Early Pseudoprogression following Chemoradiotherapy in Glioblastoma Patients: The Value of RANO Evaluation

Paulo Linhares, Bruno Carvalho, Rita Figueiredo, Rui M Reis, Rui Vaz, Paulo Linhares, Bruno Carvalho, Rita Figueiredo, Rui M Reis, Rui Vaz

Abstract

Introduction. The aim of this study was to determine the frequency of pseudoprogression in a cohort of glioblastoma (GBM) patients following radiotherapy/temozolomide (RT/TMZ) by comparing Macdonald criterial to Response Assessment in Neuro-Oncology (RANO) criteria. The impact on prognosis and survival analysis was also studied. Materials and Methods. All patients receiving RT/TMZ for newly diagnosed GBM from January 2005 to December 2009 were retrospectively evaluated, and demographic, clinical, radiographic, treatment, and survival data were reviewed. Updated RANO criteria were used for the evaluation of the pre-RT and post-RT MRI and compared to classic Macdonald criteria. Survival data was evaluated using the Kaplan-Meier and log-rank analysis. Results and Discussion. 70 patients were available for full radiological response assessment. Early progression was confirmed in 42 patients (60%) according to Macdonald criteria and 15 patients (21%) according to RANO criteria. Pseudoprogression was identified in 10 (23.8%) or 2 (13.3%) patients in Macdonald and RANO groups, respectively. Cumulative survival of pseudoprogression group was higher than that of true progression group and not statistically different from the non-progressive disease group. Conclusion. In this cohort, the frequency of pseudoprogression varied between 13% and 24%, being overdiagnosed by older Macdonald criteria, which emphasizes the importance of RANO criteria and new radiological biomarkers for correct response evaluation.

Figures

Figure 1
Figure 1
T1-contrast-enhanced and FLAIR magnetic resonance imaging (MRI) documenting pseudoprogression. Compared with pre-RT/TMZ MRI, the 1-month post-RT/TMZ showed increasing areas of contrast enhancement suggestive of tumoral progression. The patient remained clinically stable with stable dose of corticotherapy. Adjuvant TMZ treatment cycles were maintained and serial MRI at 4, 7, 10, and 15 months showed a consistent reduction in the size and the contrast of the lesion as well as in FLAIR signal.
Figure 2
Figure 2
T1-contrast-enhanced magnetic resonance imaging (MRI) documenting pseudoprogression according to Macdonald criteria showing a significant increase in cingulate gyrus enhancing lesion at 1 month after RT/TMZ with subsequent stabilization (stable corticosteroid dose and functional status). FLAIR sequence shows increased signal extending to contralateral hemisphere anticipating true progressive disease.
Figure 3
Figure 3
Kaplan-Meier analysis of overall survival curves according to different progression groups: true-progressive disease (tPD), blue; Pseudoprogression (psPD), green; Nonprogressive disease (nPD), yellow; and different response assessment criteria: (a), Macdonald; (b), RANO.
Figure 4
Figure 4
Kaplan-Meier analysis of progression-free survival curves according to different progression groups: true-progressive disease (tPD), blue; pseudoprogression (psPD), green; nonprogressive disease (nPD), yellow; and different response assessment criteria: (a) Macdonald and (b) RANO.

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