Diagnostic value of integrated ¹⁸F-fluoro-2-deoxyglucose positron emission tomography/computed tomography in recurrent epithelial ovarian cancer: accuracy of patient selection for secondary cytoreduction in 134 patients

18F-FDG PET/MRI and 18F-FDG PET/CT for the Management of Gynecological Malignancies: A Comprehensive Review of the Literature

OBJECTIVE

Positron emission tomography with 2-deoxy-2-[fluorine-18] fluoro- D-glucose integrated with computed tomography (18F-FDG PET/CT) or magnetic resonance imaging (18F-FDG PET/MRI) has emerged as a promising tool for managing various types of cancer. This review study was conducted to investigate the role of 18F- FDG PET/CT and FDG PET/MRI in the management of gynecological malignancies.

SEARCH STRATEGY

We searched for relevant articles in the three databases PubMed/MEDLINE, Scopus, and Web of Science.

SELECTION CRITERIA

All studies reporting data on the FDG PET/CT and FDG PET MRI in the management of gynecological cancer, performed anywhere in the world and published exclusively in the English language, were included in the present study.

DATA COLLECTION AND ANALYSIS

We used the EndNote software (EndNote X8.1, Thomson Reuters) to list the studies and screen them on the basis of the inclusion criteria. Data, including first author, publication year, sample size, clinical application, imaging type, and main result, were extracted and tabulated in Excel. The sensitivity, specificity, and diagnostic accuracy of the modalities were extracted and summarized.

MAIN RESULTS

After screening 988 records, 166 studies published between 2004 and 2022 were included, covering various methodologies. Studies were divided into the following five categories: the role of FDG PET/CT and FDG-PET/MRI in the management of: (a) endometrial cancer (n = 30); (b) ovarian cancer (n = 60); (c) cervical cancer (n = 50); (d) vulvar and vagina cancers (n = 12); and (e) gynecological cancers (n = 14).

CONCLUSIONS

FDG PET/CT and FDG PET/MRI have demonstrated potential as non-invasive imaging tools for enhancing the management of gynecological malignancies. Nevertheless, certain associated challenges warrant attention.

Meta-analysis of the diagnostic value of 18F-FDG PET/CT in the recurrence of epithelial ovarian cancer

BACKGROUND

Ovarian cancer is the leading cause of cancer-related death among gynecologic malignancies. With much evidence suggesting that 18F-FDG PET/CT may be an excellent imaging test for the diagnosis of epithelial ovarian cancer recurrence, we conducted a systematic review and meta-analysis to summarize relevant studies and evaluate the accuracy and application value of 18F-FDG PET/CT in the diagnosis of recurrence of epithelial ovarian cancer.

MATERIALS AND METHODS

Clinical trials of 18F-FDG PET/CT for the diagnosis of recurrence of epithelial ovarian cancer were systematically searched in PubMed, Embase, Cochrane Library, Web of Science and OVID database. The relevant literature was searched until May 22, 2022. Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used to evaluate the quality of the included original studies, and the meta-analysis was performed using a bivariate mixed-effects model and completed in Stata 15.0.

RESULTS

A total of 17 studies on 18F-FDG PET/CT for the diagnosis of epithelial ovarian cancer recurrence were included in this systematic review, involving 639 patients with epithelial ovarian cancer. Meta-analysis showed that the sensitivity, specificity and area under the curve of 18F-FDG PET/CT for the diagnosis of epithelial ovarian cancer recurrence were 0.88 (95% CI: 0.79 - 0.93), 0.89 (95% CI: 0.72 - 0.96) and 0.94 (95% CI: 0.91- 0.96), respectively. Subgroup analysis showed higher diagnostic efficacy in prospective studies than in retrospective studies, and no significant publication bias was observed in Deeks' funnel plot, with sensitivity analysis revealing the stability of results. Meta regression shows that the heterogeneity of this study comes from study type.

CONCLUSION

18F-FDG PET/CT has good diagnostic value in the recurrence of epithelial ovarian cancer.

Role of 18F FDG PET/CT in evaluation of post-operative ovarian carcinoma

Background

We evaluated the sensitivity, specificity and accuracy of fluorine-18-fluorodeoxyglucose with positron emission tomography/computed tomography (18F-FDG-PET/CT) in a group of patients with suspicion of ovarian cancer recurrence. It is considered a diagnostic dilemma, particularly in the 2 years following first-line therapy. CA125 serum levels computed tomography (CT) and other modalities are used during routine follow-up. These traditional modalities could provide a significant number of false-negative or equivocal results even in the presence of elevated CA125 levels. So the performance of 18F-FDG-PET/CT is essential for the optimal diagnosis of recurrence and treatment planning.

