Advertisement

Annals of Nuclear Medicine

, Volume 27, Issue 8, pp 756–763 | Cite as

Do clinical characteristics and metabolic markers detected on positron emission tomography/computerized tomography associate with persistent disease in patients with in-operable cervical cancer?

  • Burcu Esen Akkas
  • Busra Bedriye DemirelEmail author
  • Aysen Dizman
  • Gulin Ucmak Vural
Original Article

Abstract

The objective of this retrospective study was to evaluate the prognostic significance of volume-based metabolic markers of PET/CT along with clinical characteristics in patients with in-operable cervical carcinoma.

Methods

Fifty-eight patients with cervical carcinoma (stage IIB–IVB) underwent FDG PET/CT for pretreatment evaluation and included in this study. Patients were staged according to International Federation of Gynecology and Obstetrics [FIGO] system. After chemoradiation therapy, patients were evaluated for persistent disease (PD) by clinical examinations, smear tests, pelvic MRI and PET/CT. Based upon follow-up results, clinical characteristics (patient age, tumor histology, FIGO stage) and PET/CT findings such as presence of PET-positive pelvic/para-aortic lymph nodes (LN), metabolic tumor volume (MTV), total lesion glycolysis (TLG), maximum standardized uptake values (SUVmax) of tumor and lymph nodes were analyzed for disease persistence. Survival analysis for disease-free survival and overall survival was performed with Kaplan–Meier method using PET findings and clinical characteristics.

Results

At the time of last follow-up (mean: 22 ± 12.6 months, range 6–48), 38 patients (65 %) had PD, 20 patients (35 %) had no evidence of disease (NED). Patient age, tumor histology, MTV, TLG and tumor SUVmax did not differ between groups. The frequency of PET-positive pelvic/para-aortic lymph nodes (84 vs. 60 %, p = 0.03), LN SUVmax (10.2 vs. 6.5, p = 0.02), and FIGO stage differed significantly between PD and NED groups. Cox proportional hazards model demonstrated advanced FIGO stage and the presence of PET-positive para-aortic LN were independent predictors for PD. Both disease-free survival and overall survival curves showed progressive worsening as the disease advanced, p = 0.015. PET LN status was the most important prognostic indicator for disease-free survival and overall survival. The worst outcome curves were detected for patients with PET-positive para-aortic lymph nodes among all patients, p = 0.03.

Conclusion

Advanced FIGO stage and the presence of FDG-avid para-aortic lymph nodes on pretreatment PET/CT are significant prognostic biomarkers for PD and decreased overall survival in patients with in-operable cervical carcinoma independent from MTV, TLG, tumor and lymph node SUVmax.

Keywords

Cervical cancer PET/CT Metabolic tumor volume Total lesion glycolysis Prognosis SUVmax 

