Preoperative PET/CT FDG standardized uptake value of pelvic lymph nodes as a significant prognostic factor in patients with uterine cervical cancer. Eur J Nucl Med Mol Imaging. 2014;41:674-681. [PMID: 24233005 DOI: 10.1007/s00259-013-2626-1]

Long-term outcomes of cervical cancer patients with complete metabolic response after definitive chemoradiotherapy

OBJECTIVE

We investigated the importance of metabolic parameters measured with 18F-fluorodeoxyglucose positron-emission tomography integrated with computed tomography (FDG-PET/CT) for predicting progression-free survival (PFS) and overall survival (OS) in cervical cancer with complete metabolic response (CMR) after chemoradiotherapy (ChRT).

METHODS

The clinical data and PET parameters including standardized uptake value (SUV), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of 122 patients having CMR in post-treatment 18F-FDG-PET/CT delivered a median of 3.9 months after ChRT completion were analyzed.

RESULTS

With a median follow-up of 8.4 years, 55 patients (45%) presented with disease a median of 19.7 months after ChRT. For SUVp, MTVp, TLGp, SUVln, MTVln, and TLGp, the cut-off values for OS determined by receiver operating curve analysis were 15.8, 48.7 cm³, 552.3, 8.7, 7.0 cm³, respectively. All metabolic PET parameters were significant prognostic factors for OS and PFS in univariate analysis. International Federation of Gynecology and Obstetrics (FIGO) stage was predictive of both OS and PFS, while pelvic and/or para-aortic lymph node metastasis were predictive of OS only. In multivariate analysis, FIGO stage ≥IIB, MTVp ≥49.8 cm³, and TLGp ≥597.4 were predictive of worse OS. Advanced stage, presence of lymph node metastasis, higher TLGp, and larger MTVln were significant factors for poor PFS rates.

CONCLUSION

We found that advanced stage and higher TLGp values were significant predictors for poor survival and higher progression rates. Volumetric PET parameters could be used to predict treatment outcomes in patients with CMR after definitive ChRT.

Tumour and pelvic lymph node metabolic activity on FDG-PET/CT to stratify patients for para-aortic surgical staging in locally advanced cervical cancer

PURPOSE

The aim of our study was to comprehensively evaluate the most valuable metabolic parameters of cervical tumours and pelvic lymph nodes (PLN) by FDG-PET/CT to predict para-aortic lymph node (PALN) metastasis and stratify patients for surgical staging.

METHODS

The study included patients with locally advanced cervical cancer, negative PALN uptake on preoperative FDG-PET/CT, and para-aortic lymphadenectomy. Two senior nuclear medicine physicians expert in gynaecologic oncology reviewed all PET/CT exams, and extracted tumour SUVmax, MTV, and TLG, as well as PLN. Prognostic parameters of PALN involvement were identified using ROC curves and logistic regression analysis.

RESULTS

One hundred and twenty-five consecutive locally advanced cervical cancer patients were included. The FDG-PET/CT false-negative rate was, respectively, 27.7% (13/47) and 5.1% (4/78) in patients with and without FDG-PET/CT PLN uptake. The AUC of cervical tumour size, SUVmax, MTV, and TLG was, respectively, 0.75 (0.62-0.87), 0.59 (0.44-0.76), 0.75 (0.60-0.90), and 0.71 (0.56-0.86). The AUC of PLN size, SUVmax, SUVmean, PLN SUVmax/Tumour SUVmax ratio, MTV, and TLG was, respectively, 0.57 (0.37-0.78), 0.82 (0.68-0.95), 0.77 (0.61-0.94), 0.85 (0.72-0.98), 0.69 (0.51-0.87), and 0.74 (0.57-0.91). The metabolic parameter showing the best trade-off between sensitivity and specificity to predict PALN involvement was the ratio between PLN and tumour SUVmax.

CONCLUSION

The risk of PALN metastasis in FDG-PET/CT negative PLN patients is very low, so para-aortic lymphadenectomy does not seem justified. In patients with preoperative PLN uptake on FDG-PET/CT, surgical staging led to treatment modification in more than 25% of cases and should therefore be performed. Patients with more than one positive PLN and high PLN metabolic activity are at high risk of para-aortic extension and recurrence. Further prospective evaluation is required to consider intensified treatment modalities without prior PALN dissection.

The efficacy of pretreatment and after treatment 18F-FDG PET/CT metabolic parameters in patients with locally advanced squamous cell cervical cancer

OBJECTIVES

Cervical cancer is one of the main causes of cancer death worldwide. Fluorine-18-fluorodeoxyglucose (F-FDG) PET/computed tomography (PET/CT) has been playing an increasingly important role in staging and monitoring treatment response in the disease. In the current study, we investigated metabolic F-FDG PET/CT parameters among patients with locally advanced squamous cell cervical cancer treated with concurrent chemoradiotherapy for predicting disease-free survival (DFS).

