Prediction of surgical resectability in patients with hepatic colorectal metastases.

OBJECTIVE: To evaluate the efficacy of two distinct imaging techniques to predict, before operation, unresectability compared with standard computed tomographic scan (CT).

SUMMARY BACKGROUND: Accurate preoperative identification of the number, size, and location of hepatic lesions is crucial in planning hepatic resection for colorectal hepatic metastases. Although infusion-enhanced CT is the standard, its limitations are the imaging of relatively isodense and/or small (< 1 cm) lesions. The increased sensitivity of CT arterial portography (CTAP) may be offset by false-positive results caused by benign lesions and flow artifacts.

METHODS: Fifty-eight selected patients considered to be eligible for resection by standard CT had laparotomy. Before operation and in addition to CT, all patients had CT arterial portography and hepatic artery perfusion scintigraphy (HAPS) using radiolabeled macroaggregated albumin. Early studies showed an increased sensitivity for detecting small lesions using the invasive CTAP. Similarly, the HAPS study has detected malignant lesions not observed by standard CT.

RESULTS: Of 58 patients having laparotomy, 40 were resectable by either lobectomy (22) or trisegmentectomy (1) and the rest by single or multiple wedge resections. Eighteen patients could not be resected because of combined intra- and extrahepatic disease or the number and location of metastases. Standard CT detected 64% of all lesions (12% of lesions less than 1 cm). Unresectability was accurately predicted by CTAP and HAPS in 16 (88%) and 15 (83%), respectively, of the 18 patients considered ineligible for resection at laparotomy. Of the 40 patients who had resection for possible cure, CTAP and HAPS falsely predicted unresectability in 6 of 40 patients (15%) and in 10 of 40 patients (25%), respectively. The positive predictive value for unresectability of CTAP and HAPS was 73% and 60%, respectively. False-positive lesions after CTAP included hemangiomas, cysts, granulomas, and flow artifacts. False-positive HAPS lesions included patients in whom no tumor was found at surgery but with some identified by intraoperative ultrasound, blind biopsy, and blind resection.

CONCLUSIONS: False-positive results by HAPS and CTAP may limit the ability of these tests to accurately predict unresectability before operation and may deny patients the chance for surgical resection. The HAPS study does, however, detect small lesions not seen by CT or CTAP. Standard CT, although less sensitive, followed by surgery and intraoperative ultrasound, does not necessarily preclude patients who could be resected.