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

PET Imaging for Gynecologic Malignancies

This review article summarizes the clinical applications of established and emerging PET tracers in the evaluation of the 5 most common gynecologic malignancies: endometrial, ovarian, cervical, vaginal, and vulvar cancers. Emphasis is given to 2-deoxy-2-[¹⁸F]fluoro-d-glucose as the most widely used and studied tracer, with additional clinical tracers also explored. The common imaging protocols are discussed, including standard dose ranges and uptake times, established roles, as well as the challenges and future directions of these imaging techniques. The key points are emphasized with images from selected cases.

Role of 18F-FDG PET/CT in restaging and follow-up of patients with uterine sarcomas

PURPOSE

Uterine sarcomas are rare tumors with poor prognosis due to the high recurrence rates. The current role of ¹⁸F-FDG PET/CT in the post-therapy surveillance is not established yet.

MATERIALS AND METHODS

Forty-one women with uterine sarcoma underwent 73 ¹⁸F-FDG PET/CT for restaging in suspected recurrence or during follow-up in asymptomatic patients. Histopathology results and/or clinical/imaging follow-up for at least 12 months were considered the reference standard. The diagnostic accuracy and clinical impact of ¹⁸F-FDG PET/CT was calculated.

RESULTS

Thirty-three ¹⁸F-FDG PET/CT were positive, while the remaining 40 studies were negative. The overall sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of ¹⁸F-FDG PET/CT were 88%, 98%, 97%, 91% and 93%, respectively. Considering patients with clinical or radiological suspicion of recurrence (n=47) and those during follow-up (n=26), sensitivity, specificity, PPV, NPV and accuracy of ¹⁸F-FDG PET/CT were 89%, 100%, 100%, 86% and 94%, and 80%, 95%, 80%, 95% and 92%, respectively. ¹⁸F-FDG PET/CT had a positive clinical impact in 9/73 (12%) studies and changed the clinical management in 8/41 (20%) patients.

CONCLUSIONS

¹⁸F-FDG PET/CT seems to be an accurate method for detection and localization of local and distant recurrence in patients with uterine sarcoma with good sensitivity and specificity and significant impact on clinical decision making.

Value of 18F-FDG PET/CT imaging in the staging, restaging, monitoring of response to therapy and surveillance of uterine leiomyosarcomas

OBJECTIVE

Leiomyosarcoma (LMS) is the most common subtype of uterine sarcomas. It is a rare and aggressive tumour. The aim of the present study was to assess the performance of fluorine-18-fluorodeoxyglucose (F-FDG) PET/CT imaging in four clinical settings: initial staging, restaging, monitoring of response to therapy and post-therapy surveillance of uterine LMS.

PATIENTS AND METHODS

A bicentric retrospective study was carried out on a group of 21 patients with uterine LMS for whom a total of 52 PET/CT scans were available in initial staging (n=11), restaging (n=11), monitoring of response to therapy (n=17) and post-therapy surveillance (n=13). Clinical (minimum 6 months after PET/CT scan) and/or imaging follow-up and pathology were used as the reference standard.

RESULTS

In the initial staging, the sensitivity, specificity and accuracy of PET imaging were 80, 100 and 91%, respectively. In the restaging and monitoring of response to therapy, all these indices were 100%, whereas they were lower in post-therapy surveillance at 75, 100 and 85%, respectively, because of two false-negative results. False-negative lesions were an infracentimetric lung nodule in the initial staging and a peritoneal nodule that had increased in size between two PET/CT scans in post-therapy surveillance. PET-negative lesions were all identified on the computed tomography (CT) part of the PET/CT; thus, the performances of the exam improved to 100% on taking into account the CT component of the PET/CT.

CONCLUSION

PET/CT imaging has a high diagnostic yield in the initial staging and restaging of uterine LMS, but seems less sensitive in post-therapy surveillance. Evaluation of the CT part improves the sensitivity of the PET scan. Thus, PET/CT imaging should be considered in patients presenting with LMS.

