conclusions
All the above mentioned studies have shown promising results of different application of nuclear medicine in the field of GBM. Nevertheless, the clinical approach of GBM patients remains the same from the Stupp trial [2]. In this context, considering the poor OS, several efforts must be taken in near future in order to increase the therapeutic efficacy of different therapies.
Conversely, despite an impressive number of retrospective studies, the number of prospective clinical trials investigating the potential role of nuclear medicine in GBM patients remains somewhat low (see Table 3).
There are still some limitations to resolve before nuclear medicine techniques can be successfully applied in the clinical management of GBM patients. More specifically, current major pitfalls in nuclear medicine are the big heterogeneity of tracers adopted, the lack of image standardization and the lack of standardization of volumes definition to be used in the treatment planning.
Nuclear medicine actually represents one of the most interesting approaches of tailored medicine in this disease. Future research will also need to focus on big data analysis and artificial intelligence in order to facilitate the clinical application of nuclear medicine in the management of GBM patients.
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All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by VN, ID, LD, IM, LV, EG. The first draft of the manuscript was written by VN, ID, LD, IM, LV, EG, FC, AC. The Review and Editing was performed by CG, AC, MPB, FC, MS, CV, LM, AR, SC. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
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Nardone, V., Desideri, I., D’Ambrosio, L. et al. Nuclear medicine and radiotherapy in the clinical management of glioblastoma patients. Clin Transl Imaging 10, 477–493 (2022). https://doi.org/10.1007/s40336-022-00495-8
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DOI: https://doi.org/10.1007/s40336-022-00495-8