Radiation Necrosis Vs High-grade Recurrent Glioma: Differentiation by Using Dual-isotope SPECT with 201TI and 99mTc-HMPAO

Conventional imaging techniques are often unreliable in distinguishing between radiation necrosis and recurrent glioma in patients who are symptomatic after high-dose radiotherapy. We performed dual-isotope single-photon emission computed tomography (SPECT) with the use of thallium-201 (201TI) and the perfusion agent 99mTc-hexamethyl-propyleneamine oxime (HMPAO) to aid in this differentiation in 15 patients with glioma prior to biopsy. We found that dual-isotope SPECT scanning correlated with the pathologic findings in 14 of the 15 cases. All patients with high 201TI uptake in their treated tumor beds had local tumor recurrence, and all patients with low 201TI uptake showed only radiation changes without evidence of solid tumor. In patients with an intermediate level of 201TI concentration in their tumor bed, 99mTc-HMPAO uptake differentiated those patients with active tumor from those without; three of four patients with preserved or increased perfusion had pathologic evidence of solid tumor, whereas none of the four patients with decreased perfusion to the tumor bed had evidence of local recurrence. We believe that dual-isotope SPECT with 201TI and 99mTc-HMPAO may be useful in differentiating sites of likely tumor growth from nonspecific radiation changes in patients treated for malignant glioma.