A Prospective Evaluation of¹⁸F-FDG and¹¹C-Acetate PET/CT for Detection of Primary and Metastatic Hepatocellular Carcinoma

Abstract

Because 18 F-FDG PET has insufficient sensitivity for the detection of hepatocellular carcinoma (HCC), 11 C-acetate PET has been proposed as another technique for this use. We prospectively evaluated the value of PET/CT using these 2 tracers for the detection of primary and metastatic HCC. Methods: One hundred twelve patients (99 with HCC, 13 with cholangiocellular carcinoma) underwent biopsy and 18 F-FDG and 11 C-acetate PET/CT. Results: The overall sensitivities of 18 F-FDG, 11 C-acetate, and dual-tracer PET/CT in the detection of 110 lesions in 90 patients with primary HCC were 60.9%, 75.4%, and 82.7%, respectively. Elevated serum a-fetoprotein levels, an advanced tumor stage, portal vein tumor thrombosis, large tumors, and multiple tumors were significantly associated with positive 18 F-FDG PET/CT results. Uptake of 11 C-acetate was associated with large and multiple tumors. For 18 F-FDG, the sensitivities according to tumor size (1-2, 2-5, and $5 cm) were 27.2%, 47.8%, and 92.8%, respectively; for 11 C-acetate, these respective values were 31.8%, 78.2%, and 95.2%. 18 F-FDG was more sensitive in the detection of poorly differentiated HCC. Overall survival was lower in patients with 18 F-FDG PET/CT positive for all indexed lesions than in those with FDG negative or partially positive through the entire follow-up period. In analysis based on biopsied lesions, the sensitivity of 18 F-FDG PET/CT was 64.4% for primary HCC and 84.4% for 11 C-acetate PET/CT. The overall sensitivities of 18 F-FDG, 11 C-acetate, and dual-tracer PET/CT for 35 metastatic HCCs were 85.7%, 77.0%, and 85.7%, respectively. There was no significant difference in the sensitivity of tracers according to metastatic tumor size, location, or differentiation. Conclusion: The addition of 11 C-acetate to 18 F-FDG PET/CT increases the overall sensitivity for the detection of primary HCC but not for the detection of extrahepatic metastases. 18 F-FDG, 11 C-acetate, and dual-tracer PET/CT have a low sensitivity for the detection of small primary HCC, but 18 F-FDG PET/CT has a relatively high sensitivity for the detection of extrahepatic metastases of HCC.

Detection of Hepatocellular Carcinoma with PET/CT: A Prospective Comparison of18F-Fluorocholine and18F-FDG in Patients with Cirrhosis or Chronic Liver Disease

“…The observed uptake of a lipid tracer by cholangiocarcinoma is in accordance with the results of Park et al (25): a 69% (9/13) detection rate for 11 C-acetate versus 100% for 18 F-FDG. However, in a previous study, none of the 3 cholangiocarcinoma patients was 11 C-acetate PET-positive (17).…”

“…As we expected when designing the study, the diagnostic performance of 18 F-fluorocholine for the detection of intrahepatic HCC was close to published values for 11 C-acetate, with a sensitivity ranging from 75% to 87% (18,25). Using 11 C-choline PET and considering only foci with increased uptake as positive, Yamamoto et al (22) recently reported a lesion-based sensitivity of 63% only.…”

“…Concerning PET detection of distant metastases of HCC, a trend for a better sensitivity for 18 F-FDG than for 11 Cacetate has been reported, but diagnostic performance improved by performing PET/CT examinations with both radiopharmaceuticals (25,26). In the present study, there was only one histologically proven metastasis of HCC, and no conclusion can be drawn.…”

Underestimated Role of 18F-FDG PET for HCC Evaluation and Promise of 18F-FDG PET/MR Imaging in This Setting

“…In fact, we have also published on the role of 18 F-FDG in the detection of poorly differentiated HCC and microvascular invasion for patients receiving a liver transplant. Patients with HCC tumors avid for 18 F-FDG have significantly less favorable overall survival and an increased chance of HCC recurrence (4).…”

Whole-body PET/MRI in oncology: current status and clinical applications

“…FDG PET/CT has a low sensitivity in hepatic primary tumors (hepatocellular cancer), with radiotracers other than FDG showing better results [35]. No data on PET/MRI in this setting have been published so far; however, it is conceivable that combined PET/MRI, with the addition of fMRI, would perform as well as MRI alone.…”