Preoperative lymph node staging of early-stage cervical carcinoma by [18F]-fluoro-2-deoxy-D-glucose-positron emission tomography

18F-FDG PET/MRI and 18F-FDG PET/CT for the Management of Gynecological Malignancies: A Comprehensive Review of the Literature

OBJECTIVE

Positron emission tomography with 2-deoxy-2-[fluorine-18] fluoro- D-glucose integrated with computed tomography (18F-FDG PET/CT) or magnetic resonance imaging (18F-FDG PET/MRI) has emerged as a promising tool for managing various types of cancer. This review study was conducted to investigate the role of 18F- FDG PET/CT and FDG PET/MRI in the management of gynecological malignancies.

SEARCH STRATEGY

We searched for relevant articles in the three databases PubMed/MEDLINE, Scopus, and Web of Science.

SELECTION CRITERIA

All studies reporting data on the FDG PET/CT and FDG PET MRI in the management of gynecological cancer, performed anywhere in the world and published exclusively in the English language, were included in the present study.

DATA COLLECTION AND ANALYSIS

We used the EndNote software (EndNote X8.1, Thomson Reuters) to list the studies and screen them on the basis of the inclusion criteria. Data, including first author, publication year, sample size, clinical application, imaging type, and main result, were extracted and tabulated in Excel. The sensitivity, specificity, and diagnostic accuracy of the modalities were extracted and summarized.

MAIN RESULTS

After screening 988 records, 166 studies published between 2004 and 2022 were included, covering various methodologies. Studies were divided into the following five categories: the role of FDG PET/CT and FDG-PET/MRI in the management of: (a) endometrial cancer (n = 30); (b) ovarian cancer (n = 60); (c) cervical cancer (n = 50); (d) vulvar and vagina cancers (n = 12); and (e) gynecological cancers (n = 14).

CONCLUSIONS

FDG PET/CT and FDG PET/MRI have demonstrated potential as non-invasive imaging tools for enhancing the management of gynecological malignancies. Nevertheless, certain associated challenges warrant attention.

Novel prognostic nomograms in cervical cancer based on analysis of 1075 patients

OBJECTIVE

To explore the factors affecting the prognosis of cervical cancer (CC), and to construct and evaluate predictive nomograms to guide individualized clinical treatment.

METHODS

The clinicopathological and follow-up data of CC patients from June 2013 to December 2019 in Sun Yat-sen Memorial Hospital of Sun Yat-sen University were retrospectively analyzed. Log-rank test was used for univariate survival analysis, and Cox multivariate regression was used to identify independent prognostic factors, based on which nomogram models were established and evaluated in multiple aspects.

RESULTS

Patients were randomly assigned into the training (n = 746) and validation sets (n = 329). Survival analysis of the training set identified cervical myometrial invasion, parametrial involvement, and malignant tumor history as prognosticators of postoperative DFS and pathological type, cervical myometrial invasion, and history of STD for OS. C-index was 0.799 and 0.839 for the nomograms for DFS and OS, respectively. Calibration curves and Brier scores also indicated high performance. Importantly, decision curve analysis suggested great clinical applicability of these nomograms.

CONCLUSIONS

In this study, we analyzed a cohort of 1075 CC patients and identified DFS- or OS-associated clinicohistologic characteristics. Two nomograms were subsequently constructed for DFS and OS prognostication, respectively, and showed high performance in terms of discrimination, calibration, and clinical applicability. These models may facilitate individualized treatment and patient selection for clinical trials. Future investigations with larger cohorts and prospective designs are warranted for validating these prognostic models.

Adenocarcinoma of the uterine cervix, gastric-type (GAS): a review of the literature focused on pathology and multimodality imaging

Adenocarcinoma of the uterine cervix, gastric-type (GAS) is a rare, well-differentiated subtype of HPV-independent endocervical adenocarcinoma. It classically arises in middle-aged women with symptoms, including profuse watery vaginal discharge and abnormal uterine bleeding. Given the rarity of this disease, misdiagnosis is common and prognosis remains poorly defined. Distinct pathology and imaging findings can aid in diagnosis. A literature review was performed to ascertain recurring pathologic and radiologic characteristics of GAS. Key pathologic features of GAS include cytologically benign appearing mucinous glands that infiltrate into the deep stroma and may demonstrate lymphovascular or perineural invasion. Multiple imaging modalities including transvaginal ultrasound, CT, and MRI may aid in diagnosis of GAS, which characteristically is seen as a multicystic mass with solid components. MRI in particular is the preferred imaging study because it offers the best chance of identifying a potential solid component, which is key to making the diagnosis of GAS and distinguishing it from other endocervical diseases processes. Careful attention to histopathologic and radiologic details, in conjunction with clinical correlation, is necessary to distinguish GAS from other multicystic cervical lesions.

Improved stratification of stage-specific survival for cervical uterine cancer by integrating FDG-PET/CT and MRI for lymph node staging in 2018 FIGO classification

OBJECTIVE

Staging carcinoma of the uterine cervix (CCU) by FIGO-2018 suggests stage migration of FIGO-2009 stage I-III patients with lymph node metastasis into FIGO-2018 stage IIIC. We aimed to investigate the prognostic value of lymph node metastases identified by imaging.

METHODS

We enrolled all patients with biopsy-verified CCU from 2007 to 2016 at Odense University Hospital, Denmark. FDG-PET/CT and MRI were performed before clinical examination in general anesthesia. Disease-specific mortality was compared between women with lymph node-positive and lymph node-negative imaging.

RESULTS

In total, 488 patients underwent clinical staging according to FIGO-2009. Lymph node-positive imaging was identified in 146 (30%) patients: 0/36 (0%) in stage IA, 22/195 (11%) in IBI, 14/30 (47%) in IB2, 70/164 (43%) in II and 40/63 (63%) in III. The 5-year cumulative incidence of death due to CCU lymph node-negative vs. lymph node-positive patients was 0.8% vs. 7.1% (p = 0.034) in stage IBI, 0% vs. 34.5% (p = 0.003) in stage IB2, 15.1% vs. 41.4% (p < 0.0001) in stage II, and 33.3% vs. 46.6% (p = 0.28) in stage III by FIGO-2009.

CONCLUSIONS

One of three women with FIGO-2009 stage I-III CCU had suspected lymph node metastasis on imaging and is upstaged to stage IIIC according to FIGO-2018. The cancer-specific mortality by CCU was significantly lower in the lymph node-negative women stages IBI-II, thus supporting stage migration due to suspected lymph node metastasis. However, the exact prognostic value within stage IIIC is challenged, and future revision of FIGO stages may include new sub-stages.

Upstaging by para-aortic lymph node dissection in patients with locally advanced cervical cancer: A systematic review and meta-analysis

BACKGROUND

Accurate staging of para-aortic nodal status in cervical cancer is of great importance for individualizing treatment and impacting outcomes. Three-dimensional imaging (i.e. PET, CT, MRI) may miss para-aortic lymph node (PALN) metastases. The aim of this study was to systematically review and meta-analyze the proportion of upstaging by PALN dissection in patients with locally advanced cervical cancer without suspicious PALNs on imaging.

