Computer tomography, magnetic resonance imaging, and positron emission tomography or positron emission tomography/computer tomography for detection of metastatic lymph nodes in patients with ovarian cancer: A meta-analysis

Magnetic resonance imaging at ultra-high magnetic field strength: An in vivo assessment of number, size and distribution of pelvic lymph nodes

Objective

The definition of an in vivo nodal anatomical baseline is crucial for validation of representative lymph node dissections and accompanying pathology reports of pelvic cancers, as well as for assessing a potential therapeutic effect of extended lymph node dissections. Therefore the number, size and distribution of lymph nodes in the pelvis were assessed with high-resolution, large field-of-view, 7 Tesla (T) magnetic resonance imaging (MRI) with frequency-selective excitation.

Materials and methods

We used 7 T MRI for homogeneous pelvic imaging in 11 young healthy volunteers. Frequency-selective imaging of water and lipids was performed to detect nodal structures in the pelvis. Number and size of detected nodes was measured and size distribution per region was assessed. An average volunteer-normalized nodal size distribution was determined.

Results

In total, 564 lymph nodes were detected in six pelvic regions. Mean number was 51.3 with a wide range of 19–91 lymph nodes per volunteer. Mean diameter was 2.3 mm with a range of 1 to 7 mm. 69% Was 2 mm or smaller. The overall size distribution was very similar to the average volunteer-normalized nodal size distribution.

Conclusions

The amount of in vivo visible lymph nodes varies largely between subjects, whereas the normalized size distribution of nodes does not. The presence of many small lymph nodes (≤2mm) renders representative or complete removal of pelvic lymph nodes to be very difficult. 7T MRI may shift the in vivo detection limits of lymph node metastases in the future.

Apparent Diffusion Coefficient Histogram Analysis for Assessing Tumor Staging and Detection of Lymph Node Metastasis in Epithelial Ovarian Cancer: Correlation with p53 and Ki-67 Expression

PURPOSE

To investigate the potential of apparent diffusion coefficient (ADC) histogram parameters in epithelial ovarian cancer (EOC) for distinguishing different tumor stages and determining lymph node status and correlations between ADC values and p53 and Ki-67 expression.

PROCEDURES

Forty-nine EOC patients underwent preoperative magnetic resonance imaging. Staging and lymph node status were determined postoperatively. ADC values were measured using histogram analysis and compared between groups. Relationships between ADCs and Ki-67 and p53 expression were explored.

RESULTS

DC parameters differed significantly between stage I vs II, I vs III, and I vs IV. The parameters were significantly lower in the lymph node-positive group than in the lymph node-negative group, were significantly negatively correlated with Ki-67 labeling index, and were all significantly lower in the mutation-type p53 group than in the wild-type p53 group.

CONCLUSIONS

ADC histogram analysis can help discriminate stage I from advanced-stage EOC and predict lymph node metastasis. ADC parameters were correlated with Ki-67 labeling index; the parameters may help indicate p53 expression.

Preoperative PET/CT score can predict complete resection in advanced epithelial ovarian cancer: a prospective study

Background

To assess the ability of preoperative positron emission tomography/computed tomography (PET/CT) scans to predict postoperative residual disease in advanced epithelial ovarian cancer (AEOC).

Methods

Thirty-one women with suspected AEOC were enrolled in our prospective study before surgery from July 2016 to December 2017. Complete resection was determined as no residual disease (R0) after surgery. A PET/CT scan was obtained within 2 weeks before surgery in our hospital. The PET score was the sum of each score of the radiological criteria from Suidan's model. The correlations between the PET score and tumor burden and surgical complexity were evaluated by Pearson correlation analysis. T-test or Fisher's exact test was used to compare differences in the variables between the complete and incomplete resection groups. Receiver operating characteristic (ROC) curve analysis was performed to assess the accuracy of the PET score for predicting complete postoperative resection.

Results

The median [range] of PET score was 2 [0-8], and the PET score in 20 (65%) patients was less than 3. Complete resection was achieved in 11 (35.5%) patients after surgery, including 10 (90.91%) with low PET scores and only 1 (9.09%) with a high score. The PET score had a significant positive correlation with tumor burden [Eisenkop: r=0.603, P<0.001; peritoneal cancer index (PCI): r=0.522, P=0.003] but not with surgery complexity (Aletti: r=0.291, P=0.113). Patients with lower PET scores (P=0.046) and tumor burdens (Eisenkop: P=0.013; PCI: P=0.012) had higher rates of complete resection. The PET score and tumor burden were effective for predicting complete resection. The AUC_PET, AUC_Eisenkop, and AUC_PCI were 0.797 (95% CI: 0.633-0.961, P=0.01), 0.847 (95% CI: 0.707-0.988, P=0.003), and 0.811 (95% CI: 0.653-0.969, P=0.007), respectively. However, surgery complexity was not useful for assessing complete resection.

