paywalled: Computer tomography, magnetic resonance imaging, and positron emission tomography or positron emission tomography/computer tomography for detection of metastatic lymph nodes in patients with ovarian cancer: A meta-analysis

Computer tomography, magnetic resonance imaging, and positron emission tomography or positron emission tomography/computer tomography for detection of metastatic lymph nodes in patients with ovarian cancer: A meta-analysis

Abstract 

Objectives

To compare the diagnostic performances of computed tomography (CT), magnetic resonance (MR) imaging, and positron emission tomography (PET or PET/CT) for detection of metastatic lymph nodes in patients with ovarian cancer.

Methods

Relevant studies were identified with MEDLINE and EMBASE from January 1990 to July 2010. We estimated the weighted summary sensitivities, specificities, OR (odds ratio), and summary receiver operating characteristic (sROC) curves of each imaging technique and conducted pair-wise comparisons using the two-sample Z-test. Meta-regression, subgroup analysis, and funnel plots were also performed to explain the between-study heterogeneity.

Results

Eighteen eligible studies were included, with a total of 882 patients. PET or PET/CT was a more accurate modality (sensitivity, 73.2%; specificity, 96.7%; OR [odds ratio], 90.32). No significant difference was detected between CT (sensitivity, 42.6%; specificity, 95.0%; OR, 19.87) and MR imaging (sensitivity, 54.7%; specificity, 88.3%; OR, 12.38). Meta-regression analyses and subgroup analyses revealed no statistical difference. Funnel plots with marked asymmetry suggested a publication bias.

Conclusion

FDG-PET or FDG-PET/CT is more accurate than CT and MR imaging in the detection of lymph node metastasis in patients with ovarian cancer.

JCO Editorial (re: Ontario/Pritchard et al) [18F]Fluorodeoxyglucose Positron Emission Tomography–Computed Tomography in Breast Cancer: When… and When Not?

[18F]Fluorodeoxyglucose Positron Emission Tomography–Computed Tomography in Breast Cancer: When… and When Not?

"....It has taken a relatively long time to generate the data needed to guide appropriate use of FDG PET/CT for breast cancer for all phases of the disease. The task is still not quite complete but is propelled by studies such as Pritchard et al.⁶ We hope that the approach for directing new imaging procedures into clinical practice will continue to improve and be ready when the next imaging breakthrough emerges."

"Diagnostic imaging plays an important role in the care of patients with breast cancer and is used for breast cancer detection, diagnosis, staging, and therapeutic response evaluation.¹ Advances in imaging technology, especially relatively newer technologies such as magnetic resonance imaging (MRI) and positron emission tomography without or with integrated computed tomography (PET or PET/CT) provide powerful diagnostic tools, but also generate questions and controversy regarding where and when to use these new modalities. Early studies of new imaging approaches most often come from centers that are scientifically invested in the development of the technology. Typically, small and highly selected patient populations are evaluated, and these preliminary studies often indicate excellent diagnostic performance. Later on, when large multicenter trials are performed with more clinically representative patient populations, the new test invariably performs less well. Nevertheless, the excitement surrounding early results from a new imaging technology and the increasing public access to these early results fuel the desire by patients for access to new forms of diagnostic imaging. Physicians and patients share the wish for diagnostic certainty in excluding cancer spread at the time of diagnosis and may reason that a purely diagnostic procedure, even if untested, can do no harm. These factors, combined with the challenge and expense of carrying out larger scale diagnostic imaging trials, can lead to the early adoption of new imaging studies into clinical practice, often before their performance and optimal use have been fully determined. However, ......."

abstract: Prospective Study of 2-[18F]Fluorodeoxyglucose Positron Emission Tomography in the Assessment of Regional Nodal Spread of Disease in Patients With Breast Cancer: An Ontario Clinical Oncology Group Study

Prospective Study of 2-[18F]Fluorodeoxyglucose Positron Emission Tomography in the Assessment of Regional Nodal Spread of Disease in Patients With Breast Cancer: An Ontario Clinical Oncology Group Study

 Purpose 2-[¹⁸F]fluorodeoxyglucose (FDG) positron emission tomography (PET) is potentially useful in assessing lymph nodes and detecting distant metastases in women with primary breast cancer.


