2-[Fluorine-18]-fluoro-2-deoxy-d-glucose positron emission tomography in the diagnosis of recurrent ovarian cancer

Evaluation of follow-up strategies for women with epithelial ovarian cancer following completion of primary treatment

BACKGROUND

This is an update of a previous Cochrane Review, last updated in 2014. Ovarian cancer is the eighth most common cancer and seventh most common cause of death due to cancer in women worldwide. Traditionally, most women who have been treated for cancer undergo long-term follow-up in secondary care. However, it has been suggested that the use of routine review may not be effective in improving survival, or health-related quality of life (HRQOL), or relieving anxiety. In addition, traditional follow-up may not be cost-effective.

OBJECTIVES

To compare the potential effects of different strategies of follow-up in women with epithelial ovarian cancer, following completion of primary treatment.

SEARCH METHODS

For this update, we searched the Cochrane Gynaecological Cancer Group Trials Register, CENTRAL 2022, Issue 11, MEDLINE, and Embase from August 2013 to November 2022. We also searched review articles and contacted experts in the field.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that evaluated follow-up strategies for women with epithelial ovarian cancer following completion of primary treatment.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology. Two review authors independently selected potentially relevant trials, extracted data, and assessed risk of bias. They compared results, and resolved disagreements by discussion. We assessed the certainty of evidence, using the GRADE approach, for the outcomes of interest: overall survival (OS), health-related quality of life (HRQOL), psychological effects, and cost analysis.

MAIN RESULTS

For this update, we included one new RCT, including 112 women with ovarian, fallopian tube, or peritoneal cancer, who had completed primary treatment by surgery, with or without chemotherapy. This study reported the effect of individualised, i.e. individually tailored, nurse-led follow-up versus conventional medical follow-up on HRQOL, psychological outcomes, and cost-analysis. Individualised follow-up improved HRQOL in one of the two scales, with a decrease in mean difference (MD) in the QLQ-C30 discomfort scale following 12 months of individualised treatment compared to 12 months of conventional treatment (MD -5.76 points, 95% confidence interval (CI) -10.92 to -0.60; 1 study, 112 participants; low-certainty evidence; minimal important difference 4 to 10 points). There may be little or no difference in the other HRQOL scale (QLQ-Ov28, MD -0.97 points, 95% CI -2.57 to 0.63; 1 study, 112 participants: low-certainty evidence); psychological outcome, measured with the hospital anxiety and depression scale (HADS; MD 0.10 point, 95% CI -0.81 to 1.02; 1 study, 112 participants: low-certainty evidence), or cost analysis (MD -GBP 695.00, 95% CI -1467.23 to 77.23; 1 study, 112 participants: moderate-certainty evidence). Our previous review included one RCT, with 529 women in a confirmed remission, with normal CA125 concentration and no radiological evidence of disease, after surgery and first-line chemotherapy for ovarian cancer. This study evaluated immediate treatment of ovarian cancer relapse following a rise of serum CA125 levels versus delaying treatment until symptoms developed for OS, and HRQOL. There was little or no difference in OS between the immediate and delayed arms after a median follow-up of 56.9 months (unadjusted hazard ratio (HR) 0.98, 95% CI 0.80 to 1.20; 1 study, 529 participants; moderate-certainty evidence). Time from randomisation to first deterioration in global health score or death was shorter in the immediate treatment group than in the delayed treatment group (HR 0.71, 95% CI 0.58 to 0.88).

AUTHORS' CONCLUSIONS

Limited evidence from one trial suggests that routine surveillance with CA125 in asymptomatic women and treatment at CA125-defined relapse does not seem to offer survival advantage when compared to treatment at symptomatic relapse. However, this study pre-dates the use of PARPi maintenance treatment and the increased use of secondary cytoreductive surgery, so the results may be limited in their applicability to current practice. Limited evidence from one trial suggests that individualised nurse-led follow-up may improve HRQOL in women with ovarian cancer following completion of primary treatment. Large RCTs are needed to compare different types of follow-up, looking at survival, HRQOL, psychological effects, and cost as outcomes.

The value of PET/CT for cytoreductive surgery selection in recurrent ovarian carcinoma

OBJECTIVE

To evaluate the value of positron emission tomography/computed tomography (PET/CT) in predicting no residual disease (NRD) after secondary cytoreductive surgery (SCS) compared with MSK criteria, the iMODEL, and the AGO score.

METHODS

We analyzed 112 patients with platinum-sensitive ovarian carcinoma who underwent SCS. We excluded patients for whom PET/CT was not performed, those without sufficient data, and who received chemotherapy before SCS. Ultimately, 69 patients were included.

RESULTS

Variables that correlated with NRD were peritoneal carcinomatosis index (odds ratio [OR]=0.91; 95% confidence interval [CI]=0.83-0.99; p=0.044), European Cooperative Oncology Group Performance Status (ECOG) 0 (OR=8.0; 95% CI=1.34-47.5; p=0.022), and ≤2 lesions by PET/CT (OR=4.36; 95% CI=1.07-17.7; p=0.039). Of the patients with ≤2 lesions by PET/CT, 48 (92.3%) underwent complete SCS. The sensitivity, positive predictive value, negative predictive value, and accuracy of PET/CT for NRD were 85.7%, 92.3%, 33.3%, and 81.2%, respectively. NRD was achieved after fulfilling the MSK criteria, iMODEL and AGO Score in 89.1%, 88.1% and 85.9%, respectively. The accuracy of the MSK criteria, iMODEL, and AGO score in predicting NRD was 87%, 83.3%, and 77.3%, respectively. The PET/CT findings agreed well with the AGO score and iMODEL. The addition of PET/CT to these models increased the NRD rates (92.2%, 91.8%, and 89.4% for MSK+PET/CT, iMODEL+PET/CT, and AGO+PET/CT, respectively), but lowered their accuracy.

CONCLUSION

We observed NRD in 92.3% of patients with ≤2 lesions by PET/CT, with an accuracy of 81.2%. PET/CT did not increase the accuracy of the MSK criteria, iMODEL, or AGO score models.

Imaging strategy in recurrent ovarian cancer: a practical review

Ovarian cancer is one of the most aggressive gynaecologic malignancies in women worldwide. The lack of proper screening programs and the characteristic abdominal spreading with minimal clinical symptoms give rise of its high lethality. Most patients show advanced disease at diagnosis and have a poor prognosis. The surveillance of ovarian cancer patients after initial treatment is a challenging question in clinical practice and there is no consensus in literature about the most appropriate follow-up strategy for these women. The role of Imaging has become increasingly important, allowing to properly monitor patients, distinguishing the different relapse patterns, thus guiding the correct management and therapy. In this review, we report and analyze the scientific evidence about the role of the different imaging modalities now available in the follow-up strategy and management of Epithelial Ovarian Cancer patients with recurrent disease.

