Extrahepatic Lesions Research Articles

Management of Adrenal Metastasis from Hepatocellular Carcinoma

Although the adrenal gland is a common site of extrahepatic metastasis from hepatocellular carcinoma (HCC), there are no definitive guidelines for the treatment of adrenal metastasis. This study examines the effectiveness of various treatments for this disease. We retrospectively analyzed 20 patients treated for adrenal metastasis of HCC by adrenalectomy ( n = 13), transarterial chemoembolization (TACE), or percutaneous ethanol injection therapy (PEIT) ( n = 7). There were no significant differences in cumulative survival rates between patients given adrenalectomy and those given TACE or PEIT, either after completing treatment for primary HCC or after the first treatment for adrenal metastasis. Six of seven patients with tumor thrombi in the inferior vena cava (IVC) from adrenal metastasis underwent adrenalectomy combined with intracaval thrombectomy, five of whom survived for more than 1 year after surgery, and two of whom are still alive without any recurrence more than 3 years after surgery. PEIT showed good results for small adrenal metastasis. These findings suggest that therapeutic modalities should be chosen according to the clinical features of each individual, including the size of the metastatic tumor, whether there is invasion into the IVC, the function of the remaining liver, and the existence of intra- and/or nonadrenal extrahepatic lesions. Furthermore, intracaval tumor thrombectomy could be indicated for patients with IVC thrombus if they are suitable candidates for surgery.

Radiofrequency ablation of liver tumors: Influence of technique and tumor size

Background. Radiofrequency thermal ablation (RFA) of liver tumors is done by both radiologists and surgeons by using various techniques for a variety of indications. This report describes our initial experience with RFA in 45 patients with hepatic malignancies. Methods. Patients with primary or secondary hepatic malignancies who were not candidates for resection underwent ultrasound-guided RFA under general anesthesia. End points were recurrence within or adjacent to the ablation zone or new hepatic or extrahepatic lesions. Product limit survival estimates for both ablation site recurrence-free survival and disease-free survival were calculated and compared for tumor size (less than 4 cm or 4 cm or greater), operative approach (percutaneous, laparoscopy, or open), and tumor type (hepatocellular cancer, colorectal cancer, or other metastatic disease). Results. Patients with hepatocellular cancer (n = 11) and with secondary hepatic malignancies (n = 34) had 84 lesions ablated with a median follow-up of 12 months. Largest ablated tumor size of 4 cm or greater (P <.001) and the percutaneous approach (P <.02) were associated with worse ablation site recurrence-free survival but not overall disease-free survival (P =.06). The 15 patients with colorectal cancer had worse disease-free survival compared with other tumor types (P <.01). Conclusions. RFA of hepatic malignancies can be done by using a percutaneous, laparoscopic, or open approach. Local control appears superior for tumors less than 4 cm and when an open surgical approach is used. The difficulty in achieving prolonged disease-free survival, especially in colorectal cancer, underscores the need to investigate multimodality approaches that include local ablative techniques. Future RFA studies should consider tumor size, operative technique, and tumor type in trial design. (Surgery 2002;132:605-12.)

Extrahepatic spread of hepatocellular carcinoma: a pictorial review.

Although extrahepatic spread of hepatocellular carcinoma (HCC) is uncommon, it can be found anywhere in the body. Most extrahepatic metastases of HCC occur in patients with advanced-stage intrahepatic tumor, but incidental extrahepatic lesions have also occasionally been found in patients with early-stage intrahepatic HCC. The detection of extrahepatic metastatic disease is crucial when planning therapy for patients with HCC and should be used to avoid unnecessary surgical intervention. In this study we illustrate the radiologic findings of extrahepatic metastases of HCC involving various sites. The presumed mechanism of extrahepatic extension of HCC is also discussed.

Gall bladder and extrahepatic bile duct changes in Opisthorchis viverrini-infected hamsters

Opisthorchis viverrini infection is associated with several hepatobiliary diseases, but few reports have described extrahepatic lesions in opisthorchiasis. We therefore sequentially investigated histological changes of the gall bladder and extrahepatic bile duct in hamsters infected with 25 (group 1), 50 (group 2) and 100 (group 3) metacercariae for up to 180 days. Acute inflammatory reactions, including congestion, neutrophil and eosinophil infiltration, occurred in the gall bladder as early as day 7 of groups 2 and 3 and on day 14 in group 1; the extrahepatic bile ducts exhibited the changes on day 3 post-infection (p.i.). Mononuclear cell infiltration, mucus hypersecretion and fibrosis were gradually observed thereafter. Active inflammation reached a plateau at approximately 60 days in all infected groups. The well-established chronic histological changes of the gall bladder and extrahepatic bile duct were fibrosis and mononuclear cell infiltration with lymphoid aggregation and, additionally, ductal dilatation for the latter. Overall, the pathological changes in the extrahepatic bile duct were more severe than those in the gall bladder for the same dose and period of infection. The results demonstrate that pathological changes in the gall bladder and extrahepatic bile duct do occur in O. viverrini infection and may be extrapolated to human infection.

