PET-CT versus MRI in the identification of hepatic metastases from colorectal carcinoma: An evidence based review of the current literature.

PET-CT versus MRI in the identification of hepatic metastases from colorectal carcinoma: An evidence based review of the current literature. Poster No.: C-1275 Congress: ECR 2017 Type: Scientific Exhibit Authors: S. Power, M. Staunton ; Cork, Cork/IE, Cork/IE Keywords: Abdomen, Liver, Oncology, MR, PET-CT, PET, Comparative studies, Diagnostic procedure, Outcomes analysis, Metastases, Neoplasia, Outcomes DOI: 10.1594/ecr2017/C-1275 1 2 1 2 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 16

Aims and objectives This poster aims to summarise the latest available literature regarding the identification of hepatic metastases from colorectal carcinoma using PET-CT and MRI. Colorectal carcinoma affects an average of 150000 patients globally each year. The liver is the most common site of metastases in stage IV disease. Between 15-25% of patient diagnosed with colorectal carcinoma will have hepatic metastases at diagnosis - 50-70% will eventually develop hepatic metastases. CT is the primary imaging modality for pre-operative planning, lesion detection and tumour surveillance with reported sensitivities ranging from 60-90%. However, it can miss up to 25% of hepatic metastases. Patients with colorectal liver metastases have a median survival of 8 months. Five year survival rates of 45-60% can be achieved post resection (in appropriately selected patients). Methods and materials This literature review was carried out using a PICO search format: Population: Patients diagnosed with metastatic colorectal cancer Intervention: Magnetic resonance imaging Comparison: Positron emission tomography +/- computed tomography Outcome: Identification of hepatic metastases The literature review was carried out using the Trip database, Pubmed/MEDLINE, SUMSearch 2 and searchingradiolgy.com The following MESH criteria were used on Pubmed Fig. 1 on page 3 : Page 2 of 16

Fig. 1: MESH terms used to guide literature search References: Pubmed These MESH terms returned 197 studies: this was further limited to studies published within the past five years to ensure only current data was assessed and to allow for technical advances in MRI (e.g. novel contrast agents and diffusion weighted imaging) and PET-CT. This returned 68 publications. Three well designed meta-analyses (level 1A evidence) were identified and included as the primary sources for this literature review: 1. Maffione AM, Lopci E, Bluemel C et al. Diagnostic accuracy and impact on 18 2. 3. managment of F-FDG PET and PET/CT in colorectal liver metastasis: a meta-analysis and systematic review. Eur J Nucl Med Mol Imaging (2015); 42: 152-163 Niekel MC, Bipat S, Stoker J. Diagnostic imaging of colorectal liver metastases with CT, MR imaging, FDG PET, and/or FDG PET/CT: A metaanalysis of prospective studies including patients who have not previously undergone treatment. Radiology (2010); 257: 674-684 Floriani I, Torri V, Rulli E et al. Performance of imaging modalities in diagnosis of liver metastases from colorectal cancer: A systematic review and meta-analysis. Journal of Magnetic Resonance Imaging (2010): 31: 19-31 (However, these authors reviewed publications only up to 2008, and given recent advances in MR imaging, it was decided to concentrate this poster on the Niekel and Maffione meta-analyses) A tabulated summary of the available literature is provided in the conclusion of this poster. Images for this section: Fig. 1: MESH terms used to guide literature search Pubmed Page 3 of 16

Results 18 Maffione (2015): Diagnostic accuracy and impact on managment of F-FDG PET and PET/CT in colorectal liver metastasis: a meta-analysis and systematic review. Fig. 2: Maffione et al (2015) References: Eur J Nucl Med Mol Imaging (2015) Page 4 of 16

Fig. 3: European Journal of Nuclear Medicine and Molecular Imaging References: European Journal of Nuclear Medicine and Molecular Imaging Page 5 of 16