Conclusions

The preoperative PET score can noninvasively reflect tumor burden and helps predict complete resection after surgery in AEOC patients.

Cardiac amyloidosis imaging with amyloid positron emission tomography: A systematic review and meta-analysis

BACKGROUND

Recent progress in amyloid positron emission tomography (PET) has enabled the targeted imaging of cardiac amyloidosis with accuracy. We performed a systematic review and meta-analysis on the diagnostic performance of cardiac amyloidosis using amyloid PET.

METHODS

A systematic search was performed using key words: cardiac amyloidosis, amyloid, and PET. We estimated the pooled sensitivity, specificity, positive and negative likelihood ratio (LR), and diagnostic odds ratio (DOR). Furthermore, the semiquantitative parameters of PET were evaluated to diagnose cardiac amyloidosis and discern its type [systemic light chain amyloidosis (AL) vs transthyretin amyloidosis (ATTR)] using the pooled standardized mean difference (SMD).

RESULTS

In total, six eligible studies with a total of 98 subjects were included in this meta-analysis. The pooled sensitivity was 0.95, the specificity was 0.98, positive LR was 10.130, negative LR was 0.1, and DOR was 148.83. The semiquantitative parameters of amyloid PET showed significantly higher values for cardiac amyloidosis patients than those for controls (pooled SMD = 1.42; P < .001), and in AL than ATTR (pooled SMD = 0.96; P < .001).

CONCLUSION

Amyloid PET imaging can be a useful method for diagnosing cardiac amyloidosis. The semiquantitative parameters of amyloid PET can help diagnose cardiac amyloidosis and discern its type.

Sentinel-node biopsy in early stage ovarian cancer: a prospective multicentre study (SELLY)

BACKGROUND

Systematic para-aortic and bilateral pelvic lymphadenectomy is included in the standard comprehensive surgical staging in presumed early epithelial ovarian cancer. No prospective randomized evidence suggests it has potential therapeutic value, and related morbidity is not negligible.

PRIMARY OBJECTIVES

To assess sensitivity, safety, and feasibility of the sentinel lymph node technique in identifying the presence of lymph node metastases in patients with early stage epithelial ovarian cancer.

STUDY HYPOTHESIS

Sentinel lymph node detection with indocyanine green can accurately predict nodal status in a cohort of women with early stage epithelial ovarian cancer.

TRIAL DESIGN

The SELLY trial is a prospective phase II interventional multicenter study.

MAJOR INCLUSION/EXCLUSION CRITERIA

Inclusion criteria: Eastern Cooperative Oncology Group 0-1, apparent International Federation of Gynecology and Obstetrics (FIGO) stage I-II, histologically proven epithelial ovarian cancer.

EXCLUSION CRITERIA

evidence of carcinomatosis, mucinous only at definitive histology.

ENDPOINTS

Primary endpoint is sensitivity (true positive rate). Secondary endpoints include safety (complications rate of the procedure) and feasibility.

SAMPLE SIZE

Assuming a sensitivity of 98.5% in predicting positive sentinel lymph nodes at histology, a pathological lymph node prevalence of 14.2%, a precision of estimate (ie, the maximum marginal error) d=5%, and a type I error α=0.05, a sample size of 160 patients is needed to test the general hypothesis (ie, to answer whether sentinel lymph nodes identified with indocyanine green can accurately predict nodal status at histology of patients with apparently early epithelial ovarian cancer). Assuming a drop-out rate of 10%, a total of 176 patients will be enrolled in the study.

ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS

The accrual should be completed by December 2020 and results should be presented by March 2021.

TRIAL REGISTRATION

The trial is registered at clinicaltrials.gov (NCT03563781).

PET/MR Imaging of the Female Pelvis

High-quality imaging diagnostics play a fundamental role in patient and therapy management of cancers of the female pelvis. Magnetic resonance imaging (MRI) and positron emission tomography (PET) represent two important imaging modalities, which are frequently applied for primary tumor evaluation, therapy monitoring, and assessment of potential tumor relapse. Based on its high soft-tissue contrast, MRI has been shown superior toward CT for the determination of the local extent of primary tumors and for the differentiation between post-therapeutic changes and tumor relapse. Molecular imaging utilizing ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) PET facilitates an insight into tumor metabolism depending on the glycolytic activity of tumorous cells. As the current gold standard of hybrid imaging, ¹⁸F-FDG-PET/CT has been demonstrated highly accurate and superior to conventional imaging modalities for the detection of tumorous tissue due to the combined analysis of metabolic and morphologic data. Therefore, ¹⁸F-FDG-PET has emerged to become a well-established imaging modality for the detection, re-/staging and therapy response monitoring of a variety of solid tumors, including gynecologic cancers. Integrated PET/MRI systems have been successfully introduced into scientific and clinical applications within the past 8 years. This new-generation hybrid imaging technology enables the simultaneous acquisition of PET- and MR Datasets, providing complementary metabolic, functional, and morphologic information of tumorous tissue. Combining the high soft-tissue contrast of MRI and the metabolic information derived from PET, PET/MRI bears the potential to be utilized as an accurate and efficient diagnostic tool for primary tumor staging, therapy monitoring and restaging of tumors of the female pelvis and plays a valuable role in the management of targeted tumor therapies in the future.

