Research ArticleClinical Investigations

Metabolic Tumor Volume on 18F-FDG PET/CT Improves Preoperative Identification of High-Risk Endometrial Carcinoma Patients

Jenny A. Husby, Bernt C. Reitan, Martin Biermann, Jone Trovik, Line Bjørge, Inger J. Magnussen, Øyvind O. Salvesen, Helga B. Salvesen and Ingfrid S. Haldorsen
Journal of Nuclear Medicine August 2015, 56 (8) 1191-1198; DOI: https://doi.org/10.2967/jnumed.115.159913

Article Figures & Data

Figures

  • FIGURE 1.
    FIGURE 1.

    18F-FDG PET/CT images depicting manually drawn MTV in 3 planes: axial (A), coronal (B), and sagittal (C) in 63-y-old woman with FIGO stage 1A endometrioid grade 1 endometrial cancer. In this patient, MTV was 22.4 mL, SUVmax 13.5, and SUVmean 5.5.

  • FIGURE 2.
    FIGURE 2.

    Receiver-operating-characteristic curves for various tumor quantifications for prediction of myometrial invasion (A) and lymph node metastases (B) and ROC curves for 2 observers for MTV to predict myometrial invasion (C) and MTV to predict the presence of lymph node metastases (D) in patients with endometrial carcinoma. P values refer to test of equal areas under the curve across tumor quantifications. AUC = area under the curve.

  • FIGURE 3.
    FIGURE 3.

    Flowchart of significant incidental findings (defined as 18F-FDG uptake with possible therapeutic consequence) on PET/CT in 129 endometrial carcinoma patients. *One lesion did not have increased uptake. **One patient had 2 separate incidental findings. EC = endometrial cancer; GE = gynecologic examination; GI = gastrointestinal; GP = general practitioner; TSH = thyroid-stimulating hormone; US = ultrasound.

Tables

  • TABLE 1

    Diagnostic Performance of 18F-FDG PET/CT Compared with Surgical Staging

    ParameterCervical stroma invasionLymph node metastases
    Sensitivity
     Observer 18/24 (33%)10/13 (77%)
     Observer 28/24 (33%)10/13 (77%)
     Clinical report6/24 (25%)11/13 (85%)
    Specificity
     Observer 175/102 (74%)81/89 (91%)
     Observer 275/102 (74%)85/89 (96%)
     Clinical report89/102 (87%)82/89 (92%)
    Accuracy
     Observer 183/126 (66%)91/102 (89%)
     Observer 283/126 (66%)95/102 (93%)
     Clinical report96/126 (76%)93/102 (91%)
    Positive predictive value
     Observer 124/49 (49%)13/21 (62%)
     Observer 224/49 (49%)13/17 (76%)
     Clinical report24/37 (65%)13/20 (65%)
    Negative predictive value
     Observer 1102/118 (86%)89/92 (97%)
     Observer 2102/118 (86%)89/92 (97%)
     Clinical report102/120 (85%)89/91 (98%)
    False-positive/-negative  findings
     Observer 125/168/3
     Observer 225/164/3
     Clinical report13/187/2

    • Data are numbers of patients or findings.

  • TABLE 2

    Quantitative Tumor Parameters Assessed by 18F-FDG PET/CT in Relation to Clinical and Histologic Characteristics

