Clinical impact of positron emission tomography or positron emission tomography/computed tomography in the posttherapy surveillance of endometrial carcinoma: evaluation of 88 patients

Reassessment of intensive surveillance practices adopted for endometrial cancer survivors

Background

In Japan, 17,000 women are newly diagnosed with endometrial cancer in 2018. The healthcare insurance policy in Japan provides more intensive patient surveillance compared with the United States and European countries. The aim of this study was to retrospectively analyze data, including surveillance methods, recurrence sites, salvage therapy, and survival period after recurrence, to consider the benefits of surveillance for patients with endometrial cancer.

Methods

Between January 2009 and December 2015, the medical records of patients who were initially diagnosed with the International Federation of Gynecology and Obstetrics stage I–IV endometrial cancer and treated were enrolled in this retrospective study. Only patients with stage IV cancer with peritoneal dissemination were included. Within the first 2 years, the included patients underwent tumor marker tests, Papanicolaou smear test every 1–3-months, and imaging analysis at 6–12- month intervals. Until 4 years, the patients underwent regular surveys every 4 months and imaging analysis annually. Subsequently, the patients received regular surveys every 6 -to 12-months. Results.

Among 847 patients, 88 experienced recurrence, and their clinicopathological data were statistically analyzed. The recurrence site was not associated with the initial treatment method or histology. Among the patients with recurrence, 75% were asymptomatic. Univariate analysis demonstrated that time to recurrence and local recurrence were significant factors for survival outcomes, whereas multivariate analysis indicated that only local recurrence was a significant factor. In patients with distant metastasis, neither symptomatic nor asymptomatic recurrence showed a significant difference in survival.

Conclusions

In this retrospective study, an intensive surveillance protocol did not benefit patients with endometrial cancer. Thus, we hypothesize that the characterization of tumors by emerging technologies that can precisely predict the nature of the tumor will help tailor individualized and efficient surveillance programs. In addition, the ideal salvage therapy needs to be developed to benefit patients after recurrence.

KSNM60 in Clinical Nuclear Oncology

Since the foundation of the Korean Society of Nuclear Medicine in 1961, clinical nuclear oncology has been a major part of clinical nuclear medicine in Korea. There are several important events for the development of clinical nuclear oncology in Korea. First, a scintillating type gamma camera was adopted in 1969, which enabled to perform modern oncological gamma imaging. Second, Tc-99 m generator was imported to Korea since 1979, which promoted the wide clinical use of gamma camera imaging by using various kinds of Tc-99 m labeled radiopharmaceuticals. Third, a gamma camera with single photon emission tomography (SPECT) capability was first installed in 1980, which has been used for various kinds of tumor SPECT imaging. Fourth, in 1994, clinical positron emission tomography (PET) scanner and cyclotron with a production of F-18 fluorodeoxyglucose were first installed in Korea. Fifth, Korean Board of Nuclear Medicine was established in 1995, which contributed in the education and manpower training of dedicated nuclear medicine physicians in Korea. Finally, an integrated PET/CT scanner was first installed in 2002. Since that, PET/CT imaging has been a major imaging tool in clinical nuclear oncology in Korea. In this review, a brief history of clinical nuclear oncology in Korea is described.

How Do We Follow Up Patients With Endometrial Cancer?

PURPOSE OF REVIEW

In this review, we present the existing evidence regarding follow-up care after endometrial cancer, including content of follow-up and type of provider. We furthermore discuss the future perspectives for follow-up care and research in the field.

RECENT FINDINGS

Recently published randomized controlled trials show that nurse-led telephone follow-up and patient-initiated follow-up are feasible alternatives to routine hospital-based follow-up. No randomized or prospective study has evaluated the effect of routine follow-up on survival. Hence, current knowledge is derived from retrospective studies with the inherent risk of bias. The most important method for recurrence detection is a review of symptoms. There is no evidence to support a survival benefit from the use of routine physical examinations, additional tests, or imaging. One in three of the women attending hospital-based follow-up experience unmet needs, and alternative models for follow-up focused on survivorship care and empowerment should be tested.

Clinical and prognostic value of 18F-FDG PET/CT in recurrent endometrial carcinoma

PURPOSE

Endometrial carcinoma (EC) is a cancer with a good overall prognosis, except in cases of recurrent or advanced EC. The aim of this study was to assess the diagnostic performance, the prognostic value and the impact on therapeutic management of ¹⁸F-FDG PET/CT in suspected recurrent EC.