METHODS

PubMed/MEDLINE and Embase were systematically searched. The analysis included diagnostic studies that reported on 3D imaging and pre-therapeutic surgical assessment of PALN status in patients with cervical cancer. An overall pooled upstaging rate was calculated using a random-effects model.

RESULTS

The search identified 16 eligible studies including 18 cohorts with a total of 1530 patients. Pooling of 12 cohorts demonstrated an upstaging rate of 12% (95% confidence interval [CI] 10-15%) by PALN dissection after negative PET or PET-CT. Pooling of 6 cohorts demonstrated a pooled upstaging rate of 11% (95% CI: 8-16%) by PALN dissection after negative MRI or CT. No significant heterogeneity in upstaging proportions across cohorts was observed (I² = 0% and 27%, respectively). In 7 cohorts including only patients with pelvic nodal metastases on imaging (but no suspicion of PALN involvement) a pooled upstaging rate by PALN dissection of 21% (95% CI: 17-26%) was found (I² = 0%).

CONCLUSIONS

This meta-analysis demonstrates that in case of no suspicious PALN on PET-CT or MRI, PALN dissection still identifies lymph node metastases in a considerable amount of patients with locally advanced cervical cancer and especially in those patients with confirmed pelvic nodal metastases.

Definitive Chemoradiotherapy versus Radical Hysterectomy Followed by Tailored Adjuvant Therapy in Women with Early-Stage Cervical Cancer Presenting with Pelvic Lymph Node Metastasis on Pretreatment Evaluation: A Propensity Score Matching Analysis

Simple Summary

Pelvic nodal involvement is frequently present in early-stage cervical cancer patients on pretreatment imaging studies. However, it is unclear whether radical chemoradiotherapy (CRT) or radical hysterectomy RH followed by tailored adjuvant radiotherapy is more appropriate in these patients. We compared oncological outcomes of up-front surgery followed by tailored adjuvant radiotherapy and definitive CRT in these patients. We found no differences in outcomes existed between definitive CRT and hysterectomy with tailored adjuvant radiotherapy. However, after surgery, 88.7% of patients required adjuvant radiotherapy. These findings suggest that definitive CRT can avoid unplanned tri-modality therapy without compromising oncologic outcomes.

Abstract

To compare the oncologic outcomes between chemoradiotherapy (CRT) and radical hysterectomy followed by tailored adjuvant therapy in patients with early cervical cancer presenting with pelvic lymph node metastasis. We retrospectively analyzed the medical records of women with early cervical cancer presenting with positive pelvic nodes identified on pretreatment imaging assessment. Propensity score matching was employed to control for the heterogeneity between two groups according to confounding factors. Overall survival, disease-free survival, and pattern of failure were compared between the two groups. A total of 262 patients were identified; among them, 67 received definitive CRT (group A), and 195 received hysterectomy (group B). Adjuvant therapy was administered to 88.7% of group B. There were no significant differences between group A and group B regarding the 5-year overall survival rates (89.2% vs. 89.0%) as well as disease-free survival rates (80.6% vs. 82.7%), and patterns of failure. Distant metastasis was the major failure pattern identified in both groups. In multivariate analysis, non-squamous histology was significantly associated with poorer overall survival. As there are no significant differences in 5-year OS, DFS, and patterns of failure, definitive CRT could avoid the combined modality therapy without compromising oncologic outcomes.

Standardized Uptake Value for 18F-Fluorodeoxyglucose Is a Marker of Inflammatory State and Immune Infiltrate in Cervical Cancer

PURPOSE

Chemoradiotherapy for locally advanced cervical cancer fails in over a third of patients. Biomarkers with therapeutic implications are therefore needed. We investigated the relationship between an established prognostic marker, maximum standardized uptake value (SUV_max) on ¹⁸F-fluorodeoxyglucose positron emission tomography, and the inflammatory and immune state of cervical cancers.

EXPERIMENTAL DESIGN

An SUV_max most prognostic for freedom from progression (FFP) was identified and compared with known prognostic clinical variables in a cohort of 318 patients treated with definitive radiation with prospectively collected clinical data. Gene set enrichment analysis (GSEA) and CIBERSORT of whole-transcriptome data from 68 patients were used to identify biological pathways and immune cell subpopulations associated with high SUV_max. IHC using a tissue microarray (TMA, N = 82) was used to validate the CIBERSORT findings. The impact of macrophages on cervical cancer glucose metabolism was investigated in coculture experiments.

RESULTS

SUV_max <11.4 was most prognostic for FFP (P = 0.001). The GSEA showed that high SUV_max is associated with increased gene expression of inflammatory pathways, including JAK/STAT3 signaling. CIBERSORT and CD68 staining of the TMA showed high SUV_max tumors are characterized by a monocyte-predominant immune infiltrate. Coculture of cervical cancer cells with macrophages or macrophage-conditioned media altered glucose uptake, and IL6 and JAK/STAT3 signaling contribute to this effect.

CONCLUSIONS

SUV_max is a prognostic marker in cervical cancer that is associated with activation of inflammatory pathways and tumor infiltration of myeloid-derived immune cells, particularly macrophages. Macrophages contribute to changes in cervical cancer glucose metabolism.See related commentary by Williamson et al., p. 4136.

EANM/SNMMI practice guideline for [18F]FDG PET/CT external beam radiotherapy treatment planning in uterine cervical cancer v1.0

PURPOSE

The aim of this EANM / SNMMI Practice Guideline with ESTRO endorsement is to provide general information and specific considerations about [18F]FDG PET/CT in advanced uterine cervical cancer for external beam radiotherapy planning with emphasis on staging and target definition, mostly in FIGO stages IB3-IVA and IVB, treated with curative intention.

METHODS

Guidelines from related fields, relevant literature and leading experts have been consulted during the development of this guideline. As this field is rapidly evolving, this guideline cannot be seen as definitive, nor is it a summary of all existing protocols. Local variations should be taken into consideration when applying this guideline.

CONCLUSION

The background, common clinical indications, qualifications and responsibilities of personnel, procedure / specifications of the examination, documentation / reporting and equipment specifications, quality control and radiation safety in imaging is discussed with an emphasis on the multidisciplinary approach.

Prognostic Nomograms Predicting Survival in Patients With Locally Advanced Cervical Squamous Cell Carcinoma: The First Nomogram Compared With Revised FIGO 2018 Staging System

Objectives

To develop nomograms to assess prognostic factors for 5-year overall survival (OS) and 5-year progression-free survival (PFS) in locally advanced cervical squamous cell carcinoma (LACSC).

Methods

Overall, 618 patients with LACSC were included in this retrospective analysis. Nomograms for 5-year OS and PFS were developed based on Cox proportional hazards regression models. Concordance index (C-index) and calibration curves were used to define the predictive and discriminatory capacity of the nomogram. A comparison between the nomogram and the International Federation of Gynecology and Obstetrics (FIGO) staging system was conducted using time-dependent receiver operating characteristic (tROC) and area under the curve (tAUC).