肝細胞癌外科的治療後の肝外転移に対する治療法の検討

From 1996 to 2000, 105 patients with hepatocellular carcinoma (HCC) underwent inital surgical treatment (hepatectomy in 62 and ablation in 43) at our institute. Twelve of the 105 suffered extrahepatic metastasis. Nine of the 12 had intrahepatic metastasis, and 6 were controlled by various treatment to liver (TAE, CAI, MCT, RFA and resection). Metastatic sites of the 12 with multiple organ recurrence were lung (7), peritoneum (5), lymph node (4), adrenal gland (3), bone (1), brain (1), and stomach (1). These extrahepatic lesions were treated by resection in 15, systemic chemotherapy in 6, and radiation in 3 (overlapping occurred). The 1-year survival of the 12 was 67% and 3-year survival was 39%. The 3-year survival of those with resected extrahepatic metastasis (69%, n=7) was significantly better than that of unresected (0%, n=5, p=0.0045). In those with resected extrahepatic metastasis, intrahepatic recurrence was controlled of all. These results suggest that extrahepatic HCC metastasis should be resected if the lesion is completely resectable and intrahepatic recurrence is controlled.

Complications following repair of extrahepatic bile duct injuries after blunt abdominal trauma.

Extrahepatic bile duct traumatic injuries are extremely rare and their treatment is difficult and with several controversies. The aim of this study was to offer some more clinical information on their surgical repair and outcome. We present seven patients with extrahepatic biliary tract lesions after blunt abdominal trauma, (isolated gallbladder lesions were excluded) four males and three females from 23 to 51 years of age (mean age 35.1 years). All patients had suffered high-energy blunt abdominal trauma and presented associated injuries, mostly liver trauma and lung contusions. Six gallbladder lesions and six common bile duct injures were identified; a right hepatic duct laceration and a left hepatic duct transection were also present. Injuries were treated either with primary repair or with duct-jejunal anastomoses with Roux-en-Y reconstruction. Principal complications were postoperative anastomotic leakage (1 case) and recurrent cholangitis (3 cases) with or without stricture. Not-diagnosed injuries caused substantial morbidity. We prefer and recommend the use of primary repair in partial ruptures with no significant tissue loss and biliary-enteric anastomoses in large injuries and complete transections because they offer the best long-term drainage with less risk of stricture formation than end-to-end anastomoses. We defend the use of long duration (6 to 9 months) transanastomotic stents.

Nitinol stents for palliative treatment of malignant obstructive jaundice: should we stent the sphincter of Oddi in every case?

To evaluate the necessity of metallic stenting of the sphincter of Oddi in malignant obstructive jaundice when the tumor is more than 2 cm from the papilla of Vater. Sixty-seven self-expandable biliary stents were used in 60 patients with extrahepatic lesions of the common hepatic or common bile duct and with the distal margin of the tumor located more than 2 cm from the papilla of Vater. Stents were placed above the papilla in 30 cases (group A) and in another 30 with their distal part protruding into the duodenum (group B). The 30-day mortality was 15%, due to the underlying disease. The stent occlusion rate was 17% after a mean period of 4.3 months. No major complications were noted. Average survival was 132 days for group A and 140 days for group B. In group A, 19 patients survived < or = 90 days and in eight of these, cholangitis occurred at least once. Of 11 patients in group A with survival > 90 days, only two developed cholangitis. In group B, 13 patients who survived < or = 90 days had no episodes of cholangitis and in 17 with survival > 90 days, cholangitis occurred in three. There is a statistically significant difference (p < 0.05) regarding the incidence of cholangitis in favor of group A. In patients with extrahepatic lesions more than 2 cm from the papilla and with a relative poor prognosis (< or = 3 months), due to more advanced disease or to a worse general condition, the sphincter of Oddi should also be stented in order to reduce the postprocedural morbidity.

