Skip to main content
Egyptian Journal of Radiology and Nuclear Medicine
Download PDF

Risk stratification of endometrial cancer and lymph node metastases prediction using 18F-FDG PET/CT: role of metabolic tumor volume and total lesion glycolysis

Egyptian Journal of Radiology and Nuclear Medicine volume 53, Article number: 49 (2022) Cite this article

Abstract

Background

Endometrial cancer is the commonest gynecologic malignancy. Pelvic lymph node metastasis is considered one of its most important prognostic factors. Surgery is considered the most important and effective treatment, still there is controversy about indication and necessity of pelvic lymph node dissection. 18F-fluorodeoxyglucose positron emission tomography/computed tomography is investigated in his study to evaluate its value in preoperative detection of lymph node metastases and risk stratification of endometrial cancer.

Results

Reviewing the records of 33 women with endometrial cancer, all 18F-FDG PET/CT studied indices, SUVmax, SUVmean, MTV and TLG, mean difference was statistically significant in all the studied risk categories (tumor grade, Myometrial invasion, lymphovascular space invasion, tumor stage, and risk stratification). SUVmax and TLG showed highest area under the curve for detection of Myometrial invasion > 50% (AUC = 0.911) with cut-off value of SUVmax > 14.55 showing 88.89% sensitivity and 86.67% specificity, and TLG > 192.653 having 88.89% sensitivity and 80% specificity. TLG showed highest AUC (0.889 and 0.921) for detection of LVSI and LNMs with 100% sensitivity and 66.67% specificity for cut-off value > 179.374 and 88.89% sensitivity and 83.33% specificity for cut-off value > 249.366, respectively. Concerning risk stratification of EC, SUVmax and TLG showed highest AUC (0.839) with cut-off value > 14.55 showing 77.27% sensitivity and 90.91% specificity, and > 192.653 having 77.27% sensitivity and 81.82% specificity, respectively.

Conclusion

The results of this study suggest that 18F-FDG PET/CT is a very valuable tool for prediction of lymph node metastases and risk stratification in endometrial cancer patients. Applying TLG cutoff values increases the accuracy and preoperative diagnosis of lymph node metastases which aids in sparing women with low-risk early stage EC unnecessary surgical risk and morbidity of lymphadenectomy.

Background

Endometrial cancer (EC) is the commonest gynecologic malignancy that is prevalent among women in developed countries and the second most common among those in developing countries [1]. Natural course of EC is slow and is characterized by rather good prognosis [2]. However, women with recurrent or advanced disease, or when fertility preservation is required, limited treatment options are available [3]. Important risk factors for disease recurrence and survival are advanced International Federation of Gynecology and Obstetrics (FIGO) surgical stage, non-endometrioid histological sub-type, poorly differentiated tumor, more than half myometrial invasion, large tumor size, lymph-node metastasis, and lymphovascular space invasion (LVSI) [4, 5].

Pelvic lymph node metastasis (LNMs) is considered one of the most important prognostic factors in EC [6, 7]. The survival rate would be lower if the EC patients had pelvic or para-aortic LNMs [8,9,10].

Surgery is considered the most important and effective treatment of primary EC, but there is still a great deal of controversy about indication and necessity of pelvic lymph node dissection [11]. Clinicians do not support lymphadenectomy in low-risk group EC women based on low probability of LNMs [12], because only 5% are present or suspected [13]. Also, iliac lymphadenectomy is not considered an easy procedure and is often associated with complication due to the anatomical complexity in this region [12]. It seems to be of great importance to find the subgroup of patients with the good prognosis, who would not need comprehensive surgical staging and further treatment. It is especially important for older patients who suffer from severe concomitant diseases with high risk of complications during and after surgery. It is also very important for young patients, where fertility preservation is desired [14]. For preoperative risk stratification, a noninvasive diagnostic method that is able to predict tumor aggressiveness and pathological features would be useful [15].