Results

Multivariate analysis identified several prognostic factors for OS including squamous cell carcinoma antigen (SCC-Ag), body mass index (BMI), tumor size, pelvic wall involvement, and para-aortic lymph node metastasis (PALNM). Prognostic factors for PFS included BMI, hemoglobin (HGB), tumor size, pelvic wall involvement, pelvic lymph node metastasis (PLNM) and PALNM. Following bootstrap correction, the C-index of OS and PFS was 0.713 and 0.686, respectively. These nomograms showed superior performance compared with the FIGO 2009 and 2018 staging schema.

Conclusions

Nomograms were developed to identify prognostic factors for 5-year OS and PFS in patients with LACSC. These nomograms showed good prognostication and are more comprehensive in predicting survival outcomes than existing staging criteria.

Augmented Whole-Body Scanning via Magnifying PET

A novel technique, called augmented whole-body scanning via magnifying PET (AWSM-PET), that improves the sensitivity and lesion detectability of a PET scanner for whole-body imaging is proposed and evaluated. A Siemens Biograph Vision PET/CT scanner equipped with one or two high-resolution panel-detectors was simulated to study the effectiveness of AWSM-PET technology. The detector panels are located immediately outside the scanner's axial field-of-view (FOV). A detector panel contains 2 ×8 detector modules each consisting of 32 ×64 LSO crystals ( 1.0 ×1.0 ×10.0 mm3 each). A 22Na point source was stepped across the scanner's FOV axially to measure sensitivity profiles at different locations. An elliptical torso phantom containing 7×9 spherical lesions was imaged at different axial locations to mimic a multi-bed-position whole-body imaging protocol. Receiver operating characteristic (ROC) curves were analyzed to evaluate the improvement in lesion detectability by the AWSM-PET technology. Experimental validation was conducted using an existing flat-panel detector integrated with a Siemens Biograph 40 PET/CT scanner to image a torso phantom containing spherical lesions with diameters ranging from 3.3 to 11.4 mm. The contrast-recovery-coefficient (CRC) of the lesions was evaluated for the scanner with or without the AWSM-PET technology. Monte Carlo simulation shows 36%-42% improvement in system sensitivity by a dual-panel AWSM-PET device. The area under the ROC curve is 0.962 by a native scanner for the detection of 4 mm diameter lesions with 5:1 tumor-to-background activity concentration. It was improved to 0.977 and 0.991 with a single- and dual-panel AWSM-PET system, respectively. Experimental studies showed that the average CRC of 3.3 mm and 4.3 mm diameter tumors were improved from 2.8% and 4.2% to 7.9% and 11.0%, respectively, by a single-panel AWSM-PET device. With a high-sensitivity dual-panel device, the corresponding CRC can be further improved to 11.0% and 15.9%, respectively. The principle of the AWSM-PET technology has been developed and validated. Enhanced system sensitivity, CRC and tumor detectability were demonstrated by Monte Carlo simulations and imaging experiments. This technology may offer a cost-effective path to realize high-resolution whole-body PET imaging clinically.

Diagnostic value of sentinel lymph node scintigraphy and 2-[18F]-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography in the detection of metastatic lymph nodes in patients with early-stage cervical cancer

Cervical cancer is staged clinically using the International Federation of Gynaecology and Obstetrics staging system. Although lymph node status does not form part of the staging, it has important prognostic and potential therapeutic implications. The aim of the study was to evaluate the role of sentinel lymph node (SLN) scintigraphy and 2-[¹⁸F]-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) in detecting lymph node metastases in patients with early-stage cervical cancer. Thirty-six patients with early-stage cervical cancer underwent SLN detection during primary operation. Of the 36 patients, 28 patients underwent ¹⁸F-FDG PET/CT before surgery. The ¹⁸F-FDG PET/CT images were analyzed with the histopathological findings as the reference standard. The diagnostic performance of ¹⁸F-FDG PET/CT in the detection of nodal disease was reported in terms of accuracy value. The SLN detection rate was the highest (91.7%) using the combined method (lymphoscintigraphy, intraoperative gamma probe, and blue dye). Seven of the thirty-six patients had lymph node involvement (19.4%), of which five had preoperative ¹⁸F-FDG PET/CT imaging. On overall patient-based analysis, the sensitivity, specificity, positive predictive value, negative predictive value (NPV), and accuracy of ¹⁸F-FDG PET/CT were 40.0%, 78.3%, 28.6%, 85.7%, and 71.4%, respectively. The combination of radiolabeled nanocolloid with blue dye is safe and reliable and allows successful detection of SLNs in patients with early-stage cervical cancer in a population with high prevalence of human immunodeficiency virus. The specificity and NPV of ¹⁸F-FDG PET/CT are high and can be used in conjunction with SLN biopsy.

Prognostic Performance of the 2018 International Federation of Gynecology and Obstetrics Cervical Cancer Staging Guidelines

OBJECTIVE

To examine the prognostic performance of the revised 2018 International Federation of Gynecology and Obstetrics (FIGO) cervical cancer staging schema.

METHODS

We used the National Cancer Database to identify women with cervical cancer diagnosed from 2004 to 2015. Using clinical and pathologic data, each patient's stage was classified using three staging schemas: American Joint Committee on Cancer 7th edition, FIGO 2009 and FIGO 2018. The FIGO 2018 revised staging classifies stage IB tumors into three substages based on tumor size (IB1-IB3) and classifies patients with positive lymph nodes (pathologically or clinically detected) as stage IIIC1 (positive pelvic nodes) or IIIC2 (positive para-aortic nodes). Five-year survival rates were estimated for each stage grouping. We sought to determine whether the 2018 FIGO staging system was able to offer improved 5-year survival rate differentiation compared with older staging schemas.

RESULTS

A total of 62,212 women were identified. The classification of stage IB tumors into three substages improved discriminatory ability. Five-year survival in the FIGO 2018 schema was 91.6% (95% CI 90.4-92.6%) for stage IB1 tumors, 83.3% (95% CI 81.8-84.8%) for stage IB2 neoplasms, and 76.1% (95% CI 74.3-77.8%) for IB3 lesions. In contrast, for women with stage III tumors, higher FIGO staging was not consistently associated with worse 5-year survival rates: stage IIIA (40.7%, 95 CI 37.1-44.3%), stage IIIB (41.4%; 95% CI 39.9-42.9%), stage IIIC1 (positive pelvic nodes) was 60.8% (95% CI 58.7-62.8%) and stage IIIC2 37.5% (95% CI 33.3-41.7%).

CONCLUSION

The FIGO 2018 staging schema provides improved discriminatory ability for women with stage IB tumors; however, classification of all women with positive lymph nodes into a single stage results in a very heterogeneous group of patients with highly variable survival rates.

