Preoperative [(11)C]methionine PET to personalize treatment decisions in patients with lower-grade gliomas

BACKGROUND: PET with radiolabeled amino acids is used in the preoperative evaluation of patients with glial neoplasms. This study aimed to assess the role of [(11)C]methionine (MET) PET in assessing molecular features, tumor extent, and prognosis in newly diagnosed lower-grade gliomas (LGGs) surgically treated. METHODS: One hundred and fifty-three patients with a new diagnosis of grade 2/3 glioma who underwent surgery at our Institution and were imaged preoperatively using [(11)C]MET PET/CT were retrospectively included. [(11)C]MET PET images were qualitatively and semi-quantitatively analyzed using tumor-to-background ratio (TBR). Progression-free survival (PFS) rates were estimated using the Kaplan-Meier method and Cox proportional-hazards regression was used to test the association of clinicopathological and imaging data to PFS. RESULTS: Overall, 111 lesions (73%) were positive, while thirty-two (21%) and ten (6%) were isometabolic and hypometabolic at [(11)C]MET PET, respectively. [(11)C]MET uptake was more common in oligodendrogliomas than IDH-mutant astrocytomas (87% vs 50% of cases, respectively). Among [(11)C]MET-positive gliomas, grade 3 oligodendrogliomas had the highest median TBR(max) (3.22). In 25% of patients, PET helped to better delineate tumor margins compared to MRI only. In IDH-mutant astrocytomas, higher TBR(max) values at [(11)C]MET PET were independent predictors of shorter PFS. CONCLUSIONS: This work highlights the role of preoperative [(11)C]MET PET in estimating the type of suspected LGGs, assessing tumor extent, and predicting biological behavior and prognosis of histologically confirmed LGGs. Our findings support the implementation of [(11)C]MET PET in routine clinical practice to better manage these neoplasms.