Immunoreactivity for hepatocyte paraffin 1 antibody in hepatoid adenocarcinomas of the gastrointestinal tract.

Hepatocyte paraffin 1 (Hep Par 1) is a monoclonal antibody considered almost specific for normal and neoplastic hepatocytes, that can be used on formalin-fixed paraffin-embedded tissues. Hep Par 1 reactivity has been demonstrated consistently in hepatocellular carcinomas and hepatoblastomas but only rarely in cholangiocarcinomas and metastatic tumors to the liver. Although its role as a marker of hepatocytic differentiation in primary liver tumors has been studied extensively, Hep Par 1 expression has not been explored in extrahepatic lesions, especially rare adenocarcinomas with hepatoid morphologic features. We studied 7 hepatoid adenocarcinomas of the gastrointestinal tract (6 gastric and 1 from the gallbladder) for Hep Par 1 immunoreactivity. Focal Hep Par 1 expression was seen in 6 of 7 tumors. These hepatoid adenocarcinomas also showed reactivity for alpha-fetoprotein and carcinoembryonic antigen. The presence of Hep Par 1 reactivity in extrahepatic hepatoid adenocarcinomas underscores the fact that Hep Par 1 expression is not unique to primary hepatocellular neoplasms. Adenocarcinomas with hepatoid features must be considered in the differential diagnosis of Hep Par 1-positive lesions.

Massive progression of diffuse hepatic lymphangiomatosis after liver resection and rapid deterioration after liver transplantation

Hepatic involvement is an exceptional presentation of lymphangiomatosis. In this case report we describe a patient who underwent liver transplantation secondary to progressive hepatic involvement, which occurred 2 yr after partial hepatectomy. Within 1 yr after liver transplantation the disease condition deteriorated, with rapid progression of pre-existing skeletal lesions and development of pulmonary disease. We conclude that liver transplantation may be a treatment option for hepatic lymphangiomatosis. In the presence of pre-existing extrahepatic lesions, however, liver transplantation seems to be contraindicated.

Usefulness of intraoperative radiofrequency thermoablation of liver tumours associated or not with hepatectomy

Introduction A probe emitting radiofrequency (RF) waves is able to destroy tumour tissue by thermal ablation. The purpose of this study was to undertake a prospective estimation of the benefit of RF thermoablation of liver tumours during hepatic and extrahepatic resections aimed at obtaining an R0 status in patients in whom disease is notoriously considered unresectable. Method Twenty-one patients underwent surgery between January 1997 and September 1999. In 17 cases, RF was associated with a hepatectomy and in nine of these cases with resection of extrahepatic lesions. In two cases, extensive resection of extrahepatic lesions was associated with RF to treat liver metastases, and in two cases RF was ultimately performed alone. The mean number of liver metastases was 6.2±4.3 (range 1–15) per patient. A total of 32 lesions were treated with RF. The mean size of the 33 RF-thermoablated tumours was 13.6±9.7 mm (range 5–52 mm), and in all but one case, a Pringle manoeuvre was performed during the RF procedure. Results: A probable R0-resection was obtained in 18 cases. No operative deaths or any RF-related complications occurred. If we exclude the case in which it was clearly impossible to destroy liver metastases intraoperatively, only one local recurrence occurred (3%) among the 32 thermoablated lesions after a mean follow-up of 17.3 months. The 2-year overall and disease-free survival rates for this initially unresectable population were 94.7% and 22%, respectively. Conclusion: Intraoperative use of RF to destroy unresectable liver tumours increases the rate of curative resections. Future progress in RF technology and adequate vascular clamping during RF should increase this rate.

The role of positron emission tomography with fluorine-18-deoxyglucose in identifying colorectal cancer metastases to liver.

Liver metastasis is a common consequence of colorectal carcinoma. Early and accurate detection of liver metastasis is crucial for a decision about partial hepatectomy, which is considered a standard and potentially curative therapy in such a setting. The presence of extrahepatic metastases will exclude surgical resection as a therapeutic option. Positron emission tomography with fluorine-18-deoxyglucose (FDG-PET) has been successful in detecting and staging a variety of malignancies. The purpose of this study was to assess the utility of FDG-PET in the accurate detection of liver and distal metastases from colorectal cancer. The results of 80 PET and computed tomography (CT) scans were compared with surgical pathology and clinical outcome. FDG-PET detected liver metastases in 28 patients, with a sensitivity of 100%. CT detected metastasis in 20 patients, giving a sensitivity of 71.4%. In addition, in one patient with negative CT findings, PET detected a focus of hypermetabolism in the region adjacent to liver, which was proven to be a second focus of primary colon carcinoma. In six patients with liver metastases, PET correctly detected extrahepatic lesions, while CT only detected hepatic lesions. In conclusion, FDG-PET is an excellent imaging modality for the detection and staging of liver metastases in patients with colorectal carcinomas.

