Prediction of surgical resectability in patients with hepatic colorectal metastases

Care of cancer patients with liver and bone metastases - the place of pharmaceutical care in a balanced plan, focused on the patient's needs and goals

Metastatic cancer, especially in the growing population of geriatric patients, presents a big challenge to these patients, as well as to treatment teams and the entire health care system. This article describes some common medical problems faced by patients with metastases to liver and bone, and presents a diagnostic approach, and therapeutic management of various symptoms, relevant to advanced stages of the malignant disease. The article highlights the importance of patient education on various aspects of metastatic cancer, and underscores the unique position of pharmacists practicing pharmaceutical care, which is particularly beneficial in this group of patients with advanced malignancy. Also, this paper emphasizes that achieving a proper balance between managing the malignant disease and maintaining the patients' quality of life, especially in the elderly population, should involve coordinated efforts of the oncology treatment team, primary care physicians, pharmacists, therapists and nurses, as well as patients, their families and caregivers.

Imaging of Hepatic Metastases

BACKGROUND

Imaging plays an important role not only in screening, evaluating, staging, and monitoring disease, but also in surveillance following tumor ablation. Advances in imaging techniques have increased our ability to detect and characterize focal liver lesions, resulting in improvements in diagnostic capability and improved monitoring of liver metastases. This has led to increased interest in both hepatic imaging and image-guided hepatic interventions.

METHODS

Several imaging options are reviewed according to their effective application, notably computed tomography (CT), CT during arterial portography, ultrasound, magnetic resonance imaging, positron emission tomography, and integrated PET/CT imaging.

RESULTS

Although there are exceptions regarding imaging options based on patient selection and on institution preference and expertise, multidetector helical CT scanning remains the dominant modality in the evaluation of suspected hepatic metastases, and for preoperative planning, treatment monitoring, and posttreatment follow-up.

CONCLUSIONS

Ultimately, the choice of imaging modality must be based not only on the patient and the clinical situation, but also on the imaging expertise within each institution.

The Precision of Hepatic Arterial Infusion Scintigraphy as a Quantitative Biomarker of Tumor Microvasculature

OBJECTIVE

Optimal clinical development of new cancer therapies targeting tumor vasculature requires new target-specific response assays. This clinical study examined the test-retest repeatability of SPECT as an in vivo assay of angiogenic hepatic tumor microvasculature using an intraarterial infusion of 99mTc-macroaggregated albumin (MAA) delivered via a hepatic artery infusion (HAI) pump.

MATERIALS AND METHODS

Patients with primary or secondary cancerous liver tumors with HAI pump-catheter implants placed for HAI chemotherapy underwent hepatic SPECT after separate arterial infusions of 37 and 185 MBq of 99mTc-MAA via an HAI pump. Quantitative measures of hepatic tumor MAA uptake were obtained from paired test-retest SPECT datasets. Repeatability was defined by quotients of paired measurands with 95% CIs and coefficients of repeatability (CRs).

RESULTS

Test-retest HAI pump SPECT yielded highly repeatable measurements in quantitative indexes of tumor microvasculature. Variability in repeat test-retest measurements was small relative to the range of observed measurements between different tumors. The total hepatic tumor microvascular MAA accumulation (percentage injected dose) proved most repeatable, with test-retest value quotients near unity (quotients: median, 1.10 ± 0.09 [SD]; range, 1.03-1.32; 95% CI, 1.07-1.19) and 1.6% CR. Tumor MAA uptake values ranged from 5% to 18% injected dose.

CONCLUSION

This article describes the precision of HAI SPECT as a quantitative biomarker of tumor microvasculature under conditions of repeatability. The results support clinical testing of HAI SPECT as a radiologic response biomarker for angiotropic tumor therapy.

FDG PET and PET/CT for colorectal cancer

The evaluation of patients with known or suspected recurrent colorectal carcinoma is now an accepted indication for positron emission tomography using (18)F-fluorodeoxyglucose (FDG-PET) imaging. PET and CT are complimentary, and therefore, integrated PET/CT imaging should be performed where available. FDG-PET/CT is indicated as the initial test for diagnosis and staging of recurrence, and for preoperative staging (N and M) of known recurrence that is considered to be resectable. FDG-PET imaging is valuable for the differentiation of posttreatment changes from recurrent tumor, differentiation of benign from malignant lesions (indeterminate lymph nodes, hepatic, and pulmonary lesions), and the evaluation of patients with rising tumor markers in the absence of a known source. The addition of FDG-PET/CT to the evaluation of these patients reduces overall treatment costs by accurately identifying patients who will and will not benefit from surgical procedures. This new powerful technology provides more accurate interpretation of both CT and FDG-PET images and therefore more optimal patient care. PET/CT fusion images affect the clinical management by guiding further procedures (biopsy, surgery, and radiation therapy), excluding the need for additional procedures, and changing both inter- and intramodality therapy.