PATIENTS AND METHODS

Forty-four patients with biopsy-proven locally advanced squamous cell cervical cancer were included in the study. Pretreatment and after treatment F-FDG PET/CT metabolic parameters [metabolic tumor volume, tumor lesion glycolysis, maximum standard uptake value (SUVmax)] for the primary tumor area and/or pelvic/para-aortic lymph nodes and also accompanying distant metastases were analyzed. Treatment response was divided into four groups according to a post-treatment F-FDG PET/CT scan.

RESULTS

For all patients, the 3-year DFS was 79%. Pretreatment primary tumor SUVmax and tumor lesion glycolysis, pelvic lymph node SUVmax, and pretreatment para-aortic lymph node SUVmax were significant prognostic factors for DFS with different cut-off values. In contrast, for metabolic tumor volume-T1, there was no statistical significance for DFS.

CONCLUSION

F-FDG PET/CT cut-off values may help clinicians with their treatment planning and follow-up in locally advanced squamous cell cervical cancer patients.

Prognostic Value of Pretreatment Metabolic PET Parameters in Cervical Cancer Patients With Metabolic Complete Response After Concurrent Chemoradiotherapy

PURPOSE

Cervical cancer may recur after concurrent chemoradiotherapy (CCRT), even in patients with metabolic complete response (mCR) on post-CCRT F-FDG PET. We retrospectively analyzed the value of metabolic parameters, measured by pretreatment PET, as prognostic factors for predicting recurrence and death in cervical cancer patients with mCR.

METHODS

In 61 patients who reached mCR on post-CCRT, metabolic PET parameters including SUVmax, metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of the primary tumors, as well as those of the metastatic lymph nodes, were measured by pre-CCRT PET. Total MTV and total TLG were also measured from primary tumors and metastatic lymph nodes. Survival analyses for disease-free survival (DFS) and overall survival (OS) were performed.

RESULTS

Eleven patients (18.0%) presented with recurrence of cervical cancer, and 12 (19.7%) died during follow-up. SUVmax, MTV, TLG of metastatic lymph nodes, and total TLG could significantly predict DFS, and nodal SUVmax could predict OS. Para-aortic lymph node metastasis also significantly correlated with both DFS and OS. In multivariate analysis, nodal SUVmax and para-aortic lymph nodes metastasis were prognostic factors for DFS, and the best predictor was nodal SUVmax. For OS, nodal MTV and para-aortic lymph node metastasis were significant prognostic factors in multivariate analysis, and the best predictor was para-aortic lymph node metastasis.

CONCLUSIONS

Metabolic PET parameters, SUVmax or MTV values of metastatic lymph nodes, may be surrogate prognostic markers for recurrence or death in patients with locally advanced cervical cancer who reached mCR after definitive CCRT.

Prognostic implication of the metastatic lesion-to-ovarian cancer standardised uptake value ratio in advanced serous epithelial ovarian cancer

OBJECTIVES

To evaluate the prognostic value of metabolic activity of metastatic lesions measured by ¹⁸F-flurodeoxyglucose (¹⁸F-FDG) uptake on preoperative positron emission tomography/computed tomography (PET/CT) in patients with advanced serous epithelial ovarian cancer (EOC).

METHODS

Clinico-pathological variables and PET/CT parameters such as the maximum standardised uptake value of the ovarian cancer (SUV_ovary), metastatic lesions (SUV_meta), and the metastatic lesion-to-ovarian cancer standardised uptake value ratio (SUV_meta/SUV_ovary) were assessed in International Federation of Gynaecology and Obstetrics (FIGO) stage III, IV patients.

RESULTS

Clinico-pathological data were retrospectively reviewed for 94 eligible patients. The median progression-free survival (PFS) was 18.5 months (range, 6-90 months), and 57 (60.6%) patients experienced recurrence. Older age [P = 0.017, hazard ratio (HR) 1.036, 95% CI 1.006-1.066], residual disease after surgery (P = 0.024, HR 1.907, 95% CI 1.087-3.346), and high SUV_meta/SUV_ovary (P = 0.019, HR 2.321, 95% CI 1.148-4.692) were independent risk factors of recurrence. Patients with high SUV_meta/SUV_ovary showed a significantly worse PFS than those with low SUV_meta/SUV_ovary (P = 0.007, log-rank test).

CONCLUSIONS

Preoperative SUV_meta/SUV_ovary was significantly associated with recurrence and has an incremental prognostic value for PFS in patients with advanced serous EOC.

KEY POINTS

• The prognostic value of the metabolic activity of metastatic lesions was investigated. • SUV_meta/SUV_ovary was significantly associated with recurrence of serous EOC. • Preoperative SUV_meta/SUV_ovary can be a predicator of serous EOC recurrence.

