PET/CT scanning guided intensity-modulated radiotherapy in treatment of recurrent ovarian cancer

Investigation of the distribution of inguinal lymph nodes and delineation of the inguinal clinical target volume using 18F-FDG PET/CT

OBJECTIVE

Radiotherapy is a crucial treatment modality for pelvic cancers, but uncertainties persist in defining the clinical target volume (CTV) for the inguinal lymphatic drainage region. Suboptimal CTV delineation may compromise treatment efficacy and result in subpar disease control. This study aimed to investigate and map the distribution of lymph node metastases (LNM) in the groin area to facilitate an improved and detailed CTV definition using 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT).

METHODS

Inguinal LNM in patients with biopsy-proven pelvic malignancies were identified using 18F-FDG PET/CT scan. The longitudinally nearest axial plane was determined based on six typical bony landmarks, and the axial direction relative to the femoral artery of LNM was recorded. The distances from the LNM to the nearest edge of the femoral artery were measured on the axial plane. An optimal margin to cover 95% of LNM was estimated to develop contouring recommendations.

RESULTS

In this study, 500 positive LNM were identified by 18F-FDG PET/CT among 185 patients with primary pelvic malignancies. Relative to the femoral artery, lymph nodes were distributed laterally (10:00-11:00, n = 35), anteriorly (12:00-1:00, n = 213), and medially (2:00-4: 00, n = 252). For CTV delineation, the recommended distances from the femoral artery on the SFH were lateral 19 mm, anterior 19 mm, and medial 25 mm; on the SGT were lateral 26 mm, anterior 20 mm, and medial 25 mm; on the SPS were lateral 28 mm, anterior 29 mm, and medial 26 mm; on the IPS were anterior 29 mm and medial 28 mm; on the IIT were anterior 27 mm and medial 27 mm; on the ILT were anterior 25 mm and medial 23 mm. Use interpolation to contour the area between six axial slices, including any radiographically suspicious LNM.

CONCLUSIONS

Using 18F-FDG PET/CT, we investigated the distribution pattern of inguinal LNM and propose a more comprehensive guideline for inguinal CTV delineation.

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.

Role of Positron Emission Tomography/Computed Tomography in Epithelial Ovarian Cancer

Ovarian cancer (OC) is the most lethal gynecological malignancy with majority of cases diagnosed in advanced stages and associated with high morbidity and mortality. Positron emission tomography/computed tomography (PET/CT) has emerged as an integral part of the management of several nongynecological cancers. We used PubMed search engine using MeSH words "ovarian cancer" and "PET/CT" and reviewed the current status of PET/CT in epithelial OC. Its application related to ovarian tumor including adnexal mass evaluation, baseline staging, as a triaging tool for upfront surgery or neoadjuvant chemotherapy, for response assessment and prognostication, and for relapse detection and treatment planning has been highlighted. we highlight the current guidelines and newer upcoming PET modalities and radiotracers.

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.

Safety and Efficacy of the Metabolic Profiling of the BIMRT Utilizing 18F FDG PET-CT

AIM

This study aims to evaluate the safety and efficacy of fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG-PET/CT) guided intensity-modulated radiation therapy (IMRT) for patients with peritoneal metastases.

PATIENTS AND METHODS

A total of 55 patients with peritoneal metastases were treated with 18F-FDG-PET/CT-guided IMRT (BIMRT) from January 2012 to January 2019. They were prescribed with a fraction of the median dose of 2 Gy to a total dose of 50.4 Gy. The multivariate analysis was used the Cox proportional hazard model and the Kaplan-Meier plot was used to perform local control rate (LCR), progression-free survival (PFS), and overall survival (OS) analysis.

RESULTS

The 1-year, 2-year, and 3-year LCR were 72.7%, 36.4%, and 9.1%, respectively; the 1-year, 2-year, and 3-year PFS were 69.1%, 30.9%, and 7.3%, respectively, and the median PFS time was 18 months. The 1-year, 3-year and 5-year OS were 70.9%, 28.7%, and 4.2%, respectively. Based on the multivariate analysis using the Cox proportional hazard model, the Karnofsky performance status (KPS) score and radiotherapy joint chemotherapy (RJC) method were independent prognostic-related indicators (P < 0.0001).