PET and PET-CT for evaluation of colorectal carcinoma

The evaluation of patients with known or suspected recurrent colorectal carcinoma is now an accepted indication for positron emission tomography using (18)F-fluorodeoxyglucose (FDG-PET) imaging. FDG-PET does not replace imaging modalities such as computed tomography (CT) for preoperative anatomic evaluation but is indicated as the initial test for diagnosis and staging of recurrence and for preoperative staging (N and M) of known recurrence that is considered to be resectable. FDG-PET imaging is valuable for the differentiation of posttreatment changes from recurrent tumor, differentiation of benign from malignant lesions (indeterminate lymph nodes, hepatic and pulmonary lesions), and the evaluation of patients with rising tumor markers in the absence of a known source. The addition of FDG-PET to the evaluation of these patients reduces overall treatment costs by accurately identifying patients who will and will not benefit from surgical procedures. Although initial staging at the time of diagnosis is often performed during colectomy, FDG-PET imaging is recommended for a subgroup of patients at high risk (with elevated CEA levels) and normal CT and for whom surgery can be avoided if FDG-PET shows metastases. Screening for recurrence in patients at high risk has also been advocated. FDG-PET imaging seems promising for monitoring patient response to therapy but larger studies are necessary. The diagnostic implications of integrated PET-CT imaging include improved detection of lesions on both the CT and FDG-PET images, better differentiation of physiologic from pathologic foci of metabolism, and better localization of the pathologic foci. This new powerful technology provides more accurate interpretation of both CT and FDG-PET images and therefore more optimal patient care. PET-CT fusion images affect the clinical management by guiding further procedures (biopsy, surgery, radiation therapy), excluding the need for additional procedures, and changing both inter- and intramodality therapy.

Multi-detector row helical CT in preoperative assessment of small (< or = 1.5 cm) liver metastases: is thinner collimation better?

PURPOSE

To determine the value of collimations less than 5 mm in detecting hepatic metastases 1.5 cm or smaller by using multi-detector row helical computed tomography (CT).

MATERIALS AND METHODS

Thirty-one patients underwent contrast material-enhanced multi-detector row helical CT before hepatic resection in this prospective study. Images were reconstructed at collimations of 5.00, 3.75, and 2.50 mm with 50% overlap and reviewed independently by three radiologists. Each lesion was characterized as metastatic, benign, or equivocal and graded for conspicuity. Criterion standards were pathologic assessment of the resected liver and follow-up of the nonresected liver. Only lesions 1.5 cm or smaller were analyzed.

RESULTS

There were a total of 88 liver lesions 1.5 cm or smaller, and 25 of these were metastases. Pooled sensitivity for all lesions improved with thinner collimation (66% [58 of 88 lesions], 69% [61 of 88], and 82% [72 of 88] at collimations of 5.00, 3.75, and 2.50 mm, respectively), and this was statistically significant (P =.01). However, no significant difference was noted between collimations in the pooled sensitivity for metastatic lesions (80% [20 of 25 lesions] at all collimations) (P >.99). No statistical difference was noted in the conspicuity of lesions at different collimations (P =.18).

CONCLUSION

Image reconstruction with multi-detector row helical CT at collimations less than 5 mm may not improve sensitivity in the detection of hepatic metastases 1.5 cm or smaller.

