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Evaluation of Liver Metastases After Radiofrequency Ablation: Utility of ¹⁸F-FDG PET and PET/CT

Department of Radiology, Wake Forest University, Medical Center Blvd., Winston-Salem, NC 27157.

View larger version (128K): [in a new window]   Fig. 1A. —78-year-old man with metastatic pancreatic adenocarcinoma with initial good result after liver radiofrequency ablation but with evidence of recurrence on follow-up PET and CT. Unenhanced CT scan shows low-density lesion in right lobe of liver (arrow), which was new compared with prior imaging studies and highly suspicious for metastasis.

View larger version (124K): [in a new window]   Fig. 1B. —78-year-old man with metastatic pancreatic adenocarcinoma with initial good result after liver radiofrequency ablation but with evidence of recurrence on follow-up PET and CT. Unenhanced CT scan obtained during treatment shows radiofrequency ablation probe at lesion site.

View larger version (141K): [in a new window]   Fig. 1C. —78-year-old man with metastatic pancreatic adenocarcinoma with initial good result after liver radiofrequency ablation but with evidence of recurrence on follow-up PET and CT. Immediate post-radiofrequency ablation enhanced CT scan shows hypovascular ablation defect (white arrow), adjacent gas, and incidental portal venous gas (black arrows), all expected findings.

View larger version (89K): [in a new window]   Fig. 1D. —78-year-old man with metastatic pancreatic adenocarcinoma with initial good result after liver radiofrequency ablation but with evidence of recurrence on follow-up PET and CT. 18F-FDG PET scan obtained 2 months after radiofrequency ablation shows focal abnormal uptake (arrow) along deep aspect of ablation defect consistent with residual/recurrent tumor.

View larger version (148K): [in a new window]   Fig. 1E. —78-year-old man with metastatic pancreatic adenocarcinoma with initial good result after liver radiofrequency ablation but with evidence of recurrence on follow-up PET and CT. Concurrent enhanced CT scan shows corresponding nodular enhancement (arrow) at anteromedial aspect of ablation defect.

View larger version (150K): [in a new window]   Fig. 2A. —64-year-old man with metastatic colorectal adenocarcinoma with successful liver radiofrequency ablation and no evidence of recurrence at ablation site on follow-up imaging. Enhanced CT scan obtained before radiofrequency ablation shows hypovascular liver lesion (arrow). Biopsy performed at time of ablation confirmed adenocarcinoma.

View larger version (136K): [in a new window]   Fig. 2B. —64-year-old man with metastatic colorectal adenocarcinoma with successful liver radiofrequency ablation and no evidence of recurrence at ablation site on follow-up imaging. Unenhanced CT scan shows approach with radiofrequency ablation probe.

View larger version (155K): [in a new window]   Fig. 2C. —64-year-old man with metastatic colorectal adenocarcinoma with successful liver radiofrequency ablation and no evidence of recurrence at ablation site on follow-up imaging. Enhanced CT scan obtained immediately after radiofrequency ablation shows ablation defect. Note peripheral enhancement (arrows), which is related to hyperemia and should not be confused with residual tumor enhancement. Peripheral enhancement gradually decreases over period of weeks to months.

View larger version (129K): [in a new window]   Fig. 2D. —64-year-old man with metastatic colorectal adenocarcinoma with successful liver radiofrequency ablation and no evidence of recurrence at ablation site on follow-up imaging. Enhanced CT scan obtained 3 months after radiofrequency ablation shows no evidence of abnormal enhancement and no increase in lesion size to suggest recurrent tumor.

View larger version (113K): [in a new window]   Fig. 2E. —64-year-old man with metastatic colorectal adenocarcinoma with successful liver radiofrequency ablation and no evidence of recurrence at ablation site on follow-up imaging. Concurrent 18F-FDG PET scan shows ablation defect (arrow) with no abnormal uptake.

View larger version (114K): [in a new window]   Fig. 2F. —64-year-old man with metastatic colorectal adenocarcinoma with successful liver radiofrequency ablation and no evidence of recurrence at ablation site on follow-up imaging. Enhanced CT scan obtained 9 months after radiofrequency ablation shows no significant change.

View larger version (140K): [in a new window]   Fig. 3A. —52-year-old man with metastatic colorectal carcinoma with initially successful liver radiofrequency ablation but with evidence of recurrence on follow-up CT and PET. Enhanced CT scan obtained before radiofrequency ablation shows hypovascular left liver lesion (arrow), which is enlarged compared with prior imaging studies.