Uterine leiomyosarcoma: Epidemiology, contemporary treatment strategies and the impact of uterine morcellation

Leiomyosarcoma, a rare tumor subtype, accounts for 1% of all uterine malignancies, but contributes to a significant proportion of uterine cancer deaths. Surgery is considered the mainstay of treatment for all soft tissue sarcomas, including uterine variants. However, uterine leiomyosarcoma is challenging to diagnose preoperatively and can mimic the appearance of benign uterine leiomyomas. Recently, concerns have grown in this regard, as surgeons have utilized uterine morcellation and myomectomy procedures unknowingly in the setting of occult uterine sarcoma. Because of aggressive tumor biology and relative chemotherapy and radiotherapy resistance, efficacious therapies to achieve prolonged survival or cure in those with both early and advanced-stage uterine leiomyosarcoma have been elusive. The strongest determinant of survival remains stage at diagnosis, though prediction models may provide a more accurate prognosis. Given the aggressive nature of this sarcoma subtype, novel early detection strategies and targeted therapies are the focus of several recently published and ongoing studies. While gemcitabine/docetaxel and doxorubicin remain the most active regimens in the treatment of advanced or recurrent disease, currently available cytotoxic regimens remain inadequate, with 5-year disease-specific survival of <30%. Pazopanib, trabectedin and olaratumab, are FDA-approved, targeted therapies with activity in uterine and other leiomyosarcomas, while aromatase inhibitors and immunotherapies are under active investigation. This review provides a critical appraisal of the literature regarding the contemporary surgical and medical management of uterine leiomyosarcoma, the role of targeted therapies, and the implications of uterine morcellation on gynecologic surgical practice.

Long-Term Survival in a Patient With Abdominal Sarcomatosis From Uterine Leiomyosarcoma: Role of Repeated Laparoscopic Surgery in Treatment and Follow-Up

Uterine leiomyosarcoma (LMS) in some cases may disseminate through the abdominal cavity, without extra-abdominal spreading, determining a condition of abdominal sarcomatosis, which represents a peculiar situation. Only radical surgical removal offers a chance of long-term survival in such cases of LMS. Here we describe a case of diffuse abdominal sarcomatosis from uterine LMS in a 51-year-old perimenopausal woman who underwent laparoscopic radical hysterectomy, bilateral salpingo-oophorectomy, total pelvic peritonectomy, pelvic lymphadenectomy to the mesenteric inferior artery, and omentectomy. Then, given the high probability of disease recurrence, the patient underwent a close follow-up consisting of positron emission tomography (PET)/computed tomography every 3 months and diagnostic (and if necessary operative) laparoscopy every 6 months. To date, the patient had 11 laparoscopies; 5 of them were preceded by a PET indicative of the presence of disease with high metabolic activity, which was confirmed at surgery and each time completely removed laparoscopically with no evidence of residual disease. To date, 5 years from diagnosis the patient is alive and continues her follow-up. Our report brings to light the ability of laparoscopic surgery to obtain disease control in a case of LMS with abdominal dissemination. Moreover, laparoscopic surgery, as demonstrated in our case, may have an important role in the close follow-up of the disease and allow a timely and early radical surgical approach of relapses before they become extremely large and difficult to remove radically.

Imaging Features of Uncommon Gynecologic Cancers

OBJECTIVE

The role of imaging in patients with suspected gynecologic malignancies is to provide an accurate diagnosis to achieve the best and most tailored treatment plan. Uncommon cancers pose a distinct challenge, because current knowledge of these diseases is still limited. Our purpose is to highlight the role of cross-sectional imaging techniques, including ultrasound, CT, MRI, and PET/CT, in the diagnosis and pretreatment stratification of patients with rare gynecologic cancers.

CONCLUSION

This review shows the relevance of imaging findings for diagnosis, staging, and treatment planning in patients with uncommon uterine, cervical, vaginal, vulvar, and ovarian cancers.

Sarcoma of the Uterus. Guideline of the DGGG (S2k-Level, AWMF Registry No. 015/074, August 2015)

Purpose: Official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). Due to their rarity and their heterogeneous histopathology uterine sarcomas remain challenging tumors to manage and need a multidisciplinary approach. To our knowledge so far there is no evidence-based guideline on the appropiate management of these heterogeneous tumors. Methods: This S2k-guideline is the work of an representative committee of experts from a variety of different professions who were commissioned by the DGGG to carry out a systematic literature review of uterine sarcoma. Members of the participating scientific societies developed a structured consensus in a formal procedure. Recommendations: 1. The incidence and histopathologic classification of uterine sarcoma. 2. The clinical manifestations, diagnosis and staging of uterine sarcoma. 3. The management of leiomyosarcoma. 4. The management of endometrial stromal sarcoma and undifferentiated uterine sarcoma. 5. The management of adenosarcoma as well as carcinosarcomas. 6. The management of morcellated uterine sarcoma.