Current value of intraoperative sonography during surgery for hepatic neoplasms

Noninvasive liver imaging has developed rapidly resulting in increased accuracy for detecting primary and secondary hepatic tumors. Intraoperative ultrasonography (IOUS) was commonly considered to be the gold standard for liver staging, but the current value of IOUS is unknown in view of more sophisticated radiologic tools. The purpose of this prospective study was to evaluate the impact of IOUS on the treatment of 149 patients undergoing liver surgery for malignant disease (colorectal metastasis, 61 patients; hepatoma, 52 patients; other hepatic malignant tumors, 36 patients). The sensitivities of computed tomography (CT), helical CT, magnetic resonance imaging, and IOUS in patients with colorectal metastases were 69.2%, 82.5%, 84.9%, and 95.2% in a segment-by-segment analysis; in patients with hepatoma their sensitivities were 76.9%, 90.9%, 93.0%, and 99.3%; and in patients with other hepatic malignancies they were 66.7%, 89.6%, 93.3%, and 98.9%, respectively. Additional malignant lesions (AMLs) were first detected by inspection and palpation in 20 patients (13.4%). In another 18 patients (12.1%) IOUS revealed at least one AML. Overall, the findings obtained only by IOUS changed the surgical strategy in 34 cases (22.8%). It was concluded that IOUS, having undergone some refinement as well, still has immense diagnostic value in hepatectomy candidates. Frequently avoiding palliative liver resection and occasionally disproving unresectability as assessed by preoperative imaging, IOUS still has a significant impact on surgical decision making and should still be considered the gold standard.

Follow-up of patients with colorectal cancer: numbers needed to test and treat

Follow-up after curative treatment of patients with colorectal cancer has as its main aims the quality assessment of the treatment given, patient support, and improved outcome by the early detection and treatment of cancer recurrence. How often, and to what extent, the final aim, improved survival, is indeed realised is so far unclear. A literature search was performed to provide quantitative estimates for the main determinants of the effectiveness of the follow-up. Data were extracted from a total of 267 articles and databases, and were aggregated using modern meta-analytic methods. In order to provide one more colorectal cancer patient with long-term survival through follow-up, 360 positive follow-up tests and 11 operations for colorectal cancer recurrence are needed. In the remaining 359 tests and 10 operations, either no gains are achieved or harm is done. As the third aim of colorectal cancer follow-up, improved survival, is realised in only few patients, follow-up should focus less on diagnosis and treatment of recurrences. It should be of limited intensity and duration (3 years), and the search for preclinical cancer recurrence should primarily be performed by carcino-embryonic antigen (CEA) testing and ultrasound (US). The focus of colorectal cancer follow-up should shift from the early detection of recurrence towards quality assessment and patient support. As support that is as good or even better can be provided by a patient's general practitioner (GP) or by specialised nursing personnel, there is no need for routine follow-up to be performed by the surgeon.

Positron emission tomography for evaluation of colorectal carcinoma

Evaluation of patients with known or suspected recurrent colorectal carcinoma is now an accepted indication for FDG PET imaging. FDG PET does not replace imaging modalities such as CT for preoperative anatomic evaluation but is indicated as the initial test for diagnosis and staging of recurrence and for preoperative staging (N and M) of known recurrence that is considered to be resectable. FDG PET imaging is valuable for differentiation of posttreatment changes from recurrent tumor, differentiation of benign from malignant lesions (indeterminate lymph nodes, hepatic and pulmonary lesions), and evaluation of patients with rising tumor markers in the absence of a known source. Addition of FDG PET to the evaluation of these patients reduces overall treatment costs by accurately identifying patients who will and will not benefit from surgical procedures. Although initial staging at the time of diagnosis is often performed during colectomy, FDG PET imaging is recommended for a subgroup of patients at high risk (with elevated CEA levels) and normal CT and for whom surgery can be avoided if FDG PET shows metastases. Screening for recurrence in patients at high risk has also been advocated. FDG PET imaging seems promising for monitoring therapy, but larger studies are necessary.

Usefulness of intraoperative sonography for revealing hepatic metastases from colorectal cancer in patients selected for surgery after undergoing FDG PET

OBJECTIVE

The purpose of this study was to compare the diagnostic performance of preoperative positron emission tomography (PET) with FDG and intraoperative sonography with the standard of histologic examination of resected liver specimens in evaluating patients for curative resection of liver metastases from colorectal cancer.

MATERIALS AND METHODS

We retrospectively identified 47 patients with recurrent colorectal cancer who underwent surgical exploration for possible curative resection of hepatic metastases. All patients underwent CT or MR imaging and FDG PET preoperatively and intraoperative sonography. The performance of the imaging techniques was evaluated through review of the radiologic reports and correlation with surgical and histopathologic findings.

