Role of 18F-FDG PET in the management of gestational trophoblastic neoplasia

  • P. Mapelli
  • G. Mangili
  • M. PicchioEmail author
  • C. Gentile
  • E. Rabaiotti
  • V. Giorgione
  • E. G. Spinapolice
  • L. Gianolli
  • C. Messa
  • M. Candiani
Original Article



Gestational trophoblastic neoplasia (GTN) is a rare and aggressive tumour that is usually sensitive to chemotherapy. The usefulness of conventional imaging modalities in evaluating treatment response is limited, mainly due to the difficulty in differentiating between residual tumour tissue and necrosis. The aim of the present study was to evaluate the role of FDG PET or PET/CT in primary staging and in monitoring treatment efficacy. The effect of FDG PET and combined PET/CT on the management of patients with GTN was also evaluated comparing the differences between standard treatments based on conventional imaging and alternative treatments based on PET.


This retrospective study included 41 patients with GTN referred to San Raffaele Hospital between 2002 and 2010. All patients were studied by either PET or PET/CT in addition to conventional imaging. Of the 41 patients, 38 were evaluated for primary staging of GTN and 3 patients for chemotherapy resistance after first-line chemotherapy performed in other Institutions. To validate the PET data, PET and PET/CT findings were compared with those from conventional imaging, including transvaginal ultrasonography (TV-US) in those with uterine disease, CT and chest plain radiography in those with lung disease and whole-body CT in those with systemic metastases. Conventional imaging was considered positive for the presence of uterine disease and/or metastases when abnormal findings relating to GTN were reported. PET and PET/CT were considered concordant with conventional imaging when metabolic active disease was detected at the sites corresponding to the pathological findings on conventional imaging. In addition, in 12 of the 41 patients showing extrauterine disease, FDG PET/CT was repeated to monitor treatment efficacy, in 8 after normalization of beta human chorionic gonadotropin (βHCG) and in 4 with βHCG resistance. In some patients, PET or PET/CT findings led to an alternative nonconventional treatment, and this was considered a change in patient management for the study analysis.


When compared to TV-US, chest radiography and CT for staging, PET showed a concordance in 91 %, 84 % and 81 % of patients, respectively. In 8 of the 41 patients with extrauterine disease during staging, PET/CT showed a complete response to therapy after βHCG normalization. PET and PET/CT identified the sites of persistent disease in all seven high-risk patients with βHCG resistance, of whom four underwent second-line chemotherapy, two surgical removal of resistant disease instead of additional chemotherapy, and one surgical removal of resistant disease and second-line chemotherapy with subsequent negative βHCG.


In staging, PET cannot replace conventional imaging and does not show any information in addition to that shown by conventional imaging. The additional value of PET/CT in GTN with respect to conventional imaging is found in patients with high-risk disease. PET can identify the sites of primary and/or metastatic disease in patients with persistent high levels of βHCG after first-line chemotherapy and may be of additional value in patient management for guiding alternative treatment.


