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