RESULTS

Eighty-seven malignant hepatic lesions were identified by histopathologic analysis of liver specimens, and 23 benign hepatic abnormalities were documented histopathologically or by uroradiologic imaging. For hepatic sections characterized as containing metastases by radiologic imaging, the positive predictive value for FDG PET was 93% (54/58); for intraoperative sonography, 87% (52/60); and for conventional imaging, 83% (43/52). For individual lesions characterized as probably malignant, the positive predictive value for FDG PET was 93% (62/68); for intraoperative sonography, 89% (63/71); and for conventional imaging, 78% (46/59). The findings at intraoperative sonography led to a change in the clinical treatment of only one patient (2%).

CONCLUSION

The results indicate that FDG PET effectively screens potential candidates for curative liver resection. Although intraoperative sonography helps to determine the anatomic location of metastases thus facilitating surgical resection, its adjunctive use in patients screened preoperatively by FDG PET has limited impact on treatment selection.

The role of positron emission tomography in colorectal carcinoma

Positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) is a functional imaging modality that provides mapping of glucose metabolism in the whole body. The glucose analogue fluorodeoxyglucose is labeled with the cyclotron-produced, positron-emitting radioisotope fluorine-18. The resulting radiopharmaceutical FDG is a substrate for glucose transport proteins (Glut) in cell membranes and accumulates intracellularly. Increased metabolic activity in malignant tissue is accompanied by increased glucose uptake relative to that of surrounding normal tissue. This focal increase in glucose uptake can be identified with FDG PET, which allows identification of malignant tumor foci. Multiple reports have shown that positron emission tomography with 18F-fluorodeoxyglucose scanning (FDG-PET) is highly accurate in detecting early localized tumor recurrence with a sensitivity and specificity in the mid nineties. FDG-PET scanning evaluates abdomen, chest, and pelvis in one examination setting, permiting identification of local recurrence as well as distant metastasis. FDG-PET is also highly sensitive in detecting hepatic and extra-hepatic metastasis. Finally, FDG-PET scanning can distinguish post-treatment (postoperative and postradiation therapy) scarring from recurrent tumors since malignant tumors are metabolically active and FDG-avid on PET imaging and scar tissue is not. This high accuracy in identifying early stage recurrent tumors with FDG-PET is crucial for potential surgical cure and improving patient outcomes.

Positron emission tomography imaging in oncology

The applications for FDG-PET imaging are rapidly growing and accepted in the field of oncology. FDG-PET imaging does not replace other imaging modalities, such as CT, but seems to be very helpful in specific situations where CT has known limitations, such as differentiation of benign from malignant indeterminate lesions on CT, differentiation of post-treatment changes versus recurrent tumor, differentiation of benign from malignant lymph nodes, and monitoring therapy. The biggest use of FDG-PET presently is in N and M staging of various body tumors. The addition of FDG-PET in the evaluation of oncologic patients in well-defined algorithms including a combination of imaging studies seems to be cost effective by accurately identifying patients who benefit from invasive procedures and saving unnecessary costly invasive procedures on patients who do not benefit from them. Although PET imaging may decrease the cost of health care by reducing the number of invasive procedures, implementation of clinical PET has been hindered by the high cost of the purchase, operation expenses, and maintenance of PET systems; the need for immediate access to a source of 18F (owing to the 110-minute half-life); and the limited reimbursement for clinical procedures by third-party payers. These combined factors have resulted in the development by manufacturers of hybrid gamma camera systems capable of performing positron imaging. These systems can be used to image conventional radiopharmaceuticals used in general nuclear medicine and positron-emitting radiopharmaceuticals. The performance of these camera-based PET systems has improved markedly over the past few years with the introduction of thicker NaI (T1) crystals, iterative reconstruction algorithms, and attenuation correction. These new developments in medical imaging instrumentation have contributed to the expansion of the number of cyclotrons, and have driven the concept of commercial FDG distribution centers.

Imaging of anorectal disease

BACKGROUND

Over the past two decades developments in imaging have changed the assessment of patients with anorectal disease.

METHODS

The literature on imaging techniques for anorectal diseases was reviewed over the period 1980-1999.