Impact of tumor histology on detection of pelvic and para-aortic nodal metastasis with 18F-fluorodeoxyglucose-positron emission tomography in stage IB cervical cancer

OBJECTIVE

¹⁸F-fluorodeoxyglucose-positron emission tomography (FDG-PET) detection of metastatic nodal disease is useful for guiding cervical cancer treatment but the impact of tumor histology is unknown. This study reports the detection of FDG avid pelvic and para-aortic lymph nodes in patients with early stage cervical cancer with squamous carcinoma and adenocarcinoma tumor histology.

METHODS

Patients with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB1-2 cervical cancer who underwent pre-surgical FDG-PET between March 1999 and February 2018 were identified in a tertiary academic center database. All patients had radical hysterectomy with pelvic and para-aortic lymph node dissection. Detection of pelvic and para-aortic lymph nodes by FDG-PET versus surgical dissection was compared. FDG-PET sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were determined and stratified by tumor histology.

RESULTS

We identified 212 patients with early stage cervical cancer (84% FIGO IB1, 16% IB2) who underwent pre-surgical FDG-PET; 137 (65%) patients had squamous carcinoma and 75 (35%) patients had adenocarcinoma. PET/computed tomography was performed in 189 (89%) patients and 23 (11%) had PET only. Surgical dissection revealed positive pelvic and para-aortic lymph nodes in 25% and 3.3% of patients, respectively. For squamous carcinoma, sensitivity, specificity, PPV, and NPV of FDG-PET for pelvic nodal metastasis were 44%, 99%, 95%, and 78%, respectively. For adenocarcinoma, the corresponding results for pelvic nodal metastasis were 25%, 99%, 67%, and 92%, respectively. The overall values for sensitivity, specificity, PPV, and NPV of FDG-PET for para-aortic nodal metastasis were 29%, 99%, 67%, and 98%, respectively.

DISCUSSION

Pelvic nodal metastasis was less likely to be detected by FDG-PET in patients with early stage adenocarcinoma than with squamous carcinoma.

The diagnostic performance of PET/CT scans for the detection of para-aortic metastatic lymph nodes in patients with cervical cancer: A meta-analysis

Objective

We performed a meta-analysis to evaluate the diagnostic value of positron emission tomography/computed tomography (PET/CT) in the detection of para-aortic lymph node metastasis in cervical cancer.

Methods

We searched the PubMed, Embase, Web of Science, Cochrane Library, Chinese Biological Medicine (CBM), Chinese National Knowledge Infrastructure (CNKI), Wanfang and VIP databases in all languages from their inception to September 2018. Stat15.0 software was used to obtain pooled estimates of sensitivity (SEN), specificity (SPE), positive likelihood ratio (PLR), and negative likelihood ratio (NLR) as well as a summary receiver operating characteristic (SROC) curves. Deek‘s funnel plot was used to assess publication bias. QUADAS-2 was used to evaluate the quality of the studies. The protocol for this meta-analysis is registered in PROSPERO (CRD42019115330).

Results

We obtained 14 studies, and the pooled estimates for sensitivity and specificity of PET/CT were 0.71 (95% confidence interval (CI) = 0.54–0.83) and 0.97 (95% CI = 0.93–0.98), respectively. Pooled PLR and NLR were 21.53 and 0.30, respectively. The diagnostic odds ratio (DOR) was70.59, and the area under the curve (AUC) was 0.95.

Conclusion

PET/CT is an effective and important imaging method for the diagnosis of para-aortic lymph node metastasis in early cervical cancer.

Detection of distant metastatic disease by positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET) at initial staging of cervical carcinoma

OBJECTIVE

The detection of distant metastatic disease in cervical cancer patients at diagnosis is critical in accurate prognostication and directing treatment strategies. This study describes the frequency and sites of distant metastatic disease at diagnosis in patients with cervical cancer as detected by positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET).

METHODS

Patients with newly diagnosed cervical cancer underwent pre-treatment whole-body FDG-PET starting in 1997 at an academic institution. Patients with evidence of distant FDG-avid disease, defined as disease outside of typical sites of lymphatic spread, were included for analyses. Patients were not surgically staged, but biopsy to confirm metastatic disease was attempted at the discretion of the treating physicians. Overall survival was calculated using Kaplan-Meier analysis.

RESULTS

From 1997 to 2017, 72 (6.2%) of 1158 consecutively evaluated cervical cancer patients exhibited FDG-avid distant disease at diagnosis; 27 (38%) of these had biopsy confirmation of distant disease. Only 35 (49%) of FDG-detected metastases were clinically apparent. The sites of distant disease were lung (35%), multiple sites (25%), omentum (16.5%), bone (16.5%), and liver (7%). There were 12 (17%) patients with distant disease who did not display FDG-avid lymph nodes. Median overall survival among patients with distant FDG-avid disease was 7.0 months (95% CI 4.3 to 9.7). Patients with multiple sites of distant disease demonstrated the worst overall survival.

CONCLUSIONS

Distant metastatic disease detected by FDG-PET is found in 6.2% of patients with cervical cancer at the time of initial diagnosis and the most common site of disease is the lung. Further prospective investigation is warranted to delineate best treatment practices for cervical cancer patients presenting with distant metastases.

18F-FDG PET/CT in locally advanced cervical cancer: A review

Cervical cancer is the second most common gynecological cancer worldwide. In locally advanced cervical cancer, ¹⁸F-FDG PET/CT has become important in the initial staging, particularly in the detection of nodal and distant metastasis, aspects with treatment implications and prognostic value. The aims of this study were to review the role of ¹⁸F-FDG PET/CT in uterine cervical cancer, according to the guidelines of the main scientific institutions (FIGO, NCCN, SEGO, SEOM, ESGO, and ESMO) and its diagnostic accuracy compared to conventional radiological techniques, as well as to review the acquisition protocol and its utility in radiotherapy planning, response assessment and detection of recurrence.

18F-FDG PET/CT in the evaluation of cancer cervix: Where do we stand today?

The incidence of gynecological malignancies is on the rise partly because of the availability of screening programmes, awareness, higher technological advancements, and availability of better medical care. Early diagnosis of any malignancy leads to prompt treatment. Use of 18Fluorine-Fluorodeoxyglucose (F-FDG) PET/CT in the treatment and follow-up of patients with Ca cervix considerably improves patient management. The primary diagnosis of Ca cervix is made either by biopsy of a visible tumor on the cervix or by a cone biopsy of a nonvisible malignant cervical focus. The staging procedure is purely clinical (i.e. gynecologic examination under general anesthesia) according to the International Federation of Gynaecology and Obstetrics classification. Earlier, with the nonavailability of sophisticated medical equipment and imaging specialists, oncologists relied heavily on clinical examination. However, anatomical and functional imaging has been proven to be considerably superior in understanding parametrial involvement and nodal/distant metastases in the cancer cervix than clinical examination alone. Data are evolving on the usage of F-FDG PET/CT in initial staging, treatment planning, and monitoring therapy response for gynecological malignancies. Prognostic information derived from the primary lesion such as the maximum standardized uptake value, metabolic tumor volume, and extent of para-aortic nodal metastatic disease plays a critical role in tailoring therapy on the basis of patient tumor-specific factors rather than on International Federation of Gynaecology and Obstetrics stage alone. Thus, F-FDG PET/CT needs to be listed not only under the panel of pretherapy investigations for Ca cervix but also for recurrence and therapy response assessments. It allows a more confident approach to patient management at initial staging, especially in terms of the decision to choose surgical versus palliation measures.

