Research ArticleCLINICAL INVESTIGATIONS

Functional Images Reflect Aggressiveness of Endometrial Carcinoma: Estrogen Receptor Expression Combined with 18F-FDG PET

Tetsuya Tsujikawa, Yoshio Yoshida, Takashi Kudo, Yasushi Kiyono, Tetsuji Kurokawa, Masato Kobayashi, Tatsuro Tsuchida, Yasuhisa Fujibayashi, Fumikazu Kotsuji and Hidehiko Okazawa
Journal of Nuclear Medicine October 2009, 50 (10) 1598-1604; DOI: https://doi.org/10.2967/jnumed.108.060145

Article Figures & Data

Figures

  • FIGURE 1. 
    FIGURE 1. 

    Box-and-whisker plots of uptake of each tracer among 3 groups. Horizontal bars inside boxes indicate median values. Error bars indicate farthest points that are not outliers. Significant differences in 18F-FDG accumulation were observed between hyperplasia and high-risk (P < 0.0001) or low-risk (P < 0.005) endometrial carcinoma. 18F-FDG accumulation was not significantly different between high-risk and low-risk carcinoma, although 18F-FES PET showed significant difference between these 2 groups (P < 0.05). High-R = high-risk carcinoma; low-R = low-risk carcinoma; NS = not significant.

  • FIGURE 2. 
    FIGURE 2. 

    Box-and-whisker plots of 18F-FDG–to–18F-FES SUV ratio among 3 groups. Significant differences were observed between high-risk and low-risk carcinoma (P < 0.01), between high-risk carcinoma and hyperplasia (P < 0.005), and between low-risk carcinoma and hyperplasia (P < 0.0001). High-R = high-risk carcinoma; low-R = low-risk carcinoma.

  • FIGURE 3. 
    FIGURE 3. 

    T2-weighted (A), contrast-enhanced T1-weighted MR (B), 18F-FDG (C), and 18F-FES PET (D) images of 60-y-old woman with endometrial carcinoma (arrows). PET images showed intense 18F-FDG uptake (SUV, 11.6) and moderate 18F-FES uptake (SUV, 4.7) in tumor. Preoperative staging by MRI suggested no myometrial invasion, whereas PET findings with an 18F-FDG–to–18F-FES ratio of 2.5 indicated high-risk carcinoma. Postoperative histopathologic result was high-risk carcinoma with FIGO stage Ic and histologic grade 2.

  • FIGURE 4. 
    FIGURE 4. 

    Sagittal T2-weighted (A), contrast-enhanced T1-weighted MR (B), 18F-FDG (C), and 18F-FES PET (D) images of 50-y-old woman with low-risk endometrial carcinoma (FIGO stage Ib and histologic grade 1, arrows). PET images showed intense accumulation for both tracers in endometrial lesion. Region of 18F-FES uptake (SUV, 8.1) appeared larger than that of 18F-FDG (SUV, 10.2) because of 18F-FES avidity in myometrial inner layer. 18F-FDG–to–18F-FES ratio was 1.3.

  • FIGURE 5. 
    FIGURE 5. 

    A 39-y-old woman who had endometrial hyperplasia with relatively low intensity on sagittal T2-weighted (A) and contrast-enhanced T1-weighted (B) MR images (arrows). PET images showed low 18F-FDG (SUV, 1.4) (C) and high 18F-FES (SUV, 5.9) (D) accumulation in endometrial lesion of uterus. 18F-FDG–to–18F-FES ratio was 0.2.

Tables

  • TABLE 1

    Patient Characteristics

    CharacteristicValue
    Total patients (n)31
    Mean age (y)56 ± 15
    Age range (y)30–84
    Menopausal status (n)
     Premenopausal13
     Postmenopausal18
    Histopathologic type (n)
     Endometrial adenocarcinoma22
     Endometrial hyperplasia9
    Stage of carcinoma (n)
     Ia or Ib14
     Ic3
     II2
     III3
    Differentiation grade (n)
     G112
     G29
     G31
    Tumor size (n)
     <1 cm14
     1–2 cm8
     2 cm <9
    High-risk carcinoma (n)11
    Low-risk carcinoma (n)11

    • Carcinoma of stage Ib or lower with grade G2 or G3 was included in high-risk group.

  • TABLE 2

    Regional SUVs and 18F-FDG–to–18F-FES SUV Ratio

    ClassPatients18F-FDG SUV18F-FES SUV18F-FDG–to–18F-FES ratio
    High-risk carcinoma (stage ≥ Ic or grade ≥ 2)119.9 ± 2.6* (5.4–14.8)3.4 ± 1.6 (1.3–6.3)3.6 ± 2.1 (1.3–7.4)
    Low-risk carcinoma (stage ≤ Ib and grade 1)117.1 ± 3.7 (2.4–12.5)5.3 ± 1.8 (2.1–8.1)1.3 ± 0.5 (0.5–1.8)
    Endometrial hyperplasia91.5 ± 0.3 (1.1–1.9)5.6 ± 2.4† (2.7–11.0)0.3 ± 0.1 (0.2–0.4)

    • ↵* P < 0.0001.

    • ↵† P < 0.005 significantly higher between the 2 PET tracers (paired t test).

    • Values are mean ± SD. Statistical significance for group comparison is given in Figures 1 and 2. Data in parentheses are ranges.

  • TABLE 3

    Diagnostic Accuracy in Differentiating High- and Low-Risk Carcinoma

    SensitivitySpecificityPPVNPVAccuracy
    Parametern95% CI (%)n95% CI (%)n95% CI (%)n95% CI (%)n95% CI (%)
    18F-FDG–to–18F-FES ratio (2.0)*8/11 (73%)39–9411/11 (100%)76–1008/8 (100%)69–10011/14 (79%)49–9519/22 (86%‡)65–97
    18F-FES SUV (4.4)*9/11 (82%)48–978/11 (73%)39–949/12 (75%)43–958/10 (80%)44–9717/22 (77%)55–92
    18F-FDG SUV (4.0)*11/11 (100%)76–1004/11 (36%)11–6911/18 (61%)36–834/4 (100%)47–10015/22 (68%‡)45–86
    MRI†4/8 (50%)16–8413/14 (93%)66–1004/5 (80%)28–9913/17 (76%)50–9317/22 (77%)55–92

    • ↵* Optimal cutoff value.

    • ↵† Discrimination of stage ≥ Ic from ≤ Ib irrespective of histologic grade.

    • ↵‡ P < 0.005 in comparison between 18F-FDG–to–18F-FES ratio and 18F-FDG SUV using McNemar test.

    • PPV = positive predictive value; NPV = negative predictive value.

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