RESULTS

For the staging of primary rectal tumours, phased array magnetic resonance imaging (MRI) may be regarded as the most appropriate single technique. The combination of endosonography or endoluminal MRI with ultrasonography or spiral computed tomography yields similar results. All techniques have limitations both for local staging and in the assessment of distant metastases. MRI or positron emission tomography is preferable for tumour recurrence. For perianal fistula, high-resolution MRI (phased array or endoluminal) is the technique of choice. For constipation, defaecography is the preferred technique, nowadays with emphasis on functional information. The role of magnetic resonance defaecography is currently being evaluated. For faecal incontinence, endosonography and endoluminal MRI give similar results in detecting sphincter defects; endoluminal MRI has the advantage of detecting external sphincter atrophy.

CONCLUSION

High-resolution MRI, endosonography and defaecography are currently the optimal imaging techniques for anorectal disease.

Management of hepatic metastases

Although the liver is the most common site of metastatic disease from a variety of tumor types, isolated hepatic metastases most commonly occur from colorectal cancer and, less frequently, from neuroendocrine tumors, gastrointestinal sarcoma, ocular melanoma, and others. Complete evaluation of the extent of metastatic disease, both intrahepatically and extrahepatically, is important before considering treatment options. Based on a preponderance of uncontrolled studies for hepatic metastatic colorectal carcinoma, surgical resection offers the only potential for cure of selected patients with completely resected disease, with 5-year survival rates of 25% to 46%. Systemic and hepatic arterial infusion chemotherapy may be useful treatment options in patients with unresectable disease and possibly as an adjuvant treatment after liver resection. Other techniques of local tumor ablation, including cryotherapy and radiofrequency ablation, although promising, remain unproved. Management of hepatic metastases from neuroendocrine tumors and other noncolorectal primary tumors should be individualized based on the patient's clinical course, extent of disease, and symptoms.

Scintigraphic techniques for hepatic imaging. Update for 2000

Nuclear medicine continues to evolve from a generic imaging approach to a collection of imaging techniques that are disease-specific. In-111 octreotide SPECT scan has quickly become the method of choice to image gastrinoma. A number of other agents have a role in other tumor models. FDG imaging of the liver is in its infancy, but has potential to outperform anatomic methods (CT scan, MR imaging), particularly in the detection of colorectal cancer metastases. The imaging of FDG in nuclear medicine involves rapidly evolving technology and has the potential to diffuse to the community level practice. To further face the controversial areas head on, another problem for nuclear medicine's role in hepatic imaging remains its somewhat separate existence from radiology. Frequently, the abdominal imager or the general radiologist is in the best position to recommend a scintigraphic liver study. A broad knowledge of these techniques by all radiologists is essential for their ultimate success.

Management strategies for colorectal liver metastases--Part I

Colorectal cancer is a common malignancy and the incidence of this disease is increasing. Approximately 50% of patients with colorectal cancer die from recurrent disease following an apparently curative resection of the primary tumour and the liver is the most frequent site of relapse. Although only a small proportion of patients will benefit from resection of liver metastases, this form of treatment offers the only possibility of cure. In selected patients, 5-year survival rates of 25-35% may be achieved following liver resection. A poor prognosis after resection of hepatic metastases is likely when there are more than three metastatic deposits, involved resection margins often as a result of ¿wedge' resections, when there is extrahepatic disease, or when there is nodal involvement at the primary tumour site. Regional hepatic artery infusion chemotherapy may provide palliation and possibly even prolongation of survival for some patients with unresectable metastases. Cytoreductive techniques may also provide palliation in selected patients with hepatic metastases unsuitable for resection; cryotherapy is the most promising of these methods.

The approach to the patient with single and multiple liver metastases, pulmonary metastases, and intra-abdominal metastases from colorectal carcinoma

Recurrent colorectal carcinoma constitutes a major health care problem, with 90,000 patients diagnosed annually with metastatic disease. Recent advances have offered treatment to selected patients with liver, lung, and intra-abdominal metastases. Resection of liver secondary tumors improves 5-year survival from 0% to approximately 30% and offers the only possibility for cure. As experience mounts, hepatic surgery can be performed with quite acceptable morbidity and mortality. Adjuvant therapies are being developed that may improve results with surgery alone. Cryoablation is a new technique that appears to effectively eradicate liver tumors, but its role remains to be defined. In patients with unresectable disease, the benefit of hepatic artery infusion of chemotherapy is unproven. Resection of pulmonary metastases significantly improves survival in patients with solitary nodules. Consistent data regarding the benefit of pulmonary metastatectomy in patients with multiple nodules are not available. Combined cytoreductive surgery and intraperitoneal hyperthermic chemotherapy is being investigated as a treatment for peritoneal carcinomatosis from colorectal cancer. Although selected patients may benefit, this combined treatment modality appears to be less effective in patients with colorectal cancer than with other types of cancer.