MATERIALS AND METHODS

We retrospectively evaluated 157 patients with histologically proven EC and restaging ¹⁸F-FDG PET/CT for suspected recurrence. The PET images were analyzed visually and semi-quantitatively by measuring SUVmax, MTV and TLG. A combination of clinical/imaging follow-up and/or histopathology was taken as reference standard. Progression-free survival (PFS) and overall survival (OS) were computed using Kaplan-Meier curves.

RESULTS

Seventy-nine patients had positive ¹⁸F-FDG PET/CT showing the presence of at least one hypermetabolic lesion consistent with recurrence, while the remaining 78 were negative. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of ¹⁸F-FDG PET/CT were 96%, 99%, 99%, 96%, 97%, respectively, and were higher compared to conventional imaging: 97%, 62%, 72%, 96%, 80%. After a mean follow-up of 39months, relapse/progression occurred in 58 patients and death in 37 with an average time of 22.1 and 27.6months, respectively. A positive ¹⁸F-FDG PET/CT and advanced FIGO stage were significantly associated with shorter PFS and OS. PET/CT results had a significant impact on therapeutic approach in 33 patients: avoiding unnecessary therapies in 28 and modifying therapy in 5.

CONCLUSIONS

¹⁸F-FDG PET/CT has a very good diagnostic performance in patients with suspected recurrent EC and has an important prognostic value in assessing PFS and OS. Moreover, PET/CT allowed for a change in treatment decision in about 20% of cases.

The Complementary Role of Imaging and Tumor Biomarkers in Gynecological Cancers: An Update of the Literature

Gynecological tumors, including endometrial, cervical and ovarian cancer, have increased in incidence over time. The widespread introduction of screening programs and advances in diagnostic imaging methods has lead to a progressive increase in gynecological cancer detection. Accurate diagnosis and proper monitoring of disease remain the primary target for a successful treatment. In the last years, knowledge about cancer biomarkers has considerably increased providing great opportunities for improving cancer detection and treatment. In addition, in the last few years there has been an important development of imaging techniques. Nowadays, a multimodal approach including the evaluation of serum tumor biomarkers combined with imaging techniques, seems to be the best strategy for assessing tumor presence, spread, recurrence, and/or the response to treatment in female cancer patients In this review we provide an overview of the application of biomarkers combined with novel imaging methods and highlight their roles in female cancer diagnosis and follow-up.

Surveillance Imaging in Patients With Endometrial Cancer in First Remission

OBJECTIVE

The clinical benefit of surveillance imaging in endometrial cancer remains undefined. This retrospective study was conducted to evaluate the positive predictive value (PPV) of surveillance imaging in endometrial cancer.

METHODS

A total of 128 patients in first remission after treatment for endometrial cancer (uterine papillary serous, clear cell, stage III endometroid) who had surveillance imaging were retrospectively identified. The surveillance period was defined from the time of first-negative scan after treatment to the time when treatment was started for recurrent disease. Reports of surveillance scans were reviewed for the presence or absence of findings. The primary outcome was PPV of surveillance imaging. Cost and radiation exposure from surveillance imaging were also evaluated.

RESULTS

A total of 128 patients had 707 surveillance scans (computed tomography, positron emission tomography-computed tomography with 2-deoxy-2-[¹⁸F]fluoro-d-glucose, magnetic resonance image, and bone scans). Median follow-up was 54 months (range: 9-173). Of all, 47 patients (37%) started therapy for recurrent endometrial cancer at the discretion of the treating physician. PPV of all surveillance imaging was 57.7%. Per patient, the mean number of surveillance scans was 5.6 (range: 2-21). The mean cost of imaging was $4200 (range: $1200-$18,700) and mean radiation exposure was 109.6mSV (range: 16-445mSv).

CONCLUSIONS

Surveillance imaging detected a significant number of recurrences in patients with high-risk endometrial cancer at a reasonable cost related to the overall risk. Well-designed prospective imaging trials are warranted to assess the clinical benefit of surveillance imaging.

