23Na-MRI of recurrent glioblastoma multiforme after intraoperative radiotherapy: technical note

Abstract

Introduction: We report the first case of an intraoperative radiotherapy (IORT) in a patient with recurrent glioblastoma multiforme (GBM) who was followed up with a novel magnetic resonance imaging (MRI) method—23Na-MRI—in comparison to a standard contrast-enhanced 1H-MRI and 18F-FET-PET. Methods: A 56-year-old female patient with diagnosed GBM in July 2012 underwent tumor resection, radiochemotherapy, and three cycles of chemotherapy. After a relapse, 6 months after the initial diagnosis, an IORT was recommended which was performed in March 2013 using the INTRABEAM system (Carl Zeiss Meditec AG, Germany) with a 3-cm applicator and a surface dose of 20 Gy. Early post-operative contrast-enhanced and 1-month follow-up 1H-MRI and a 18F-FET-PET were performed. In addition, an IRB-approved 23Na-MRI was performed on a 3.0-T MR scanner (MAGNETOM TimTrio, Siemens Healthcare, Germany). Results: After re-surgery and IORT in March 2013, only a faint contrast enhancement but considerable surrounding edema was visible at the medio-posterior resection margins. In April 2013, new and progressive contrast enhancement, edema, 23Na content, and increased uptake in the 18F-FET-PET were visible, indicating tumor recurrence. Increased sodium content within the area of contrast enhancement was found in the 23Na-MRI, but also exceeding this area, very similar to the increased uptake depicted in the 18F-FET-PET. The clearly delineable zone of edema in both examinations exhibits a lower 23Na content compared to areas with suspected proliferating tumor tissue. Conclusion: 23Na-MRI provided similar information in the suspicious area compared to 18F-FET-PET, exceeding conventional 1H-MRI. Still, 23Na-MRI remains an investigational technique, which is worth to be further evaluated.