CONCLUSION

BIMRT may be a safe and effective treatment for patients with peritoneal metastases, especially for patients who cannot undergo surgery. In addition, the results indicated that the patient's KPS score and RJC method were independent prognostic-related indicators for patients survival time.

Metastatic Ovarian Cancer Presenting as Inflammatory Breast Cancer: A Case Report

Metastatic ovarian cancer to the breast is a rare presentation, with limited cases reported worldwide. Common sites for distant metastasis in ovarian cancer are to the liver, lung, and pleura [Dauplat et al. Cancer. 1987 Oct 1;60(7):1561-6]. Usually, such cases predict poor prognosis with troublesome management. We present one challenging case of a 54-year-old female patient with recurrent clear cell ovarian cancer, presenting with right breast mass of primary versus secondary origin, progressing into inflammatory breast cancer picture. Our report aims to shed light on the value of early suspicion and low threshold of detecting secondary breast masses of ovarian cancer origin.

18F-FDG-PET/CT-guided intensity-modulated radiotherapy for 42 FIGO III/IV ovarian cancer: A retrospective study

The aim of the present study was to evaluate the curative effect of fludeoxyglucose-positron emission tomography/computed tomography (18F-FDG-PET/CT)-guided intensity-modulated radiotherapy (IMRT) for 42 patients with International Federation of Gynecology and Obstetrics (FIGO) stage III/IV ovarian cancer. Between January 2012 and December 2015, 42 patients with FIGO stage III/IV ovarian cancer who were treated with 18F-FDG-PET/CT-guided IMRT at the Department of Radiation Oncology were analyzed. A total of 21 patients who exhibited recurrence following surgery and 11 patients who were unable to tolerate or rejected surgery received 5-10 cycles of chemotherapy only. A total of 10 patients, who were either older (>70 years) or in poor general health were unable to undergo surgery and only received IMRT. The patients received a total radiation dose of 5,040 cGy (range, 4,500-5,500 cGy), with a dose fraction of 200 cGy/fx, administered a total of 10-14 times, 5 times/week, prior to being rested for half an hour to relocate lesions and undergoing a second round of radiotherapy for 10-14 cycles. The 1-, 2- and 3-year progression-free survival (PFS) rates of the patients were 66.7, 33.3 and 21.4%, respectively, and the median PFS time was 20.3 months. The 1-, 2- and 3-year local control rates of the patients were 90.5, 83.3 and 69.0%, respectively, and the 1-, 2- and 3-year overall survival (OS) rates were 73.8, 64.3 and 52.4%, respectively. According to the results of multivariate analysis using the Cox proportional hazards model, the Karnofsky performance status (KPS) score (1) was the only index associated with prognosis (P<0.003). The study concluded that for patients with advanced ovarian cancer, particularly for patients unable to undergo surgery or chemotherapy, 18F-FDG PET/CT-guided IMRT is a safe and effective treatment method, and it may be considered as an equally effective treatment option. Furthermore, the results of the present study suggested that the KPS score of a patient is the only factor affecting the OS time.

Successful treatment of platinum refractory ovarian clear cell carcinoma with secondary cytoreductive surgery and implantable transponder placement to facilitate targeted volumetric arc radiation therapy

We describe a case of the first successful treatment of platinum refractory clear cell ovarian cancer with secondary cytoreductive surgery and placement of Calypso transponders to facilitate post-operative volumetric arc radiation therapy. In the setting of both primary and recurrent disease, patients with clear cell ovarian cancer are less responsive to standard chemotherapy and those treated with radiation therapy may have improved outcomes compared to the use of other treatment modalities. Volumetric arc radiation therapy with implantable transponders is feasible, and allows for the targeted treatment of sites of metastatic disease while limiting toxicity to surrounding structures and can be considered for patients with recurrent ovarian cancer and oligometastatic disease.

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Post-operative VMAT is feasible for patients with recurrent ovarian cancer.

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VMAT minimizes toxicity and facilitates radiation therapy delivery.

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Implantable transponders are a novel approach for targeted radiation therapy.