FDG-PET/CT in the Postoperative Period: Utility, Expected Findings, Complications, and Pitfalls

FDG-PET/CT as a modality is increasingly used for detection of recurrence and for restaging in patients with clinical suspicion of malignancy, as well as in patients with elevated tumor markers. However, there are many pitfalls in the interpretation of these scans when the studies are performed after some treatment. Some of these are attributed to normal physiological distribution and are compounded when there are inflammatory changes occurring after surgery. The body's inherent response to the surgical insult results in this inflammation. In addition, there are also complications that can happen following surgery, causing increased FDG uptake. Despite various fallacies, FDG-PET/CT provides valuable information in evaluation of residual and recurrent malignant disease. In this article, we aim to describe some of these postsurgical changes secondary to inflammation, common surgical complications, and finally, the utility of FDG-PET/CT in these patients to detect recurrent disease, even in the background of postsurgical changes.

Trends in Periodic Surveillance Testing for Early-Stage Uterine Cancer Survivors

OBJECTIVE

To examine the use of periodic surveillance testing for early-stage endometrial cancer survivors.

METHODS

We performed a population-based analysis using the Surveillance, Epidemiology, and End Results-Medicare database, which was used to identify patients with stage I-II endometrioid endometrial cancer treated from 1992 to 2011. Three surveillance periods (7-18, 19-30, 31-42 months) after hysterectomy were examined. Use of vaginal cytology and imaging were quantified.

RESULTS

We identified 17,638 patients. From 1992 to 2011, the use of chest radiography decreased (46.3-34.2%) during the first surveillance period, whereas imaging with chest computed tomography (CT) (0.9-12.6%), abdominopelvic CT (11.7-24.8%), and positron emission tomography (0-2.9%) increased (P<.001 for all). The use of cytology increased from 68.5% in 1992 to 72.3% in 2007 and then decreased to 66.9% in 2011 (P=.02). The mean number of cytologic samples obtained per patient increased from 1.3 in 1992 to 1.6 in 2008 and then declined to 1.3 in 2011, whereas the mean per patient number of chest CTs (0.02-0.2), abdominopelvic CTs (0.2-0.4), and positron emission tomographies (0-0.03) rose from 1992 to 2011. In 2011, 49.3% underwent radiologic surveillance 7-18 months after diagnosis, whereas 11.9% underwent two or more radiologic assessments in combination with cytology. These findings were similar for surveillance periods 2 and 3.

CONCLUSION

The use of chest radiography has decreased and use of cytology has started to decline. However, the use of more costly imaging modalities is increasing despite a lack of evidence for the efficacy of these tests for early-stage endometrial cancer survivors.

High Diagnostic Value of 18F-FDG PET/CT in Endometrial Cancer: Systematic Review and Meta-Analysis of the Literature

The aim of this study was to evaluate the diagnostic performance of (18)F-FDG PET/CT for the preoperative assessment of lymph node metastases (LNM) in endometrial cancer patients and for the assessment of endometrial cancer recurrence (ECR) after primary surgical treatment.

METHODS

A comprehensive search was performed on Pubmed/MEDLINE databases for studies reporting the diagnostic performance of (18)F-FDG PET/CT for assessment of LNM and ECR published up to August 15, 2015. Twenty-one studies (13 for LNM and 8 for ECR) were included in the systematic review and meta-analysis. Pooled estimates of sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of the (18)F-FDG PET/CT were calculated along with 95% confidence intervals (CIs). A summary receiver-operating-characteristics curve (SROC) was constructed, and the area under the SROC curve (AUC) was determined along with Q* index.

RESULTS

The overall pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and AUC (with 95% CI) of (18)F-FDG PET/CT for detection of LNM were 0.72 (95% CI, 0.63-0.80), 0.94 (95% CI, 0.93-0.96), 10.9 (95% CI, 7.9-15.1), 0.36 (95% CI, 0.27-0.48), 39.7 (95% CI, 21.4-73.6), and 0.94 (95% CI, 0.85-0.99), respectively, whereas the corresponding numbers for detection of ECR were 0.95 (95% CI, 0.91-0.98), 0.91 (95% CI, 0.86-0.94), 8.8 (95% CI, 6.0-12.7), 0.08 (95% CI, 0.05-0.15), 171.7 (95% CI, 67.9-434.3), and 0.97 (95% CI, 0.95-0.98), respectively. The overall diagnostic accuracy (Q* index) in LNM and ECR were 0.88 and 0.93, respectively.

CONCLUSION

(18)F-FDG PET/CT has an excellent diagnostic performance for detecting LNM preoperatively and disease recurrence postoperatively in endometrial cancer patients.

