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Figures
- FIGURE 1.
Kaplan–Meier curves for overall survival of patients with clinically suspected recurrence of cervical cancer according to CWU of experts 1 (A) and 2 (B) and according to 18F-FDG PET (C).
Tables
Characteristic Value No. of patients 40 Median age at diagnosis (y) 41 (range, 27–61) FIGO stage (n) IB 13 IIA 3 IIB 6 IIIA 1 IIIB 13 IVA 1 IVB 1 Unknown 2 Histology (n) Squamous cell carcinoma 25 Adenocarcinoma 11 Large cell 2 Glassy cell 1 Unknown 1 Primary therapy (n) Surgery 11 Radiotherapy 7 Chemoradiation 13 Surgery + radiotherapy 3 Surgery + chemotherapy 1 Surgery + chemoradiation 5 Median time to 18F-FDG PET after primary presentation (mo) 16 (IQR, 10–34) Median duration of follow-up after 18F-FDG PET (mo) 18 (IQR, 10–37) FIGO = Fédération Internationale de Gynécologie et d'Obstétrique.
Sign or symptom Cause of first clinical suspicion Indication for 18F-FDG PET Elevated tumor markers 7 3 Equivocal lesions on CT or MRI 8 24 Clinical symptoms 23 3 Abnormality on physical examination 2 — Equivocal result on pathologic examination — 10 Original 18FDG PET report Expert 18FDG PET reading Recurrence* Present Local Regional Distant Absent Present 24 0 0 0 1 Recurrence* Local 0 8 0 0 1 Regional 0 0 13 0 0 Distant 0 0 0 6 0 Absent 1 1 0 0 14 ↵* Recurrence of disease was categorized as local, regional, and distant. For example, when local recurrence with distant metastases was suspected, patient's extent of recurrence was categorized as “local” and “distant.”
Diagnosis Before PET After PET Changed Change in diagnosis specified* Expert 1 Recurrence, n (%) 28 (70) 24 (60) 12 (30) (−8, +4) Extent of recurrence, n (%)† Local 17 (43) 8 (20) 14 (35) (−12, +2) Regional 11 (28) 13 (33) 10 (25) (−4, +6) Distant 3 (8) 6 (15) 7 (18) (−2, +5) Median confidence about diagnosis, % (IQR)‡ 65 (58–73) 82 (71–89) +14 (6–23) Expert 2 Recurrence, n (%) 27 (68) 23 (58) 10 (25) (−7,+3) Extent of recurrence, n (%)† Local 9 (23) 9 (23) 10 (25) (−5, +5) Regional 16 (40) 12 (30) 12 (30) (−8, +4) Distant 6 (15) 7 (18) 5 (13) (−2, +3) Median confidence about diagnosis, % (IQR)‡ 50 (50–63) 80 (70–90) +25 (10–30) ↵* Number of cases in which presence or extent of recurrence was decreased (−) or increased (+) with added 18F-FDG PET information.
↵† Extent of disease was categorized as local, regional, and distant recurrence. For example, when local recurrence with distant metastases was suspected, patient's extent of recurrence was categorized as “local” and “distant”; percentage of cases was defined as percentage of total number of cases (n = 40).
↵‡ Confidence of expert about diagnosis significantly increased after 18F-FDG PET (Wilcoxon signed rank test, P < 0.0001).
Management Before PET (n) After PET (n) Changed* (n) Change in diagnosis specified† Expert 1 Local therapy‡ 17 14 10 Surgery (1) 6 5 2 1→6 (2×) Radiotherapy (2) 7 6 4 2→6 (4×) Hyperthermia (3) 5 3 4 3→2, 3→5, 3→6 (2×) Systemic therapy 11 9 6 Chemotherapy (4) 6 3 3 4→2, 4→5, 4→6 Palliative treatment (5) 5 6 3 5→1, 5→3, 5→4 Expectative (6) 12 17 4 6→1, 6→2, 6→5 (2×) Curative§ 26 26 4 Curative→palliative (4×) Palliative 14 14 2 Palliative→curative (2×) Expert 2 Local therapy‡ 13 13 7 Surgery (1) 0 2 0 — Radiotherapy (2) 7 8 4 2→4, 2→6 (3×) Hyperthermia (3) 5 3 3 3→4, 3→6 (2×) Systemic therapy 6 6 6 Chemotherapy (4) 6 6 3 4→2 (3×) Palliative treatment (5) 0 0 0 — Expectative (6) 22 21 6 6→1 (2×), 6→2 (2×), 6→3, 6→4 Curative§ 22 24 2 Curative→palliative (2×) Palliative 18 16 6 Palliative→curative (4×) ↵* Number of cases in which pre-PET management plan was changed after 18F-FDG PET.
↵† Change in management specified: 1, surgery; 2, radiotherapy; 3, hyperthermia; 4, chemotherapy; 5, palliative treatment; and 6, expectative.
↵‡ Local therapy for localized recurrence that could be combined with other treatment modalities. Surgery could be combined with radiotherapy, chemoradiation, hyperthermia, or chemotherapy. Radiotherapy could be combined with hyperthermia or chemotherapy. Hyperthermia could be combined with chemotherapy.
↵§ Management plans of patients without suspicion of recurrence were classified under curative intent.
Impact Expert 1 (%) Expert 2 (%) 18F-FDG PET led me to choose therapy that, in retrospect, was not in best interest of patient. 2.5 2.5 18F-FDG PET led to investigations I would not otherwise have performed, but this did not harm patient. 2.5 0.0 18F-FDG PET was of no influence in my diagnosis and choice of treatment. 7.5 15.0 18F-FDG PET provided information that substantially improved my understanding of this patient's disease but did not alter my choice of treatment. 27.5 17.5 18F-FDG PET led to better diagnosis and to beneficial change in management. 60.0 65.0 ↵* Adapted from Wittenberg et al. (15–17).
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