Role of MR Imaging and FDG PET/CT in Selection and Follow-up of Patients Treated with Pelvic Exenteration for Gynecologic Malignancies

Abstract

Pelvic exenteration (PE) is a radical surgical procedure used for the past 6 decades to treat locally advanced malignant diseases confined to the pelvis, particularly persistent or recurrent gynecologic cancers in the irradiated pelvis. The traditional surgical technique known as total PE consists of resection of all pelvic viscera followed by reconstruction. Depending on the tumor extent, the procedure can be tailored to remove only anterior or posterior structures, including the bladder (anterior exenteration) or rectum (posterior exenteration). Conversely, more extended pelvic resection can be performed if the pelvic sidewall is invaded by cancer. Preoperative imaging evaluation with magnetic resonance (MR) imaging and fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is central to establishing tumor resectability and therefore patient eligibility for the procedure. These imaging modalities complement each other in diagnosis of tumor recurrence and differentiation of persistent disease from posttreatment changes. MR imaging can accurately demonstrate local tumor extent and show adjacent organ invasion. FDG PET/CT is useful in excluding nodal and distant metastases. In addition, FDG PET/CT metrics may serve as predictive biomarkers for overall and disease-free survival. This pictorial review describes different types of exenterative surgical procedures and illustrates the central role of imaging in accurate patient selection, treatment planning, and postsurgical surveillance.

MR guided high intensity focused ultrasound (MRgHIFU) for treating recurrent gynaecological tumours: a pilot feasibility study

“…Therefore, HIFU offers a potential alternative treatment in patients with recurrent gynaecological tumours, particularly as recurrence often occurs at a single site. 12 However, evidence for efficacy of HIFU treatment of these tumours is extremely limited, comprising only two case-reports in two females with recurrent cervical tumours. 13,14 In both cases, patients gained significant short-term improvements in pain and/or bleeding without adverse events, but long-term follow up was unavailable.…”

Guidelines of the Brazilian Society of Oncologic Surgery for pelvic exenteration in the treatment of cervical cancer

“…A positron emission tomography (PET) CT has a higher sensitivity (100%) and specificity (73%) compared to CT and MRI, with a high accuracy to rule out extrapelvic disease. Moreover, PET‐CT is able to differentiate an active lesion from a pelvic fibrosis . Invasive examinations such as cystoscopy and rectoscopy may also assist in surgical programming…”

“…Moreover, PET-CT is able to differentiate an active lesion from a pelvic fibrosis. [24][25][26] Invasive examinations such as cystoscopy and rectoscopy may also assist in surgical programming. 20…”

Pelvic exenteration case series: A single surgeon’s experience at one institution in Trinidad and Tobago

“…The optimal imaging modality when considering PE is positron emission tomography/computed tomography (PET/CT). While magnetic resonance imaging and stand-alone CT have demonstrated utility in mapping the pelvic tumor burden, PET/CT’s ability to identify recurrent disease in patients with gynecologic malignancies and distinguish persistent or recurrent tumors from those induced by post–PE radiotherapy renders it superior [13] . Currently, PET imaging units are not available in Trinidad and Tobago or most developing countries, limiting a surgical teams’ ability to assess tumor characteristics and determine patients’ eligibility for PE.…”