Extrahepatic metastases of hepatocellular carcinoma.

To determine the relative frequency, incidence, and locations of metastases of hepatocellular carcinoma (HCC), correlate extrahepatic metastatic disease with intrahepatic tumor staging, and determine the computed tomographic (CT) manifestations of HCC metastases. CT findings in 403 consecutive patients with HCC at our institution since 1992 were reviewed retrospectively. One hundred forty-eight patients with extrahepatic metastatic HCC were identified, and the locations, sizes, and attenuation and enhancement characteristics of the lesions were recorded. A majority (128 [86%] of 148) of patients with extrahepatic HCC foci had either intrahepatic stage IVA tumor (112 [76%] patients) or an intrahepatic stage III tumor (16 [11%] patients) at the occurrence of metastases. The most frequent site of the first detectable metastasis was the lung (58 [39%] patients). Tabulation of all extrahepatic metastatic sites showed the most common to be the lung in 81 (55%) patients, the abdominal lymph nodes in 60 (41%) patients, and the bone in 41 (28%) patients. The lung, abdominal lymph nodes, and bone are the most common sites of extrahepatic metastatic HCC. Most extrahepatic HCC occurs in patients with advanced intrahepatic tumor stage (stage IVA). Incidental extrahepatic lesions at CT in patients with stage I or II intrahepatic HCC are unlikely to represent metastatic HCC.

Radical resection for colorectal liver metastases accompanied by extrahepatic lesions

Radical resection for colorectal liver metastases accompanied by extrahepatic lesions

Hepatic epithelioid hemangioendothelioma: resection or transplantation, which and when?

Hepatic epithelioid hemangioendothelioma (HEHE) is a rare tumor with an unpredictable course and prognosis. The aim of this study is to describe our experience with liver resection, as well as transplantation, in the treatment of this tumor. We retrospectively analyzed the clinical features, pathological findings, and postoperative results in a series of 11 patients presenting between 1990 and 1998. Five patients (45%) presented with abdominal pain, 3 patients (27%) with jaundice and ascites, and the rest were asymptomatic. Computed tomography or magnetic resonance imaging showed localized lesions in 2 patients (18%) and multifocal disease in the others. Seven patients (64%) had extrahepatic lesions, detected either by preoperative imaging or discovered at exploration. Two resections of apparently localized lesions were followed by rapid and aggressive recurrence. Five patients were treated with transplantation, including 1 patient who had previously undergone resection. Of these 5 patients, 2 patients are currently free of detectable disease, 1 patient who had severe ascites and jaundice is now asymptomatic with stable extrahepatic lesions, and 2 patients (including 1 who had previously undergone a resection) died of tumor recurrence. One patient with advanced tumor died while waiting for transplantation. The remaining 4 patients are free of symptoms and have stable hepatic and extrahepatic disease. HEHE is nearly always multifocal, and our results with resection were dismal. Because of the unpredictable nature of the tumor, the indications for transplantation in patients without liver-related symptoms should be carefully evaluated. Nevertheless, extrahepatic disease should not be an absolute contraindication for liver transplantation in patients with severe liver dysfunction.

Phase II Study of Combined Administration of 5-Fluorouracil, Epirubicin and Mitomycin-C by Hepatic Artery Infusion in Patients with Liver Metastases of Gastric Cancer

This multicenter phase II study evaluated the efficacy of the FEM regimen (5-fluorouracil 333 mg/m² each week, epirubicin 30 mg/m² once every 4 weeks and mitomycin-C 2.7 mg/m² once every 2 weeks) administered by hepatic artery infusion (HAI) for unresectable hepatic metastases of gastric cancer. The response rates were 55.6% (complete response: 3, partial response: 32, no change: 21, progressive disease: 7/63) and the mean 50% survival was 10.5 months. Most responders died due to the progression of extrahepatic lesions. HAI of the FEM regimen induced a high response rate in patients with hepatic metastases of gastric cancer, and the prognosis-determining factor was the existence of extrahepatic lesions in many patients.

