The role of F18-FDG PET/CT in predicting secondary optimal de-bulking in patients with recurrent ovarian cancer
Introduction
Ovarian cancer is the leading cause of death from gynecological cancer in the western world [1]. Despite good initial response, approximately 80% of patients ultimately relapse and require additional therapy [2]. Recurrence is usually characterized by multi-site disease, and the treatment of choice is second-line chemotherapy. In a subset of patients, recurrent disease is localized and surgical intervention to obtain second optimal debulking is an optional treatment. However, the role of secondary cytoreductive surgery in recurrent ovarian cancer (ROC) is not clearly defined since there are no available randomized controlled studies that show survival benefit for this approach [3], [4], [5]. Nevertheless, retrospective studies have demonstrated an association between secondary tumor reduction to optimal residuals, < 5 mm, as well as < 1 cm, and improved survival [5], [6]. Identification of patients for whom the potential benefits of secondary cytoreductive surgery outweigh the risks is challenging. Clinical criteria have been used, such as the outcome of primary surgery, long disease-free interval (>12 months), site/size of recurrence and the general well-being of the patient, as well as platinum sensitivity [7], [8], [9]. Harter at al reported the usefulness of an Arbeitsgemeinschaft Gynaekologische Onkologie (AGO) score in predicting the probability of successful optimal debulking [10]. The above-mentioned factors have been shown to be associated with better post-recurrence survival time; however, their value is limited [11], [12]. Therefore, other modalities are needed to improve patient selection for surgery.
Several investigations have demonstrated the utility of FDG-PET/CT for early detection of recurrent ovarian disease [13], and its superiority over CT, MRI and US in the evaluation of patients with recurrent ovarian cancer [14], [15], [16], [17], [18]. However, none of them attempted to translate imaging superiority to clinical benefit, such as the probability of achieving optimal debulking. The primary objective of the current study was to determine whether PET/CT imaging can predict optimal debulking in patients who undergo secondary cytoreductive surgery.
Section snippets
Materials and methods
In the year 2004, the teams of the Gyneco-Oncology Units at Rambam Health Care Campus and Carmel Medical Center decided that every woman with suspected recurrence of ovarian cancer would undergo CT. If the CT would not show multi-focal disease, but rather negative or indeterminate findings, or indicate localized disease, she would be referred to FDG-PET/CT, and subsequently to secondary debulking if the PET findings would indicate localized disease. In 2015, following approval of the Ethics
Results
The flow of the study population is depicted in Fig. 1. Of the 282 women evaluated for suspected recurrent ovarian cancer during the study period, 234 were referred for chemotherapy, following evidence of disease in more than two sites according to CT scans. The clinical characteristics of the 48 women who underwent FDG PET/CT are presented in Table 1. All patients had undergone primary debulking surgery and had received primary chemotherapy. Their mean age was 54 years (range 27–79 years). Of
Discussion
When FDG-PET/CT results were considered alone, their positive predictive value for optimal debulking was 83.3%. This supports the usefulness of fused FDG-PET/CT as a predictor for successful secondary cytoreductive surgery.
Our protocol was based on the assumption that optimal debulking in second cytoreduction associates with survival benefit in patients with recurrent ovarian cancer. A number of documentations have demonstrated survival benefits when optimal debulking was obtained [3], [8], [9]
Conclusions
Our results should be interpreted with caution due to the relatively small cohort size. Clinical indices should still play a significant role in selecting the patients who may benefit from a second attempt to achieve optimal debulking. However, our results, in combination with previously reported findings, support the utility of FDG-PET/CT for improving the identification of patients who will benefit from surgical procedure, and for avoiding unnecessary procedures in those who will not benefit.
Disclosure statement
The authors report no conflict of interest.
Brief summary
Our results support the utility of FDG-PET/CT for improving the identification of patients who will benefit from a second attempt to achieve optimal debulking.
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