Binu John MD, MPH on behalf of co-investigatorsBinu John MD, MPH on behalf of co-investigators Binu...
Transcript of Binu John MD, MPH on behalf of co-investigatorsBinu John MD, MPH on behalf of co-investigators Binu...
Binu John MD, MPH on behalf of co-investigators
Binu V John, Sean Aubuchon, Bassam Dahman, Yangyang Deng, Venkata Rajesh Konjeti, Latha
Sundaram, Eleanor Love, Smitha John, Michael Chang, James Tatum
Bruce W Carter Miami VA Medical Center,
Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
Addition of118FDG PET-CT to Cross Sectional Imaging Improves Staging and Alters Management in HCC-Results from North American
Prospective Study
Disclosures
Binu John: Research support: Eisai, Bristol Myers Squibb,
Bayer, Exact Sciences, Varian
Advisory Board: Gilead, Eisai
No other disclosures
Introduction: Staging of HCC
• Barcelona Clinic Liver Cancer (BCLC) algorithm is the
most commonly used staging system
• Relies on cross-sectional imaging such as contrast-
enhanced CT and MRI
18F-Fluorodeoxyglucose (FDG) positron emission
tomography with computed tomography (PET/CT) used
commonly in many cancers detect occult disease,
metastatic lymphadenopathy
• PET-CT not used in staging -third of lesions (typically well
differentiated) do not take up FDG
• Data from Europe and Asia: PET-CTs have a role in HCC
to detect occult disease
Aim
Characterize role of FDG PET-CT in the staging and management
of patients with HCC in North American population
Methods
Single center study -IRB approved in 2011
Prospectively recruit patients with HCC
First four patients were consented
Subsequently FDG PET/CT incorporated into standard of
care
Therefore subsequent patients underwent PET/CT per
criteria and retrospectively analyzed
Study Design
HCC diagnosed LIRADS 5 lesion on
CT/MRI
MDLTB
BCLC/TNM stagingPET/CT
New lesions on PET/CT confirmed
by biopsy/LIRADS/growth on f/u imaging
Re-staging based on PET/CT
Methods-Patient selection
HCC patients
2011-2018
(N=602)
Lesions not LIRADS 5 (N=98)
PET/CT>3 months (N=52)
Non-compliant (N=32)
Cancelled (N=20)
E-consults (N=252)
Methods-Patient selection
HCC patients
2011-2018
(N=602)
Lesions not LIRADS 5 (N=98)
Eligible patients (N=148)
181 FDG PET/CT studies
101-Rx naïve
80-Rx experienced
PET/CT>3 months (N=52)
Non-compliant (N=32)
Cancelled (N=20)
E-consults (N=252)
Baseline characteristicsVariable Number of patients (n=148)
Gender, N (%)
Male 147 (99.3%)
Age at first HCC Diagnosis, Median (IQR) 62.7 (6.2)
Race / Ethnicity, N (%)
Caucasian 81 (54.7%)
Black 53 (35.8%)
Hispanic 10 (6.8%)
Cirrhosis, N (%)
Yes 144 (97.3%)
Etiology of Liver Disease, N (%)
Hepatitis C virus 64 (43.2%)
Hepatitis C + alcohol 54 (36.5%)
Alcohol 11 (7.4%)
NASH 11 (7.4%)
Baseline characteristicsVariable Number of patients (n=148)
Gender, N (%)
Male 147 (99.3%)
Age at first HCC Diagnosis, Median (IQR) 62.7 (6.2)
Race / Ethnicity, N (%)
Caucasian 81 (54.7%)
Black 53 (35.8%)
Hispanic 10 (6.8%)
Cirrhosis, N (%)
Yes 144 (97.3%)
Etiology of Liver Disease, N (%)
Hepatitis C virus 64 (43.2%)
Hepatitis C + alcohol 54 (36.5%)
Alcohol 11 (7.4%)
NASH 11 (7.4%)
Baseline characteristicsVariable Number of patients (n=148)
Gender, N (%)
Male 147 (99.3%)
Age at first HCC Diagnosis, Median (IQR) 62.7 (6.2)
Race / Ethnicity, N (%)
Caucasian 81 (54.7%)
Black 53 (35.8%)
Hispanic 10 (6.8%)
Cirrhosis, N (%)
Yes 144 (97.3%)
Etiology of Liver Disease, N (%)
Hepatitis C virus 64 (43.2%)
Hepatitis C + alcohol 54 (36.5%)
Alcohol 11 (7.4%)
NASH 11 (7.4%)
Baseline characteristicsVariable Number of patients (n=148)
Gender, N (%)
Male 147 (99.3%)
Age at first HCC Diagnosis, Median (IQR) 62.66 (6.2)
Race / Ethnicity, N (%)
Caucasian 81 (54.7%)
Black 53 (35.8%)
Hispanic 10 (6.8%)
Cirrhosis, N (%)
Yes 144 (97.3%)
Etiology of Liver Disease, N (%)
Hepatitis C virus 64 (43.2%)
Hepatitis C + alcohol 54 (36.5%)
Alcohol 11 (7.4%)
NASH 11 (7.4%)
Baseline characteristicsVariable Number of patients (n=148)
Gender, N (%)
Male 147 (99.3%)
Age at first HCC Diagnosis, Median (IQR) 62.66 (6.2)
Race / Ethnicity, N (%)
Caucasian 81 (54.7%)
Black 53 (35.8%)
Hispanic 10 (6.8%)
Cirrhosis, N (%)
Yes 144 (97.3%)
Etiology of Liver Disease, N (%)
Hepatitis C virus 64 (43.2%)
Hepatitis C + alcohol 54 (36.5%)
