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¹¹C-Acetate PET Imaging in Hepatocellular Carcinoma and Other Liver Masses

¹ Department of Nuclear Medicine and PET, Hong Kong Sanatorium and Hospital, Hong Kong, China
² Department of Radiology, University of Hong Kong, Hong Kong, China
³ Department of Diagnostic Radiology and Organ Imaging, Prince of Wales Hospital, Hong Kong, China

It is well known that ¹⁸F-FDG PET has a high average false-negative rate of 40%–50% in the detection of hepatocellular carcinoma (HCC). This is not an acceptable accuracy, particularly in countries where this tumor is prevalent. In this study, we evaluated prospectively the characteristics of ¹¹C-acetate and ¹⁸F-FDG metabolism in HCC and other liver masses. Methods: Fifty-seven patients were recruited into this study, with masses consisting of 39 HCC; 3 cholangiocarcinomas; 10 hepatic metastases from lung, breast, colon, and carcinoid primary malignancies; and 5 benign pathologies, including focal nodular hyperplasia (FNH), adenoma, and hemangioma. All patients, except 2 with typical findings of hemangioma and 3 clinically obvious metastases, were confirmed histopathologically by liver biopsy or resection. All patients fasted for at least 6 h and blood glucose concentration was measured before they underwent dual PET radiopharmaceutical evaluation of the upper abdomen with ¹¹C-acetate and ¹⁸F-FDG. Results: In the subgroup of HCC patients with the number of lesions 3 (32 patients; 55 lesions; mean size ± SD, 3.5 ± 1.9 cm), the sensitivity of detection by ¹¹C-acetate is 87.3% (¹¹C-acetate maximum SUV [SUV_max] = 7.32 ± 2.02, with a lesion-to-normal liver ratio of 1.96 ± 0.63), whereas the sensitivity of detection by ¹⁸F-FDG is only 47.3%, and 34% lesions show uptake of both tracers. None of the lesions was negative for both tracers (100% sensitivity using both tracers). In some lesions and in the subgroup of HCC patients (n = 7) with multifocal or diffuse disease, dual-tracer uptake by different parts of the tumor is demonstrated. Histopathologic correlation suggests that the well-differentiated HCC tumors are detected by ¹¹C-acetate and the poorly differentiated types are detected by ¹⁸F-FDG. All 16 non-HCC malignant (cholangiocarcinoma and metastatic) liver lesions do not show abnormal ¹¹C-acetate metabolism. Of the benign liver lesions, only FNH shows mildly increased ¹¹C-acetate activities (¹¹C-acetate SUV_max = 3.59, with a lesion-to-normal liver ratio of 1.25). Conclusion: ¹¹C-Acetate has a high sensitivity and specificity as a radiotracer complementary to ¹⁸F-FDG in PET imaging of HCC and evaluation of other liver masses.

Key Words: ¹¹C-acetate • PET • hepatocellular carcinoma

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