Results

Studying PET/CT behaviour in the detection of ovarian cancer recurrence, 18F-FDG-PET/CT had an accuracy of 98% with sensitivity and specificity of 98% and 100%, respectively. 18F-FDG-PET/CT had a PPV of 100% and NPV of 83%. While studying the CA125 level (> 35 U/ml) to detect the ovarian cancer recurrence during patient follow-up, the CA125 level had an accuracy of 50% with a sensitivity ratio and specificity ratio of 47% and 80%, respectively. CA-125 level had a PPV of 95% and NPV of 14%. In comparison between conventional CT and PET/CT studies, the PET/CT diagnosed local tumor recurrence in 16 patients (32%), while CT scan diagnosed local tumor recurrence in only 3 patients (6%), and PET/CT detected peritoneal recurrence in 34 patients (68%). CT scan found peritoneal deposits in 11 patients (22%), also the PET/CT showed suspicious abdominal LNS in 22 patients (44%) while, CT scan showed suspicious abdominal LNS in 4 patients (8%), and PET/CT showed suspicious pelvic LNS in 16 patients (32%). CT scan showed suspicious pelvic LNS in 7 patients (14%). PET/CT detected distant organ metastases in 18 patients (36%). CT scan detected distant organ metastasis in only 8 patients (16%). Comparison between CT and PET/CT in 32 follow-up cases for the detection of local tumor recurrence, peritoneal deposits, suspicious abdominal/pelvic LNs and distant organ metastasis. There was a statistically significant difference between CT and PET/CT the end results (p < 0.0001, p = 0.0047, p = 0.001, p = 0.03).

Conclusions

18F-FDG-PET/CT is more sensitive in detection and localization of ovarian cancer recurrence and more superior than the other imaging modalities.

Current update on malignant epithelial ovarian tumors

Epithelial ovarian cancer (EOC) represents the most frequently occurring gynecological malignancy, accounting for more than 70% of ovarian cancer deaths. Preoperative imaging plays an important role in assessing the extent of disease and guides the next step in surgical decision-making and operative planning. In this article, we will review the multimodality imaging features of various subtypes of EOC. We will also discuss the role of imaging in the staging, management, and surveillance of EOC.

18F-FDG PET/CT in ovarian cancer recurrence: Clinical impact, correlation with ceCT and CA-125, and prognostic value

AIM

To evaluate ¹⁸F-FDG-PET/CT for suspected ovarian cancer relapse with negative/inconclusive conventional imaging, or restaging potentially resectable ovarian cancer relapse.

MATERIAL AND METHODS

Thirty-six cases and 140 locations were studied. PET/CT, ceCT and serum CA-125 was conducted in all cases. Nineteen cases were requested for restaging, 17 for suspected relapse. We compared ceCT and PET/CT, assessed by histopathology or radiological follow-up, calculating sensitivity (S) and positive predictive value (PPV) by cases and lesions. We evaluated the correlation between size, number, uptake of the lesions and CA-125. We conducted survival analysis, using ROC curves to calculate the optimal cut-off of SUVmax for survival prediction. We checked whether PET/CT modify the therapeutic attitude vs. conventional imaging.

RESULTS

PET/CT and ceCT were concordant in 12 cases: 11 positives (30 lesions), all confirmed. There was 1 FN. In the 24 non-concordant, PET/CT was positive in 19 (97 lesions); ceCT in 21 (59 lesions); 54% of the lesions were concordant. Overall, PET/CT detected 127 lesions, with S = 97% and PPV = 100%. ceCT detected 89 lesions, with S = 61% and PPV = 90%. No significant correlation was found between CA-125 and the other parameters. PET/CT detected 10 positive cases, with normal CA-125. PET/CT modified therapeutic management in 15 cases. Significant differences were found in survival with SUVmax = 11.8 CONCLUSIONS: PET/CT plays an important role in ovarian cancer relapse, with sensitivity and PPV higher than ceCT, modified therapeutic management in up to 42% of cases, and could be a valuable tool for predicting survival.

18F-FDG PET/CT in ovarian cancer recurrence: Clinical impact, correlation with ceCT and CA-125, and prognostic value

AIM

To evaluate ¹⁸F-FDG-PET/CT for suspected ovarian cancer relapse with negative/inconclusive conventional imaging, or restaging potentially resectable ovarian cancer relapse.

MATERIAL AND METHODS

Thirty-six cases and 140 locations were studied. PET/CT, ceCT and serum CA-125 was conducted in all cases. Nineteen cases were requested for restaging, 17 for suspected relapse. We compared ceCT and PET/CT, assessed by histopathology or radiological follow-up, calculating sensitivity (S) and positive predictive value (PPV) by cases and lesions. We evaluated the correlation between size, number, uptake of the lesions and CA-125. We conducted survival analysis, using ROC curves to calculate the optimal cut-off of SUVmax for survival prediction. We checked whether PET/CT modify the therapeutic attitude vs. conventional imaging.

RESULTS

PET/CT and ceCT were concordant in 12 cases: 11 positives (30 lesions), all confirmed. There was 1 FN. In the 24 non-concordant, PET/CT was positive in 19 (97 lesions); ceCT in 21 (59 lesions); 54% of the lesions were concordant. Overall, PET/CT detected 127 lesions, with S=97% and PPV=100%. ceCT detected 89 lesions, with S=61% and PPV=90%. No significant correlation was found between CA-125 and the other parameters. PET/CT detected 10 positive cases, with normal CA-125. PET/CT modified therapeutic management in 15 cases. Significant differences were found in survival with SUVmax=11.8 CONCLUSIONS: PET/CT plays an important role in ovarian cancer relapse, with sensitivity and PPV higher than ceCT, modified therapeutic management in up to 42% of cases, and could be a valuable tool for predicting survival.