Dual-time point images of the liver with 18F-FDG PET/CT in suspected recurrence from colorectal cancer | Revista Española de Medicina Nuclear e Imagen Molecular (English Edition)

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Rebollo-Aguirre, M. Gallego-Peinado, S. Menjón-Beltrán, J. García-García, E. Pastor-Pons, C.E. Chamorro-Santos, C. Ramos-Font, A. Salamanca-Ballesteros, J.M. Llamas-Elvira, N. Olea-Serrano" "autores" => array:10 [ 0 => array:2 [ "nombre" => "Á.C." "apellidos" => "Rebollo-Aguirre" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Gallego-Peinado" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Menjón-Beltrán" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "García-García" ] 4 => array:2 [ "nombre" => "E." "apellidos" => "Pastor-Pons" ] 5 => array:2 [ "nombre" => "C.E." "apellidos" => "Chamorro-Santos" ] 6 => array:2 [ "nombre" => "C." "apellidos" => "Ramos-Font" ] 7 => array:2 [ "nombre" => "A." "apellidos" => "Salamanca-Ballesteros" ] 8 => array:2 [ "nombre" => "J.M." "apellidos" => "Llamas-Elvira" ] 9 => array:2 [ "nombre" => "N." 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Fuster, S. Lafuente, X. Setoain, I. Navales, A. Perissinotti, J. Pavia, P. Paredes, F. Lomeña, F. Pons" "autores" => array:9 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Fuster" "email" => array:1 [ 0 => "dfuster@clinic.ub.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "S." "apellidos" => "Lafuente" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "X." "apellidos" => "Setoain" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "I." "apellidos" => "Navales" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "A." "apellidos" => "Perissinotti" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "J." "apellidos" => "Pavia" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 6 => array:3 [ "nombre" => "P." "apellidos" => "Paredes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "F." "apellidos" => "Lomeña" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 8 => array:3 [ "nombre" => "F." "apellidos" => "Pons" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Clínic, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "18F-FDG PET/TC con imagen hepática en dos tiempos en la sospecha de recidiva del cáncer colorrectal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1167 "Ancho" => 2493 "Tamanyo" => 159573 ] ] "descripcion" => array:1 [ "en" => "(A) Correlation between the hepatic SUVmean obtained in the standard and delayed images. A reduction can be seen in the hepatic SUVmean in the delayed image. (B) Correlation between the SUVmean of the spleen obtained in the standard and delayed images. Stability is seen in the SUVmean of the spleen between the early and delayed images." ] ] ] "textoCompleto" => "IntroductionColorectal cancer is the third most common type of cancer in both men and women and is the second cause of death associated with cancer in the United States of America. The clinical follow-up of these patients usually includes the determination of tumoral markers and the carcinoembryonary antigen (CEA), endoscopy and imaging techniques. Treatment with curative surgery is effective in up to 50% of the cases, although recurrence of colorectal cancer is high, being of up to 30–40% in stages II and III of the disease. An important part of the recurrences appears in only one organ allowing surgical treatment which is vital for the prognosis of the patient.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Colorectal cancer usually disseminates to the regional lymph nodes or the liver through the portal venous circulation. The liver is the most frequent visceral localization and constitutes the initial site of distant metastasis in one third of the patients with recurrence, finally affecting more than two thirds of the patients during the evolution of the disease.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> The treatment of liver metastasis of potentially resectable colorectal cancer is surgical if allowed by the conditions of the patient since it has demonstrated an increase in the survival of the patients.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> However, according to the number of nodes and the presence of risk factors (Fond criteria), the administration of chemotherapy or radiofrequency may be required to complement surgery in partially resectable lesions. Thus, correct staging of the presence of liver metastasis and the number of lesions is necessary to choose the optimum treatment for each patient.At present, the staging and follow-up on the suspicion of recurrence of colorectal cancer are performed by computerized tomography (CT). It has been demonstrated that this technique may have difficulties in differentiating the presence of active disease from changes by fibrosis secondary to the surgery or other treatments or in detecting peritoneal invasion. In this regard several studies have demonstrated that positron emission tomography with 18F-fluorodesoxyglucose (FDG-PET) is more reliable in operated patients with suspicion of relapse.<a class="elsevierStyleCrossRefs" href="#bib0020">4–6</a> With respect to liver involvement, CT has shown good results in local extension similar to those of FDG-PET,<a class="elsevierStyleCrossRef" href="#bib0035">7</a> although adequate differential diagnosis with lesions of another etiology may be difficult with both techniques in small-sized lesions,<a class="elsevierStyleCrossRef" href="#bib0040">8</a> with MR being the technique with the greatest capacity in its diagnosis.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>Dual time-point images with PET/CT have been used in different clinical situations for the study of the behavior of malignant tumors in an attempt to improve the specificity of this technique. The studies performed have demonstrated that the behavior in the incorporation of 18F-FDG over time is different in benign or high grade or metastatic neoproliferative processes which may aid in establishing a correct differential diagnosis in the identification and nature of the lesions.<a class="elsevierStyleCrossRefs" href="#bib0050">10–16</a> Some studies have suggested the utility of dual time-point PET/CT images in the diagnosis of liver metastasis, although heterogeneous groups have been studied and the parameters of adequate FDG uptake for analysis remain to be established.<a class="elsevierStyleCrossRefs" href="#bib0085">17–19</a>The aim of the present study was to determine the utility of an additional delayed image with PET/CT in the detection of liver metastasis in patients with suspicion of recurrence of colorectal cancer.Material and methodsPatientsWe prospectively included 71 patients (22 females, 49 males) with a mean age of 65±11 years with previous intention-to-cure surgery for colorectal cancer and clinical, biochemical or radiological suspicion of disease recurrence. The time interval from the end of treatment to PET/CT was always greater than 2 months and did not include patients with a history of previous liver disease. The levels of lactate-dehydrogenase (LDH), alkaline phosphatase (AP) and CEA were determined, and the possible association with the presence of recurrence was evaluated. The clinical characteristics of the patients are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. All the findings were confirmed by histopathologic study of the lesions and/or a minimum follow-up of 6 months with diagnosis of progression by imaging techniques. The study was approved by the Ethical Committee of the hospital and informed consent was obtained from each patient.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>PET/CT acquisitionPET/CT was performed using a hybrid system (Biograph, Siemens, Erlangen, Germany) with a PET ECAT Exact HR+ BGO and a helical CT (Somatom, Emotion). The patient underwent a 4-h fast period with blood glucose levels less than 140mg/dl prior to the intravenous administration of 0.11mCi (4.07MBq)/kg of 18F-FDG. Whole-body images were performed after 60min (standard image) and 1–2 liver fields at 2h post-FDG injection (delayed image). Patients were allowed to breathe normally during images acquisition and were placed in a supine position with their arms extended upwards. The mode of acquisition was 3D with a time of 5min per bed. The PET images were reconstructed with attenuation correction based on the images obtained with the CT.QuantificationVisual analysis of the PET/CT findings was performed by two observers who were unaware of the clinical information and the results obtained in the follow-up of the patients. A region of interest (ROI) was created around the liver lesions showing FDG uptake and areas of reference in the liver and the spleen, in both the standard PET image and the delayed PET image. The mean SUV (SUVmean) was calculated in the liver to observe possible washout of activity from this organ as well as in the spleen to obtain a stable area of reference. The maximum SUV (SUVmax) was calculated in the liver lesions detected on PET. These parameters are based on the main activity, the corrected dose injected by the decline and the weight of each patient: SUVmean=mean activity (ROI) (MBq/mL)/dose injected (MBq)/weight (kg); SUVmax=maximum activity (ROI) (MBq/mL)/dose injected (MBq)/weight (kg).Statistical analysisThe results are expressed as mean±standard deviation. The sensitivity and specificity were determined using conventional methods. The Kappa index was calculated to measure the concordance between the SUV values obtained. The variables were compared with Student's t-test considering associations with p values <0.05 as statistically significant. Normality could not be assumed on evaluation of CEA and thus, a logarithmic transformation was applied (logCEA).ResultsConfirmation of the presence of metastatic liver disease was obtained in 37/71 patients, detecting a single metastatic liver lesion in 15/37 cases and a total number of metastases of 79. The presence of liver metastasis was confirmed by histopathologic study in 29/37 cases and by lesion progression during follow-up in 8/37 cases.Up to 38/71 patients showed disease dissemination at an extra-hepatic level as local relapse (19), abdominopelvic (3) or mediastinal adenopathies (3), bone (1) or pulmonary metastasis (16) and carcinomatosis (10). Involvement in both localizations (liver and extra-hepatic metastasis) was demonstrated in 21/71 patients (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Twelve of the 71 patients remained without lesions during the follow-up without the appearance of signs suggestive of disease recurrence. No significant association was found between the presence or absence of disease recurrence and the clinical indexes studied (AP, LDH and CEA). There were not significant differences based on the localization of the primary tumor and/or the performance of adjuvant or neoadjuvant treatment with chemotherapy and/or radiotherapy (RDT).PET/CT in liver diseaseThe sensitivity and specificity for the diagnosis of liver metastasis were calculated based on the standard (81 and 91%) and delayed images (95 and 97%) of each patient. The total number of liver metastases diagnosed was greater with the delayed (66/79) than the standard images (57/79). The Kappa index indicates a good concordance in the diagnosis of liver metastasis between the dual time-point images (K=0.86), observing discrepancies in 5 patients with a single metastasis which only the delayed image was able to detect (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The concordance comparing the two images with the diagnostic follow-up of the liver metastasis was greater in the delayed (K=0.94) than in the standard images (K=0.8) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The SUVmax in the liver metastasis showed a significant increase between the standard and delayed images (standard SUVmax=5.8±2.5 and delayed SUVmax=7.7±3.8; p<0.05). We did not observe any case in which the liver lesions showed a reduction in SUVmax in the delayed image. The SUVmean in the spleen did not show significant changes (SUVmean standard image=1.78±0.36; SUVmean delayed image=1.79±0.34) (p=ns), with a significant reduction in the healthy liver tissue (SUVmean standard image=2.67±0.58; SUVmean delayed image=2.28±0.43) (p<0.05) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>PET/CT in extra-hepatic diseasePET/CT diagnosed 32/38 patients with extra-hepatic disease with a sensitivity and specificity of PET/CT of 84 and 70%, respectively (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). FDG deposits were found and interpreted as recurrence in 10 patients who were found to be false positives due to: persistent inflammatory changes in the surgical bed of the primary tumor (3), reactive adenopathies (4), suspicion of carcinomatosis (2) and unspecific uptake in the parotid gland (1). PET/CT was not able to diagnose 6 cases with metastatic lesions, 4 of which had a high mucinous component. It should be mentioned that PET/CT contributed to the unsuspected diagnosis of synchronic tumors in the lung (2), transverse colon (1), cecum (1) and thyroid gland (1).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>PET/CT with clinical indexesThe AP, LDH and CEA values were calculated taking into account the group of patients in which the PET/CT demonstrated liver disease, extra-hepatic disease and those who were free of disease. Significantly higher levels of AP were observed in the group of patients demonstrating active liver metastasis in both the baseline (p=0.026) and the delayed PET/CT images (p=0.029). A significant association was found between the CEA and the SUVmax of the liver metastasis (p<0.05), observing that the SUVmax increased with the increase in CEA of the lesions of the standard (correlation coefficient of 0.54) and delayed images (correlation coefficient of 0.46) indicating a moderate lineal correlation. No significant association was found between PET/CT findings and LDH levels.DiscussionThe use of PET/CT was found to be useful in patients with clinical suspicion of recurrence of colorectal cancer to detect the presence of locoregional recurrence or disease metastasis. However, the results of this technique in hepatic diagnosis and staging compared with anatomical imaging techniques such as CT and MRI are more controversial.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>The additional acquisition of a delayed image has been successfully used in the differential diagnosis between neoplasms or metastasis and processes of benign etiology with the exception of some low grade tumors, infections and cases of treatment with RDT.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> One documented theory reports that the acquisition of delayed images of high grade tumoral processes and metastasis may increase FDG uptake by up to 30%.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> In this study we observed a significant increase in FDG uptake in liver metastasis in the delayed images (standard SUVmax=5.8±2.5 and delayed SUVmax=7.7±3.8; p<0.05) with a greater concordance between the presence of liver metastasis and the findings of the delayed (K=0.94) than the standard images (K=0.8). These results, together with the proven fact that a washout of metabolic activity was produced in the healthy liver in this series of patients (standard image SUVmean=2.67±0.58; delayed image SUVmean=2.28±0.43) (p<0.05), contributed to achieving better evaluation of FDG uptake in the liver lesions. The stability of the uptake in the spleen found in this series of patients (standard image SUVmean=1.78±0.36; delayed image SUVmean=1.79±0.34) (p=ns) indicates that the variations in FDG uptake in the liver are probably organ-specific.PET/CT demonstrated an evidently greater sensitivity and specificity for the diagnosis of liver metastasis in the delayed (95 and 97%) than in the standard images (81 and 91%). Taking the number of metastasis into account, a greater sensitivity was also observed in detecting lesions, with the delayed image being able to visualize up to 9/79 liver metastasis which did not show evident uptake in the standard image. These findings are important in the management of these patients since the decision as to the performance of direct liver surgery, neoadjuvant therapy or palliative chemotherapy may depend on the grade of liver involvement. It is of note that 5 patients had a confirmed single metastasis which only the delayed PET/CT image was able to detect. In these patients this diagnosis was crucial to establish the diagnosis of liver recurrence and was decisive for both disease management and prognosis.Lee et al. evaluated the utility of dual time-point PET/CT images in patients with operated colorectal cancer, although the study was retrospective and with inclusion criteria of heterogeneous patients. The authors recommended quantification of liver lesions in the delayed images using a tumor/background uptake index. In this study the potential contribution of this technique in the differential diagnosis of liver lesions visualized by CT with contrast and with histological diagnosis is analyzed, although the small number of benign lesions reported did not allow extrapolation of relevant conclusions.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> These authors coincide with our series of patients in that the delayed image findings did not cause a loss of specificity in the diagnosis of liver metastasis.PET/CT is considered a good technique to rule out locoregional recurrence or extra-hepatic metastasis of colorectal cancer compared with reference technique in clinical practice which usually includes CT with thoracoabdominal contrast and, on some occasions, ultrasonography or MRI.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> The studies published indicate that PET/CT has greater sensitivity and specificity, being especially useful due to the difficulty of CT to evaluate the surgical bed and small adenopathies.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> The sensitivity and specificity of PET/CT to detect recurrence or extra-hepatic metastasis in this series of patients were 84 and 70%, respectively. However, suspicious lesions were detected in 10 patients who were finally shown to be false positives, thereby encouraging interpretation of findings with caution and avoidance of the indiscriminate use of PET/CT in patients with no clinical suspicion of recurrence. It should be taken into account that similar to what has been described in the literature,<a class="elsevierStyleCrossRef" href="#bib0130">26</a> PET/CT in this series of cases also showed a low sensitivity for detecting disease recurrence in tumors with a high mucinous component, being falsely negative in up to 4 patients. PET/CT also contributed to the non-suspected diagnosis of synchronous tumors in 5/71 patients, thereby influencing the therapeutic management, probably being relevant in their prognosis.The quantification of PET/CT by SUVmax has shown promising results in the evaluation of response to treatment and as a prognostic factor in colorectal cancer.<a class="elsevierStyleCrossRefs" href="#bib0135">27,28</a> In this series of patients significantly higher AP levels were found in the group demonstrating active liver metastasis on PET/CT, particularly in the delayed images (p=0.029). We also found a significant association between CEA and the SUVmax of liver metastases (p<0.05). These findings should be evaluated with caution due to the presence of contradictory results,<a class="elsevierStyleCrossRefs" href="#bib0130">26–29</a> although they do open a way of interest which should be analyzed by prospective studies to evaluate their potential use in clinical practice.In conclusion, PET/CT is a useful technique for the diagnosis of locoregional recurrence and extra-hepatic metastasis in the therapeutic management of patients with suspicion of relapse of colorectal cancer. Dual time-point liver images improved the sensitivity of PET/CT to identify liver metastasis in this series of patients.Conflict of interestThe authors declare no conflict of interest.Financial supportThis study received partial financial support from the RTICC (RD06/0020/0038) and AGAUR (2009 SGR 1049)." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres120318" "titulo" => array:5 [ 0 => "Abstract" 1 => "Aim" 2 => "Material and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec107599" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres120317" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec107598" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "PET/CT acquisition" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Quantification" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "PET/CT in liver disease" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "PET/CT in extra-hepatic disease" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "PET/CT with clinical indexes" ] ] ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflict of interest" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Financial support" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-08-16" "fechaAceptado" => "2011-10-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec107599" "palabras" => array:5 [ 0 => "Colorectal cancer" 1 => "Liver metastasis" 2 => "PET/CT" 3 => "Delayed images" 4 => "Recurrence" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec107598" "palabras" => array:5 [ 0 => "Cáncer colorrectal" 1 => "Metástasis hepáticas" 2 => "PET/TC" 3 => "Imagen tardía" 4 => "Recidiva" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "AimTo analyze the potential improvement of 18F-fluorodeoxyglucose (FDG) PET/CT using additional delayed images of the liver in operated colorectal cancer. Material and methodsThe study prospectively included 71 patients (22 women, 49 men) with mean age of 65±11 years with clinical, biochemical or radiological suspicion of current disease. A whole body PET/CT scan was performed at 60min (standard images) and after 2h (delayed images) post-injection of 4.07MBq/kg of 18F-FDG. Visual and quantitative SUV analysis of PET/CT findings were done. All findings were confirmed by histopathology and/or at least 6 months follow-up. ResultsThirty-seven out of 71 patients were diagnosed of liver metastases (79 metastases). In 38/71 cases there was extra-hepatic disease in the form of local recurrence (10), abdominopelvic (3) or mediastinal (3) lymph nodes, bone (1) or lung metastases (16) and carcinomatosis (10). Sensitivity and specificity for the diagnosis of liver metastases in a patient-by-patient basis in standard (81% and 91%) and in delayed images (95% and 97%) were calculated. The number of lesions detected in delayed images was significantly higher (66/79) than in standard images (57/79). Sensitivity and specificity for PET/CT in the diagnosis of extra-hepatic disease were 84% and 70%, contributing to the detection of synchronous tumors in 5 patients. ConclusionsPET/CT may be useful in the diagnosis of extra-hepatic disease in suspected recurrence of colorectal cancer. Delayed images on PET/CT may increase the sensitivity to identify liver metastases." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "ObjetivoAnalizar el potencial de la PET/TC usando imagen tardía del hígado en pacientes con sospecha de recidiva de cáncer colorrectal. Material y métodosSe han incluido prospectivamente 71 pacientes (22 mujeres, 49 hombres) con edad de 65±11 años y sospecha clínica, analítica o radiológica de recurrencia. Se realizó PET/TC después de la inyección de 4,07MBq/kg de 18F-FDG con imagen de cuerpo entero a los 60min (imagen estándar) y hepática a las 2h (imagen tardía). Se efectuó análisis visual y cuantitativo mediante SUV de los hallazgos de la PET/TC. Se obtuvo confirmación de las lesiones por estudio histopatológico y/o seguimiento mínimo de 6 meses. ResultadosSe diagnosticaron metástasis hepáticas en 37/71 pacientes (79 metástasis). Un total de 38/71 pacientes mostraban enfermedad extra-hepática en forma de recidiva local (10), adenopatías abdominopélvicas (3) o mediastínicas (3), metástasis óseas (1) o pulmonares (16) y carcinomatosis (10). Se calculó la sensibilidad y especificidad para el diagnóstico de metástasis hepáticas en base a cada paciente para la imagen estándar (81 y 91%) y la imagen tardía (95 y 97%). El número de metástasis hepáticas diagnosticadas fue mayor con la imagen tardía (66/79) que con la imagen estándar (57/79). La sensibilidad y especificidad de la PET/TC en lesiones extra-hepáticas fue de 84 y 70%, contribuyendo al diagnóstico no sospechado de 5 tumores sincrónicos. ConclusionesLa PET/TC es recomendable para descartar enfermedad extra-hepática en sospecha de recidiva de cáncer colorrectal. La realización de imagen tardía mejora la sensibilidad de la PET/TC en el diagnóstico de metástasis hepáticas." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Fuster D, et al. 18F-FDG PET/TC con imagen hepática en dos tiempos en la sospecha de recidiva del cáncer colorrectal. Rev Esp Med Nucl Imagen Mol. 2012;31:111–6." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1092 "Ancho" => 2290 "Tamanyo" => 202989 ] ] "descripcion" => array:1 [ "en" => "No alterations were observed in the axial PET, CT and PET/CT slices in the liver in the standard images (a) while an active focal lesion can be seen in the delayed images, corresponding to a single liver metastasis (b)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1167 "Ancho" => 2493 "Tamanyo" => 159573 ] ] "descripcion" => array:1 [ "en" => "(A) Correlation between the hepatic SUVmean obtained in the standard and delayed images. A reduction can be seen in the hepatic SUVmean in the delayed image. (B) Correlation between the SUVmean of the spleen obtained in the standard and delayed images. Stability is seen in the SUVmean of the spleen between the early and delayed images." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 745 "Ancho" => 2318 "Tamanyo" => 174641 ] ] "descripcion" => array:1 [ "en" => "(A) In the axial PET, CT and PET/CT slices of the liver, two liver metastases are observed in the standard images (a) while a third active focal lesion also appears in the delayed images, corresponding to another liver metastasis (b). (B) An active image is observed in the axial, coronal and sagittal PET/CT slices in the surgical bed of the primary tumor located at the rectosigmoid junction corresponding with local recurrence." ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Characteristics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Values \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">primary tumor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ascending colon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">transverse colon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">descending colon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">rectosigmoid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time from surgery (months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32.3±16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LDH (250–450U/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">393.60±174 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AP (90–290U/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">235.02±99 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CEA (0.0–4.0ng/mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43.60±186 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chemotherapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">adjuvant \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">neoadjuvant \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">radiotherapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">adjuvant \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">neoadjuvant \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab208236.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical characteristics of the patients." ] ] 4 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:3 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Standard image \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Delayed image</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">M0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">M1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Standard/delayed image</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (9)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">41 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57.75% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 (57)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.25% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 (66)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50.70% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49.30% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100.00% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab208235.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Standard image \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Definitive diagnosis</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">M0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">M1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Standard image/definitive diagnosis</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (22)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">41 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57.75% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 (57)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.25% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 (79)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47.89% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">52.11% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100.00% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab208237.png" ] ] 2 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Delayed image \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Definitive diagnosis</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">M0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">M1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Delayed image/definitive diagnosis</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (13)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50.70% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 (66)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49.30% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " 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Original article

