The relative cerebral blood volume in normal-appearing white and grey matter remains almost constant following radio(chemo)therapy

Introduction: Adjuvant radio(chemo)therapy (RT) is part of the treatment of primary brain tumor patients. In order to capture microscopic tumor extension and to compensate for random and systematic positioning uncertainties, it is inevitable that tumor-surrounding normal brain tissue is irradiated. The aim of this study was to determine relative cerebral blood volume (rCBV) changes in glioma patients before and after RT in normal appearing white matter (WM) and grey matter (GM). Methods: As part of an ongoing study, anatomical and functional MRI data of glioma patients undergoing gross tumor resection followed by RT is being collected. The analysis of a subset of this cohort, 17 glioma patients (3 grade II, 11 grade III, 3 grade IV, average age 46.9y ± 13.2y) is presented here. Two patients were treated with photon therapy, 14 patients with proton therapy and one patient received treatment modalities. MRI scans acquired prior to RT and at least one follow-up MRI obtained 3, 6 and 9 months after RT was evaluated. All MRI data were collected on a 3T Philips Ingenuity PET/MR scanner (Philips, Eindhoven, The Netherlands) using an 8 channel head coil and included anatomical T1w-images (3D-GRE, TR/TE=10/3.7ms, FA=20°, voxel size 1×1×1mm3) and dynamic susceptibility contrast (DSC) imaging using a PRESTO sequence (TR/TE=15/21ms, 60 dynamics, dynamic scantime=1.7s, voxel size 3.6×3.6×3.5mm3) with intravenous gadolinium contrast agent (0.1mol/kg, 4ml/s, 7s delay) followed by a saline flush (20ml, 4ml/s). The CBV-map (fig. 1D) was calculated as the area under curve (AUC) of the voxelwise time course of the 4D PRESTO image. Computed tomographies (CTs) used for planning, radiation dose (fig.1C) and clinical target volume (CTV) contours were registered to the T1w images using ANTs1 . T1w-images were segmented into GM and WM using SPM122 and the corresponding 95% tissue probability maps were rigidly registered with ANTs1 to the CBV-map. B1 inhomogeneities as well as voxels with strong signal loss due to susceptibility artefacts were excluded. Only voxels outside the CTV and without any abnormalities appearing on the FLAIR image were considered. Symmetrical GM and WM ROIs in supraventricular contralateral and ipsilateral hemisphere (fig.1A,B) were evaluated. The relative CBV (rCBV) was calculated as the ratio of the mean ipsilateral and contralateral CBV: rCBV=(CBV_ipsi)/(CBV_contra ) The radiation dose in the ROI was determined as the dose difference of ipsilateral to contralateral side. In a second analysis, the ROI was divided into bins of relative dose differences (ΔRD): low (0-20Gy), medium (20-40Gy) and high (>40Gy). Time-dependent alteration of rCBV was determined by the normalized difference between follow-up (v0x) and baseline measurement: ΔrCBV=(rCBV_v0x–rCBV_baseline)/(rCBV_baseline ) Dose- and time-dependent ΔrCBV distributions were compared with the paired Wilcoxon signed-rank test. Results: The entire ROIs (fig. 2G,H) as well as the dose-separated regions (fig. 2A-F) of GM and WM rCBV did not show significant changes between baseline and follow-up, neither over time nor with increasing dose. One exception was the statistically significantly reduced mean ΔrCBV of -7.6% (p