Positron emission tomography (PET) and magnetic resonance imaging (MRI) for assessing tumour resectability in advanced epithelial ovarian/fallopian tube/primary peritoneal cancer

Joline F Roze; Jacob P Hoogendam; Fleur T van de Wetering; René Spijker; Leen Verleye; Joan Vlayen; Wouter B Veldhuis; Rob JPM Scholten; Ronald P Zweemer

doi:10.1002/14651858.CD012567.pub2

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Figure 1

Definitions of the two by two table, wherein the index tests are tabulated against the reference standard outcome, on the analysis: macroscopic debulking versus incomplete debulking with residual disease of any size (i.e. consisting of deposits ≤ 1 cm and > 1 cm in diameter ). TP = true positive, FP = false positive, FN = false negative, TN = true negative.

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Figure 2

Definitions of the two by two table, wherein the index tests are tabulated against the reference standard outcome, on the analysis: macroscopic debulking or incomplete debulking with residual disease ≤ 1 cm in diameter versus incomplete resection with residual disease > 1 cm in diameter. TP = true positive, FP = false positive, FN = false negative, TN = true negative.

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Figure 3

Visual representation of 2 x 2 table. TP = true positive, FP = false positive, FN = false negative, TN = true negative.

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Figure 4

Study flow diagram.

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Figure 5

Risk of bias and applicability concerns summary: review authors' judgements about each domain for each included study

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Figure 6

Forest plot of tests: 1 PET/CT for assessing incomplete debulking with residual disease of any size, 4 MRI for assessing incomplete debulking with residual disease of any size, 2 MRI for assessing incomplete debulking with residual disease > 1 cm, 3 MRI for assessing incomplete debulking with residual disease > 2 cm.

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Test 1

PET/CT for assessing incomplete debulking with residual disease of any size.

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Test 2

MRI for assessing incomplete debulking with residual disease > 1 cm.

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Test 3

MRI for assessing incomplete debulking with residual disease > 2 cm.

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Test 4

MRI for assessing incomplete debulking with residual disease of any size.

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Summary of findings Diagnostic accuracy of FDG‐PET/CT and MRI for assessing tumour resectability in advanced epithelial ovarian/fallopian tube/primary peritoneal cancer

What is the diagnostic accuracy of FDG‐PET/CT or MRI for assessing tumour resectability in advanced epithelial ovarian/fallopian tube/primary peritoneal cancer? Patients Women suspected of ovarian cancer scheduled for surgery Prior testing Conventional diagnostic work‐up (e.g. physical examination, ultrasound) Setting University hospitals or specialised cancer institutes Index test FDG‐PET/CT or MRI. In all studies, the index test was evaluated as a replacement of abdominal CT. No studies were identified that followed an add‐on design. Target condition Residual disease assessed after debulking surgery
Test	Target condition	No. of women (studies)	Prevalence in study	Sensitivity (95% CI)	Specificity (95% CI)	No. of false negatives* per 1000 tested	No. of false positives per 1000 tested**	Test accuracy certainty (quality) of evidence (sensitivity/specificity)^a
FDG‐PET/CT	Residual disease > 0 cm	23/343 (2)	26%/65%	1.0 (0.54 to 1.0) and 0.66 (0.60 to 0.73)	1.0 (0.80 to 1.0) and 0.88 (0.80 to 0.93)	211 (167 to 248)^b	46 (27 to 76)^b	Low^c/moderate^d
DW‐MRI	Residual disease > 0 cm	94 (1)	53%	0.94 (0.83 to 0.99)	0.98 (0.88 to 1.00)	37 (6 to 105)^b	8 (0 to 46)^b	Low^c/moderate^d
DW‐MRI	Residual disease > 1 cm	34 (1)	23.5%	0.75 (0.35 to 0.97)	0.96 (0.80 to 1.00)	59 (7 to 153)	31 (0 to 153)	Very low/very low ^{e, f}
Conventional MRI	Residual disease > 2 cm	50 (1)	22%	0.91 (0.59 to 1.00)	0.97 (0.87 to 1.00)	20 (0 to 90)	23 (0 to 101)	Very low/very low ^e,g
CT^h	Residual disease > 0 cm	94 (1)	53%	0.66 (95% CI 0.52 to 0.78)	0.77 (95% CI 0.63 to 0.87)	211 (136 to 298)^b	87 (49 to 141)^b	Low/low^c
CI: confidence interval CT: computed tomography DW‐MRI: diffusion‐weighted Magnetic Resonance Imaging FDG: fluorodeoxyglucose‐18 PET: positron emission tomography * False negatives (FNs): judged as feasible for surgery based on imaging, with an incomplete debulking at surgery. ** False positives (FPs): judged as not feasible for surgery based on imaging, with a complete debulking at surgery. ^a. According to GRADE for sensitivity (false negatives (FNs)) and specificity (false positives (FPs)), respectively ^b. Numbers are calculated based on the results of the largest study (Shim 2015) at the mean prevalence of incomplete debulking (62%) of the two largest studies that addressed debulking with residual disease of any size (Michielsen 2017; Shim 2015). The prevalence of incomplete debulking was calculated as (TP + FN)/total study subjects (273/437 = 62%). ^c. Downgraded two levels for very wide confidence interval for number of FNs (sensitivity) ^d. Downgraded one level for wide confidence interval for number of FPs (specificity) ^e. Downgraded two levels as very small sample size; very wide confidence intervals for number of FNs (sensitivity) and number of FPs (specificity). ^f. Downgraded one level due to applicability concerns for the Index test since the radiologists were blinded for (presurgical) clinical data. ^g. Downgraded one level due to high risk of bias for patient selection and flow and timing. ^h. To compare the findings of the included studies (performing PET/CT or MRI to assess tumour resectability) with CT (the current gold standard), we provided the diagnostic accuracy of CT from the study with the best quality of evidence and with the target condition that is currently used in practice (Michielsen 2017).

