Prognostic parameters in recurrent colorectal cancer: A role of control or restaging by FDG-PET/CT

Oguz Hancerliogullari; Kursat Okuyucu; Semra Ince; Subutay Peker; Nuri Arslan

doi:10.2298/VSP170817065H

Oguz Hancerliogullari University of Health Sciences, Gulhane Training and Research Hospital, Department of General Surgery, Ankara, Turkey
Kursat Okuyucu University of Health Sciences, Gulhane Training and Research Hospital, Department of Nuclear Medicine, Ankara, Turkey
Semra Ince University of Health Sciences, Gulhane Training and Research Hospital, Department of Nuclear Medicine, Ankara, Turkey
Subutay Peker University of Health Sciences, Gulhane Training and Research Hospital, Department of General Surgery, Ankara, Turkey
Nuri Arslan University of Health Sciences, Gulhane Training and Research Hospital, Department of Nuclear Medicine, Ankara, Turkey

DOI: https://doi.org/10.2298/VSP170817065H

Keywords: colorectal neoplasms, neoplasm staging, prognosis, radiopharmaceuticals, recurrence, sensitivity and specificity, tomography, emission-computed, tomography, x-ray computed

Abstract

Background/Aim. Colorectal cancer ranks the third most frequent cancer in the world. Approximately 40% of the disease recurs after surgical resection. Determination of predictive parameters for recurrence may help in stratification of patients and contribute to patient management. There are still very few studies which sought factors to predict the recurrence of colorectal cancer. The aim of this study was to examine the predefined risk factors in metastatic development and evaluate clinical significance of 18F-fluorodeoxyglucose (FDG) uptake. Methods. The study was conducted with 56 patients for whom FDG-PET/CT (FDG-positron emission tomography/computed tomography) was requested for the suspicious recurrence or metastasis by routine conventional screening tests. Thirty three patients in whom recurrence/metastases were established with final histopathologic diagnosis formed the malignant group, and 23 patients with no recurrence/metastases formed the benign group. Risk factors [age, serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (Ca 19-9) levels, the maximum standardized uptake volume (SUVmax), tumor size (TS), CT/magnetic resonance imaging (MRI) findings, sex, primary tumor localization, lymphovascular invasion, perineural invasion (PNI), initial neoadjuvant therapy, lymph node initial metastasis (ILNM) excision, stage, tumor differentiation] were compared between these groups. Results. CEA, Ca 19-9, SUVmax, TS, PNI, ILNM, FDG uptake pattern, pattern of lesions on CT and tumor differentiation were found statistically significant by univariate analysis. After multivariate analysis, SUVmax and ILNM remained as the main risk parameters impacting recurrence/metastases. Mean SUVmax was 7.25 in the benign group, while it was 11.7 in the malignant group (p = 0.019). ILNM was present in 66.5% of patients in the malignant group, and in 30.5% of patients in the benign group (p = 0.015). For an estimated cut-off value of 6.3 and 12.5, respectively on ROC curve, the calculated specificities were 61% and 87%, respectively. Conclusion. ILNM and SUVmax are the main risk factors for recurrence of colorectal cancer and the patients with these factors must be followed up carefully. FDG-PET/CT is very sensitive for the detection of recurrence/metastases of colorectal cancer and SUVmax appears to improve its specificity.

References

Ryuk JP, Choi GS, Park JS, Kim HJ, Park SY, Yoon GS, et al. Predictive factors and the prognosis of recurrence of colorec-tal cancer within 2 years after curative resection. Ann Surg Treat Res 2014; 86(3): 143–51.

Chen CH, Hsieh MC, Lai CC, Yeh CY, Chen JS, Hsieh PS, et al. Lead time of carcinoembryonic antigen elevation in the post-operative follow-up of colorectal cancer did not affect the survival rate after recurrence. Int J Colorectal Dis 2010; 25(5): 567–71.

Chiaravalloti A, Fiorentini A, Palombo E, Rinino D, Lacanfora A, Danieli R, et al. Evaluation of recurrent disease in the re-staging of colorectal cancer (18)F-FDG PET/CT: Use of CEA and CA 19-9 in patient selection. Oncol Lett 2016; 12(5): 4209–13.

Yakabe T, Nakafusa Y, Sumi K, Miyoshi A, Kitajima Y, Sato S, et al. Clinical significance of CEA and CA19-9 in postoperative follow-up of colorectal cancer. Ann Surg Oncol 2010; 17(9): 2349–56.

Filella X, Molina R, Piqué JM, Garcia-Valdecasas JC, Grau JJ, Novell F, et al. Use of CA 19-9 in the early detection of recur-rences in colorectal cancer: Comparison with CEA. Tumour Biol 1994; 15(1): 1–6.

Panagiotidis E, Datseris IE, Rondogianni P, Vlontzou E, Skilakaki M, Exarhos D, et al. Does CEA and CA 19-9 combined in-crease the likelihood of 18F-FDG in detecting recurrence in colorectal patients with negative CeCT? Nucl Med Commun 2014; 35(6): 598–605.

Gade M, Kubik M, Fisker RV, Thorlacius-Ussing O, Petersen LJ. Diagnostic value of (18)F-FDG PET/CT as first choice in the detection of recurrent colorectal cancer due to rising CEA. Cancer Imaging 2015; 15: 11.