Noninvasive detection of cancer spread to lymph nodes: A review of molecular imaging principles and protocols

Identification of cancer spread to tumor-draining lymph nodes offers critical information for guiding treatment in many cancer types. Current clinical methods of nodal staging are invasive and can have substantial negative side effects. Molecular imaging protocols have long been proposed as a less invasive means of nodal staging, having the potential to enable highly sensitive and specific evaluations. This review article summarizes the current status and future perspectives for molecular targeted nodal staging.

Evaluation of Therapeutic Potential of Eugenol-A Natural Derivative of Syzygium aromaticum on Cervical Cancer

Background: The intendment of this study is to determine the pursuance in – vitro anticancer activity and cytotoxicity of Syzygium aromaticum against the human cervical cancer cell line (HeLa) compared to the normal cell lines. Apoptogenic properties of DCM extract of Eugenol was determined in this entire study. Materials and Methods: HeLa cell lines were cultured in DMEM medium and incubated with different concentration of DCM – Eugenol extract. MTT assay brought out the way to determine the cell viability and quantification was done with the optical absorbance at 570 nm and 620 nm as reference. Apoptotic cells were affirmed by dual staining using acridine orange bromide. Besides, the morphology of the nucleus was also confirmed by dual staining. Eugenol inhibited 50% growth (IC50) of HeLa cell lines at 200 mg/ml of extract concentration. Results: Inhibitory efficacy of eugenol isolated from Syzyzgyium aromaticum showed the cell – viability in time and dose dependent manner with consistent morphological changes. Flow cytometer determined the apoptosis confirming the cytotoxicity value for MTT at IC50 with 81.85% cell viability. Dual staining firmly enacts the damaged cells due to AO indicating apoptosis confirmation by dual staining. Morphological analysis also clearly states that nil apoptosis has been seen in control and similarly in eugenol treated when compared to cancerous HeLa cell – line. Conclusion: Evaluation of cytotoxicity effect of eugenol isolated from Syzygium aromaticum showed it can be unrivalled dormant source of prodigious changes in HeLa cell line indicating (revealing) that chemotherapeutic agent.

(18F)-FDG PET/CT parameters to predict survival and recurrence in patients with locally advanced cervical cancer treated with chemoradiotherapy

PURPOSE

To identify predictive (¹⁸F)-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT)-based parameters for locoregional control, disease-free survival and overall survival, by testing different thresholds of metabolic tumor volume and total lesion glycolysis in patients with locally-advanced cervical cancer.

PATIENTS AND METHODS

Thirty-seven patients treated with standard chemoirradiation underwent a pretreatment (¹⁸F)-FDG-PET/CT. Using different thresholds of maximum standardized uptake value, the following PET parameters were computed: maximum standardized uptake value, mean standardized uptake value, metabolic tumor volume and total lesion glycolysis for primary tumor and lymph nodes and a new parameter combining the metabolic tumor volume and the distance between lymph nodes and the primary tumor, namely metabolic node distance. Correlation between PET and clinical parameters with clinical outcome (overall survival, disease-free survival, and locoregional control) was assessed using univariate and multivariate analyses (Cox model).

RESULTS

In univariate analyses, PET/CT parameters associated with overall survival and disease-free survival were: metabolic tumor volume and total lesion glycolysis of the primary tumor, total lesion glycolysis of lymph nodes and metabolic node distance. The most predictive threshold segmentation for metabolic tumor volume and total lesion glycolysis was 48% of maximum standardized uptake value for the primary tumor and 30% for the lymph nodes. In multivariate Cox analysis, the total lesion glycolysis of primary tumor 48% and metabolic node distance were the two independent risk factors for overall survival (P<0.01), disease-free survival (P<0.01) and locoregional control (P=0.046).

CONCLUSION

Total lesion glycolysis of primary tumor and distance between the invaded positive lymph node and the primary tumor seem to have the highest predictive value when compared to classical clinical prognostic parameters and may be useful to identify high risk groups at time of diagnosis and to tailor the therapeutic approach in locally-advanced cervical cancer.

[18F]FDG-PET/CT and MRI for initial pelvic lymph node staging in patients with cervical carcinoma: The potential usefulness of [18F]FDG-PET/MRI

The current study aimed to determine the optimum diagnostic imaging technique out of magnetic resonance imaging (MRI), ¹⁸F-fludeoxyglucose positron emission tomography/computed tomography ([¹⁸F]FDG-PET/CT, otherwise known as PET/CT) and [¹⁸F]FDG-PET/MRI (otherwise known as PET/MRI) for the pelvic lymph node staging (N-staging) of untreated cervical carcinoma (CC). A total of 27 patients were included in the present study. All patients had undergone pre-treatment with PET/CT and MRI ≤45 days prior to undergoing a lymphadenectomy. The results from PET (separated from PET/CT), MRI and the statistically combined results of (virtual) PET/MRI were compared to those from histological analyses (the gold standard). A per-patient-based analysis of the detection of pelvic lymph node metastases indicated that PET/MRI had a sensitivity of 64%. The specificity of PET/CT and MRI were 69 and 62%, respectively. The positive predictive value (PPV) was 69 and 64% for PET/CT and MRI, respectively. The negative predictive value (NPV) was 64 and 62% for PET/CT and MRI, respectively. The sensitivity of the PET-guided PET/MRI and the MRI-guided PET/MRI was 64% for both. The specificity of the PET-guided PET/MRI and the MRI-guided PET/MRI was 77 and 62%, respectively. The PPV was 75% for PET-guided PET/MRI and 64% for MRI-guided PET/MRI, and the NPV was 67 and 62%, respectively. PET/CT and the virtual PET/MRI exhibited the same low sensitivity (64%). PET/MRI exhibited slightly better results than PET/CT regarding specificity (77 vs. 69%, respectively), PPV (75 vs. 69%, respectively) and NPV (67 vs. 64%, respectively). The results of the present study suggested that PET/CT and MRI are not optimal diagnostic modalities, and that PET/MRI does not necessarily lead to better results than PET/CT, in the pelvic N-staging of CC.

The role of 18F-FDG PET CT in common gynaecological malignancies

[fluorine-18]-fluoro-2-deoxy-D-glucose positron emission tomography (¹⁸F-FDG PET CT) has increasing clinical applications supplementing conventional TVUS, CT and MRI imaging in assessing ovarian, cervical and endometrial cancer. The published literature on the applications of ¹⁸F-FDG PET CT shows its use can have significant impact on patient management by improving staging of the cancers, influencing patient selection for treatment and in detecting early recurrent disease. However, the increasing clinical use of PET CT does not always align with the guidelines, recommendations or expert opinion in the use of PET CT. This article summarizes the existing evidence base for the established clinical applications and the emerging roles for ¹⁸F-FDG PET CT in the common gynaecological malignancies.