Diagnostic value of positron emission tomography (PET) and PET/computed tomography in recurrent/metastatic ovarian cancer: A meta-analysis

AIM

The study was conducted to assess and compare the overall diagnostic value of positron emission tomography (PET) alone and PET/computed tomography (CT) for the detection of recurrent/metastatic ovarian cancer.

METHODS

A systematic literature search in PubMed, EMBASE and Chinese literature databases (CNKI, VIP and Wanfang) up to August 2014 was performed to identify relevant articles. The diagnostic performance of PET alone or PET/CT was assessed in terms of the following evaluation indexes: summary sensitivity, specificity, positive and negative likelihood ratio, diagnostic odds ratio and area under the curve summary receiver operating characteristics.

RESULTS

Sixty-four studies with 3722 patients were included in this meta-analysis. Favorable results were obtained for both PET/CT and PET alone with similar sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio and area under the curve in diagnosing recurrent/metastatic ovarian cancer (P > 0.05). However, the sensitivity of PET/CT was significantly higher than PET alone in European patients.

CONCLUSIONS

Both PET and PET/CT have promising diagnostic value in recurrent/metastatic ovarian cancer. The diagnostic performance of PET/CT may be superior to PET alone in European patients.

An update on the role of PET/CT and PET/MRI in ovarian cancer

This review article summarizes the role of PET/CT and PET/MRI in ovarian cancer. With regard to the diagnosis of ovarian cancer, the presence of FDG uptake within the ovary of a postmenopausal woman raises the concern for ovarian cancer. Multiple studies show that FDG PET/CT can detect lymph node and distant metastasis in ovarian cancer with high accuracy and may, therefore, alter the management to obtain better clinical outcomes. Although PET/CT staging is superior for N and M staging of ovarian cancer, its role is limited for T staging. Additionally, FDG PET/CT is of great benefit in evaluating treatment response and has prognostic value in patients with ovarian cancer. FDG PET/CT also has value to detect recurrent disease, particularly in patients with elevated serum CA-125 levels and negative or inconclusive conventional imaging test results. PET/MRI may beneficial for tumor staging because MRI has higher soft tissue contrast and no ionizing radiation exposure compared to CT. Some non-FDG PET radiotracers such as ¹⁸F-fluorothymidine (FLT) or ¹¹C-methionine (MET) have been studied in preclinical and clinical studies as well and may play a role in the evaluation of patients with ovarian cancer.

Role of PET-CT Scan in Gynaeconcology

THE PURPOSE OF THIS STUDY

This study was undertaken to evaluate the role of positron emission tomography-CT (PET-CT) in diagnosis and management of gynecological malignancies in primary and recurrent settings and also to investigate its role in inappropriately treated patients, for pretreatment evaluation (staging) to help in proper therapeutic management.

METHOD

This is a retrospective study of 56 patients of gynecological malignancy registered in Gujarat Cancer Research Institute from June 2011 to December 2013.

RESULTS

Out of 56 cases where PET was done, the results were as follows: carcinoma cervix-23, carcinoma ovary-20, carcinoma endometrium-9, carcinoma vulva-1, carcinoma vagina-2, and GTN-1. PET scan was negative in 37 % of patients where CT scan was suspicious, which changed the therapeutic modality and prevented further unnecessary interventions. In cases where clinical suspicion of recurrence was high based on rising tumor marker and CT scan was negative, subsequent PET-CT was able to pick up malignancy in 75 % cases. Eleven patients (25 %) with suspected recurrence with inconclusive CT scan and negative PET-CT scan were kept on follow-up, thus reducing further morbidity and cost.

CONCLUSION

Addition of PET-CT, a noninvasive method to the oncologist's imaging armamentarium may ultimately improve both outcomes and costs by altering management strategies in primary and recurrent settings. The potential use of PET-CT appears promising in several decision-making steps in the management of patients with gynecological malignancy. It defines the extent of metastatic disease which enables the clinician to decide regarding salvageable surgical intervention or palliative measures.

Posttreatment FDG PET/CT in predicting survival of patients with ovarian carcinoma

BACKGROUND

The purposes of this study are to evaluate the prognostic value of posttreatment (18)F-FDG PET/CT in predicting the survival of patients with ovarian carcinoma and to determine incremental value of combining posttreatment PET/CT with traditional prognostic factors in a multivariate model.

METHODS

This was an IRB-approved retrospective study. From July 2001 to July 2011, 48 patients who completed initial therapy for ovarian carcinoma with concurrent 3- to 9-month initial posttreatment (18)F-FDG PET/CT and serum CA-125 were identified from the radiology database. Prognostic value of posttreatment PET/CT, CA-125, age, race, and tumor stage were determined from Cox proportional hazard model using univariate and multivariate analyses. Time-dependent receiver operator curves were also calculated at various follow-up intervals.

RESULTS

In a univariate model, overall survival (OS) was associated with PET/CT (hazard ratio = 4.18; 95 % CI 1.49-11.70) and CA-125 (hazard ratio = 11.09; 95 % CI 4.27-28.79). When the effects of posttreatment PET/CT and CA-125 were combined in the multivariate analysis, hazard ratio for PET/CT increased to 4.84 (95 % CI 1.59-14.73, p = 0.005) and hazard ratio for CA-125 increased to 14.43 (95 % CI 4.65-44.84, p < 0.001). In the subset of patients with negative CA-125, posttreatment PET/CT had a hazard ratio of 2.98 (95 % CI 0.86-10.37), supporting the role of posttreatment PET/CT in risk stratification of patients with negative CA-125. Time-dependent receiver operator curves showed that the combination of PET/CT and CA-125 improved prognostic accuracy compared to PET/CT or CA-125 alone at 12-, 24-, 30-, and 36-month follow-up.

CONCLUSIONS

Posttreatment PET/CT can predict the survival of patients with ovarian carcinoma. The addition of posttreatment PET/CT to the CA-125 serum biomarker has an incremental value in improving prognostic accuracy, particularly in the subset of patients with negative CA-125.

The next steps in improving the outcomes of advanced ovarian cancer

Worldwide ovarian cancer affects over 200,000 women per year. Overall survival rates are poor due to two predominate reasons. First, the majority of patients present with advanced disease creating significant difficulty with effecting disease eradication. Second, acquisition of chemotherapy resistance results in untreatable progressive disease. Advances in treatment of advanced ovarian cancer involve a spectrum of interventions including improvements in frontline debulking surgery and combination chemotherapy. Anti-angiogenic factors have been shown to have activity in frontline and recurrent disease while novel chemotherapeutic agents and targeted treatments are in development particularly for disease that is resistant to platinum-based chemotherapy. These developments aim to improve the progression-free and overall survival of women with advanced ovarian cancer.

