THE VALUE OF PET/CT IN DETECTING COLORECTAL CANCER RECURRENCE IN PATIENTS WITH NEGATIVE CT FINDINGS
Abstract
Computed tomography (CT) is widely accepted imaging modality used to detect recurrent colorectal cancer (CRC) in the routine follow up, though further imaging may be required. The objective of this research is to investigate the value of PET/CT in detecting colorectal cancer recurrence despite negative CT findings. A retrospective review of colorectal cancer patients referred for 18F-FDG PET/CT imaging to the University institute of positron emission tomography in Skopje, between July 2018 and January 2020. All of the patients had a stage III disease and were clinically suspicious of recurrence (elevated CEA or presence of symptoms) despite recent negative CT findings. Twenty one patients (10 women and 11 men, mean age 56.95) met the above criteria. In 6 patients (28%) cancer recurrence was detected. Negative PET/CT findings were reported in eleven patients and in only one patient (1/11, 9%) recurrence was detected within one year of PET/CT. Equivocal PET/CT finding were reported in three patients, further work-up proved metastasis. In eight (8/9, 88%) patients with abnormal level of CEA, PET/CT detected or initiated further work-up that led to malignancy detection. Patients with stage III CRC had the most positive PET/CT findings 4/7 (57%) compared to others. PET/CT could detect disease recurrence in patients when clinically suspicion persists in spite of negative CT findings. Elevated CEA and the primary tumor stage were dominant features of the patients with recurrent disease. Negative predictive value of PET/CT is high enough to reassure clinicians and reduce patient anxiety.
Kew words:colorectal cancer, cancer recurrence, PER/CT, CEA, CT
https://doi.org/10.55302/JMS2142057s
References
1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN
estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin.
2018;68(6):394–424.
2. Shallow TA, Wagner FB, Colcher RE. Clinical Evaluation of 750 Patients with Colon Cancer. Ann Surg
[Internet]. 1955 Aug;142(2):164–75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/13239050
3. Gold P, Freedman SO. Demonstration of tumor-specific antigens in human colonic carcinomata by
immunological tolerance and absorption techniques. J Exp Med [Internet]. 1965 Mar 1;121:439–62. Available
from: http://www.ncbi.nlm.nih.gov/pubmed/14270243
4. Minton JP, Hoehn JL, Gerber DM, Horsley JS, Connolly DP, Salwan F, et al. Results of a 400-patient
carcinoembryonic antigen second-look colorectal cancer study. Cancer [Internet]. 1985 Mar 15;55(6):1284–90.
Available from: https://onlinelibrary.wiley.com/doi/10.1002/1097-0142(19850315)55:6%3C1284::AID-CNCR2820550622%3E3.0.CO;2-B
5. Institue for Health and Care Excellence N. NICE guideline [Internet]. 2020. Available from: https://www.nice.org.uk/guidance/ng151/resources/colorectal-cancer-pdf-66141835244485
6. Network NCC. Colon cancer [Internet]. NCCN Guidelines Version 2.2021. 2021. Available from: https://www.nccn.org/professionals/physician_gls/pdf/colon.pdf
7. Argilés G, Tabernero J, Labianca R, Hochhauser D, Salazar R, Iveson T, et al. Localised colon cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol [Internet]. 2020 Oct;31(10):1291–305. Available from: https://doi.org/10.1016/j.annonc.2020.06.022
8. Selzner M, Hany TF, Wildbrett P, McCormack L, Kadry Z, Clavien P-A. Does the Novel PET/CT Imaging Modality Impact on the Treatment of Patients With Metastatic Colorectal Cancer of the Liver? Ann Surg [Internet]. 2004 Dec;240(6):1027–36. Available from: https://journals.lww.com/00000658-200412000-00012
9. Chan VO, Das JP, Gerstenmaier JF, Geoghegan J, Gibney RG, Collins CD, et al. Diagnostic performance of MDCT, PET/CT and gadoxetic acid (Primovist®)-enhanced MRI in patients with colorectal liver metastases being considered for hepatic resection: initial experience in a single centre. Ir J Med Sci [Internet]. 2012 Dec 17;181(4):499–509. Available from: http://link.springer.com/10.1007/s11845-012-0805-x
10. Sobhani I, Itti E, Luciani A, Baumgaertner I, Layese R, André T, et al. Colorectal cancer (CRC) monitoring by 6-monthly 18FDG-PET/CT: An open-label multicentre randomised trial. Ann Oncol. 2018;29(4):931–7.