View larger version (141K): [in a new window]   Fig. 3B. —52-year-old man with metastatic colorectal carcinoma with initially successful liver radiofrequency ablation but with evidence of recurrence on follow-up CT and PET. Unenhanced CT scan shows approach with radiofrequency ablation probe.

View larger version (139K): [in a new window]   Fig. 3C. —52-year-old man with metastatic colorectal carcinoma with initially successful liver radiofrequency ablation but with evidence of recurrence on follow-up CT and PET. Enhanced CT scan obtained immediately after radiofrequency ablation shows ablation defect with thin rim enhancement (arrows), again compatible with hyperemia.

View larger version (141K): [in a new window]   Fig. 3D. —52-year-old man with metastatic colorectal carcinoma with initially successful liver radiofrequency ablation but with evidence of recurrence on follow-up CT and PET. Enhanced CT scan obtained 15 months after radiofrequency ablation shows significant enlargement of left liver lesion (large arrow), ill-defined margins, and minimal peripheral enhancement compatible with recurrence. Wedge-shaped peripheral defect (small arrow) is noted in right lobe of liver. This is site of metastasis identified during interval surgery and treated with wedge resection. CT appearance of this latter lesion is believed to represent postsurgical change.

View larger version (91K): [in a new window]   Fig. 3E. —52-year-old man with metastatic colorectal carcinoma with initially successful liver radiofrequency ablation but with evidence of recurrence on follow-up CT and PET. Concurrent 18F-FDG PET scan shows focal uptake in both lesions, compatible with recurrence. Note that most of 18F-FDG uptake in larger lesion (arrow) is along leftward margin. This information would be helpful in guiding repeat radiofrequency ablation procedure and is information not provided by CT scan.

View larger version (165K): [in a new window]   Fig. 4A. —75-year-old man with metastatic colorectal adenocarcinoma after liver radiofrequency ablation with no evidence of recurrence on CT scan but with PET scan that reveals recurrent tumor. Coronal reformatted image from enhanced CT scan obtained 15 months after radiofrequency ablation shows ablation defect (arrow) but no evidence of enlargement or abnormal enhancement to suggest tumor recurrence.

View larger version (114K): [in a new window]   Fig. 4B. —75-year-old man with metastatic colorectal adenocarcinoma after liver radiofrequency ablation with no evidence of recurrence on CT scan but with PET scan that reveals recurrent tumor. Concurrent coronal 18F-FDG PET image shows focal abnormal uptake (white arrow) along medial aspect of ablation defect (black arrow) compatible with recurrence.

View larger version (177K): [in a new window]   Fig. 4C. —75-year-old man with metastatic colorectal adenocarcinoma after liver radiofrequency ablation with no evidence of recurrence on CT scan but with PET scan that reveals recurrent tumor. Transaxial CT image (C) and transaxial PET image (D) from the same studies as (A) and (B) again show the ablation defect (black arrow, C) and abnormal uptake on PET (arrows, D).

View larger version (82K): [in a new window]   Fig. 4D. —75-year-old man with metastatic colorectal adenocarcinoma after liver radiofrequency ablation with no evidence of recurrence on CT scan but with PET scan that reveals recurrent tumor. Transaxial CT image (C) and transaxial PET image (D) from the same studies as (A) and (B) again show the ablation defect (black arrow, C) and abnormal uptake on PET (arrows, D). Transaxial PET image of same lesion shows abnormal uptake (arrows).

View larger version (155K): [in a new window]   Fig. 4E. —75-year-old man with metastatic colorectal adenocarcinoma after liver radiofrequency ablation with no evidence of recurrence on CT scan but with PET scan that reveals recurrent tumor. Six weeks later, unenhanced CT scan obtained before repeat radiofrequency ablation shows placement of biopsy needle, guided by uptake on PET scan. Specimen confirmed adenocarcinoma.

View larger version (172K): [in a new window]   Fig. 4F. —75-year-old man with metastatic colorectal adenocarcinoma after liver radiofrequency ablation with no evidence of recurrence on CT scan but with PET scan that reveals recurrent tumor. Unenhanced CT scan shows initial probe placement for ablation. Probe was then repositioned to adjacent sites, for total of five ablations, each lasting 10-12 min and each guided by corresponding PET information.