Follow-up in Gynecological Malignancies: A State of Art

Objective

The main purpose of this article is to explore the current practice for follow-up of gynecological cancer, pointing out the different procedures, to determine the most clinically and cost-effective surveillance strategies after the primary treatment.

Materials and Methods

We analyzed the follow up strategies for ovarian, endometrial, and cervical cancer. All of the topics discussed below arose from the “ESGO State of Art Conference—Follow-up in gynaecological malignancies” in Turin, (September 11–13, 2014;http://torino2014.esgo.org/).

Results

Physical but these practices should be integrated with biomarkers or imaging strategies. Currently, most recommendations about follow-up are based on retrospective studies and expert opinion, and there is some disagreement on surveillance strategies due to lack of evidence-based knowledge.

Conclusions

All surveillance procedures should be evidence-based with a clearly defined purpose: there is a need for prospective studies to compare the effectiveness of different follow-up regimens measuring overall survival, detection of recurrence, quality of life (QoL), and costs as outcomes.

Gynecologic oncologic imaging with PET/CT

FDG-PET/CT has been evaluated in a variety of gynecologic malignancies in a variety of settings and is approved by the Centers for Medicare & Medicaid Services for the initial and subsequent treatment strategies of these malignancies. Cervical cancer is typically very FDG avid, and FDG-PET/CT appears to be most valuable for initial staging, radiation therapy planning, and detection of recurrent disease. For ovarian cancer, the most value of FDG-PET/CT appears to be for detecting recurrent disease in the setting of rising CA-125 level and negative or equivocal anatomical imaging studies. Initial studies evaluating response to therapy are promising and further work in this area is needed. FDG uptake in both nonmalignant and physiological processes in the pelvis can make interpretation of FDG-PET/CT in this region challenging and knowledge of these entities and patterns can avoid misinterpretation. Some of the most common findings relate to the cyclic changes that occur as part of the menstrual cycle in premenopausal women. Mucinous tumors and low-volume or peritoneal carcinomatosis are causes of false-negative results on FDG-PET/CT studies. As new tracers are developed, comparisons with patient outcomes and standards of care (eg, FDG-PET/CT) will be needed.

Role of 18F-FDG PET/CT in the carcinoma of the uterus: a review of literature

In the present review we reported the value of 18F-fluorodeoxyglucose (FDG) PET/CT in face of uterine cancer, in terms of sensitivity, specificity and accuracy. Moreover, we made a comparison with the other imaging techniques currently used to evacuate these tumors including contrast-enhanced CT, contrast enhanced-MRI and transvaginal ultrasonography. FDG PET/CT has been reported to be of particular value in detecting occult metastatic lesions, in prediction of response to treatment and as a prognostic factor.

[Follow-up of endometrial cancer]

Available data on appropriate follow-up in endometrial cancer highlight the need of well-conducted studies. Most recurrences tend to occur within three years and involve symptoms. Routine tests are not advocated without symptoms. In case of suspicious recurrence, TEP/CT seems to be the most sensitive and specific method. There is limited evidence to decide whether follow-up schedules with multiple visits result in survival benefits. An appropriate follow-up should be discussed based upon the risk of recurrence. Counselling on the potential symptoms of recurrence should be a major aim.

Carcinoma endometrium: role of 18-FDG PET/CT for detection of suspected recurrence

OBJECTIVE

Recurrent carcinoma endometrium has a poor prognosis. However, successful salvage with long-term survival has been achieved after hormone therapy, radical surgery, and radiotherapy/chemotherapy in patients with recurrent disease. Conventional imaging (CI) and tumor marker have limited accuracy for detecting recurrence in these patients. The aim of the present study was to evaluate the role of 18-flurodeoxyglucose (FDG) positron emission tomography-computed tomography (PET/CT) in patients suspected to have recurrence of carcinoma endometrium.

METHODS

In this retrospective study, total 101 patients were evaluated. All patients had undergone surgery with/without adjuvant therapy (chemotherapy/radiotherapy/both) for histologically proven carcinoma endometrium. They underwent 18-FDG PET/CT studies for suspected recurrence. Comparable CI (contrast-enhanced CT and/or magnetic resonance imaging) was available for 76 patients. Results of FDG PET/CT were confirmed with clinical/imaging follow-up and/or histopathology.