11. Deleau C, Buecher B, Rousseau C, Kraeber-Bodéré F, Flamant M, des Varannes SB, et al. Clinical impact of fluorodeoxyglucose-positron emission tomography scan/computed tomography in comparison with computed tomography on the detection of colorectal cancer recurrence. Eur J Gastroenterol Hepatol [Internet]. 2011 Mar;23(3):275–81. Available from: https://journals.lww.com/00042737-201103000-00013
12. Caglar M, Yener C, Karabulut E. Value of CT, FDG PET-CT and serum tumor markers in staging recurrent colorectal cancer. Int J Comput Assist Radiol Surg [Internet]. 2015 Jul;10(7):993–1002. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25213271
13. Fehr M, Müller J, Knitel M, Fornaro J, Horber D, Koeberle D, et al. Early Postoperative FDG-PET-CT Imaging Results in a Relevant Upstaging in the pN2 Subgroup of Stage III Colorectal Cancer Patients. Clin Colorectal Cancer [Internet]. 2017;16(4):343–8. Available from: http://dx.doi.org/10.1016/j.clcc.2017.03.007
14. Metser U, You J, McSweeney S, Freeman M, Hendler A. Assessment of Tumor Recurrence in Patients With Colorectal Cancer and Elevated Carcinoembryonic Antigen Level: FDG PET/CT Versus Contrast-Enhanced 64-MDCT of the Chest and Abdomen. Am J Roentgenol [Internet]. 2010 Mar;194(3):766–71. Available from: http://www.ajronline.org/doi/10.2214/AJR.09.3205
15. Mittal BR, Senthil R, Kashyap R, Bhattacharya A, Singh B, Kapoor R, et al. 18F-FDG PET-CT in evaluation of postoperative colorectal cancer patients with rising CEA level. Nucl Med Commun [Internet]. 2011 Sep;32(9):789–93. Available from: https://journals.lww.com/00006231-201109000-00004
16. Lee JH, Park SG, Jee KN, Park DG, Namgung H, Song IH. Performance of FDG PET/CT in postoperative colorectal cancer patients with a suspected recurrence and a normal CEA level. Nucl Med Commun [Internet]. 2010 Jun;31(6):576–82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20216474
17. Chen L-B. 18 F-DG PET/CT in detection of recurrence and metastasis of colorectal cancer. World J Gastroenterol [Internet]. 2007 Oct 7;13(37):5025. Available from: http://www.embase.com/search/results?subaction=viewrecord&from=export&id=L47496838
18. Fraum TJ, Fowler KJ, McConathy J, Dehdashti F. Indeterminate Findings on Oncologic PET/CT: What Difference Does PET/MRI Make? Nucl Med Mol Imaging (2010) [Internet]. 2016;50(4):292–9. Available from: http://dx.doi.org/10.1007/s13139-016-0405-1
19. Kudura K, Dimitriou F, Mihic-Probst D, Muehlematter UJ, Kutzker T, Basler L, et al. Malignancy Rate of Indeterminate Findings on FDG-PET/CT in Cutaneous Melanoma Patients. Diagnostics [Internet]. 2021 May 15;11(5):883. Available from: https://www.mdpi.com/2075-4418/11/5/883
20. Vallam KC, Guruchannabasavaiah B, Agrawal A, Rangarajan V, Ostwal V, Engineer R, et al. Carcinoembryonic antigen directed PET−CECT scanning for postoperative surveillance of colorectal cancer. Color Dis [Internet]. 2017 Oct;19(10):907–11. Available from: http://doi.wiley.com/10.1111/codi.13695
21. Ince S, Okuyucu K, Hancerliogulları O, Alagoz E, San H, Arslan N. Clinical significance of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography in the follow-up of colorectal cancer: searching off approaches increasing specificity for detection of recurrence. Radiol Oncol [Internet]. 2017 Nov 1;51(4):378–85. Available from: https://www.degruyter.com/doi/10.1515/raon-2017-0045
22. Ozkan E, Soydal C, Araz M, Kir KM, Ibis E. The role of 18F-FDG PET/CT in detecting colorectal cancer recurrence in patients with elevated CEA levels. Nucl Med Commun [Internet]. 2012 Apr;33(4):395–402. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22367859
23. Makis W, Kurzencwyg D, Hickeson M. 18F-FDG PET/CT superior to serum CEA in detection of colorectal cancer and its recurrence. Clin Imaging [Internet]. 2013;37(6):1094–7. Available from: http://dx.doi.org/10.1016/j.clinimag.2013.04.004
24. Yu X, Zhu L, Dai D, Song X, Chen W, Zhu Y, et al. Application and Indication of Carcinoembryonic Antigen Triggered 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Scanning in the Detection of Relapse of Colorectal Cancer Patients after Curative Therapy. J Comput Assist Tomogr. 2017;41(5):719–25.
