ASL-derived fractional tumor burden effectively discriminates recurrent tumor and radiation necrosis in post-SRS brain metastases

ASL-derived fractional tumor burden (FTB)-high differentiated recurrent tumor from radiation necrosis in 102 brain metastases after SRS (AUC 0.81, sensitivity 0.79, specificity 0.74). It performed comparably to perfusion metrics and outperformed delta T1.

• Primary endpoint: Normalized FTB-high AUC 0.81 (95% CI 0.71-0.90) for distinguishing tumor from radiation necrosis.
• Performance was comparable to absolute FTB-high (AUC 0.75, P=0.22) and other ASL metrics (AUCs 0.79-0.83).
• Normalized FTB-high significantly outperformed delta T1 (ΔAUC 0.19, P=0.004) and showed a monotonic association with tumor probability (OR 1.62 per 10% increase, P=0.001).

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