View larger version (174K): [in a new window]   Fig. 4G. —75-year-old man with metastatic colorectal adenocarcinoma after liver radiofrequency ablation with no evidence of recurrence on CT scan but with PET scan that reveals recurrent tumor. Enhanced CT scan obtained immediately after radiofrequency ablation shows adequate ablation defect (arrows).

View larger version (75K): [in a new window]   Fig. 5A. —60-year-old man with metastatic colorectal adenocarcinoma and suspicious enhancing lesion in dome of liver treated with two separate radiofrequency ablation procedures. Enhanced CT scan obtained before radiofrequency ablation shows suspicious hypervascular lesion (arrow) in dome of liver.

View larger version (79K): [in a new window]   Fig. 5B. —60-year-old man with metastatic colorectal adenocarcinoma and suspicious enhancing lesion in dome of liver treated with two separate radiofrequency ablation procedures. Concurrent 18F-FDG PET scan (coronal image) shows corresponding focal increased uptake (arrow) consistent with malignancy.

View larger version (95K): [in a new window]   Fig. 5C. —60-year-old man with metastatic colorectal adenocarcinoma and suspicious enhancing lesion in dome of liver treated with two separate radiofrequency ablation procedures. 18F-FDG PET scan (coronal image) obtained 4 months after laparoscopic radiofrequency ablation shows large ablation defect (white arrow) but persistent focal uptake in liver dome (black arrow).

View larger version (93K): [in a new window]   Fig. 5D. —60-year-old man with metastatic colorectal adenocarcinoma and suspicious enhancing lesion in dome of liver treated with two separate radiofrequency ablation procedures. Enhanced CT scan obtained 5 months after radiofrequency ablation shows interval enlargement of enhancing focus (arrow).

View larger version (142K): [in a new window]   Fig. 5E. —60-year-old man with metastatic colorectal adenocarcinoma and suspicious enhancing lesion in dome of liver treated with two separate radiofrequency ablation procedures. Unenhanced CT scan shows percutaneous approach for second radiofrequency ablation procedure.

View larger version (128K): [in a new window]   Fig. 5F. —60-year-old man with metastatic colorectal adenocarcinoma and suspicious enhancing lesion in dome of liver treated with two separate radiofrequency ablation procedures. Enhanced CT scan performed 1 month after second radiofrequency ablation procedure shows no evidence of abnormal enhancement to suggest recurrent tumor. High density in more central aspect of ablation site is unchanged from prior CT scans and likely represents debris related to coagulative necrosis.

View larger version (96K): [in a new window]   Fig. 5G. —60-year-old man with metastatic colorectal adenocarcinoma and suspicious enhancing lesion in dome of liver treated with two separate radiofrequency ablation procedures. Concurrent 18F-FDG PET scan (coronal image) (G) and transaxial image (arrow, H) of same lesion show ablation defect (black arrow, G), resolution of previous metabolically active lesion, but evidence of new focal uptake (white arrow, G) along superior leftward aspect of ablation site compatible with recurrent tumor. Again, PET data would be helpful in targeting any subsequent radiofrequency ablation procedure.

View larger version (102K): [in a new window]   Fig. 5H. —60-year-old man with metastatic colorectal adenocarcinoma and suspicious enhancing lesion in dome of liver treated with two separate radiofrequency ablation procedures. Concurrent 18F-FDG PET scan (coronal image) (G) and transaxial image (arrow, H) of same lesion show ablation defect (black arrow, G), resolution of previous metabolically active lesion, but evidence of new focal uptake (white arrow, G) along superior leftward aspect of ablation site compatible with recurrent tumor. Again, PET data would be helpful in targeting any subsequent radiofrequency ablation procedure.

View larger version (124K): [in a new window]   Fig. 6A. —66-year-old woman with metastatic colorectal adenocarcinoma after multiple liver radiofrequency ablation procedures with recurrent/residual tumor delineated by PET/CT. Scan from unenhanced CT portion of examination shows multiple large and small, low- and mixed-density lesions throughout liver likely representing combination of ablation defects and recurrent/residual tumor.

View larger version (104K): [in a new window]   Fig. 6B. —66-year-old woman with metastatic colorectal adenocarcinoma after multiple liver radiofrequency ablation procedures with recurrent/residual tumor delineated by PET/CT. Fused PET/CT image from same examination shows three foci of increased 18F-FDG uptake, clearly distinguishing tumor from ablation change and providing precise localization for radiofrequency ablation planning.

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