Journal of Gastrointestinal Surgery

, Volume 11, Issue 9, pp 1112–1119 | Cite as

Chemotherapy-Induced Normalization of FDG Uptake by Colorectal Liver Metastases Does Not Usually Indicate Complete Pathologic Response

  • Marcus C. B. Tan
  • David C. Linehan
  • William G. Hawkins
  • Barry A. Siegel
  • Steven M. StrasbergEmail author


Dramatic responses are being observed in colorectal cancer liver metastases treated with newer chemotherapeutic regimens. These have been associated with normalization of [18F]fluoro-2-deoxy-d-glucose (FDG) uptake (complete metabolic response) on follow-up Positron Emission Tomography with [18F]fluoro-2-deoxy-d-glucose (FDG-PET) scans in some patients. It is unclear how often complete metabolic response is indicative of complete tumor destruction. We analyzed a subset of patients who had neoadjuvant chemotherapy for hepatic metastases from colorectal adenocarcinoma. Inclusion criteria were: (1) FDG-avid hepatic lesions before initiation of chemotherapy; (2) complete metabolic response of the same lesions after chemotherapy; and (3) histopathologic examination of hepatic lesions. Complete pathologic response was defined as no histologically identifiable viable tumor. Fourteen patients fit the inclusion criteria. All had synchronous, hepatic-only colorectal metastases. On microscopic examination, complete pathologic response to the neoadjuvant regimen was found in only 5 of 34 lesions (15%) and in only 3 of the 14 patients (21%). Seven lesions had complete metabolic response and disappeared on computed tomography (CT); of these, six still contained viable tumor. We conclude that complete metabolic response on FDG-PET after neoadjuvant chemotherapy is an unreliable indicator of complete pathologic response. Therefore, currently, curative resection of liver metastases in these patients should not be deferred on the basis of FDG-PET findings.


Colorectal cancer Hepatic metastasis FDG-PET Response to therapy Chemotherapy 



The authors would like to thank Dr. James Lewis, Jr., (Department of Pathology, Washington University School of Medicine) for assistance with the figures.