Different imaging techniques for the detection of pelvic lymph nodes metastasis from gynecological malignancies: a systematic review and meta-analysis

OBJECTIVE

This study aimed to evaluate the diagnostic performance of different imaging techniques and the corresponding diagnostic criteria for preoperative detection of pelvic lymph node metastasis from gynecological carcinomas.

METHODS

Six databases were systematically searched for retrieving eligible studies. Study inclusion, data extraction and risk of bias assessment were performed by 2 reviewers independently. STATA 14.0 was used to perform the meta-analysis.

RESULTS

Eighty eligible studies were collected. The pooled sensitivity, specificity, and area under curve (AUC) of CT, MRI and DWI were 47%, 93%, 0.7424; 50%, 95%, 0.8039 and 84%, 95%, 0.9523 respectively. As regards PET, PET-CT and US, the pooled sensitivity, specificity and AUC were 56%, 97%, 0.9592; 68%, 97%, 0.9363 and 71%, 99%, 0.9008 respectively. The summary receiver operating characteristic (SROC) curve indicated that the systematic diagnostic performances of PET, PET-CT, DWI were superior to other imaging modalities.

CONCLUSIONS

The present work demonstrated that DWI, PET, PET-CT were the top-priority consideration of imaging modalities for detecting metastatic pelvic lymph node in gynecological carcinoma. DWI was recommended as the first choice for metastasis exclusion and all the other imaging techniques including CT and MRI were suitable for metastasis conformation. However, for the early stage lymph node malignancy, PET or PET-CT could represent a better choice. More studies exploring the diagnostic efficacy of detailed criteria are required in the future.

Effect of number of retrieved lymph nodes on prognosis in FIGO stage IB-IIA cervical cancer patients treated with primary radical surgery

AIM

In the treatment of cervical cancer, the extent of lymphadenectomy is a matter of debate. The goal of the current study was to examine the question of whether the number of retrieved lymph nodes (RLN) can influence survival of patients with early stage cervical cancer.

METHODS

The medical records of 180 FIGO stage IB-IIA cervical cancer patients treated with primary radical surgery were reviewed. Patients were divided into two groups: those with ≤ 40 RLN and those with > 40 RLN. Patients were also assigned to either the bulky (tumor size > 4 cm) cervical cancer group or the non-bulky (tumor size ≤ 4 cm) cervical cancer group.

RESULTS

The number of RLN had a statistically significant effect on both disease-free survival (P = 0.04) and overall survival (P = 0.02) of all patients. Patients with > 40 RLN had better prognoses than those with ≤ 40 RLN. In the bulky cervical cancer group, the number of RLN was an independent prognostic factor. In multivariate analysis for the bulky cervical cancer group, > 40 RLN had a significant positive effect on disease-free survival (adjusted hazard ratio, 0.36; 95% confidence interval, 0.13-0.97) and overall survival (adjusted hazard ratio, 0.23; 95% confidence interval, 0.06-0.90). However, number of RLN was not an independent prognostic factor in the non-bulky cervical cancer group.

CONCLUSIONS

A more extensive lymphadenectomy increased the survival of bulky cervical cancer patients. This finding may be helpful in determining surgical extent before surgery for cervical cancer.

Pre-treatment MRI minimum apparent diffusion coefficient value is a potential prognostic imaging biomarker in cervical cancer patients treated with definitive chemoradiation

Background

Diffusion Weighted (DW) Magnetic Resonance Imaging (MRI) has been studed in several cancers including cervical cancer. This study was designed to investigate the association of DW-MRI parameters with baseline clinical features and clinical outcomes (local regional control (LRC), disease free survival (DFS) and disease specific survival (DSS)) in cervical cancer patients treated with definitive chemoradiation.

Methods

This was a retrospective study approved by an institutional review board that included 66 women with cervical cancer treated with definitive chemoradiation who underwent pre-treatment MRI at our institution between 2012 and 2013. A region of interest (ROI) was manually drawn by one of three radiologists with experience in pelvic imaging on a single axial CT slice encompassing the widest diameter of the cervical tumor while excluding areas of necrosis. The following apparent diffusion coefficient (ADC) values (×10⁻³ mm²/s) were extracted for each ROI: Minimum - ADC_min, Maximum - ADC_max, Mean - ADC_mean, and Standard Deviation of the ADC - ADC_dev. Receiver operating characteristic (ROC) curves were built to choose the most accurate cut off value for each ADC value. Correlation between imaging metrics and baseline clinical features were evaluated using the Mann Whitney test. Confirmatory multi-variate Cox modeling was used to test associations with LRC (adjusted by gross tumor volume – GTV), DFS and DSS (both adjusted by FIGO stage). Kaplan Meyer curves were built for DFS and DSS. A p-value < 0.05 was considered significant.

Women median age was 52 years (range 23–90). 67 % had FIGO stage I-II disease while 33 % had FIGO stage III-IV disease. Eighty-two percent had squamous cell cancer. Eighty-eight percent received concurrent cisplatin chemotherapy with radiation. Median EQD2 of external beam and brachytherapy was 82.2 Gy (range 74–84).

Results

Women with disease staged III-IV (FIGO) had significantly higher mean ADC_max values compared with those with stage I-II (1.806 (0.4) vs 1.485 (0.4), p = 0.01). Patients with imaging defined positive nodes also had significantly higher mean (±SD) ADC_max values compared with lymph node negative patients (1.995 (0.3) vs 1.551 (0.5), p = 0.03).

With a median follow-up of 32 months (range 5–43) 11 patients (17 %) have developed recurrent disease and 8 (12 %) have died because of cervical cancer. ROC curves based on DSS showed optimal cutoffs for ADC_min (0.488 × 10⁻³), ADC_mean (0.827 × 10⁻³), ADC_max (1.838 × 10⁻³) and ADC_dev (0.148 × 10⁻³). ADC_min higher than the cutoff was significantly associated with worse DFS (HR = 3.632–95 % CI: 1.094–12.054; p = 0.035) and DSS (HR = 4.401–95 % CI: 1.048–18.483; p = 0.043).

Conclusion

Pre-treatment ADC_max measured in the primary tumor may be associated with FIGO stage and lymph node status. Pre-treatment ADC_min may be a prognostic factor associated with disease-free survival and disease-specific survival in cervical cancer patients treated with definitive chemoradiation. Prospective validation of these findings is currently ongoing.

18F-FDG-PET/CT is of limited value in primary staging of early stage cervical cancer

PURPOSE

To assess the clinical benefit of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (18F-FDG-PET/CT) in evaluating pelvic lymph nodes in patients with early stage cervical cancer (FIGO stage 1a–1b1), who have magnetic resonance imaging (MRI)-defined lymph node negative disease, with histopathologic results as the reference standard.

