Negative 18F-2-fluorodeoxyglucose PET/CT predicts good cancer specific survival in patients with a suspicion of recurrent ovarian cancer

Metabolic markers derived from 18 F-FDG PET/CT in suspected recurrent ovarian carcinoma: predictive value for disease burden and prognosis

OBJECTIVE

This study aims to assess the role of 18 F-fluorodeoxyglucose (FDG) PET/computed tomography (CT) in suspected recurrent ovarian carcinoma. Several clinical and PET parameters were assessed to evaluate disease burden and prognosis.

METHODS

We did a single-center, retrospective study in patients with suspected recurrent ovarian carcinoma who underwent 18 F-FDG PET/CT. The disease burden on the scan was evaluated. We calculated several semiquantitative markers, including standard uptake values (SUV), metabolic tumor volume (MTV), and total lesion glycolysis (TLG). Survival analysis was done with clinical parameters, CA-125 levels, disease distribution, and metabolic markers.

RESULTS

Fifty-two patients were included in the study. Half of the patients had suspected recurrence within 12 months of primary diagnosis. PET/CT scan suggested disease in 35 (67.3%) patients. Multiple metastatic sites were noted in 21 (40.4%) patients. Extra-abdominal metastases were seen in 15 (28.8%) patients. Eight patients had 18 F-FDG avid disease despite a low CA-125 level (<35 IU). Young patients (<50 years), extra-abdominal disease, multiple metastases, and higher restaging were associated with poor outcomes. Meanwhile, treatment history, CA-125 level, and post-PET/CT treatment had no significant effect on survival. MTV@40% SUV (>17.21) and TLG@40% SUV (>68.7) had the sensitivity of 87.5% and 75% for predicting disease outcome.

CONCLUSION

Recurrent ovarian carcinoma commonly presents with multiple metastasis and extra-abdominal metastases. 18 F-FDG PET/CT-guided patterns of disease distribution were significant markers for poor prognosis. Disease burden on PET/CT-derived semiquantitative parameters was associated with poor outcomes.

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

Background

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

Results

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

Conclusions

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

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.

Glycolytic phenotypes in an evaluation of ovarian carcinoma based on carcinogenesis and BRCA mutation

BACKGROUNDS

Recently, a dualistic carcinogenesis model of ovarian cancer has emerged. We aimed to investigate differences in the glycolytic phenotypes of type I and type II ovarian carcinoma on the basis of FDG uptake and in the pathological features according to tumour grade and histology.

MATERIALS AND METHODS

In total, 386 epithelial ovarian carcinoma patients underwent debulking surgery, and the histopathological results of the patients were retrospectively reviewed from 2003 to 2017. Among these patients, 170 patients had histopathological data that were available due to primary cytoreductive surgery and could be analysed regarding FDG avidity in type I and type II ovarian cancer. The FDG uptake of the tumour (SUVmax), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) were analysed according to the tumour grade, histology and type of ovarian carcinogenesis (type I and II) and prognosis.

RESULTS

Among the 386 patients, there was a significant difference in SUVmax among ovarian cancer subtypes. There was a significant increase in SUVmax as the tumour grade increased (8.08 ± 0.63, 10.5 ± 0.40, and 12.7 ± 0.38 for grades I, II and III, respectively, Kruskal-Wallis test, p < 0.0001). Among the 90 type I and 80 type II ovarian carcinoma patients, there was a significant difference in SUVmax (type I and II, 9.47 ± 0.54 and 12.97 ± 0.70, respectively, Mann-Whitney test, p = 0.0003). However, no significant change in SUVmax was observed between BRCA-positive and BRCA-negative patients (N = 80, 13.8 ± 5.78 and 12.4 ± 6.30, Student's t-test, p = 0.3075). Among clinicopathologic and metabolic parameters, type of ovarian cancer, MTV and CA125 were significant factors in the prediction of recurrence.

CONCLUSIONS

The glycolytic phenotype was related to tumour grade and histological subtype, with significant differences between type I and II ovarian cancer. SUVmax of the ovarian cancer would be considered in the differentiation of type I and II ovarian cancer.