Clinical experience with radiolabelled monoclonal antibodies in the detection of colorectal and ovarian carcinoma recurrence and review of the literature.

A retrospective study was carried out to determine the diagnostic value of OncoScint CR/OV immunoscintigraphy in assessing patients with suspected recurrence of carcinoma of the colon and ovary. The scintigraphic results of 31 patients were compared with surgical and histopathological findings, conventional radiological examinations and clinical disease outcome over an average 3-year follow-up. Detected lesions were divided by location into hepatic or extrahepatic and the latter group was classified as local recurrence at the resection site, pelvic or abdominal regional lymph node involvement and distant metastatic disease. The combined sensitivity and accuracy of immunoscintigraphy in the detection of extra-hepatic disease was significantly higher than that of cross-sectional radiological imaging (87% and 83% vs 44% and 53% respectively) with equal specificity of 74%. Scintigraphy identified 14 (36%) of 39 extra-hepatic malignant lesions not diagnosed by conventional radiological techniques and influenced therapeutic planning in 8 (26%) of 31 patients studied. In the liver, conventional imaging had a significantly higher detection rate than immunoscintigraphy (sensitivity 93% vs 28%). In conclusion, these results show that OncoScint scintigraphy is a sensitive method for the detection of local recurrence and extra-hepatic metastases in colorectal and ovarian carcinoma and has an important role in the therapeutic decision-making process.

99m-Tc-Tetrofosmin Scintigraphy and Breast Cancer

Background.99m-Tc-tetrofosmin holds significant interest among medical oncologists because of its high positive predictive value (>90%) in pilot trials, exceeding sensitivity and specificity rates of mammography.Objective.Our objective was to assess the diagnostic accuracy of 99m-Tc-tetrofosmin whole-body scintigraphy in outpatients.Patients and methods.Thirty-one patients with an abnormal mammograph (n= 22) or follow-up patients (n= 9), 7 of whom were known to have metastatic disease, were included. Tracer (550 MBq) was injected into the cubital vein. Whole-body planar and single photon emission computed tomography images of regions of interest were obtained. Histology, computed tomography (CT), or magnetic resonance imaging (MRI) were performed to confirm scintigraphic results. Correlation between scintigraphy and CT or MRI was assessed by two independent radiologists. Accuracy, sensitivity, and specificity rates for the diagnosis of local and distant breast cancer lesions were given.Results.Of the 22 first-visit patients, 15 had breast cancer, and 7 had no evidence of any malignant disease. Of all patients examined (n= 31), 21 had distant metastases. Breast tumors were correctly diagnosed in 14/15 patients (93%), with only 1 false-negative result. Extrahepatic metastatic lesions (n= 16) were correctly diagnosed in 14 (88%) patients, whereas the method was not suitable for the diagnosis of liver metastases.Conclusion.Tetrofosmin scintigraphy has shown very high detection rates of breast tumors and of metastatic lesions and is therefore a valuable option in breast cancer diagnosis.

Use of somatostatin receptor scintigraphy to image extrahepatic metastases of neuroendocrine tumors

Background: The presence of lymph node metastases significantly influences the modality of treatment in patients with liver metastases of neuroendocrine tumors (NET). Somatostatin receptor scintigraphy (Octreo-Scan, Mallinckrodt-Diagnostica, Petten, the Netherlands) is a method for localization and staging NET. The aim of our prospective study was to evaluate the effectiveness of somatostatin receptor scintigraphy in the identification of extrahepatic tumor spread. Methods: Thirty-five patients with liver metastases of NET were studied over a 5-year period. The presence of NET was confirmed histologically in all cases. To detect extrahepatic metastases or local tumor recurrence, conventional imaging techniques and somatostatin receptor scintigraphy were carried out. Results: In correlation with the findings of conventional imaging methods, somatostatin receptor scintigraphy confirmed liver metastases in all patients. Additionally, 19 of 35 patients (54.2%) had extrahepatic tumor lesions not detected by other imaging techniques. Of those, 15 had extensive abdominal or thoracic lymph node metastases, 3 patients had bone metastases, and in 1 patient with bronchial carcinoid local tumor recurrence was detected. All 19 patients were excluded from further evaluation for liver resection or transplantation and subjected to conservative treatment. The somatostatin receptor scintigraphy sensitivity, confirmed at the time of operation, was 91.6%. In 1 patient, in whom cluster transplantation was performed, somatostatin receptor scintigraphy failed to disclose disseminated carcinosis of the pleural cavity, detected at autopsy (false-negative rate 8.3%). Conclusion: In our experience, somatostatin receptor scintigraphy provides a highly sensitive diagnostic method to localize metastases of NET. We recommend somatostatin receptor scintigraphy before liver surgery in every patient with hepatic metastases of NET to identify candidates suitable for resection. (Surgery 1998;124:1000-4.)

