Diagnostic and prognostic evaluation of fluorodeoxyglucose positron emission tomography/computed tomography and its correlation with serum cancer antigen-125 (CA125) in a large cohort of ovarian cancer patients

Do PET-positive supradiaphragmatic lymph nodes predict overall survival or the success of primary surgery in patients with advanced ovarian cancer?

OBJECTIVES

Compared to conventional computed tomography (CT), fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) detects higher rates of lymph node and distant metastases in patients with ovarian cancer. However, FDG-PET/CT is not routinely performed during preoperative work-up. Therefore, we investigated the prognostic value of preoperative FDG-PET/CT in advanced epithelial ovarian cancer (EOC) and its predictive value for surgical resection in patients with no residual disease. The potential significance of PET-positive supradiaphragmatic lymph nodes (SDLNs) for these parameters was evaluated.

METHODS

All patients with FIGO IIA-IVB EOC diagnosed between March 2014 and January 2021 at our certified gynaecological cancer centre, who underwent FDG PET/CT before primary surgery were retrospectively included.

RESULTS

Fifty-three consecutive patients were included in the study. Eighteen (34 %) patients had PET-positive SDLNs. We could not demonstrate a significant correlation between PET-positive SDLNs and median overall survival (OS; SDLN-positive: 58.76 months, SDLN-negative: 60.76 months; p = 0.137) or intra- or perioperative outcomes.

CONCLUSIONS

FDG PET/CT has a higher detection rate for SDLNs in patients with ovarian cancer than CT has, as described in the literature. Moreover, PET-positive SDLNs failed to predict intraoperative outcomes or overall survival.

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.

Evaluation of patients with advanced epithelial ovarian cancer before primary treatment: correlation between tumour burden assessed by [18F]FDG PET/CT volumetric parameters and tumour markers HE4 and CA125

OBJECTIVES

Accurate assessment of disease extent is required to select the best primary treatment for advanced epithelial ovarian cancer patients. Estimation of tumour burden is challenging and it is usually performed by means of a surgical procedure. Imaging techniques and tumour markers can help to estimate tumour burden non-invasively. 2-[¹⁸F]FDG PET/CT allows the evaluation of the whole-body disease. This study aimed to correlate HE4 and CA125 serum concentrations with tumour burden evaluated by volumetric 2-[¹⁸F]FDG PET/CT parameters in advanced high-grade epithelial ovarian cancer.

METHODS

We included 66 patients who underwent 2-[¹⁸F]FDG PET/CT and serum tumour markers determination before primary treatment. Volumes of interest were delimited in every pathological uptake. Whole-body metabolic tumour volume (wb_MTV) and total lesion glycolysis (wb_TLG) were calculated summing up every VOI's MTV value. SUVmax thresholds were set at 40% (MTV40 and TLG40) and 50% (MTV50 and TLG50). In addition, four VOI subgroups were defined: peritoneal carcinomatosis, retroperitoneal nodes, supradiaphragmatic nodes, and distant metastases. MTV and TLG were calculated for each group by adding up the corresponding MTV values. TLG was calculated likewise.

RESULTS

wb_MTV and wb_TLG were found to be significantly correlated with serum CA125 and HE4 concentrations. The strongest correlation was observed between HE4 and wb_MTV40 (r = 0.62, p < 0.001). Pearson's correlation coefficients between peritoneal carcinomatosis MTV40 and tumour markers were 0.61 (p < 0.0001) and 0.29 (p = 0.02) for HE4 and CA125 respectively. None of these tumour markers showed a positive correlation with tumour load outside the abdominal cavity assessed by volumetric parameters.

CONCLUSION

HE4 performs better than CA125 to predict metabolic tumour burden in high-grade epithelial ovarian cancer before primary treatment. 2-[18F]FDG PET/CT volumetric parameters arise as feasible tools for the objective assessment of tumour load and its anatomical distribution. These results support the usefulness of HE4 and PET/CT to improve the stratification of these patients in clinical practice.

KEY POINTS

• In patients with high-grade advanced ovarian epithelial carcinoma, both CA125 and HE4 correlate to whole-body tumour burden assessed by PET/CT before primary treatment. • HE4 estimates peritoneal disease much better than CA125. • PET/CT volumetric parameters arise as feasible tools for the objective assessment of tumour load and its anatomical distribution.