Molecular Imaging of Ovarian Cancer

Ovarian cancer is the most lethal gynecologic malignancy and the fifth leading cause of cancer-related death in women. Over the past decade, medical imaging has played an increasingly valuable role in the diagnosis, staging, and treatment planning of the disease. In this "Focus on Molecular Imaging" review, we seek to provide a brief yet informative survey of the current state of the molecular imaging of ovarian cancer. The article is divided into sections according to modality, covering recent advances in the MR, PET, SPECT, ultrasound, and optical imaging of ovarian cancer. Although primary emphasis is given to clinical studies, preclinical investigations that are particularly innovative and promising are discussed as well. Ultimately, we are hopeful that the combination of technologic innovations, novel imaging probes, and further integration of imaging into clinical protocols will lead to significant improvements in the survival rate for ovarian cancer.

Comparison of FDG PET/CT and MRI in lymph node staging of endometrial cancer

OBJECTIVE

Endometrial cancer is the most frequent cancer occurring in the female genital tract in the Western countries. Because surgical staging is currently the standard, noninvasive techniques that accurately identify lymph node (LN) metastases would be beneficial by reducing costs and complications. The purpose of our study is to compare the diagnostic accuracy of 2-[(18)F]fluoro-2-deoxy-D-glucose ((18)F-FDG) positron emission tomography/computed tomography (PET/CT) with that of magnetic resonance imaging (MRI) for detecting LN metastases in the preoperative staging of endometrial cancer.

METHODS

Two hundred eighty-seven consecutive patients with endometrial cancer underwent preoperative PET/CT and MRI for staging. The malignancy criteria for LNs were a short diameter of 1 cm or more by MRI and focally increased (18)F-FDG uptake by PET/CT. After evaluating PET/CT and MRI separately, morphologic and functional image findings were compared with the histological findings regarding LN metastasis for all patients. PET/CT and MRI images were classified on the basis of histological findings as true-positive, true-negative, false-positive, or false-negative. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated.

RESULTS

Histologic examination revealed LN metastases in 51 patients (17.8%). The maximal standardized uptake values (SUVmax) of the primary lesions by PET/CT ranged from 1.4 to 37.7, with a mean value of 9.3, whereas those of the metastatic LNs ranged from 2.0 to 22.5 with a mean of 7.3. On a per-patient basis, node staging resulted in sensitivities of 70.0% with (18)F-FDG PET/CT and 34.0% with MRI, and specificities of 95.4 % with PET/CT and 95.0% with MRI. The NPV of PET/CT was 94.3%, and that of MRI was 87.2%. On a lesion base analysis, sensitivity of PET/CT was 79.4% while that of MRI was 51.6%. In detecting distant metastasis, the sensitivity, specificity, accuracy, PPV, and NPV of PET/CT were 92.9, 98.9, 98.6, 81.3, and 99.6%, respectively.

CONCLUSION

Diagnostic performance of FDG PET/CT was better than MRI for detecting metastatic lymph nodes in patients with endometrial cancer both by patient basis and lesion basis analyses. Due to high NPV, FDG PET-CT could aid in selecting candidates for lymphadenectomy.

Gynecologic oncologic imaging with PET/CT

FDG-PET/CT has been evaluated in a variety of gynecologic malignancies in a variety of settings and is approved by the Centers for Medicare & Medicaid Services for the initial and subsequent treatment strategies of these malignancies. Cervical cancer is typically very FDG avid, and FDG-PET/CT appears to be most valuable for initial staging, radiation therapy planning, and detection of recurrent disease. For ovarian cancer, the most value of FDG-PET/CT appears to be for detecting recurrent disease in the setting of rising CA-125 level and negative or equivocal anatomical imaging studies. Initial studies evaluating response to therapy are promising and further work in this area is needed. FDG uptake in both nonmalignant and physiological processes in the pelvis can make interpretation of FDG-PET/CT in this region challenging and knowledge of these entities and patterns can avoid misinterpretation. Some of the most common findings relate to the cyclic changes that occur as part of the menstrual cycle in premenopausal women. Mucinous tumors and low-volume or peritoneal carcinomatosis are causes of false-negative results on FDG-PET/CT studies. As new tracers are developed, comparisons with patient outcomes and standards of care (eg, FDG-PET/CT) will be needed.

Usefulness of increased 18F-FDG uptake for detecting local recurrence in patients with extremity osteosarcoma treated with surgical resection and endoprosthetic replacement

OBJECTIVE

To investigate the changes of increased F-18 fluorodeoxyglucose ((18)F-FDG) uptake around the prosthesis and its ability to differentiate local recurrence from postsurgical change after endoprosthetic replacement in extremity osteosarcoma.

MATERIALS AND METHODS

A total of 355 positron emission tomography (PET)/computed tomography (CT) scans in 109 extremity osteosarcoma patients were retrospectively analyzed. All patients were followed up with (18)F-FDG PET/CT for more than 3 years after tumor resection. For semiquantitative assessment, we drew a volume of interest around the entire prosthesis of the extremity and measured the maximum standardized uptake value (SUV max). Independent samples t test was used to compare SUV max at each follow-up time. SUV max at 3 months (SUV1) and SUV max at the time of local recurrence in patients with recurrence or at the last follow-up in others (SUV2) were compared using the Mann-Whitney test. Diagnostic performances of PET parameters were assessed using ROC curve analyses.

RESULTS

Nine patients (8 %) showed a local recurrence. Mean SUV max at 3, 12, 24, and 36 months was 3.1 ± 1.5, 3.8 ± 1.9, 3.6 ± 1.9, and 3.7 ± 1.5 respectively. In ROC curve analysis, the combination of SUV2 >4.6 and ΔSUV >75.0 was a more useful parameter for predicting local recurrence than SUV2 or ΔSUV alone. The sensitivity, specificity, and accuracy for identifying local recurrence were 89, 76, 77 % for SUV2; 78, 81, 81 % for ΔSUV; and 78, 94, 93 % for the combined criterion respectively.

CONCLUSION

The combination of SUV2 and ΔSUV was more useful than the SUV2 or ΔSUV used alone for the prediction of local recurrence.

