Supra-clavicular lymph node metastatic spread in patients with ovarian cancer disclosed at 18F-FDG-PET/CT: an unusual finding

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.

Left Supraclavicular Lymph Node Metastasis from Ovarian Cancer Associated with Papillary Thyroid Microcarcinoma, a Confusing Pathology-Essential Role of Functional Imaging

The revolution of imaging in medicine leads to new standards of care, mostly in specialties like oncology, neurology, or endocrinology. We present a review of the literature and a case report of a 62-year-old patient initially treated for a benign gynecologic pathology and followed-up for 7 years clinically, with serologic and with multiple imaging techniques. There is an actual growing use of highly sensitive functional imaging methods, like fluoro-deoxy-glucose (F18-FDG) positron emission tomography/computed tomography (PET/CT) in the evaluation of oncologic pathologies, staging, follow-up, and therapy response monitoring. This is the first case report described in the literature presenting the association of thyroid papillary microcarcinoma (MPTC) and supraclavicular metastasis of ovarian cancer. The study aims to underline the necessity of a complex and careful evaluation of each oncologic patient, due to the unexpected clinical presentation and rare association of diseases, sometimes leading to confusing management.

Prognostic significance of supraclavicular lymphadenopathy in patients with high-grade serous ovarian cancer

OBJECTIVES

To assess outcomes and patterns of recurrence in patients with high-grade serous ovarian/tubal/primary peritoneal cancers with radiographic supraclavicular lymphadenopathy at diagnosis.

METHODS

We evaluated all patients with newly diagnosed high-grade serous ovarian cancers treated at our center between January 1, 2008 and May 1, 2013 who had supraclavicular lymphadenopathy (defined as ≥1 cm in short axis) on radiographic imaging (either computed tomography or positron emission tomography) at the time of diagnosis.

RESULTS

Of 586 patients with high-grade serous ovarian cancer receiving primary treatment during the study period, we identified 13 (2.2%) with supraclavicular lymphadenopathy diagnosed on pre-treatment imaging. The median age at diagnosis was 52.0 years (range 38.2-72.3). Five (31%) had clinically palpable nodes on physical examination. Four (31%) had a known BRCA mutation. All 13 patients underwent neoadjuvant chemotherapy, followed by interval debulking surgery. Each patient received a median of four cycles of neoadjuvant intravenous chemotherapy (range 3-7). At interval debulking surgery, complete gross resection was achieved in nine (70%) patients, and optimal resection (0.1-1 cm residual disease) in four (30%). Eleven patients (85%) recurred; however, only one (8%) recurred in the supraclavicular lymph nodes. Median follow-up time was 44.3 months (range 22.4-95.0). Median progression-free survival for the cohort was 11.7 months (95% CI 9.2 to 14.1). Median overall survival was 44.3 months (95% CI 41.5 to 47.1). In patients obtaining complete gross resection at interval debulking surgery, median progression-free survival and overall survival were 13.9 months (95% CI 8.9 to 18.9) and 78.1 months (95% CI 11.1 to 145.1), respectively.

CONCLUSIONS

In our study, approximately 2% of patients with high-grade serous ovarian cancer presented with radiographic evidence of supraclavicular lymphadenopathy. Supraclavicular lymphadenopathy at diagnosis did not portend an unfavorable outcome when complete gross resection was achieved at interval debulking surgery.

Ovarian cancer initially presenting with supra-clavicular lymph node metastasis: A case report

Supra-clavicular lymph node metastasis from ovarian cancer is rare. The present study reports the unique case of a 43-years-old patient who initially presented with left supra-clavicular lymph node metastasis, and was nulliparous. According to fine-needle aspiration cytology of the metastatic left supra-clavicular lymph nodes and 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (PET/CT) scan, the patient was diagnosed with poorly differentiated serous carcinoma of ovarian cancer, stage IV. Following two cycles of platinum-based chemotherapy, PET/CT showed that the patient had achieved a complete response. Next, cytoreductive surgery was performed and the postoperative histological findings showed that the patient had achieved a complete pathological response. According to NCCN Clinical Practice Guidelines in Oncology, the patient was stage IV and four cycles of chemotherapy were provided, with no recurrence observed during 3 years of follow-up. This case indicates that patients who initially present with distant metastatic lymph nodes and are nulliparous might have a better prognosis and avoid overtreatment.