Role of computed tomographic arterial portography and intraoperative ultrasound in the evaluation of patients for resectability of hepatic lesions

Computed tomographic arterial portography (CTAP) has been shown to be the most sensitive preoperative test for determining resectability of hepatic lesions but we have shown it to have low specificity. Intraoperative ultrasound (IOUS) evaluation of the liver has also been proposed as an accurate means of assessing resectability. We sought to compare the effectiveness of the two modalities. Fifty-six patients who had been deemed candidates for liver resection based on CTAP findings underwent systematic exploration, liver mobilization, and IOUS examination. Ultrasound findings were compared with results of CTAP. In 46 patients the IOUS findings were in complete agreement with those of CTAP. In 10 patients CTAP lesions could not be verified by IOUS and these patients did not undergo resection. Follow-up of these 10 patients revealed eight who did not have progression of malignancy at the CTAP-predicted site (CTAP false positive). Two patients did have progression at a CTAP-positive IOUS-negative site (IOUS false negative). Sensitivity for CTAP and IOUS was 100% and 96%, respectively. Specificity for IOUS was 100%. These findings demonstrate the high sensitivity of CTAP and the high sensitivity and specificity of IOUS. CTAP may "overcall" hepatic lesions but IOUS can correctly identify these false positives in most instances. Because CTAP is useful for determining which patients might benefit from surgical exploration, we conclude that the two modalities are complementary for the assessment of resectability of hepatic lesions. The false positive rate for CTAP implies that caution must be used when declining to operate on patients on the basis of this test.

Positron emission tomography to stage suspected metastatic colorectal carcinoma to the liver

BACKGROUND

Accurate detection of recurrent colorectal carcinoma remains a clinical challenge. Positron emission tomography (PET) using 18F-fluorodeoxyglucose (18FDG) is an imaging technique that allows direct evaluation of cellular metabolism. 18F-fluorodeoxyglucose PET was compared to computed tomography (CT) and CT portography for staging metastatic colorectal carcinoma.

PATIENTS AND METHODS

Twenty-four patients previously treated for colorectal carcinoma who had suspected recurrence to the liver underwent an 18FDG PET scan of the entire body. All patients had either a CT scan of the abdomen (n = 17), a CT portogram (n = 18), or both (n = 11). The final diagnosis was obtained by tissue pathology in 19 patients and clinical follow-up in 5 patients.

RESULTS

A total of 60 suspicious lesions were identified. Of the 55 intrahepatic lesions, 39 were malignant and 16 were benign. Of the 5 extra-hepatic lesions, 4 were malignant. The 18FDG PET imaging had a higher accuracy (93%) than CT and CT portography (both 76%) in detecting metastatic disease to the liver, and detected unsuspected extrahepatic recurrence in 4 patients. Although the sensitivity of 18FDG PET (90%) was slightly lower than that of CT portography (97%), the specificity was much higher (100% versus 9%), including postsurgical sites. 18FDG PET altered surgical plans in 6 (25%) of 24 patients.

CONCLUSIONS

18FDG PET is extremely useful in staging patients with suspected metastatic colorectal carcinoma to the liver.

Nuclear imaging of solid hepatic masses

This review has focused on the unique role of radionuclide scintigraphy in characterization of hepatic mass lesions. Radionuclide scintigraphy, unlike most other imaging modalities, is based on specific physiological and biochemical properties of each pathological entity that affects the liver. Hepatic scintigraphy, with its widespread availability, noninvasive nature, and relatively low cost is a powerful adjunct to other imaging techniques in the investigation of hepatic mass lesions. We have reviewed clinical presentation and characteristic findings of most hepatic lesions and have described reported findings with all available imaging modalities with particular emphasis on hepatic scintigraphy (Table 1) as well as a suggested algorithm for workup of solid hepatic masses (Fig 6). Additionally, the role of newer, more specialized techniques including PET scanning, 123I-labeled VIP, and 111In-labeled DTPA-D-Phe-octreotide scanning are reviewed. Hepatic nuclear scintigraphy continues to play an important role in the management of patients with solid hepatic masses.