RESULTS

The mean age was 56.9±8.6 years. 18-FDG PET/CT was positive for recurrence in 51 (50.5%) patients and negative in 50 (49.5%). Locoregional disease was observed in 24 patients, metastatic disease was observed in 10, and 17 showed both locoregional and metastatic disease. The sensitivity, specificity, positive and negative predictive values, and accuracy of 18-FDG PET/CT were 88.9%, 93.6%, 94.1%, 88%, and 91%, respectively. 18-FDG PET/CT showed strong positive correlation with final diagnosis based on reference standard (κ 0.823; P=0.0001). Compared to CI, 18-FDG PET/CT has much higher specificity (62% vs. 96.4%), and accuracy (76.3% vs. 92.1%), with comparable sensitivity (85.1% vs. 89.5%).

CONCLUSION

18-FDG PET/CT is a highly sensitive and specific modality for detecting recurrence in post-therapy patients of carcinoma endometrium with suspected recurrence. It performs better than CI.

The role of FDG-PET/CT in gynaecological cancers

There is now a growing body of evidence supporting the use of fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) in gynaecological malignancies. Although this molecular imaging technique is becoming increasingly available, PET/CT remains an expensive imaging tool. It is essential to be familiar with the circumstances in which FDG-PET/CT can add value and contribute to patient management and indeed to know when it is unlikely to be of benefit. It is also important to understand and recognize the potential pitfalls. FDG-PET/CT has been most widely adopted for staging patients with suspected advanced disease or in suspected recurrence, offering a whole-body imaging approach. However, there is great potential for this technique to act as a predictive biomarker of response to treatment, as well as a prognostic biomarker. In addition, FDG-PET images may now be incorporated into radiotherapy planning in order to refine the delineation of dose according to metabolically active sites of disease. This article reviews the literature that provides the evidence for the use of FDG-PET in gynaecological malignancies, identifies areas of real benefit and future potential, and highlights circumstances where there is limited value.

PET/CT imaging in gynecologic malignancies: a critical overview of its clinical impact and our retrospective single center analysis

Gynecologic cancers represent a major global healthcare problem since they are associated with a significant mortality and morbidity. Over the last decade, considerable efforts have been spent in the development and optimization of novel diagnostic modalities to achieve an early diagnosis, aid in choosing appropriate treatment, improving long term surveillance, with the ultimate goal of increasing survival of gynecologic cancer patients. A growing body of evidence defines PET/CT as one of the most powerful tools for tumor, nodal and metastasis (TNM) cancer staging both in pre-treatment and in post treatment follow-up settings. At any phase of cancer evaluation, detection of metastasis represents one of the most critical impediments to the cure of tumor; traditional diagnostic imaging modalities, such as computed tomography (CT), are frequently found to inadequately stage the tumor, based on subsequent outcomes. As a consequence, patients may undergo pointless surgery for disease that could be treated with local medical therapies. In the setting of restaging, the ability to describe primary lesion, lymph nodes, possible metastases to peritoneum, bone, liver, lungs and brain renders PET/CT a potential alternative for a series of tests, including bone scanning, MRI or ultrasound, diagnostic CT, lymph node surgical sampling, that need to be used in combination in order to obtain a level of clinical confidence. In this review, we describe, the theoretical advantage and prognostic implications of PET/CT in the management of gynecologic cancer patients.

ACR appropriateness Criteria® pretreatment evaluation and follow-up of endometrial cancer of the uterus

Endometrial cancer is one of the common malignancies in the female genital tract. Imaging in pretreatment evaluation may play an important role in an assessment of morphological prognostic factors including tumor size, depth of myometrial invasion, endocervical extent, and lymph node status. Imaging is also useful in posttreatment evaluation of patients with clinically suspected recurrence. Various modalities including MRI, CT ultrasound and FDG PET-CT-CT have been used for evaluation of the endometrial cancer in both before and after treatment settings. Literature on the indications and usefulness of these imaging studies for endometrial cancer is reviewed.

The value of FDG-PET/CT in the post-treatment evaluation of endometrial carcinoma: a comparison of PET/CT findings with conventional imaging and CA 125 as a tumour marker

OBJECTIVES

This retrospective study was designed to assess the value of positron emission tomography/computed tomography imaging (PET/CT) in the post-treatment evaluation of the patients with endometrial carcinoma and to compare PET/CT scan with conventional imaging (CI) including computed tomography (CT), ultrasonography (US) and magnetic resonance imaging (MRI) and CA 125 with both 20U/ml and 35U/ml cut-off values.