18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) is an advanced imaging modality that has combined morphological and functional imaging capabilities and is widely used for diagnosis and re-staging of cancer [8]. In the current practice, maximum standardized uptake value (SUVmax), a semi-quantitative parameter determined by positron emission tomography (PET), is known to be a useful indicator of tumor aggressiveness and prognosis in a variety of malignant tumors. Several groups have addressed the relationship between SUVmax and histological prognostic factors in EC [16]. However, SUVmax has the limitation of measuring from a single spot of the most hyper-metabolic area of the tumor mass [17]. It cannot be used for assessment of the tumor mass overall glucose metabolic activity [18]. On the other hand, total lesion glycolysis (TLG) and metabolic tumor volume (MTV) are indicators of metabolic activity throughout the tumor volume. Therefore, these parameters potentially reflect tumor biology, treatment response, and prognosis more accurately than SUVmax [19]. Only few studies addressed the prognostic value of TLG and MTV in EC preoperative risk stratification [16].

The aim of this study is to evaluate the value of 18F-FDG PET/CT in preoperative risk stratification of women with EC.

Methods

This retrospective study was conducted during the period from January 2017 to June 2021. Retrospective collection of data was done for women with EC who underwent hysterectomy and bilateral salpingo-oophorectomy (TAH + BSO) with pelvic lymphadenectomy and had preoperative 18F-FDG PET/CT done for them. Women who had 18F-FDG PET/CT done more than one month before surgery, incomplete surgical staging, or unavailable postoperative pathology report were excluded from the study.

18F-FDG PET/CT imaging protocol

Special pre-procedure precautions were done [fasting for 4–6 h, blood glucose level less than 200 mg/dl, avoidance of vigorous activity 24 h before the procedure and avoidance of talking following injection of the radioisotope to avoid physiologic background muscle uptake of the tracer]. PET/CT examination was performed using machine [Philips® Ingenuity TF 128 multi slice PET/CT] and GE® multislice Discovery IQ 5 Rings machine with Dual Acquisition Channels, 50-slice equivalent CT speed. For all cases, 5–10 mCi (approximate dose to patient, 1 mCi /10 kg) of 18F-FDG was the usual dose administered to each patient about one hour before the examination. The examination started with a low-dose non-enhanced routine CT scan from the skull base to the mid-thigh performed for attenuation correction. The images were acquired with 6 to 8 bed positions on a 3D mode for 3 min per bed position; then, PET study was performed. Following this, a diagnostic enhanced CT scan was obtained using 60–100 ml of non-ionic iodinated contrast material according to patient’s weight. The parameters of the CT scan were 150 kV, 150–250 mAs, slice thickness of 3.5 mm pitch = 0.9, covering the same transverse field of view. Delayed images after 2 h following micturition were taken when necessary, e.g.: LNs near UB.

All PET/CT images were reviewed by two independent experienced nuclear medicine physicians who had no knowledge of the patient's clinical information, and a standard PET/ CT imaging report was generated. The artifactual and physiological soft tissue accumulation of 18F-FDG was taken into consideration for accurate interpretation. Primary tumor lesions were diagnosed when abnormal FDG uptake increase in irregular, nodular, or lumpy appearance on PET images was encountered, with SUVmax over 2.5. Using GE® advanced workstation (AW05) and Philips® intellispace Portal workstation. Volume of interests (VOIs) was delineated on PET images, and manual adjustment was performed on axial, sagittal, and coronal images obtaining the optimal boundary of primary focus. The SUVmax, SUVmean, and MTV were generated automatically by the workstation (Figs. 1, 2, 3). TLG was calculated as MTV × SUVmean.

Fig. 1
figure 1

The uterus is enlarged, showing endometrial intensely avid heterogeneous soft tissue lesion, measuring ± 40 × 34 × 19 mm [Image A]. The myometrium shows few fibroids, and the largest one [measuring ± 7 × 6 cm] is seen at the posterior wall, accommodating internal confluent dystrophic calcifications. The endometrial lesion achieves 26.9 SUVmax, 10.4 SUVmean and MTV = 37,056 mm3 at the corresponding PET images [image B]. Bilateral few small non-avid external iliac lymph nodes [arrows, image C, superior image], measuring 11 × 4mm and 10 × 9mm on the right and left side, respectively. No hypermetabolic pelviabdominal lymphadenopathy detected

Full size image
Fig. 2
figure 2

The uterus is mildly enlarged in size, showing irregular hypermetabolic hypodense remarkable endometrial soft tissue thickening reaching up to 26.5 mm in maximal thickness with zones of active myometrial invasion at the fundus and posterior wall [image A], achieving up to 12.9 SUVmax, 7.81 SUVmean and MTV = 1024 mm3 on corresponding PET images [image B]. A small right external iliac LN is noted [image C superior image], measuring about 10 mm achieving 3.25 SUV max, 2.7 SUVmean and Volume = 1024 mm3. Another nonavid larger LN seen in the opposite left external iliac group [image C, inferior image] measuring about 22 × 17 mm devoid of any appreciable metabolic activity with loss of its fatty hilum