Sentinel-node biopsy in early-stage ovarian cancer: preliminary results of a prospective multicentre study (SELLY)

BACKGROUND

Systematic paraaortic and bilateral pelvic lymphadenectomy is the standard of a comprehensive surgical staging in presumed early epithelial ovarian cancer, but no prospective randomized evidence suggests a possible therapeutic value. Moreover, this procedure is associated with potential severe morbidity. The Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial is a prospective study designed to test whether sentinel node detection can accurately predict nodal status in a cohort of women with early epithelial ovarian cancer.

OBJECTIVES

We here present the results of the first part of the Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial, regarding the feasibility of the sentinel lymph node technique and the preliminary findings regarding its safety and accuracy.

STUDY DESIGN

The Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial is a prospective, phase II, single-arm study included patients with presumed stages I-II epithelial ovarian cancer planned for immediate or delayed minimally invasive comprehensive staging. The ovarian pedicle is injected with 2 mL of a 1.25 mg/mL indocyanine green solution. The pelvic and lumboaortic retroperitoneum is then accessed and inspected to identify and remove sentinel nodes. After sentinel node procedure, staging is completed including systematic pelvic and paraaortic lymphadenectomy. Assuming a sensitivity of 98.5% in predicting positive sentinel lymph nodes at histology, a pathological lymph node prevalence of 14.2%, a precision of estimate (ie, the maximum marginal error) d = 5%, a type I error α = 0.05, a sample size of 160 patients is needed to test the general hypothesis. Here we present the preliminary results on the first 31 patients enrolled.

RESULTS

Thirty-one patients were included. Sentinel node was identified in 21 patients (detection rate, 67.7%). The detection rate was significantly higher in women undergoing immediate vs delayed staging (88.9% vs 41.7%, P = .003). Four patients had positive nodes. In all the patients with lymphatic dissemination, a positive sentinel node was identified (sensitivity, 100%; false-negative rate, 0%; negative predictive value, 100%). One (3.2%) intra- and 2 (6.5%) postoperative grade I complications occurred.

CONCLUSION

Our data show that the detection of sentinel node in early epithelial ovarian cancer is low when patients are submitted to delayed-staging surgery. However, sentinel node procedure is feasible and has the potential to provide reliable and useful information on nodal status and may allow the avoidance of systematic lymphadenectomy in the majority of patients.

The diagnostic performance of PET/CT scans for the detection of para-aortic metastatic lymph nodes in patients with cervical cancer: A meta-analysis

Objective

We performed a meta-analysis to evaluate the diagnostic value of positron emission tomography/computed tomography (PET/CT) in the detection of para-aortic lymph node metastasis in cervical cancer.

Methods

We searched the PubMed, Embase, Web of Science, Cochrane Library, Chinese Biological Medicine (CBM), Chinese National Knowledge Infrastructure (CNKI), Wanfang and VIP databases in all languages from their inception to September 2018. Stat15.0 software was used to obtain pooled estimates of sensitivity (SEN), specificity (SPE), positive likelihood ratio (PLR), and negative likelihood ratio (NLR) as well as a summary receiver operating characteristic (SROC) curves. Deek‘s funnel plot was used to assess publication bias. QUADAS-2 was used to evaluate the quality of the studies. The protocol for this meta-analysis is registered in PROSPERO (CRD42019115330).

Results

We obtained 14 studies, and the pooled estimates for sensitivity and specificity of PET/CT were 0.71 (95% confidence interval (CI) = 0.54–0.83) and 0.97 (95% CI = 0.93–0.98), respectively. Pooled PLR and NLR were 21.53 and 0.30, respectively. The diagnostic odds ratio (DOR) was70.59, and the area under the curve (AUC) was 0.95.

Conclusion

PET/CT is an effective and important imaging method for the diagnosis of para-aortic lymph node metastasis in early cervical cancer.

Performance of pre-treatment ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography for detecting metastasis in ovarian cancer: a systematic review and meta-analysis

OBJECTIVE

We describe a systematic review and meta-analysis of the performance of ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) for detecting metastasis in ovarian cancer.

METHODS

MEDLINE and Embase were searched for diagnostic accuracy studies that used ¹⁸F-FDG PET or PET/CT for pre-treatment staging, using surgical findings as the reference standard. Sensitivities and specificities were pooled and plotted in a hierarchic summary receiver operating characteristic plot. Potential causes of heterogeneity were explored through sensitivity analyses.