MicroRNA-508 suppresses epithelial-mesenchymal transition, migration, and invasion of ovarian cancer cells through the MAPK1/ERK signaling pathway

Ovarian cancer (OC) is the sixth most common cancer in women worldwide. Despite advances in detection and therapies, it still represents the most lethal gynecologic malignancy in the industrialized countries. Unfortunately, the molecular events that lead to the development of this highly aggressive disease remain largely unknown. The study explored the ability of microRNA-508 (miR-508) to influence proliferation, migration, invasion, and epithelial-mesenchymal transition (EMT) in OC cells. We quantified the level of miR-508 cancer tissues with corresponding adjacent normal tissues collected from 84 patients with OC. Human OC cells SKOV3 and A2780 were treated with negative control (NC), miR-508 mimics, miR-508 inhibitors, and miR-508 inhibitors + a specific MAPK/ERK kinase inhibitor (PD98059) to validate the interaction between miR-508 and MAPK/ERK signaling. The miR-508 expression level was lower while MAPK1 and ERK expression levels were higher in the cancer tissues than in the adjacent normal tissues. Dual-luciferase reporter assay indicated MAPK1 as a target gene of miR-508. The miR-508 mimics reduced the expression of MAPK1, p-MAPK1, ERK, p-ERK and Vimentin, inhibited cell proliferation, migration and invasion, and increased the expression of E-cadherin, while the miR-508 inhibitors resulted in an opposed trend in OC cells. The effects of miR-508 inhibitors on OC cells were lost when the MAPK1/ERK signaling pathway was inhibited by PD98059. Collectively, our data indicate that miR-508 plays a tumor suppressor role in the development and progression of OC and may be a novel therapeutic target against OC.

Normal Variants and Pitfalls Encountered in PET Assessment of Gynecologic Malignancies

Combined PET/computed tomography is used for oncological indications. PET/computed tomography benefits from the metabolic information of PET and the anatomic localization of computed tomography. The integrated scanner provides data with accurate registration of anatomy and molecular information. Many physiologic conditions, normal variants, and benign lesions within the pelvis and the body can cause confusion and uncertainty. False-negative results owing to low 18F-fluorodeoxyglucose uptake from the tumor can produce diagnostic challenges and inaccurate conclusions. This article reviews normal variants and potential pitfalls encountered in PET assessment of gynecologic malignancies to provide useful information for the referring and reporting physicians.

Relationship between HER2 and JAK/STAT-SOCS3 signaling pathway and clinicopathological features and prognosis of ovarian cancer

OBJECTIVE

The study aims to explore the relationship between expressions of HER2 and JAK/STAT3-SOCS3 signaling pathway and clinicopathological features and prognosis of ovarian cancer (OC).

METHODS

A total of 136 OC patients were collected. Immunohistochemistry was applied to measure the expressions of STAT3, p-STAT3, SOCS3, HER2 and p-HER2 in the tumor tissues and adjacent normal tissues. Quantitative real-time polymerase chain reaction (qRT-PCR) was used to detect the mRNA expressions of HER2, SOCS3 and STAT3 and western blotting was applied for protein expressions of HER2, p-HER2, SOCS3, STAT3 and p-STAT3 in the tumor tissues and adjacent normal tissues. Flow cytometry was used for the cell apoptosis in the blank, afatinib (A), ruxolitinib (R) and afatinib + ruxolitinib (A + R) groups. Follow-up was performed to explore relationship of HER2, SOCS3, and STAT3 expressions with survival time of OC patients.

RESULTS

HER2, p-HER2, STAT3, and p-STAT3 expressions were higher while SOCS3 expression was lower in the tumor tissues. The positive expressions of STAT3, HER2, p-HER2 and p-STAT3 were lower while the positive expression of SOCS3 was higher in the adjacent normal tissues. The expressions of HER2, SOCS3, and p-STAT3 were associated with clinical stage and lymph node metastasis (LNM), and STAT3 expression has correlation with histological grade and LNM. The mRNA and protein expressions of HER2, STAT3 and p-STAT3 in the tumor tissues were higher than those in the adjacent normal tissues, but SOCS3 expression was significantly decreased. The positive expressions of HER2, p-HER2 and STAT3, the negative expression of SOCS3 and pathological stages were important risk factors for the prognosis of patients with OC.

CONCLUSION

Our study showed that the expressions of HER2, STAT3, and SOCS3 are associated with the progression of OC, and higher expressions of HER2 and STAT3 and lower expression of SOCS3 predict poor prognosis of OC.

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.

Intensity modulated radiation therapy for recurrent ovarian cancer refractory to chemotherapy

OBJECTIVE

To evaluate local control, survival outcomes, and toxicity after intensity modulated radiotherapy (IMRT) for recurrent chemorefractory ovarian cancer.

