The role of PET/CT in preoperative decision-making for secondary cytoreduction in recurrent ovarian cancer

Secondary cytoreductive surgery is a feasible treatment option in recurrent ovarian cancer. Patient selection for surgery remains challenging, as conventional imaging, such as CT and MRI, is unreliable for predicting complete gross resection. PET/CT is a modality that combines metabolic and anatomical imaging. Although there are studies supporting the use of PET/CT in ovarian cancer, there is very limited evidence specifically assessing PET/CT-guided selection for secondary cytoreductive surgery under the latest eligibility criteria. This study aims to evaluate the added value of PET/CT for predicting no residual tumor volume after secondary surgical cytoreduction. We conducted a retrospective data collection on patients diagnosed with ovarian cancer who underwent a PET/CT examination between 2018 and 2023 in our center. Patients with suspected recurrence considered for secondary cytoreduction based on conventional imaging and clinical criteria, were included in our analysis. Besides descriptive statistics we performed decision curve analysis (DCA) to determine the added value of PET/CT in surgical decision-making. 22 patients were potentially eligible for secondary debulking according to clinical criteria and conventional imaging findings. 13/22 patients were found to be operable based on preoperative PET/CT results, and 11/13 had a successful resection (no gross residual tumor) (PPV: 85%). 9/22 patients were found ineligible for secondary cytoreduction based on PET/CT results. 7/9 had inoperable lesions, and in two cases, no malignant lesions were detected. Decision curve analysis showed that PET/CT provided superior clinical utility compared to both conventional imaging and a “treat none” approach, yielding a higher net benefit across a broad range of surgical decision thresholds. Our results demonstrate that PET/CT adds significant clinical value in selecting appropriate candidates for secondary cytoreduction, mainly by reinforcing potential operability. These findings suggest that PET/CT may provide incremental information during preoperative assessment; however, prospective validation is required.