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Usefulness of FDG-PET for assessment of recurrent gynecological cancer
International Congress Series 1264 (2004) 227 – 232
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Usefulness of FDG-PET for assessment of recurrent gynecological cancer Yoshihiro Nishiyama *, Yuka Yamamoto, Koiku Yokoe, Kenji Kanenishi, Katashi Satoh, Motoomi Ohkawa Department of Radiology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan Department of Obstetrics and Gynecology, Faculty of Medicine, Kagawa University, Kagawa, Japan
Abstract. We evaluated the usefulness of positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET) in the detection of gynecological cancer recurrence. Methods: The study evaluated 35 gynecological cancer patients who were suspected of recurrence. FDG-PET imaging was performed at 1 h after 18F-FDG injection. The final diagnosis of recurrence was established by histological findings or clinical follow-up. Results: FDG-PET correctly identified the presence of recurrence in 11 of 12 patients and its absence in 20 of 23 patients. Furthermore, FDG-PET showed new foci that could not be detected by the conventional imaging modalities. These lesions were in supraclavicular lymph node, bone or peritoneum. Furthermore, in two recurrent patients, therapeutic mode was changed from radiotherapy to chemotherapy. Conclusions: FDG-PET imaging is useful to evaluate recurrence of gynecological cancer and to identify more lesions in patients with suspicion of recurrence based on increased tumor marker levels. Furthermore, FDG-PET appears to provide important additional information concerning re-staging, which may help in improving therapeutic strategies in patients with recurrent gynecological cancer. D 2004 Elsevier B.V. All rights reserved. Keywords: Gynecological cancer; FDG; PET
1. Background Follow-up of patients with gynecological cancer includes use of biological tumor markers such as CA125, CA19-9 and SCC and conventional imaging techniques including CT and MRI. Suspected recurrence, based on increased tumor marker levels but no morphologic abnormality on imaging, is a frequent situation. 2. Purpose The purpose of the present study was to evaluate the usefulness of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in the detection of gynecological cancer recurrence. * Corresponding auhtor. Tel.: +81-87-891-2219; fax: +81-87-891-2220. E-mail address: [email protected] (Y. Nishiyama). 0531-5131/ D 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.ics.2003.12.070
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Fig. 1. Radiological findings in a 72-year-old female with postoperative ovarian cancer. Serum CA125 level was 267 U/ml. FDG-PET showed abnormal FDG uptake in the left supraclavicular and abdominal region, suspicious for recurrence (A). CT images revealed paraaorta lymph node enlargement (B), but missed supraclavicular lymph node (C).
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Fig. 2. Radiological findings in a 54-year-old female with postoperative uterine cancer. Patient had back pain. FDG-PET showed abnormal FDG uptake in the thoracic spine and abdomen, suspicious for recurrence (A). Bone scintigraphy showed no abnormal uptake in the thoracic spine (B).
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Fig. 3. Radiological findings in a 70-year-old female with postoperative ovarian cancer. Serum CA125 level was 125 U/ml. FDG-PET showed abnormal FDG uptake in the pelvis, suspicious for recurrence (A). CT images revealed small tumor corresponding to the intense FDG uptake (B, C). Recurrent tumors of ovarian cancer were histologically proven.
