The Colon Club

So, my husband had a PET scan this week and it showed several things that really concern me. The oncologist is mainly concerned about the liver. He previously had a ct and mri and the lesions that they found on the pet of the liver are new! So, 3 hypermetabolic hepatic lesions that are consistent with metastasis from primary colon cancer were found. 1 of the lesions showed intense FDG uptake with SUV of 6. The 2nd one showed intense FDG uptake with SUV of 4.4. And the 3rd with SUV of 3.6. Also the lung nodules that were there previously showed on the pet and were marked hypermetabolic. And new mildly metabolic left para aortic lymph node showed up. The oncologist is concerned with the liver and said we would still just watch the lung nodules. So, he now wants my husband to have a needle biopsy on the liver. What I don't understand is why the biopsy if the PET scan shows it? My husband talked to the oncologist over the phone so I wasn't able to ask this question and he didn't think to ask. So, now his chemo that he was supposed to start next week has been delayed to see about the liver lesions found. Any thoughts or experience with this? Is it standard to biopsy after a pet scan?

I was in the same situation but in the other direction. CT scan showed two lesions suspicious for metastasis when I was first diagnosed. A PET was ordered which showed no hypermetabolic activity in the lesions. I consulted with a liver specialist who said he still wants to do a biopsy to confirm these lesions are benign; suspecting they're hemangiomas. He said he wanted to be sure as people are often wary about false positives with PETs, but he said there are false negatives too. So he was in the OR with my CRC surgeon during my resection. He did his biopsy first. The samples were sent down to the pathology lab at the hospital to do an immediate examination. If the samples were benign, he would scrub out and my CRC surgeon would then do his part. If the samples were malignant, then he was ready to do a liver resection and then my CRC surgeon would follow up with resecting my colon. The result of the biopsy was benign tissue...hemangiomas.

Hope this helps.

praying3,

I don't know if it is standard or not but every doctor we have asked what method is the best tool of diagnosis and surveillance for liver mets has told us abdominal MRI with contrast. This would include two oncologists and two liver surgeons.

On the other hand, the radiologist at our local hospital read husband's locally done MRI as showing two liver mets but the radiologist at Mass General Hospital read a follow-up MRI done there with their better equipment as showing one liver met and one benign hemangioma. So, the value of the test highly depends on the quality of the machinery and the skill/experience of the radiologist.

I also don't think that the suggestion for a needle biopsy is unusual. A friend of ours had a 5 cm mass on her liver and after PET scans and MRI scans, the liver surgeon (same as the one I mention above as we consulted with him for a second opinion) recommended she have a needle biopsy. The mass was going to be surgically removed anyway (was done a few weeks ago) so she opted not to have the biopsy done.

DH PET scan showed 3 lung lesions with high SUV uptake. But the CT shows 6 spots. I just don't get it. Which test is the most reliable?

mpbser wrote:praying3,
. . . . I also don't think that the suggestion for a needle biopsy is unusual. . . .

Be very careful there. Know the surgeon and his/her experience. When dealing with a liver and biopsy, sometimes cancer cells get left behind (seeding). Then you have many new tumors. For some reason and I don't know why, this can be a problem with liver biopsy. Does not seem such a problem with lung biopsy.

Get the facts before going down this path, good luck, all the best,

Lee

Lee wrote:

mpbser wrote:praying3,
. . . . I also don't think that the suggestion for a needle biopsy is unusual. . . .

Be very careful there. Know the surgeon and his/her experience. When dealing with a liver and biopsy, sometimes cancer cells get left behind (seeding). Then you have many new tumors. For some reason and I don't know why, this can be a problem with liver biopsy. Does not seem such a problem with lung biopsy.

Get the facts before going down this path, good luck, all the best,

Lee

See, this scares me. It is supposed to be a CT guided needle biopsy. I did read a little about seeding, but it seems to be rare. We have a meeting with the oncologist tomorrow and I am going to ask about this risk. I just don't understand why if the PET scan shows this as cancer why we have to do this. The oncologist said he just wanted to be sure. So apparently somewhere down the line PET scans have been wrong I guess. I just hate all of this period. I just can't believe in a matter of like 6 weeks new lesions have shown up on his liver!

prayingof3 wrote:
See, this scares me. It is supposed to be a CT guided needle biopsy. I did read a little about seeding, but it seems to be rare. We have a meeting with the oncologist tomorrow and I am going to ask about this risk. I just don't understand why if the PET scan shows this as cancer why we have to do this. The oncologist said he just wanted to be sure. So apparently somewhere down the line PET scans have been wrong I guess. I just hate all of this period. I just can't believe in a matter of like 6 weeks new lesions have shown up on his liver!