Preoperative fluorine 18 fluorodeoxyglucose tumoral uptake ratio between upper and lower abdomen in primary advanced-stage ovarian cancer

OBJECTIVE

The objective of this study was to assess whether the ratio of upper abdomen (UA) to lower abdomen (LA) (relative to the umbilicus) standardized fluorine 18 fluorodeoxyglucose uptake, as measured by preoperative positron emission tomography and computed tomography, is predictive of recurrence, survival, and suboptimal cytoreduction (residual tumor >1.0 cm) in advanced-stage ovarian cancer (AOC).

METHODS

Positron emission tomography/computed tomography before surgical staging was performed in 159 AOC patients. The ratio between the highest maximum standardized uptake value (SUV(max)) in the UA and the LA was expressed as UA/LA SUV(max). Clinicopathological characteristics and follow-up information were collected retrospectively. Cox proportional hazards analysis was used to identify prognostic factors for recurrence and survival. Logistic regression analysis was used to identify predictors of suboptimal cytoreduction.

RESULTS

The median age and follow-up period were 55 years (range, 27-80 years) and 32 months (range, 1-92 months), respectively; 133 and 26 patients had stage III and IV disease, respectively. There were 120 and 54 cases of recurrence and disease-specific death, respectively. Multivariate analysis showed that recurrence was associated significantly with high UA/LA SUV(max) (P < 0.05; hazard ratio [HR], 4.902; 95% confidence interval [CI], 2.521-9.531) and suboptimal cytoreduction (P < 0.05; HR, 2.431; 95% CI, 1.561-3.788), and that disease-specific death was significantly associated with high UA/LA SUV(max) (P < 0.05; HR, 2.777; 95% CI, 1.270-6.075), suboptimal cytoreduction (P < 0.05; HR, 1.951; 95% CI, 1.080-3.524), and histology (P < 0.05; HR, 4.134; 95% CI, 1.676-10.196). Upper abdomen/lower abdomen SUV(max) was the only independent predictor of suboptimal cytoreduction (P < 0.05; odds ratio, 4.644; 95% CI, 1.676-12.862).

CONCLUSIONS

High preoperative UA/LA SUV(max) was significantly associated with poor prognosis and may be predictive of suboptimal cytoreduction in AOC. This parameter may be considered in the treatment of AOC patients.

Fluid biopsy for circulating tumor cells in an occult ovarian cancer patient exhibiting bilateral supraclavicular lymph node metastases: A case report

Metastases to the supraclavicular region usually originate from the head and neck or from infraclavicular tumors. Ovarian primaries of supraclavicular metastases are extremely rare. The present study reports the case of a 60-year-old patient with a bilateral supraclavicular mass that was diagnosed as a poorly-differentiated squamous cell carcinoma of unknown primary, following a fine-needle aspiration biopsy (FNAB) and comprehensive clinical investigation. The analysis of a peripheral blood sample using the CellSearch system revealed the presence of circulating tumor cells (CTCs) that were positive for epithelial cell adhesion molecule (EpCAM) and cytokeratin (CK) expression. Since EpCAM is usually expressed in adenocarcinoma, an excisional biopsy of the right supraclavicular lymph node was performed. The patient was diagnosed with occult ovarian low-grade serous carcinoma by immunohistochemistry. To the best of our knowledge, this is the first report to demonstrate that CTCs may be detected in the peripheral blood of a patient with cancer of unknown primary (CUP) by using the CellSearch system. A literature review was performed to analyze the diagnostic procedures of CUP metastatic to the cervical lymph nodes and the clinical features of CTCs.

Noninvasive and invasive staging of ovarian cancer: review of the literature

The use of F-18 FDG PET/CT in the characterization of doubtful adnexal findings and in the staging of ovarian cancer is being extensively evaluated. The purpose of our article is to review the literature and to add our experience to the published works. We concluded that F-18 FDG PET/CT could represent an important method in addition to other imaging modalities (transvaginal ultrasound-, and contrast-enhanced computed tomography) in the characterization of adnexal masses and in the staging of ovarian cancer patients, particularly in assessing the presence of extra-abdominal metastatic spread.