EANM guideline on the role of 2-[18F]FDG PET/CT in diagnosis, staging, prognostic value, therapy assessment and restaging of ovarian cancer, endorsed by the American College of Nuclear Medicine (ACNM), the Society of Nuclear Medicine and Molecular Imaging (SNMMI) and the International Atomic Energy Agency (IAEA)

In most patients with ovarian carcinoma, the diagnosis is reached when the disease is long past the initial stages, presenting already an advanced stage, and they usually have a very bad prognosis. Cytoreductive or debulking surgical procedures, platinum-based chemotherapy and targeted agents are key therapeutic elements. However, around 7 out of 10 patients present recurrent disease within 36 months from the initial diagnosis. The metastatic spread in ovarian cancer follows three pathways: contiguous dissemination across the peritoneum, dissemination through the lymphatic drainage and, although less importantly in this case, through the bloodstream. Radiological imaging, including ultrasound, CT and MRI, are the main imaging techniques in which management decisions are supported, CT being considered the best available technique for presurgical evaluation and staging purposes. Regarding 2-[¹⁸F]FDG PET/CT, the evidence available in the literature demonstrates efficacy in primary detection, disease staging and establishing the prognosis and especially for relapse detection. There is limited evidence when considering the evaluation of therapeutic response. This guideline summarizes the level of evidence and grade of recommendation for the clinical indications of 2-[¹⁸F]FDG PET/CT in each disease stage of ovarian carcinoma.

A Comparative Study between 18F-FDG PET/CT and Conventional Imaging in the Evaluation of Progressive Disease and Recurrence in Ovarian Carcinoma

The aim of this study is to compare the efficiency of conventional imaging and 18F-FDG PET-CT in detecting progressive disease and recurrences over a period of one year (2018), in the case of ovarian cancer, and also to assess the importance of 18F-FDG PET/CT in changing the course of the treatment for these patients. This study included 29 patients diagnosed in various stages with ovarian carcinoma, most of them of epithelial origin. All patients were evaluated throughout their treatment using 18F-FDG PET/CT and various conventional techniques (computed tomography (CT), magnetic resonance imaging (MRI), abdominal and intravaginal ultrasound, chest X-ray). PET/CT was more useful and effective in our group of patients in detecting progressive disease compared with conventional imaging (37.93% vs. 17.24%) and also in establishing the recurrences (24.14% vs. 6.90%). Moreover, F18-FDG PET-CT led to a therapeutic change in 55.17% of the patients of our group, compared with only 17.24% after conventional imaging. This underlines the crucial aspect of the metabolic changes of tumors that should be assessed alongside the morphological ones, with PET-CT imaging remaining the only viable tool for achieving that at present. PET/CT with 18F-FDG represents one of the most important imaging techniques used in the diagnosis and management of ovarian carcinoma. Our results seem to fall in line with what other authors reported, indicating that 18F-FDG PET-CT is potentially gaining more ground in the management of ovarian carcinoma, by influencing therapeutic strategies and by being able to detect relapse and progression accurately.

Diagnostic performance of PET/CT and PET/MR in the management of ovarian carcinoma-a literature review

Ovarian cancer is a challenging disease. It often presents at an advanced stage with frequent recurrence despite optimal management. Accurate staging and restaging are critical for improving treatment outcomes and determining the prognosis. Imaging is an indispensable component of ovarian cancer management. Hybrid imaging modalities, including positron emission tomography/computed tomography (PET/CT) and PET/magnetic resonance imaging (MRI), are emerging as potential non-invasive imaging tools for improved management of ovarian cancer. This review article discusses the role of PET/CT and PET/MRI in ovarian cancer.

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.