Summary of findings Diagnostic accuracy of FDG‐PET/CT and MRI for assessing tumour resectability in advanced epithelial ovarian/fallopian tube/primary peritoneal cancer

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Table 1. Criteria to consider primary debulking unfeasible

Criteria to consider primary debulking unfeasible according to study methods
	Alessi	Shim	Espada	Forstner	Michielsen
Site of tumour involvement
Liver/porta hepatis	Yes	No	No	Yes	Yes
Mesentery	Yes	Yes	Yes	Yes	No
Colon	Yes, when necessitating > 4 bowel resections	No	No	No	Yes, when necessitating multiple bowel resections
Stomach	Yes	No	Yes	No	Yes
Pancreas	Yes	No	No	No	Yes
Duodenum	Yes	No	No	No	Yes
Diaphragm	No	Yes	No	Yes	No
Ascites	No	Yes	No	No	No
Peritoneal carcinomatosis	Yes	Yes	No	No	No
Lesser sac/bursa omentalis	No	No	Yes	Yes	No
Spleen/splenic hilum	No	No	Yes	No	No
Lymph nodes above level of renal vessels/at coeliac axis	No	No	Yes	Yes	Yes
Gastrosplenic ligament	No	No	No	Yes	No
Presacral extraperitoneal disease	No	No	No	Yes	No
Extra‐abdominal distant metastasis	No	No	No	No	Yes
Vessels of coeliac trunk	No	No	No	No	Yes
Hepatoduodenal ligament	No	No	No	No	Yes
Superior mesenteric artery	No	No	No	No	Yes
Yes: site of tumour involvement is selected as one of the criteria to consider primary debulking unfeasible No: site of tumour involvement is not selected as a criterion to consider primary debulking unfeasible

Table 1. Criteria to consider primary debulking unfeasible

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Table Tests. Data tables by test

Test	No. of studies	No. of participants
1 PET/CT for assessing incomplete debulking with residual disease of any size Show forest plot	2	366

2 MRI for assessing incomplete debulking with residual disease > 1 cm Show forest plot	1	34

3 MRI for assessing incomplete debulking with residual disease > 2 cm Show forest plot	1	50

4 MRI for assessing incomplete debulking with residual disease of any size Show forest plot	1	94

Table Tests. Data tables by test

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