Quantitative metabolic parameters measured on F-18 FDG PET/CT predict survival after relapse in patients with relapsed epithelial ovarian cancer
Introduction
Ovarian cancer is the leading cause of death among women with gynecologic cancers and the third most common malignant tumor of the reproductive system, preceded by cervical and uterine cancer [1]. Initial response rates to standard primary treatments, including cytoreductive surgery and platinum-based combined chemotherapy, are approximately 80%, but most patients with advanced disease relapse within 2 years [2]. Relapse of epithelial ovarian cancer (EOC) occurs in a heterogeneous group of patients, with a wide variation in progression-free survival ranging from a few weeks to > 3 years [3].
Several predictors of prolonged post-relapse survival (PRS) including young age, prolonged platinum-free interval (PFI), low level of serum cancer antigen 125 (CA125), absence of ascites, localized relapse, completeness of secondary cytoreductive surgery (SCS) with no residual disease, and good response to second-line chemotherapy have been reported [4], [5], [6].
Currently, F-18 fludeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) has been widely used in detecting relapse and restaging in patients with EOC. Metabolic tumor volume (MTV) and total lesion glycolysis (TLG) measured on FDG PET/CT are quantitative metabolic parameters that reflect both the metabolic activity and tumor volume. In recent years, a few studies reported that pretreatment MTV [7] and TLG [8] showed statistically significant associations with relapse in EOC patients. The results of that study suggested that quantitative metabolic parameters are more important predictors of relapse than any of the previously known clinicopathological parameters in EOC. However, pretreatment quantitative metabolic parameters are not entirely reflective of the true tumor burden at the time of relapse. In another prospective study to use FDG PET/CT in optimizing patient selection for SCS in relapsed EOC, SCS was proactively considered only in patients whose FDG uptake patterns are localized and achieved a high rate of complete resection [9]. However, there are no published data on the clinical utility of quantitative metabolic parameters measured on FDG PET/CT at the time of relapse in patients with relapsed EOC.
In this study, we attempted to determine whether quantitative metabolic parameters measured on FDG PET/CT at the time of the first relapse could predict PRS in patients with relapsed EOC and to design a more robust prognostic model specifically targeting relapsed EOC incorporating clinical and quantitative metabolic parameters.
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Patients
We performed a retrospective review of 56 consecutive patients who had a first EOC relapse between August 2005 and June 2013. The inclusion criteria were as follows: (1) histopathologically confirmed diagnosis of EOC, according to the World Health Organization criteria; (2) standard first-line treatment based on cytoreductive surgery followed by platinum-based combined chemotherapy, such as cisplatin or carboplatin (6–9 cycles); (3) histological or imaging evidence of relapse of EOC; and (4) FDG
Clinical features and treatment outcomes
The distribution of clinical characteristics in 56 patients with relapsed EOC is shown in Table 1. The median duration of follow-up was 46.2 months (range, 11–145 months). By the time of analysis, 32 patients (57%) had died from the disease, and 5 of 32 patients died within 6 months after relapse following rapid disease progression. The median PRS duration for surviving patients was 35 months (range 16–90 months).
Thirty-one patients (55%) had serous histology, and 25 patients (45%) had non-serous
Discussion
The aim of this study was to investigate the relationship between quantitative metabolic parameters and PRS in patients with relapsed EOC. To our knowledge, this study is the first to suggest that quantitative metabolic parameters measured on FDG PET/CT at the time of relapse are significant prognostic parameters in patients with relapsed EOC, despite the small number of patients included in the analysis.
Conclusion
Our results suggest that the quantitative metabolic parameters measured on FDG PET/CT at the time of relapse have significant predictive values for PRS. The quantitative metabolic parameters measured on FDG PET/CT at the time of relapse can reflect relapsed tumor burden in the whole body and have a relation with conventional clinical parameters. Incorporating quantitative metabolic parameters and clinical parameters has a superior prognostic discrimination compared with clinical parameters
Conflict of interest statement
The authors declare that they have no conflict of interest.
Acknowledgments
We thank Dr. Won Kee Lee for the statistical advice. This work was supported by grants from the Korea Health Technology Research and Development Project, Ministry of Health & Welfare, Republic of KOREA (Grant number A111345) and a grant from the National Nuclear Research and Development Program through the National Research Foundation of Korea funded by the Ministry of Education, Science and Technology (Grant number 2012M2A2A7014020 & NRF-2009-0078234).
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Department of Nuclear Medicine, Kyungpook National University School of Medicine/Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 700-721, Republic of Korea. Fax: + 82 53 200 3419.