Follow-up in Gynecological Malignancies: A State of Art

Objective

The main purpose of this article is to explore the current practice for follow-up of gynecological cancer, pointing out the different procedures, to determine the most clinically and cost-effective surveillance strategies after the primary treatment.

Materials and Methods

We analyzed the follow up strategies for ovarian, endometrial, and cervical cancer. All of the topics discussed below arose from the “ESGO State of Art Conference—Follow-up in gynaecological malignancies” in Turin, (September 11–13, 2014;http://torino2014.esgo.org/).

Results

Physical but these practices should be integrated with biomarkers or imaging strategies. Currently, most recommendations about follow-up are based on retrospective studies and expert opinion, and there is some disagreement on surveillance strategies due to lack of evidence-based knowledge.

Conclusions

All surveillance procedures should be evidence-based with a clearly defined purpose: there is a need for prospective studies to compare the effectiveness of different follow-up regimens measuring overall survival, detection of recurrence, quality of life (QoL), and costs as outcomes.

Gynecologic Cancer InterGroup (GCIG) consensus review: uterine and ovarian leiomyosarcomas

OBJECTIVES

The Gynecologic Cancer InterGroup aimed to provide an overview of uterine and ovarian leiomyosarcoma management.

METHODS

Published articles and author experience were used to draft management overview. The draft manuscript was circulated to international members of the Gynecologic Cancer InterGroup for review and comment, and appropriate revisions were made.

RESULTS

The approach to management of uterine and ovarian leiomyosarcoma management is reviewed.

CONCLUSIONS

Uterine and ovarian leiomyosarcomas are rare and aggressive cancers that require specialized expertise for optimal management.

Diagnostic accuracy of integrated (18)F-FDG PET/CT for restaging patients with malignant germ cell tumours

OBJECTIVE

Evaluation of utility of fluorine-18 fludeoxyglucose ((18)F-FDG) positron emission tomography/CT (PET/CT) for restaging patients with primary malignant germ cell tumours (GCTs).

METHODS

Data of 92 patients (age, 31.94 ± 10.1 years; male/female, 86/6) with histopathologically confirmed malignant GCTs (gonadal, 88; mediastinal, 4; seminomatous, 47 and non-seminomatous, 45) who underwent (18)F-FDG PET/CT for restaging (suspected recurrence/post-therapy evaluation) were retrospectively analysed. Two experienced nuclear medicine physicians reviewed the PET/CT images in consensus, qualitatively and semi-quantitatively [maximum standardized uptake value (SUVmax)]. Histopathology (if available) and clinical/imaging/biochemical follow-up (minimum of 6 months) were employed as the reference standard.

RESULTS

(18)F-FDG PET/CT was interpreted as positive in 59 and negative in 33 patients. Local disease was seen in 5, nodal disease in 50 and distant metastasis in 22 patients. PET/CT was true positive in 49, false positive in 10, true negative in 30 and false negative in 3 patients. (18)F-FDG PET/CT showed sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 94.2%, 75.0%, 83.0%, 90.9% and 85.8% overall; 90.0%, 74.0%, 72.0%, 90.9% and 80.8% in seminomatous GCT; and 96.8%, 76.9%, 91.1%, 90.9% and 91.1% in non-seminomatous GCT, respectively. Difference in PET/CT accuracy for seminomatous and non-seminomatous GCTs was not significant (p = 0.263). PET/CT demonstrated disease in 13 patients with negative/equivocal conventional imaging findings and in 9 patients with normal tumour markers. No site- or histology-based difference was seen in SUVmax.

CONCLUSION

(18)F-FDG PET/CT demonstrates high diagnostic accuracy for restaging patients with malignant GCTs. It has comparable diagnostic performance in both seminomatous and non-seminomatous malignant GCTs.