The maximum standardized uptake value and extent of peritoneal involvement may predict the prognosis of patients with recurrent ovarian cancer after primary treatment: A retrospective clinical study

We investigated the effect of the maximum standardized uptake value (SUVmax) and peritoneal dissemination derived from F-fluorodeoxyglucose (F-FDG) positron emission tomography/computed tomography (PET/CT) imaging on prognosis in patients with recurrent ovarian cancer.We retrospectively analyzed 145 patients with suspected recurrent ovarian cancer who had undergone F-FDG PET/CT scans after cytoreductive surgery and chemotherapy. The degree of peritoneal spread was classified as localized (1-3 FDG foci) or diffuse (>3 FDG foci). Receiver operating characteristic (ROC) curve analysis was performed to determine the cut-off values for predicting recurrence.A total of 145 patients were retrospectively reviewed in this study. 29 patients were excluded as their follow-up results were not available. One hundred sixteen patients were included in the final analysis. The median duration of progression-free survival was 14 months. F-FDG PET/CT detected peritoneal carcinomatosis in 82 patients. With a cut-off SUVmax of 2.0 obtained from the ROC curve analysis, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of SUVmax of peritoneal carcinomatosis for predicting recurrence were 77.6%, 87.5%, 65.1%, 97.4%, and 38.9%, respectively. The area under the curve was 0.85. In a multivariate analysis, significant independent prognostic variables were SUVmax of peritoneal disease, peritoneal dissemination, and CA125 levels. In patients with peritoneal involvement, the Kaplan-Meier survival curves showed significantly longer PFS in those with localized disease.SUVmax of peritoneal disease is valuable in predicting the recurrence of ovarian cancer. SUVmax of peritoneal disease, peritoneal dissemination and CA125 level could be used as independent prognostic factors for ovarian cancer patients.

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.

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.

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.

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.

Predictive value of (18)F-FDG PET/CT in restaging patients affected by ovarian carcinoma: a multicentre study

PURPOSE

Ovarian cancer is the eighth most common malignancy among women and has a high mortality rate. Prognostic factors able to drive an effective therapy are essential. (18)F-Fluoro-2-deoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) has been investigated in patients with epithelial ovarian cancer and showed promise in diagnosing, staging, detecting recurrent lesions and monitoring treatment response. Conversely, its prognostic role remains unclear. We aimed at assessing the prognostic value of (18)F-FDG PET/CT performed in the restaging process in a multicentre study.

METHODS

We evaluated 168 patients affected by ovarian carcinoma, who underwent a restaging (18)F-FDG PET/CT. The presence of local recurrences, lymph node involvement and distant metastasis was recorded as well as lesion dimensions, maximum and mean standardized uptake values (SUVmax and SUVmean, respectively). Progression-free survival (PFS) and overall survival (OS) at 3 and 4 years were computed by using Kaplan-Meier curves. Increased odds ratio was assessed using Cox regression analysis testing all lesion parameters measured by PET/CT.

RESULTS

PFS was significantly longer in patients with a negative than a positive restaging PET/CT study (3- and 4-year PFS 64 and 53% vs 23 and 12%, respectively; p < 0.001). Similarly, a negative study was associated with a significantly higher OS rate after 4 years of follow-up (67 vs 25% in negative and positive groups, respectively; p < 0.001). Lymph node or distant involvement were also independently associated with an increased risk of disease progression [hazard ratio (HR) 1.6 and 2.2, respectively; p = 0.003]. Moreover, PET/CT showed an incremental prognostic value compared to the International Federation of Gynecology and Obstetrics (FIGO) staging system. In the analysis of patient subsets, individuals with the same FIGO stage I-II but with negative PET had a significantly better 4-year OS than patients with low FIGO stage but positive PET. This implies that patients with the same FIGO stage can be further prognostically stratified using PET (p = 0.01). At receiver-operating characteristic (ROC) analysis, no thresholds for semiquantitative parameters were predictive of a worse outcome.

CONCLUSION

(18)F-FDG PET/CT has an important prognostic value in assessing the risk of disease progression and mortality rate. An efficacious therapy planning might therefore effectively rely on (18)F-FDG PET/CT findings. Semiquantitative data were not proven to be an effective tool to predict disease progression.

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.

Fludeoxyglucose F 18 PET-Computed Tomography: Management Changes Effecting Patient Outcomes in Gynecologic Malignancies

Outcome analysis in oncologic imaging is complex because of the multiple variables that can affect survival, including how early disease is diagnosed, the accuracy of staging at diagnosis, and where and how the patient is treated. Risk for tumor recurrence is estimated based on tumor histologic grade, stage at diagnosis, and other factors, including expressed molecular markers. This article reviews the data supporting the use of F 18 fluorodeoxyglucose PET-computed tomography in endometrial, ovarian, and cervical malignancies, with emphasis on the impact of imaging on treatment stratification and prognosis.