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      Preoperative Staging With Positron Emission Tomography in Patients With Colorectal Cancer

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      Annals of Coloproctology
      The Korean Society of Coloproctology

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          Abstract

          See Article on Page 259-265 The current National Comprehensive Cancer Network guideline for colon and rectal cancer designates that positron emission tomography-computed tomography (PET-CT) does not supplant a contrast-enhanced diagnostic CT scan. PET-CT should only be used to evaluate an equivocal finding on a contrast-enhanced CT scan or in patients with strong contraindications to IV contrast [1, 2]. In addition, as of 2015, the Korea Health Insurance Review & Assessment Service will not pay for PET-CT as a routine follow-up test. In this regard, colorectal surgeons should be cautious when planning PET-CT as an initial staging modality in clinical practice. PET is a promising tool as a preoperative imaging modality for colorectal cancer, but still lacks firm evidence supporting its use as a routine test. In this issue of the Annals of Coloproctology, Yi et al. [3] demonstrated effectively that preoperative PET-CT is useful in detecting regional and distant node metastasis in patients with colon cancer. Previously, Yoo et al. [4] had observed that preoperative PET-CT was useful in the detection of synchronous distant metastases (7.8%) and multiple primary malignancies (5.3%) in patients with colorectal cancer. Lee and Lee [5] also showed that preoperative use of PET-CT had resulted in a change in the treatment plan in 7% of colon-cancer patients when compared to the use of multidetector CT. In a recent meta-analysis, PET-CT showed, on a per patient basis, the highest sensitivity (94.1%) for the initial detection of liver metastases when compared to CT (83.6%) and magnetic resonance imaging (88.2%) [6]. All these retrospective findings are valuable; however, before the preoperative use of PET-CT can be incorporated into clinical practice, such use must be validated through large prospective trials.

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          Diagnostic imaging of colorectal liver metastases with CT, MR imaging, FDG PET, and/or FDG PET/CT: a meta-analysis of prospective studies including patients who have not previously undergone treatment.

          To obtain diagnostic performance values of computed tomography (CT), magnetic resonance (MR) imaging, fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET), and FDG PET/CT in the detection of colorectal liver metastases in patients who have not previously undergone therapy. A comprehensive search was performed for articles published from January 1990 to January 2010 that fulfilled the following criteria: a prospective study design was used; the study population included at least 10 patients; patients had histopathologically proved colorectal cancer; CT, MR imaging, FDG PET, or FDG PET/CT was performed for the detection of liver metastases; intraoperative findings or those from histopathologic examination or follow-up were used as the reference standard; and data for calculating sensitivity and specificity were included. Study design characteristics, patient characteristics, imaging features, reference tests, and 2 × 2 tables were recorded. Thirty-nine articles (3391 patients) were included. Variation existed in study design characteristics, patient descriptions, imaging features, and reference tests. The sensitivity estimates of CT, MR imaging, and FDG PET on a per-lesion basis were 74.4%, 80.3%, and 81.4%, respectively. On a per-patient basis, the sensitivities of CT, MR imaging, and FDG PET were 83.6%, 88.2%, and 94.1%, respectively. The per-patient sensitivity of CT was lower than that of FDG PET (P = .025). Specificity estimates were comparable. For lesions smaller than 10 mm, the sensitivity estimates for MR imaging were higher than those for CT. No differences were seen for lesions measuring at least 10 mm. The sensitivity of MR imaging increased significantly after January 2004. The use of liver-specific contrast material and multisection CT scanners did not provide improved results. Data about FDG PET/CT were too limited for comparisons with other modalities. MR imaging is the preferred first-line modality for evaluating colorectal liver metastases in patients who have not previously undergone therapy. FDG PET can be used as the second-line modality. The role of FDG PET/CT is not yet clear owing to the small number of studies. http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.10100729/-/DC1. © RSNA, 2010
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            Positron Emission Tomography/Computed Tomography in the Staging of Colon Cancer

            Purpose Accurate preoperative staging of colon cancer is essential for providing the optimal treatment strategy and evaluating the expected prognosis. The aim of this study is to assess the value of positron emission tomography/computed tomography (PET/CT) over conventional studies in the staging of colon cancer. Methods A total of 266 colon cancer patients diagnosed between January 2008 and December 2010 were assessed with both PET/CT and conventional studies. Discordance with PET/CT and conventional studies were evaluated, and changes in the management strategy were assessed for each stage. Discordant findings were verified by using intraoperative examination, pathology reports, and follow-up imaging studies. Results Multidetector computed tomography (MDCT) and PET/CT showed similar accuracy in detecting lymph node metastasis in patients with clinical stage III (36.2% vs. 42%, P = 0.822) and stage IV (60.3% vs. 63.5%, P = 0.509) disease. PET/CT led to a change in management strategy for 1 of 40 patients (2.5%) with clinical stage I, 0 of 25 patients (0%) with stage II, 9 of 138 patients (6.5%) with stage III, and 8 of 63 patients (12.7%) with stage IV disease. Conclusion PET/CT changed the management plan in 6.5% of patients with clinical stage III and 12.7% of patients with clinical stage IV colon cancer. Our findings suggest that PET/CT may be considered as a routine staging tool for clinical stage III and IV colon cancers.
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              Reliability of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in the Nodal Staging of Colorectal Cancer Patients

              Purpose Lymph-node metastasis is considered as critical prognostic factor in colorectal cancer. A preoperative evaluation of lymph-node metastasis can also help to determine the range of distant lymph node dissection. However, the reliability of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in the detection of lymph-node metastasis is not fully known. Methods The medical records of 433 patients diagnosed with colorectal cancer were reviewed retrospectively. FDG-PET/CT and CT were performed on all patients. Lymph nodes were classified into regional and distant lymph nodes according to the American Joint Committee on Cancer (AJCC) Cancer Staging Manual, 7th edition. Results The patients included 231 males (53.3%) and 202 females (46.7%), with a mean age of 64.7 ± 19.0 years. For regional lymph nodes, the sensitivity of FDG-PET/CT was lower than that of CT (57.1% vs. 73.5%, P < 0.001). For distant lymph nodes, the sensitivity of FDG-PET/CT was higher than that of CT (64.7% vs. 52.9%, P = 0.012). The sensitivity of FDG-PET/CT for regional lymph nodes was higher in patients with larger primary tumors. The positivity of lymph-node metastasis for FDG-PET/CT was affected by carcinoembryonic antigen levels, tumor location, and cancer stage for regional lymph nodes and by age and cancer stage for distant lymph nodes (P < 0.05). Conclusion The sensitivity of FDG-PET/CT for regional lymph-node metastasis was not superior to that of CT. However, FDG-PET/CT provides helpful information for determining surgical plan especially in high risk patients group.
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                Author and article information

                Journal
                Ann Coloproctol
                Ann Coloproctol
                AC
                Annals of Coloproctology
                The Korean Society of Coloproctology
                2287-9714
                2287-9722
                December 2014
                31 December 2014
                : 30
                : 6
                : 247
                Affiliations
                Division of Colorectal Surgery, Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea.
                Author notes
                Correspondence to: Ik Yong Kim, M.D. Division of Colorectal Surgery, Department of Surgery, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju 220-701, Korea. Tel: +82-33-741-0573, Fax: +82-33-744-6604, iykim@ 123456yonsei.ac.kr
                Article
                10.3393/ac.2014.30.6.247
                4286768
                b340d746-3b87-4e1a-b05f-6b6a28098e84
                © 2014 The Korean Society of Coloproctology

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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