ADVANCES IN KNOWLEDGE

The present article demonstrates high diagnostic accuracy of (18)F-FDG PET/CT for restaging both seminomatous and non-seminomatous malignant GCTs in a large patient population.

Diagnostic performance of fluorine-18-fluorodeoxyglucose positron emission tomography imaging in uterine sarcomas: systematic review and meta-analysis of the literature

OBJECTIVE

We reviewed the medical literature on the application of fluorine-18-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) imaging in the management of uterine sarcomas and presented the results in systematic review and meta-analysis format.

METHODS

Medline, SCOPUS, and ISI Web of Knowledge were searched electronically with "PET AND (Uterine OR Uterus)" as key words. All studies evaluating the accuracy of (18)F-FDG imaging in the staging or restaging of uterine sarcomas were included if enough data could be extracted for calculation of sensitivity and/or specificity.

RESULTS

Eight studies were included in the systematic review. Only 2 studies reported the accuracy of (18)F-FDG PET imaging in the primary staging of uterine sarcoma with low sensitivity for lymph node staging. For restaging (detection of recurrence), all 8 included studies had quantitative data, and the patient-based pooled sensitivity and specificity were 92.1% (95% confidence interval [95% CI], 82.4-97.4) and 96.2% (95% CI, 87-99.5), respectively. On a lesion-based analysis, sensitivity was 86.3% (95% CI, 76.7-92.9), and specificity was 94.4% (95% CI, 72.7-99.9). Device used (PET vs PET/CT), spectrum of studied patients, and histology of the sarcoma seem to be factors influencing the overall accuracy of (18)F-FDG PET imaging.

CONCLUSIONS

(8)Fluorine-18-fluorodeoxyglucose PET and PET/CT seem to be accurate methods for detection and localization of recurrence in patients with uterine sarcoma. Further large multicenter studies are needed to validate our results and to correlate both sarcoma type and spectrum of patients to the diagnostic performance of (18)F-FDG PET imaging in recurrence detection. The studies evaluating the accuracy of (18)F-FDG PET imaging for the primary staging of uterine sarcoma are very limited, and no definite conclusion can be made in this regard.

Surgical outcomes for 131 cases of carcinosarcoma of the hepatobiliary tract

Carcinosarcoma of the hepatobiliary tract is highly aggressive and has a poor prognosis even after curative resection. The purpose of this study was to collate and analyze published data to clarify the surgical outcome of carcinosarcoma of the hepatobiliary tract and the relationships between potential prognostic factors and survival after surgery. We surveyed worldwide literature from 1970 to 2012 and obtained clinicopathological data for 131 patients who had undergone surgical resection for carcinosarcoma of the hepatobiliary tract, including one patient from our clinic. The relationships between potential prognostic factors and survival rates were examined using the Kaplan-Meier method and the log-rank test. The overall 1-, 3-, and 5-year survival rates for patients with carcinosarcoma of the hepatobiliary tract after surgery were 44.0, 29.3, and 27.0 %, respectively. In univariate analyses, age and gender were not significant prognostic factors; however, advanced stage according to the classification of the Union for International Cancer Control in resected specimens was significantly associated with a shorter survival time after surgery. Although carcinosarcoma of the hepatobiliary tract remains a rare disease worldwide, its poor prognosis, even after curative resection, demands further epidemiological and pathological study that could lead to the development of new management strategies.

Differentiation of aggressive and indolent subtypes of uterine sarcoma using maximum standardized uptake value

Objective

The aim of the study was to elucidate the differential metabolic activities in aggressive and indolent subtypes of uterine sarcomas, which may aid in managing these heterogeneous tumours.

Methods

We retrospectively analysed the PET/computed tomography scans of consecutive patients (N=18) diagnosed with uterine sarcoma at our unit. The patients were divided into indolent (N=4) and aggressive (N=14) tumour groups, and the maximum standardized uptake values (SUV_max) of all lesions (n=134) were measured. The SUV_max of the lesions were compared between the two tumour groups using the Mann–Whitney U-test. We calculated the optimal cutoff value as determined by receiver operating characteristic analysis. A P-value less than 0.05 was considered statistically significant.

