Evaluation of patients with liver metastases from colorectal cancer for locally ablative treatment with laser induced thermotherapy

Summary

Purpose: Before locally ablative treatment of colorectal liver metastases, patients have to be carefully evaluated to decide whether this is the adequate therapy. In this study we determined the value of FDG-PET in comparison to conventional staging procedures. Patients, methods: In 68 consecutive patients referred for laser induced thermotherapy (LITT) of liver metastases from colorectal cancer, pretherapeutic staging with conventional imaging (thoracic and abdominal CT, liver MRI, chest X-ray) and FDG-PET was performed. The examinations were analysed separately and blinded. Based on the staging information, therapeutic decisions were made by an interdisciplinary review board according to a standardized algorithm. The results were compared between conventional imaging and FDG-PET, and were validated by clinical follow up data and histopathology, respectively. Results: On FDG-PET 210 lesions were interpreted as tumour manifestations. 48 of these were not seen on conventional imaging (true positive, n=46). In contrast, 24 lesions were visualized by conventional imaging only (true positive, n=12). Compared to conventional imaging, discrepant findings on FDG-PET led to treatment modifications in 25 patients (37%); these were correct in 20/25 patients. According to the actual treatment course, the inadequate treatment modifications in the remaining 5 patients were avoided by further diagnostic procedures (i.e. biopsies). Conclusion: In the evaluation of patients with known liver metastases from colorectal cancer before LITT, FDG-PET depicts relevant findings subsidiary to conventional imaging and thus is of high value for therapeutic decision making.

Zusammenfassung

Ziel: Vor lokalablativer Therapie kolorektaler Lebermetastasen müssen die Patienten sorgfältig evaluiert werden, um adäquate Therapieentscheidung treffen zu können. Die Wertigkeit der FDG-PET sollte bestimmt und mit dem konventionellen Staging verglichen werden. Patienten, Methoden: Bei 68 konsekutiven Patienten, die sich zur Laserinduzierten Thermotherapie (LITT) von kolorektalen Lebermetastasen vorstellten, erfolgte ein präinterventionelles Staging mit konventioneller Bildgebung (Thorax/Abdomen- CT, Leber-MRT und Röntgen-Thorax) und einer FDGPET. Das Bildmaterial wurde separat verblindet analysiert. Mit den Ergebnissen des Stagings wurden Therapieentscheidungen in einer interdisziplinären Expertenrunde, anhand eines standardisierten Algorithmus getroffen. Die Resultate der konventionellen Bildgebung und der FDG-PET wurden verglichen und mit dem klinischen Verlauf sowie den histopathologischen Ergebnissen validiert. Ergebnisse: Die FDG-PET detektierte 210 tumorsuspekte Läsionen; davon waren 48 mit der konventionellen Bildgebung nicht erfasst worden (richtig positiv: 46/48). Demgegenüber waren 24 Läsionen nur mit der konventionellen Bildgebung erfasst worden (richtig positiv: 12/24). Im Vergleich zur konventionellen Bildgebung führten diskrepante Befunde in der FDG-PET bei 25 Patienten (37%) zu Therapieänderungen, die in 20/25 Fällen korrekt waren. In den übrigen 5 Fällen zeigte der klinische Verlauf, dass eine inadäquate Therapieänderung durch nachgeschaltete Biopsien vermieden werden konnte. Schlussfolgerung: Bei der Evaluation von Patienten mit Lebermetastasen kolorektaler Karzinome vor LITT erfasst die FDG-PET, ergänzend zur konventionellen Bildgebung, relevante Befunde und ist damit für die Therapieentscheidung von hohem Wert.

Keywords

Colorectal cancer - laser induced thermotherapy - liver metastases - positron emission tomography

Schlüsselwörter

Kolorektales Karzinom - Laser-induzierte Thermotherapie - Lebermetastasen - FDG-PET

^* Holger Amthauer and Timm Denecke contributed equally to this work.