Full size image
Fig. 3
figure 3

A large hypermetabolic endometrial soft tissue thickening [image A], mainly involving the left lateral aspect of the endometrium, measuring ± 36 × 30 × 41mm at its maximal AP, TR & CC dimensions having intense avidity for FDG uptake [23.9 SUV max, SUV mean 10.32 and MTV = 17,280 mm3], on corresponding PET image [image B]. Associated infiltration of more than 50% of the myometrial coat yet no associated extra uterine or parametrial extensions. Regional solitary right internal iliac LN is noted about 13 × 12 mm having intense metabolic activity [image C], 9.5 SUV max, 6.46 SUVmean and vol. = 896 mm3

Full size image

Postoperative pathological reports were reviewed. Women with EC were classified either to low-risk or high-risk groups according to risk stratification standards proposed by European Society for Medical Oncology; Low-risk: histological grade 1 (G1), Myometrial invasion (MI) less than half of the myometrium, and FIGO stage IA, and high-risk: histological grade 2/3 (G2/3), positive lymphovascular space involvement (LVSI), MI more than half of the myometrium, or non-endometrioid EC [20]. Also, lymph nodes status and LNMs were reported. Results of 18F-FDG PET/CT were compared to pathological outcome.

Statistical analysis performed using IBM© SPSS© Statistics version 20 (IBM© Corp., Armonk, NY, USA). Data were collected, tabulated and then, analyzed using appropriate statistical tests. The D’Agostino–Pearson test was used to test the normality of numerical data distribution. Numerical data are presented as mean and standard deviation (if normally distributed) or as median and interquartile range (if skewed). Categorical data are presented as number and percentage or as ratio. The following diagnostic indices were calculated for each diagnostic tool: sensitivity, specificity, positive predictive value, and negative predictive value. Receiver-operating characteristic (ROC) curve analysis was used to examine the value of the diagnostic indices for the diagnosis of abnormal PI. The best cut-off value was identified as that associated with the highest Youden (J) index. P-value < 0.05 is considered statistically significant.

Results

During the period from January 2017 to June 2021, 44 18F-FDG PET/CT done for women with endometrial cancer were reviewed. Five cases were excluded as the pathology report showed that they underwent hysterectomy without formal staging, and six cases were excluded due to unavailability of pathology reports. Thus, 33 women were included in the study with mean age 56.67 ± 6.66 years (42–71 years) and BMI 30.4 ± 2.49 kg/m2 (23.6–35.7 kg/m2). The histological characteristics of EC in the studied women are shown in Table 1 (Table 1), where only 5 cases showed non-endometrioid carcinoma (three cases were papillary serous carcinoma (9.1%), and two were clear cell carcinoma (6.1%)).

Table 1 Histopathological characteristics of EC
Full size table

All 18F-FDG PET/CT studied indices, SUVmax, SUVmean, MTV and TLG, showed significant difference between; histological grade 1 tumor and grade 2&3, Myometrial invasion < 50% and > 50%, the presence of LVSI, LNMs, and between low- and high-risk tumors (Table 2). Sensitivity and specificity of different PET-CT parameters for LNMs detection and risk stratification of EC are shown in Table 3, SUVmax, and TLG showed highest area under the curve for detection of Myometrial invasion > 50% (AUC = 0.911) with cut-off value of SUVmax > 14.55 showing 88.89% sensitivity and 86.67% specificity, and TLG > 192.653 having 88.89% sensitivity and 80% specificity. TLG showed highest AUC (0.889 and 0.921) for detection of LVSI and LNMs with 100% sensitivity and 66.67% specificity for cut-off value > 179.374 and 88.89% sensitivity and 83.33% specificity for cut-off value > 249.366, respectively. Concerning risk stratification of EC, SUVmax and TLG showed highest AUC (0.839) with cut-off value > 14.55 showing 77.27% sensitivity and 90.91% specificity, and > 192.653 having 77.27% sensitivity and 81.82% specificity, respectively (Table 3).