MATERIALS AND METHODS

We assessed one hundred and seventy nine sequential 18F-FDG-PET/CT scans in women with newly diagnosed cervical carcinoma between January 2009 and September 2011. 47 of these patients had early stage disease (FIGO stage 1a–1b1) with no suspicious lymph nodes on MRI. 18F-FDG-PET/CT images were analyzed and histopathological findings (pelvic lymph node resection) served as the reference standard.

RESULTS

The median age of patients was 48 (range 22–86) years. 66 % had squamous histotype. Median number of nodes dissected per patient was 21 (range 8–47), 2 of 47 patients had nodal metastases (4.25 %). All patients in this group had no suspicious lymph nodes on 18F-FDG-PET/CT. Overall patient based sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 18F-FDG-PET/CT for detection of nodal disease were 0 %, 100 %, 0 %, 96 %, and 96 % respectively.

CONCLUSION

Pathologic validation of 18F-FDG-PET/CT imaging demonstrates little value for 18F-FDG-PET/CT in patients with early stage (FIGO stage 1a–1b1) MRI-defined lymph node negative cervical carcinoma. Since the likelihood of metastatic nodal disease is very low in women with stage 1a–1b1 cervical cancer, we believe that 18F-FDG-PET/CT should not have a role in the routine pre-treatment evaluation of these women.

Utility of PET for Radiotherapy Treatment Planning

PET imaging has contributed substantially in oncology by allowing improved clinical staging and guiding appropriate cancer management. Integration with radiotherapy planning via PET/computed tomography (CT) simulation enables improved target delineation, which is paramount for conformal radiotherapy techniques. This article reviews the present literature regarding implications of PET/CT for radiotherapy planning and management.

Gynecologic oncologic imaging with PET/CT

FDG-PET/CT has been evaluated in a variety of gynecologic malignancies in a variety of settings and is approved by the Centers for Medicare & Medicaid Services for the initial and subsequent treatment strategies of these malignancies. Cervical cancer is typically very FDG avid, and FDG-PET/CT appears to be most valuable for initial staging, radiation therapy planning, and detection of recurrent disease. For ovarian cancer, the most value of FDG-PET/CT appears to be for detecting recurrent disease in the setting of rising CA-125 level and negative or equivocal anatomical imaging studies. Initial studies evaluating response to therapy are promising and further work in this area is needed. FDG uptake in both nonmalignant and physiological processes in the pelvis can make interpretation of FDG-PET/CT in this region challenging and knowledge of these entities and patterns can avoid misinterpretation. Some of the most common findings relate to the cyclic changes that occur as part of the menstrual cycle in premenopausal women. Mucinous tumors and low-volume or peritoneal carcinomatosis are causes of false-negative results on FDG-PET/CT studies. As new tracers are developed, comparisons with patient outcomes and standards of care (eg, FDG-PET/CT) will be needed.

Integration of PET/CT into the preoperative evaluation of patients with early cervical cancer does not decrease the proportion of patients with positive lymph nodes found after surgery

PURPOSE

The aim of this study was to evaluate whether preoperative positron emission tomography/computed tomography (PET/CT) in patients with early-stage cervical carcinoma reduced the proportion of patients with metastatic lymph nodes identified after surgery.

PATIENTS AND METHODS

This is a multicenter case-control study of 599 patients with early cervical cancer who underwent radical hysterectomy and pelvic lymphadenectomy at 1 of 10 gynecological oncology units in Israel. The patients were divided into 2 groups according to whether or not they underwent a preoperative PET/CT. The primary outcome was the proportion of patients with nodal involvement. The 2 groups were compared with regard to the clinical and histological variables.

RESULTS

Of the 599 patients who underwent surgery, 180 (36%) had preoperative PET/CT study. There were no significant differences between the PET/CT and control groups with regard to clinical and histological risk factors. The proportion of patients with involved nodes was similar in the control and PET/CT groups (20.8% vs 19%; P = 0.73) as well as the proportion of patients receiving adjuvant radiotherapy/chemoradiation (58.3% vs 55.1%; P = 0.55).

CONCLUSIONS

Preoperative PET/CT in patients with early cervical cancer does not reduce proportion of patients with metastatic nodal involvement and the employment of multimodality treatment. Prospective clinical trials comparing management based on PET/CT findings are warranted.

Staging for cervix cancer: Role of radiology, surgery and clinical assessment

Staging is necessary in determining the extent of disease, its prognosis and in the formulation of optimal treatment protocols for patients with cancer. Clinical examination of patients and subsequent histopathological assessment when available has traditionally been used to determine the application of different primary and adjuvant treatment modalities. Over the years, surgery, radiotherapy and chemotherapy all have been used either singly or in combinations, and the resulting survival and patterns of failure studies have contributed much in the development of less toxic and more effective protocols. All three modalities of treatments work through separate mechanisms, and they are effective in different stages of cervix cancer. Even within the same stage, the extent of the disease, tumour volume, tissue infiltration and lymph-node metastases requires the use of differing protocols for the disease control. More recently, advances in magnetic resonance imaging (MRI) and positron emission tomography/computerised tomography (PET/CT) have made it possible to examine many of the prognostic factors non-invasively. In addition to clinical assessment, surgical and radiological staging has enabled us to triage patients far more accurately for surgery or for primary radiotherapy, such as unnecessary multimodality treatments are avoided. Only patients with poor prognosis are subjected to a combined modality treatment. Those with poorer prognosis still can be selected for clinical studies exploring new treatment.

PET-based radiation therapy planning

In this review, we review the literature on the use of PET in radiation treatment planning, with an emphasis on describing our institutional methodology (where applicable). This discussion is intended to provide other radiation oncologists with methodological details on the use of PET imaging for treatment planning in radiation oncology, or other oncologists with an introduction to the use of PET in planning radiation therapy.

Positron Emission Tomography (PET) in Oncology

Since its introduction in the early nineties as a promising functional imaging technique in the management of neoplastic disorders, FDG-PET, and subsequently FDG-PET/CT, has become a cornerstone in several oncologic procedures such as tumor staging and restaging, treatment efficacy assessment during or after treatment end and radiotherapy planning. Moreover, the continuous technological progress of image generation and the introduction of sophisticated software to use PET scan as a biomarker paved the way to calculate new prognostic markers such as the metabolic tumor volume (MTV) and the total amount of tumor glycolysis (TLG). FDG-PET/CT proved more sensitive than contrast-enhanced CT scan in staging of several type of lymphoma or in detecting widespread tumor dissemination in several solid cancers, such as breast, lung, colon, ovary and head and neck carcinoma. As a consequence the stage of patients was upgraded, with a change of treatment in 10%-15% of them. One of the most evident advantages of FDG-PET was its ability to detect, very early during treatment, significant changes in glucose metabolism or even complete shutoff of the neoplastic cell metabolism as a surrogate of tumor chemosensitivity assessment. This could enable clinicians to detect much earlier the effectiveness of a given antineoplastic treatment, as compared to the traditional radiological detection of tumor shrinkage, which usually takes time and occurs much later.