FDG-PET/CT in advanced ovarian cancer staging: value and pitfalls in detecting lesions in different abdominal and pelvic quadrants compared with laparoscopy

INTRODUCTION AND AIM

Ovarian carcinoma (OC) is a common cancer in the Western Countries, and an important cause of death in patients suffering with gynaecologic malignancies. The majority of patients present with advanced disease at the time of diagnosis. Treatment with debulking surgery followed by chemotherapy is the standard approach while chemotherapy is contemplated when surgery is not possible. A correct pre-operative staging is important to ensure a most appropriate management. Laparoscopy (LPS) is the standard diagnostic tool for the assessment of intraperitoneal infiltration but is invasive and requires general anaesthesia. FDG-PET/CT is increasingly used for staging different types of cancer, and the aim of this study is to assess the value of FDG-PET/CT in staging advanced OC and its sensitivity to detect lesions in different quadrants of the abdominal-pelvic area compared to laparoscopy.

MATERIALS AND METHODS

From September 2004 till April 2008, 40 patients with high suspicion of OC were referred to our hospital for diagnostic LPS to explore the possibility of optimal debulking surgery. Those who were not suitable for surgery were referred for chemotherapy. Before chemotherapy, the patients underwent an FDG-PET/CT scan. The findings in 9 quadrants of abdominal-pelvic area (total 360 quadrants) for PET/CT and LPS were recorded and compared.

RESULTS

In 14/360 areas (3.8%), surgical evaluation was not possible because of presence of adhesions, thus the number of areas explored by laparoscopy was 346. Tumour was found in 308 quadrants (38 quadrants free of disease). PET/CT was positive in all 40 patients with true negative results in 26/346 quadrants (7.5%), and true positives results in 243/346 quadrants (70.2%). False positive and negative PET/CT results were found in 12/346 and 65/346 quadrants, respectively. False positive PET/CT findings were evenly present in all quadrants. False negative PET/CT findings were present in 31/109 (28.4%) upper abdominal quadrants (epigastrium and diaphragmatic areas). Final analysis showed a sensitivity and specificity for PET/TC of 78.9 and 68.4% respectively with a positive predictive value of 95.3%. A significant difference was noted between mean SUVmax associated with lesions smaller or larger than 0.5 cm (p=0.006).

CONCLUSION

Our results suggest that PET/CT may prove a useful tool for pre-surgical staging of ovarian cancer with a sensitivity and specificity of 78 and 68%, respectively. However, it may be used in combination with laparoscopy for better results. PET/CT showed an adequate correlation between SUVmax values and laparoscopy findings of lesions>5mm, but a high rate of false negative results in lesions<5mm such as in carcinomatosis. PET/CT should be used carefully in early stage disease, with low risk of peritoneal infiltration, because of high rate of false positive results, to avoid unnecessary therapy procedures.

Present and future of PET and PET/CT in gynaecologic malignancies

OBJECTIVES

To review the published data in literature on patients affected by gynaecological malignancies to establish the role of (18)F-FDG positron emission tomography (PET) and PET/CT in comparison to conventional imaging (CI).

MATERIALS AND METHODS

All papers specifically addressed to the role of (18)F-FDG PET and PET/CT in gynaecological malignancies published on PubMed/Medline, in abstracts from the principal international congresses, in the guidelines from national Societies that had appeared in literature until November 2009 were considered for the purpose of the present study.

RESULTS AND CONCLUSIONS

The use of (18)F-FDG PET, and even more of (18)F-FDG PET/CT, is increasing in the follow up of patients with gynaecologic malignancies and suspected recurrent disease: there is evidence in the literature that (18)F-FDG PET/CT has a higher sensitivity than CI in depicting occult metastatic spread. An interesting issue is represented by patients with ovarian cancer with an increase of the specific biomarker, CA-125, and negative/inconclusive findings at CI. The use of (18)F-FDG PET in differential diagnosis and staging is more controversial, but there is some evidence that a baseline PET examination performed before commencing therapy, for staging purpose, is also useful to evaluate the response to chemoradiation treatment. In several papers it has been suggested a relevant role of (18)F-FDG PET/CT in evaluating the entity of response to treatment and therefore to plan the subsequent therapeutic strategy.

