Evaluation of benign vs malignant hepatic lesions with positron emission tomography

Background: In most malignant cells, the relatively low level of glucose-6-phosphatase leads to accumulation and trapping of [F-18]fluorodeoxyglucose (EDG) intracellularly, allowing the visualization of increased uptake compared with normal cells. Objectives: To assess the value of FDG positron emission tomography (PET) to differentiate benign from malignant hepatic lesions and to determine in which types of hepatic tumors PET can help evaluate stage, monitor response to therapy, and detect recurrence. Design: Prospective blinded-comparison clinical cohort study. Setting: Tertiary care university hospital and clinic. Patients: One hundred ten consecutive referred patients with hepatic lesions 1 cm or larger on screening computed tomographic (CT) images who were seen for evaluation and potential resection underwent PET imaging. There were 60 men and 50 women with a mean (+/-SD) age of 59 +/- 14 years. Follow-up was 100%. Interventions: A PET scan using static imaging was performed on all patients. The PET scan imaging and biopsy, surgery, or both were performed, providing pathological samples within 2 months of PET imaging. All PET images were correlated with CT scan to localize the lesion. However, PET investigators were unaware of any previous interpretation of the CT scan. Main Outcome Measures: Visual interpretation, lesion-to-normal liver background (VB) ratio of radioactivity, and standard uptake value (SUV) were correlated with pathological diagnosis. Results: All (100%) liver metastases from adenocarcinoma and sarcoma primaries in 66 patients and all cholangiocarcinomas in 8 patients had increased uptake values, LIE ratios greater than 2, and an SUV greater than 3.5. Hepatocellular carcinoma had increased FDG uptake in 16 of 23 patients and poor uptake in 7 patients. All benign hepatic lesions (n = 23), including adenoma and fibronodular hyperplasia, had poor uptake, an YB ratio of less than 2, and an SUV less than 3.5, except for 1 of 3 abscesses that had definite uptake. Conclusions: The PET technique using FDG static imaging was useful to differentiate malignant from benign lesions in the liver. Limitations include false-positive results in a minority of abscesses and false-negative results in a minority of hepatocellular carcinoma. The PET technique was useful in tumor staging and detection of recurrence, as well as monitoring response to therapy for all adenocarcinomas and sarcomas and most hepatocellular carcinomas. Therefore, pretherapy PET imaging is recommended to help assess new hepatic lesions.