Behandeling van colorectale levermetastasen. Rol van beeldvorming van de lever bij colorectaal carcinoom

Transcription

1 Behandeling van colorectale levermetastasen Rol van beeldvorming van de lever bij colorectaal carcinoom B. Op de Beeck Universitair Ziekenhuis Antwerpen AZ Turnhout campus Sint-Jozef

2 Introduction The liver is a common site of metastatic disease in many tumours 30 years ago, metastases were regarded as incurable Significant progress in medical and surgical oncology long-term survival is often achievable Much of this progress field of colorectal cancer

3 Introduction COLORECTAL CANCER About 65% of patients with CRC develop distant metastases Liver is the commonest site (40%) Resection of liver metastases is the optimal strategy Surgical series report 5-year survival rates of up to % variable (mean 40%) 10-year survival rates: from 22 28% more consistently Jemal A, Siegel R, Ward. Cancer Statistics Cancer J Clin 200;57: Donadon M, et al. Gastrointest Cancer Res 2007; 1:20-27.

4 Role of imaging Detection (number, size, location) Differential diagnosis (benign lesions) Select potentially resectable lesions Determine the response to treatment

5 US vs MDCT vs MRI vs PET Detection and characterization of liver lesions - one of the most common issues detection: US abdomen: unsuspected lesion no chronic liver disease no history of malignancy confident diagnosis if - cyst (anechoic) - hemangioma (with typical hyperechoic appearance) lesions with non-specific US features or in oncologic settings further investigation: MDCT or MRI

6 Matig gedif sigmoid adenoca KRAS/NRAS: WT pt4bn1am CASUS start chemo mfolfox-6/5-fu/ Oxaliplatine + Bevacizumab tumorprogressie

7 start chemo FOLFIRI (Irinotecan, Folinezuur, 5-FU +/- Rumicurimab)

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10 US vs MDCT vs MRI vs PET Detection and characterization of liver lesions - one of the most common issues detection: US abdomen: unsuspected lesion no chronic liver disease no history of malignancy confident diagnosis if - cyst (anechoic) - hemangioma (with typical hyperechoic appearance) lesions with non-specific US features or in oncologic settings further investigation: MDCT or MRI

11 MDCT vs MRI Characterization of incidental liver lesions - MDCT: limitations for small incidental lesions - MRI: primary diagnostic technique - MDCT: lesion density and contrast behaviour - MRI: lesion SI T1 and T2, DWI, CE dynamic studies, hepatobiliary agents

12 Case 1 & 2 Two patients with colorectal carcinoma Both have a lesion in segment IV

13 CT Patient 1 Patient 2

14 T2 WI T1 WI DWI

15 T1 WI + C (ART) T1 WI + C (PORT)

16 T1 WI + C (ART) Metastasis T1 WI + C (PORT)

17 T2 WI T2 WI T1 WI DWI

18 T2 WI T2 WI T1 WI T1 WI DWI

19 T2 WI T2 WI T1 WI T1 WI DWI DWI

20 T1 WI + C (ART) Metastasis T1 WI + C (ART) T1 WI + C (PORT) T1 WI + C (PORT)

21 T1 WI + C (ART) Metastasis T1 WI + C (ART) T1 WI + C (PORT) T1 WI + C (PORT)

22 T1 WI + C (ART) Metastasis T1 WI + C (ART) Pseudolesion? T1 WI + C (PORT) T1 WI + C (PORT)

23 Pseudolesion GRE T1 IN phase GRE T1 OPP phase

24 Pseudolesion GRE T1 IN phase GRE T1 OPP phase Steatosis

25 Pseudolesion GRE T1 IN phase GRE T1 OPP phase CT post-op Steatosis

26 Colorectal cancer Case

27 Metastases post-chemotherapy Imaging appearance histopathologic features Reduced cellularity More central necrosis Residual mucin and fibrosis Conventionally assessed by anatomic imaging changes in SIZE ( RECIST) Last years paradigm shift (morphological changes) Therapy (both systemic and local) produces qualitative changes in the imaging appearance in addition to these quantitative effects (change in size)

28 Metastases post-chemotherapy MDCT morphologic changes of CRM after chemo Pre Post heterogeneous homogeneous attentuation variable degree of enhancement hypoattenuating lesions ill-defined well-defined borders

29 PD RECIST1.1

30 Follow-up CRC metastasis MRI Diagnosis After chemotherapy morphology DWI perfusion

31 Detection of metastases post-chemotherapy Detection Imaging is less accurate after treatment MDCT sensitivity 65-70% after 80% before FDG-PET 49-62% after 90% before MRI no data concerning accuracy before and after treatment MRI >>>> CT > FDG PET * Carnaghi C et al. Nuc Med Rev 2007 Utility of 18-FDG PET and contrast-enhanced CT scan in the assessment of residual liver metastasis from colorectal cancer following adjuvant chemotherapy. Angliviel B et al. Ann Surg Oncol 2009 Impact of chemotherapy on the accuracy of computed tomography scan for the evaluation of colorectal liver metastases. * Van Kessel CS et al. Preoperatieve Imaging of Colorectal Liver Metastases After Neoadjuvant Chemotherapy: A Meta-Analysis. Ann Surg Oncol 2012

32 BG 05/10/1947 MRI Metastases colorectal cancer treated with Avastin Folfiri

33 MRI MRI

34 FDG PET Normal COMPLETE RESPONSE ON IMAGING COMPLETE RESPONSE ON HISTOPATHOLOGY

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36 FDG PET recurrence Recurrence in previous lesion sites!