Alcohol 11 (7.4%)
NASH 11 (7.4%)
Baseline characteristicsVariable Number of patients (n=148)
Method of Diagnosis, N (%)
Biopsy 58 (39.4%)
Contrast MR 57 (38.8%)
Contrast CT 33 (22.4%)
Initial Treatment Modality, N (%)
Ablation 48 (32.4%)
TACE 45 (24.9%)
Hepatectomy 13 (8.8%)
Sorafenib 11 (7.4%)
SBRT 5 (3.4%)
Y90 3 (2.0%)
Transplant 3 (2.0%)
No Treatment 20 (13.5%)
FDG PET/CT changes HCC staging and management in
treatment naïve patients (n=101)
Number of PET-CT Studies 101
Detect Extrahepatic Metastasis, N (%) 12 (11.9%)
Detect Intrahepatic Lesion, N (%) 7 (6.9%)
Change BCLC Staging, N (%) 6 (5.9%)
Change TNM Staging, N (%) 14 (13.9%)
Change Management, N (%) 10 (9.9%)
FDG PET/CT changes HCC staging and management in
treatment naïve patients
Number of PET-CT Studies 101
Detect Extrahepatic Metastasis, N (%) 12 (11.9%)
Detect Intrahepatic Lesion, N (%) 7 (6.9%)
Change BCLC Staging, N (%) 6 (5.9%)
Change TNM Staging, N (%) 14 (13.9%)
Change Management, N (%) 10 (9.9%)
Metastatic lymphadenopathy
FDG PET/CT changes BCLC staging in treatment naïve
patients
BCLC staging
based on
Cross-sectional
Imaging
BCLC staging based on Cross-sectional Imaging plus PET-CT (n=101)
BCLC 0 BCLC A BCLC B BCLC C BCLC D
BCLC 0 5 0 0 1 0
BCLC A 0 40 1 0 0
BCLC B 0 0 23 4 0
BCLC C 0 0 0 17 0
BCLC D 0 0 0 0 10
FDG PET/CT changes HCC staging and management in
treatment naïve patients
Number of PET-CT Studies 101
Detect Extrahepatic Metastasis, N (%) 12 (11.9%)
Detect Intrahepatic Lesion, N (%) 7 (6.9%)
Change BCLC Staging, N (%) 6 (5.9%)
Change TNM Staging, N (%) 14 (13.9%)
Change Management, N (%) 10 (9.9%)
Change in Management-Rx naive
Additional loco-regional: 2%
Change to Systemic therapy: 6%
Change to Best Supportive Care: 2%
FDG PET/CT changes HCC staging and management in
treatment experienced patients (n=80)
No of PET/CT Studies 80
Detect Extrahepatic Metastasis, N (%) 13 (16.3)
Detect Intrahepatic Lesion, N (%) 7 (8.8)
Detect Recurrence, N (%) 15 (18.8)
Change BCLC Staging, N (%) 15 (18.8)
Change TNM Staging, N (%) 17 (21.3)
Change Management, N (%) 17 (21.3)
FDG PET/CT changes HCC staging and management in
treatment experienced patients
No of PET/CT Studies 80
Detect Extrahepatic Metastasis, N (%) 13 (16.3)
Detect Intrahepatic Lesion, N (%) 7 (8.8)
Detect Recurrence, N (%) 15 (18.8)
Change BCLC Staging, N (%) 15 (18.8)
Change TNM Staging, N (%) 17 (21.3)
Change Management, N (%) 17 (21.3)
FDG PET/CT changes HCC staging and management in
treatment experienced patients
No of PET/CT Studies 80
Detect Extrahepatic Metastasis, N (%) 13 (16.3)
Detect Intrahepatic Lesion, N (%) 7 (8.8)
Detect Recurrence, N (%) 15 (18.8)
Change BCLC Staging, N (%) 15 (18.8)
Change TNM Staging, N (%) 17 (21.3)
Change Management, N (%) 17 (21.3)
FDG PET/CT in treatment experienced
FDG PET/CT changes BCLC staging in treatment
experienced patients
BCLC staging
based on
Cross-sectional
Imaging
BCLC staging based on Cross-sectional Imaging plus PET-CT (n=80)
BCLC 0 BCLC A BCLC B BCLC C BCLC D
BCLC 0 17 7 0 3 0
BCLC A 0 19 0 2 0
BCLC B 0 0 13 3 0
BCLC C 0 0 0 10 0
BCLC D 0 0 0 0 6
FDG PET/CT changes HCC staging and management in
treatment experienced patients
No of PET/CT Studies 80
Detect Extrahepatic Metastasis, N (%) 13 (16.3)
Detect Intrahepatic Lesion, N (%) 7 (8.8)
Detect Recurrence, N (%) 15 (18.8)
Change BCLC Staging, N (%) 15 (18.8)
Change TNM Staging, N (%) 17 (21.3)
Change Management, N (%) 17 (21.3)
Change in Management-Rx Experienced
Additional LRT: 10%
Change from LRT to Systemic: 7.5%
Change to Best Supportive Care: 3.8%
Limitations
Single center study
Selection bias: Patients with higher risk of
recurrence may have enrolled
Ascertainment bias
All patients underwent standardized protocol
imaging
Lack of tissue and serum precluded biomarker
correlation with FDG uptake
Conclusion
• PET-CT accurately change BCLC and TNM staging : 6%
of Rx naïve, 19% Rx experienced
• Detected extrahepatic metastasis that were
indeterminate on cross-sectional imaging, differentiating
metastatic from reactive lymphadenopathy
• Useful in differentiating early post-treatment hyperemia
from residual disease/recurrence
• Resulted in change in management of one in six patients
overall