At the end of the day, it's your DH life's on the line, not mine or your oncologist. My prior statement is based on hanging around here for 10 plus years. I am not an MD, but I've learned a few thing through the (10+ years) of hanging around here. And many years ago, I had to get a PET scan, because my Onc at that time told me a PET scan was the "gold standard" for monitoring cancer activity.

I would be asking the Onc why do you question the results of a PET scan, and the concerns of doing a liver biopsy (with the known risk). Would the Onc expose s/he or a family member to such a risk?

Hope this help, all the best to you and your husband.

Lee

Lee,


Thank you so much! This is pretty much what I am going to ask. I appreciate your knowledge in this. All of these decisions are just hard. Cancer is hard period.

My wife is in a similar spot. We had a PET that shows no activity on the liver and an initial CT that shows a cyst on the liver. After radiation and chemo we now have 4-5 tiny 4-5mm spots on the liver. They do not want to do a needle biopsy first they are too small second they don't want to spread it in the liver. They are hesitant of doing it. On thursday we had our surgery where the doctors removed her rectum, uterus, overies and iliac nodes on right side. He also to out two of the spots that are on the lower right lobe. We are waiting our pathology but he is thinking cancer.

prayingof3 wrote: . . . We have a meeting with the oncologist tomorrow and I am going to ask about this risk. I just don't understand why if the PET scan shows this as cancer why we have to do this. . . .

Hope the meeting went well. Did you learn anything new?

Thinking of you both,

Lee

tater wrote:My wife is in a similar spot. We had a PET that shows no activity on the liver and an initial CT that shows a cyst on the liver. After radiation and chemo we now have 4-5 tiny 4-5mm spots on the liver. They do not want to do a needle biopsy first they are too small second they don't want to spread it in the liver. They are hesitant of doing it. On thursday we had our surgery where the doctors removed her rectum, uterus, overies and iliac nodes on right side. He also to out two of the spots that are on the lower right lobe. We are waiting our pathology but he is thinking cancer.

Hope your wife is recovering from surgery without issues or problems. Best advice I can give. Walk, walk, walk, those hospital halls.

all the best to you and your wife,

Lee

PET shows up as bright when there is increased uptake of glucose in a part of the body, which can happen with cancer, infection and other conditions. Cancer tends to have higher SUV than infection, but if the lesion is small, the SUV is not reliable. Although the SUV value can favor one diagnosis over another, tissue sampling is the only way to confirm.

CT is based on how dense something is -- how much does it "attenuate" the X-ray beam.

MRI is based on proton spin. It is better at differentiating soft tissue. In the liver, with the right sequences, it can help differentiate between hemangiomas, focal nodular hyperplasia, adenomas, hepatocellular cancer and other neoplasms (including metastasis), which may look similar on CT.

These are all different modalities. Some things show up better on one test compared to another.

A lesion has to be at least 8 mm to show up on a PET scan. CT has better spatial resolution so tiny things can be seen on CT and not PET. Same with MRI, which needs a larger size voxel than CT.

Medical imaging is complex. There are lots of factors. Even just breathing can affect how good one scan is. MRI sequences take longer than CT, so motion is more of an issue. You can ask your doctor when you have doubt. If you don't get a specific enough answer (to your satisfaction), ask the radiologist.

I try to ask myself these questions when I have to decide on something:
- Will this test/procedure change clinical management of my disease? Will it change outcome?
- What are the risks, benefits and alternatives?
- What do my doctors recommend?
- What does my independent research show?


Then I decide. At least I know I made an informed decision. The rest is really out of my control.

In your specific case, you can ask if the needle biopsy will change management (chemo vs no chemo, RFA or liver section vs no surgery, change in chemo, longer chemo, etc). Is the alternative to go straight to an invasive procedure? Is it better to do minimally invasive biopsy first? Hopefully once you have discussed these things, you will feel confident in whichever option you choose.

Wanted to update.. the meeting with the oncologist went well. After lengthy discussion about the biopsy and how it would change his treatment, we are doing the biopsy today. He was supposed to start FOLFOX this week but because of results from PET, that was put on hold for a couple of weeks. The oncologist said there was a very small chance this isn't cancer, but we didn't want to add unnecessary treatment without knowing for sure. So if biopsy is positive, treatment will change to FOLFOX with Avastin added for 3 months. Then a break, then liver resection, then healing, then 3 more months of chemo. So, we are confident in this plan and are hoping that we are in that small percent that the liver biopsy is negative. We still have the issue of watching those lung lesions too! But he is not as concerned with those right now. Thanks so much for the support and I will update when we get results!

Sounds like an informed decision to me. That is the best.

Here's hoping it is NOT cancer.

Lee

Hello everyone! I said I would update. It is cancer in his liver. I was hoping so much that the PET scan was wrong. But still weird that it didn't show up on the CT or the MRI. Guess it was hiding or grew really fast. They are also checking it for mutations, but we don't have those results yet. So now he will be restaged at stage 4. I'm devastated!