Conclusion
FDG-PET is not sufficiently sensitive to detect positive axillary lymph nodes, nor is it sufficiently specific to appropriately identify distant metastases. However, the very high positive predictive value (96%) suggests that PET when positive is indicative of disease in axillary nodes, which may influence surgical care.

abstract: Preoperative Identification of a Suspicious Adnexal Mass: A Systematic Review and Meta-analysis. PET/MRI/U/S

 Blogger's Note: this abstract provides little comprehensive information (as per most abstracts)  noting that the journal of Gynecologic Oncology is a subscriber-based journal ($$$); 'nail in the coffin'  for ovarian cancer/pre-surgical assessment ??
                    ~~~~~~~~~~~~~~~~~~~

abstract: Preoperative Identification of a Suspicious Adnexal Mass: A Systematic Review and Meta-analysis [Gynecol Oncol. 2012] - PubMed - NCBI

Abstract

OBJECTIVE:

To systematically review the existing literature in order to determine the optimal strategy for preoperative identification of the adnexal mass suspicious for ovarian cancer.

METHODS:

A review of all systematic reviews and guidelines published between 1999 and 2009 was conducted as a first step. After the identification of a 2004 AHRQ systematic review on the topic, searches of MEDLINE for studies published since 2004 was also conducted to update and supplement the evidentiary base. A bivariate, random-effects meta-regression model was used to produce summary estimates of sensitivity and specificity and to plot summary ROC curves with 95% confidence regions.

RESULTS:

Four meta-analyses and 53 primary studies were included in this review. The diagnostic performance of each technology was compared and contrasted based on the summary data on sensitivity and specificity obtained from the meta-analysis. Results suggest that 3D ultrasonography has both a higher sensitivity and specificity when compared to 2D ultrasound. Established morphological scoring systems also performed with respectable sensitivity and specificity, each with equivalent diagnostic competence. Explicit scoring systems did not perform as well as other diagnostic testing methods. Assessment of an adnexal mass by colour Doppler technology was neither as sensitive nor as specific as simple ultrasonography. Of the three imaging modalities considered, MRI appeared to perform the best, although results were not statistically different from CT. PET did not perform as well as either MRI or CT. The measurement of the CA-125 tumour marker appears to be less reliable than do other available assessment methods.

CONCLUSION:

The best available evidence was collected and included in this rigorous systematic review and meta-analysis. The abundant evidentiary base provided the context and direction for the diagnosis of early-staged ovarian cancer.

abstract: Evaluation of 2-Deoxy-2-[18F]Fluoro-D-glucose- and 3′-Deoxy-3′-[18F]Fluorothymidine–Positron Emission Tomography as Biomarkers of Therapy Response in Platinum-Resistant Ovarian Cancer

Molecular Imaging and Biology, Online First™ 

Abstract

Purpose  

We evaluated whether 2-deoxy-2-[¹⁸F]fluoro-D-glucose ([¹⁸F]FDG) and 3′-deoxy-3′-[¹⁸F]fluorothymidine ([¹⁸F]FLT) positron emission tomography (PET) could be used as imaging biomarkers of platinum resensitization in ovarian cancer.

Procedures  

Paired platinum-sensitive and platinum-resistant ovarian cancer cells from the same patient, PEO1 and PEO4, grown as tumor xenografts in nude mice, were assessed by PET.

Results  

The AKT inhibitor, API-2, resensitized platinum-resistant PEO4 tumors to cisplatin, leading to a markedly lower Ki67 labeling index (p ≤ 0.006, n = 6 per group). [¹⁸F]FDG-PET and [¹⁸F]FLT-PET imaging variables were lower after combination treatment compared with vehicle treatment (p ≤ 0.006, n = 6 per group). No changes were seen with either drug alone. PRAS40 phosphorylation status was a sensitive biochemical marker of pathway inhibition, whereas reductions thymidine kinase 1 expression defined the [¹⁸F]FLT response.

