MRI in addition to CT in patients scheduled for local therapy of colorectal liver metastases (CAMINO): an international, multicentre, prospective, diagnostic accuracy trial

Author(s): Burak Görgec, MD^1,2,3; Ingrid S Hansen, MD^4,5,6; Gunter Kemmerich, MD⁷; Trygve Syversveen, MD⁷; Prof Mohammed Abu Hilal, MD⁸; Eric J T Belt, MD⁹; Koop Bosscha, MD¹⁰; Mark C Burgmans, MD¹¹; Vincent C Cappendijk, MD¹²; Mathieu D’Hondt, MD¹³; Prof Bjørn Edwin, MD^4,5,6; Arian R van Erkel, MD¹¹; Hugo A J Gielkens, MD¹⁴; Dirk J Grünhagen, MD^16,17; Paul D Gobardhan, MD¹⁸; Henk H Hartgrink, MD¹⁹; Karin Horsthuis, MD²⁰; Elisabeth G Klompenhouwer, MD²¹; Niels F M Kok, MD²²; Peter A M Kint, MD²³; Koert Kuhlmann, MD²²; Wouter K G Leclercq, MD²⁴; Daan J Lips, MD²⁵; Bart Lutin, MD²⁶; Monique Maas, MD²¹; Hendrik A Marsman, MD²⁷; Prof Martijn Meijerink, MD^3,20; Yannick Meyer, MD^16,17; Mario Morone, MD²⁸; Jan Peringa, MD²⁹; Jasper P Sijberden, MD^1,2,3; Prof Otto M van Delden, MD^2,3; Janneke E van den Bergh, MD^3,20; Inge J S Vanhooymissen, MD²⁰; Maarten Vermaas, MD³⁰; François E J A Willemssen, MD³¹; Prof Marcel G W Dijkgraaf, PhD^32,33; Prof Patrick M Bossuyt, PhD³²; Rutger-Jan Swijnenburg, MD^1,3,34; Åsmund A Fretland, MD^4,5; Prof Cornelis Verhoef, MD^16,17; Prof Marc G Besselink, MD^1,3; Prof Jaap Stoker, MD^2,3

Source: https://doi.org/10.1016/S1470-2045(23)00572-7

Dr. Anjan Patel's Thoughts

This is a nice, practical study showing that when considering liver directed therapy, options in metastatic CRC, CT’s alone are insufficient and contrasted MRI can be helpful. More than 30% of patients had care that was impacted using MRI prior to any therapeutic decisions.

BACKGROUND

Guidelines are inconclusive on whether contrast-enhanced MRI using gadoxetic acid and diffusion-weighted imaging should be added routinely to CT in the investigation of patients with colorectal liver metastases who are scheduled for curative liver resection or thermal ablation, or both. Although contrast-enhanced MRI is reportedly superior than contrast-enhanced CT in the detection and characterisation of colorectal liver metastases, its effect on clinical patient management is unknown. We aimed to assess the clinical effect of an additional liver contrast-enhanced MRI on local treatment plan in patients with colorectal liver metastases amenable to local treatment, based on contrast-enhanced CT.

METHODS

We did an international, multicentre, prospective, incremental diagnostic accuracy trial in 14 liver surgery centres in the Netherlands, Belgium, Norway, and Italy. Participants were aged 18 years or older with histological proof of colorectal cancer, a WHO performance status score of 0–4, and primary or recurrent colorectal liver metastases, who were scheduled for local therapy based on contrast-enhanced CT. All patients had contrast-enhanced CT and liver contrast-enhanced MRI including diffusion-weighted imaging and gadoxetic acid as a contrast agent before undergoing local therapy. The primary outcome was change in the local clinical treatment plan (decided by the individual clinics) on the basis of liver contrast-enhanced MRI findings, analysed in the intention-to-image population. The minimal clinically important difference in the proportion of patients who would have change in their local treatment plan due to an additional liver contrast-enhanced MRI was 10%. This study is closed and registered in the Netherlands Trial Register, NL8039.

FINDINGS

Between Dec 17, 2019, and July 31, 2021, 325 patients with colorectal liver metastases were assessed for eligibility. 298 patients were enrolled and included in the intention-to-treat population, including 177 males (59%) and 121 females (41%) with planned local therapy based on contrast-enhanced CT. A change in the local treatment plan based on liver contrast-enhanced MRI findings was observed in 92 (31%; 95% CI 26–36) of 298 patients. Changes were made for 40 patients (13%) requiring more extensive local therapy, 11 patients (4%) requiring less extensive local therapy, and 34 patients (11%) in whom the indication for curative-intent local therapy was revoked, including 26 patients (9%) with too extensive disease and eight patients (3%) with benign lesions on liver contrast-enhanced MRI (confirmed by a median follow-up of 21·0 months [IQR 17·5–24·0]).

INTERPRETATION

Liver contrast-enhanced MRI should be considered in all patients scheduled for local treatment for colorectal liver metastases on the basis of contrast-enhanced CT imaging.

FUNDING

The Dutch Cancer Society and Bayer AG – Pharmaceuticals.

Author Affiliations

¹Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; ²Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; ³Cancer Centre Amsterdam, Amsterdam, Netherlands; ⁴Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway; ⁵The Intervention Centre, Oslo University Hospital-Rikshospitalet, Oslo, Norway; ⁶Institute of Clinical Medicine, University of Oslo, Oslo, Norway; ⁷Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway; ⁸Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy; ⁹Department of Surgery, Albert Schweitzer Hospital, Dordrecht, Netherlands; ¹⁰Department of Surgery, Jeroen Bosch Hospital, ‘s-Hertogenbosch, Netherlands; ¹¹Department of Radiology, Leiden University Medical Centre, Leiden, Netherlands; ¹²Department of Radiology, Jeroen Bosch Hospital, ‘s-Hertogenbosch, Netherlands; ¹³Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium; ¹⁴Department of Radiology, Medical Spectrum Twente, Enschede, Netherlands; ¹⁶Department of Surgical Oncology, Erasmus Medical Centre, Rotterdam, Netherlands; ¹⁷Erasmus Medical Centre Cancer Institute, Erasmus Medical Centre, Rotterdam, Netherlands; ¹⁸Department of Surgery, Amphia Hospital, Breda, Netherlands; ¹⁹Department of Surgery, Leiden University Medical Centre, Leiden, Netherlands; ²⁰Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, Netherlands; ²¹Department of Radiology, Netherlands Cancer Institute, Amsterdam, Netherlands; ²²Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands; ²³Department of Radiology, Amphia Hospital, Breda, Netherlands; ²⁴Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands; ²⁵Department of Surgery, Medical Spectrum Twente, Enschede, Netherlands; ²⁶Department of Radiology, Groeninge Hospital, Kortrijk, Belgium; ²⁷Department of Surgery, OLVG, Amsterdam, Netherlands; ²⁸Department of Radiology, Poliambulanza Foundation Hospital, Brescia, Italy; ²⁹Department of Radiology, OLVG, Amsterdam, Netherlands; ³⁰Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, Netherlands; ³¹Department of Radiology, Erasmus Medical Centre, Rotterdam, Netherlands; ³²Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; ³³Amsterdam Public Health, Methodology, Amsterdam, Netherlands; ³⁴Department of Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, Netherlands

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