Novel perioperative imaging with 18F-FDG PET/CT and intraoperative 18F-FDG detection using a handheld gamma probe in recurrent ovarian cancer

doi:10.1016/j.ygyno.2008.04.026

Gynecologic Oncology

Volume 110, Issue 2, August 2008, Pages 152-157

https://doi.org/10.1016/j.ygyno.2008.04.026 Get rights and content

Abstract

Objective

Diagnostic ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) is an established method for detecting ovarian cancer. However, there is no established method to detect hypermetabolic tumor intraoperatively to evaluate disease extent and assure complete resection. We describe an innovative approach for intraoperative tumor localization and verification of tumor resection utilizing ¹⁸F-FDG for perioperative PET/CT imaging and intraoperative gamma probe detection in ovarian cancer.

Methods

Three patients with recurrent ovarian cancer in the lymph nodes were evaluated. Diagnostic ¹⁸F-FDG PET/CT was performed before surgery to establish the disease location. Preoperatively, ¹⁸F-FDG was injected intravenously. Intraoperatively, tumors were localized with a handheld gamma probe. Postoperatively, resected tumors were scanned with a specimen PET/CT to confirm metabolic activity in those specimens.

Results

All patients had recurrent epithelial ovarian cancer with groin or retroperitoneal lymph node metastasis diagnosed with PET/CT. In two patients, intraoperative gamma probe detection, specimen PET/CT, and postoperative PET/CT verified complete resection of the clinical and hypermetabolic lesions (in one case, the extent of disease was not fully apparent intraoperatively by gross palpation or inspection). The other patient was demonstrated to have extensive, unresectable disease in the porta hepatis and celiac axis, much of which was recognized only with the intraoperative gamma probe and not with the initial intraoperative survey.

Conclusions

Perioperative PET/CT imaging with intraoperative detection using a gamma probe following a single ¹⁸F-FDG injection dose is feasible, establishes the location and extent of disease, and confirms a complete cytoreduction for recurrent ovarian cancer.

Introduction

Ovarian cancer is the most lethal gynecologic malignancy in the United States [1]. Despite aggressive surgical therapy with comprehensive staging or cytoreduction, followed by intensive intravenous or intraperitoneal chemotherapy, the majority of women with ovarian cancer will experience recurrence of and death from their disease. Follow-up of patients with ovarian cancer generally is with symptom evaluation, physical examination, and CA125 serum testing. Suspicion of recurrence by these modalities will lead to diagnostic cross sectional imaging with computed tomography (CT), ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET) or ¹⁸F-FDG PET/CT (PET/CT) [2]. Recently, evidence has suggested that fusion imaging with PET/CT is superior to CT alone in the detection of recurrent ovarian cancer [3]. With the diagnosis of recurrent ovarian cancer, certain imaging characteristics combined with clinical criteria may lead to subsequent cytoreduction followed by chemotherapy with the intent of increasing progression free survival compared with chemotherapy alone [4].

In patients undergoing subsequent cytoreduction based on suspicion for recurrence documented on diagnostic ¹⁸F-FDG PET or PET/CT, it may be difficult to intraoperatively localize tumors. While the existing practice of preoperative imaging provides a static roadmap for guiding the surgical approach, it does not provide real-time intraoperative information. In this report, we describe an innovative combined perioperative and intraoperative approach for the localization of tumors and documentation of complete cytoreduction utilizing single-dose ¹⁸F-FDG, perioperative PET/CT imaging, and intraoperative handheld gamma probe detection in three patients with recurrent epithelial ovarian cancer.

Section snippets

Patients

Three patients with apparently recurrent epithelial ovarian cancer were identified as candidates for secondary cytoreductive surgery at the Arthur G. James Cancer Hospital and Solove Research Institute of The Ohio State University College of Medicine based on rising CA125 and cross sectional imaging with PET/CT demonstrating measurable disease. Written informed consent was obtained from each patient after all aspects of the proposed imaging, detection, and surgical schema that were to be

Patient 1

A 63 year-old Caucasian female was diagnosed with a stage IIIC high-grade serous adenocarcinoma of the ovary in 2003 following an optimal cytoreduction that included hysterectomy, oophorectomy, lymphadenectomy, appendectomy, splenectomy, sigmoid colectomy, and end sigmoid colostomy. She was treated with a clinical trial utilizing carboplatin and paclitaxel for 8 cycles with liposomal doxorubicin being administered every other cycle. She experienced a complete clinical response, including a

Discussion

We describe a novel technique of using perioperative ¹⁸F-FDG PET/CT imaging and intraoperative gamma probe detection to evaluate disease distribution, and assist in complete cytoreduction. ¹⁸F-FDG PET imaging has demonstrated utility in the diagnosis of recurrent disease in many malignant conditions, including ovarian cancer [7], [8]. In particular, PET and PET/CT have been shown to be effective in establishing the location of recurrent ovarian cancer and may help to identify patients

Conflict of interest statement

The authors declare that they have no conflicts of interest.

Acknowledgments

The authors are grateful to Deborah Hurley in the Division of Nuclear Medicine, Department of Radiology, for her ongoing efforts in the coordination and management of these cases.

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Novel perioperative imaging with 18F-FDG PET/CT and intraoperative 18F-FDG detection using a handheld gamma probe in recurrent ovarian cancer

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Patients

Patient 1

Discussion

Conflict of interest statement

Acknowledgments

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Clin Positron Imaging

Clin Positron Imaging

Ann Thorac Surg

Cancer statistics

CA Cancer J Clin

Clinically occult recurrent ovarian cancer: patient selection for secondary cytoreductive surgery using combined PET/CT

Gynecol Oncol

PET-CT vs. CT alone in ovarian cancer.

Abdom Imaging

Secondary cytoreductive surgery for recurrent ovarian cancer. A prospective study

Cancer

Combined approach of perioperative 18F-FDG PET/CT imaging and intraoperative 18F-FDG handheld gamma probe detection for tumor localization and verification of complete tumor resection in breast cancer

World J Surg Oncol

Novel perioperative imaging with ¹⁸F-FDG PET/CT and intraoperative ¹⁸F-FDG detection using a handheld gamma probe in recurrent ovarian cancer

Combined approach of perioperative ¹⁸F-FDG PET/CT imaging and intraoperative ¹⁸F-FDG handheld gamma probe detection for tumor localization and verification of complete tumor resection in breast cancer