Prognostic value of total lesion glycolysis measured by 18F-FDG PET/CT in patients with locally advanced cervical cancer

AIM

The aim of this study was to determine the most relevant parameters of fluorine-18 fluorodeoxyglucose (F-FDG) PET/computed tomography (CT) for predicting recurrence in patients with locally advanced cervical cancer.

MATERIALS AND METHODS

Fifty-six patients diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage IIB to IVA cervical cancer who underwent F-FDG PET/CT before definitive chemoradiotherapy were retrospectively enrolled. Various PET parameters, namely, maximum standardized uptake value, mean standardized uptake value, metabolic tumor volume, and total lesion glycolysis (TLG) of the primary tumor, were analyzed to evaluate the relationship between these PET parameters and recurrence-free survival (RFS). The cut-off values of PET parameters that showed the best trade-off between sensitivity and specificity for RFS were determined by receiver operating characteristic curve analysis.

RESULTS

The median follow-up was 20 months (range, 6-63 months). Univariate analysis indicated that higher FIGO stage [hazard ratio (HR) 5.606, 95% confidence interval (CI) 1.682-18.68, P=0.005], metabolic tumor volume more than 47.81 cm (HR 6.203, 95% CI 1.351-28.481, P=0.019), and TLG more than 215.02 (HR 11.817, 95% CI 1.518-91.963, P=0.018) were associated with RFS. In multivariate analysis, FIGO stage (HR 4.618, 95% CI 1.295-16.463, P=0.018) and TLG more than 215.02 (HR 10.171, 95% CI 1.246-83.044, P=0.030) were independent predictive factors for RFS. Kaplan-Meier curves for RFS indicated that patients with TLG less than or equal to 215.02 showed better RFS (P=0.003).

CONCLUSION

Pretreatment TLG proved to be an independent prognostic factor for RFS in patients with locally advanced cervical cancer treated by definitive chemoradiotherapy.

Prognostic value of pre-treatment F-18-FDG PET-CT in patients with hepatocellular carcinoma undergoing radioembolization

AIM

To evaluate the value of pre-treatment 18F-FDG PET/CT in patients with HCC following liver radioembolization.

METHODS

We identified 34 patients with HCC who underwent an FDG PET/CT scan prior to hepatic radioembolization at our institution between 2009 and 2013. Patients were seen in clinic one month after radioembolization and then at 2-3 mo intervals. We assessed the influence of FDG tumor uptake on outcomes including local liver control (LLC), distant liver control (DLC), time to distant metastases (DM), progression free survival (PFS) and overall survival (OS).

RESULTS

The majority of patients were males (n = 25, 74%), and had Child Pugh Class A (n = 31, 91%), with a median age of 68 years (46-84 years). FDG-avid disease was found in 19 (56%) patients with SUVmax ranging from 3 to 20. Female patients were more likely to have an FDG-avid HCC (P = 0.02). Median follow up of patients following radioembolization was 12 months (1.2-62.8 mo). FDG-avid disease was associated with a decreased 1 year LLC, DLC, DM and PFS (P < 0.05). Using multivariate analysis, FDG avidity predicted for LLC, DLC, and PFS (all P < 0.05).

CONCLUSION

In this retrospective study, pre-treatment HCC FDG-avidity was found to be associated with worse LLC, DLC, and PFS following radioembolization. Larger studies are needed to validate our initial findings to assess the role of F-18-FDG PET/CT scans as biomarker for patients with HCC following radioembolization.

The Volume-metabolic Combined Parameters from (18)F-FDG PET/CT May Help Predict the Outcomes of Cervical Carcinoma

RATIONALE AND OBJECTIVES

The aim of this study was to evaluate the prognostic value of 18-fluoro-2-deoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) volume-metabolic combined parameters in patients with cervical carcinoma.

MATERIALS AND METHODS

We retrospectively reviewed 91 consecutive patients' whole-body FDG-PET/CT images, and further measured and calculated FDG PET/CT volume-metabolic parameters, including cervical metabolic tumor volume (CMTV), cervical total lesion glycolysis (CTLG), whole-body metabolic tumor volume (WB-MTV), whole-body total lesions glycolysis (WB-TLG). The prognostic value of these tumor volume-metabolic measures was assessed by Cox Proportional Hazard Regression Analysis.

RESULTS

The overall survival (OS) was 88.8% for patients with low CMTV (≤53.75 mL) and 45.5% for those with high CMTV (>53.75 mL), respectively (P < 0.01, 95% confidence interval). Univariate analysis showed that CMTV and CTLG were significant prognostic factors for OS, in addition to International Federation of Gynecology and Obstetrics (FIGO) stage, age, lymphadenopathy, and maximum standardized uptake value (SUVmax) (P < 0.05 for all). On multivariate analysis, CMTV remained significant for OS, in addition to FIGO stage (P < 0.05 for all). CMTV remains as prognostic factor for OS regardless of patients' FIGO stages (P < 0.05). In patients in the metastatic diseases group, univariate and multivariate analyses demonstrated that CMTV, WB-MTV, and WB-TLG were independent prognostic factors for OS (P < 0.05 for all).