Dual-time point images of the liver with 18F-FDG PET/CT in suspected recurrence from colorectal cancer

18F-FDG PET/TC con imagen hepática en dos tiempos en la sospecha de recidiva del cáncer colorrectal

D. Fustera,b,

Corresponding author

dfuster@clinic.ub.es

Corresponding author.

, S. Lafuentea, X. Setoaina,b,c, I. Navalesa, A. Perissinottia, J. Paviaa,b,c, P. Paredesa, F. Lomeñaa, F. Ponsa,b

a Servicio de Medicina Nuclear, Hospital Clínic, Barcelona, Spain

b Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

c Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Barcelona, Spain

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        "titulo" => "<span class="elsevierStyleSup">18</span>F-FDG PET&#47;TC con imagen hep&#225;tica en dos tiempos en la sospecha de recidiva del c&#225;ncer colorrectal"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Correlation between the hepatic SUVmean obtained in the standard and delayed images&#46; A reduction can be seen in the hepatic SUVmean in the delayed image&#46; &#40;B&#41; Correlation between the SUVmean of the spleen obtained in the standard and delayed images&#46; Stability is seen in the SUVmean of the spleen between the early and delayed images&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Colorectal cancer is the third most common type of cancer in both men and women and is the second cause of death associated with cancer in the United States of America&#46; The clinical follow-up of these patients usually includes the determination of tumoral markers and the carcinoembryonary antigen &#40;CEA&#41;&#44; endoscopy and imaging techniques&#46; Treatment with curative surgery is effective in up to 50&#37; of the cases&#44; although recurrence of colorectal cancer is high&#44; being of up to 30&#8211;40&#37; in stages II and III of the disease&#46; An important part of the recurrences appears in only one organ allowing surgical treatment which is vital for the prognosis of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Colorectal cancer usually disseminates to the regional lymph nodes or the liver through the portal venous circulation&#46; The liver is the most frequent visceral localization and constitutes the initial site of distant metastasis in one third of the patients with recurrence&#44; finally affecting more than two thirds of the patients during the evolution of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The treatment of liver metastasis of potentially resectable colorectal cancer is surgical if allowed by the conditions of the patient since it has demonstrated an increase in the survival of the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However&#44; according to the number of nodes and the presence of risk factors &#40;Fond criteria&#41;&#44; the administration of chemotherapy or radiofrequency may be required to complement surgery in partially resectable lesions&#46; Thus&#44; correct staging of the presence of liver metastasis and the number of lesions is necessary to choose the optimum treatment for each patient&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">At present&#44; the staging and follow-up on the suspicion of recurrence of colorectal cancer are performed by computerized tomography &#40;CT&#41;&#46; It has been demonstrated that this technique may have difficulties in differentiating the presence of active disease from changes by fibrosis secondary to the surgery or other treatments or in detecting peritoneal invasion&#46; In this regard several studies have demonstrated that positron emission tomography with <span class="elsevierStyleSup">18</span>F-fluorodesoxyglucose &#40;FDG-PET&#41; is more reliable in operated patients with suspicion of relapse&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a> With respect to liver involvement&#44; CT has shown good results in local extension similar to those of FDG-PET&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> although adequate differential diagnosis with lesions of another etiology may be difficult with both techniques in small-sized lesions&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> with MR being the technique with the greatest capacity in its diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Dual time-point images with PET&#47;CT have been used in different clinical situations for the study of the behavior of malignant tumors in an attempt to improve the specificity of this technique&#46; The studies performed have demonstrated that the behavior in the incorporation of <span class="elsevierStyleSup">18</span>F-FDG over time is different in benign or high grade or metastatic neoproliferative processes which may aid in establishing a correct differential diagnosis in the identification and nature of the lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;16</span></a> Some studies have suggested the utility of dual time-point PET&#47;CT images in the diagnosis of liver metastasis&#44; although heterogeneous groups have been studied and the parameters of adequate FDG uptake for analysis remain to be established&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#8211;19</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of the present study was to determine the utility of an additional delayed image with PET&#47;CT in the detection of liver metastasis in patients with suspicion of recurrence of colorectal cancer&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patients</span><p id="par0030" class="elsevierStylePara elsevierViewall">We prospectively included 71 patients &#40;22 females&#44; 49 males&#41; with a mean age of 65<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 years with previous intention-to-cure surgery for colorectal cancer and clinical&#44; biochemical or radiological suspicion of disease recurrence&#46; The time interval from the end of treatment to PET&#47;CT was always greater than 2 months and did not include patients with a history of previous liver disease&#46; The levels of lactate-dehydrogenase &#40;LDH&#41;&#44; alkaline phosphatase &#40;AP&#41; and CEA were determined&#44; and the possible association with the presence of recurrence was evaluated&#46; The clinical characteristics of the patients are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; All the findings were confirmed by histopathologic study of the lesions and&#47;or a minimum follow-up of 6 months with diagnosis of progression by imaging techniques&#46; The study was approved by the Ethical Committee of the hospital and informed consent was obtained from each patient&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">PET&#47;CT acquisition</span><p id="par0035" class="elsevierStylePara elsevierViewall">PET&#47;CT was performed using a hybrid system &#40;Biograph&#44; Siemens&#44; Erlangen&#44; Germany&#41; with a PET ECAT Exact HR&#43; BGO and a helical CT &#40;Somatom&#44; Emotion&#41;&#46; The patient underwent a 4-h fast period with blood glucose levels less than 140<span class="elsevierStyleHsp" style=""></span>mg&#47;dl prior to the intravenous administration of 0&#46;11<span class="elsevierStyleHsp" style=""></span>mCi &#40;4&#46;07<span class="elsevierStyleHsp" style=""></span>MBq&#41;&#47;kg of <span class="elsevierStyleSup">18</span>F-FDG&#46; Whole-body images were performed after 60<span class="elsevierStyleHsp" style=""></span>min &#40;standard image&#41; and 1&#8211;2 liver fields at 2<span class="elsevierStyleHsp" style=""></span>h post-FDG injection &#40;delayed image&#41;&#46; Patients were allowed to breathe normally during images acquisition and were placed in a supine position with their arms extended upwards&#46; The mode of acquisition was 3D with a time of 5<span class="elsevierStyleHsp" style=""></span>min per bed&#46; The PET images were reconstructed with attenuation correction based on the images obtained with the CT&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Quantification</span><p id="par0040" class="elsevierStylePara elsevierViewall">Visual analysis of the PET&#47;CT findings was performed by two observers who were unaware of the clinical information and the results obtained in the follow-up of the patients&#46; A region of interest &#40;ROI&#41; was created around the liver lesions showing FDG uptake and areas of reference in the liver and the spleen&#44; in both the standard PET image and the delayed PET image&#46; The mean SUV &#40;SUVmean&#41; was calculated in the liver to observe possible washout of activity from this organ as well as in the spleen to obtain a stable area of reference&#46; The maximum SUV &#40;SUVmax&#41; was calculated in the liver lesions detected on PET&#46; These parameters are based on the main activity&#44; the corrected dose injected by the decline and the weight of each patient&#58; SUVmean<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>mean activity &#40;ROI&#41; &#40;MBq&#47;mL&#41;&#47;dose injected &#40;MBq&#41;&#47;weight &#40;kg&#41;&#59; SUVmax<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>maximum activity &#40;ROI&#41; &#40;MBq&#47;mL&#41;&#47;dose injected &#40;MBq&#41;&#47;weight &#40;kg&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">The results are expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46; The sensitivity and specificity were determined using conventional methods&#46; The Kappa index was calculated to measure the concordance between the SUV values obtained&#46; The variables were compared with Student&#39;s <span class="elsevierStyleItalic">t</span>-test considering associations with <span class="elsevierStyleItalic">p</span> values &#60;0&#46;05 as statistically significant&#46; Normality could not be assumed on evaluation of CEA and thus&#44; a logarithmic transformation was applied &#40;log<span class="elsevierStyleHsp" style=""></span>CEA&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">Confirmation of the presence of metastatic liver disease was obtained in 37&#47;71 patients&#44; detecting a single metastatic liver lesion in 15&#47;37 cases and a total number of metastases of 79&#46; The presence of liver metastasis was confirmed by histopathologic study in 29&#47;37 cases and by lesion progression during follow-up in 8&#47;37 cases&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Up to 38&#47;71 patients showed disease dissemination at an extra-hepatic level as local relapse &#40;19&#41;&#44; abdominopelvic &#40;3&#41; or mediastinal adenopathies &#40;3&#41;&#44; bone &#40;1&#41; or pulmonary metastasis &#40;16&#41; and carcinomatosis &#40;10&#41;&#46; Involvement in both localizations &#40;liver and extra-hepatic metastasis&#41; was demonstrated in 21&#47;71 patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Twelve of the 71 patients remained without lesions during the follow-up without the appearance of signs suggestive of disease recurrence&#46; No significant association was found between the presence or absence of disease recurrence and the clinical indexes studied &#40;AP&#44; LDH and CEA&#41;&#46; There were not significant differences based on the localization of the primary tumor and&#47;or the performance of adjuvant or neoadjuvant treatment with chemotherapy and&#47;or radiotherapy &#40;RDT&#41;&#46;</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">PET&#47;CT in liver disease</span><p id="par0060" class="elsevierStylePara elsevierViewall">The sensitivity and specificity for the diagnosis of liver metastasis were calculated based on the standard &#40;81 and 91&#37;&#41; and delayed images &#40;95 and 97&#37;&#41; of each patient&#46; The total number of liver metastases diagnosed was greater with the delayed &#40;66&#47;79&#41; than the standard images &#40;57&#47;79&#41;&#46; The Kappa index indicates a good concordance in the diagnosis of liver metastasis between the dual time-point images &#40;<span class="elsevierStyleItalic">K</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;86&#41;&#44; observing discrepancies in 5 patients with a single metastasis which only the delayed image was able to detect &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The concordance comparing the two images with the diagnostic follow-up of the liver metastasis was greater in the delayed &#40;<span class="elsevierStyleItalic">K</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;94&#41; than in the standard images &#40;<span class="elsevierStyleItalic">K</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;8&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The SUVmax in the liver metastasis showed a significant increase between the standard and delayed images &#40;standard SUVmax<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;5 and delayed SUVmax<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;8&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; We did not observe any case in which the liver lesions showed a reduction in SUVmax in the delayed image&#46; The SUVmean in the spleen did not show significant changes &#40;SUVmean standard image<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;78<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;36&#59; SUVmean delayed image<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;79<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;34&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>ns&#41;&#44; with a significant reduction in the healthy liver tissue &#40;SUVmean standard image<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;58&#59; SUVmean delayed image<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;28<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;43&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">PET&#47;CT in extra-hepatic disease</span><p id="par0070" class="elsevierStylePara elsevierViewall">PET&#47;CT diagnosed 32&#47;38 patients with extra-hepatic disease with a sensitivity and specificity of PET&#47;CT of 84 and 70&#37;&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; FDG deposits were found and interpreted as recurrence in 10 patients who were found to be false positives due to&#58; persistent inflammatory changes in the surgical bed of the primary tumor &#40;3&#41;&#44; reactive adenopathies &#40;4&#41;&#44; suspicion of carcinomatosis &#40;2&#41; and unspecific uptake in the parotid gland &#40;1&#41;&#46; PET&#47;CT was not able to diagnose 6 cases with metastatic lesions&#44; 4 of which had a high mucinous component&#46; It should be mentioned that PET&#47;CT contributed to the unsuspected diagnosis of synchronic tumors in the lung &#40;2&#41;&#44; transverse colon &#40;1&#41;&#44; cecum &#40;1&#41; and thyroid gland &#40;1&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">PET&#47;CT with clinical indexes</span><p id="par0075" class="elsevierStylePara elsevierViewall">The AP&#44; LDH and CEA values were calculated taking into account the group of patients in which the PET&#47;CT demonstrated liver disease&#44; extra-hepatic disease and those who were free of disease&#46; Significantly higher levels of AP were observed in the group of patients demonstrating active liver metastasis in both the baseline &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;026&#41; and the delayed PET&#47;CT images &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;029&#41;&#46; A significant association was found between the CEA and the SUVmax of the liver metastasis &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; observing that the SUVmax increased with the increase in CEA of the lesions of the standard &#40;correlation coefficient of 0&#46;54&#41; and delayed images &#40;correlation coefficient of 0&#46;46&#41; indicating a moderate lineal correlation&#46; No significant association was found between PET&#47;CT findings and LDH levels&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">The use of PET&#47;CT was found to be useful in patients with clinical suspicion of recurrence of colorectal cancer to detect the presence of locoregional recurrence or disease metastasis&#46; However&#44; the results of this technique in hepatic diagnosis and staging compared with anatomical imaging techniques such as CT and MRI are more controversial&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The additional acquisition of a delayed image has been successfully used in the differential diagnosis between neoplasms or metastasis and processes of benign etiology with the exception of some low grade tumors&#44; infections and cases of treatment with RDT&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> One documented theory reports that the acquisition of delayed images of high grade tumoral processes and metastasis may increase FDG uptake by up to 30&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> In this study we observed a significant increase in FDG uptake in liver metastasis in the delayed images &#40;standard SUVmax<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;5 and delayed SUVmax<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;8&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; with a greater concordance between the presence of liver metastasis and the findings of the delayed &#40;<span class="elsevierStyleItalic">K</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;94&#41; than the standard images &#40;<span class="elsevierStyleItalic">K</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;8&#41;&#46; These results&#44; together with the proven fact that a washout of metabolic activity was produced in the healthy liver in this series of patients &#40;standard image SUVmean<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;58&#59; delayed image SUVmean<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;28<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;43&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; contributed to achieving better evaluation of FDG uptake in the liver lesions&#46; The stability of the uptake in the spleen found in this series of patients &#40;standard image SUVmean<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;78<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;36&#59; delayed image SUVmean<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;79<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;34&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>ns&#41; indicates that the variations in FDG uptake in the liver are probably organ-specific&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">PET&#47;CT demonstrated an evidently greater sensitivity and specificity for the diagnosis of liver metastasis in the delayed &#40;95 and 97&#37;&#41; than in the standard images &#40;81 and 91&#37;&#41;&#46; Taking the number of metastasis into account&#44; a greater sensitivity was also observed in detecting lesions&#44; with the delayed image being able to visualize up to 9&#47;79 liver metastasis which did not show evident uptake in the standard image&#46; These findings are important in the management of these patients since the decision as to the performance of direct liver surgery&#44; neoadjuvant therapy or palliative chemotherapy may depend on the grade of liver involvement&#46; It is of note that 5 patients had a confirmed single metastasis which only the delayed PET&#47;CT image was able to detect&#46; In these patients this diagnosis was crucial to establish the diagnosis of liver recurrence and was decisive for both disease management and prognosis&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Lee et al&#46; evaluated the utility of dual time-point PET&#47;CT images in patients with operated colorectal cancer&#44; although the study was retrospective and with inclusion criteria of heterogeneous patients&#46; The authors recommended quantification of liver lesions in the delayed images using a tumor&#47;background uptake index&#46; In this study the potential contribution of this technique in the differential diagnosis of liver lesions visualized by CT with contrast and with histological diagnosis is analyzed&#44; although the small number of benign lesions reported did not allow extrapolation of relevant conclusions&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> These authors coincide with our series of patients in that the delayed image findings did not cause a loss of specificity in the diagnosis of liver metastasis&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">PET&#47;CT is considered a good technique to rule out locoregional recurrence or extra-hepatic metastasis of colorectal cancer compared with reference technique in clinical practice which usually includes CT with thoracoabdominal contrast and&#44; on some occasions&#44; ultrasonography or MRI&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> The studies published indicate that PET&#47;CT has greater sensitivity and specificity&#44; being especially useful due to the difficulty of CT to evaluate the surgical bed and small adenopathies&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> The sensitivity and specificity of PET&#47;CT to detect recurrence or extra-hepatic metastasis in this series of patients were 84 and 70&#37;&#44; respectively&#46; However&#44; suspicious lesions