Gestational trophoblastic tumour GTN FDG PET/CT PET Staging 


Conflicts of interest



  1. 1.
    Lurain JR. Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. Am J Obstet Gynecol. 2010;203(6):531–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Ngan HY, Bender H, Benedet JL, Jones H, Montruccoli GC, Pecorelli S. Gestational trophoblastic neoplasia, FIGO 2000 staging and classification. Int J Gynaecol Obstet. 2003;83 Suppl 1:175–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Lurain JR, Casanova LA, Miller DS, Rademaker AW. Prognostic factors in gestational trophoblastic tumors: a proposed new scoring system based on multivariate analysis. Am J Obstet Gynecol. 1991;164(2):611–6.PubMedGoogle Scholar
  4. 4.
    Lurain JR. Gestational trophoblastic disease II: classification and management of gestational trophoblastic neoplasia. Am J Obstet Gynecol. 2011;204(1):11–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Chang TC, Yen TC, Li YT, Wu YC, Chang YC, Ng KK, et al. The role of 18F-fluorodeoxyglucose positron emission tomography in gestational trophoblastic tumours: a pilot study. Eur J Nucl Med Mol Imaging. 2006;33(2):156–63.PubMedCrossRefGoogle Scholar
  6. 6.
    McNeish IA, Strickland S, Holden L, Rustin GJ, Foskett M, Seckl MJ, et al. Low-risk persistent gestational trophoblastic disease: outcome after initial treatment with low-dose methotrexate and folinic acid from 1992 to 2000. J Clin Oncol. 2002;20:1838–44.PubMedCrossRefGoogle Scholar
  7. 7.
    Lehman E, Gershenson DM, Burke TW, Levenback C, Silva EG, Morris M. Salvage surgery for chemorefractory gestational trophoblastic disease. J Clin Oncol. 1994;12:2737–42.PubMedGoogle Scholar
  8. 8.
    Newlands ES, Bower M, Holden L, Short D, Seckl MJ, Rustin GJ, et al. Management of resistant gestational trophoblastic tumours. J Reprod Med. 1998;43:111–8.PubMedGoogle Scholar
  9. 9.
    Allen SD, Lim AK, Seckl MJ, Blunt DM, Mitchell AW. Radiology of gestational trophoblastic neoplasia. Clin Radiol. 2006;61(4):301–13.PubMedCrossRefGoogle Scholar
  10. 10.
    Ak I, Stokkel MP, Pauwels EK. Positron emission tomography with 2-[18F]fluoro-2-deoxy-D-glucose in oncology. Part II. The clinical value in detecting and staging primary tumours. J Cancer Res Clin Oncol. 2000;126:560–74.PubMedCrossRefGoogle Scholar
  11. 11.
    Cavoretto P, Gentile C, Mangili G, Garavaglia E, Valsecchi L, Spagnolo D, et al. Transvaginal ultrasound predicts delayed response to chemotherapy and drug resistance in stage I low-risk trophoblastic neoplasia. Ultrasound Obstet Gynecol. 2012;40(1):99–105.PubMedCrossRefGoogle Scholar
  12. 12.
    Hebart H, Erley C, Kaskas B, Mayer R, Konig M, Einsele H, et al. Positron emission tomography helps to diagnose tumor emboli and residual disease in choriocarcinoma. Ann Oncol. 1996;7:416–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Zhuang H, Yamamoto AJ, Ghesani N, Alavi A. Detection of choriocarcinoma in the lung by FDG positron emission tomography. Clin Nucl Med. 2001;26:723.PubMedCrossRefGoogle Scholar
  14. 14.
    Sironi S, Picchio M, Mangili G, Garavaglia E, Zangheri B, Messa C, et al. [18F]fluorodeoxyglucose positron emission tomography as a useful indicator of metastatic gestational trophoblastic tumor: preliminary results in three patients. Gynecol Oncol. 2003;91(1):226–30.PubMedCrossRefGoogle Scholar
  15. 15.
    Dhillon T, Palmieri C, Sebire NJ, Lindsay I, Newlands ES, Schmid P, et al. Value of whole body 18FDG-PET to identify the active site of gestational trophoblastic neoplasia. J Reprod Med. 2006;51(11):879–87.PubMedGoogle Scholar
  16. 16.
    Nieves L, Hoffman J, Allen G, Currie J, Sorosky JI. Placental-site trophoblastic tumor with PET scan-detected surgically treated lung metastasis. Int J Clin Oncol. 2008;13(3):263–5.PubMedCrossRefGoogle Scholar
  17. 17.
    Dose J, Bohuslavizki K, Huneke B, Lindner C, Janicke F. Detection of intramural choriocarcinoma of the uterus with FDG-PET: a case report. Clin Positron Imaging. 2000;3:37–40.PubMedCrossRefGoogle Scholar