This large meta-analysis reviewed all published data up to 2014 (and provides the most up-to-date information). It included retrospective and prospective studies. It included any studies in which PET had been carried out prior to surgery, required at least 18 patients in each study and required sensitivity and specificity calculations. The three aims of the study were to: 1. 2. 3. 18 Obtain diagnostic performance values of F-FDG PET for the detection and staging of liver metastases in patients with colorectal cancer. Compare PET and conventional imaging modalities Evaluate the impact of PET on patient management. 12 studies were identified which compared PET and conventional imaging modalities. 7 of these studies directly compared MRI to PET-CT. Sensitivity on a lesion based analysis was provided in three of these studies. Specificity for lesion based analysis was provided in only one study Fig. 4 on page 11. Fig. 4: Maffione Results - Sensitivity and specificity of MRI and PET-CT in the identification of hepatic metastases from colorectal carcinoma. References: Maffione et al The study demonstrated that PET-CT is extremely accurate for the detection of liver metastases on a per-patient basis. However, performance is less impressive on a perlesion basis and MRI was more sensitive and specific. The information provided by PET changed management in 24% of patients. Niekel MC, Bipat S, Stoker J. Diagnostic imaging of colorectal liver metastases with CT, MR imaging, FDG PET, and/or FDG PET/CT: A meta-analysis of prospective studies including patients who have not previously undergone treatment. Page 6 of 16

Fig. 9: Niekel et al (2010) References: Niekel et al (2010) This meta-analysis reviewed data between 1990-2010 - it only included studies in which the data was collected in a prospective fashion. It included any studies which included greater than 10 patients with histopathologically proven colorectal carcinoma and who had not undergone prior treatment. It compared CT, MRI, PET and PET/CT versus histopathology results. The QUADAS tool (Quality Assessment of Diagnostic Accuracy Studies) was used to extract data on each study. The literature search carried out by these authors initially identified 15960 studies, with 312 potentially relevant - this was refined to 39 studies which fulfilled all of the inclusion criteria. 3391 individual patients were included in the meta-analysis. When all studies were initially combined, the results were equivocal with PET appearing to provide a similar sensitivity to MRI Fig. 5 on page 11 Page 7 of 16

Fig. 5: Combined results References: Niekel et al (2010) However, when a sub-analysis of the studies was provided, including studies which used modern MRI techniques (diffusion weighted imaging and liver specific contrast agents) post 2004, the sensitivity of MRI improved to 84.9% on a per lesion basis Fig. 7 on page 11. The benefits of adding contrast agents to the MRI protocol were also highlighted by this study Fig. 8 on page 11. Fig. 7: Changing sensitivity with improved MRI techniques References: Niekel et al (2010) Fig. 8: Increased sensitivity for metastasis detection post contrast administration References: Niekel et al (2010) Page 8 of 16

Images for this section: Fig. 2: Maffione et al (2015) Eur J Nucl Med Mol Imaging (2015) Page 9 of 16

Fig. 3: European Journal of Nuclear Medicine and Molecular Imaging Page 10 of 16

European Journal of Nuclear Medicine and Molecular Imaging Fig. 4: Maffione Results - Sensitivity and specificity of MRI and PET-CT in the identification of hepatic metastases from colorectal carcinoma. Maffione et al Fig. 5: Combined results Niekel et al (2010) Fig. 7: Changing sensitivity with improved MRI techniques Niekel et al (2010) Page 11 of 16

Fig. 8: Increased sensitivity for metastasis detection post contrast administration Niekel et al (2010) Fig. 9: Niekel et al (2010) Niekel et al (2010) Page 12 of 16

Conclusion MRI is more sensitive than PET-CT on a per-lesion basis in the diagnosis of hepatic metastases from colorectal carcinoma It is significantly more sensitive since 2004 (related to advances in MRI imaging - liver specific contrast agents, advanced sequences, higher field strengths) MRI is also considerably more sensitive in the detection of lesions smaller than 10mm A summary of published results is provided below Fig. 6 on page 13 Fig. 6: Summary of recently published literature including sensitivity values for identification of hepatic metastases References: Radiology, Cork University Hospital, Cork University Hospital - Cork/IE Images for this section: Page 13 of 16

