Impact of 18F-FDG-PET/CT on Clinical Management in Patients with Cholangiocellular Carcinoma

Abstract

Objective: To determine the impact of ¹⁸F-FDG-PET/CT on clinical management of patients with cholangiocellular carcinoma (CCA).

Methods: Patients with CCA undergoing clinically indicated ¹⁸F-FDG-PET/CT between 04/2013 and 08/2018 were prospectively included in a local PET/CT registry study. Intended clinical management ("non-treatment" such as watchful-waiting or additional diagnostic tests, and "palliative" or "curative treatment") was recorded before and after PET/CT. Changes in intended management after PET/CT were analyzed.

Results: 27 patients (mean age: 60 years, IQR: 51.5-67.5 years, 56% males) with 43 PET/CT examinations were included. Intended management changed in 35/43 cases (81.4%) following PET/CT. Major changes (i.e., between "non-treatment" and "treatment" strategies or between a "curative" and "palliative" treatment goal) occurred in 27/43 (62.8%) cases. Before PET/CT, additional imaging and/or biopsy were intended in 21/43 (48.8%) and 9/43 (20.9%) cases, respectively. After PET/CT, further imaging was carried out in one case and imaging-targeted biopsy in eight cases. Although the absolute number of biopsies after PET/CT did not decrease, in only one of these eight cases biopsy had already been planned before PET/CT, whereas in the other eight cases, the originally planned biopsies were dispensable after PET/CT.

Conclusions: ¹⁸F-FDG-PET/CT significantly impacts clinical management of patients with CCA. It guides decisions on treatment strategy (especially curative vs palliative treatment goal) and on additional tests, particularly by helping referring clinicians to avoid unnecessary imaging and by guiding targeted biopsy.

Advances in knowledge: Systematic implementation of ¹⁸F-FDG-PET/CT may enable a more appropriate and tailored treatment of patients with CCA, especially in cases of suspected recurrence.

Figure 1.

Definition of changes in clinical management in patients with CCA.

Figure 2.

Sankey diagram showing the frequency of changes in the “treatment” and “non-treatment” management category under consideration of the treatment goal after ¹⁸F-FDG-PET/CT in 27 patients with CCA. The widths of the bands are directly proportional to the number of PET/CT scans (N = 43).

Figure 3.

Sankey diagram showing the frequency of changes in the demand for additional tests (imaging and/or biopsy) after ¹⁸F-FDG-PET/CT in 27 patients with CCA. The widths of the bands are directly proportional to the number of PET/CT scans (N = 43).

Figure 4.

Survival of 27 patients with CCA after the first ¹⁸F-FDG-PET/CT examination. A Overall survival of all 27 patients (mean survival time after first ¹⁸F-FDG-PET/CT examination: 1.81 years (95% CI 1.29–2.34 years)). B Overall survival after first ¹⁸F-FDG-PET/CT examination of patients in whom a “curative treatment” regimen was intended after PET/CT (N = 6) (mean survival time: 2.21 years (95% CI 0.76–3.66 years), and in whom a “palliative treatment” regimen was intended after PET/CT (N = 12) (mean survival time: 1.21 years (95% CI 0.72–1.69 years).

Figure 5.

Example of a 36-year-old female patient with recurrent CCA in the left liver lobe after right hemihepatectomy and systemic chemotherapy (gemcitabine/cisplatin), not detected on CT and MRI. Recurrence was suspected clinically by elevated tumor markers (CA 19.9). Before PET/CT, clinicians intended further imaging and biopsy to prove suspected recurrence, and revised their “non-treatment” strategy into a “palliative treatment” goal (with change of chemotherapy regimen) after PET/CT (major change).