CardioVascular and Interventional Radiology

, Volume 42, Issue 1, pp 60–68 | Cite as

Real-Time US-18FDG-PET/CT Image Fusion for Guidance of Thermal Ablation of 18FDG-PET-Positive Liver Metastases: The Added Value of Contrast Enhancement

  • Giovanni MauriEmail author
  • Nicolò Gennaro
  • Stefano De Beni
  • Tiziana Ierace
  • S. Nahum Goldberg
  • Marcello Rodari
  • Luigi Alessandro Solbiati
Clinical Investigation Interventional Oncology
Part of the following topical collections:
  1. Interventional Oncology



To assess the feasibility of US-18FDG-PET/CT fusion-guided microwave ablation of liver metastases either poorly visible or totally undetectable with US, CEUS and CT, but visualized by PET imaging.

Materials and Methods

Twenty-three patients with 58 liver metastases underwent microwave ablation guided by image fusion system that combines US with 18FDG-PET/CT images. In 28/58 tumors, 18FDG-PET/CT with contrast medium (PET/CECT) was used. The registration technical feasibility, registration time, rates of correct targeting, technical success at 24 h, final result at 1 year and complications were analyzed and compared between the PET/CT and PET/CECT groups.


Registration was successfully performed in all cases with a mean time of 7.8 + 1.7 min (mean + standard deviation), (4.6 + 1.5 min for PET/CECT group versus 10.9 + 1.8 min for PET/CT group, P < 0.01). In total, 46/58 (79.3%) tumors were correctly targeted, while 3/28 (10.7%) and 9/30 (30%) were incorrectly targeted in PET/CT and PET/CECT group, respectively (P < 0.05). Complete ablation was obtained at 24 h in 70.0% of cases (n = 40 tumors), 23/28 (82.1%) in the PET/CECT group and 17/30 (56.7%) in the PET/CT group (P < 0.037). Fourteen tumors underwent local retreatment (11 ablations, 2 with resection and 1 with stereotactic body radiation therapy), while 4 tumors could not be retreated because of distant disease progression and underwent systemic therapy. Finally, 54/58 (93.1%) tumors were completely treated at 1 year. One major complication occurred, a gastrointestinal hemorrhage which required surgical repair.


Percutaneous ablation of 18FDG-PET-positive liver metastases using fusion imaging of real-time US and pre-acquired 18FDG-PET/CT images is feasible, safe and effective. Contrast-enhanced PET/CT improves overall ablation accuracy and shortens procedural duration time.


Thermal ablation Fusion imaging Liver Metastasis Ultrasound PET 



Contrast-enhanced computed tomography


Contrast-enhanced ultrasound


Computed tomography


18Fluorodeoxyglucose positron emission tomography


Magnetic resonance imaging


Positron emission tomography




Stereotactic body radiation therapy


Compliance with Ethical Standards

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. Giovanni Mauri received consultancy fee from Elesta Srl, speaker honorarium from Guerbet and travel support from RGG. S. Nahum Goldberg performs unrelated consulting for Angiodynamics and Cosman Instruments.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Consent for Publication

Consent for publication was obtained from all individual participants included in the study.