Sanli Y, Kuyumcu S, Ozkan ZG, Kilic L, Balik E, Turkmen C, et al. The utility of FDG-PET/CT as an effective tool for de-tecting recurrent colorectal cancer regardless of serum CEA levels. Ann Nucl Med 2012; 26(7): 551–58.

Zhuang H, Alavi A. 18-Fluorodeoxyglucose positron emission tomographic imaging in the detection and monitoring of infec-tion and inflammation. Semin Nucl Med 2002; 32(1): 47–59.

Chan K, Welch S, Walker-Dilks C, Raifu A. Ontario provincial Gastrointestinal Disease Site Group.Evidence-based guideline recommendations on the use of positron emission tomography imaging in colorectal cancer. Clin Oncol (R Coll Radiol) 2012; 24(4): 232–49.

Aghili M, Izadi S, Madani H, Mortazavi H. Clinical and patho-logical evaluation of patients with early and late recurrence of colorectal cancer. Asia Pac J Clin Oncol 2010; 6(1): 35–41.

Longo WE, Johnson FE. The preoperative assessment and post-operative surveillance of patients with colon and rectal cancer. Surg Clin North Am 2002; 82(5): 1091–108.

Bowne WB, Lee B, Wong WD, Ben-Porat L, Shia J, Cohen AM, et al. Operative salvage for locoregional recurrent colon cancer after curative resection: an analysis of 100 cases. Dis Colon Rectum 2005; 48(5): 897–909.

Artiko V, Odalovic S, Sobic-Saranovic D, Petrovic M, Stojiljkovic M, Petrovic N, et al. Can (18)F-FDG PET/CT scan change treat-ment planning and be prognostic in recurrent colorectal carci-noma? A prospective and follow-up study. Hell J Nucl Med 2015; 18(1): 35–41.

Kobayashi H, Mochizuki H, Sugihara K, Morita T, Kotake K, Tera-moto T, et al. Characteristics of recurrence and surveillance tools after curative resection for colorectal cancer: a multicen-ter study. Surgery 2007; 141(1): 67–75.

Bozkurt O, Inanc M, Turkmen E , Karaca H, Berk V, Duran AO, et al. Clinicopathological characteristics and prognosis of pa-tients according to recurrence time after curative resection for colorectal cancer. Asian Pac J Cancer Prev 2014; 15(21): 9277–81.

Park IJ, Choi GS, Jun SH. Prognostic value of serum tumor an-tigen CA19-9 after curative resection of colorectal cancer. Anticancer Res 2009; 29(10): 4303–8.

Bentzen SM, Balslev I, Pedersen M, Teglbjaerg PS, Hanberg-Sørensen F, Bone J, et al. Time to loco-regional recurrence after resection of Dukes' B and C colorectal cancer with or without adjuvant postoperative radiotherapy: a multivariate regression analysis. Br J Cancer 1992; 65(1): 102–7.

Tsai HL, Chu KS, Huang YH, Su YC, Wu JY, Kuo CH, et al. Predictive factors of early relapse in UICC stage I-III colorec-tal cancer patients after curative resection. J Surg Oncol 2009; 100(8): 736–43.

Tsai HL, Cheng KI, Lu CY, Kuo CH, Ma CJ, Wu JY, et al. Prognostic significance of depth of invasion, vascular invasion and numbers of lymph node retrievals in combination for pa-tients with stage II colorectal cancer undergoing radical resec-tion. J Surg Oncol 2008; 97(5): 383–7.

Odalovic S, Stojiljkovic M, Sobic-Saranovic D, Pandurevic S, Brajkovic L, Milosevic I, et al. Prospective study on diagnostic and prog-nostic significance of postoperative FDG PET/CT in recur-rent colorectal carcinoma patients: comparison with MRI and tumor markers. Neoplasma 2017; 64(6): 954–61.

Scott AM, Gunawardana DH, Kelley B, Stuckey JG, Byrne AJ, Ramshaw JE, et al.PET changes management and improves prognostic stratification in patients with recurrent colorectal cancer: results of a multicenter prospective study. J Nucl Med 2008; 49(9): 1451–7.

Fujita S, Shimoda T, Yoshimura K, Yamamoto S, Akasu T, Moriya Y. Prospective evaluation of prognostic factors in patients with colorectal cancer undergoing curative resection. J Surg Oncol 2003; 84(3): 127–31.

Okuyucu K, Ince S, Alagoz E, Emer O, San H, Balkan E, et al. Risk factors and stratification for recurrence of patients with differentiated thyroid cancer, elevated thyroglobulin and nega-tive I-131 whole-body scan, by restaging 18F-FDG PET/CT. Hell J Nucl Med 2016; 19(3): 208-217.

Shmidt E, Nehra V, Lowe V, Oxentenko AS. Clinical signifi-cance of incidental [18 F]FDG uptake in the gastrointestinal tract on PET/CT imaging: a retrospective cohort study. BMC Gastroenterol 2016; 16(1): 125.

Marcus C, Wray R, Taghipour M, Marashdeh W, Ahn SJ, Mena E, et al. JOURNAL CLUB: Value of Quantitative FDG PET/CT Volumetric Biomarkers in Recurrent Colorectal Cancer Patient Survival. AJR Am J Roentgenol 2016; 207(2): 257–65.

Shamim SA, Kumar R, Halanaik D, Shandal V, Reddy RM, Bal CS, et al. Role of FDG-PET/CT in detection of recurrent disease in colorectal cancer. Nucl Med Commun 2010; 31(6): 590–6.