Investigation of blood perfusion and metabolic activity of brain tumours in adults by using 99mTc-methoxyisobutylisonitrile.

Objectives: (i) To examine blood perfusion and metabolic activity of various brain tumours using radionuclide cerebral angiography (RCA) and single-photon emission tomography (SPET) after a single dose of Tc-methoxyisobutylisonitrile (MIBI). (ii) To examine if the inclusion of RCA can improve insight into the relative contribution of tumour perfusion to the uptake of MIBI shown by SPET, and to improve evaluation of tumour biology. (iii) To determine the value and the roles of MIBI in the management of brain tumour patients.

Methods: Fifty adult patients (38 male, 12 female) with a total of 56 intracranial space-occupying lesions have been included prospectively, 37 of which were newly diagnosed and the remaining with signs of recurrence/rest of earlier resected and irradiated brain tumours. The control group consisted of nine volunteers with no evidence of organic cerebral disease. Scintigraphic examination consisted of a dynamic first-pass study lasting 60 s (3 s/frame) and two SPET studies (60 projections each, 25 s/projection), starting 15 min and 2 h after intravenous injection of MIBI. Regions of interest of the tumour and normal brain tissue were drawn on RCA and both early and delayed SPET slices. The following tumour/brain activity ratios have been calculated: (i) tumour perfusion index (P); (ii) early uptake index (E); (iii) delayed uptake index (D); and(iv) retention index (R). Analogous indices have been calculated from the same examinations performed in controls, reflecting maximal physiologic regional variations of perfusion and uptake in brain tissue.

Results: Mean P of various brain tumours (low-grade gliomas 0.98, anaplastic gliomas 1.14, glioblastoma multiforme 1.20, metastases 1.09, lymphomas 1.08) differ little from each other and do not exceed maximal physiologic regional variations of cerebral perfusion (1.33), with the exception of meningioma (1.87, F=2.83, P=0.015). The receiver operating characteristics curve analysis of P showed that for the cut-off value of 1.45 the sensitivity for distinguishing meningioma from other tumours is 75%, specificity 87%, positive predictive value 33% and negative predictive value 97%. Mean E of malignant brain tumours (8.3, n=31, 23 primary, eight secondary), except anaplastic gliomas (3.5, n=5), differed significantly (P=0.02) from those of benign gliomas (3, n=9) but not from that of meningioma (11.9, n=4). The cut-off value for distinguishing malignant from benign lesions on the basis of E set at 4.8 resulted in sensitivity 67%, specificity 75%, accuracy 70%, positive predictive value 80% and negative predictive value 60%. D and R showed tendency of wash-out of MIBI from meningiomas, but otherwise did not improve the results substantially.

Conclusion: Integrated results of RCA and SPET with Tc-MIBI indicate that blood perfusion, blood-tumour barrier permeability and metabolic activity of the tumour are all very important for the resultant uptake shown by SPET. If the perfusion index is less than 1.45, then meningioma can be ruled out. Early SPET is recommendable for distinguishing glioblastoma from low-grade gliomas, as a complement to standard magnetic resonance imaging and/or computed tomography.