METHODS

Between 2006 and 2014, 33 patients were treated with IMRT for recurrent ovarian cancer. Patients received a median of 3 chemotherapy regimens prior to IMRT (range, 1-12) with 11 (33%) undergoing concurrent therapy. Local control (LC), recurrence free survival (RFS), and overall survival (OS) were calculated via Kaplan-Meier method. Toxicity was assessed using the Common Terminology Criteria for Adverse Events (CTCAE) v4.03. Impact of patient characteristics on outcomes was evaluated via Cox's proportional hazard model.

RESULTS

Median follow up was 23.7 months. Forty-nine sites were treated to a median dose of 5040cGy (range, 4500-7000). Nine (18%) of the 49 sites had in-field failures. Two year actuarial LC, RFS, and OS were 82%, 11%, and 63%, respectively. Seventeen patients had both a pre and post-treatment FDG-PET/CT; 6 (35%) had a complete metabolic response while 11 (65%) had a partial metabolic response. Acute ≥ grade 3 gastrointestinal (GI) toxicities occurred in 2 (6%) patients, late ≥ grade 3 GI toxicities occurred in 12 (36%), acute ≥ grade 3 hematological toxicities occurred in 5 (15%) and late ≥ grade 3 hematological toxicities occurred in 14 (42%).

CONCLUSIONS

IMRT for recurrent chemorefractory ovarian cancer is associated with excellent local control and limited radiation related toxicity. Future studies will be required to determine which subpopulation will benefit most from IMRT and whether alternative techniques such as stereotactic body radiotherapy may be feasible.

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.

Predictive value of pre-therapy (18)F-FDG PET/CT for the outcome of (18)F-FDG PET-guided radiotherapy in patients with head and neck cancer

PURPOSE

The aim of this study was to evaluate the predictive role of pre-therapy fluorodeoxyglucose (FDG) uptake parameters of primary tumour in head and neck cancer (HNC) patients undergoing intensity-modulated radiotherapy (IMRT) with simultaneous integrated boost (SIB) on FDG-positive volume-positron emission tomography (PET) gross tumour volume (PET-GTV).

METHODS

This retrospective study included 19 patients (15 men and 4 women, mean age 59.2 years, range 23-81 years) diagnosed with HNC between 2005 and 2011. Of 19 patients, 15 (79 %) had stage III-IV. All patients underwent FDG PET/CT before treatment. Metabolic indexes of primary tumour, including metabolic tumour volume (MTV), maximum and mean standardized uptake value (SUVmax, SUVmean) and total lesion glycolysis (TLG) were considered. Partial volume effect correction (PVC) was performed for SUVmean and TLG estimation. Correlations between PET/CT parameters and 2-year disease-free survival (DFS), local recurrence-free survival (LRFS) and distant metastasis-free survival (DMFS) were assessed. Median patient follow-up was 19.2 months (range 4-24 months).

RESULTS

MTV, TLG and PVC-TLG predicting patients' outcome with respect to all the considered local and distant disease control endpoints (LRFS, DMFS and DFS) were 32.4 cc, 469.8 g and 547.3 g, respectively. SUVmean and PVC-SUVmean cut-off values predictive of LRFS and DFS were 10.8 and 13.3, respectively. PVC was able to compensate errors up to 25 % in the primary HNC tumour uptake. Moreover, PVC enhanced the statistical significance of the results.

CONCLUSION

FDG PET/CT uptake parameters are predictors of patients' outcome and can potentially identify patients with higher risk of treatment failure that could benefit from more aggressive approaches. Application of PVC is recommended for accurate measurement of PET parameters.

[Positron emission tomography for volume delineation of pelvic nodal involvement]

Radiotherapy planification has recently known important developments, with the rise of new technologies, such as conformational radiation therapy, intensity-modulated radiation therapy (IMRT) or stereotaxic radiation therapy. Delineation of target volumes has become primordial. Hybrid imaging by positron emission tomography associated to computed tomography scanner (PET-CT) gives an access to functional and morphological information. Radiotherapist and nuclear physicians working closely have the potential to allow a more optimal delineation, and a better preservation of organs at risk. During the past few years, this has been explored by many articles, and we propose a literature review organized by localization, about the use of PET-CT for pelvic nodes delineation.