Elsevier

Gynecologic Oncology

Volume 96, Issue 1, January 2005, Pages 241-244
Gynecologic Oncology

Case Reports
Laparoscopic resection of occult metastasis using the combination of FDG-positron emission tomography/computed tomography image fusion with intraoperative probe guidance in a woman with recurrent ovarian cancer

https://doi.org/10.1016/j.ygyno.2004.09.030Get rights and content

Abstract

Background

Positron emission tomography and computed tomography (PET/CT) have a potential role in detecting and locating recurrent ovarian cancer. Precise tumor location during surgical treatment is often difficult, owing to limited tumor size and post-surgical anatomic modifications. The surgical gamma probe, which has become increasing popular in recent years with the development of sentinel node mapping, may improve tumor detection and facilitate resection of occult metastases.

Case report.

We describe the first case of laparoscopic resection of occult metastasis using the combination of FDG-PET/CT image fusion with intraoperative FDG-sensitive probing in a patient with recurrent ovarian cancer.

Conclusion.

FDG-sensitive probe combined with preoperative PET/CT image fusion can help to detect occult metastasis and guide laparoscopic excision.

Introduction

Epithelial ovarian cancer is the leading fatal gynecologic malignancy. In 2000, there were about 24,400 new cases of ovarian cancer and 14,500 deaths in the USA [1]. Following primary surgical cytoreduction, the current standard of care for ovarian cancer includes systemic platinum-based chemotherapy. Despite a high response rate to chemotherapy, the 5-year survival rate among women with advanced disease remains low [2]. A number of approaches, including CA125 serum assay, computed tomography (CT), and magnetic resonance imaging (MRI), have been used to detect recurrent disease. Recognized limitations include failure to detect small recurrent lesions [3], [4].

[18F]-fluorodeoxyglucose positron emission tomography (FDG-PET) has been used to detect recurrent ovarian cancer [5], [6]. This technology uses radiolabeled glucose, which is preferentially trapped in tissues with increased glucose consummation such as malignant tumors. FDG-PET has proven useful for detecting early recurrences potentially accessible to secondary surgery [7].

Precise anatomic tumor location can be improved by combining FDG-PET with CT image fusion. This can be achieved by using combined software analysis of images from separate devices, or more recent combined PET/CT devices that offer contemporaneous sequential acquisition and co-registration. However, exact location of occult metastases during secondary surgery is often difficult, owing to small tumor size and treatment-induced anatomic modifications.

The use of surgical gamma probes has become increasingly popular over the past few years, with the development of sentinel node (SN) mapping in gynecologic malignancies [8], [9]. FDG-sensitive probes, which detect differences in radioactivity emitted from tumor-bearing and adjacent normal tissue, can improve the detection and facilitate the resection of occult metastases. Few studies, mostly in colorectal cancer, have tested the combined use of whole-body PET with FDG and intraoperative FDG-sensitive probe for the detection of occult tumors [10], [11], [12].

We describe the first case of laparoscopic resection of occult metastasis based on the combined use of FDG-PET/CT image fusion and intraoperative FDG-sensitive probe guidance in a patient with recurrent ovarian cancer.

Section snippets

Case report

In August 1999, a 62-year-old postmenopausal woman was referred to our gynecology department with a history of metrorrhagia and stress urinary incontinence. Ultrasonography revealed uterine myomas. Vaginal hysterectomy with bilateral salpingo-oophorectomy, sacrospinofixation, and the tension vaginal tape procedure were performed. Final histology revealed a right ovarian serous adenocarcinoma with a peritoneal implant. She then underwent laparoscopic peritoneal washing, para-aortic and bilateral

Discussion

Unresectable recurrent ovarian cancer is uniformly fatal, despite responses to second- or third-line chemotherapy. Early detection of potentially resectable recurrences is based on biological markers and imaging techniques but its impact on survival is controversial [6]. CA125 serum assay is recommended during follow-up of women with ovarian cancer, and an increase of at least 35 U/ml strongly suggests recurrence after initial complete surgery. CA125 serum levels were normal in our patient, as

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