Fig. 6: Summary of recently published literature including sensitivity values for identification of hepatic metastases Radiology, Cork University Hospital, Cork University Hospital - Cork/IE Page 14 of 16

Personal information References 1. Maffione AM, Lopci E, Bluemel C et al. Diagnostic accuracy and impact on managment of 18F-FDG PET and PET/CT in colorectal liver metastasis: a meta-analysis and systematic review. Eur J Nucl Med Mol Imaging (2015); 42: 152-163 2. Niekel MC, Bipat S, Stoker J. Diagnostic imaging of colorectal liver metastases with CT, MR imaging, FDG PET, and/or FDG PET/CT: A meta-analysis of prospective studies including patients who have not previously undergone treatment. Radiology (2010); 257: 674-684 3. Floriani I, Torri V, Rulli E et al. Performance of imaging modalities in diagnosis of liver metastases from colorectal cancer: A systematic review and metaanalysis. Journal of Magnetic Resonance Imaging (2010): 31: 19-31 4. Maegerlein C, Fingerle AA, Souvatzoglou M et al. Detection of liver metastases in patients with adenocarcinomas of the gastrointestinal tract: comparison of (18)F-FDG PET/CT and MR imaging. Adbom Imaging (2015): 40(5): 1213-22 5. Seo HJ, Kim MJ, Lee JD et al. Gadoxetate disodium-enhanced magnetic resonance imaging versus contrastenhanced 18F-fluorodeoxyglucose positron emission tomography/computed tomography for the detection of colorectal liver metastases. Invest Radiol (2011); 46(9): 548-55. 6. Mainenti PP, Mancini M, Mainolfi C et al. Detection of colorectal liver metastases: prospective comparison of contrast enhanced US, multidetector CT, PET/CT and 1.5T MR with extracellular and reticulo-endothelial cell specific contrast agents. Abdom Imaging (2010); 35(5): 511-21 7. Bacigalupo L, Aufort S, Eberlé MC, Assenat E, Ychou M, Gallix B. Assessment of liver metastases from colorectal adenocarcinoma following chemotherapy: SPIO-MRI versus FDG-PET/CT. Radiol Med (2010);115(7):1087-100. 8. Donati OF, Hany TF, Reiner CS et al., Value of retrospective fusion of PET and MR images in detection of hepatic metastases: comparison with 18FFDG PET/CT and Gd-EOB-DTPA enhanced MRI. Journal of Nuclear Medicine (2010); 51(5), 692-699. 9. Coenegrachts K, De Geeter F, ter Beek L et al. Comparison of MRI (including SS SE-EPI and SPIO enhanced MRI) and FDG-PET/CT for the detection of colorectal liver metastases. Eur Radiol (2009);19(2):370-9. 10. Cantwell CP, Setty BN, Holalkere N, Sahani DV, Fischman AJ, Blake MA. Liver lesion detection and characterization in patients with colorectal cancer: a comparison of low radiation dose nonenhanced Page 15 of 16

11. 12. 13. 14. PET/CT, contrast-enhanced PET/CT, and liver MRI. J Comput Assist Tomogr. (2008);32(5):738-44. Rappeport ED, Loft A, Berthelsen AK et al Contrast-enhanced FDG-PET/CT vs SPIO enhanced MRI vs. FDG-PET vs. CT in patients with liver metastases from colorectal cancer: a prospective study with intraoperative confirmation. Acta Radiol (2007);48(4):369-78. Bipat S, Van Leeuwen MS, Comans EF et al. Colorectal liver metastases: CT, MR imaging and PET for diagnosis - meta-analysis. Radiology (2005): 237(1): 123-31 Kinkel K, Lu Y, Both M, Warren RS, Thoeni RF. Detection of hepatic metastases from cancers of the gastrointestinal tract by using non-invasive imaging methods (US, CT, MR imaging, PET): a meta-analysis. Radiology (2002);224:748-756. Schulz A, Viktil E, Godt J et al Diagnostic performance of CT, MRI and PET/ CT in patients with suspected colorectal liver metastases: the superiority of MRI. Acta Radiol (2016): 57(9): 1040-8 Page 16 of 16