Notes

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin. 2011;61:69–90.PubMedCrossRefGoogle Scholar
  2. 2.
    WHO/ICO Information Center of HPV and Cervical Cancer (HPV Information Center). Human papillomavirus and related cancers in the world. Summary report 2010. http://www.who.int/hpvcentre/en/.
  3. 3.
    Narayan K, Fisher R, Bernshaw D. Significance of tumor volume and corpus uteri invasion in cervical cancer patients treated by radiotherapy. Int J Gynecol Cancer. 2006;16:623–30.PubMedCrossRefGoogle Scholar
  4. 4.
    Kim H, Kim W, Lee M, Song E, Loh JJK. Tumor volume and uterine body invasion assessed by MRI for prediction of outcome in cervical carcinoma treated with concurrent chemotherapy and radiotherapy. Jpn J Clin Oncol. 2007;37:858–66.PubMedCrossRefGoogle Scholar
  5. 5.
    Chung HH, Kim JW, Han KH, Eo JS, Kang KW, Park NH, et al. Prognostic value of metabolic tumor volume measured by FDG-PET/CT in patients with cervical cancer. Gynecol Oncol. 2011;120:270–4.PubMedCrossRefGoogle Scholar
  6. 6.
    Burghardt E, Hofmann HM, Ebner F, Haas J, Tamussino K, Justich E. Magnetic resonance imaging in cervical cancer: a basis for objective classification. Gynecol Oncol. 1989;33:61–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Eifel PJ, Winter K, Morris M, Levenback C, Grigsby PW, Cooper J, et al. Pelvic irradiation with concurrent chemotherapy versus pelvic and para-aortic irradiation for high-risk cervical cancer: an update of radiation therapy oncology group trial (RTOG) 90–01. J Clin Oncol. 2004;22:872–80.PubMedCrossRefGoogle Scholar
  8. 8.
    Jacobs AJ, Faris C, Perez CA, Kao MS, Galakatos A, Camel HM. Short-term persistence of carcinoma of the uterine cervix after radiation. An indicator of long-term prognosis. Cancer. 1986;57:944–50.PubMedCrossRefGoogle Scholar
  9. 9.
    Kidd EA, Siegel BA, Dehdashti F, Grigsby PW. The standardized uptake value for F-18 fluorodeoxyglucose is a sensitive predictive biomarker for cervical cancer treatment response and survival. Cancer. 2007;110:1738–44.PubMedCrossRefGoogle Scholar
  10. 10.
    Kidd EA, Siegel BA, Dehdashti F, Rader JS, Mutch DG, Powell MA, et al. Lymph node staging by positron emission tomography in cervical cancer: relationship to prognosis. J Clin Oncol. 2010;28:2108–13.PubMedCrossRefGoogle Scholar
  11. 11.
    Akkas BE, Demirel BB, Vural GU. Clinical impact of FDG PET/CT in the pretreatment evaluation of patients with locally advanced cervical carcinoma. Nucl Med Commun. 2012;33:1081–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Choi HJ, Roh JW, Seo SS, Lee S, Kim JY, Kim SK, et al. Comparison of the accuracy of magnetic resonance imaging and positron emission tomography/computed tomography in the presurgical detection of lymph node metastases in patients with uterine cervical carcinoma: a prospective study. Cancer. 2006;106:914–22.PubMedCrossRefGoogle Scholar
  13. 13.
    Son H, Kositwattanarerk A, Hayes MP, Chuang L, Rahaman J, Heiba S, et al. PET/CT evaluation of cervical cancer: spectrum of disease. Radiographics. 2010;30:1251–68.PubMedCrossRefGoogle Scholar
  14. 14.
    Yoo J, Choi JY, Moon SH, Bae DS, Park SB, Choe YS, Lee KH, Kim BT. Prognostic significance of volume-based metabolic parameters in uterine cervical cancer determined using 18F-fluorodeoxyglucose positron emission tomography. Int J Gynecol Cancer. 2012;22:1226–33.PubMedCrossRefGoogle Scholar
  15. 15.
    Yen TC, See LC, Lai CH, Tsai CS, Chao A, Hsueh S, Hong JH, Chang TC, Ng KK. Standardized uptake value in para-aortic lymph nodes is a significant prognostic factor in patients with primary advanced squamous cervical cancer. Eur J Nucl Med Mol Imaging. 2008;35:493–501.PubMedCrossRefGoogle Scholar
  16. 16.
    Kidd EA, El Naqa I, Siegel BA, Dehdashti F, Grigsby PW. FDG-PET-based prognostic nomograms for locally advanced cervical cancer. Gynecol Oncol. 2012;127:136–40.PubMedCrossRefGoogle Scholar
  17. 17.
    Vansteenkiste JF, Stroobants SG, Dupont PJ, De Leyn PR, Verbeken EK, Deneffe GJ, et al. Prognostic importance of the standardized uptake value on (18)F-fluoro-2-deoxy-glucose-positron emission tomography scan in non-small-cell lung cancer: an analysis of 125 cases. Leuven Lung Cancer Group. J Clin Oncol. 1999;17:3201–6.PubMedGoogle Scholar
  18. 18.
    Schwartz DL, Rajendran J, Yueh B, Coltrera MD, Leblanc M, Eary J, et al. FDG-PET prediction of head and neck squamous cell cancer outcomes. Arch Otolaryngol Head Neck Surg. 2004;130:1361–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Hanin FX, Lonneux M, Cornet J, Noirhomme P, Coulon C, Distexhe J, et al. Prognostic value of FDG uptake in early stage non-small cell lung cancer. Eur J Cardiothorac Surg. 2008;33:819–23.PubMedCrossRefGoogle Scholar
  20. 20.
    Nair VS, Barnett PG, Ananth L, Gould MK. Veterans affairs solitary nodule accuracy project cooperative studies group PET scan 18F-fluorodeoxyglucose uptake and prognosis in patients with resected clinical stage IA non-small cell lung cancer. Chest. 2010;137:1150–6.PubMedCrossRefGoogle Scholar
  21. 21.
