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COLORECTAL LIVER METASTASES: To resect the unresectable : which imaging after treatment ?

Raffaella Basilico. COLORECTAL LIVER METASTASES: To resect the unresectable : which imaging after treatment ?. Chieti, 19 Ottobre 2017. Dipartimento di Neuroscienze e Imaging Sezione di Imaging Integrato e Terapie Radiologiche CHIETI. BEFORE AND AFTER TREATMENT.

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COLORECTAL LIVER METASTASES: To resect the unresectable : which imaging after treatment ?

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  1. Raffaella Basilico COLORECTAL LIVER METASTASES: To resect the unresectable: whichimagingafter treatment ? Chieti, 19 Ottobre 2017 Dipartimento di Neuroscienze e Imaging Sezione di Imaging Integrato e Terapie Radiologiche CHIETI

  2. BEFORE AND AFTER TREATMENT PREOPERATIVE IMAGING Distribution (UnilobarBilobar) Volumetricassessment Number Vesselsrelationship Future liverremnant

  3. Preoperativeimaging BEFORE TREATMENT 1990-2010

  4. Preoperativeimaging BEFORE TREATMENT Sensitivity Lesion per lesion basis >10 mm Patient per patient basis CT 81,2% MR 93,4% FDG-PET 94 % CT 74,4% MR 80,3% FDG-PET 81,4% < 10 mm MR > CT (p=.006)

  5. Preoperativeimaging BEFORE TREATMENT First line modality MR FDG-PET Second line modality FDG-PET/CT * extrahepatic disease FDG-PET/CT Small number of studies *Georgakopoulos A et al Clin Imaging Oct 2012

  6. Preoperativeimaging BEFORE TREATMENT HOW TO PERFORM MRI ? 2000-2015 DWI-MRI It is an unenhanced MRI method of supplying information of molecular diffusion of water in biologic tissues

  7. Preoperativeimaging BEFORE TREATMENT DWI-MRI alone DWI -MRI+ CE- MRI Sensitivity 87,1% 95,5%

  8. Preoperativeimaging WHAT HAPPENS AFTER TREATMENT? Colorectal liver metastases - Radiofrequency ablation Neoadjuvant Chemotherapy - Radiotherapy - y 90 Radioembolization Immunotherapy - Chemoembolization

  9. Colorectalmetastases NEOADJUVANT CHEMOTHERAPY Imaging modalities limitations Chemotherapy-associated hepatic parenchymal injury Steatosis Steatohepatitis Sinusoidal dilatation Imaging sensitivity and specificity • Hôpital Beaujon - Paris Focal fatty sparing or liver metastasis?

  10. Colorectalmetastases POST NEOADJUVANT CHEMOTHERAPY SENSITIVITY FDG-PET/CT < MDCT* Immediate resection 33 lesions Neoadjuvant chemotherapy 122 lesions FDG-PET/CT 93,3% MDCT 87,5% FDG-PET/CT 49% MDCT 65,3% *Lubezky N et al J Gastroint Surg 2007; 11: 472

  11. Colorectalmetastases POST NEOADJUVANT CHEMOTHERAPY SENSITIVITY FDG-PET/CT < MDCT* Bevacizumab - Bevacizumab + FDG-PET/CT 59% MDCT 67% FDG-PET/CT 39% MDCT 63% *Lubezky N et al J Gastroint Surg 2007; 11: 472

  12. POST NEOADJUVANT CHEMOTHERAPY Colorectalmetastases FDG-PET/CT < MDCT WHY ? - Size of the lesion decrease in size of the lesion following CHT - Reductionof FDG uptakealteredtumorglucose metabolisminducedbychemotherapy - Heterogeneous FDG uptake - Lesionuptakeonlyslightlygreaterthanrelatively high FDG uptake in normalliver centralnecrosis (Bevacizumab!)

  13. Colorectalmetastases POST NEOADJUVANT CHEMOTHERAPY Normalization of FDG uptake not usually related to complete pathologic response Tan M. et al J Gastroint Surgery 2007; 11. 1112

  14. Colorectalmetastases POST NEOADJUVANT CHEMOTHERAPY FDG-PET/CT 34 lesions = complete metabolic response 5 lesions 29 lesions complete tumor destruction at pathology viable tumor at pathology Contrast–enhanced FDG PET/CT ? Eur J Radiol Feb 2013

  15. Colorectalmetastases POST NEOADJUVANT CHEMOTHERAPY SENSITIVITY MDCT* Neoadjuvant chemotherapy 60 pts NO neoadjuvant chemotherapy 32 pts Lesion per lesion basis 71% 76% Patient per patient basis 54% 69% *Angiviel B et al Ann Surg Oncol 2009; 16 (5): 1247

  16. Colorectalmetastases POST NEOADJUVANT CHEMOTHERAPY MDCT MORFOLOGIC ASSESSMENT vs RECIST CRITERIA* (Bevacizumab) RECIST-stable disease and morphological optimal response * Chun S et al Jama 2009; 302 (21): 2338