• References

• 1 Adam R, Avisar E, Ariche A. et al. Five-year survival following hepatic resection after neoadjuvant therapy for nonresectable colorectal. Ann Surg Oncol 2001; 8: 347-53.
• 2 Akhurst T, Kates TJ, Mazumdar M. et al. Recent chemotherapy reduces the sensitivity of ¹⁸Fluorodeoxyglucose positron emission tomography in the detection of colorectal metastases. J Clin Oncol 2005; 23: 8713-6.
• 3 Arulampalam TH, Francis DL, Visvikis D. et al. FDG-PET for the pre-operative evaluation of colorectal liver metastases. Eur J Surg Oncol 2004; 30: 286-91.
• 4 Berber E, Pelley R, Siperstein AE. Predictors of survival after radiofrequency thermal ablation of colorectal cancer metastases to the liver: a prospective study. J Clin Oncol 2005; 23: 1358-64.
• 5 Bipat S, Leeuwen MS, Comans EF. et al. Colorectal liver metastases: CT, MR imaging, and PET for diagnosis-meta-analysis. Radiology 2005; 237: 123-31.
• 6 Delbeke D, Vitola JV, Sandler MP. et al. Staging recurrent metastatic colorectal carcinoma with PET. J Nucl Med 1997; 38: 1196-201.
• 7 Denecke T, Rau B, Hoffmann KT. et al. Comparison of CT, MRI and FDG-PET in response prediction of patients with locally advanced rectal cancer after multimodal preoperative therapy: Is there a benefit in using functional imaging?. Eur Radiol 2005; 15: 1658-66.
• 8 Fernandez FG, Drebin JA, Linehan DC. et al. Fiveyear survival after resection of hepatic metastases from colorectal cancer in patients screened by positron emission tomography with F-18 fluorodeoxyglucose (FDG-PET). Ann Surg 2004; 240: 438-47.
• 9 Flamen P, Stroobants S, van Cutsem E. et al. Additional value of whole-body positron emission tomography with fluorine-18-2-fluoro-2-deoxy- D-glucose in recurrent colorectal cancer. J Clin Oncol 1999; 17: 894-901.
• 10 Fong Y, Cohen AM, Fortner JG. et al. Liver resection for colorectal metastases. J Clin Oncol 1997; 15: 938-46.
• 11 Franke J, Rosenzweig S, Reinartz P. et al. Value of positron emission tomography (¹⁸F-FDG-PET) in the diagnosis of recurrent rectal cancer. Chirurg 2000; 71: 80-5.
• 12 Harris M. Monoclonal antibodies as therapeutic agents for cancer. Lancet Oncol 2004; 5: 292-302.
• 13 Holen KD, Saltz LB. New therapies, new directions: advances in the systemic treatment of metastatic colorectal cancer. Lancet Oncol 2001; 2: 290-7.
• 14 Hosten N, Kreissig R, Puls R. et al. Fusion of CT and PET data: methods and clinical relevance for planning laser-induced thermotherapy of liver metastases. Röfo 2000; 172: 630-5.
• 15 Huebner RH, Park KC, Shepherd JE. et al. A metaanalysis of the literature for whole-body FDG PET detection of recurrent colorectal cancer. J Nucl Med 2000; 41: 1177-89.
• 16 Hughes KS, Rosenstein RB, Songhorabodi S. et al. Resection of the liver for colorectal carcinoma metastases. A multi-institutional study of longterm survivors. Dis Colon Rectum 1988; 31: 1-4.
• 17 Kantorova I, Lipska L, Belohlavek O. et al. Routine ¹⁸F-FDG PET preoperative staging of colorectal cancer: comparison with conventional staging and its impact on treatment decision making. J Nucl Med 2003; 44: 1784-8.
• 18 Kinkel K, Lu Y, Both M. et al. Detection of hepatic metastases from cancers of the gastrointestinal tract by using noninvasive imaging methods (US, CT, MR imaging, PET): a meta-analysis. Radiology 2002; 224: 748-56.