37 FDG PET MRI DWI Recurrence in previous lesion sites!

38 Disappearing lesions Majority of lesions that disappeared on imaging still contained viable tumor after surgery Cancer persists in more than 80% of cases at the initial site Impossible to predict lesion viability of very small lesions or lesions that become invisible Importancy Surgery Recurrence look at previous lesion sites Benoist S et al. J Clin Oncol 2006 Complete response of colorectal liver metastases after chemotherapy: doest it mean cure? Tan MC et al. J Gastrointest Surg 2007 Chemotherapy-induced normalization of FDG uptake by colorectal liver metastases does not usually indicate complete pathologic response.

39 CRC pre pre pre post post post

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41 Liver metastases rectal adenocarcinoma

42 Liver metastases rectal adenocarcinoma: role of DWI

43 To remember Follow-up and treatment of tumours require a multidisciplinary approach Important role for MRI with DWI and Gd Early recognition of tumor recurrence is crucial Familiarity with response evaluation criteria (and its limits) is essential and becoming more important in day-to-day cancer imaging Size still matters, but functional and molecular imaging is becoming more and more important

44 Post chemotherapy liver Modern systemic agents have improved survival and resectability rates in CRC potential liver injury Chemotherapy-induced liver injury Steatosis CASH SOS sinusoidal obstruction syndrome Pseudocirrhosis, fibrosis Peliosis hepatis, sclerosing cholangitis Varies between individual patients Could increase the risks of surgery and even preclude liver resection

45 Post chemotherapy liver Steatosis CASH Reversible steatosis is common (in up to 30%) Chemotherapy associated steatohepatitis» Severe steatosis» Lobular inflammation» Ballooned hepatocytes 5-FU (Folfiri and Folfox) Steatosis Irinotecan Steatosis and steatohepatitis Can progress to fibrosis, cirrhosis and liver failure Appears to impair the functional reserve and regenerative capacity of the liver Report to the surgeon and be aware of pseudolesions Zorzi D et al. Chemotherapy-associated hepatotoxicity and surgery for colorectal liver metastases. British Journal of Surgery 2007;94: Kooby DA, Fong Y, Suriawinata A et al. Impact of steatotis on perioperative outcome following hepatic resection. J Gastrointest Surg 2003;7: Bilchik AJ et al. Neoadjuvant chemotherapy for metastatic colon cancer: a cautionary note. J Clin Oncol 2005;23:

46 Post chemotherapy liver T1 In phase T1 Opp phase Not every new lesion in an oncologic patient, is a metastatic lesion pseudolesions and steatosis

47 Post chemotherapy liver T2 HASTE T1 FS T1 FS Gd DWI B 1000 T1 In phase T1 Opp phase Not every new lesion in an oncologic patient, is a metastatic lesion pseudolesions and steatosis

48 Post chemotherapy liver SOS - Sinusoidal obstruction syndrome Oxaliplatin (Folfox) VOD-like, hepatomegaly, ascites, jaundice Sinusoids become clogged with débris from endothelial cell necrosis perisinusoidal fibrosis fibrotic venular occlusion sinusoidal obstruction syndrome Imaging: hepatomegaly patchy liver enhancement after IV contrast absence of hepatic vein thrombosis and congestive heart failure Rubbia-Brandt L et al. Severe hepatic sinusoidal obstruction associated with oxaliplatinbased chemotherapy in patients with metastatic colorectal cancer. Ann Oncol 2004;15:460-6.

49 Post chemotherapy liver Pseudocirrhosis Resembles macronodular cirrhosis Chemotherapy treatment areas of retracted tumor tissue and scarring Seen in metastatic breast cancer to liver Gupa AA, Kim DC, Krinsky GA, Lee VS. CT and MRI of cirrhosis and its mimics. AJR 2004;183(6):

50 Colorectal cancer with metastases at the right liver and metastasis within segment III inoperable! Multi-slice CT

51 DW MRI Metastases right lobe of the liver MRI: no tumor within segment III Surgery!

52 55-y-old male Extended right hepatectomy? Tot. liver vol.: 1744 cc Tot. tumour vol.: 309 cc Volume segment II + III: 540 cc (=37%)

53 embolization right portal vein

54 55-y-old male Extended right hepatectomy? Tot. liver vol.: cc Tot. tumour: cc Volume segment II + III: 540 cc (=37%) 732 cc (=48%)

55 RFA

56 Take Home Points MDCT is the imaging modality for staging oncologic patients and includes chest plus abdominal CT But MR is better for detecting small liver metastases MR has a crucial role in characterizing liver tumors in oncologic patients DWI shoud be included in the liver imaging protocol Dynamic contrast-enhanced MRI > unenhanced MRI Gd chelates - easy to use, less sequence dependent

57 Thank you