title: Utility of apparent diffusion coefficient in predicting the outcome of Gamma Knife-treated brain metastases prior to changes in tumor volume: a preliminary study.
abstract: OBJECTIVE
  Gamma Knife surgery (GKS) is often the sole treatment for brain metastases. The authors hypothesized that early post-GKS measures of the relative apparent diffusion coefficient (rADC) could predict therapeutic response, recurrence, and radionecrosis prior to changes in tumor volume.
  
  
  METHODS
  Magnetic resonance (MR) images of 25 metastatic tumors in 15 patients were reviewed. Inclusion criteria included a history of surgery or GKS, a minimum tumor diameter of 5 mm at treatment, and a minimum of two follow-up MR images. Tumor volumes were normalized to baseline, and tumor ADC values were normalized to normal-appearing white matter (rADC). A successful therapeutic response (STR) was defined by a monotonically decreasing tumor volume throughout the follow-up period. Magnetic resonance spectroscopy was used to classify non-STRs as radionecrosis or tumor recurrence. All tumors exhibited a decreased normalized volume (mean 37%) at the first follow-up examination (range 33-124 days after GKS, mean 54 days), and three distinct rADC patterns subsequently evolved: Group 1 (STR [10 cases]), monotonically decreasing volume with gradually increasing rADC; Group 2 (radionecrosis [three cases]), initial volume reduction followed by gradual increase, with initial rapidly increasing rADC followed by more gradual increase or plateau; and Group 3 (recurrent tumor [12 cases]), initial volume decrease followed by increase, with a preceding gradual decrease in the rADC.
  
  
  CONCLUSIONS
  The rADC patterns outperform initial post-GKS tumor volume in predicting the long-term response to treatment. Decreasing tumor volume with an increasing rADC predicts an STR. For lesions with increasing volume, antecedent rADC reduction predicts recurrence, whereas a rapidly increasing rADC predicts radionecrosis. Evaluation of the rADC at the initial post-GKS follow-up examination appears to be a useful prognostic measure of metastatic tumor response.
authors.affiliation: Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island 02903, USA.
authors.forename: Marc
authors.initials: M
authors.lastname: Goldman
authors.forename: Jerrold L
authors.initials: JL
authors.lastname: Boxerman
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Rogg
authors.forename: Georg
authors.initials: G
authors.lastname: Norén
mesh_terms: D000328:Adult; D000368:Aged; D001932:Brain Neoplasms / Q000473:pathology / Q000556:secondary* / Q000601:surgery*; D015331:Cohort Studies; D038524:Diffusion Magnetic Resonance Imaging; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009336:Necrosis; D011237:Predictive Value of Tests; D011832:Radiation Injuries / Q000473:pathology; D016634:Radiosurgery; D012189:Retrospective Studies; D016896:Treatment Outcome; D047368:Tumor Burden