Gonadotropin-regulated lymphangiogenesis in ovarian cancer is mediated by LEDGF-induced expression of VEGF-C

The risk and severity of ovarian carcinoma, the leading cause of gynecologic malignancy death, are significantly elevated in postmenopausal women. Ovarian failure at menopause, associated with a reduction in estrogen secretion, results in an increase of the gonadotropic luteinizing hormone (LH) and follicle-stimulating hormone (FSH), suggesting a role for these hormones in facilitating the progression of ovarian carcinoma. The current study examined the influence of hormonal stimulation on lymphangiogenesis in ovarian cancer cells. In vitro stimulation of ES2 ovarian carcinoma cells with LH and FSH induced expression of vascular endothelial growth factor (VEGF)-C. In vivo, ovariectomy of mice resulted in activation of the VEGF-C promoter in ovarian carcinoma xenografts, increased VEGF-C mRNA level, and enhanced tumor lymphangiogenesis and angiogenesis. Seeking the molecular mechanism, we examined the role of lens epithelium-derived growth factor (LEDGF/p75) and the possible contribution of its putative target, a conserved stress-response element identified in silico in the VEGF-C promoter. Using chromatin immunoprecipitation, we showed that LEDGF/p75 indeed binds the VEGF-C promoter, and binding is augmented by FSH. A corresponding hormonally regulated increase in the LEDGF/p75 mRNA and protein levels was observed. Suppression of LEDGF/p75 expression using small interfering RNA, suppression of LH and FSH production using the gonadotropin-releasing hormone antagonist cetrorelix, or mutation of the conserved stress-response element suppressed the hormonally induced expression of VEGF-C. Overall, our data suggest a possible role for elevated gonadotropins in augmenting ovarian tumor lymphangiogenesis in postmenopausal women.

Surveillance of patients after initial treatment of ovarian cancer

The surveillance of ovarian cancer patients after initial treatment is a challenging question in clinical practice. Serum CA 125 assay, physical examination, and imaging examinations have been employed with different time schedules for the follow-up of asymptomatic patients. Rising serum CA 125 levels may precede the clinical detection of relapse in 56-94% of cases with a median lead time of 3-5 months. An ongoing randomised phase III European trial is comparing the benefits of early administration of chemotherapy based on serum CA 125 assay alone versus delaying treatment until clinical or radiological detection of recurrent disease. Physical examination, with or without ultrasound, is very useful for the surveillance of these patients, since approximately 25-50% of relapses involve the pelvis. Additional radiological imaging techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI), are usually performed in asymptomatic patients with rising CA 125 levels as well as in patients with suspicious symptoms or signs. Integrated positron emission tomography (PET) and CT scanners (PET/CT) can identify recurrent disease in tissues that appear normal at CT imaging as well as metastatic lesions intimately associated with the bowel wall that are difficult to detect with CT or MRI, so that in most series PET/CT has a higher diagnostic reliability than that of conventional imaging techniques. Moreover, PET/CT can disclose unusual supra-diaphragmatic spreading of the disease and may be very helpful for treatment planning, especially for the selection of patients suitable for secondary surgical cytoreduction. A prospective, randomised trial of therapeutic interventions based on stratification by PET/CT disease status could elucidate the real impact of this diagnostic procedure in the management of patients with recurrent ovarian cancer.

Are Surveillance Procedures of Clinical Benefit for Patients Treated for Ovarian Cancer?: A Retrospective Italian Multicentric Study

The aim of this retrospective investigation was to assess the pattern of failures of 412 patients with recurrent ovarian cancer followed up with different surveillance protocols.

Time to recurrence was less than 6 months in 98 women (23.8%), 6 to 12 months in 102 women (24.7%), and more than 12 months in 212 women (51.5%). Symptoms at relapse were referred by 81 women (19.7%). Among the 331 asymptomatic patients, the surveillance procedure that raised the suspect of recurrent disease was clinical examination in 49 (14.8%), imaging technique in 90 (27.2%), serum CA 125 in 77 (23.3%), and both serum CA 125 and imaging technique in 115 (34.7%). At univariate analysis, survival from initial diagnosis was related to stage (P = 0.004), residual disease after initial surgery (P < 0.0001), time to recurrence (P < 0.0001), site of relapse (P = 0.04), and treatment at recurrence (P < 0.0001), and survival after recurrence was related to stage (P = 0.01), residual disease (P < 0.0001), time to recurrence (P < 0.0001), and treatment at recurrence (P < 0.0001). Conversely, symptoms at recurrence had no prognostic relevance. Cox proportional hazards model showed that residual disease and time to recurrence were the only independent prognostic variables for both survival from initial diagnosis (P < 0.0001) and survival after recurrence (P < 0.0001). In conclusion, there was no survival difference between asymptomatic and symptomatic patients at the time of relapse, and therefore, the diagnostic anticipation allowed by a scheduled follow-up protocol did not seem to improve the clinical outcome of patients who ultimately developed recurrent disease.