Immuno-PET of epithelial ovarian cancer: harnessing the potential of CA125 for non-invasive imaging

Background

Epithelial ovarian cancer (EOC) is characterized by the overexpression of cancer antigen 125 (CA125), a mucinous glycoprotein that serves as a tumor biomarker. Early diagnosis of EOC is plagued by its asymptomatic nature of progression and the limitations of currently used immunoassay techniques that detect CA125 as a shed antigen in serum samples. Presently, there is no technique available for the in vivo evaluation of CA125 expression in malignant tissues. Moreover, there could be an unexplored pathophysiological time window for the detection of CA125 in EOC, during which it is expressed on tumor cells prior to being shed into the bloodstream. A method for the in vivo evaluation of CA125 expression on ovarian neoplasms earlier along disease progression and/or recurrence can potentially contribute to better disease management. To this end, the present work utilizes an anti-CA125 monoclonal antibody (MAb) and a single-chain variable fragment (scFv) labeled with the positron-emitting radionuclide ⁶⁴Cu for preclinical molecular imaging of CA125 expression in vivo.

Methods

Anti-CA125 MAb and scFv were prepared and functionally characterized for target binding prior to being tested as radiotracers in a preclinical setting.

Results

Immunoblotting, immunofluorescence, and flow cytometry revealed specific binding of CA125-targeting vectors to NIH:OVCAR-3 cells and no binding to antigen-negative SKOV3 cells. ⁶⁴Cu-labeled anti-CA125 MAb and scFv were obtained in specific activities of 296 and 122 MBq/mg, respectively. Both radioimmunoconjugate vectors demonstrated highly selective binding to NIH:OVCAR-3 cells and virtually no binding to SKOV3 cells. In vivo radiopharmacological evaluation using xenograft mouse models injected with ⁶⁴Cu-labeled anti-CA125 MAb provided a standardized uptake value (SUV) of 5.76 (29.70 %ID/g) in OVCAR3 tumors 24 h post-injection (p.i.) versus 1.80 (5.91 %ID/g) in SKOV3 tumors. ⁶⁴Cu-labeled anti-CA125 scFv provided an SUV of 0.64 (3.21 %ID/g) in OVCAR3 tumors 24 h p.i. versus 0.25 (1.49 %ID/g) in SKOV3 tumors. Results from small-animal PET imaging were confirmed by ex vivo autoradiography and immunohistochemistry.

Conclusions

Radiolabeling of anti-CA125 MAb and scFv with ⁶⁴Cu did not compromise their immunoreactivity. Both radioimmunoconjugates presented specific tumor uptake and expected biological clearance profiles. This renders them as potential immuno-PET probes for targeted in vivo molecular imaging of CA125 in EOC.

Electronic supplementary material

The online version of this article (doi:10.1186/s13550-014-0060-4) contains supplementary material, which is available to authorized users.

Positron Emission Tomography (PET) in Oncology

Since its introduction in the early nineties as a promising functional imaging technique in the management of neoplastic disorders, FDG-PET, and subsequently FDG-PET/CT, has become a cornerstone in several oncologic procedures such as tumor staging and restaging, treatment efficacy assessment during or after treatment end and radiotherapy planning. Moreover, the continuous technological progress of image generation and the introduction of sophisticated software to use PET scan as a biomarker paved the way to calculate new prognostic markers such as the metabolic tumor volume (MTV) and the total amount of tumor glycolysis (TLG). FDG-PET/CT proved more sensitive than contrast-enhanced CT scan in staging of several type of lymphoma or in detecting widespread tumor dissemination in several solid cancers, such as breast, lung, colon, ovary and head and neck carcinoma. As a consequence the stage of patients was upgraded, with a change of treatment in 10%-15% of them. One of the most evident advantages of FDG-PET was its ability to detect, very early during treatment, significant changes in glucose metabolism or even complete shutoff of the neoplastic cell metabolism as a surrogate of tumor chemosensitivity assessment. This could enable clinicians to detect much earlier the effectiveness of a given antineoplastic treatment, as compared to the traditional radiological detection of tumor shrinkage, which usually takes time and occurs much later.

Evaluation of follow-up strategies for patients with epithelial ovarian cancer following completion of primary treatment

BACKGROUND

Ovarian cancer is the sixth most common cancer and seventh commonest cause of death in women worldwide. Traditionally, many people who have been treated for cancer undergo long-term follow-up in secondary care. However, it has been suggested that the use of routine review may not be effective in improving survival, quality of life (QoL), or relieving anxiety, or both. In addition, traditional follow-up may not be cost-effective.

OBJECTIVES

To compare the potential benefits of different strategies of follow-up in patients with epithelial ovarian cancer following completion of primary treatment.

SEARCH METHODS

For this update we searched the Cochrane Gynaecological Cancer Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 7, 2013, MEDLINE and EMBASE from November 2010 to July 2013. We also searched reference lists of review articles and contacted experts in the field.

SELECTION CRITERIA

All relevant randomised controlled trials (RCTs) that evaluated follow-up strategies for women with epithelial ovarian cancer following completion of primary treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias.

MAIN RESULTS

The authors did not identify any new studies that were eligible for inclusion in this update of the review. The search for the original review identified only one RCT that met the inclusion criteria, which included 529 women. This study reported data on immediate treatment of ovarian cancer relapse following rise of serum CA125 levels versus delaying treatment until symptoms developed. All the women participating had previous confirmation of remission, with normal CA125 concentration and no radiological evidence of disease, after surgery and first-line chemotherapy for ovarian cancer.Overall survival between the immediate and delayed arms showed no difference after a median follow-up of 56.9 months (unadjusted hazard ratio (HR) 0.98, 95% confidence interval (CI) 0.80 to 1.20; P value 0.85). Time from randomisation to first deterioration in global health score or death was shorter in the immediate treatment group than in the delayed treatment group (HR 0.71, 95% CI 0.58 to 0.88; P value < 0.01). The trial was at low risk of bias.

AUTHORS' CONCLUSIONS

Limited evidence from a single trial suggests that routine surveillance with CA125 in asymptomatic patients and treatment at CA125 relapse does not seem to offer survival advantage when compared to treatment at symptomatic relapse. RCTs are needed to compare different types of follow-up, looking at survival, QoL, cost and psychological effects as outcomes.

Positron emission tomography in gynecological malignancies

Positron emission tomography (PET) is a functional diagnostic imaging technique. F-18 fluoro-2-deoxy-d-glucose (FDG) is a commonly used radiopharmaceutical that is an analog of glucose. PET with FDG is now the standard of care in initial staging, monitoring the response to the therapy and management of various cancers. There is not sufficient data to support the use of PET in the initial diagnosis of cervical cancer; however, FDG-PET has a role in initial staging in the detection of distant metastases in patients with cervical cancer. PET has limited value in lesion localization in early stages of ovarian cancer, but plays a significant role in identifying recurrent tumors in patients with rising tumor markers. In this article, the clinical application of PET in gynecological malignancies is reviewed.

