Multi-Tracer PET Assessment of Primary Brain Tumors
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The standard treatment approach for patients with high-grade primary brain tumors includes maximum feasible surgical resection, followed by 6 weeks of concurrent cranial irradiation and daily low-dose temozolomide chemotherapy, followed by 12 cycles of high-dose temozolomide administered for 5 consecutive days every 4 weeks [Stupp 2005]. Contrast-enhanced MRI is the current standard for evaluating the success of therapy and monitoring for tumor recurrence. MRI is typically obtained prior to initial surgery, within 24 hours after surgery, at the conclusions of cranial irradiation, and then every 8 weeks during temozolomide chemotherapy until evidence of recurrence. Despite this careful clinical and radiographic surveillance, and despite decades of research into the histologic and molecular classification of primary brain tumors, our ability to predict tumor behavior remains very limited. Some gliomas will result in overall survival times of only months, whereas other histologically-identical gliomas may yield survivals of years to decades [Carson 2007, Curran 1993, Lamborn 2004]. Current assessment of tumor response to therapy is also poor. Patients with complete radiographic response after cranial irradiation often progress rapidly post-irradiation. In contrast, some patients with enhancing masses at the end of chemoradiotherapy may respond dramatically to further chemotherapy alone, or the masses may even disappear in the absence of further therapy (so called "tumor pseudoprogression") [Chamberlain 2007]. This confounding situation demonstrates a need for better assessment of tumor response.
Condition or disease
Radiation: Multi-tracer PET exams of 18F-FDG, 18F-FLT, 11C-ACE, and 15O-H2O
Radiation: Multi-tracer PET exams of 18F-FDG, 18F-FLT, 11C-ACE, and 15O-H2O
Baseline: prior to surgery or immediately after surgery and prior to any tumor-directed therapy;
After the initial (~6-8 weeks) chemoradiotherapy;
At the time of MRI-documented recurrence within 2 years (patients with a known primary brain tumor who have previously undergone treatment and have recurred will be eligible for study). The PET scanning will be implemented in two phases: Phase A (separate single-tracer scans with each tracer) will be completed with imaging over two consecutive days and Phase B (where two or more tracers will be imaged in a single scan using rapid multi-tracer PET techniques under development) in one or two imaging sessions according to the best method validated from the Phase A results. The exact order and timing of the multi-tracer exams will vary.
Rapid, single-scan multi-tracer PET imaging can recover PET imaging biomarker information of each tracer that are not significantly different from those obtained from conventional, single-tracer scans of each tracer. [ Time Frame: June 2014 ]
Multi-tracer PET biomarkers, obtained in conjunction, are better able to predict tumor aggressiveness than individual-tracer biomarkers or conventional radiographic imaging. [ Time Frame: June 2014 ]
Multi-tracer PET biomarkers, obtained in conjunction, are better able to detect functional changes in tumor state that occur in response to therapy than individual-tracer biomarkers or conventional radiographic imaging. [ Time Frame: June 2014 ]
Characterization of multiple aspects of tumor function (glucose metabolism, proliferation, membrane growth, and perfusion) provides new insight into tumor status that can guide selection of the most appropriate therapy. [ Time Frame: June 2014 ]
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Ages Eligible for Study:
18 Years and older (Adult, Older Adult)
Sexes Eligible for Study:
Accepts Healthy Volunteers:
Study patients: Adult patients (n = 20) with (Group 1) compelling MRI evidence of a new primary brain tumor who have not yet undergone surgery or any tumor-directed therapy, or (Group 2) newly diagnosed primary malignant brain tumors (WHO Grade II-IV glial-based tumors)who have not had a complete surgical resection and by contrast MRI have residual tumor greater than 1.0 cm in diameter and will be receiving radiotherapy and/or chemotherapy, or (Group 3) patients with recurrent primary barin tumor as determined by standard clinical criteria and MRI imaging. Four to eight patients per year will be enrolled during the first 3 years, for a total of 20 patients. Enrollment will be weighted toward lower-grade tumors during year 1 in order to allow for longer followup times during the life of the project. Dr. Jensen or Dr. Colman will identify and recruit patients for participation and obtain informed consent.
Three different adult patient groups will be eligible for inclusion in this study:
Group 1: Adult patients with compelling evidence of primary brain tumor based on clinical and MRI imaging characteristics that have not yet received surgery, histological diagnosis, or any tumor-directed therapy. Such evidence will include: MRI or CT scan-documented mass lesion within the brain, accompanied by anatomically appropriate neurological signs and symptoms, in the absence of a probable competing diagnosis such as brain abscess or primary intracranial hematoma.
Group 2: Newly diagnosed primary malignant brain tumors (WHO Grade II - IV glial-based tumors) who have not had a complete surgical resection and by contrast MRI have residual tumor greater than 1.0 cm in diameter and will be receiving radiotherapy and/or chemotherapy.
Group 3: Patients with recurrent primary brain tumor as determined by standard clinical criteria and MRI imaging.
Patients must be 18 years or older for inclusion in this study. There is little experience with the safety of [18F]FLT in children, and the risks associated with radiation exposure may be increased for children under 18 years old as well.
Karnofsky performance status > 60%.
Patients must document their willingness to be followed for at least 24 months after recruitment by signing informed consent documenting their agreement to have clinical endpoints and the results of histopathologic tissue analysis (when tissue becomes available from routine care) entered into a research database.
All patients, or their legal guardians, must sign a written informed consent and HIPAA authorization in accordance with institutional guidelines.
Determination of pregnancy status: Female patients that are not postmenopausal or surgically sterile will undergo a serum pregnancy test prior to each set of multi-tracer PET scans. A negative test will be necessary for such patients to undergo research PET imaging.
Pre-treatment laboratory tests for patients receiving [18F]FLT must be performed within 21 days prior to study entry. These must be less than 2.5 times below or above the upper or lower limit range for the respective laboratory test for entry into the study. In those instances where a baseline laboratory value is outside of this range, then such a patient will be ineligible for enrollment. For the followup scanning sessions after therapy has been instituted, laboratory testing will also be required due to the use of FLT. The patients have brain tumors and will receive various forms of therapy; therefore many routine laboratory tests may not be within the typical normal range. As such, a factor of 4.0 times above or below the upper or lower value for the normal range for any laboratory test will be used to determine the acceptable range for the 2nd and possible 3rd imaging timepoints. The baseline laboratory testing will include liver enzymes (ALT, AST, ALK, LDH), bilirubin (total), serum electrolytes, CBC with platelets and absolute neutrophil counts, prothrombin time, partial thromboplastin time, BUN, creatinine. Previous urinalysis abnormalities will not preclude the patient from being studied. For those patients receiving coumadin or another anticoagulant the upper limit for prothrombin time or partial thromboplastin time must not exceed 6 times the upper limit of the normal range.
Patients with clinically significant signs of uncal herniation, such as acute pupillary enlargement, rapidly developing motor changes (over hours), or rapidly decreasing level of consciousness, are not eligible.
Patients with known allergic or hypersensitivity reactions to previously administered radiopharmaceuticals. Patients with significant drug or other allergies or autoimmune diseases may be enrolled at the Investigator's discretion.
Patients who are pregnant or lactating or who suspect they might be pregnant. Serum pregnancy tests will be obtained prior to each set of multi-tracer PET scans in female patients that are not postmenopausal or surgically sterile.
Adult patients who require monitored anesthesia for PET scanning.
HIV positive patients due to the previous toxicity noted with FLT in this patient group.
Patients who have undergone surgery or receive any previous tumor-directed therapy for their brain tumor.