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3. Materials and methods The study evaluated 35 gynecological cancer patients (uterine cancer 15, ovarian cancer 20; all female; mean age 49.0 years; age range 29 –76 years) who were suspected of recurrence. FDG-PET imaging (whole body) was performed at 1 h after 185 – 200 MBq 18F-FDG injection. 3D acquisition was undertaken on Siemens ECAT HR+ (3 min for emission and 2 min for transmission scans, per bed) and iterative reconstruction was performed. Qualitative evaluation was performed by visual analysis. The interpretation of FDGPET findings was compared with the final results, which were based on surgical pathology or repeated radiographic examinations. 4. Results FDG-PET correctly identified the presence of recurrence in 11 of 12 patients and its absence in 20 of 23 patients. Furthermore, FDG-PET showed new foci that could not be detected by the conventional imaging modalities. These lesions were in supraclavicular lymph node, bone marrow or peritoneum. In four patients with recurrence, FDG-PET indicated extensive disease resulting in an up-stage. In two of these four patients, therapeutic mode was changed from radiotherapy to chemotherapy. Radiological findings in a representative case are shown in Figs. 1, 2 and 3. 5. Discussion About half of all cases of recurrent uterine gynecological cancer are confined to the pelvic cavity, but some cases show metastatic lesions in the lymph nodes, lung, bone and liver [1]. The treatment of recurrent tumor differs according to the extent of the recurrent lesion. If this is confined to the pelvic cavity, pelvic exenteration is the treatment of choice. On the other hand, if it recurs beyond the pelvic cavity, radiation therapy or chemotherapy is preferred. The detection and exact localization of a recurrent lesion are therefore very important. FDG-PET is expected to provide functional imaging that is not possible with conventional imaging modalities [2]. Recently, the newer PET machines can image the whole body and detect unexpected lesions outside the pelvis. In our study, FDG-PET could detect unsuspected metastasis such as supraclavicular, mediastinal lymph node metastasis, bone and skin metastasis, and in two patients, therapeutic mode was changed from radiotherapy to chemotherapy. The other advantage of FDG-PET is that it provides more important images when anatomy has been distorted after surgery or radiation treatment. Because FDG-PET scan can provide functional information on the lesions rather than anatomic images, it can detect recurrent lesions independent of the size [3]. Furthermore, FDG-PET provides more important images when anatomy has been distorted after surgery or radiation treatment [4]. In our study, FDG-PET could detect peritoneal dissemination, which was difficult to detect in the anatomic image such as CT. One of the problems of a PET study is nonspecific uptake in the alimentary and urinary tract [5]. Physiologic colon and ureter uptake are sometimes difficult to differentiate from that observed in pathologic lesion. In our study, two of three false-positive cases are these
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physiologic colon and ureter uptake. The other one is also physiologic hilar and mediastinum uptake. 6. Conclusion FDG-PET imaging is useful to evaluate recurrence of gynecological cancer and to identify more lesions in patients with suspicion of recurrence based on increased tumor marker levels. Furthermore, FDG-PET appears to provide important additional information concerning re-staging which may help in improving therapeutic strategies in patients with recurrent gynecological cancer. References [1] V. Carlson, L. Delclos, G.H. Fletcher, Distant metastases in squamous-cell carcinoma of the uterine cervix, Radiology 88 (1967) 961 – 966. [2] T. Torizuka, T. Kanno, M. Futatsubashi, E. Yoshikawa, H. Okada, M. Takekuma, M. Maeda, Y. Ouchi, Ovarian cancer recurrence: role of whole-body positron emission tomography using 2-[fluorine-18]-fluoro-2deoxy-D-glucose, Eur. J. Nucl. Med. 29 (2002) 797 – 803. [3] R.L. Wahl, G.D. Hutchins, D.J. Buchsbaum, M. Liebert, H.B. Grossman, S. Fisher, 18F-Fluoro-2-deoxy-Dglucose uptake into human tumor xenografts: feasibility studies for cancer imaging with positron-emission tomography, Cancer 67 (1991) 1544 – 1550. [4] S.Y. Ryu, M.H. Kim, S.C. Choi, C.W. Choi, K.H. Lee, Detection of early recurrence with 18F-FDG PET in patients with cervical cancer, J. Nucl. Med. 44 (2003) 347 – 352. [5] Y. Nakamoto, T. Saga, T. Ishimori, M. Mamede, K. Togashi, T. Higuchi, M. Mandai, S. Fujii, H. Sakahara, J. Konishi, Clinical value of positron emission tomography with FDG for recurrent ovarian cancer, AJR 176 (2001) 1449 – 1454.
