Elsevier

Surgical Oncology

Volume 26, Issue 4, December 2017, Pages 347-351
Surgical Oncology

The role of F18-FDG PET/CT in predicting secondary optimal de-bulking in patients with recurrent ovarian cancer

https://doi.org/10.1016/j.suronc.2017.07.004Get rights and content

Abstract

Background and objectives

The decision to perform secondary cytoreductive surgery for recurrent ovarian cancer is generally determined by clinical criteria. The aim of this study was to assess the predictive capability of FDG-PET/CT in identifying patients for whom secondary optimal debulking can be obtained.

Methods

We reviewed the records of all women with suspected recurrent ovarian cancer (CA-125 levels >35 U/ml and/or clinical symptoms), at two medical centers, between January 2004 and December 2013. Patients in whom CT scans were negative, indeterminate or indicative of localized disease, were referred for preoperative FDG-PET/CT study. We analyzed the outcomes of those who subsequently underwent cytoreductive surgery.

Results

Of 282 women with suspected recurrent ovarian cancer, 48 underwent FDG-PET/CT. The 24 for whom localized disease was detected on PET/CT, subsequently underwent secondary debulking surgery. Patients with PET/CT evidence of multifocal recurrent sites were referred for chemotherapy. Tumor debulking was optimal in 20 patients, and suboptimal in 4. The positive predictive value of PET/CT for optimal debulking was 83.3%.

Conclusions

The findings extend prior reports on the role of FDG-PET/CT in the management of recurrent ovarian cancer, to the prediction of secondary optimal debulking. Future studies should aim to investigate the impact on survival.

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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