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PET/CT Pattern Analysis for Surgical Staple Line Recurrence in Patients With Colorectal Cancer

Paul B. Shyn¹, Rachna Madan¹, Christopher Wu¹, . Mehmet Ertrk² and Stuart G. Silverman¹

¹ Division of Abdominal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115.
² Department of Radiology, Sisli Etfal Training and Research Hospital, Istanbul, Turkey.

OBJECTIVE. The purpose of our study was to determine whether ¹⁸F-FDG PET/CT interpretation with metabolic–anatomic pattern analysis can be used to accurately assess for surgical staple line recurrence after colorectal cancer resection.

MATERIALS AND METHODS. Seventy-nine consecutive patients with previous surgical resection of colorectal cancer were studied retrospectively. The surgical anastomotic or Hartmann's pouch staple lines were evaluated for presence or absence of tumor recurrence with FDG PET/CT metabolic–anatomic pattern analysis. Focal, eccentric, or perianastomotic CT masses with any associated PET pattern were regarded as positive for staple line recurrence. If the perianastomotic CT abnormality was presacral in location, then FDG uptake at least as intense as normal liver was required for positive interpretation. Eccentric or perianastomotic PET patterns matched with normal or diffuse thickening CT patterns were regarded as indeterminate. Presence or absence of recurrent tumor was confirmed by pathology, surgery, colonoscopy, imaging follow-up of at least 3 months, or clinical follow-up of at least 1 year.

RESULTS. Nine patients (11.4%) had staple line recurrence and 70 (88.6%) did not. FDG PET/CT interpretation yielded sensitivity, specificity, positive predictive value, negative predictive value, and accuracy results of 100% (9/9), 97.1% (68/70), 81.8% (9/11), 100% (68/68), and 97.5% (77/79), respectively. All nine patients with staple line recurrence showed perianastomotic or eccentric masses on CT, eight with matching perianastomotic or eccentric FDG uptake patterns. Background, diffuse, curvilinear, or focal FDG uptake patterns, regardless of FDG uptake intensity, paired with normal findings or diffuse mural thickening on CT were seen only in patients without staple line recurrence.

CONCLUSION. FDG PET/CT pattern analysis enables accurate assessment for staple line recurrence in patients with previous resection of colorectal cancer. The most reliable PET/CT pattern predicting staple line recurrence is an eccentric or perianastomotic mass on CT with corresponding eccentric or perianastomotic FDG uptake on PET. Background, diffuse (on one or both sides of the staple line), curvilinear, and focal patterns of FDG uptake do not correlate with recurrence in the absence of a mass on CT.

Keywords: anastomosis • colorectal cancer • PET/CT • recurrent colorectal cancer • staple line

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