RESULTS

Eight studies with 594 patients were included. The overall pooled sensitivity and specificity for metastasis were 0.72 (95% confidence interval [CI]=0.61-0.81) and 0.93 (95% CI=0.85-0.97), respectively. There was considerable heterogeneity in sensitivity (I²=97.57%) and specificity (I²=96.74%). In sensitivity analyses, studies that used laparotomy as the reference standard showed significantly higher sensitivity and specificity (0.77; 95% CI=0.67-0.87 and 0.96; 95% CI=0.92-0.99, respectively) than those including diagnostic laparoscopy (0.62; 95% CI=0.46-0.77 and 0.84; 95% CI=0.69-0.99, respectively). Higher specificity was shown in studies that confirmed surgical findings by pathologic evaluation (0.95; 95% CI=0.90-0.99) than in a study without pathologic confirmation (0.69; 95% CI=0.24-1.00). Studies with a lower prevalence of the FDG-avid subtype showed higher specificity (0.97; 95% CI=0.94-1.00) than those with a greater prevalence (0.89; 95% CI=0.80-0.97).

CONCLUSION

Pre-treatment ¹⁸F-FDG PET/CT shows moderate sensitivity and high specificity for detecting metastasis in ovarian cancer. With its low false-positive rate, it can help select surgical approaches or alternative treatment options.

The role of sentinel node in early ovarian cancer: a systematic review

INTRODUCTION

Early ovarian cancer (EOC) is defined as ovarian cancer macroscopically limited to the ovaries at the time of initial diagnosis. Approximately only 25% of patients with ovarian cancer are affected by EOC. This condition requires complete surgical staging, including systematic lymphadenectomy up to the level of the renal vessels, with the consequent risk of complications and morbidity. With the aim to reduce the procedure-related morbidity, sentinel lymph node mapping (SLNm) has been introduced as an experimental procedure in EOC staging. The aim of the present study is to systematically review the available series on this interesting issue.

EVIDENCE ACQUISITION

Studies were identified by searching electronic databases. The search was systematically applied to PubMed, ClinicalTrials.gov, Scopus and Web of Science looking for records describing the use of sentinel lymph node technique in EOC from January 1st, 1989 to January 1st, 2019. A total of 10 studies were identified for inclusion. Of the 121 patients involved in these studies, only 43 had a histologically-confirmed diagnosis of EOC and were included in the present analysis.

EVIDENCE SYNTHESIS

SLN (paraaortic and/or pelvic) overall detection rate (DR) was of 97.6%. The overall sensitivity (SS) and negative predictive value (NPV) of the included cases were 66.7% and 96.6%, respectively. We calculated also NPV, SS and DR based on the anatomical lymph node district, with a value of 100% both in the lumbo-aortic and in the pelvic district and a DR of 83.3% and 43% respectively.

CONCLUSIONS

This review shows that evidence on SLNm in EOC is still scant. Based on the limited data available, SLNm may provide potentially useful information on nodal status in patients affected by this disease.

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.

The Role of 18F-FDG PET/CT in Detecting Ovarian Cancer Recurrence in Patients with Elevated CA-125 Levels

Objectives:

To investigate the role of ¹⁸F-FDG positron emission tomography/computed tomography (PET/CT) in detection of recurrence in ovarian cancer patients with increased CA-125 levels.

Methods:

Fifty-two patients (30-80 years old, mean: 58.5±10.6 years) who had been histopathologically diagnosed with ovarian cancer, underwent ¹⁸F-FDG PET/CT imaging for re-staging due to elevation of CA-125 levels were included in this retrospective study. ¹⁸F-FDG PET/CT findings were compared with histopathological, radiological and clinical follow-up results.

Results:

CA-125 levels ranged between 35.2-2740 U/mL (N: 0-35 U/mL). Recurrent disease was detected in 45 of 52 patients on PET/CT imaging. There were three false negative and one false positive result. In addition to abdominal and pelvic lesions, 14 distant metastatic lesions (brain, lung, liver and bone metastasis) were identified correctly on PET/CT imaging. Sensitivity, specificity, positive and negative predictive value and accuracy of ¹⁸F-FDG PET/CT were calculated as 94%, 75%, 98%, 50% and 96%, respectively.

Conclusion:

¹⁸F-FDG PET/CT is a useful imaging method that can be used in detection of ovarian cancer recurrence in patients with elevated CA-125 levels. Since this modality offers whole body imaging, distant metastases could be detected in addition to abdominal and pelvic lesions thus contributing to patient management.