  1. 1.
    Solbiati L, Ahmed M, Cova L, et al. Small liver colorectal metastases treated with percutaneous radiofrequency ablation: local response rate and long-term survival with up to 10-year follow-up. Radiology. 2012;265:958–68. Scholar
  2. 2.
    Mauri G, Cova L, De Beni S, et al. Real-time US-CT/MRI image fusion for guidance of thermal ablation of liver tumors undetectable with US: results in 295 cases. Cardiovasc Intervent Radiol. 2015;38:143–51. Scholar
  3. 3.
    Dong Y, Wang W-P, Mao F, et al. Application of imaging fusion combining contrast-enhanced ultrasound and magnetic resonance imaging in detection of hepatic cellular carcinomas undetectable by conventional ultrasound. J Gastroenterol Hepatol. 2016;31:822–8. Scholar
  4. 4.
    Liu F-Y, Yu X-L, Liang P, et al. Microwave ablation assisted by a real-time virtual navigation system for hepatocellular carcinoma undetectable by conventional ultrasonography. Eur J Radiol. 2012;81:1455–9. Scholar
  5. 5.
    Hakime A, Deschamps F, De Carvalho EGM, et al. Clinical evaluation of spatial accuracy of a fusion imaging technique combining previously acquired computed tomography and real-time ultrasound for imaging of liver metastases. Cardiovasc Intervent Radiol. 2011;34:338–44. Scholar
  6. 6.
    Lee MW. Fusion imaging of real-time ultrasonography with CT or MRI for hepatic intervention. Ultrasonography. 2014;33:227–39. Scholar
  7. 7.
    Hustinx R, Bénard F, Alavi A. Whole-body FDG-PET imaging in the management of patients with cancer. Semin Nucl Med. 2002;32:35–46. Scholar
  8. 8.
    Oriuchi N, Higuchi T, Ishikita T, et al. Present role and future prospects of positron emission tomography in clinical oncology. Cancer Sci. 2006;97:1291–7. Scholar
  9. 9.
    Pauwels EK, Ribeiro MJ, Stoot JH, et al. FDG accumulation and tumor biology. Nucl Med Biol. 1998;25:317–22.CrossRefGoogle Scholar
  10. 10.
    Wiering B, Ruers TJM, Krabbe PFM, et al. Comparison of multiphase CT, FDG-PET and intra-operative ultrasound in patients with colorectal liver metastases selected for surgery. Ann Surg Oncol. 2007;14:818–26. Scholar
  11. 11.
    Shyn PB. Interventional positron emission tomography/computed tomography: state-of-the-art. Tech Vasc Interv Radiol. 2013;16:182–90. Scholar
  12. 12.
    Tatli S, Gerbaudo VH, Mamede M, et al. Abdominal masses sampled at PET/CT-guided percutaneous biopsy: initial experience with registration of prior PET/CT images. Radiology. 2010;256:305–11. Scholar
  13. 13.
    Shyn PB, Tatli S, Sahni VA, et al. PET/CT-guided percutaneous liver mass biopsies and ablations: targeting accuracy of a single 20 s breath-hold PET acquisition. Clin Radiol. 2014;69:410–5. Scholar
  14. 14.
    Ryan ER, Thornton R, Sofocleous CT, et al. PET/CT-guided interventions: personnel radiation dose. Cardiovasc Intervent Radiol. 2013;36:1063–7. Scholar
  15. 15.
    Ryan ER, Sofocleous CT, Schöder H, et al. Split-dose technique for FDG PET/CT-guided percutaneous ablation: a method to facilitate lesion targeting and to provide immediate assessment of treatment effectiveness. Radiology. 2013;268:288–95. Scholar
  16. 16.
    Tatli S, Gerbaudo VH, Feeley CM, et al. PET/CT-guided percutaneous biopsy of abdominal masses: initial experience. J Vasc Interv Radiol. 2011;22:507–14. Scholar
  17. 17.
    Cornelis F, Petre EN, Vakiani E, et al. Immediate post-ablation FDG-injection and corresponding standardized uptake value is a surrogate biomarker of local tumor progression after thermal ablation of colorectal carcinoma liver metastases. J Nucl Med. 2018. Scholar
  18. 18.
    Cornelis F, Sotirchos V, Violari E, et al. 18F-FDG PET/CT is an immediate imaging biomarker of treatment success after liver metastasis ablation. J Nucl Med. 2016;57:1052–7. Scholar
  19. 19.
    Sotirchos VS, Petrovic LM, Gönen M, et al. Colorectal cancer liver metastases: biopsy of the ablation zone and margins can be used to predict oncologic outcome. Radiology. 2016;280:949–59. Scholar
  20. 20.
    Klaeser B, Mueller MD, Schmid RA, et al. PET-CT-guided interventions in the management of FDG-positive lesions in patients suffering from solid malignancies: initial experiences. Eur Radiol. 2009;19:1780–5. Scholar
  21. 21.
    Di Mauro E, Solbiati M, De Beni S, et al. Virtual navigator real-time ultrasound fusion imaging with positron emission tomography for liver interventions. Conf Proc IEEE Eng Med Biol Soc. 2013;2013:1406–9. Scholar
  22. 22.