www.ics-elsevier.com
Usefulness of FDG-PET for assessment of recurrent gynecological cancer Yoshihiro Nishiyama *, Yuka Yamamoto, Koiku Yokoe, Kenji Kanenishi, Katashi Satoh, Motoomi Ohkawa Department of Radiology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan Department of Obstetrics and Gynecology, Faculty of Medicine, Kagawa University, Kagawa, Japan
Abstract. We evaluated the usefulness of positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET) in the detection of gynecological cancer recurrence. Methods: The study evaluated 35 gynecological cancer patients who were suspected of recurrence. FDG-PET imaging was performed at 1 h after 18F-FDG injection. The final diagnosis of recurrence was established by histological findings or clinical follow-up. Results: FDG-PET correctly identified the presence of recurrence in 11 of 12 patients and its absence in 20 of 23 patients. Furthermore, FDG-PET showed new foci that could not be detected by the conventional imaging modalities. These lesions were in supraclavicular lymph node, bone or peritoneum. Furthermore, in two recurrent patients, therapeutic mode was changed from radiotherapy to chemotherapy. Conclusions: FDG-PET imaging is useful to evaluate recurrence of gynecological cancer and to identify more lesions in patients with suspicion of recurrence based on increased tumor marker levels. Furthermore, FDG-PET appears to provide important additional information concerning re-staging, which may help in improving therapeutic strategies in patients with recurrent gynecological cancer. D 2004 Elsevier B.V. All rights reserved. Keywords: Gynecological cancer; FDG; PET
1. Background Follow-up of patients with gynecological cancer includes use of biological tumor markers such as CA125, CA19-9 and SCC and conventional imaging techniques including CT and MRI. Suspected recurrence, based on increased tumor marker levels but no morphologic abnormality on imaging, is a frequent situation. 2. Purpose The purpose of the present study was to evaluate the usefulness of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in the detection of gynecological cancer recurrence. * Corresponding auhtor. Tel.: +81-87-891-2219; fax: +81-87-891-2220. E-mail address: [email protected] (Y. Nishiyama). 0531-5131/ D 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.ics.2003.12.070
228
Y. Nishiyama et al. / International Congress Series 1264 (2004) 227–232
Fig. 1. Radiological findings in a 72-year-old female with postoperative ovarian cancer. Serum CA125 level was 267 U/ml. FDG-PET showed abnormal FDG uptake in the left supraclavicular and abdominal region, suspicious for recurrence (A). CT images revealed paraaorta lymph node enlargement (B), but missed supraclavicular lymph node (C).
Y. Nishiyama et al. / International Congress Series 1264 (2004) 227–232
229
Fig. 2. Radiological findings in a 54-year-old female with postoperative uterine cancer. Patient had back pain. FDG-PET showed abnormal FDG uptake in the thoracic spine and abdomen, suspicious for recurrence (A). Bone scintigraphy showed no abnormal uptake in the thoracic spine (B).
230
Y. Nishiyama et al. / International Congress Series 1264 (2004) 227–232
Fig. 3. Radiological findings in a 70-year-old female with postoperative ovarian cancer. Serum CA125 level was 125 U/ml. FDG-PET showed abnormal FDG uptake in the pelvis, suspicious for recurrence (A). CT images revealed small tumor corresponding to the intense FDG uptake (B, C). Recurrent tumors of ovarian cancer were histologically proven.
