Preoperative risk stratification using metabolic parameters of 18F-FDG PET/CT in patients with endometrial cancer

  • Kazuhiro KitajimaEmail author
  • Yuko Suenaga
  • Yoshiko Ueno
  • Tetsuo Maeda
  • Yasuhiko Ebina
  • Hideto Yamada
  • Takashi Okunaga
  • Kazuhiro Kubo
  • Keitarou Sofue
  • Tomonori Kanda
  • Yukihisa Tamaki
  • Kazuro Sugimura
Original Article



To evaluate the usefulness of metabolic parameters obtained by 18F-FDG PET/CT for preoperative stratification of high-risk and low-risk endometrial carcinomas.


Preoperative 18F-FDG PET/CT was performed in 56 women with endometrial cancer. Maximum standardized uptake values (SUVmax), metabolic tumour volume (MTV) and total lesion glycolysis (TLG) of primary tumours were compared with clinicopathological features of surgical specimens. Diagnostic performance in terms of differentiation of low-risk disease (endometrioid histology, histological grade 1 or 2, invasion of less than half of the myometrium, and FIGO stage I) from high-risk disease was assessed.


MTV and TLG were significantly higher in patients with higher histological grade (p = 0.0026 and p = 0.034), larger tumour size (p = 0.002 and p = 0.0017), lymphovascular space involvement (LVSI; p = 0.012 and p = 0.0051), myometrial invasion (p = 0.027 and p = 0.031), cervical stromal invasion (p = 0.023 and p = 0.014), ovarian metastasis (p = 0.00022 and p = 0.00034), lymph node metastasis (p < 0.0001 and p < 0.0001), and higher FIGO stage (p = 0.0011 and p = 0.00048). SUVmax was significantly higher in patients with larger tumour size (p = 0.0025), LVSI (p = 0.00023) and myometrial invasion (p < 0.0001). The areas under the ROC curves (AUCs) for distinguishing high-risk from low-risk carcinoma were 0.625, 0.829 and 0.797 for SUVmax, MTV and TLG, respectively. AUCs for both MTV and TLG were significantly larger than that for SUVmax (p = 0.0049 and p = 0.021). The optimal TLG cut-off value of 70.2, determined by ROC analysis, was found to have 72.0 % sensitivity and 74.2 % specificity for risk stratification.


MTV and TLG of primary endometrial cancer show better correlations with clinicopathological features and are more useful for differentiating high-risk from low-risk carcinoma than SUVmax.


FDG PET/CT Endometrial cancer SUVmax MTV TLG 


Compliance with ethical standards

Conflicts of interest


Research involving human participants and/or animals

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

This article does not contain any studies with animals performed by any of the authors.

Informed consent

This retrospective study was approved by the institutional review board, and the need for patient informed consent was waived.


We wish to express special thanks to Hirofumi R.T. Kawakami (GE healthcare) for his outstanding technical assistance.