Laparoscopic lymphadenectomy in advanced cervical cancer: prognostic and therapeutic value

OBJECTIVE

Clinical benefit of surgical staging in locally advanced cervical cancer has not yet been proved. The goal of this study was to analyze the prognostic and therapeutic value of laparoscopic para-aortic lymphadenectomy with selective excision of suspicious pelvic nodes in patients with locally advanced cervical cancer.

METHODS

This is a retrospective study including 109 women treated in a single institution from 2000 to 2009. The International Federation of Gynecology and Obstetrics stage was IB2 in 12 women, IIB in 58 women, and IIIB in 39 women. None had suspicious para-aortic nodes by presurgical imaging evaluation. All patients underwent extraperitoneal para-aortic laparoscopic lymphadenectomy with selective excision of enlarged pelvic nodes and received pelvic radiotherapy with concomitant chemotherapy. Extended lumboaortic radiation therapy was added to patients with metastatic para-aortic nodes. The mean ± SD follow-up time was 43.1 ± 33.7 months.

RESULTS

Metastatic lymph nodes were identified in 23 (21.1%) of 109 patients in the para-aortic area and in 24 (53.3%) of 45 patients who underwent selective excision of pelvic nodes. Patients with nodal metastases had increased risk of mortality than those with negative nodes independently of the location (pelvic and/or para-aortic) of the metastases (hazard ratio, 4.07; 95% confidence interval, 1.36-12.16 for patients with pelvic metastases [P = 0.012]; and 3.73; 95% confidence interval, 1.38-10.09 for patients with para-aortic metastases [P = 0.010]). In the subset of women with para-aortic metastases treated by extended lumboaortic radiation therapy, neither the number of lymph nodes removed nor the number of positive nodes were associated with survival (P = 0.556 and P = 0.195, respectively).

CONCLUSION

Para-aortic and pelvic lymphadenectomy provides valuable information about mortality risk in patients with locally advanced cervical cancer.

Current status of sentinel lymph node mapping in the management of cervical cancer

The status of regional lymph nodes is the most important prognostic factor in early cervical cancer patients. Pelvic lymph node dissections are routinely performed as a part of standard surgical treatment. Systematic pelvic lymphadenectomy is associated with short- and long-term morbidities. This review discusses single components of the sentinel lymph node mapping (SLNM) technique and results of the detection of sentinel lymph nodes. SLNM biopsy performed by an experienced team for small volume tumors (<2 cm) has high specific side detection rate, excellent negative-predictive value and high sensitivity. Uncommon lymphatic drainage has been reported in 15% of cervical cancer patients. There is sufficient data now to suggest that SLNM with 99mTc plus blue dye in the hands of a surgeon with extensive experience should prove to be an important part of individualized cervical cancer surgery and increase the safety of less radical or fertility-sparing surgery.

Preoperative nomogram for the identification of lymph node metastasis in early cervical cancer

Background:

The objective of this study is to construct a preoperative nomogram predicting lymph node metastasis (LNM) in early-cervical cancer patients.

Methods:

Between 2009 and 2012, 493 early-cervical cancer patients received hysterectomy and pelvic/para-aortic lymphadenectomy. Patients who were diagnosed during 2009–2010 were assigned to a model-development cohort (n=304) and the others were assigned to a validation cohort (n=189). A multivariate logistic model was created from preoperative clinicopathologic data, from which a nomogram was developed and validated. A predicted probability of LNM<5% was defined as low risk.

Results:

Age, tumour size assessed by magnetic resonance imaging, and LNM assessed by positron emission tomography/computed tomography were independent predictors of nodal metastasis. The nomogram incorporating these three predictors demonstrated good discrimination and calibration (concordance index=0.878; 95% confidence interval (CI), 0.833−0.917). In the validation cohort, the discrimination accuracy was 0.825 (95% CI, 0.736−0.895). In the model-development cohort, 34% of them were classified as low risk and negative predictive value (NPV) was 99.0%. In the validation cohort, 38% were identified as low risk and NPV was 95.8%. Integrating the model-development and validation cohorts, negative likelihood ratio was 0.094 (95% CI, 0.036−0.248).

Conclusion:

A robust nomogram predicting LNM in early cervical cancer was developed. This model may improve clinical trial design and help physicians to decide whether lymphadenectomy should be performed.

Positron emission tomography with [(18)F]-3'-deoxy-3'fluorothymidine (FLT) as a predictor of outcome in patients with locally advanced resectable rectal cancer: a pilot study

PURPOSE

This pilot study was performed to evaluate whether tumor uptake of (18)F-labeled 3'-deoxy-3'fluorothymidine (FLT), a proliferative radiotracer, at baseline and early during therapy, is predictive of outcome in locally advanced rectal cancer.

PROCEDURES

Fourteen patients underwent positron emission tomography (PET) with 2-deoxy-2-[(18)F]fluoro-D-glucose (FDG) and FLT before therapy and PET with FLT approximately 2 weeks after initiating neoadjuvant chemoradiotherapy. FLT and FDG uptake were evaluated qualitatively and by maximum standardized uptake value (SUV(max)). Tumor FLT and FDG uptake were correlated with disease-free survival (DFS).

RESULTS

Thirteen patients underwent surgery after therapy, one died before surgery with progressive disease. FDG-PET/computed tomography detected regional lymph node metastases in five and FLT-PET was positive in one. High pretherapy FDG uptake (SUV(max) ≥ 14.3), low during-therapy FLT uptake (SUV(max) < 2.2), and high percentage change in FLT uptake (≥60 %) were predictive of improved DFS (p < 0.05 for all three values).

CONCLUSION

Pretherapy FDG uptake, during-therapy FLT uptake, and percentage change in FLT uptake were equally predictive of DFS.

The role of PET/CT in the management of cervical cancer

OBJECTIVE. Cervical cancer is the second most common malignancy in women worldwide and the third most common cause of cancer mortality in the United States. The aim of this article is to describe cervical cancer and outline the value of (18)F-FDG PET/CT in the management of cervical malignancy. CONCLUSION. The value of PET/CT has been found in staging and treatment strategy for cervical cancer. FDG PET/CT facilitates decision-making and radiation treatment planning and provides important information about treatment response, disease recurrence, and long-term survival.

[Positron emission tomography for volume delineation of pelvic nodal involvement]

Radiotherapy planification has recently known important developments, with the rise of new technologies, such as conformational radiation therapy, intensity-modulated radiation therapy (IMRT) or stereotaxic radiation therapy. Delineation of target volumes has become primordial. Hybrid imaging by positron emission tomography associated to computed tomography scanner (PET-CT) gives an access to functional and morphological information. Radiotherapist and nuclear physicians working closely have the potential to allow a more optimal delineation, and a better preservation of organs at risk. During the past few years, this has been explored by many articles, and we propose a literature review organized by localization, about the use of PET-CT for pelvic nodes delineation.