    SUVmaxSUVmeanMTV (mL)TLG (g)
    ParameternMeanPMeanPMeanPMeanP
    Myometrial invasion0.008*0.000*0.000*0.000*
     <50%8612.9 (11.4–14.4)5.3 (4.9–5.7)20 (15–25)141 (98–185)
     ≥50%3816.4 (14.5–18.3)6.6 (6.0–7.2)53 (38–68)361 (263–459)
    Cervical stroma invasion0.050.050.034*0.05
     Yes2316.5 (14.1–18.8)6.4 (5.6–7.2)37 (24–51)245 (157–333)
     No10013.5 (12.1–14.9)5.6 (5.2–6.0)28 (21–35)203 (148–257)
    Lymph node metastases0.010*0.002*0.000*0.000*
     Yes1320.7 (17.1–24.4)7.6 (6.4–8.8)65 (47–83)479 (353–604)
     No8813.3 (12.0–14.7)5.7 (5.3–6.1)25 (19–32)183 (132–233)
    Histologic subtype0.881.000.550.47
     Endometrioid9714.3 (12.9–15.6)5.8 (5.4–6.2)28 (22–35)202 (153–252)
     Nonendometrioid3014.1 (11.5–16.6)5.6 (5.0–6.3)38 (22–55)259 (146–372)
    Histologic grade†0.013*0.003*0.001*0.002*
     15112.8 (11.1–14.5)5.3 (4.8–5.8)20 (14–27)135 (87–182)
     22814.7 (11.7–17.8)6.0 (5.1–6.9)36 (19–53)268 (141–394)
     31219.0 (15.8–22.1)7.6 (6.3–8.9)49 (31–67)370 (243–496)
    DNA ploidy0.660.400.029*0.026*
     Diploid4815.9 (14.2–17.6)6.2 (5.6–6.8)35 (25–46)252 (170–335)
     Aneuploid1516.8 (13.3–20.4)6.7 (5.5–8.0)58 (34–82)383 (247–520)
    Age at diagnosis (y)0.100.260.960.62
     <666015.4 (13.5–17.2)6.1 (5.5–6.7)27 (20–34)211 (149–274)
     ≥666713.2 (11.7–14.7)5.5 (5.1–5.9)33 (23–44)219 (152–186)

    • ↵* Statistically significant.

    • ↵† Endometrioid subtype only.

    • Data in parentheses are 95% confidence intervals. P values were obtained using Mann–Whitney U test for 2 categories and Jonckheere-Terpsta trend test for multiple categories.

  • TABLE 3

    ORs for 18F-FDG PET/CT Prediction of Deep Myometrial Invasion, Cervical Stroma Invasion, and Lymph Node Metastases

    ParameterSUVmaxSUVmeanMTV (mL)TLG (g)
    Deep myometrial invasion (n = 124)
     Unadjusted OR1.091.441.031.004
      95% CI1.02–1.161.16–1.791.02–1.051.002–1.005
      P0.008*0.001*<0.001*<0.001*
     Adjusted OR1.081.401.031.003
      95% CI1.02–1.161.12–1.751.01–1.041.001–1.005
      P0.013*0.003*<0.001*0.001*
    Cervical stroma invasion (n = 123)
     Unadjusted OR1.071.221.011.00
      95% CI1.00–1.150.97–1.521.00–1.021.00–1.00
      P0.060.090.230.47
     Adjusted OR1.061.151.0031.00
      95% CI1.00–1.150.91–1.460.99–1.021.00–1.002
      P0.100.230.630.98
    Lymph node metastases (n = 101)
     Unadjusted OR1.221.531.031.004
      95% CI1.09–1.381.14–2.051.01–1.051.002–1.006
      P0.001*0.005*0.001*0.001*
     Adjusted OR1.241.511.021.003
      95% CI1.08–1.431.07–2.131.005–1.041.001–1.005
      P0.002*0.021*0.013*0.008*

    • ↵* Statistically significant.

    • ORs are given both unadjusted and adjusted for risk from preoperative endometrial biopsy indicating nonendometrioid subtype or endometrioid grade 3. P values were obtained using logistic regression analysis.

  • TABLE 4

    Interobserver Variability for Tumor SUV and Metabolic Volume Measurements

    Mean
    ParameterObs 1Obs 2Mean difference between 1 and 2ICCMDC
    SUVmax14.213.70.04 (SD, 1.3)0.982.6
    SUVmean6.05.40.5 (SD, 0.9)0.872.1
    Metabolic volume (mL)263812 (SD, 36)0.5674.1
    TLG (g)17722952 (SD, 183)0.5772.2

    • ICC = intraclass correlation coefficient; MDC = minimal detectable change.

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