  1. 1.
    Amant F, Moerman P, Neven P, Timmerman D, Van Limbergen E, Vergote I. Endometrial cancer. Lancet. 2005;366:491–505.PubMedCrossRefGoogle Scholar
  2. 2.
    Bakkum-Gamez JN, Gonzalez-Bosquet J, Laack NN, Mariani A, Dowdy SC. Current issues in the management of endometrial cancer. Mayo Clin Proc. 2008;83:97–112.PubMedCrossRefGoogle Scholar
  3. 3.
    Wright JD, Barrena Medel NI, Sehouli J, Fujiwara K, Herzog TJ. Contemporary management of endometrial cancer. Lancet. 2012;379:1352–60.PubMedCrossRefGoogle Scholar
  4. 4.
    Torizuka T, Nakamura F, Takekuma M, Kanno T, Ogusu T, Yoshikawa E, et al. FDG PET for the assessment of myometrial infiltration in clinical stage I uterine corpus cancer. Nucl Med Commun. 2006;27:481–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Tsujikawa T, Yoshida Y, Kudo T, Kiyono Y, Kurokawa T, Kobayashi M, et al. Functional images reflect aggressiveness of endometrial carcinoma: estrogen receptor expression combined with 18F-FDG PET. J Nucl Med. 2009;50:1598–604.PubMedCrossRefGoogle Scholar
  6. 6.
    Nakamura K, Kodama J, Okumura Y, Hongo A, Kanazawa S, Hiramatsu Y. The SUVmax of 18F-FDG PET correlates with histological grade in endometrial cancer. Int J Gynecol Cancer. 2010;20:110–5.PubMedCrossRefGoogle Scholar
  7. 7.
    Nakamura K, Hongo A, Kodama J, Hiramatsu Y. The measurement of SUVmax of the primary tumor is predictive of prognosis for patients with endometrial cancer. Gynecol Oncol. 2011;123:82–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Lee HJ, Ahn BC, Hong CM, Song BI, Kim HW, Kang S, et al. Preoperative risk stratification using 18F-FDG PET/CT in women with endometrial cancer. Nuklearmedizin. 2011;50:204–13.PubMedCrossRefGoogle Scholar
  9. 9.
    Kitajima K, Kita M, Suzuki K, Senda M, Nakamoto Y, Sugimura K. Prognostic significance of SUVmax (maximum standardized uptake value) measured by [18F]FDG PET/CT in endometrial cancer. Eur J Nucl Med Mol Imaging. 2012;39:840–5.PubMedCrossRefGoogle Scholar
  10. 10.
    Antonsen SL, Loft A, Fisker R, Nielsen AL, Andersen ES, Høgdall E, et al. SUVmax of 18FDG PET/CT as a predictor of high-risk endometrial cancer patients. Gynecol Oncol. 2013;129:298–303.PubMedCrossRefGoogle Scholar
  11. 11.
    Walentowicz-Sadlecka M, Malkowski B, Walentowicz P, Sadlecki P, Marszalek A, Pietrzak T, et al. The preoperative maximum standardized uptake value measured by 18F-FDG PET/CT as an independent prognostic factor of overall survival in endometrial cancer patients. Biomed Res Int. 2014;2014:234813.PubMedCentralPubMedCrossRefGoogle Scholar
  12. 12.
    Ghooshkhanei H, Treglia G, Sabouri G, Davoodi R, Sadeghi R. Risk stratification and prognosis determination using 18F-FDG PET imaging in endometrial cancer patients: a systematic review and meta-analysis. Gynecol Oncol. 2014;132:669–76.PubMedCrossRefGoogle Scholar
  13. 13.
    Pak K, Cheon GJ, Nam HY, Kim SJ, Kang KW, Chung JK, et al. Prognostic value of metabolic tumor volume and total lesion glycolysis in head and neck cancer: a systematic review and meta-analysis. J Nucl Med. 2014;55:884–90.PubMedCrossRefGoogle Scholar
  14. 14.
    Liu FY, Chao A, Lai CH, Chou HH, Yen TC. Metabolic tumor volume by 18F-FDG PET/CT is prognostic for stage IVB endometrial carcinoma. Gynecol Oncol. 2012;125:566–71.PubMedCrossRefGoogle Scholar
  15. 15.
    Chung HH, Lee I, Kim HS, Kim JW, Park NH, Song YS, et al. Prognostic value of preoperative metabolic tumor volume measured by 18F-FDG PET/CT and MRI in patients with endometrial cancer. Gynecol Oncol. 2013;130:446–51.PubMedCrossRefGoogle Scholar
  16. 16.
    Crivellaro C, Signorelli M, Guerra L, De Ponti E, Pirovano C, Fruscio R, et al. Tailoring systematic lymphadenectomy in high-risk clinical early stage endometrial cancer: the role of 18F-FDG PET/CT. Gynecol Oncol. 2013;130:306–11.PubMedCrossRefGoogle Scholar
  17. 17.
    Shim SH, Kim DY, Lee DY, Lee SW, Park JY, Lee JJ, et al. Metabolic tumour volume and total lesion glycolysis, measured using preoperative 18F-FDG PET/CT, predict the recurrence of endometrial cancer. BJOG. 2014;121:1097–106.PubMedCrossRefGoogle Scholar
  18. 18.
    Sudo S, Hattori N, Manabe O, Kato F, Mimura R, Magota K, et al. FDG PET/CT diagnostic criteria may need adjustment based on MRI to estimate the presurgical risk of extrapelvic infiltration in patients with uterine endometrial cancer. Eur J Nucl Med Mol Imaging. 2015;42:676–84.PubMedCrossRefGoogle Scholar
  19. 19.
    Lee JA. Segmentation of positron emission tomography images: some recommendations for target delineation in radiation oncology. Radiother Oncol. 2010;96:302–7.PubMedCrossRefGoogle Scholar
  20. 20.
    Maffione AM, Ferretti A, Grassetto G, Bellan E, Capirci C, Chondrogiannis S, et al. Fifteen different 18F-FDG PET/CT qualitative and quantitative parameters investigated as pathological response predictors of locally advanced rectal cancer treated by neoadjuvant chemoradiation therapy. Eur J Nucl Med Mol Imaging. 2013;40:853–64.PubMedCrossRefGoogle Scholar
  21. 21.
    Chen SW, Chen WT, Wu YC, Yen KY, Hsieh TC, Lin TY, et al. Which FDG/PET parameters of the primary tumors in colon or sigmoid cancer provide the best correlation with the pathological findings? Eur J Radiol. 2013;82:e405–10.PubMedCrossRefGoogle Scholar
  22. 22.
    Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet. 2009;105:103–4.PubMedCrossRefGoogle Scholar
  23. 23.
    Benedetti Panici P, Basile S, Maneschi F, Alberto Lissoni A, Signorelli M, Scambia G, et al. Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial. J Natl Cancer Inst. 2008;100:1707–16.PubMedCrossRefGoogle Scholar
  24. 24.
    ASTEC study group, Kitchener H, Swart AM, Qian Q, Amos C, Parmar MK. Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study. Lancet. 2009;373:125–36.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Kazuhiro Kitajima
    • 1
    • 6
    Email author
  • Yuko Suenaga
    • 1
  • Yoshiko Ueno
    • 1
  • Tetsuo Maeda
    • 1
  • Yasuhiko Ebina
    • 2
  • Hideto Yamada
    • 2
  • Takashi Okunaga
    • 3
  • Kazuhiro Kubo
    • 3
  • Keitarou Sofue
    • 1
  • Tomonori Kanda
    • 4
  • Yukihisa Tamaki
    • 5
  • Kazuro Sugimura
    • 1
  1. 1.Department of RadiologyKobe University School of MedicineKobeJapan
  2. 2.Department of Obstetrics and GynecologyKobe University School of MedicineKobeJapan
  3. 3.Department of Radiology DivisionKobe University HospitalKobeJapan
  4. 4.Department of RadiologyTeikyo University School of MedicineTokyoJapan
  5. 5.Department of Radiation OncologyShimane University School of MedicineShimaneJapan
  6. 6.Department of RadiologyKobe University Graduate School of MedicineKobeJapan

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