25. Kang MK, Hong SP, Lee JE, Jeon TJ, Kim JW, Kwon C Il, et al. The Usefulness of F 18 -FDG PET/CT in Detection of Colonic Neoplasm. Intest Res [Internet]. 2010;8(1):18. Available from: http://irjournal.org/journal/view.php?doi=10.5217/ir.2010.8.1.18
26. Khan K, Athauda A, Aitken K, Cunningham D, Watkins D, Starling N, et al. Survival Outcomes in Asymptomatic
Patients With Normal Conventional Imaging but Raised Carcinoembryonic Antigen Levels in Colorectal Cancer
Following Positron Emission Tomographyâ€Computed Tomography Imaging. Oncologist [Internet]. 2016 Dec
14;21(12):1502–8. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1634/theoncologist.2017-0051
27. McCall JL, Black RB, Rich CA, Harvey JR, Baker RA, Watts JM, et al. The value of serum carcinoembryonic antigen in predicting recurrent disease following curative resection of colorectal cancer. Dis Colon Rectum [Internet]. 1994 Sep;37(9):875–81. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8076486
28. Amin A, Reddy A, Wilson R, Jha M, Miranda S, Amin J. Unnecessary surgery can be avoided by judicious use of PET/CT scanning in colorectal cancer patients. J Gastrointest Cancer [Internet]. 2012 Dec;43(4):594–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22552946
29. Kyoto Y, Momose M, Kondo C, Itabashi M, Kameoka S, Kusakabe K. Ability of 18F-FDG PET/CT to diagnose
recurrent colorectal cancer in patients with elevated CEA concentrations. Ann Nucl Med [Internet]. 2010
Jun;24(5):395–401. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20364373
30. Gade M, Kubik M, Fisker R V., Thorlacius-Ussing O, Petersen LJ. Diagnostic value of 18F-FDG PET/CT as first
choice in the detection of recurrent colorectal cancer due to rising CEA. Cancer Imaging [Internet].
2015;15(1):1–8. Available from: http://dx.doi.org/10.1186/s40644-015-0048-y
31. Duineveld LAM, van Asselt KM, Bemelman WA, Smits AB, Tanis PJ, van Weert HCPM, et al. Symptomatic and
Asymptomatic Colon Cancer Recurrence: A Multicenter Cohort Study. Ann Fam Med [Internet].
2016;14(3):215–20. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27184991
32. Hung H, You J, Chiang J, Hsieh P, Chiang S, Lai C, et al. Why recurrence was initially suspected during
colorectal cancer postoperative surveillance?: A retrospective analysis. Medicine (Baltimore) [Internet]. 2020
Oct 23;99(43):e22803. Available from: http://www.ncbi.nlm.nih.gov/pubmed/33120800
estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin.
2018;68(6):394–424.
2. Shallow TA, Wagner FB, Colcher RE. Clinical Evaluation of 750 Patients with Colon Cancer. Ann Surg
[Internet]. 1955 Aug;142(2):164–75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/13239050
3. Gold P, Freedman SO. Demonstration of tumor-specific antigens in human colonic carcinomata by
immunological tolerance and absorption techniques. J Exp Med [Internet]. 1965 Mar 1;121:439–62. Available
from: http://www.ncbi.nlm.nih.gov/pubmed/14270243
4. Minton JP, Hoehn JL, Gerber DM, Horsley JS, Connolly DP, Salwan F, et al. Results of a 400-patient
carcinoembryonic antigen second-look colorectal cancer study. Cancer [Internet]. 1985 Mar 15;55(6):1284–90.