MATERIALS AND METHODS

A total of 31 patients who were treated for histopathologically proven endometrial adenocarcinoma, underwent PET/CT examination for restaging and suspected recurrence. Thirty five PET/CT studies were performed in 31 patients. Lesion status was determined on the basis of clinical follow-up including radiological imaging (follow-up CT scan) at least 6 months and response to therapy.

RESULTS

Of the 35 PET/CT studies, 13 (37%) studies were positive, whereas 22 (63%) of them were negative. On study-based analysis the overall sensitivity, specificity, accuracy for PET/CT imaging were 100%, 96% and 97%, respectively. The corresponding information for CI were 46%, 87% and 74%, for CA 125 (cut off=20U/ml) measurement were 45%, 88% and 74%, and for CA 125 (cut off=35U/ml) measurement were 27%, 100% and 78%, respectively. On lesion-based analysis, PET/CT revealed only one false positive case. In none of 21 patients with negative 22 PET/CT studies, no subsequent clinical or radiological recurrences were observed with a follow-up of at least 6 months.

CONCLUSION

FDG-PET/CT is found more useful modality than CI and CA 125 in the evaluation of post-treatment endometrial carcinoma patients, for suspected recurrence.

PET/CT in gynecologic cancer: present applications and future prospects--a clinician's perspective

This article briefly reviews the epidemiology, diagnosis, and treatment of the common gynecologic malignancies, with an emphasis on the shortcomings of current clinical practice. The persistent need to achieve early diagnosis, adjust proper treatment, enhance surveillance, and improve the outcome of these patients has led to the development of new diagnostic modalities. Novel tools such as 18F-fluorodeoxyglucose PET/CT should aim at enhancing the clinician's ability to make critical decisions in treating difficult scenarios.

Posttreatment surveillance and diagnosis of recurrence in women with gynecologic malignancies: Society of Gynecologic Oncologists recommendations

Although gynecologic cancers account for only 10% of all new cancer cases in women, these cancers account for 20% of all female cancer survivors. Improvements in cancer care have resulted in almost 10 million cancer survivors, and this number is expected to grow. Therefore, determining the most cost-effective clinical surveillance for detection of recurrence is critical. Unfortunately, there has been a paucity of research in what are the most cost-effective strategies for surveillance once patients have achieved a complete response. Currently, most recommendations are based on retrospective studies and expert opinion. Taking a thorough history, performing a thorough examination, and educating cancer survivors about concerning symptoms is the most effective method for the detection of most gynecologic cancer recurrences. There is very little evidence that routine cytologic procedures or imaging improves the ability to detect gynecologic cancer recurrence at a stage that will impact cure or response rates to salvage therapy. This article will review the most recent data on surveillance for gynecologic cancer recurrence in women who have had a complete response to primary cancer therapy.

Established, emerging and future applications of FDG-PET/CT in the uterine cancer

Integrated positron emission tomography/computed tomography (PET/CT) with 2-[¹⁸F]fluoro-2-deoxy-D-glucose (FDG) is a useful technique to acquire both glucose metabolic and anatomic imaging data using a single device in a single diagnostic session and has opened a new field in clinical oncologic imaging. FDG-PET/CT has been used successfully for the staging, optimization of treatment, re-staging, therapy monitoring, and prognostic prediction of uterine cervical cancer and endometrial cancer as well as various malignant tumours. The present review discusses the current role of FDG-PET/CT in the management of uterine cancer, discussing its usefulness and limitations in the imaging of these patients.

PET/CT Imaging in Gynecologic Malignancies Other than Ovarian and Cervical Cancer

Fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) is an imaging modality used for staging, assessing response to therapy, and diagnosis of recurrent cervical and ovarian cancer. The potential role of FDG-PET/CT in other gynecologic malignancies such as endometrial cancer, uterine sarcomas, vaginal, and vulvar cancer has not been fully explored.

Current status in the management of uterine corpus cancer in Korea

Uterine corpus cancer has increased in prevalence in Korean women over the last decade. Recently, elegant studies have been reported from many institutes. To improve treatment strategies, a review of our own data is warranted. This work will discuss the risks and prognostic factors for uterine corpus cancer, and the radiologic evaluation, prediction of lymph node metastasis, systematic lymphadenectomy, minimally invasive surgery, ovarian-saving surgery, fertility-sparing treatment, and adjuvant treatment in women with uterine cancer.