Imaging for Peritoneal Metastases

MRI provides considerable advantages for imaging of patients with peritoneal tumor. Its inherently superior contrast resolution compared with computed tomography allows MRI to more accurately depict small peritoneal tumors that are often missed on other imaging tests. Combining different contrast mechanisms, including diffusion-weighted MRI and gadolinium-enhanced MRI, provides a powerful tool for preoperative and surveillance imaging in patients being considered for cytoreductive surgery and heated intraperitoneal chemotherapy.

The Prognostic Value of 18F-FDG PET/CT in Monitoring Chemotherapy in Ovarian Cancer Both at Initial Diagnosis and at Recurrent Disease

Published experiences related to the prognostic relevance of negative or positive FDG PET/CT in patients treated for ovarian cancer for progression-free survival and overall survival are typically heterogeneous retrospective analyses. Several points have been well defined, these are as follows: (a) there is a correlation between FDG tumor uptake and prognosis; (b) ovarian cancer patients treated by neoadjuvant or adjuvant chemotherapy can be divided into responders with reduction in tumor FDG uptake during and after treatment and nonresponders where tumor FDG uptake remains stable or increases after treatment;

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.

Molecular Imaging and Precision Medicine in Uterine and Ovarian Cancers

Gynecologic cancer is a heterogeneous group of diseases both functionally and morphologically. Today, PET coupled with computed tomography (PET/CT) or PET/MR imaging play a central role in the precision medicine algorithm of patients with gynecologic malignancy. In particular, PET/CT and PET/MR imaging are molecular imaging techniques that not only are useful tools for initial staging and restaging but provide anatomofunctional insight and can serve as predictive and prognostic biomarkers of response in patients with gynecologic malignancy.

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.

Heterogeneity in Cancer Metabolism: New Concepts in an Old Field

SIGNIFICANCE

In the last years, metabolic reprogramming, fluctuations in bioenergetic fuels, and modulation of oxidative stress became new key hallmarks of tumor development. In cancer, elevated glucose uptake and high glycolytic rate, as a source of adenosine triphosphate, constitute a growth advantage for tumors. This represents the universally known Warburg effect, which gave rise to one major clinical application for detecting cancer cells using glucose analogs: the positron emission tomography scan imaging. Recent Advances: Glucose utilization and carbon sources in tumors are much more heterogeneous than initially thought. Indeed, new studies emerged and revealed a dual capacity of tumor cells for glycolytic and oxidative phosphorylation (OXPHOS) metabolism. OXPHOS metabolism, which relies predominantly on mitochondrial respiration, exhibits fine-tuned regulation of respiratory chain complexes and enhanced antioxidant response or detoxification capacity.

CRITICAL ISSUES

OXPHOS-dependent cancer cells use alternative oxidizable substrates, such as glutamine and fatty acids. The diversity of carbon substrates fueling neoplastic cells is indicative of metabolic heterogeneity, even within tumors sharing the same clinical diagnosis. Metabolic switch supports cancer cell stemness and their bioenergy-consuming functions, such as proliferation, survival, migration, and invasion. Moreover, reactive oxygen species-induced mitochondrial metabolism and nutrient availability are important for interaction with tumor microenvironment components. Carcinoma-associated fibroblasts and immune cells participate in the metabolic interplay with neoplastic cells. They collectively adapt in a dynamic manner to the metabolic needs of cancer cells, thus participating in tumorigenesis and resistance to treatments.

FUTURE DIRECTIONS

Characterizing the reciprocal metabolic interplay between stromal, immune, and neoplastic cells will provide a better understanding of treatment resistance. Antioxid. Redox Signal. 26, 462-485.

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.

Applications of PET/MR Imaging in Urogynecologic and Genitourinary Cancers

Positron emission tomograph (PET)-magnetic resonance (MR) is a new modality combining PET and MR. In gynecologic cancers it can be used for staging of cervical and endometrial cancer, planning of radiation therapy in cervical cancer, assessing response to chemotherapy in ovarian cancer, and detection of recurrence in most gynecologic cancers. It is being explored for prostate cancer and other genitourinary cancers, but is still in experimental stages.

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.

18F-FDG positron emission tomography in oncology: main indications

The development of molecular and functional imaging with new imaging techniques such as computed tomography, magnetic resonance imaging, and positron emission tomography (PET) among others, has greatly improved the detection of tumors, tumor staging, and the detection of possible recurrences. Furthermore, the combination of these different imaging modalities and the continual development of radiotracers for PET have advanced our understanding and knowledge of the different pathophysiological processes in cancer, thereby helping to make treatment more efficacious, improving patients' quality of life, and increasing survival. PET is one of the imaging techniques that has attracted the most interest in recent years for its diagnostic capabilities. Its ability to anatomically locate pathologic foci of metabolic activity has revolutionized the detection and staging of many tumors, exponentially broadening its potential indications not only in oncology but also in other fields such as cardiology, neurology, and inflammatory and infectious diseases.