Conclusions  

Therapeutic inhibition of AKT activation in acquired platinum-resistant disease can be imaged noninvasively by [¹⁸F]FDG-PET and [¹⁸F]FLT-PET warranting further assessment. 

Complete response with pegylated liposomal doxorubicin as a second-line therapy in metastatic ovarian carcinosarcoma: Significance of assessment of the response by FDG-PET 10.1016/j.gynor.2012.02.004 : Gynecologic Oncology Case Reports

".....Furthermore, our case illustrates that the Response Evaluation Criteria in Solid Tumors (RECIST) metric is unreliable in predicting the histopathological treatment response in carcinosarcomas. In our patient, pathological analyses of the tissue removed during the debulking surgery showed more than 75% pathological necrosis, whereas the CT scan revealed stable disease. Furthermore, changes in tumor size evaluated on the CT scan after the treatment with PLD were poorly correlated with the metabolic changes and the tumoral viability (and outcome). A recent study showed that FDG-PET was significantly more accurate than size-based criteria at assessing the histopathological response to neoadjuvant therapy in high-grade, soft-tissue sarcomas (Evilevitch et al., 2008). In our opinion, FDG-PET should be considered as a modality to monitor the treatment response in patients with carcinosarcoma of the ovary.

In conclusion, our case illustrates that PLD might have a role in the treatment of ovarian carcinosarcoma that should be evaluated in future studies. This case also emphasizes the need to monitor the treatment response in these patients with FDG-PET."

JNCI extract: Radiologists Urge FDA To Accept PET-Based Tumor Response Criteria in Clinical Trials

Recurrent Ovarian Cancer: Use of Contrast-enhanced CT and PET/CT to Accurately Localize Tumor Recurrence and to Predict Patients’ Survival1 — Radiology

Abstract

Purpose: To compare accuracy and interobserver variability in the detection and localization of recurrent ovarian cancer with contrast material–enhanced (CE) computed tomography (CT) and positron emission tomography (PET)/CT and determine whether imaging findings can be used to predict survival.

Conclusion: Preliminary data suggest that CE CT and PET/CT may have similar accuracy in detection of recurrent ovarian cancer. Tumor size, number, and SUVmax may have potential as prognostic biomarkers for patients with recurrent ovarian cancer.

abstract: How to follow-up patients with epithelial ovarian cancer : Current Opinion in Oncology

How to follow-up patients with epithelial ovarian cancer
Miller, Rowan E; Rustin, Gordon JS

Abstract

Purpose of review: Despite optimal primary treatment most patients with advanced epithelial ovarian cancer will relapse. This review discusses the controversy regarding surveillance and the timing of treatment for recurrent disease.

Recent findings: Routine physical examination has a limited role in the detection of recurrent ovarian cancer. PET/computed tomography (CT) has been shown to be useful in detecting small volume disease not apparent on traditional imaging in patients with suspected recurrence based on symptoms and/or rising CA125. The results of PET/CT can alter treatment plans and have particular use in guiding site-directed therapy. The benefits of early detection and systemic treatment of recurrence are now in doubt following the presentation of the MRC/EORTC CA125 surveillance trial. The impact on survival of secondary cytoreductive surgery requires more investigation.

Summary: Uncertainties remain in the surveillance and timing of treatment for relapsed disease. Patients should be informed of these uncertainties and become involved in decisions regarding their follow-up.

Vanderbilt First to Use Specialized PET/CT Scan to Uncover Cancerous Tumors

"....The 68Ga-DOTATATE PET/CT scan offers higher resolution and sensitivity locating tumors. Although performed in Europe, this specialized type of radiologic scan has been viewed in the U.S. as offering only limited benefit to a small number of cancer patients. However a recent increase of neuroendocrine cancers seen at Vanderbilt led Walker and his associates to more widely apply usage of this new technology...."

