SUVmax of 18FDG PET/CT as a predictor of high-risk endometrial cancer patients,☆☆

https://doi.org/10.1016/j.ygyno.2013.01.019Get rights and content

Abstract

Objective

To evaluate SUVmax in the assessment of endometrial cancer preoperatively with particular focus on myometrial invasion (MI), cervical invasion (CI), FIGO stage, risk-stratification and lymph node metastases (LNM).

Methods

A total of 268 women with endometrial cancer or atypical endometrial hyperplasia underwent FDG PET/CT imaging before surgical treatment. SUVmax of the primary tumour was compared with histological prognostic factors.

Results

SUVmax was significantly higher in patients with high FIGO stages (p < 0.0001), deep MI (p = 0.002), CI (p = 0.04), LNM (p = 0.04) and high risk tumours (p = 0.003). Linear regression found that SUVmax was dependent of MI (p = 0.001, 95% CI 2.863–11.098), CI (p = 0.001, 95% CI 2.896–11.499), risk (p = 0.004, 95% CI 0.077–0.397), LNM (p = 0.04, 95% CI 0.011–0.482) and FIGO stage (p < 0.0001, 95% CI 0.158–0.473).

Conclusions

Preoperative PET/CT scanning and SUVmax measurements of the primary tumour may provide additional clinical and prognostic information about MI, CI, LNM and high risk disease in patients with endometrial cancer and allow for individualization of patient care. However, the sensitivity and specificity of the SUVmax in staging endometrial cancer is not high enough to reliably replace surgical staging.

Highlights

► SUVmax was significantly higher in high risk endometrial cancer patients. ► SUVmax was positively correlated to known prognostic factors for endometrial cancer. ► SUVmax can be used in the multidisciplinary work-up of endometrial cancer patients.

Introduction

Endometrial cancer (EC) is the most common gynaecological cancer in the Western world with an incidence of 15–20 per 100,000 women per year [1]. More than 75% of cases are diagnosed in early stages [1] because of early symptoms such as vaginal spotting and bleeding. The treatment is primarily surgical involving hysterectomy and bilateral salpingooophorectomy (BSO). The extent of surgery relies on the suspected stage of disease and risk of extra-uterine disease. The most important risk factors for poor prognosis are extent of myometrial invasion (MI), cervical involvement (CI) and lymph node metastases (LNM) but these cannot be revealed by clinical examination. It is known that patients with greater than 50% MI have a six–seven-fold higher prevalence of pelvic or paraaortic LNM and of advanced stage of disease when compared with patients with less than 50% MI [2]. The clinical challenge is the optimal selection of patients for more radical surgery with lymphadenectomy in patients with high-risk of advanced disease, while avoiding overtreatment in low-risk patients. This is especially important in EC as it mostly occur in postmenopausal women with potentially serious co-morbidity. Accordingly, a non-invasive diagnostic method that is able to predict tumour aggressiveness and stage would be useful.

Positron emission tomography (PET) with computed tomography (CT) with 2-18F-flouro-2-deoxy-D-glucose (FDG) is a combined functional and morphologic imaging technique. PET is a functional method based on the increased glucose metabolism of malignant tumours. FDG is actively taken up and accumulated in cancer cells [3]. With the integrated CT scan, this system provides both metabolic and anatomic imaging data with precise anatomic localization of suspicious areas of increased FDG uptake. The potential value of PET/CT for staging and lymph node assessment in EC has not yet been established. However, the standardized uptake value (SUV), a semi-quantitative parameter for the degree of FDG uptake, is known to be a significant indicator of tumour aggressiveness and prognosis in a variety of malignant tumours [4] and has the potential of being a non-invasive marker for studying the biochemical and metabolic changes in cancer tissues. A few studies have assessed the relationship between SUV and prognostic factors in EC [5], [6], [7], [8] and the SUVmax has been reported to be correlated to tumour proliferation rate, tumour grade, tumour histology, and maximum tumour size [6].

The aim of this prospective multicenter study was to evaluate SUVmax in the assessment of preoperative staging of EC with particular focus on MI, CI, International Federation of Gynaecology and Obstetrics (FIGO) stage, risk stratification and LNM.

Section snippets

Material and methods

The population consisted of patients with a preoperative histological diagnosis of EC or atypical endometrial hyperplasia (AEH) included in the Danish Endometrial Cancer Study (ENDOMET). Patients with a preoperative diagnosis of AEH were included because we previously found that up to 59% of these patients have coexisting EC [9]. The patients were referred to three Danish tertiary gynaecological oncology centres for surgery between September 1, 2009 and January 1, 2012. All patients underwent

Results

A total of 467 women with EC or AEH were referred to the departments in the period. Twenty-seven patients did not want to participate, and 172 patients had an exclusion criterion or were not scanned because of logistical problems leaving 268 patients eligible for this study. Thirty-three tumours had no pathological FDG uptake. Clinico-pathological characteristics of these 33 tumours are listed in Table 1. Of the patients with EC, eight were diagnosed in the primary biopsy with no or

Discussion

A non-invasive preoperative technique that accurately evaluates and stages EC patients would be beneficial in individualizing and improving treatment and minimizing costs. The knowledge of tumour extension into the cervix or the myometrium influences the decision whether to perform a more radical hysterectomy with pelvic and/or paraaortic lymphadenectomy. Preoperative staging also influences the location of surgery, as lymphadenectomy should be performed by specialized surgeons.

The aim of this

Conflict of interest statement

There are no financial disclosures or conflict of interest from any author.

Acknowledgements

We are grateful to the funds that supported this study: Arvid Nilssons Foundation, Doctor Agnethe Løvgreens Foundation, The Danish Cancer Society, Hørslev Foundation, Harboe Foundation, Aase og Ejnar Danielsens Foundation, King Christian X Foundation, Augustinus Foundation, Dagmar Marshalls Foundation, Manufacturer Einar Willumsens Memorial Grant, Beckett Foundation & Hede Nielsens Family Foundation.

References (20)

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Funding: Arvid Nilssons Foundation, Doctor Agnethe Løvgreens Foundation, The Danish Cancer Society, Hørslev Foundation, Harboe Foundation, Aase og Ejnar Danielsens Foundation, King Christian X Foundation, Augustinus Foundation, Dagmar Marshalls Foundation, Manufacturer Einar Willumsens Memorial Grant, Beckett Foundation & Hede Nielsens Family Foundation.

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Financial disclosures: there are no financial disclosures from any author.

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