Elsevier

Clinical Radiology

Volume 72, Issue 4, April 2017, Pages 302-306
Clinical Radiology

Detection of extra-regional tumour recurrence with 18F-FDG-PET/CT in patients with recurrent gynaecological malignancies being considered for radical salvage surgery

https://doi.org/10.1016/j.crad.2016.12.009Get rights and content

Highlights

  • For a small proportion of patients with recurrent gynecological malignancy, radical salvage surgery can be a successful treatment option.

  • Appropriate patient selection and exclusion of extra-regional metastases is paramount.

  • PET may identify more extra-regional recurrences than conventional imaging, facilitating patient selection for surgical salvage.

Aim

To compare the detection rate of extra-regional metastases in patients with recurrent gynaecological malignancies being considered for radical salvage surgery with combined 2-[18F]-fluoro-2-deoxy-d-glucose (18F-FDG) positron-emission tomography (PET)/computed tomography (CT) compared to conventional imaging.

Materials and methods

A retrospective review was performed of all patients in a provincial database with recurrent gynaecological malignancies being considered for pelvic exenteration that underwent restaging with CT/PET between March 2011 and October 2014. Findings on PET and conventional imaging (CT ± pelvic MRI) were abstracted. Disease sites were classified according to the location (regional nodal metastases, extra-regional nodal metastases, peritoneum, or other distant sites) and diagnostic certainty (definitive or equivocal). The proportion of patients positive for extra-regional recurrence was calculated for PET and conventional imaging. In addition, the proportion of patients with indeterminate lesions only was calculated for each modality and the sites of indeterminate findings were tabulated.

Results

There were 85 patients (median age, 50 years; range: 30–81 years) with carcinoma of cervix (n=51), endometrium (n=18), vagina (n=6), or vulva (n=10). Extra-regional recurrence was detected in 8/85 (9.4%) and 24/85 (28.2%) patients on conventional imaging and PET, respectively (p=0.0017). The greatest impact of PET compared to conventional imaging was in the detection of extra-regional nodal metastases. PET had significantly fewer examinations equivocal for extra-regional recurrence versus conventional imaging (6/85 [7.1%] and 38/85 [44.7%], respectively, p<0.001).

Conclusion

In patients with recurrent gynaecological malignancies being considered for radical salvage surgery, PET may identify significantly more extra-regional recurrence than conventional imaging. PET may also result in fewer equivocal lesions. The impact of these results on patient management and outcome should be confirmed in future prospective trials.

Introduction

In patients with recurrent gynaecological malignancies, treatment choice is dictated by a multitude of patient-related factors including age, performance status, and comorbidities; tumour-related factors, such as primary tumour site and volume, stage and histological subtype; prior therapy; and time interval from previous treatment.1, 2 Post-progression treatment is most often systemic chemotherapy with or without radiation delivered with a palliative intent; however, for a small proportion of patients who present with central disease recurrence following a significant treatment-free interval, radical salvage surgery, such as a pelvic exenteration, can be a successful treatment option. Pelvic exenteration is a radical surgical procedure involving the en-bloc resection of pelvic organs, which may include the internal reproductive organs, urinary bladder, rectosigmoid, and perineal structures. Bowel and urinary diversion are also performed as indicated.1 Depending on local tumour extent, in some patients resection of pelvic floor muscles and perineal reconstruction with myocutaneous flap is also performed.3 These radical procedures may be offered to patients with isolated central persistent or recurrent cervical, endometrial, vaginal, or vulvar cancer, or to selected patients with lateral recurrence with no involvement of the sciatic nerve. Patients with multifocal recurrence and those with distant visceral and lymph node metastases do not benefit from attempt at curative surgery. Although this may be the only potentially curative procedure for these patients, it is associated with significant morbidity (reported in 31–92% of patients2) and mortality (<5%). Therefore, appropriate patient selection, and exclusion of extra-regional metastases is paramount.

Assessment of recurrent gynaecological malignancy is performed with clinical examination and imaging studies. Magnetic resonance imaging (MRI) may delineate local tumour extent, including invasion of pelvic structures, and computed tomography (CT) is used to detect pelvic and extrapelvic metastases.4, 5 There is evidence to support the use of positron-emission tomography (PET) and integrated PET/CT using 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) in gynaecological malignancies, predominantly in staging and therapy planning.6, 7, 8, 9, 10, 11 Few studies have assessed the utility of PET in patients with recurrent gynaecological cancers in whom radical salvage surgical intervention is being planned.12, 13 These studies have been limited due to either small sample size (only 20 patients assessed in a prospective study by Husain et al.12), or lack of consistent correlation of PET to conventional imaging.13 The purpose of the current study was to assess the incremental value of PET in the selection of patients with biopsy-proven recurrent gynaecological malignancies for radical salvage surgery.

Section snippets

Patient database

This was a retrospective review of a provincial database including all patients with recurrent gynaecological malignancies being considered for radical surgical salvage and who underwent restaging with PET between March 2011 and October 2014. For this indication, access to PET is approved through a provincial case-by-case review programme — “PET Access” — operated by Cancer Care Ontario (CCO). Requisitions are adjudicated by a panel of three physicians, including a nuclear medicine physician

Results

The study included 85 patients (median age, 50 years; range: 30–81 years) diagnosed with recurrent carcinoma of the cervix (n=51), endometrium (n=18), vagina (n=6), and vulva (n=10). Table 1 summarises the results for PET and conventional workup for the presence of metastases. Overall, PET was positive for metastases more often than conventional imaging. Furthermore, it detected extra-regional metastases in significantly more patients than conventional imaging (24 versus 8, respectively; p

Discussion

Since originally described by Alexander Brunschwig in 1948 as a palliative procedure, pelvic exenteration has evolved as potentially curative surgery for patients with persistent or recurrent gynaecological malignancies that are limited to the central pelvis and in which microscopically negative margins are achievable.2 Depending on local tumour extent, surgical salvage may include partial extirpation of the pelvic organs with anterior or posterior exenteration, if there is limited involvement

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