    Venkatesan AM, Kadoury S, Abi-Jaoudeh N, et al. Real-time FDG PET guidance during biopsies and radiofrequency ablation using multimodality fusion with electromagnetic navigation. Radiology. 2011;260:848–56. Scholar
  23. 23.
    Appelbaum L, Solbiati L, Sosna J, et al. Evaluation of an electromagnetic image-fusion navigation system for biopsy of small lesions: assessment of accuracy in an in vivo swine model. Acad Radiol. 2013;20:209–17. Scholar
  24. 24.
    Shady W, Petre EN, Gonen M, et al. Percutaneous radiofrequency ablation of colorectal cancer liver metastases: factors affecting outcomes–a 10-year experience at a single center. Radiology. 2016;278:601–11. Scholar
  25. 25.
    Shady W, Petre EN, Do KG, et al. Percutaneous microwave versus radiofrequency ablation of colorectal liver metastases: ablation with clear margins (A0) provides the best local tumor control. J Vasc Interv Radiol. 2018;29(268–275):e1. Scholar
  26. 26.
    Calandri M, Yamashita S, Gazzera C, et al. Ablation of colorectal liver metastasis: interaction of ablation margins and RAS mutation profiling on local tumour progression-free survival. Eur Radiol. 2018;28:2727–34. Scholar
  27. 27.
    Ahmed M, Solbiati L, Brace CL, et al. Image-guided tumor ablation: standardization of terminology and reporting criteria–a 10-year update. Radiology. 2014;273:241–60. Scholar
  28. 28.
    Filippiadis DK, Binkert C, Pellerin O, et al. Cirse quality assurance document and standards for classification of complications: the cirse classification system. Cardiovasc Intervent Radiol. 2017;40:1141–6. Scholar
  29. 29.
    Mauri G, Cova L, Tondolo T, et al. Percutaneous laser ablation of metastatic lymph nodes in the neck from papillary thyroid carcinoma: preliminary results. J Clin Endocrinol Metab. 2013;98:E1203–7. Scholar
  30. 30.
    Gadaleta CD, Solbiati L, Mattioli V, et al. Unresectable lung malignancy: combination therapy with segmental pulmonary arterial chemoembolization with drug-eluting microspheres and radiofrequency ablation in 17 patients. Radiology. 2013;267:627–37. Scholar
  31. 31.
    Hakime A, Yevich S, Tselikas L, et al. Percutaneous thermal ablation with ultrasound guidance. fusion imaging guidance to improve conspicuity of liver metastasis. Cardiovasc Intervent Radiol. 2017;40:721–7. Scholar
  32. 32.
    Mauri G, Porazzi E, Cova L, et al. Intraprocedural contrast-enhanced ultrasound (CEUS) in liver percutaneous radiofrequency ablation: clinical impact and health technology assessment. Insights Imaging. 2014;5:209–16. Scholar
  33. 33.
    Solbiati L, Ierace T, Tonolini M, Cova L. Guidance and monitoring of radiofrequency liver tumor ablation with contrast-enhanced ultrasound. Eur J Radiol. 2004;51(Suppl):S19–23.CrossRefGoogle Scholar
  34. 34.
    Shyn PB, Mauri G, Alencar RO, et al. Percutaneous imaging-guided cryoablation of liver tumors: predicting local progression on 24-hour MRI. AJR Am J Roentgenol. 2014;203:W181–91. Scholar
  35. 35.
    Rempp H, Waibel L, Hoffmann R, et al. MR-guided radiofrequency ablation using a wide-bore 1.5-T MR system: clinical results of 213 treated liver lesions. Eur Radiol. 2012;22:1972–82. Scholar
  36. 36.
    Shady W, Petre EN, Vakiani E, et al. Kras mutation is a marker of worse oncologic outcomes after percutaneous radiofrequency ablation of colorectal liver metastases. Oncotarget. 2017;8:66117–27. Scholar
  37. 37.
    Odisio BC, Yamashita S, Huang SY, et al. Local tumour progression after percutaneous ablation of colorectal liver metastases according to RAS mutation status. Br J Surg. 2017;104:760–8. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2018

Authors and Affiliations

  • Giovanni Mauri
    • 1
    Email author
  • Nicolò Gennaro
    • 2
  • Stefano De Beni
    • 3
  • Tiziana Ierace
    • 4
  • S. Nahum Goldberg
    • 5
    • 6
  • Marcello Rodari
    • 7
  • Luigi Alessandro Solbiati
    • 4
    • 8
  1. 1.Department of Interventional RadiologyIEO, European Institute of Oncology IRCCSMilanItaly
  2. 2.Training School in RadiologyHumanitas UniversityPieve Emanuele, MilanItaly
  3. 3.Esaote S.p.AGenoaItaly
  4. 4.Department of RadiologyIRCCS Humanitas Clinical and Research HospitalRozzano, MilanItaly
  5. 5.Department of RadiologyHadassah Hebrew University Medical CentreJerusalemIsrael
  6. 6.Department of RadiologyBeth Israel Deaconess Medical CenterBostonUSA
  7. 7.Department of Nuclear MedicineIRCCS Humanitas Clinical and Research HospitalRozzano, MilanItaly
  8. 8.Department of Biomedical SciencesHumanitas UniversityPieve Emanuele, MilanItaly

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