Recruiting: Positron Emission Tomography/Computed Tomography (PET/CT) for the Diagnosis of Recurrent Cancer: a Feasibility Study - Full Text View - ClinicalTrials.gov (PETREC)

Ontario Clinical Oncology Group (OCOG)

Condition	Intervention
Non-small Cell Lung Cancer Breast Cancer Head and Neck Cancer Ovarian Cancer Esophageal Cancer Lymphoma	Other: PET/CT scan

PET Scans Ontario - Cancer Care Ontario

PET in women with high risk for breast or ovarian cancer : The Lancet Oncology

Summary

Data on the use of PET in women with genetic or familial high-risk for breast or ovarian cancer are scarce.

Open issues include the complementary use of dedicated breast-PET scanners in patients at high-risk for breast cancer, the relation between pathological characteristics of cancer diagnosed in BRCA carriers and 18F-fluorodeoxyglucose (18F-FDG)-avidity, and the predictive value of PET in patients at high-risk for ovarian cancer presenting with a pelvic mass or potential chemical markers. Therefore, the use of PET in high-risk patients with unproven malignant disease needs to be investigated in well designed clinical trials.

Once breast or ovarian cancer is diagnosed, indications for 18F-FDG-PET or PET—CT imaging are similar for high-risk patients and patients with sporadic cancer. However, PET can provide data that are beyond tumour detection per se. Future directions of PET in high-risk patients might include monitoring the response of BRCA carriers to new treatments such as poly-ADP ribose polymerase (PARP) inhibitors, personalisation of treatment, and the use of new PET tracers to investigate the tissue changes related to increased risk for breast and ovarian cancer.

Impact of positron emission tomography/computed tomography in the management of patients with epithelial ovarian carcinoma after treatment.

CONCLUSIONS:
Both integrated FDG-PET/CT and contrast-enhanced multidetector CT are sensitive surveillance modalities for the detection of recurrent ovarian cancer; the use of both modalities aids decisions on treatment plans and may ultimately have a favorable impact on prognosis. However, contrast-enhanced multidetector CT is recommended for the regular follow-up for ovarian cancer patients after initial treatment.

abstract: How to follow-up patients with epithelial ovarian cancer.

Abstract

PURPOSE OF REVIEW: Despite optimal primary treatment most patients with advanced epithelial ovarian cancer will relapse. This review discusses the controversy regarding surveillance and the timing of treatment for recurrent disease.
RECENT FINDINGS: Routine physical examination has a limited role in the detection of recurrent ovarian cancer. PET/computed tomography (CT) has been shown to be useful in detecting small volume disease not apparent on traditional imaging in patients with suspected recurrence based on symptoms and/or rising CA125. The results of PET/CT can alter treatment plans and have particular use in guiding site-directed therapy. The benefits of early detection and systemic treatment of recurrence are now in doubt following the presentation of the MRC/EORTC CA125 surveillance trial. The impact on survival of secondary cytoreductive surgery requires more investigation.
SUMMARY: Uncertainties remain in the surveillance and timing of treatment for relapsed disease. Patients should be informed of these uncertainties and become involved in decisions regarding their follow-up.

AJR Am J Roentgenol. 2010 Role of PET/CT in Ovarian Cancer

Abstract OBJECTIVE: The purpose of this article is to review the role of FDG PET/CT in ovarian cancer, which is the leading cause of death among gynecologic cancers. CONCLUSION: FDG PET/CT can significantly modify the assessment of the extent of primary and recurrent ovarian cancer and, hence, often alters patient management substantially. FDG PET/CT has thus become a critical tool for the preoperative evaluation of women with primary ovarian cancer and for postoperative follow-up assessment for evidence of recurrence in these patients.

abstract: Imaging ovarian cancer and peritoneal metastases - current and emerging techniques Nature Reviews Clinical Oncology

PET/MRI: paving the way for the next generation of clinical multimodality imaging applications.