Authors’ Disclosures of Potential Conflicts of Interest



  1. 1.
    Fernandez FG, Drebin JA, Linehan DC, Dehdashti F, Siegel BA, Strasberg SM. Five-year survival after resection of hepatic metastases from colorectal cancer in patients screened by positron emission tomography with F-18 fluorodeoxyglucose (FDG-PET). Ann Surg 2004;240:438–447.PubMedCrossRefGoogle Scholar
  2. 2.
    Fong Y, Fortner J, Sun RL, Brennan MF, Blumgart LH. Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1001 consecutive cases. Ann Surg 1999;230:309–318.PubMedCrossRefGoogle Scholar
  3. 3.
    Jaeck D, Bachellier P, Guiguet M, Boudjema K, Vaillant JC, Balladur P, Nordlinger B. Long-term survival following resection of colorectal hepatic metastases. Association Francaise de Chirurgie. Br J Surg 1997;84:977–980.PubMedCrossRefGoogle Scholar
  4. 4.
    Scheele J, Stang R, Altendorf-Hofmann A, Paul M. Resection of colorectal liver metastases. World J Surg 1995;19:59–71.PubMedCrossRefGoogle Scholar
  5. 5.
    Stangl R, Altendorf-Hofmann A, Charnley RM, Scheele J. Factors influencing the natural history of colorectal liver metastases. Lancet 1994;343:1405–1410.PubMedCrossRefGoogle Scholar
  6. 6.
    Goldberg RM, Sargent DJ, Morton RF, Fuchs CS, Ramanathan RK, Williamson SK, Findlay BP, Pitot HC, Alberts SR. A randomized controlled trial of fluorouracil plus leucovorin, irinotecan, and oxaliplatin combinations in patients with previously untreated metastatic colorectal cancer. J Clin Oncol 2004;22:23–30.PubMedCrossRefGoogle Scholar
  7. 7.
    Souglakos J, Androulakis N, Syrigos K, Polyzos A, Ziras N, Athanasiadis A, Kakolyris S, Tsousis S, Kouroussis C, Vamvakas L, Kalykaki A, Samonis G, Mavroudis D, Georgoulias V. FOLFOXIRI (folinic acid, 5-fluorouracil, oxaliplatin and irinotecan) vs FOLFIRI (folinic acid, 5-fluorouracil and irinotecan) as first-line treatment in metastatic colorectal cancer (MCC): a multicentre randomised phase III trial from the Hellenic Oncology Research Group (HORG). Br J Cancer 2006;94:798–805.PubMedCrossRefGoogle Scholar
  8. 8.
    Tournigand C, Andre T, Achille E, Lledo G, Flesh M, Mery-Mignard D, Quinaux E, Couteau C, Buyse M, Ganem G, Landi B, Colin P, Louvet C, de Gramont A. FOLFIRI followed by FOLFOX6 or the reverse sequence in advanced colorectal cancer: a randomized GERCOR study. J Clin Oncol 2004;22:229–237.PubMedCrossRefGoogle Scholar
  9. 9.
    Giantonio BJ, Levy DE, O’dwyer PJ, Meropol NJ, Catalano PJ, Benson AB, III. A phase II study of high-dose bevacizumab in combination with irinotecan, 5-fluorouracil, leucovorin, as initial therapy for advanced colorectal cancer: results from the Eastern Cooperative Oncology Group study E2200. Ann Oncol 2006;17:1399–1403.PubMedCrossRefGoogle Scholar
  10. 10.
    Hurwitz H, Fehrenbacher L, Novotny W, Cartwright T, Hainsworth J, Heim W, Berlin J, Baron A, Griffing S, Holmgren E, Ferrara N, Fyfe G, Rogers B, Ross R, Kabbinavar F. Bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer. N Engl J Med 2004;350:2335–2342.PubMedCrossRefGoogle Scholar
  11. 11.
    Kabbinavar FF, Schulz J, McCleod M, Patel T, Hamm JT, Hecht JR, Mass R, Perrou B, Nelson B, Novotny WF. Addition of bevacizumab to bolus fluorouracil and leucovorin in first-line metastatic colorectal cancer: results of a randomized phase II trial. J Clin Oncol 2005;23:3697–3705.PubMedCrossRefGoogle Scholar
  12. 12.
    Bipat S, van Leeuwen MS, Comans EF, Pijl ME, Bossuyt PM, Zwinderman AH, Stoker J. Colorectal liver metastases: CT, MR imaging, and PET for diagnosis-meta-analysis. Radiology 2005;237:123–131.PubMedCrossRefGoogle Scholar
  13. 13.
    Huebner RH, Park KC, Shepherd JE, Schwimmer J, Czernin J, Phelps ME, Gambhir SS. A meta-analysis of the literature for whole-body FDG PET detection of recurrent colorectal cancer. J Nucl Med 2000;41:1177–1189.PubMedGoogle Scholar
  14. 14.
    Kinkel K, Lu Y, Both M, Warren RS, Thoeni RF. Detection of hepatic metastases from cancers of the gastrointestinal tract by using noninvasive imaging methods (US, CT, MR imaging, PET): a meta-analysis. Radiology 2002;224:748–756.PubMedCrossRefGoogle Scholar
  15. 15.
    Yang YYL, Fleshman JW, Strasberg SM. Detection and management of extrahepatic colorectal cancer in patients with resectable liver metastases. J Gastrointest Surg 2007;11:929. Published online at:DOI  10.1007/s11605-006-0067-x.Google Scholar
  16. 16.
    Therasse P, Arbuck SG, Eisenhauer EA, Wanders J, Kaplan RS, Rubinstein L, Verweij J, Van Glabbeke M, van Oosterom AT, Christian MC, Gwyther SG. New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada. J Natl Cancer Inst 2000;92:205–216.PubMedCrossRefGoogle Scholar