Value of [18F]FDG-PET/CT and CA125, serum levels and kinetic parameters, in early detection of ovarian cancer recurrence: Influence of histological subtypes and tumor stages

To assess the diagnostic accuracy of CA125, its kinetic values and positron emission tomography/computed tomography with 2-deoxy-2-[F]fluoro-D-glucose ([F]FDG-PET/CT), in relation with tumor characteristics for suspected recurrence of ovarian cancer. To evaluate the performance of CA125-related parameters as a selection criteria to perform a [F]FDG-PET/CT.A retrospective analysis of 69 [F]FDG-PET/CT for suspected recurrence of ovarian cancer was performed. All patients had 2 measurements of CA125, before PET/CT, to calculate kinetic values, as CA125vel (CA125vel = [CA125a - CA125b]/time) and CA125dt (CA125dt = [log2 × time]/[logCA125a - CA125b]). Maximum standard uptake value (SUVmax) was calculated. The diagnostic accuracy was calculated for all the variables and the optimal cut-off value of each of them by the receiver-operating characteristics (ROC) analysis. All the tests were compared with tumor characteristics and clinical-radiological evolution during follow-up of at least 6 months.Fifty-five cases were diagnosed of recurrence (11 with CA125 <35 U/mL), while 14 showed no disease (11 with CA125 < 35 U/mL). All of them were correctly cataloged by PET/CT. CA125, CA125vel, and SUVmax showed higher levels in recurrent patients (mean 129.54 U/mL, 24.58 U/mL per mo, and 8.69 g/mL, respectively) than in nonrecurrent (mean 20.35 U/mL, 0.60 U/mL per mo, and 0.64 g/mL, respectively). No statistical differences in CA125dt were found. Patients with recurrence of high-grade serous carcinoma (HGSC) showed higher CA125 and CA125vel, without differences in the rest of subtypes and International Federation of Gynecology and Obstetrics stages. The ROC analyses for CA125, CA125vel, and CA125dt showed an area under the curve (AUC) of 0.873 (95% confidence interval [CI] 0.77-0.969), 0.903 (95% CI 0.813-0.994), and 0.727 (95% CI 0.542-0.913), respectively, with an optimal cut-off point of 23.95 U/mL, 4.49 U/mL per mo, and 3.36 months, respectively, while for the SUVmax the AUC was of 0.982 (95% CI 0.948-1.000), and the cut-off point of 2. Multivariate regression analysis identified CA125 and CA125vel as predictors of recurrence.[F]FDG-PET/CT is more accurate than the parameters obtained from the CA125 to detect early recurrence. CA125vel is the most suitable parameter, mainly in HGSC. Levels of CA125vel ≥ 4.49 U/mL per mo facilitate earlier detection by the execution of a [F]FDG-PET/CT. The calculation of these parameters is independent of tumor stage at diagnosis.

Fludeoxyglucose F 18 PET/CT Assessment of Ovarian Cancer

Ovarian cancer is one of the most common gynecologic cancers and one of the leading causes of cancer death in women. It is often asymptomatic in early stages, and thus most patients are diagnosed when it is of advanced stage. For these reasons, the role of biomarkers and tomographic imaging is crucial. Fludeoxyglucose F 18 PET/CT is a useful imaging modality in different clinical settings of the disease, overcoming some limits of conventional imaging and influencing prognosis and therapeutic approaches. PET/MR imaging is an emerging modality, and its potential role remains to be explored.

Systematic Review on the Accuracy of Positron Emission Tomography/Computed Tomography and Positron Emission Tomography/Magnetic Resonance Imaging in the Management of Ovarian Cancer: Is Functional Information Really Needed?

Ovarian cancer (OC) often presents at an advanced stage with frequent relapses despite optimal treatment; thus, accurate staging and restaging are required for improving treatment outcomes and prognostication. Conventionally, staging of OC is performed using contrast-enhanced computed tomography (CT). Nevertheless, recent advances in the field of hybrid imaging have made positron emission tomography/CT (PET/CT) and PET/magnetic resonance imaging (PET/MRI) as emerging potential noninvasive imaging tools for improved management of OC. Several studies have championed the role of PET/CT for the detection of recurrence and prognostication of OC. We provide a systematic review and meta-analysis of the latest publications regarding the role of molecular imaging in the management of OC. We retrieved 57 original research articles with one article having overlap in both diagnosis and staging; 10 articles (734 patients) regarding the role of PET/CT in diagnosis of OC; 12 articles (604 patients) regarding staging of OC; 22 studies (1429 patients) for detection of recurrence; and 13 articles for prognostication and assessment of treatment response. We calculated pooled sensitivity and specificity of PET/CT performance in various aspects of imaging of OC. We also discussed the emerging role of PET/MRI in the management of OC. We aim to give the readers and objective overview on the role of molecular imaging in the management of OC.

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.