Revised FIGO staging system for cancer of the ovary, fallopian tube, and peritoneum: important implications for radiologists

Ovarian cancer is the seventh most common cancer diagnosis among women worldwide. The International Federation of Gynecology and Obstetrics recently significantly revised staging criteria for cancer of the ovary. The latest revision was based on the concept that high-grade serous tubal intraepithelial carcinoma (STIC) may be the origin of some high-grade serous carcinomas of the ovary and peritoneum. Therefore, staging criteria for the ovary, fallopian tube, and peritoneum have been unified. Understanding this background and other important revised points are essential for radiologists concerned with imaging diagnosis in gynecologic oncology. Through this review, we introduce the STIC theory and show examples of diseases in accordance with the new staging criteria based on magnetic resonance imaging (MRI) and computed tomography (CT) results.

Intraoperative mapping of sentinel lymph node metastases using a clinically translated ultrasmall silica nanoparticle

The management of regional lymph nodes in patients with melanoma has undergone a significant paradigm shift over the past several decades, transitioning from the use of more aggressive surgical approaches, such as lymph node basin dissection, to the application of minimally invasive sentinel lymph node (SLN) biopsy methods to detect the presence of nodal micrometastases. SLN biopsy has enabled reliable, highly accurate, and low-morbidity staging of regional lymph nodes in early stage melanoma as a means of guiding treatment decisions and improving patient outcomes. The accurate identification and staging of lymph nodes is an important prognostic factor, identifying those patients for whom the expected benefits of nodal resection outweigh attendant surgical risks. However, currently used standard-of-care technologies for SLN detection are associated with significant limitations. This has fueled the development of clinically promising platforms that can serve as intraoperative visualization tools to aid accurate and specific determination of tumor-bearing lymph nodes, map cancer-promoting biological properties at the cellular/molecular levels, and delineate nodes from adjacent critical structures. Among a number of promising cancer-imaging probes that might facilitate achievement of these ends is a first-in-kind ultrasmall tumor-targeting inorganic (silica) nanoparticle, designed to overcome translational challenges. The rationale driving these considerations and the application of this platform as an intraoperative treatment tool for guiding resection of cancerous lymph nodes is discussed and presented within the context of alternative imaging technologies. WIREs Nanomed Nanobiotechnol 2016, 8:535-553. doi: 10.1002/wnan.1380 For further resources related to this article, please visit the WIREs website.

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

OBJECTIVE

We evaluated the efficacy of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in recurrent disease, response to therapy, and long-term follow-up of ovarian cancer (OC) patients in relation to cancer antigen-125 (CA125) levels and the prognostic meaning of this modality in this subset of subjects.

MATERIAL AND METHODS

Between 2005 and 2015, we retrospectively evaluated 125 patients affected by OC who underwent FDG PET/CT imaging at our institution. The indications for PET/CT were recurrence of disease in 78 patients, therapy response assessment in 29, and follow-up in 18. The results of FDG PET/CT were compared with those of histopathology and clinical and radiological progression during follow-up for at least 6 months. The median long-term follow-up was 33 months. The diagnostic accuracies for the different clinical settings were evaluated. The relationships among global survival (GS), FDG PET/CT results, and CA125 levels were evaluated by both Kaplan-Meier and Cox regression analysis.

RESULTS

CA125 results were positive (>35 UI/mL) in 62 patients and negative in 63 (49% vs. 51%). The sensitivity and specificity of CA125 were 72% and 91%, respectively. PET/CT imaging showed a sensitivity of 98.6% and a specificity of 77.8% for the assessment of recurrent disease, and a sensitivity of 72.7% and a specificity of 88.9% for therapy evaluation. Meanwhile, in 18 patients evaluated during follow-up, the specificity was 82.3%. GS was significantly higher in case of negative CA125 values at the time of FDG PET/CT, of a negative PET/CT scan and when no evidence of peritoneum recurrence and distant metastases was determined by PET. Multivariate regression analysis showed that only age and peritoneum recurrence as determined by PET were identified as independent predictors of poor prognosis.

CONCLUSION

Metabolic imaging with FDG PET/CT proved useful in patients where OC recurrence was suspected, even when the value of tumor marker CA125 was in a normal range. A positive PET/CT scan and the presence of peritoneum recurrence at PET were associated with a poor prognosis after approximately 30 months.

Clinical and Survival Impact of FDG PET in Patients with Suspicion of Recurrent Ovarian Cancer: A 6-Year Follow-Up

Background

The aim of this retrospective study was to evaluate the contribution of fluorine-18-fluoro-deoxyglucose (FDG) positron emission tomography (PET) to the clinical management and survival outcome of patients (pts) suspected of recurrent ovarian carcinoma, with the hypothesis that early diagnosis of recurrent ovarian cancer may improve overall survival (OS).

