Some centers have advocated for the routine use of positron emission tomography (PET). PET most frequently uses fludeoxyglucose (FDG), a glucose analogue which accumulates in glucose-avid rapidly metabolizing cancer cells and inflammatory cells. When comparing preoperative CT alone to combined PET and CT, Strasberg et al. reported

an improved resectability rate from 86% to 95% with the addition of PET (48). These Inhibitors,research,lifescience,medical data are encouraging because PET-CT may identify otherwise radiologically occult extrahepatic disease and may improve long term survival by selection. However, it is important to note that all of these patients had high quality CT scans as well, so the utility of PET-CT alone for evaluating liver metastasis is limited because the sensitivity Inhibitors,research,lifescience,medical of PET in the liver for small lesions is poor. PET-CT is also limited by the non-specificity of positive lesions. A recent meta-analysis suggested PET-CT may be slightly more sensitive (91-100% versus 78-94%) and specific (75-100% Inhibitors,research,lifescience,medical versus 25-98%) than CT alone for hepatic colorectal metastases (49), but these results were based on only 5 studies. It is possible that expert radiologic review of high quality CT scans

may abrogate the purported benefit of PET-CT. We currently use PET-CT selectively for patients at high risk of extrahepatic disease or indeterminate extrahepatic lesions, realizing that

subcentimeter lesions may fall below the diagnostic threshold of detection. Determining technical resectability A negative FTY720 manufacturer resection margin is associated with a lower local recurrence rate and improved long-term survival (50). Scheele et al. demonstrated that patients who undergo an R0 resection Inhibitors,research,lifescience,medical have a three-fold increase in median survival compared to R1 or R2 resections (51). Similarly, another more recent study by Pawlik et al. demonstrated a significantly higher risk Inhibitors,research,lifescience,medical of liver recurrence and decreased overall survival with positive margins (50). The optimal resection margin is still debatable. One study reported Resveratrol a resection margin of ≥1 cm being associated with improved disease-free survival, but other studies have demonstrated that the width of resection margin is not independently associated with improved oncologic outcome as long as the margin is microscopically negative (50,52). We studied 1019 patients undergoing hepatic resection for colorectal metastases and found that obtaining a >1cm margin was independently associated with improved outcome but subcentimeter resections are also associated with favorable outcomes (53). Therefore, a negative margin should be attainable for a patient to be deemed resectable and aiming for 1cm margins should be encouraged when possible. We speculate that obtaining a negative margin can be both a technical and biologic issue.