Available from: https://onlinelibrary.wiley.com/doi/10.1002/1097-0142(19850315)55:6%3C1284::AID-CNCR2820550622%3E3.0.CO;2-B
5. Institue for Health and Care Excellence N. NICE guideline [Internet]. 2020. Available from: https://www.nice.org.uk/guidance/ng151/resources/colorectal-cancer-pdf-66141835244485
6. Network NCC. Colon cancer [Internet]. NCCN Guidelines Version 2.2021. 2021. Available from: https://www.nccn.org/professionals/physician_gls/pdf/colon.pdf
7. Argilés G, Tabernero J, Labianca R, Hochhauser D, Salazar R, Iveson T, et al. Localised colon cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol [Internet]. 2020 Oct;31(10):1291–305. Available from: https://doi.org/10.1016/j.annonc.2020.06.022
8. Selzner M, Hany TF, Wildbrett P, McCormack L, Kadry Z, Clavien P-A. Does the Novel PET/CT Imaging Modality Impact on the Treatment of Patients With Metastatic Colorectal Cancer of the Liver? Ann Surg [Internet]. 2004 Dec;240(6):1027–36. Available from: https://journals.lww.com/00000658-200412000-00012
9. Chan VO, Das JP, Gerstenmaier JF, Geoghegan J, Gibney RG, Collins CD, et al. Diagnostic performance of MDCT, PET/CT and gadoxetic acid (Primovist®)-enhanced MRI in patients with colorectal liver metastases being considered for hepatic resection: initial experience in a single centre. Ir J Med Sci [Internet]. 2012 Dec 17;181(4):499–509. Available from: http://link.springer.com/10.1007/s11845-012-0805-x
10. Sobhani I, Itti E, Luciani A, Baumgaertner I, Layese R, André T, et al. Colorectal cancer (CRC) monitoring by 6-monthly 18FDG-PET/CT: An open-label multicentre randomised trial. Ann Oncol. 2018;29(4):931–7.
11. Deleau C, Buecher B, Rousseau C, Kraeber-Bodéré F, Flamant M, des Varannes SB, et al. Clinical impact of fluorodeoxyglucose-positron emission tomography scan/computed tomography in comparison with computed tomography on the detection of colorectal cancer recurrence. Eur J Gastroenterol Hepatol [Internet]. 2011 Mar;23(3):275–81. Available from: https://journals.lww.com/00042737-201103000-00013
12. Caglar M, Yener C, Karabulut E. Value of CT, FDG PET-CT and serum tumor markers in staging recurrent colorectal cancer. Int J Comput Assist Radiol Surg [Internet]. 2015 Jul;10(7):993–1002. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25213271
13. Fehr M, Müller J, Knitel M, Fornaro J, Horber D, Koeberle D, et al. Early Postoperative FDG-PET-CT Imaging Results in a Relevant Upstaging in the pN2 Subgroup of Stage III Colorectal Cancer Patients. Clin Colorectal Cancer [Internet]. 2017;16(4):343–8. Available from: http://dx.doi.org/10.1016/j.clcc.2017.03.007
14. Metser U, You J, McSweeney S, Freeman M, Hendler A. Assessment of Tumor Recurrence in Patients With Colorectal Cancer and Elevated Carcinoembryonic Antigen Level: FDG PET/CT Versus Contrast-Enhanced 64-MDCT of the Chest and Abdomen. Am J Roentgenol [Internet]. 2010 Mar;194(3):766–71. Available from: http://www.ajronline.org/doi/10.2214/AJR.09.3205
15. Mittal BR, Senthil R, Kashyap R, Bhattacharya A, Singh B, Kapoor R, et al. 18F-FDG PET-CT in evaluation of postoperative colorectal cancer patients with rising CEA level. Nucl Med Commun [Internet]. 2011 Sep;32(9):789–93. Available from: https://journals.lww.com/00006231-201109000-00004
16. Lee JH, Park SG, Jee KN, Park DG, Namgung H, Song IH. Performance of FDG PET/CT in postoperative colorectal cancer patients with a suspected recurrence and a normal CEA level. Nucl Med Commun [Internet]. 2010 Jun;31(6):576–82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20216474
17. Chen L-B. 18 F-DG PET/CT in detection of recurrence and metastasis of colorectal cancer. World J Gastroenterol [Internet]. 2007 Oct 7;13(37):5025. Available from: http://www.embase.com/search/results?subaction=viewrecord&from=export&id=L47496838
18. Fraum TJ, Fowler KJ, McConathy J, Dehdashti F. Indeterminate Findings on Oncologic PET/CT: What Difference Does PET/MRI Make? Nucl Med Mol Imaging (2010) [Internet]. 2016;50(4):292–9. Available from: http://dx.doi.org/10.1007/s13139-016-0405-1
19. Kudura K, Dimitriou F, Mihic-Probst D, Muehlematter UJ, Kutzker T, Basler L, et al. Malignancy Rate of Indeterminate Findings on FDG-PET/CT in Cutaneous Melanoma Patients. Diagnostics [Internet]. 2021 May 15;11(5):883. Available from: https://www.mdpi.com/2075-4418/11/5/883
20. Vallam KC, Guruchannabasavaiah B, Agrawal A, Rangarajan V, Ostwal V, Engineer R, et al. Carcinoembryonic antigen directed PET−CECT scanning for postoperative surveillance of colorectal cancer. Color Dis [Internet]. 2017 Oct;19(10):907–11. Available from: http://doi.wiley.com/10.1111/codi.13695
21. Ince S, Okuyucu K, Hancerliogulları O, Alagoz E, San H, Arslan N. Clinical significance of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography in the follow-up of colorectal cancer: searching off approaches increasing specificity for detection of recurrence. Radiol Oncol [Internet]. 2017 Nov 1;51(4):378–85. Available from: https://www.degruyter.com/doi/10.1515/raon-2017-0045
22. Ozkan E, Soydal C, Araz M, Kir KM, Ibis E. The role of 18F-FDG PET/CT in detecting colorectal cancer recurrence in patients with elevated CEA levels. Nucl Med Commun [Internet]. 2012 Apr;33(4):395–402. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22367859
23. Makis W, Kurzencwyg D, Hickeson M. 18F-FDG PET/CT superior to serum CEA in detection of colorectal cancer and its recurrence. Clin Imaging [Internet]. 2013;37(6):1094–7. Available from: http://dx.doi.org/10.1016/j.clinimag.2013.04.004
24. Yu X, Zhu L, Dai D, Song X, Chen W, Zhu Y, et al. Application and Indication of Carcinoembryonic Antigen Triggered 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Scanning in the Detection of Relapse of Colorectal Cancer Patients after Curative Therapy. J Comput Assist Tomogr. 2017;41(5):719–25.