Methods

Fifty-three FDG PET/CT scans were retrospectively analyzed for 42 pts. CT and PET/CT findings were confirmed by imaging and clinical follow-up, and/or pathology, which were considered as the gold standard diagnosis. The treatment plan based on CT staging was compared with that based on PET/CT findings. Medical records were reviewed for pts characteristics, progression-free survival (PFS), and OS. PFS and OS were analyzed using the Cox proportional hazards regression model.

Results

The final diagnosis of recurrence was established pathologically (n = 16), or by a median clinical follow-up of 6.5 years (range 0.5-7.5) after the PET/CT (n = 37). PET/CT provided a higher detection sensitivity (92.2%, 47/51) than CT (60.8%, 31/51) (p < 0.001). Globally, PET/CT modified the treatment plan in 56.6% (30/53) and in 65.2% (15/23) when the CT was negative prior to PET/CT. In 30 cases, those benefited from a modified treatment plan, these changes led to the intensification of a previous treatment procedure in 83.3% (25/30), and to a reduction in the previous treatment procedure in 16.6% of cases (5/30). The Cox regression multivariate analysis showed that the number of lesions visualized by CT and presence of lung lesions detected by PET/CT were significantly associated with PFS (p = 0.002 and p = 0.035, respectively).

Conclusion

On account of its impact on treatment planning, and especially in predicting patient outcome, FDG PET is a valuable diagnostic tool for cases of suspected ovarian cancer recurrence.

A retrospective study of dual-energy CT for clinical detecting of metastatic cervical lymph nodes in laryngeal and hypopharyngeal squamous cell carcinoma

CONCLUSION

After the reconstruction of imaging in dual-energy CT gemstone spectral imaging, the ratio of the two slopes curves, the target lymph node and primary lesion, respectively, might contribute to the clinical diagnosis of cervical lymph nodes in laryngeal and hypopharyngeal squamous carcinoma.

OBJECTIVE

To investigate the value of the dual-energy CT gemstone spectral imaging for clinical detecting of metastatic cervical lymph nodes in laryngeal and hypopharyngeal squamous carcinoma.

METHODS

Forty-seven cases who were suffering from laryngeal or hypopharyngeal squamous carcinoma and had complete clinical and pathological data were included, and 79 cervical lymph nodes were studied retrospectively (including 31 metastatic nodes and 48 non-metastatic nodes). Contrast-enhanced energy spectral imaging and reconstruction were performed. After the reconstruction, the slope of the curve in the target lymph node and the lesion were calculated. The ratio of the two slopes was studied. The pathological data of cervical lymph node and primary lesion were also collected.

RESULTS

The ratios were 1.20 ± 0.09 and 0.82 ± 0.12 in metastatic and non-metastatic lymph nodes, respectively. The difference was statistically significant (p < 0.05). The ratio was positively correlated to the stasis of lymph nodes only, rather than their morphological appearance, the pathological classification, or the individual difference (p < 0.05).

Location of recurrent asymptomatic ovarian cancer through endoscopic ultrasound

Ovarian cancer is frequent and recurrence happens in about 75% of patients. As it presents high rates of relapse, the exams for this diagnosis are widely discussed. Beside this, there have been discussions about benefits for early anatomic diagnosis and whether endoscopic ultrasound (EUS) can be used to track the relapse of the disease. We present a case, in which anatomic location and histological definition of an asymptomatic recurrence of the ovarian cancer was misdiagnosed with conventional methods, but was possible through EUS.

Management of epithelial ovarian cancer from diagnosis to restaging: an overview of the role of imaging techniques with particular regard to the contribution of 18F-FDG PET/CT

Epithelial ovarian carcinoma is a major form of cancer affecting women in the western world. The silent nature of this disease results in late presentation at an advanced stage in many patients. It is therefore important to assess the role of imaging techniques in the management of these patients. This article presents a review of the literature on the role of (18)F-FDG-PET/CT in the different stages of management of epithelial ovarian cancer. Moreover, a comparison with other imaging techniques has been made and the relationship between (18)F-PET/CT and the assay of serum CA-125 levels has been discussed.

Nomogram for predicting incomplete cytoreduction in advanced ovarian cancer patients

OBJECTIVE

Accurately predicting cytoreducibility in advanced-ovarian cancer is needed to establish preoperative plans, consider neoadjuvant chemotherapy, and improve clinical trial protocols. We aimed to develop a positron-emission tomography/computed tomography-based nomogram for predicting incomplete cytoreduction in advanced-ovarian cancer patients.

METHODS

Between 2006 and 2012, 343 consecutive advanced-ovarian cancer patients underwent positron-emission tomography/computed tomography before primary cytoreduction: 240 and 103 patients were assigned to the model development or validation cohort, respectively. After reviewing the detailed surgical documentation, incomplete cytoreduction was defined as a remaining gross residual tumor. We evaluated each individual surgeon's surgical aggressiveness index (number of high-complex surgeries/total number of surgeries). Possible predictors, including surgical aggressiveness index and positron-emission tomography/computed tomography features, were analyzed using logistic regression modeling. A nomogram based on this model was developed and externally validated.