Results

The mean SUV_max of aggressive (n=104) and indolent tumours (n=30) were significantly different (8.0±7.3 vs. 1.9±0.9 respectively; P<0.001). A cutoff of SUV_max greater than 4.0 was able to exclude indolent tumours, with 100% specificity and positive predictive value (sensitivity 72%, negative predictive value 50% and accuracy 78%; area under the curve 97%). By applying this same cutoff value on the most metabolic active lesion in each patient, we were able to correctly classify all but one patient into either the aggressive or indolent tumour group with 100% specificity and positive predictive value (sensitivity 93%, negative predictive value 80% and accuracy 94%).

Conclusion

Aggressive and indolent uterine sarcoma subtypes have differential metabolic activities that can be used to classify them and this can aid in patient management for preoperative surgical planning and treatment stratification.

ATL: Does Metabolic Response Predicts Survival?

Purpose

This study aimed to assess the role of18F-fluorodeoxyglucose positron emission tomography–computed tomography (18F-FDG PET-CT) in response assessment of patients with recurrent carcinoma cervix and in evaluating the predictive value of metabolic response for progression-free survival (PFS) and overall survival (OS).

Methods

Thirty-six patients with histopathologically or clinically evident recurrent cervical carcinoma underwent a pretherapy and a posttherapy18F-FDG PET-CT for treatment response evaluation. Positron emission tomography–CT images were analyzed by 2 experienced nuclear medicine physicians. Response was categorized using European Organization for Research and Treatment of Cancer (EORTC) criteria into complete metabolic response (CMR), partial metabolic response (PMR), stable metabolic disease (SMD), and progressive metabolic disease (PMD). Clinical/imaging follow-up (minimum of 6 months) and/or histopathologic findings were taken as reference standard. Patients were categorized into 2 groups, those with PMD and those without PMD (ie, CMR, PMR, and SMD). Progression-free survival and OS based on PET-CT response were measured from the date of posttherapy PET-CT to the first documentation of progression of disease and death, respectively.

Results

On the basis of metabolic response on posttherapy PET-CT, 6 patients had CMR, 12 patients had PMR, 7 patients had SMD, and 11 patients had PMD. Progression-free survival for patients with cervical carcinoma ranged from 0.5 to 26.5 months (mean [SD], 6.7 [6.1] months). Median PFS for patients with PMD was 3.1 months, whereas median PFS for those without PMD was not reached. Patients who did not show PMD on posttherapy PET-CT had a significantly better PFS than those patients who showed PMD (P< 0.0001; HR, 0.14). There was no statistically significant difference in OS between the 2 groups (P= 0.187; HR, 0.39).

Conclusions

18F-fluorodeoxyglucose PET-CT is an effective tool for treatment response evaluation in recurrent carcinoma cervix. Patients with metabolically progressive disease on posttherapy18F-FDG PET-CT have a significantly shorter PFS.

Leiomyosarcoma of the splenic vein

Leiomyosarcomas arising from the wall of blood vessels are rare and aggressive neoplasm. We report a case of a previously healthy 66-year-old woman who presented with intermittent abdominal pain, progressive constipation, and weight loss. Abdominal computed tomography showed a 12 cm solid heterogeneous tumor in the tail of the pancreas. The patient subsequently underwent surgical resection of the pancreatic mass. Surprisingly, histological and immunohistochemical analyses revealed leiomyosarcoma arising from the smooth muscle of the splenic vein. After surgery, she received adjuvant chemotherapy. One year later, there was no evidence of local recurrence. In this paper, we discuss the available information about leiomyosarcomas of splenic vein and its management.

Fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) for the detection of skeletal muscle and skin metastases in uterine leiomyosarcoma: a case report

We report the clinical value of FDG PET/CT imaging in a 57-year-old woman who was diagnosed with uterine leimyosarcoma 6 years ago. In a staging procedure, whole body FDG PET/CT discloses the presence of both local recurrence and remote metastases at widespread musculocutaneous sites, liver and femur. With its advantage of scanning the whole body in a single procedure, we propose the use of PET/CT imaging for the evaluation of patients with uterine leimyosarcomas, a tumor with a propensity for widespread hematogenous spread to unusual sites.