25. Kang MK, Hong SP, Lee JE, Jeon TJ, Kim JW, Kwon C Il, et al. The Usefulness of F 18 -FDG PET/CT in Detection of Colonic Neoplasm. Intest Res [Internet]. 2010;8(1):18. Available from: http://irjournal.org/journal/view.php?doi=10.5217/ir.2010.8.1.18
26. Khan K, Athauda A, Aitken K, Cunningham D, Watkins D, Starling N, et al. Survival Outcomes in Asymptomatic
Patients With Normal Conventional Imaging but Raised Carcinoembryonic Antigen Levels in Colorectal Cancer
Following Positron Emission Tomographyâ€Computed Tomography Imaging. Oncologist [Internet]. 2016 Dec
14;21(12):1502–8. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1634/theoncologist.2017-0051
27. McCall JL, Black RB, Rich CA, Harvey JR, Baker RA, Watts JM, et al. The value of serum carcinoembryonic antigen in predicting recurrent disease following curative resection of colorectal cancer. Dis Colon Rectum [Internet]. 1994 Sep;37(9):875–81. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8076486
28. Amin A, Reddy A, Wilson R, Jha M, Miranda S, Amin J. Unnecessary surgery can be avoided by judicious use of PET/CT scanning in colorectal cancer patients. J Gastrointest Cancer [Internet]. 2012 Dec;43(4):594–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22552946
29. Kyoto Y, Momose M, Kondo C, Itabashi M, Kameoka S, Kusakabe K. Ability of 18F-FDG PET/CT to diagnose
recurrent colorectal cancer in patients with elevated CEA concentrations. Ann Nucl Med [Internet]. 2010
Jun;24(5):395–401. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20364373
30. Gade M, Kubik M, Fisker R V., Thorlacius-Ussing O, Petersen LJ. Diagnostic value of 18F-FDG PET/CT as first
choice in the detection of recurrent colorectal cancer due to rising CEA. Cancer Imaging [Internet].
2015;15(1):1–8. Available from: http://dx.doi.org/10.1186/s40644-015-0048-y
31. Duineveld LAM, van Asselt KM, Bemelman WA, Smits AB, Tanis PJ, van Weert HCPM, et al. Symptomatic and
Asymptomatic Colon Cancer Recurrence: A Multicenter Cohort Study. Ann Fam Med [Internet].
2016;14(3):215–20. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27184991
32. Hung H, You J, Chiang J, Hsieh P, Chiang S, Lai C, et al. Why recurrence was initially suspected during
colorectal cancer postoperative surveillance?: A retrospective analysis. Medicine (Baltimore) [Internet]. 2020
Oct 23;99(43):e22803. Available from: http://www.ncbi.nlm.nih.gov/pubmed/33120800
Published
2021-07-26
How to Cite
SPIROV, Goran et al.
THE VALUE OF PET/CT IN DETECTING COLORECTAL CANCER RECURRENCE IN PATIENTS WITH NEGATIVE CT FINDINGS.
Journal of Morphological Sciences, [S.l.], v. 4, n. 2, p. 57-65, july 2021.
ISSN 2545-4706.
Available at: <http://jms.mk/jms/article/view/vol4no2-8>. Date accessed: 25 apr. 2024.
Issue
Section
Articles