    Nakamura K, Okumura Y, Kodama J, Hongo A, Kanazawa S, Hiramatsu Y. The predictive value of measurement of SUVmax and SCC-antigen in patients with pretreatment of primary squamous cell carcinoma of cervix. Gynecol Oncol. 2010;119:81–6.PubMedCrossRefGoogle Scholar
  22. 22.
    Lee P, Weerasuriya DK, Lavori PW, Quon A, Hara W, Maxim PG, et al. Metabolic tumor burden predicts for disease progression and death in lung cancer. Int J Radiat Oncol Biol Phys. 2007;69:328–33.PubMedCrossRefGoogle Scholar
  23. 23.
    Chung MK, Jeong HS, Park SG, Jang JY, Son YI, Choi JY, et al. Metabolic tumor volume of [18F]-fluorodeoxyglucose positron emission tomography/computed tomography predicts short-term outcome to radiotherapy with or without chemotherapy in pharyngeal cancer. Clin Cancer Res. 2009;15:5861–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Chen HH, Chiu NT, Su WC, Guo HR, Lee BF. Prognostic value of whole-body total lesion glycolysis at pretreatment FDG PET/CT in non- small cell lung cancer. Radiology. 2012;264:559–66.PubMedCrossRefGoogle Scholar
  25. 25.
    Lim R, Eaton A, Lee NY, Setton J, Ohri N, Rao S, Wong R, Fury M, Schoder H. 18F-FDG PET/CT metabolic tumor volume and total lesion glycolysis predict outcome in oropharyngeal squamous cell carcinoma. J Nucl Med. 2012;53:1506–13.PubMedCrossRefGoogle Scholar
  26. 26.
    Miller TR, Grigsby PW. Measurement of tumor volume by PET to evaluate prognosis in patients with advanced cervical cancer treated by radiation therapy. Int J Radiat Oncol Biol Phys. 2002;53:353–9.PubMedCrossRefGoogle Scholar
  27. 27.
    Geworski L, Knoop BO, Cabrejas ML, Knapp WH, Munz DL. Recovery correction for quantitation in emission tomography: a feasibility study. Eur J Nucl Med. 2000;27:161–9.PubMedCrossRefGoogle Scholar
  28. 28.
    National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: cervical cancer, 06/02/09 update. Available at: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp.
  29. 29.
    Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet. 2009;105:103–4.PubMedCrossRefGoogle Scholar
  30. 30.
    Grigsby PW, Siegel BA, Dehdashti F, Rader J, Zoberi I. Post therapy [18F] fluorodeoxyglucose positron emission tomography in carcinoma of the cervix: response and outcome. J Clin Oncol. 2004;22:2167–71.PubMedCrossRefGoogle Scholar
  31. 31.
    Petignat P, Loubeyre P. Should we modify the current FIGO staging system for early-stage cervical cancer? Expert Rev Anticancer Ther. 2008;8:1015–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Kidd EA, Siegel BA, Dehdashti F, Grigsby PW. Pelvic lymph node F-18 fluorodeoxyglucose uptake as a prognostic biomarker in newly diagnosed patients with locally advanced cervical cancer. Cancer. 2010;116:1469–75.PubMedCrossRefGoogle Scholar
  33. 33.
    Berman ML, Keys H, Creasman W, DiSaia P, Bundy B, Blessing J. Survival and patterns of recurrence in cervical cancer metastatic to periaortic lymph nodes (a Gynecologic Oncology Group study). Gynecol Oncol. 1984;19:8–16.PubMedCrossRefGoogle Scholar
  34. 34.
    Heller PB, Maletano JH, Bundy BN, Barnhill DR, Okagaki T. Clinical-pathologic study of stage IIB, III, and IVA carcinoma of the cervix: extended diagnostic evaluation for paraaortic node metastasis—a Gynecologic Oncology Group study. Gynecol Oncol. 1990;38:425–30.PubMedCrossRefGoogle Scholar
  35. 35.
    Varia MA, Bundy BN, Deppe G, Mannel R, Averette HE, Rose PG, et al. Cervical carcinoma metastatic to paraaortic nodes: extended field radiation therapy with concomitant 5-fluorouracil and cisplatin chemotherapy: a Gynecologic Oncology Group study. Int J Radiat Oncol Biol Phys. 1998;42:1015–23.PubMedCrossRefGoogle Scholar
  36. 36.
    Kang S, Kim SK, Chung DC, Seo SS, Kim JY, Nam BH, et al. Diagnostic value of (18)F-FDG PET for evaluation of paraaortic nodal metastasis in patients with cervical carcinoma: a metaanalysis. J Nucl Med. 2010;51:360–7.PubMedCrossRefGoogle Scholar
  37. 37.
    Schwarz JK, Siegel BA, Dehdashti F, Grigsby PW. Association of post therapy positron emission tomography with tumor response and survival in cervical carcinoma. JAMA. 2007;298:2289–95.PubMedCrossRefGoogle Scholar
  38. 38.
    Jacobs AJ, Faris C, Perez CA, Kao MS, Galakatos A, Camel HM. Short-term persistence of carcinoma of the uterine cervix after radiation. An indicator of long-term prognosis. Cancer. 1986;57:944–50.PubMedCrossRefGoogle Scholar
  39. 39.
    Schwarz JK, Grigsby PW, Dehdashti F, Delbeke D. The role of 18F-FDG PET in assessing therapy response in cancer of the cervix and ovaries. J Nucl Med. 2009;50(Suppl 1):64S–73S.PubMedCrossRefGoogle Scholar
  40. 40.
    Lin LL, Yang Z, Mutic S, Miller TR, Grigsby PW. FDG-PET imaging for the assessment of physiologic volume response during radiotherapy in cervix cancer. Int J Radiat Oncol Biol Phys. 2006;65:177–81.PubMedCrossRefGoogle Scholar

Copyright information

© The Japanese Society of Nuclear Medicine 2013

Authors and Affiliations

  • Burcu Esen Akkas
    • 1
  • Busra Bedriye Demirel
    • 1
    Email author
  • Aysen Dizman
    • 2
  • Gulin Ucmak Vural
    • 1
  1. 1.Department of Nuclear MedicineAnkara Oncology Research and Training HospitalAnkaraTurkey
  2. 2.Department of Radiation OncologyAnkara Oncology Research and Training HospitalAnkaraTurkey

Personalised recommendations