Y. Nishiyama et al. / International Congress Series 1264 (2004) 227–232
231
3. Materials and methods The study evaluated 35 gynecological cancer patients (uterine cancer 15, ovarian cancer 20; all female; mean age 49.0 years; age range 29 –76 years) who were suspected of recurrence. FDG-PET imaging (whole body) was performed at 1 h after 185 – 200 MBq 18F-FDG injection. 3D acquisition was undertaken on Siemens ECAT HR+ (3 min for emission and 2 min for transmission scans, per bed) and iterative reconstruction was performed. Qualitative evaluation was performed by visual analysis. The interpretation of FDGPET findings was compared with the final results, which were based on surgical pathology or repeated radiographic examinations. 4. Results FDG-PET correctly identified the presence of recurrence in 11 of 12 patients and its absence in 20 of 23 patients. Furthermore, FDG-PET showed new foci that could not be detected by the conventional imaging modalities. These lesions were in supraclavicular lymph node, bone marrow or peritoneum. In four patients with recurrence, FDG-PET indicated extensive disease resulting in an up-stage. In two of these four patients, therapeutic mode was changed from radiotherapy to chemotherapy. Radiological findings in a representative case are shown in Figs. 1, 2 and 3. 5. Discussion About half of all cases of recurrent uterine gynecological cancer are confined to the pelvic cavity, but some cases show metastatic lesions in the lymph nodes, lung, bone and liver [1]. The treatment of recurrent tumor differs according to the extent of the recurrent lesion. If this is confined to the pelvic cavity, pelvic exenteration is the treatment of choice. On the other hand, if it recurs beyond the pelvic cavity, radiation therapy or chemotherapy is preferred. The detection and exact localization of a recurrent lesion are therefore very important. FDG-PET is expected to provide functional imaging that is not possible with conventional imaging modalities [2]. Recently, the newer PET machines can image the whole body and detect unexpected lesions outside the pelvis. In our study, FDG-PET could detect unsuspected metastasis such as supraclavicular, mediastinal lymph node metastasis, bone and skin metastasis, and in two patients, therapeutic mode was changed from radiotherapy to chemotherapy. The other advantage of FDG-PET is that it provides more important images when anatomy has been distorted after surgery or radiation treatment. Because FDG-PET scan can provide functional information on the lesions rather than anatomic images, it can detect recurrent lesions independent of the size [3]. Furthermore, FDG-PET provides more important images when anatomy has been distorted after surgery or radiation treatment [4]. In our study, FDG-PET could detect peritoneal dissemination, which was difficult to detect in the anatomic image such as CT. One of the problems of a PET study is nonspecific uptake in the alimentary and urinary tract [5]. Physiologic colon and ureter uptake are sometimes difficult to differentiate from that observed in pathologic lesion. In our study, two of three false-positive cases are these
232
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physiologic colon and ureter uptake. The other one is also physiologic hilar and mediastinum uptake. 6. Conclusion FDG-PET imaging is useful to evaluate recurrence of gynecological cancer and to identify more lesions in patients with suspicion of recurrence based on increased tumor marker levels. Furthermore, FDG-PET appears to provide important additional information concerning re-staging which may help in improving therapeutic strategies in patients with recurrent gynecological cancer. References [1] V. Carlson, L. Delclos, G.H. Fletcher, Distant metastases in squamous-cell carcinoma of the uterine cervix, Radiology 88 (1967) 961 – 966. [2] T. Torizuka, T. Kanno, M. Futatsubashi, E. Yoshikawa, H. Okada, M. Takekuma, M. Maeda, Y. Ouchi, Ovarian cancer recurrence: role of whole-body positron emission tomography using 2-[fluorine-18]-fluoro-2deoxy-D-glucose, Eur. J. Nucl. Med. 29 (2002) 797 – 803. [3] R.L. Wahl, G.D. Hutchins, D.J. Buchsbaum, M. Liebert, H.B. Grossman, S. Fisher, 18F-Fluoro-2-deoxy-Dglucose uptake into human tumor xenografts: feasibility studies for cancer imaging with positron-emission tomography, Cancer 67 (1991) 1544 – 1550. [4] S.Y. Ryu, M.H. Kim, S.C. Choi, C.W. Choi, K.H. Lee, Detection of early recurrence with 18F-FDG PET in patients with cervical cancer, J. Nucl. Med. 44 (2003) 347 – 352. [5] Y. Nakamoto, T. Saga, T. Ishimori, M. Mamede, K. Togashi, T. Higuchi, M. Mandai, S. Fujii, H. Sakahara, J. Konishi, Clinical value of positron emission tomography with FDG for recurrent ovarian cancer, AJR 176 (2001) 1449 – 1454.