PET/CT in Gynecologic Cancer: Present Applications and Future Prospects-A Clinician's Perspective

This article briefly reviews the epidemiology, diagnosis, and treatment of the common gynecologic malignancies, with an emphasis on the shortcomings of current clinical practice. The persistent need to achieve early diagnosis, adjust proper treatment, enhance surveillance, and improve the outcome of these patients has led to the development of new diagnostic modalities. Novel tools such as 18F-fluorodeoxyglucose PET/CT should aim at enhancing the clinician's ability to make critical decisions in treating difficult scenarios.

Low-dose non-enhanced CT versus full-dose contrast-enhanced CT in integrated PET/CT studies for the diagnosis of uterine cancer recurrence

PURPOSE

To evaluate low-dose non-enhanced CT (ldCT) and full-dose contrast-enhanced CT (ceCT) in integrated (18)F-fluorodeoxyglucose (FDG) PET/CT studies for restaging of uterine cancer.

METHODS

A group of 100 women who had undergone treatment for uterine cervical (n=55) or endometrial cancer (n=45) underwent a conventional PET/CT scans with ldCT, and then a ceCT scan. Two observers retrospectively reviewed and interpreted the PET/ldCT and PET/ceCT images in consensus using a three-point grading scale (negative, equivocal, or positive) per patient and per lesion. Final diagnoses were obtained by histopathological examination, or clinical follow-up for at least 6 months.

RESULTS

Patient-based analysis showed that the sensitivity, specificity and accuracy of PET/ceCT were 90% (27/30), 97% (68/70) and 95% (95/100), respectively, whereas those of PET/ldCT were 83% (25/30), 94% (66/70) and 91% (91/100), respectively. Sensitivity, specificity and accuracy did not significantly differ between two methods (McNemar test, p=0.48, p=0.48, and p=0.13, respectively). There were 52 sites of lesion recurrence: 12 pelvic lymph node (LN), 11 local recurrence, 8 peritoneum, 7 abdominal LN, 5 lung, 3 supraclavicular LN, 3 liver, 2 mediastinal LN, and 1 muscle and bone. The grading results for the 52 sites of recurrence were: negative 5, equivocal 0 and positive 47 for PET/ceCT, and negative 5, equivocal 4 and positive 43 for PET/ldCT, respectively. Four equivocal regions by PET/ldCT (local recurrence, pelvic LN metastasis, liver metastasis and muscle metastasis) were correctly interpreted as positive by PET/ceCT.

CONCLUSION

PET/ceCT is an accurate imaging modality for the assessment of uterine cancer recurrence. Its use reduces the frequency of equivocal interpretations.

Hybrid imaging (SPECT/CT and PET/CT): improving therapeutic decisions

The incremental diagnostic value of integrated positron emission tomography-computed tomography (PET/CT) or single-photon emission computed tomography (SPECT)/CT images compared with PET or SPECT alone, or PET or SPECT correlated with a CT obtained at a different time includes the following: (1) improvement in lesion detection on both CT and PET or SPECT images, (2) improvement in the localization of foci of uptake resulting in better differentiation of physiological from pathologic uptake, (3) precise localization of the malignant foci, for example, in the skeleton vs soft tissue or liver vs adjacent bowel or node (4) characterization of serendipitous lesions, and (5) confirmation of small, subtle, or unusual lesions. The use of these techniques can occur at the time of initial diagnosis, in assessing the early response of disease to treatment, at the conclusion of treatment, and in continuing follow-up of patients. PET/CT and SPECT/CT fusion images affect the clinical management in a significant proportion of patients with a wide range of diseases by (1) guiding further procedures, (2) excluding the need of further procedures, (3) changing both inter- and intramodality therapy, including soon after treatment has been initiated, and (4) by providing prognostic information. PET/CT fusion images have the potential to provide important information to guide the biopsy of a mass to active regions of the tumor and to provide better maps than CT alone to modulate field and dose of radiation therapy. It is expected that the role of PET/CT and SPECT/CT in changing management will continue to evolve in the future and that these tools will be fundamental components of the truly "personalized medicine" we are striving to deliver.