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%)


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%)


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%)


treatment naïve patients







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


treatment naïve patients







Change in Management-Rx naive

Additional loco-regional: 2%

Change to Systemic therapy: 6%

Change to Best Supportive Care: 2%


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)


treatment experienced patients








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


treatment experienced patients








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

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