Uninterpretable Dynamic Susceptibility Contrast-Enhanced Perfusion MR Images in Patients with Post-Treatment Glioblastomas: Cross-Validation of Alternative Imaging Options

PURPOSE: The purpose of this study was to evaluate the accuracy of diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) perfusion MR imaging for distinguishing tumor recurrence from post-treatment effect as alternatives to dynamic-susceptibility contrast-enhanced (DSC) perfusion MR imaging when the DSC image is uninterpretable. MATERIALS AND METHODS: This retrospective study was approved by our institutional review board. Seventy one post-treatment glioblastoma patients who showed enlarged contrast-enhancing lesions on follow-up MR images after concurrent chemoradiotherapy and uninterpretable DSC images for corresponding enhancing lesions, underwent additional DWI and DCE MR imaging. The primary outcome was the frequency of interpretable DWI and DCE MR cases in these 71 patients. The secondary outcome was the area under the receiver operating characteristic curve (AUC) of DWI and DCE imaging parameters for distinguishing tumor recurrence from post-treatment effect in selected patients with interpretable DWI and DCE images. The imaging parameters were quantified as 10% cumulative histogram cutoff of apparent diffusion coefficient (ADC10) and 90% cumulative histogram cutoff of initial area under the time signal intensity curve (IAUC90). The AUCs were cross-validated by using leave-one-out method. RESULTS: Of the 71 patients, the uninterpretable DSC images were associated with treatment-related hemorrhage within the corresponding enhancing lesions (n = 54, 76.1%) and a near skull base location (n = 17, 23.9%). The frequencies of interpretable DWI and DCE image were 51 (71.8%) and 59 (83.1%) of the 71 cases with uninterpretable DSC images, respectively. Of the 45 selected patients with interpretable DWI and DCE images, the combination of DWI with DCE imaging showed a superior diagnostic performance than DWI or DCE imaging alone for differentiating tumor recurrence from post-treatment effect (cross-validated AUC: 0.78 versus 0.55 and 0.73 for reader 1; cross-validated AUC: 0.78 versus 0.53 and 0.75 for reader 2, respectively). Cross-validated accuracy of the single and combined imaging parameters also showed the highest for the combination of DWI with DCE MR imaging (72.9% for reader 1; 72.5% for reader 2) and the lowest for DWI alone (54.0% for reader 1; 56.4% for reader 2). Inter-reader agreement for DCE imaging was higher than that for DWI (intraclass correlation coefficient: 0.95 versus 0.87). CONCLUSION: DCE MR imaging could be a superior and more reproducible imaging biomarker than DWI for differentiating tumor recurrence from post-treatment effect in patients with post-treatment glioblastoma when DSC MR images are not interpretable.