RESULTS

Complete cytoreduction was achieved in 120 patients (35%). Surgical aggressiveness index and five positron-emission tomography/computed tomography features were independent predictors of incomplete cytoreduction. Our nomogram predicted incomplete cytoreduction by incorporating these variables and demonstrated good predictive accuracy (concordance index = 0.881; 95% CI = 0.838-0.923). The predictive accuracy of our validation cohort was also good (concordance index = 0.881; 95% CI = 0.790-0.932) and the predicted probability was close to the actual observed outcome. Our model demonstrated good performance across surgeons with varying degrees of surgical aggressiveness.

CONCLUSION

We have developed and validated a nomogram for predicting incomplete cytoreduction in advanced-ovarian cancer patients which may help stratify patients for clinical trials, establish meticulous preoperative plans, and determine if neoadjuvant chemotherapy is warranted.

Diagnostic accuracy of CT in assessing extra-regional lymphadenopathy in pancreatic and peri-ampullary cancer: a systematic review and meta-analysis

OBJECTIVES

Computed tomography (CT) is the most widely used method to assess resectability of pancreatic and peri-ampullary cancer. One of the contra-indications for curative resection is the presence of extra-regional lymph node metastases. This meta-analysis investigates the accuracy of CT in assessing extra-regional lymph node metastases in pancreatic and peri-ampullary cancer.

METHODS

We systematically reviewed the literature according to the PRISMA guidelines. Studies reporting on CT assessment of extra-regional lymph nodes in patients undergoing pancreatoduodenectomy were included. Data on baseline characteristics, CT-investigations and histopathological outcomes were extracted. Diagnostic accuracy, positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity were calculated for individual studies and pooled data.

RESULTS

After screening, 4 cohort studies reporting on CT-findings and histopathological outcome in 157 patients with pancreatic or peri-ampullary cancer were included. Overall, diagnostic accuracy, specificity and NPV varied from 63 to 81, 80-100% and 67-90% respectively. However, PPV and sensitivity ranged from 0 to 100% and 0-38%. Pooled sensitivity, specificity, PPV and NPV were 25%, 86%, 28% and 84% respectively.

CONCLUSIONS

CT has a low diagnostic accuracy in assessing extra-regional lymph node metastases in pancreatic and peri-ampullary cancer. Therefore, suspicion of extra-regional lymph node metastases on CT alone should not be considered a contra-indication for exploration.

Review of clinical practice utility of positron emission tomography with 18F-fluorodeoxyglucose in assessing tumour response to therapy

Positron emission tomography, most commonly with 18F-fluorodeoxyglucose, is being used for evaluation of tumour response to therapy. Limitations of this method are associated with (1) fluorodeoxyglucose pharmacokinetic properties, (2) the detection system, (3) discrepancies between metabolic and anatomic images, and (4) acquisition standardization. Response to therapy may be evaluated with qualitative (Deauville score), semiquantitative (standardised uptake value), and quantitative methods (European Organization for Research and Treatment of Cancer; Positron Emission Tomography Response Criteria in Solid Tumours). Methods under evaluation include metabolic tumour volume, total lesion glycolysis, and heterogeneity of fluorodeoxyglucose uptake. The development of positron emission tomography scanners that have larger fields of view may facilitate tumour assessment based on kinetic modelling. Increased clinical use of these methods will depend on the development and validation of intuitive and simple analytic tools.

Perimenopausal ovarian carcinoma patient with subclavian node metastasis proven by immunohistochemistry

Ovarian cancer is the seventh most common cancer in the world and the fifth most common cause of death from cancer; it is responsible for over half of all deaths related to gynecological cancers. The presence of lymphatic metastasis is an important prognostic factor in ovarian cancer. Nodal metastases to the pelvic and the para-aortic lymph nodes are common, particularly in an advanced of the disease (stages III-IV). The finding of distant nodal metastasis, especially subclavian lymph node metastasis, from ovarian carcinoma is very uncommon. 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) or FDG-PET/computed tomography (CT) provides an improved imaging for detecting metastatic lymph nodes in patients with ovarian cancer. Immunohistochemically, ovarian carcinoma cells are positive for estrogen receptor, progesterone receptor, cancer antigen 125, Wilms' tumor 1 protein, and p53; they are negative for thyroid transcription factor (TTF-1) and caudal-related homeobox 2 (CDX-2). This report describes a Korean woman diagnosed with ovarian cancer with subclavian lymph node metastasis revealed by FDG PET/CT and verified by an immunohistochemical staining. Differentiating between the primary ovarian lesion and the metastatic lesion will allow the initiation of an appropriate treatment and help predict the prognosis.