Prediction of suboptimal primary cytoreduction in primary ovarian cancer with combined positron emission tomography/computed tomography--a prospective study

OBJECTIVE

To prospectively identify combined PET/CT predictors of incomplete/suboptimal primary cytoreduction in advanced ovarian cancer.

METHODS

From September 2004 to March 2007, 179 patients with a Risk of Malignancy Index (RMI) >150 based on serum CA-125, ultrasound examinations and menopausal state, underwent PET/CT within 2 weeks prior to standard surgery/debulking of a pelvic tumor. Ten PET/CT features were identified and evaluated as predictors of cytoreduction in 54 patients with advanced ovarian cancer.

RESULTS

Complete cytoreduction (no macroscopic residual disease) was achieved in 35% and optimal cytoreduction (<1 cm residual disease) was achieved in 56%. Using univariate analysis, predictors of incomplete cytoreduction were large bowel mesentery implants (LBMI) (P<0.003), pleural effusion (P<0.009), ascites (P<0.009) and peritoneal carcinosis (P<0.01). LBMI (P<0.03) and ascites (P<0.05) were also predictors of suboptimal cytoreduction. Using multivariate analysis, LBMI was the only independent predictor of incomplete cytoreduction (P=0.004) and no predictor of suboptimal cytoreduction was found.

CONCLUSION

PET/CT predictors of cytoreduction were found. But they should not be used to withhold patients form primary cytoreductive surgery. We suggest PET/CT as a supplementary image modality prior to surgery in primary OC patients whenever accurate and comprehensive preoperative evaluation of primary tumor and metastases is desired.

Diagnostic accuracy of 18F-FDG PET/CT in characterizing ovarian lesions and staging ovarian cancer: correlation with transvaginal ultrasonography, computed tomography, and histology

AIMS

To (a) assess the accuracy of 18F-FDG PET/CT in distinguishing malignant from benign pelvic lesions, compared to transvaginal ultrasonography (TVUS) and (b) to establish the role of whole-body 18F-FDG PET/CT, compared to contrast enhanced computed tomography (CT), in staging patients with ovarian cancer.

PATIENTS

Fifty consecutive patients with a pelvic lesion, already scheduled for surgery on the basis of physical examination, TVUS, and serum Ca125 levels, were enrolled in the study. Patients' age ranged between 23 and 89 years (mean 64). All patients underwent TVUS including a colour Doppler study followed by a thorax and abdominal CT scan, and whole-body 18F-FDG PET/CT within 2 weeks prior to surgery. Histological findings obtained at surgery were taken as the 'gold standard' to compare 18F-FDG PET/CT and TVUS, and 18F-FDG PET/CT vs. CT. When tissue analysis showed ovarian cancer, the accuracy of 18F-FDG PET/CT and CT were compared for the purpose of obtaining a precise staging.

RESULTS

At surgery, the ovarian lesions were malignant in 32/50 patients (64%) and benign in the remaining 18/50 patients (36%). The sensitivity, specificity, NPV, PPV and accuracy of 18F-FDG PET/CT were 87%, 100%, 81%, 100% and 92%, respectively, compared with 90%, 61%, 78%, 80% and 80%, respectively, for TVUS. In staging ovarian cancer, 18F-FDG PET/CT results were concordant with final pathological staging in 22/32 (69%) patients while CT results were concordant in 17/32 (53%) patients. CT incorrectly down-staged four out of six stage IV patients by missing distant metastasis in the liver, pleura, mediastinum, and in left supraclavicular lymph nodes, which were correctly detected by 18F-FDG PET/CT.

CONCLUSION

PET/CT with 18F-FDG provides additional value to TVUS for the differential diagnosis of benign from malignant pelvic lesions, and to CT for the staging of ovarian cancer patients.