  17. Colorectalmetastases POST NEOADJUVANT CHEMOTHERAPY MDCT MORFOLOGIC ASSESSMENT vs RECIST CRITERIA* (Bevacizumab) RECIST-stable disease and morphological incomplete response * Chun S et al Jama 2009; 302 (21): 2338

  18. Colorectalmetastases POST NEOADJUVANT CHEMOTHERAPY MDCT Steatosis: a big issue • 63 year old male • 2009 colon carcinoma diagnosis • Subtotal colectomy • T3 Mo Nx G2 Adjuvant chemotherapy • Sept 2012 CT liver metastases segment III and IV • 3 cycles chemotherapy • Jan 2013 CT preoperative staging

  19. Colorectalmetastases POST NEOADJUVANT CHEMOTHERAPY MDCT Steatosis: a big issue PRE POST

  20. Colorectalmetastases POST NEOADJUVANT CHEMOTHERAPY Histopathology III 9 mm metastasis from colon carcinoma G2 III IV IV 1.1 cm fibronecrotic nodule from previous colorectal metastasis

  21. Colorectalmetastases POST NEOADJUVANT CHEMOTHERAPY 3.0 T MRI vs 64 row MDCT ( IOUS and histopathology as standard of reference) 3.0 T MRI 64 row MDCT 66/68 lesions 97% 49/68 lesions 72% p < 0.001 Lesions < 1 cm 29/31 lesions 93% 13/31 lesions 42% p < 0.001 *Berger-Kulemann et al Eur J Surg Oncol 2012; 38(8): 670 ** Macera A et al Eur Radiol 2013; 23: 739 (DWI+Gd-EOB-DTPA MRI)

  22. Preoperativeimaging POST NEOADJUVANT CHEMOTHERAPY MR > CT

  23. Preoperativeimaging POST NEOADJUVANT CHEMOTHERAPY MR > CT

  24. Livermetastases WHAT ABOUT US ? DETECTION US Sensitivity 57%-82% < 1 cm 20% Kinkel K Radiology 2002; 224:748 CEUS Sensitivity 80-98% Specificity 66-98% e 100% > 2 cm Quaia E Eur Radiology 2006; 16:1599

  25. CEUS Baseline Livermetastases WHAT ABOUT US ? CEUS foralloncologicpatientsduringfollow up? …”CEUS seems to be promising in the detection of liver metastases; however, there have not been enough studies to conduct meta-analysis. Further studies are required before this promising method can be widely used”.

  26. Contrast Tissue Discriminator CTD Hepatic metastasis of GIST Before Tt After 2 weeks • Before treatment : 90% of contraste uptake • After 14 days : total necrosis of lesions Courtesy of Dr. N. Lassau

  27. RESULTS Basilico R et al RSNA 2008 Lesionenhancement pattern Diffuse enh. Rim enh. Neoplasm CEUS MDCT MDCT CEUS 10 20 40 6 GI 6 Breast 34 5 23 Lung 6 4 5 4 Pancreas 4 2 3 2 Carcinoid 0 0 3 3 Melanoma, kidney, lymphoma 4 3 0 1 Prostate, bladder, ovary, uterus, sclerosing fibros. 1 6 4 3

  28. RESULTS Arterialphase Timing issues Basilico R et al RSNA 2008

  29. Colorectalmetastases CEUS FOLFOX + BEVACIZUMAB PRE 15 days POST

  30. Colorectalmetastases CEUS Early response to treatment • Perfusion parameters of 3D-CEUS (PE and AUC) significantly decreased respectively by up to 69% and 77% in responsive tumors within 1 day after antiangiogenetic treatment BUT Not in non responsive tumors

  31. Colorectalmetastases CEUS Before neoadjuvant chemotherapy

  32. Colorectalmetastases CEUS 2 months post FOLFOX + BEVACIZUMAB Fibroticnodule

  33. SERIAL IMAGING POST NEOADJUVANT CHEMOTHERAPY To avoid a complete radiological response when possible GOAL = resectability rather than waiting for maximum response IMAGING Disappearing of liver colo-rectal metastases at cross-sectional imaging COMPLETE RESPONSE ? Low rate of true complete response + high rate of intrahepatic recurrences in surgically untreated patients * complete surgical treatment of all original sites *Van Vledder M et al J Gastroint Surg 2010; 14: 1691

  34. POST NEOADJUVANT CHEMOTHERAPY CT vs EOB MRI Disappearing colorectal liver metastases after chemotherapy

  35. POST NEOADJUVANT CHEMOTHERAPY EOB MRI > CT Prediction of pathologic absence of tumor and lack of lesion recurrence in disappearing CRM after chemotherapy

  36. POST IMMUNOTHERAPY Initial delay in response to treatment Slow decrease in tumor size Enlarging tumors immediately after treatment Appearance of new lesion Follow up imaging studies should be performed at least 4 weeks after completion of treatment Kwak J et al Radiographics 2015: 35:424

  37. Preoperativeimaging AFTER TREATMENT First line modality MRI US contrast agents Perfusion CT/MRI Diffusion MRI Early evaluation of treatment response

  38. Preoperativeimaging LIVER METASTASES Before and After treatment MULTIDISCIPLINARY TEAM Pathology Oncology Imaging Surgery

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