Abstract
BackgroundEpithelial ovarian cancer (EOC) typically spreads intra-abdominally, but preoperative evaluation with FDG PET/CT often reveals metabolically active supradiaphragmatic lymph nodes (sdLNs). Their clinical significance and behavior during treatment has not been established.MethodsEOC patients with PET positive sdLNs at diagnosis were prospectively followed with PET/CT after primary chemotherapy and at the first recurrence. In each patient, 2 most active LNs in 5 different supradiaphramatic regions were evaluated and the size and changes in FDG uptake (SUVmax) were recorded. The patients´ overall response to primary treatment was defined with RECIST criteria. The behavior of sdLNs during chemotherapy were compared in treatment responders and non-responders. Recurrence patterns were monitored.ResultsForty-one patients with 127 PET/CT scans were systematically evaluated. In pretreatment scan, 76% (31/41) of patients had FDG-avid sdLNs in multiple anatomical sites. Only a minority (22/136) of the sdLNs were enlarged in size, but their histopathologic confirmation by biopsy was not possible. Only 6/41 patients had FDG-avid sdLNs in a single surgically approachable site. The sdLNs became inactive during primary chemotherapy more often in the RECIST responders compared to the non-responders (HR 1.46 (95%CI: 1.09–1.96), p = 0.002). The size and SUVmax values did not predict treatment outcome. In 50% of the responders the same sdLNs reactivated when recurrence occurred. Persistent post-treatment metabolic activity did not predict earlier disease relapse (p = 0.59).ConclusionThe behavior of metabolically active sdLNs during chemotherapy supports their metastatic nature. Due to their distribution to multiple regions, the benefit of removal of reachable sdLNS seems unlikely.Trial registrationNCT, NCT01276574. Registered 1 September 2010.
Highlights
The vast majority of Epithelial ovarian cancer (EOC) is diagnosed at an advanced stage [1] and optimal removal of intraabdominal tumor bulk forms a major prognostic factor for survival [2, 3]
FDG-PET/CT scans were performed at the following stages: a) the preoperative assessment, b) after neoadjuvant chemotherapy (NACT) prior to interval debulking surgery (IDS), c) after the first line standard platinum-taxane based chemotherapy, and d) at the time of the first relapse of the disease (Fig. 1)
We suggest that the centers committing cardiophrenic LNs resection should consider performing FDG-PET/CT covering thorax area prior to surgery and during the follow-up in order to clarify the clinical significance of detected FDG-avid supradiaphragmatic lymph nodes (sdLNs) and the survival benefit of cardiophrenic surgery in EOC
Summary
The vast majority of EOC is diagnosed at an advanced stage [1] and optimal removal of intraabdominal tumor bulk forms a major prognostic factor for survival [2, 3]. Increasing evidence indicates that abnormal [18F]-fluoro-2-deoxy-D-glucose (FDG) accumulation in sdLNs is a common finding in advanced EOC [4,5,6]. International Federation of Gynecology and Obstetrics (FIGO) staging system requires histopathological verification of extra-abdominal metastases [7]. Pretreatment positron emission computed tomography (PET/CT) may reveal small supradiaphragmatic lymph node metastases (sdLNM) unreachable for sampling. The common presence of FDG-avid sdLNs suggests that many FIGO stage IIIC patients have extra-abdominal disease. Epithelial ovarian cancer (EOC) typically spreads intra-abdominally, but preoperative evaluation with FDG PET/CT often reveals metabolically active supradiaphragmatic lymph nodes (sdLNs). Their clinical significance and behavior during treatment has not been established
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