Despite considerable advances in preoperative imaging, up to one-third of patients operatively explored for hepatic colorectal
metastases are unexpectedly found to harbor unresectable intrahepatic or extrahepatic disease.
Methods: The current study is a prospective, blinded study comparing utility of [18F]
2-fluoro-2-deoxyglucose positron emission tomography (18F-FDG-PET) to computed tomography (CT) and CT arterial portography (CTAP) as preoperative staging.
Results: The 125 planned subjects were enrolled. Findings seen on FDG-PET alone changed
therapy for 23 of 125 patients (18%). FDG-PET confirmed other radiologic findings in 16 cases (13%), for an overall influence on
therapy in 39 cases (31%). FDG-PET was the most sensitive diagnostic imaging test for extrahepatic
cancer; it was 80-90% sensitive for extrahepatic
cancer and 70-90% specific. For the 28 cases of unresectable disease due to extrahepatic disease, FDG-PET findings solely changed
therapies in 16 cases (57%) and influenced
therapy in seven other cases (25%). Of the 21 unresectable cases due to extent of intrahepatic disease, FDG-PET did not solely change
therapy in any. Overall, FDG-PET had the lowest sensitivity for hepatic sites compared with CT or CTAP. In particular, small (<1 cm) liver
tumors were particularly poorly detected by FDG-PET. The area under the receiver operating characteristic (ROC) curve for small
tumors was 0.58 and for patients on
chemotherapy it was 0.66, a modest improvement over no imaging.
Conclusions: FDG-PET is an important test for preoperative staging of patients with hepatic colorectal
metastases, affecting treatment decisions in nearly one-third of patients. The high yield is due mainly to detection of extrahepatic disease. It is therefore recommended in patients with extrahepatic lesions suspected to be disseminated
cancer or those with high risk for extrahepatic disease. It is not a good test for identification of small
tumors in the liver.