Elsevier

Gynecologic Oncology

Volume 97, Issue 1, April 2005, Pages 183-191
Gynecologic Oncology

FDG-PET for management of cervical and ovarian cancer

https://doi.org/10.1016/j.ygyno.2004.12.007Get rights and content

Abstract

Objective

To assess the diagnostic performance of Positron Emission Tomography using fluorodeoxyglucose (FDG-PET) in comparison to conventional imaging modalities in the assessment of patients with cervical and ovarian cancer.

Methods

Studies published between 1966 and 2003 were identified using an OVID search of the MEDLINE database. Inclusion criteria were use of a dedicated scanner, resolution specified, ≥12 human subjects, clinical follow-up ≥6 months or histopathology as reference standard, and sufficient data provided to construct a two-by-two table. Two reviewers independently abstracted data regarding sensitivity and specificity of PET.

Results

25 studies (15 cervical cancer, 10 ovarian cancer) met inclusion criteria for full text review. For cervical cancer, pooled sensitivity and specificity of PET for aortic node metastasis are 0.84 (95% CI 0.68–0.94) and 0.95 (0.89–0.98). Pooled sensitivity and specificity for detection of pelvic node metastasis are: PET, 0.79 (0.65–0.90) and 0.99 (0.96–0.99); MRI, 0.72 (0.53–0.87) and 0.96 (0.92–0.98). Pooled sensitivity for CT is 0.47 (0.21–0.73) (pooled specificity not available). Pooled sensitivity and specificity of PET for recurrent cervical cancer with clinical suspicion are 0.96 (0.87–0.99) and 0.81 (0.58–0.94). For ovarian cancer, pooled sensitivity and specificity to detect recurrence with clinical suspicion are: PET, 0.90 (0.82–0.95) and 0.86 (0.67–0.96); conventional imaging, 0.68 (0.49–0.83) and 0.58 (0.33–0.80); CA-125, 0.81 (0.62–0.92) and 0.83 (0.58–0.96). When conventional imaging and CA-125 are negative, pooled sensitivity and specificity of PET are 0.54 (0.39–0.69) and 0.73 (0.56–0.87), respectively. When CA-125 is rising and conventional imaging is negative, the pooled sensitivity and specificity of PET are 0.96 (0.88–0.99) and 0.80 (0.44–0.97).

Conclusions

There is good evidence that PET is useful for the pre-treatment detection of retroperitoneal nodal metastasis in cervical cancer. There is fair evidence that PET is useful for the detection of recurrent cervical cancer. PET is less useful for the detection of microscopic residual ovarian cancer but has fair sensitivity to detect recurrence in the setting of a rising CA-125 and negative conventional imaging studies. Available studies are limited by low numbers of patients and wide confidence intervals.

Introduction

Computed tomography (CT) and magnetic resonance (MRI) are anatomic, high-resolution imaging techniques that are commonly used to guide the management of patients with gynecologic cancers. Despite their widespread use, concerns remain that use of these conventional imaging techniques may result in false negatives due to their inability to resolve small volumes (diameter <1 cm) of disease and false positives due to their inability to distinguish between viable tumor masses and masses consisting of necrotic or scar tissue[1]. Functional imaging methods such as positron emission tomography (PET) can establish the metabolic or functional parameters of tissue and may aid in these distinctions. Instead of using anatomical deviations to identify areas of abnormality, PET uses positron-emitting radioactive tracer that accumulates in abnormal tissue. The most commonly used radioisotope tracer is 18Fluro-deoxy-glucose (FDG), a glucose analog which is preferentially taken up by and retained within malignant cells. Depending on the area or organ under study, baseline glucose metabolism may be low, further establishing the difference between normal background tissue and tumor. Thus, compared to structural imaging techniques, FDG-PET has the potential to be a more accurate technique for diagnosis, staging, and treatment decisions in oncology.

The purpose of this study was to determine via a structured literature review the diagnostic accuracy of FDG-PET in comparison to conventional structural imaging techniques for assessment of the metastatic spread and recurrence of cervical and ovarian cancer. In particular, this study addressed the following questions: (1) How does the diagnostic test performance of FDG-PET compare to conventional imaging (e.g., CT, MRI) in the detection of pre-treatment metastases in newly diagnosed cervical cancer? (2) How does the diagnostic test performance of FDG-PET compare to conventional imaging in detection of residual or recurrent cervical cancer following treatment (surgery, radiation, chemotherapy, or combination therapy)? (3) How does the diagnostic test performance of FDG-PET as an adjunct to conventional imaging (e.g., CT, MRI) compare to conventional imaging alone for ovarian cancer (a) in staging at the time of initial diagnosis, (b) in detecting recurrent disease following treatment (surgery, radiation, chemotherapy, or combination)? (4) Does FDG-PET accurately and reliably detect recurrence in a patient with a history of ovarian cancer who has a rising CA-125 and a negative CT?

Section snippets

Methods

We performed our search as part of a review done for the Centers for Medicare and Medicaid Services [2]. An OVID search of the Medline database was conducted on April 18th, 2003. Filters and limitations were used to eliminate inappropriate publications. General inclusion criteria were applied to maximize the applicability of the search results. The search used applicable MeSH headings and text words with appropriate Boolean operators. The search strategy combined the concepts of “cervical

Cervical cancer

Thirty-five abstracts were identified of which 20 articles were deemed potentially relevant to the study questions. Fifteen original articles met criteria for full text review and are summarized below. All studies failed to report whether radiologists were blinded to the pathology results, but none were excluded for this reason.

Newly diagnosed cervical cancer

Thirteen studies addressed the diagnostic accuracy of PET in the radiographic assessment of patients with newly diagnosed cervical cancer. Four prospective studies

Detection of pre-treatment metastases

Cervical cancer spreads by direct extension and via lymphatics, with pelvic node metastasis preceding aortic node metastasis in almost all cases. Sensitive and specific radiologic imaging modalities that identify occult lymph node metastasis may allow avoidance of morbid surgical procedures and facilitate the planning of such novel, tailored treatments as intensity-modulated radiation therapy, which allows a substantial radiation dose to the lymph nodes with sparing of normal structures [32].

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