were detected in 10 patients who were finally shown to be false positives&#44; thereby encouraging interpretation of findings with caution and avoidance of the indiscriminate use of PET&#47;CT in patients with no clinical suspicion of recurrence&#46; It should be taken into account that similar to what has been described in the literature&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> PET&#47;CT in this series of cases also showed a low sensitivity for detecting disease recurrence in tumors with a high mucinous component&#44; being falsely negative in up to 4 patients&#46; PET&#47;CT also contributed to the non-suspected diagnosis of synchronous tumors in 5&#47;71 patients&#44; thereby influencing the therapeutic management&#44; probably being relevant in their prognosis&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The quantification of PET&#47;CT by SUVmax has shown promising results in the evaluation of response to treatment and as a prognostic factor in colorectal cancer&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a> In this series of patients significantly higher AP levels were found in the group demonstrating active liver metastasis on PET&#47;CT&#44; particularly in the delayed images &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;029&#41;&#46; We also found a significant association between CEA and the SUVmax of liver metastases &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; These findings should be evaluated with caution due to the presence of contradictory results&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#8211;29</span></a> although they do open a way of interest which should be analyzed by prospective studies to evaluate their potential use in clinical practice&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In conclusion&#44; PET&#47;CT is a useful technique for the diagnosis of locoregional recurrence and extra-hepatic metastasis in the therapeutic management of patients with suspicion of relapse of colorectal cancer&#46; Dual time-point liver images improved the sensitivity of PET&#47;CT to identify liver metastasis in this series of patients&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Financial support</span><p id="par0120" class="elsevierStylePara elsevierViewall">This study received partial financial support from the <span class="elsevierStyleGrantSponsor" id="gs0005">RTICC</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs0005">RD06&#47;0020&#47;0038</span>&#41; and <span class="elsevierStyleGrantSponsor" id="gs0010">AGAUR</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs0010">2009 SGR 1049</span>&#41;&#46;</p></span></span>"
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          "titulo" => array:5 [
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          "titulo" => array:5 [
            0 => "Resumen"
            1 => "Objetivo"
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          "titulo" => "Palabras clave"
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          "titulo" => "Introduction"
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          "identificador" => "sec0010"
          "titulo" => "Material and methods"
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              "titulo" => "Patients"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "PET&#47;CT acquisition"
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            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Quantification"
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          "titulo" => "Results"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "PET&#47;CT in liver disease"
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            1 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "PET&#47;CT in extra-hepatic disease"
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            2 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "PET&#47;CT with clinical indexes"
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          "titulo" => "Discussion"
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    "fechaRecibido" => "2011-08-16"
    "fechaAceptado" => "2011-10-25"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec107599"
          "palabras" => array:5 [
            0 => "Colorectal cancer"
            1 => "Liver metastasis"
            2 => "PET&#47;CT"
            3 => "Delayed images"
            4 => "Recurrence"
          ]
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      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec107598"
          "palabras" => array:5 [
            0 => "C&#225;ncer colorrectal"
            1 => "Met&#225;stasis hep&#225;ticas"
            2 => "PET&#47;TC"
            3 => "Imagen tard&#237;a"
            4 => "Recidiva"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Aim</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyze the potential improvement of <span class="elsevierStyleSup">18</span>F-fluorodeoxyglucose &#40;FDG&#41; PET&#47;CT using additional delayed images of the liver in operated colorectal cancer&#46;</p> <span class="elsevierStyleSectionTitle">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The study prospectively included 71 patients &#40;22 women&#44; 49 men&#41; with mean age of 65<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 years with clinical&#44; biochemical or radiological suspicion of current disease&#46; A whole body PET&#47;CT scan was performed at 60<span class="elsevierStyleHsp" style=""></span>min &#40;standard images&#41; and after 2<span class="elsevierStyleHsp" style=""></span>h &#40;delayed images&#41; post-injection of 4&#46;07<span class="elsevierStyleHsp" style=""></span>MBq&#47;kg of <span class="elsevierStyleSup">18</span>F-FDG&#46; Visual and quantitative SUV analysis of PET&#47;CT findings were done&#46; All findings were confirmed by histopathology and&#47;or at least 6 months follow-up&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Thirty-seven out of 71 patients were diagnosed of liver metastases &#40;79 metastases&#41;&#46; In 38&#47;71 cases there was extra-hepatic disease in the form of local recurrence &#40;10&#41;&#44; abdominopelvic &#40;3&#41; or mediastinal &#40;3&#41; lymph nodes&#44; bone &#40;1&#41; or lung metastases &#40;16&#41; and carcinomatosis &#40;10&#41;&#46; Sensitivity and specificity for the diagnosis of liver metastases in a patient-by-patient basis in standard &#40;81&#37; and 91&#37;&#41; and in delayed images &#40;95&#37; and 97&#37;&#41; were calculated&#46; The number of lesions detected in delayed images was significantly higher &#40;66&#47;79&#41; than in standard images &#40;57&#47;79&#41;&#46; Sensitivity and specificity for PET&#47;CT in the diagnosis of extra-hepatic disease were 84&#37; and 70&#37;&#44; contributing to the detection of synchronous tumors in 5 patients&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">PET&#47;CT may be useful in the diagnosis of extra-hepatic disease in suspected recurrence of colorectal cancer&#46; Delayed images on PET&#47;CT may increase the sensitivity to identify liver metastases&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Analizar el potencial de la PET&#47;TC usando imagen tard&#237;a del h&#237;gado en pacientes con sospecha de recidiva de c&#225;ncer colorrectal&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se han incluido prospectivamente 71 pacientes &#40;22 mujeres&#44; 49 hombres&#41; con edad de 65<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 a&#241;os y sospecha cl&#237;nica&#44; anal&#237;tica o radiol&#243;gica de recurrencia&#46; Se realiz&#243; PET&#47;TC despu&#233;s de la inyecci&#243;n de 4&#44;07<span class="elsevierStyleHsp" style=""></span>MBq&#47;kg de <span class="elsevierStyleSup">18</span>F-FDG con imagen de cuerpo entero a los 60<span class="elsevierStyleHsp" style=""></span>min &#40;imagen est&#225;ndar&#41; y hep&#225;tica a las 2<span class="elsevierStyleHsp" style=""></span>h &#40;imagen tard&#237;a&#41;&#46; Se efectu&#243; an&#225;lisis visual y cuantitativo mediante SUV de los hallazgos de la PET&#47;TC&#46; Se obtuvo confirmaci&#243;n de las lesiones por estudio histopatol&#243;gico y&#47;o seguimiento m&#237;nimo de 6 meses&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se diagnosticaron met&#225;stasis hep&#225;ticas en 37&#47;71 pacientes &#40;79 met&#225;stasis&#41;&#46; Un total de 38&#47;71 pacientes mostraban enfermedad extra-hep&#225;tica en forma de recidiva local &#40;10&#41;&#44; adenopat&#237;as abdominop&#233;lvicas &#40;3&#41; o mediast&#237;nicas &#40;3&#41;&#44; met&#225;stasis &#243;seas &#40;1&#41; o pulmonares &#40;16&#41; y carcinomatosis &#40;10&#41;&#46; Se calcul&#243; la sensibilidad y especificidad para el diagn&#243;stico de met&#225;stasis hep&#225;ticas en base a cada paciente para la imagen est&#225;ndar &#40;81 y 91&#37;&#41; y la imagen tard&#237;a &#40;95 y 97&#37;&#41;&#46; El n&#250;mero de met&#225;stasis hep&#225;ticas diagnosticadas fue mayor con la imagen tard&#237;a &#40;66&#47;79&#41; que con la imagen est&#225;ndar &#40;57&#47;79&#41;&#46; La sensibilidad y especificidad de la PET&#47;TC en lesiones extra-hep&#225;ticas fue de 84 y 70&#37;&#44; contribuyendo al diagn&#243;stico no sospechado de 5 tumores sincr&#243;nicos&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La PET&#47;TC es recomendable para descartar enfermedad extra-hep&#225;tica en sospecha de recidiva de c&#225;ncer colorrectal&#46; La realizaci&#243;n de imagen tard&#237;a mejora la sensibilidad de la PET&#47;TC en el diagn&#243;stico de met&#225;stasis hep&#225;ticas&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Fuster D&#44; et al&#46; <span class="elsevierStyleSup">18</span>F-FDG PET&#47;TC con imagen hep&#225;tica en dos tiempos en la sospecha de recidiva del c&#225;ncer colorrectal&#46; Rev Esp Med Nucl Imagen Mol&#46; 2012&#59;31&#58;111&#8211;6&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">No alterations were observed in the axial PET&#44; CT and PET&#47;CT slices in the liver in the standard images &#40;a&#41; while an active focal lesion can be seen in the delayed images&#44; corresponding to a single liver metastasis &#40;b&#41;&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Correlation between the hepatic SUVmean obtained in the standard and delayed images&#46; A reduction can be seen in the hepatic SUVmean in the delayed image&#46; &#40;B&#41; Correlation between the SUVmean of the spleen obtained in the standard and delayed images&#46; Stability is seen in the SUVmean of the spleen between the early and delayed images&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; In the axial PET&#44; CT and PET&#47;CT slices of the liver&#44; two liver metastases are observed in the standard images &#40;a&#41; while a third active focal lesion also appears in the delayed images&#44; corresponding to another liver metastasis &#40;b&#41;&#46; &#40;B&#41; An active image is observed in the axial&#44; coronal and sagittal PET&#47;CT slices in the surgical bed of the primary tumor located at the rectosigmoid junction corresponding with local recurrence&#46;</p>"
