Assessment of Relapse in Patients with Peritoneal Carcinomatosis after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy using F-18-FDG-PET/CT

Abstract

Purpose: In patients with peritoneal carcinomatosis (PC), cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is an evolving therapeutic approach with curative intention. The differentiation between posttherapeutic findings after HIPEC and relapse of PC is challenging. We evaluated the diagnostic value of F-18-FDG-PET/CT in patients with relapse of PC after HIPEC.

Materials and Methods: 36 patients with recurring PC after HIPEC were examined on a whole-body PET/CT system (44 examinations). The examination included 3 D F-18-FDG-PET and contrast-enhanced CT. Images were assessed by two experienced readers regarding the presence and the extent of PC using the peritoneal carcinomatosis index (PCI). Imaging results were correlated with surgical findings or follow-up.

Results: Relapse was suspected in 40 of 44 examinations. Relapse was missed by F-18-FDG PET/CT in 4 patients and significantly underestimated in 8 patients. The diagnostic accuracy for the detection of PC on a patient basis was 91 %, the sensitivity was 91 % and the positive predictive value was 100 %. The mean PCI was 11.4 ± 11.9 for PET/CT, 8.4 ± 10.3 for CT and 16.6 ± 15.0 in the case of surgical exploration. The extent of PC was underestimated by PET/CT and even more by CT alone (p < 0.05).

Conclusion: The diagnostic value of F-18-FDG PET/CT after cytoreductive surgery and HIPEC in the detection of recurring PC is superior to contrast-enhanced CT. However, the quantification of the extent of PC is limited due to post-therapeutic tissue alterations.

Key Points:

• Imaging of recurrent PC after HIPEC is challenging due to posttherapeutic tissue alterations.

• The extent of recurrent PC after HIPEC is systematically underestimated by F-18-FDG PET/CT.

• F-18-FDG PET/CT provides improved sensitivity for recurrent PC compared to contrast-enhanced CT.

• The correlation of the extent of recurrent PC depicted by F-18-FDG PET/CT and surgical exploration is better than that of contrast-enhanced CT and surgical exploration.

Citation Format:

• Klumpp B, Schwenzer N F, Gatidis S et al. Assessment of Relapse in Patients with Peritoneal Carcinomatosis after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy using F-18-FDG-PET/CT. Fortschr Röntgenstr 2014; 186: 359 – 366

Zusammenfassung

Ziel: Die zytoreduktive Operation kombiniert mit einer hyperthermen intraperitonealen Chemotherapie (HIPEC) mit kurativer Zielsetzung bei Peritonealkarzinose (PK) findet zunehmend Verbreitung. Nach HIPEC besteht in der Nachsorge die Herausforderung in der Differenzierung zwischen therapieassoziierten Veränderungen und einem Rezidiv. Die Studie untersucht den diagnostischen Wert der F-18-FDG-PET/CT bei Patienten mit Rezidiv einer PK nach HIPEC.

Material und Methoden: 36 Patienten mit einem Rezidiv nach HIPEC wurden an einem Ganzkörper PET/CT-System untersucht (44 Untersuchungen). Die Untersuchung bestand aus einem 3-D-F-18-FDG-PET und einem Kontrast angehobenen CT. Die Beurteilung erfolgte durch zwei erfahrene Auswerter bezüglich Vorhandensein und Ausmaßes der PK basierend auf dem Peritonealkarzinose-Index (PCI). Die Ergebnisse wurden mit dem intraoperativen Befund oder dem Verlauf korreliert.

Ergebnisse: Bei 40 von 44 Untersuchungen ergab sich der Verdacht auf ein Rezidiv. Bei 4 Patienten wurde das Rezidiv mittels F-18-FDG PET/CT nicht entdeckt, bei 8 Patienten das Ausmaß erheblich unterschätzt. Die diagnostische Genauigkeit für den Nachweis der PK betrug Patienten basiert 91 %, die Sensitivität 91 % und der positive Vorhersagewert 100 %. Der mittlere PCI betrug für PET/CT 11,4 ± 11,9, für CT 8,4 ± 10,3 und intraoperativ 16,6 ± 15. Das Ausmaß der PK wurde mittels PET/CT und noch stärker im CT unterschätzt (p < 0,05).

Schlussfolgerung: Die diagnostische Wertigkeit der F-18-FDG PET/CT nach zytoreduktiver Chirurgie und HIPEC zum Nachweis eines PK-Rezidives ist gegenüber dem Kontrast angehobenen CT überlegen. Jedoch ist die Quantifizierung der Tumorausdehnung aufgrund posttherapeutischer Veränderungen begrenzt.

Kernaussagen:

• Posttherapeutische Veränderungen nach HIPEC stellen eine Herausforderung für die Bildgebung von PK-Rezidiven nach HIPEC dar.

• Das Ausmaß von PK-Rezidiven nach HIPEC wird mittels F-18-FDG PET/CT systematisch unterschätzt.

• Im Vergleich zur Kontrast angehobenen CT weist die F-18-FDG PET/CT eine verbesserte Sensitivität für Rezidivmanifestationen einer PK auf.

• Die Übereinstimmung hinsichtlich der Tumorausdehnung zwischen F-18-FDG PET/CT und chirurgischer Exploration ist besser als die zwischen Kontrast angehobener CT und chirurgischer Exploration.

Key words

PET/CT - peritoneal carcinomatosis - relapse - HIPEC - cytoreductive surgery

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