Positron emission tomography: clinical applications in oncology. Part 1

Positron emission tomography is a functional diagnostic imaging technique, which can accurately measure in vivo distribution of a radiopharmaceutical with high resolution. The ability of positron emission tomography to study various biologic processes opens up new possibilities for both research and day-to-day clinical use. Positron emission tomography has progressed rapidly from being a research technique in laboratories to a routine clinical imaging modality becoming part of armamentarium for the medical profession. The most widely used radiotracer in positron emission tomography is 18F-fluoro-2-deoxy-D-glucose (FDG), which is an analog of glucose. FDG uptake in cells is directly proportional to glucose metabolism of cells. Since glucose metabolism is increased many fold in malignant tumors, positron emission tomography has a high sensitivity and high negative predictive value. Positron emission tomography with FDG is now the standard of care in initial staging, monitoring the response to therapy and management of lung cancer, colorectal cancer, lymphoma, melanoma, esophageal cancer, head and neck cancer and breast cancer. The aim of this article is to review the clinical applications of positron emission tomography in oncology.

Cancer survivorship, a unique and growing cohort in medical practice: radiology perspective

The unique medical and psychologic burdens of cancer survivorship have only recently been recognized. This rapidly expanding cohort of patients will be seen increasingly by non-oncology physicians who must consider medical issues related to their cancer or its therapy for any presenting symptoms. Appropriate use of clinical imaging is essential for diagnosing treatment-related complications, recurrent tumor, or emergence of second primaries. This article will review clinical imaging in common medical problems uniquely found in cancer survivors.

High impact of FDG-PET/CT in diagnostic strategies for ovarian cancer

BACKGROUND

Ovarian cancer has the highest mortality of all gynecologic malignancies. FDG-PET/CT was proven to be accurate for identification of primary ovarian tumors, regional lymph nodes, and distant metastases.

PURPOSE

To evaluate ovarian masses at FDG-PET/CT in correlation with histopathologic findings.

MATERIAL AND METHODS

Ninety-eight patients underwent whole body FDG-PET/CT examination. Eighty-six patients with primary ovarian cancer and 12 patients with metastatic disease to the ovaries were included.

RESULTS

PET/CT imaging was true-positive in 87/94 patients with malignant tumors. In 4/4 patients with benign tumors, PET/CT results were true-negative, with sensitivity of 92.6%, specificity 100%, total test accuracy 92.9%. Fifty-seven patients were diagnosed as stage IV ovarian cancer with distant metastasis.

CONCLUSION

The anatomical/functional examination by FDG-PET/CT was proven to be valuable in increasing the diagnostic accuracy that can help improve patient management.

Carcinoma endometrium: role of 18-FDG PET/CT for detection of suspected recurrence

OBJECTIVE

Recurrent carcinoma endometrium has a poor prognosis. However, successful salvage with long-term survival has been achieved after hormone therapy, radical surgery, and radiotherapy/chemotherapy in patients with recurrent disease. Conventional imaging (CI) and tumor marker have limited accuracy for detecting recurrence in these patients. The aim of the present study was to evaluate the role of 18-flurodeoxyglucose (FDG) positron emission tomography-computed tomography (PET/CT) in patients suspected to have recurrence of carcinoma endometrium.

METHODS

In this retrospective study, total 101 patients were evaluated. All patients had undergone surgery with/without adjuvant therapy (chemotherapy/radiotherapy/both) for histologically proven carcinoma endometrium. They underwent 18-FDG PET/CT studies for suspected recurrence. Comparable CI (contrast-enhanced CT and/or magnetic resonance imaging) was available for 76 patients. Results of FDG PET/CT were confirmed with clinical/imaging follow-up and/or histopathology.

RESULTS

The mean age was 56.9±8.6 years. 18-FDG PET/CT was positive for recurrence in 51 (50.5%) patients and negative in 50 (49.5%). Locoregional disease was observed in 24 patients, metastatic disease was observed in 10, and 17 showed both locoregional and metastatic disease. The sensitivity, specificity, positive and negative predictive values, and accuracy of 18-FDG PET/CT were 88.9%, 93.6%, 94.1%, 88%, and 91%, respectively. 18-FDG PET/CT showed strong positive correlation with final diagnosis based on reference standard (κ 0.823; P=0.0001). Compared to CI, 18-FDG PET/CT has much higher specificity (62% vs. 96.4%), and accuracy (76.3% vs. 92.1%), with comparable sensitivity (85.1% vs. 89.5%).

CONCLUSION

18-FDG PET/CT is a highly sensitive and specific modality for detecting recurrence in post-therapy patients of carcinoma endometrium with suspected recurrence. It performs better than CI.

Role of FDG PET-CT in detecting recurrence in patients with uterine sarcoma: comparison with conventional imaging

PURPOSE

The purpose of the present study was to evaluate the role of 18F-fluorodeoxyglucose (FDG) PET-CT in detecting recurrent disease in posttherapy patients of uterine sarcoma and compare the same with conventional imaging (CI).

METHODS

A total of 15 FDG PET-CT studies were acquired in 12 posttherapy uterine sarcoma patients. The images were evaluated by two experienced nuclear medicine physicians in consensus. Clinical/imaging follow-up (minimum 6 months) and histopathology were taken as the reference standard. All the patients had also undergone CI (CT or MRI or ultrasonography) of the chest, abdomen, and pelvis. The diagnostic accuracy of FDG PET-CT was calculated and compared with that of CI.

RESULTS

The median age of the patients was 51.5 years (interquartile range: 47.5-53). Histopathology was leiomyosarcoma in six, carcinosarcoma in five, and endometrial stromal sarcoma in one patient. Six FDG PET-CT studies were carried out for suspected recurrence and nine for posttherapy surveillance. Six FDG PET-CTs were positive and nine were negative for recurrence. The sensitivity, specificity, and accuracy of FDG PET-CT were 85.7, 100, and 93.3%, respectively, on per study-based analysis, and 80, 100, and 83.3% on per lesion-based analysis. PET-CT showed higher sensitivity and specificity compared with CI for both study-based and lesion-based analysis. However, no significant difference was found between FDG PET-CT and CI either in the study-based or in the lesion-based analysis (P not significant).

CONCLUSION

FDG PET-CT is a highly sensitive and specific modality for detecting recurrence in posttherapy patients with uterine sarcoma. However, it provides no significant advantage over CI for this purpose.