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                  \t\t\t\t">primary tumor&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ascending colon&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>transverse colon&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>descending colon&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>rectosigmoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Time from surgery &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LDH &#40;250&#8211;450<span class="elsevierStyleHsp" style=""></span>U&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">393&#46;60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>174&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AP &#40;90&#8211;290<span class="elsevierStyleHsp" style=""></span>U&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">235&#46;02<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CEA &#40;0&#46;0&#8211;4&#46;0<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&#46;60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>186&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chemotherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>adjuvant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>neoadjuvant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">radiotherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>adjuvant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>neoadjuvant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab208236.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Clinical characteristics of the patients&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:3 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Standard image&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Delayed image</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">M0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">M1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">S<span class="elsevierStyleItalic">tandard&#47;delayed image</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>M0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;9&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&#46;75&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>M1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;57&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#46;25&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35 &#40;66&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&#46;70&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49&#46;30&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#46;00&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab208235.png"
              ]
            ]
            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Standard image&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Definitive diagnosis</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">M0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">M1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Standard image&#47;definitive diagnosis</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>M0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;22&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">57&#46;75&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>M1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">42&#46;25&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&#46;89&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52&#46;11&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#46;00&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => """
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Delayed image&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Definitive diagnosis</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">M0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">M1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>M0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;13&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&#46;70&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>M1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35 &#40;66&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">49&#46;30&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37 &#40;79&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&#46;89&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52&#46;11&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#46;00&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "nota" => "<p class="elsevierStyleNotepara">Number of liver metastases&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Concordance of the PET&#47;CT findings in patients with a diagnosis of liver metastasis between the standard and delayed images and between the two images with the definitive diagnosis&#46;</p>"
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      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:29 [
            0 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "PET changes management and improves prognostic stratification in patients with recurrent colorectal cancer&#58; results of a multicenter prospective study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;M&#46; Scott"
                            1 => "D&#46;H&#46; Gunawardana"
                            2 => "B&#46; Kelley"
                            3 => "J&#46;G&#46; Stuckey"
                            4 => "A&#46;J&#46; Byrne"
                            5 => "J&#46;E&#46; Ramshaw"
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                      "doi" => "10.2967/jnumed.108.051615"
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                        "tituloSerie" => "J Nucl Med"
                        "fecha" => "2008"
                        "volumen" => "49"
                        "paginaInicial" => "1451"
                        "paginaFinal" => "1457"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18703607"
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              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tumores del intestino delgado y grueso"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "R&#46;J&#46; Mayer"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:4 [
                        "titulo" => "Harrison&#58; Principios de la Medicina Interna"
                        "paginaInicial" => "1480"
                        "paginaFinal" => "1489"
                        "serieFecha" => "1991"
                      ]
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                ]
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            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "FDG-PET for the preoperative evaluation of colorectal liver metastases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "T&#46;H&#46; Arulampalam"
                            1 => "D&#46;L&#46; Francis"
                            2 => "D&#46; Visvikis"
                            3 => "I&#46; Taylor"
                            4 => "P&#46;J&#46; Ell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ejso.2003.10.023"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Surg Oncol"
                        "fecha" => "2004"
                        "volumen" => "30"
                        "paginaInicial" => "286"
                        "paginaFinal" => "291"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15028310"
                            "web" => "Medline"
                          ]
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                      ]
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                ]
              ]
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              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Five-year survival after resection of hepatic metastases from colorectal cancer in patients screened by positron emission tomography with F-18 fluorodeoxyglucose &#40;FDG-PET&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "F&#46;G&#46; Fernandez"
                            1 => "J&#46;A&#46; Drebin"
                            2 => "D&#46;C&#46; Linehan"
                            3 => "F&#46; Dehdashti"
                            4 => "B&#46;A&#46; Siegel"
                            5 => "S&#46;M&#46; Strasberg"
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                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Surg"
                        "fecha" => "2004"
                        "volumen" => "240"
                        "paginaInicial" => "438"
                        "paginaFinal" => "447"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15319715"
                            "web" => "Medline"
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            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Assessment of tumor recurrence in patients with colorectal cancer and elevated carcinoembryonic antigen level&#58; FDG PET&#47;CT versus contrast-enhanced 64-MDCT of the chest and abdomen"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "U&#46; Metser"
                            1 => "J&#46; You"
                            2 => "S&#46; McSweeney"
                            3 => "M&#46; Freeman"
                            4 => "A&#46; Hendler"
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                        ]
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                    0 => array:2 [
                      "doi" => "10.2214/AJR.09.3205"
                      "Revista" => array:6 [
                        "tituloSerie" => "AJR Am J Roentgenol"
                        "fecha" => "2010"
                        "volumen" => "194"
                        "paginaInicial" => "766"
                        "paginaFinal" => "771"
                        "link" => array:1 [
                          0 => array:2 [
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Article information