CONCLUSION

CMTV, WB-MTV, and WB-TLG are reliable prognostic factors for patients with cervical carcinoma and should be included in FDG-PET/CT reports to guide referral clinicians for risk-adapted therapies.

Prognostic Value of the Sum of Metabolic Tumor Volume of Primary Tumor and Lymph Nodes Using 18F-FDG PET/CT in Patients With Cervical Cancer

This is an observational study to determine the most relevant parameter of ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) for predicting recurrence in cervical cancer. Fifty-six patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIB-IVA cervical cancer who underwent pretreatment ¹⁸F-FDG PET/CT were enrolled. PET parameters including maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of both primary tumor and pelvic and/or para-aortic lymph nodes were analyzed. SUVmax-S was defined as the sum of the SUVmax of primary tumor and the higher SUVmax of either pelvic or para-aortic lymph nodes. MTV-S was defined as the sum of the MTV of primary tumor and pelvic and para-aortic lymph nodes. TLG-S was calculated in the same way as MTV-S. We evaluated the relationship between these PET parameters and recurrence-free survival (RFS). Univariate analysis revealed that higher FIGO stage (hazard ratio [HR] = 5.61, 95% confidence interval [CI]: 1.68-18.68, P = 0.005), lymph node metastasis (HR = 3.42, 95% CI: 1.08-10.84, P = 0.037), MTV of primary tumor >47.81 cm³ (HR = 6.20, 95% CI: 1.35-28.48, P = 0.019), TLG of primary tumor >215.02 (HR = 11.82, 95% CI: 1.52-91.96, P = 0.018), MTV-S > 59.01 cm³ (HR = 8.24, 95% CI: 1.80-37.77, P = 0.007), and TLG-S > 224.15 (HR =  13.09, 95% CI: 1.68-101.89, P = 0.014) were associated with RFS. In multivariate analysis, FIGO stage (HR = 4.87, 95% CI: 1.38-17.18, P = 0.014) and MTV-S > 59.01 cm³ (HR = 7.37, 95% CI: 1.54-35.16, P = 0.012) were determined to be independent predictive factors for RFS. Our preliminary results reveal that MTV-S is an independent prognostic factor for RFS in patients with cervical cancer treated by definitive chemoradiotherapy.

Role of 18F-FDG PET/CT in the carcinoma of the uterus: a review of literature

In the present review we reported the value of 18F-fluorodeoxyglucose (FDG) PET/CT in face of uterine cancer, in terms of sensitivity, specificity and accuracy. Moreover, we made a comparison with the other imaging techniques currently used to evacuate these tumors including contrast-enhanced CT, contrast enhanced-MRI and transvaginal ultrasonography. FDG PET/CT has been reported to be of particular value in detecting occult metastatic lesions, in prediction of response to treatment and as a prognostic factor.

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.

Preoperative PET/CT standardized FDG uptake values of pelvic lymph nodes as a significant prognostic factor in patients with endometrial cancer

PURPOSE

Using integrated PET/CT, we evaluated the prognostic relevance of preoperative pelvic lymph node (LN) (18)F-FDG uptake in endometrioid endometrial cancer.

METHODS

We retrospectively reviewed patients with pathologically proven endometrial cancer who underwent preoperative (18)F-FDG PET/CT scans to evaluate the prognostic significance of PET/CT parameters and other clinicopathological variables. We used Cox proportional hazards regression to examine the relationship between recurrence and the maximum standardized uptake value (SUVmax) in pelvic LNs (SUVLN) on FDG PET/CT.

RESULTS

Clinical data, treatment modalities and results were reviewed in 70 eligible patients. The median postsurgical follow-up was 29 months (range 6 to 95 months). Receiver-operating characteristic analysis identified the significant SUVLN cut-off value as 15. The SUVLN correlated with FIGO stage (P < 0.001), LN metastasis (P < 0.001), lymphovascular space invasion (P < 0.001), SUVtumour (P = 0.001), metastatic LN size (P = 0.004), primary tumour size (P = 0.012), tumour grade (P = 0.015) and depth of tumour invasion (P = 0.035). Regression analysis showed a statistically significant association between recurrence and SUVLN (P = 0.002). Recurrence differed significantly (P < 0.001) between patients with SUVLN >15 and those with SUVLN ≤15.

CONCLUSION

Preoperative pelvic LN FDG uptake exhibited a strong significant association with recurrence of endometrioid endometrial cancer.