Histologic, molecular, and cytogenetic features of ovarian cancers: implications for diagnosis and treatment

Ovarian epithelial carcinoma (OEC), the most common ovarian malignancy, is a heterogeneous disease with several histologic subtypes that show characteristic cytogenetic features, molecular signatures, oncologic signaling pathways, and clinical-biologic behavior. Recent advances in histopathology and cytogenetics have provided insights into pathophysiologic features and natural history of OECs. Several studies have shown that high- or low-grade serous, endometrioid, and clear cell carcinomas are characterized by mutations involving the TP53, K-ras/BRAF, CTNNB1, and PIK3CA genes, respectively. High-grade serous carcinomas, the most common subtype, often manifest with early transcoelomic spread of disease beyond the ovaries, whereas low-grade serous and mucinous carcinomas commonly manifest with early-stage disease, with a resultant excellent prognosis. On the basis of pathogenetic mechanisms, recent findings suggest a dualistic model of ovarian carcinogenesis consisting of types I and II. Type I (low-grade serous, mucinous, and endometrioid) cancers commonly arise from well-described, genetically stable precursor lesions (usually borderline tumors); manifest as large adnexal masses with early-stage disease; and have a relatively indolent clinical course, with an overall good prognosis. In contrast, type II carcinomas (high-grade serous, endometrioid, mixed, and undifferentiated variants) originate de novo from the adnexal epithelia, often demonstrate chromosomal instability, and have aggressive biologic behavior. Better knowledge of hereditary ovarian cancer syndromes and associated cytogenetic abnormalities has led to increased interest in novel biomarkers and molecular therapeutics. Genetic changes, pathologic features, imaging findings, and natural histories of a variety of histologic subtypes of OEC are discussed in this article.

Evaluation of follow-up strategies for patients with epithelial ovarian cancer following completion of primary treatment

BACKGROUND

Ovarian cancer is the sixth most common cancer and seventh cause of cancer death in women worldwide. Traditionally, many patients who have been treated for cancer undergo long-term follow up in secondary care. Recently however it has been suggested that the use of routine review may not be effective in improving survival, quality of life (QoL), and relieving anxiety. In addition, it may not be cost effective.

OBJECTIVES

To compare the potential benefits of different strategies of follow up in women with epithelial ovarian cancer following completion of primary treatment.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010, Issue 4), MEDLINE and EMBASE (to November 2010). We also searched CINAHL, PsycLIT, registers of clinical trials, abstracts of scientific meetings, reference lists of review articles, and contacted experts in the field.

SELECTION CRITERIA

All relevant randomised controlled trials (RCTs) that evaluated follow-up strategies for patients with epithelial ovarian cancer following completion of primary treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias.

MAIN RESULTS

We found only one RCT (Rustin 2010) that met our inclusion criteria. This trial included 529 women and reported data on immediate treatment versus delayed treatment in women with confirmation of remission and with normal CA125 concentration and no radiological evidence of disease after surgery and first-line chemotherapy.Overall survival showed no significant difference between the immediate and delayed arms after a median follow up of 56.9 months (unadjusted hazard ratio (HR) = 0·98, 95% confidence interval (CI) 0·80 to 1·20; P = 0·85). Time from randomisation to first deterioration in global health score or death was significantly shorter in the early group compared with the delayed group (HR 0·71, 95% CI 0·58 to 0·88; P < 0·01). The trial was at low risk of bias.

AUTHORS' CONCLUSIONS

There is a lack of randomised studies on most aspects of follow-up care after treatment for epithelial ovarian cancers. Limited evidence from a single trial suggests that routine surveillance with CA125 in asymptomatic patients, with treatment at CA125 relapse, does not seem to offer survival advantage when compared to treatment at symptomatic relapse. Randomised controlled trials are needed to compare different types of follow up on the outcomes of survival, quality of Life, cost and psychological effects.

Early detection of recurrent ovarian cancer in patients with low-level increases in serum CA-125 levels by 2-[F-18]fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography

PURPOSE

Serum CA-125 has been shown to be a sensitive tumor marker of recurrent ovarian cancer. The goal of this study was to evaluate the use of 2-[F-18]fluoro-2-deoxy-d-glucose-positron emission tomography/computed tomography (FDG-PET/CT) in the early detection of recurrent ovarian cancer in patients with low-level increases in serum CA-125 levels.

METHODS

Patients who demonstrated a normalization of serum CA-125 levels after complete remission of ovarian cancer were recruited for this study. FDG-PET/CT was performed to evaluate serum CA-125 levels ≥ 35 U/mL (Group 1) or progressive low-level increases in the levels of serum CA-125 (Group 2). The results were analyzed based on pathology, disease progression, and/or clinical follow-up.

RESULTS

Twenty-seven (27) consecutive patients consented to the aforementioned criteria (n = 16 in Group 1 and n = 11 in Group 2). In Group 1, of the 16 patients, 15 had a proven tumor recurrence, and the remaining 1 had a second primary cancer with no evidence of recurrent ovarian lesions. In Group 2, all 11 patients had recurrent tumors. The use of FDG-PET/CT allowed the detection of recurrences in 25 patients and a second primary cancer in 1 patient, which included all of the patients in Group 1 and 10 of the 11 patients in Group 2. The detection rate of FDG-PET/CT for recurrent ovarian cancer was 100% in Group 1 and 90.9% in Group 2 (15/15 vs. 10/11, p = 0.423). FDG-PET/CT changed the intended management in 14 (53.8%) of the patients, which included 4 cases in Group 1 and 10 cases in Group 2.

CONCLUSIONS

FDG-PET/CT has the ability to detect recurrent ovarian cancer and second primary tumors in patients with increased levels of serum CA-125. FDG-PET/CT affects the clinical management by localizing recurrent lesions and creating a specific treatment plan for each patient, especially patients who demonstrate a low-level increase in serum CA-125 levels.

Solitary Internal Mammary Lymph Node Metastases Detected by F-FDG-PET/CT in Ovarian Cancer

Internal mammary lymph nodes as solitary site of recurrent ovarian cancer have not been previously described. In this case report, 3 cases of late and very late isolated recurrence in internal mammary lymph nodes are presented. ¹⁸F-FDG-PET/CT allowed the diagnosis which was suspected by the increase of the serum CA-125 level in 2 out of 3 cases. Local treatment, consisting of surgery (in 2 patients) and radiation therapy (in 1 patient), permitted an optimal long-term disease control.