• 19 Liu FY, Chen JS, Changchien CR. et al. Utility of 2-fluoro-2-deoxy-D-glucose positron emission tomography in managing patients of colorectal cancer with unexplained carcinoembryonic antigen elevation at different levels. Dis Colon Rectum 2005; 48: 1900-12.
• 20 Navarra G, Ayav A, Weber JC. et al. Short- andlong term results of intraoperative radiofrequency ablation of liver metastases. Int J Colorectal Dis 2005; 20: 521-8.
• 21 Nordlinger B, Guiguet M, Vaillant JC. et al. Surgical resection of colorectal carcinoma metastases to the liver. A prognostic scoring system to improve case selection, based on 1568 patients. Association Franॢaise de Chirurgie. Cancer 1996; 77: 1254-62.
• 22 Ricke J, Wust P, Wieners G. et al. Liver malignancies: CT-guided interstitial brachytherapy in patients with unfavorable lesions for thermal ablation. J Vasc Interv Radiol 2004; 15: 1279-86.
• 23 Rohren EM, Paulson EK, Hagge R. et al. The role of ¹⁸F-FDG positron emission tomography in preoperative assessment of the liver in patients being considered for curative resection of hepatic metastases from colorectal cancer. Clin Nucl Med 2002; 27: 550-5.
• 24 Rosa F, Meimarakis G, Stahl A. et al. Colorectal cancer patients before resection of hepatic metastases. Impact of ¹⁸F-FDG PET on detecting extrahepatic disease. Nuklearmedizin 2004; 43: 135-40.
• 25 Ruers TJ, Langenhoff BS, Neeleman N. et al. Value of positron emission tomography with [F-18]fluorodeoxyglucose in patients with colorectal liver metastases: a prospective study. J Clin Oncol 2002; 20: 388-95.
• 26 Scheele J, Stang R, Altendorf-Hofmann A. et al. Resection of colorectal liver metastases. World J Surg 1995; 19: 59-71.
• 27 Schiepers C, Penninckx F, De Vadder N. et al. Contribution of PET in the diagnosis of recurrent colorectal cancer: comparison with conventional imaging. Eur J Surg Oncol 1995; 21: 517-22.
• 28 Schlag PM, Amthauer H, Stroszczynski C. et al. Influence of positron emission tomography on surgical therapy planning in recurrent colorectal cancer. Chirurg 2001; 72: 995-1002.
• 29 Staib L, Schirrmeister H, Reske SN. et al. Is ¹⁸F-fluorodeoxyglucose positron emission tomography in recurrent colorectal cancer a contribution to surgical decision making?. Am J Surg 2000; 180: 1-5.
• 30 Truant S, Huglo D, Hebbar M. et al. Prospective evaluation of the impact of ¹⁸F fluoro-2-deoxy- D-glucose positron emission tomography of resectable colorectal liver metastases. Br J Surg 2005; 92: 362-9.
• 31 Valk PE, Abella-Columna E, Haseman MK. et al. Whole-body PET imaging with ¹⁸F-fluorodeoxyglucose in management of recurrent colorectal cancer. Arch Surg 1999; 134: 503-11.
• 32 Vitola JV, Delbeke D, Sandler MP. et al. Positron emission tomography to stage suspected metastatic colorectal carcinoma to the liver. Am J Surg 1996; 171: 21-6.
• 33 Vogl TJ, Straub R, Eichler K. et al. Colorectal carcinoma metastases in liver: laser-induced interstitial thermotherapy--local tumor control rate and survival data. Radiology 2004; 230: 450-8.
• 34 Wallace JR, Christians KK, Quiroz FA. et al. Ablation of liver metastasis: is preoperative imaging sufficiently accurate?. J Gastrointest Surg 2001; 5: 98-107.