  17. 17.
    The terminology committee of the IHPBA. The Brisbane 2000 terminology of hepatic anatomy and resections. HPB 2000;2:333–339.Google Scholar
  18. 18.
    Kostakoglu L, Agress H, Jr., Goldsmith SJ. Clinical role of FDG PET in evaluation of cancer patients. Radiographics 2003;23:315–340.PubMedCrossRefGoogle Scholar
  19. 19.
    Kostakoglu L, Goldsmith SJ. 18F-FDG PET evaluation of the response to therapy for lymphoma and for breast, lung, and colorectal carcinoma. J Nucl Med 2003;44:224–239.PubMedGoogle Scholar
  20. 20.
    Kostakoglu L, Goldsmith SJ. PET in the assessment of therapy response in patients with carcinoma of the head and neck and of the esophagus. J Nucl Med 2004;45:56–68.PubMedGoogle Scholar
  21. 21.
    Weber WA. Use of PET for monitoring cancer therapy and for predicting outcome. J Nucl Med 2005;46:983–995.PubMedGoogle Scholar
  22. 22.
    Swisher SG, Maish M, Erasmus JJ, Correa AM, Ajani JA, Bresalier R, Komaki R, Macapinlac H, Munden RF, Putnam JB, Rice D, Smythe WR, Vaporciyan AA, Walsh GL, Wu TT, Roth JA. Utility of PET, CT, and EUS to identify pathologic responders in esophageal cancer. Ann Thorac Surg 2004;78:1152–1160.PubMedCrossRefGoogle Scholar
  23. 23.
    Wieder HA, Brucher BL, Zimmermann F, Becker K, Lordick F, Beer A, Schwaiger M, Fink U, Siewert JR, Stein HJ, Weber WA. Time course of tumor metabolic activity during chemoradiotherapy of esophageal squamous cell carcinoma and response to treatment. J Clin Oncol 2004;22:900–908.PubMedCrossRefGoogle Scholar
  24. 24.
    Guillem JG, Moore HG, Akhurst T, Klimstra DS, Ruo L, Mazumdar M, Minsky BD, Saltz L, Wong WD, Larson S. Sequential preoperative fluorodeoxyglucose-positron emission tomography assessment of response to preoperative chemoradiation: a means for determining longterm outcomes of rectal cancer. J Am Coll Surg 2004;199:1–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Kelloff GJ, Hoffman JM, Johnson B, Scher HI, Siegel BA, Cheng EY, Cheson BD, O’shaughnessy J, Guyton KZ, Mankoff DA, Shankar L, Larson SM, Sigman CC, Schilsky RL, Sullivan DC. Progress and promise of FDG-PET imaging for cancer patient management and oncologic drug development. Clin Cancer Res 2005;11:2785–2808.PubMedCrossRefGoogle Scholar
  26. 26.
    Akhurst T, Kates TJ, Mazumdar M, Yeung H, Riedel ER, Burt BM, Blumgart L, Jarnagin W, Larson SM, Fong Y. Recent chemotherapy reduces the sensitivity of [18F]fluorodeoxyglucose positron emission tomography in the detection of colorectal metastases. J Clin Oncol 2005;23:8713–8716.PubMedCrossRefGoogle Scholar
  27. 27.
    Goshen E, Davidson T, Zwas ST, Aderka D. PET/CT in the evaluation of response to treatment of liver metastases from colorectal cancer with bevacizumab and irinotecan. Technol Cancer Res Treat 2006;5:37–43.PubMedGoogle Scholar
  28. 28.
    Takahashi S, Kuroki Y, Nasu K, Nawano S, Konishi M, Nakagohri T, Gotohda N, Saito N, Kinoshita T. Positron emission tomography with F-18 fluorodeoxyglucose in evaluating colorectal hepatic metastasis down-staged by chemotherapy. Anticancer Res 2006;26:4705–4711.PubMedGoogle Scholar
  29. 29.
    Benoist S, Brouquet A, Penna C, Julie C, El Hajjam M, Chagnon S, Mitry E, Rougier P, Nordlinger B. Complete response of colorectal liver metastases after chemotherapy: does it mean cure? J Clin Oncol 2006;24:3939–3945.PubMedCrossRefGoogle Scholar
  30. 30.
    Fernandez FG, Ritter J, Goodwin JW, Linehan DC, Hawkins WG, Strasberg SM. Effect of steatohepatitis associated with irinotecan or oxaliplatin pretreatment on resectability of hepatic colorectal metastases. J Am Coll Surg 2005;200:845–853.PubMedCrossRefGoogle Scholar
  31. 31.
    Rubbia-Brandt L, Giostra E, Brezault C, Roth AD, Andres A, Audard V, Sartoretti P, Dousset B, Majno PE, Soubrane O, Chaussade S, Mentha G, Terris B. Importance of histological tumor response assessment in predicting the outcome in patients with colorectal liver metastases treated with neo-adjuvant chemotherapy followed by liver surgery. Ann Oncol 2007;18:299–304.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2007

Authors and Affiliations

  • Marcus C. B. Tan
    • 1
  • David C. Linehan
    • 1
    • 2
  • William G. Hawkins
    • 1
    • 2
  • Barry A. Siegel
    • 2
    • 3
  • Steven M. Strasberg
    • 1
    • 2
    Email author
  1. 1.Section of Hepato–Pancreato–Biliary and GI Surgery, Department of SurgeryWashington University School of MedicineSt. LouisUSA
  2. 2.Alvin J. Siteman Cancer CenterWashington University in Saint LouisSt. LouisUSA
  3. 3.Mallinckrodt Institute of RadiologyWashington University in Saint LouisSt. LouisUSA

Personalised recommendations