Gynecological cancers

The clinical problems raised in patients presenting with all forms of gynecological malignancy are currently addressed using conventional cross-sectional imaging, usually MRI. In general, F-18 FDG PET-CT has not been shown to have a clinical role in any of these cancers at presentation, although studies are under way to use this form of metabolic imaging to predict prognosis and the response to treatment. Although F-18 FDG PET-CT is superior to conventional imaging techniques, it is only moderately sensitive in demonstrating lymph node metastasis preoperatively, and is inadequate for local staging of patients with endometrial cancer. In ovarian cancer, F-18 FDG PET-CT provides an accurate assessment of the extent of disease, particularly in areas difficult to assess for metastases by CT and MRI such as the abdomen and pelvis, mediastinum, and supraclavicular region. F-18 FDG PET-CT is a sensitive method of detecting pelvic and para-aortic lymph nodal disease in cervical cancer, and appears to be superior to MRI and CT despite the limitations in identifying small foci of disease. In the main, as elsewhere in patients with cancer, the value of PET-CT is in identifying and defining the extent of recurrent disease, in distinguishing between posttreatment fibrosis and recurrence, and possibly in monitoring response to therapy.

The Roles of Fluorodeoxyglucose-PET/Computed Tomography in Ovarian Cancer: Diagnosis, Assessing Response, and Detecting Recurrence

The potential roles of fluorodeoxyglucose positron emission tomography/computed tomography imaging in ovarian cancer include noninvasive characterization of an ovarian mass, staging, and treatment planning. This article assesses these roles for predicting and monitoring response to treatment, restaging, and early diagnosis of recurrence.

Clinical utility of positron emission tomography/computed tomography in the evaluation of suspected recurrent ovarian cancer in the setting of normal CA-125 levels

OBJECTIVES

This study was conducted to estimate the accuracy of [18F]-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) as compared with contrast-enhanced CT (CECT) in detecting cancer in patients who have normal cancer antigen (CA)-125 (<35 U/dL) but are suspected of having a recurrent disease based on clinical symptoms.

METHODS

We retrospectively reviewed the records of patients who had undergone primary cytoreductive surgery and subsequently underwent CECT and FDG-PET/CT for suspected recurrence. [18F]-fluorodeoxyglucose positron emission tomography/computed tomography and CECT interpretation to evaluate a recurrent disease was carried out independently by 2 experienced radiologists who were blinded to the final diagnosis for the suspected recurrence. Long-term follow-up imaging (12 months) and biopsy reports were used to assess the true status of the suspected recurrence seen on FDG-PET/CT or CECT. Sensitivity and specificity of all modalities were estimated. McNemar test was used to compare pairs of modalities. All tests were 2-sided, and P < or = 0.05 was considered statistically significant.

RESULTS

Sixty-six patients met the eligibility criteria for inclusion in our analysis. Fifty-eight percent (18/31) and 54% (17/31) of the patients with normal CA-125 levels had evidence of a recurrent disease on FDG-PET/CT and CECT, respectively. Thirty-one percent (6/19) of the patients with no indication of cancer on CECT had evidence of disease on FDG-PET/CT images, which was supported by pathological proof.

CONCLUSION

[18F]-Fluorodeoxyglucose positron emission tomography/computed tomography is capable of detecting ovarian cancer recurrence in symptomatic patients with normal CA-125 levels and, in this setting, has slightly better sensitivity than CECT and can be considered as the frontline modality for all such patients.

Detection of recurrence by 18F-FDG PET in patients with endometrial cancer showing no evidence of disease

This study assessed the feasibility of F-18-fluorodeoxyglucose positron-emission tomography ((18)F-FDG PET) in the post-therapy surveillance for patients with endometrial cancer showing no evidence of disease (NED). From April 1997 to June 2007, 127 patients with endometrial cancer showing NED were performed (18)F-FDG PET scan. The feasibility of (18)F-FDG PET for the early detection of recurrence in patients with endometrial cancer was evaluated retrospectively. Of the 127 patients, 32 patients showed positive lesions on (18)F-FDG PET scan. Nineteen (19/127 cases, 15%) of them were confirmed to have a recurrence clinically or histologically. The sensitivity, specificity and positive and negative predictive value of (18)F-FDG PET for detecting recurrences in patients with endometrial cancer were 100%, 88%, 59% and 100%, respectively. In conclusion, (18)F-FDG PET may be a useful method for the post-therapy surveillance in patients with endometrial cancer.

Variable F-18 fluorodeoxyglucose avidity of metastatic recurrent adult granulosa cell tumor

The appearance of rare ovarian germ cell tumors such as adult granulosa cell tumor (GCT) on F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) is reported in this article. We present a patient with recurrent GCT and histologically proven intra-abdominal metastases. Most lesions were above PET resolution (>1 cm). The local recurrence demonstrated moderate FDG uptake but metastases had variable (none to mild) FDG avidity. Ovarian GCTs are of relatively low metastatic potential and frequently present as metastases with solid and cystic components, which are plausible explanations for its variable FDG uptake. Clinicians should be aware of this phenomenon and the potential for false negatives on FDG-PET.

Positron emission tomography and granulosa cell tumor recurrence: a report of 2 cases

Two case reports of women with recurrent granulosa cell tumors identified initially by increasing levels of inhibin. As part of their investigation to assess the extent of the recurrence, an abdominopelvic computed tomography and a positron emission tomography scans were performed. Interestingly, the recurrent tumors were identified on the abdominopelvic computed tomography but not on the positron emission tomography scan. These recurrences were confirmed at surgery, and the histopathologic findings were identical to the original lesion.

Hybrid imaging (SPECT/CT and PET/CT): improving therapeutic decisions

The incremental diagnostic value of integrated positron emission tomography-computed tomography (PET/CT) or single-photon emission computed tomography (SPECT)/CT images compared with PET or SPECT alone, or PET or SPECT correlated with a CT obtained at a different time includes the following: (1) improvement in lesion detection on both CT and PET or SPECT images, (2) improvement in the localization of foci of uptake resulting in better differentiation of physiological from pathologic uptake, (3) precise localization of the malignant foci, for example, in the skeleton vs soft tissue or liver vs adjacent bowel or node (4) characterization of serendipitous lesions, and (5) confirmation of small, subtle, or unusual lesions. The use of these techniques can occur at the time of initial diagnosis, in assessing the early response of disease to treatment, at the conclusion of treatment, and in continuing follow-up of patients. PET/CT and SPECT/CT fusion images affect the clinical management in a significant proportion of patients with a wide range of diseases by (1) guiding further procedures, (2) excluding the need of further procedures, (3) changing both inter- and intramodality therapy, including soon after treatment has been initiated, and (4) by providing prognostic information. PET/CT fusion images have the potential to provide important information to guide the biopsy of a mass to active regions of the tumor and to provide better maps than CT alone to modulate field and dose of radiation therapy. It is expected that the role of PET/CT and SPECT/CT in changing management will continue to evolve in the future and that these tools will be fundamental components of the truly "personalized medicine" we are striving to deliver.