Results of 136 curative hepatectomies with a safety margin of less than 10 mm for colorectal metastases.

It is now established that liver resection is beneficial for metastases from colorectal cancer. Nevertheless, a surgical margin estimated at less than 10 mm at preoperative imaging is considered an absolute contraindication to surgery by some, and a relative contraindication by others. The true impact of the width of the margin on the prognosis is unclear. From 1984 to 1996, 196 patients underwent curative hepatectomy for liver metastases and were studied prospectively. Surgery was to be curative (or a complete R0 resection) and mortality was to be avoided. Of these 196 patients, 136 had surgical margins of less than 10 mm. Sixty-eight percent had multiple liver metastases and 15% had extrahepatic metastatic lesions. Clinical and pathological factors were studied specifically and a multivariate analysis was carried out. Overall 5-year survival rate of these 136 patients (taking into account postoperative mortality which attained 1.5%) was 27.8% and the disease-free survival was 22.9%. The surgical margin was 0 mm in 30 cases. The sole prognostic factor was the discovery of unsuspected (resectable) extrahepatic lesions at laparotomy (P < 0.001) ; the width of the free margin had no significant effect. However, in the multivariate analysis of prognostic factors for the entire series (269 hepatectomies), three powerful parameters were identified : (1) the curative nature of resection (P = 0.0007), (2) less than 20% of liver involvement (P = 0.002), and (3) a free margin exceeding 9 mm (P = 0.02). A correlation was found between narrow margins and extensive disease (high number of metastases, bilateral sites, and extended hepatectomy). There was also a greater likelihood of microscopic satellite lesions within 10 mm around the metastases. The prognostic impact of the width of the surgical margin should not be overestimated. Hepatectomy for liver metastases can procure long-term survival, even in patients with supposedly poor prognostic factors. Resection is justified as long as it is complete and the risks are minimal.

Imaging of oncologic patients: benefit of combined CT and FDG PET in the diagnosis of malignancy.

The purpose of this study was to assess the benefit of combined CT and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in diagnosing malignancy. The records of 26 patients with intraabdominal and intrathoracic neoplasms who underwent CT and FDG PET between January 1995 and September 1996 were retrospectively reviewed. Most of these patients had inconclusive findings on prior CT for the diagnosis of malignancy. Only sites of potential malignant disease were included in the data analysis. Presence or absence of malignancy was confirmed by histopathology or follow-up CT. Three observers experienced in abdominal imaging used CT findings alone to estimate level of suspicion (1 = definitely not malignant to 5 = definitely malignant) for primary or recurrent neoplasms (n = 21), distant metastases (n = 25), and neoplastic nodal involvement (n = 18). Six weeks later the three observers reviewed the same CT examinations supplemented with FDG PET and reestimated suspicion of malignancy. Receiver operating characteristic methodology was used to analyze the results. Sensitivity, specificity, positive and negative predictive values, and accuracy in diagnosis of malignant disease were calculated using level 4 (probable malignancy) as the cutoff for the presence of disease. The mean area under the receiver operating characteristic curve, indicating successful diagnosis of malignancy, was .82 for CT alone and .92 for CT with FDG PET (p < .05). The accuracies for diagnosis of primary or recurrent neoplasms, distant metastases, and neoplastic nodal involvement were 62%, 68%, and 83%, respectively, for CT alone and 81% (p = .06), 88% (p = .03), and 89% (p > .25), respectively, for CT with FDG PET. Also, supplemental FDG PET imaging improved observer confidence and accuracy in diagnosing recurrent neoplasm in four (36%) of 11 patients who had undergone surgery or chemoradiation and in diagnosing four (29%) of 14 extrahepatic sites that had potential metastases. Diagnosis of malignancy in oncologic patients is significantly improved when CT is supplemented with FDG PET. Combined imaging is particularly helpful in the evaluation of potential recurrence in previously treated patients and for diagnosing extrahepatic lesions that may be distant metastases.