ISSN: 22538089
Original language: English

DOI:10.1016/j.remnie.2012.05.005

The statistics are updated each day

Year/Month	Html	Pdf	Total

2023 March	5	0	5
2018 February	37	2	39
2018 January	34	2	36
2017 December	32	4	36
2017 November	29	2	31
2017 October	30	3	33
2017 September	22	7	29
2017 August	30	2	32
2017 July	27	2	29
2017 June	49	10	59
2017 May	45	9	54
2017 April	30	3	33
2017 March	25	27	52
2017 February	33	1	34
2017 January	29	0	29
2016 December	25	5	30
2016 November	46	5	51
2016 October	45	3	48
2016 September	50	9	59
2016 August	31	4	35
2016 July	14	2	16
2016 June	24	8	32
2016 May	19	6	25
2016 April	35	10	45
2016 March	27	7	34
2016 February	39	6	45
2016 January	19	5	24
2015 December	30	8	38
2015 November	18	13	31
2015 October	24	5	29
2015 September	37	3	40
2015 August	41	3	44
2015 July	27	3	30
2015 June	23	6	29
2015 May	27	3	30
2015 April	32	5	37
2015 March	24	1	25
2015 February	21	1	22
2015 January	22	4	26
2014 December	33	4	37
2014 November	14	1	15
2014 October	16	1	17
2014 September	15	2	17
2014 August	20	2	22
2014 July	19	1	20
2014 June	10	2	12
2014 May	9	3	12
2014 April	8	3	11
2014 March	12	3	15
2014 February	16	5	21
2014 January	22	2	24
2013 December	22	4	26
2013 November	23	1	24
2013 October	37	4	41
2013 September	14	0	14
2013 August	19	1	20
2013 July	5	1	6

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