Surveillance of patients after initial treatment of ovarian cancer

The surveillance of ovarian cancer patients after initial treatment is a challenging question in clinical practice. Serum CA 125 assay, physical examination, and imaging examinations have been employed with different time schedules for the follow-up of asymptomatic patients. Rising serum CA 125 levels may precede the clinical detection of relapse in 56-94% of cases with a median lead time of 3-5 months. An ongoing randomised phase III European trial is comparing the benefits of early administration of chemotherapy based on serum CA 125 assay alone versus delaying treatment until clinical or radiological detection of recurrent disease. Physical examination, with or without ultrasound, is very useful for the surveillance of these patients, since approximately 25-50% of relapses involve the pelvis. Additional radiological imaging techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI), are usually performed in asymptomatic patients with rising CA 125 levels as well as in patients with suspicious symptoms or signs. Integrated positron emission tomography (PET) and CT scanners (PET/CT) can identify recurrent disease in tissues that appear normal at CT imaging as well as metastatic lesions intimately associated with the bowel wall that are difficult to detect with CT or MRI, so that in most series PET/CT has a higher diagnostic reliability than that of conventional imaging techniques. Moreover, PET/CT can disclose unusual supra-diaphragmatic spreading of the disease and may be very helpful for treatment planning, especially for the selection of patients suitable for secondary surgical cytoreduction. A prospective, randomised trial of therapeutic interventions based on stratification by PET/CT disease status could elucidate the real impact of this diagnostic procedure in the management of patients with recurrent ovarian cancer.

A Case Report Demonstrating Unambiguous Clinical Utility of Pet/CT Scanning in Recurrent Ovarian Cancer

There has been discussion and debate in the medical literature regarding the clinical value of PET/CT scans in ovarian cancer, particularly focusing on evidence whether the technology is of predictive versus solely prognostic utility. In the somewhat unusual case reported here, the results of the PET/CT scan were extremely helpful in developing a rational management strategy. The case emphasizes the critical need to specifically address the issue of whether data generated from an expensive diagnostic test will be useful in an individual patient's management before it is obtained.

Positron emission tomography/computed tomography introduction in the clinical management of patients with suspected recurrence of ovarian cancer: a cost-effectiveness analysis

Aim of this study was to evaluate the economic impact of the introduction of positron emission tomography/computed tomography (PET/CT) in the early detection of recurrent ovarian cancer through a cost-effectiveness analysis of different diagnostic strategies. Thirty-two consecutive patients with suspected ovarian cancer recurrence, studied by both contrast enhanced abdominal CT and PET/CT, were retrospectively included in the study. Three different diagnostic strategies were evaluated and compared: (1) CT only or baseline strategy; (2) PET/CT for negative CT or strategy A; (3) PET/CT for All or strategy B. For each one, expected costs, avoided surgery and incremental cost-effectiveness ratio (ICER) were calculated to identify the most cost-effective strategy. The number of positive patients increased from baseline strategy (20/32) to strategy A and B (30/32 and 29/32 respectively). Positron emission tomography/computed tomography reoriented physician choice in 31% and 62% of patients (strategies A and B respectively). Strategy A is dominated by strategy B, which is more expensive (2909 euro vs. 2958 euro), but also more effective (3 cases of surgery avoided) and presents an ICER of 226.77 euro per surgery avoided (range: 49.50-433.00 euro). Positron emission tomography/computed tomography introduction in this population is cost-effective and allowed to redirect the clinical management of patients towards more appropriate therapeutic choices.

Are Surveillance Procedures of Clinical Benefit for Patients Treated for Ovarian Cancer?: A Retrospective Italian Multicentric Study

The aim of this retrospective investigation was to assess the pattern of failures of 412 patients with recurrent ovarian cancer followed up with different surveillance protocols.

Time to recurrence was less than 6 months in 98 women (23.8%), 6 to 12 months in 102 women (24.7%), and more than 12 months in 212 women (51.5%). Symptoms at relapse were referred by 81 women (19.7%). Among the 331 asymptomatic patients, the surveillance procedure that raised the suspect of recurrent disease was clinical examination in 49 (14.8%), imaging technique in 90 (27.2%), serum CA 125 in 77 (23.3%), and both serum CA 125 and imaging technique in 115 (34.7%). At univariate analysis, survival from initial diagnosis was related to stage (P = 0.004), residual disease after initial surgery (P < 0.0001), time to recurrence (P < 0.0001), site of relapse (P = 0.04), and treatment at recurrence (P < 0.0001), and survival after recurrence was related to stage (P = 0.01), residual disease (P < 0.0001), time to recurrence (P < 0.0001), and treatment at recurrence (P < 0.0001). Conversely, symptoms at recurrence had no prognostic relevance. Cox proportional hazards model showed that residual disease and time to recurrence were the only independent prognostic variables for both survival from initial diagnosis (P < 0.0001) and survival after recurrence (P < 0.0001). In conclusion, there was no survival difference between asymptomatic and symptomatic patients at the time of relapse, and therefore, the diagnostic anticipation allowed by a scheduled follow-up protocol did not seem to improve the clinical outcome of patients who ultimately developed recurrent disease.

The impact of PET-CT in suspected recurrent ovarian cancer: A prospective multi-centre study as part of the Australian PET Data Collection Project

OBJECTIVE

To assess the impact of FDG PET-CT on the management of patients with suspected recurrent ovarian cancer and to determine the incremental information provided by PET-CT.

METHODS

This was a prospective, multi-centre, cohort study. Ninety women (mean age 59.9 years; age range 35-85 years) with a previous history of treated epithelial ovarian carcinoma and suspected recurrence based on elevated CA-125, anatomical imaging or clinical symptoms were studied with FDG PET-CT across two States. Referring doctors were asked to specify a management plan pre-PET, if management was altered after PET-CT and, the impact (rated - none, low, medium, high) of PET-CT on patient management. The pre-PET management plan could include radiotherapy, chemotherapy, surgery, and 'other' including observation. Patients were followed at 6 and 12 months and clinical status, evidence of recurrence and progression were recorded.

RESULTS

Patients were referred by 34 individual specialists. At least 168 additional sites of disease in 61 patients (68%), not identified by conventional imaging were identified by PET-CT. In 77% the additional lesions were located below the diaphragm and most were nodal or peritoneal. PET-CT affected management in 60% (49% high, 11% medium impact). Patients where more disease was detected with PET-CT were more likely to progress in the following 12 months.

CONCLUSIONS

For women with previously treated ovarian carcinoma with recurrent disease, PET-CT can: a) alter management in close to 60% of patients, b) detect more sites of disease than abdominal and pelvic CT, c) is superior in the detection of nodal, peritoneal and subcapsular liver disease and d) offers the opportunity for technology replacement in this setting.