  18. 18.
    Numnum TM, Leath 3rd CA, Straughn Jr JM, Conner MG, Barnes 3rd MN. Occult choriocarcinoma discovered by positron emission tomography/computed tomography imaging following a successful pregnancy. Gynecol Oncol. 2005;97(2):713–5.PubMedCrossRefGoogle Scholar
  19. 19.
    Shaw SW, Wang CW, Ma SY, Ng KK, Chang TC. Exclusion of lung metastases in placental site trophoblastic tumor using [18F]fluorodeoxyglucose positron emission tomography: a case report. Gynecol Oncol. 2005;99(1):239–42.PubMedCrossRefGoogle Scholar
  20. 20.
    Shukuya T, Hirano S, Takeda Y, Ito H, Hurihata K, Sugiyama H, et al. A case of primary mediastinal choriocarcinoma in which FDG-PET was performed for the evaluation of the treatment. Nihon Kokyuki Gakkai Zasshi. 2007;45(2):174–9.PubMedGoogle Scholar
  21. 21.
    Chang WC, Hung YC, Shen HP, Kao CH. Choriocarcinoma with pulmonary metastasis: report of a case of successful treatment with serial FDG-PET follow-up. J Reprod Med. 2007;52(5):450–2.PubMedGoogle Scholar
  22. 22.
    Bachmann J, Ernestus K, Werner T, Garnier Y, Mallmann P, Pietsch C, et al. Detection of primary choriocarcinoma in the mediastinum by F-18 FDG positron emission tomography. Clin Nucl Med. 2007;32(8):663–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Suga K, Nawata S, Kawakami Y, Hiyama A, Hori K, Matsunaga N. F-18 FDG PET/CT findings of a case of complete hydatidiform mole. Clin Nucl Med. 2009;34(5):314–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Zaheer S, Osmany S, Lai HK, Eng DN. Usefulness of F-18 fluorodeoxyglucose positron emission tomography/computed tomography in a case of choriocarcinoma presenting as pulmonary embolism. Clin Nucl Med. 2009;34(6):343–5.PubMedCrossRefGoogle Scholar
  25. 25.
    Tripathi M, D’Souza MM, Jain J, Srivastava M, Jaimini A, Jain N, et al. Metastatic choriocarcinoma with tumor thrombus in the right atrium and pulmonary vessels: diagnosis and therapy monitoring with F-18 flurodeoxyglucose PET/CT. Clin Nucl Med. 2009;34(6):381–5.PubMedCrossRefGoogle Scholar
  26. 26.
    Cimarelli S, Deshayes E, Mognetti T, Biron P, Desuzinges C, Rivoire M, et al. F-18 FDG PET/CT imaging in a case of primary choriocarcinoma in the retroperitoneum. Clin Nucl Med. 2009;34(7):449–51.PubMedCrossRefGoogle Scholar
  27. 27.
    Cortés-Charry R, Figueira LM, Nieves L, Colmenter L. Metastasis detection with 18 FDG-positron emission tomography/computed tomography in gestational trophoblastic neoplasia: a report of 2 cases. J Reprod Med. 2006;51(11):897–901.PubMedGoogle Scholar
  28. 28.
    Trunebach J, Pereira PL, Huppert PE, Farnsworth C, Mayer R, Feline U, et al. Primary choriocarcinoma of the pulmonary artery mimicking pulmonary embolism. Br J Radiol. 1997;70:843–5.Google Scholar
  29. 29.
    Yang J, Xiang Y, Wan X, Yang X. The prognosis of gestational trophoblastic neoplasia patient with residual lung tumor after completing treatment. Gynecol Oncol. 2006;103(2):479–82.PubMedCrossRefGoogle Scholar
  30. 30.
    Powles T, Savage P, Short D, Young A, Pappin C, Seckl MJ. Residual lung lesions after completion of chemotherapy for gestational trophoblastic neoplasia: should we operate? Br J Cancer. 2006;94(1):51–4.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • P. Mapelli
    • 1
  • G. Mangili
    • 2
  • M. Picchio
    • 1
    • 3
    Email author
  • C. Gentile
    • 2
  • E. Rabaiotti
    • 2
  • V. Giorgione
    • 2
  • E. G. Spinapolice
    • 1
  • L. Gianolli
    • 1
  • C. Messa
    • 3
    • 4
    • 5
  • M. Candiani
    • 2
  1. 1.Department of Nuclear MedicineSan Raffaele Scientific InstituteMilanItaly
  2. 2.Department of Gynaecology and ObstetricsSan Raffaele Scientific InstituteMilanItaly
  3. 3.National Research Council (IBFM-CNR)Institute for Bioimaging and Molecular PhysiologyMilanItaly
  4. 4.Department of Nuclear MedicineSan Gerardo HospitalMonzaItaly
  5. 5.Tecnomed FoundationUniversity of Milano-BicoccaMilanItaly

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