Table 2 PET-CT indices and EC risk stratification
Full size table
Table 3 Sensitivity and Specificity of different PET-CT parameters for LNMs detection and risk stratification of EC
Full size table

When predicting higher stage of EC than stage IA, all parameters showed significantly lower values in EC with stage IA compared to higher stages (Table 4). SUVmax and TLG showed highest AUC (cut-off value > 14.55, sensitivity 88.89%, specificity 86.67%; AUC = 0.911, p-value =  < 0.0001, 95% CI 0.759 to 0.982) and (cut-off value > 192.653, sensitivity 88.89%, specificity 80%; AUC = 0.911, p-value =  < 0.0001, 95% CI 0.759 to 0.982), respectively. SUVmean showed sensitivity 88.89%, specificity 73.33% for cut-off value > 7.15 (AUC = 0.852, p-value =  < 0.0001, 95% CI 0.685 to 0.951), while MTV showed sensitivity 77.78%, specificity 80% for cut-off value > 25.596 (AUC = 0.837, p-value =  < 0.0001, 95% CI 0.667 to 0.942).

Table 4 PET-CT parameters and EC stage
Full size table

When comparing ROC curves of the four studied PET-CT parameters for prediction of LNMs and EC risk stratification testing for equal areas under the curve across tumor quantifications AUCs, p-value was > 0.05 showing no significant difference in any of them (Fig. 4).

Fig. 4
figure 4

ROC curves for various tumor quantifications for prediction of Tumor grade (A), MI (B), LVSI (C), LNMs (D), stage > IA (E), and risk stratification (F) in patients with endometrial carcinoma

Full size image

Discussion

Endometrial cancer continues to be a serious problem facing women worldwide, with pelvic lymphadenectomy remaining as one of the important procedures performed in the management of EC. Diagnosing LNMs in EC and subsequent proper removal of these nodes allows proper staging of EC thus offering the appropriate adjuvant chemo- or radiotherapy, improves the survival rate for these women [21], also several studies reported that EC patients with LNMs had much worse prognosis than those without [9, 10]. Still, surgical lymphadenectomy is considered invasive and not without risks or potential morbidities taking in consideration the complexity of structures surrounding the lymph nodes. Several clinicians suggest omitting lymphadenectomy in low-risk EC owing to low incidence of LNMs in this group of patients and the high risk of morbidities related to the procedure [12, 22].

Accordingly, several studies have searched for the ideal pre-operative tool that can replace surgical lymphadenectomy. Reviewing literature, PET/CT was found to be superior to CT in detection of LNMs and other metastases [23]. MRI is useful in assessment of MI, tumor size, cervical involvement, and LNMs; it has better resolution for outlining anatomical lesions compared to PET/CT. Still, its diagnosis of LNMs depends on LN size (≥ 10 mm) and morphology (shape, signal intensity, and contour) which seems to be unreliable especially with the significant overlap with reactive lymph nodes [24]. Diffusion-Weighted MRI (DW-MRI) use to assess tissue diffusion and cellularity is now used with pelvic MRI to improve preoperative nodal staging but still with variable results [25].

Several authors found FDG PET/CT to have better diagnostic performance in LNMs detection compared to MRI [26, 27]. FDG PET/CT was also found superior to diffusion MRI in LNMs prediction in EC [28]. Still some overlap was found between precancerous and early EC concerning SUV-related parameters, which are sometimes difficult to discriminate between, making these early lesions non-avid to FDG PET/CT [29]. Other tracers as Fluoro-ethyl-choline (FEC)-PET/CT are studied, as cell line studies found several-fold increase of 3H choline by EC cells compared to endometrial stromal cells [30]. The MAPPING trial found better diagnostic performance for FEC PET/CT over FDG PET/CT in LNMs detection (87.5% vs. 80%) but not statistically significant. Still, all studied imaging techniques did not have enough sensitivity to replace nodal surgical staging, yet, FDG PET/CT showed high sensitivity and low false positive results that might be helpful in the arbitration of surgical planning decisions [31]. FESPET Study: Female EStrogen recePtor in Endometrial Cancer Treatment (FES-PET) is an ongoing study investigating the feasibility of FES-PET scan in EC. It combines PET-CT scan with an estrogen tracer, allowing noninvasive visualization of estrogen receptor, even in metastasis difficult to reach by biopsy [32].

In the current retrospective study, 18F-FDG PET/CT has been found to be a very valuable tool for prediction of LNMs in EC patients, all metabolic parameters of the primary tumor were found to be significantly higher in patients with LNMs compared to those without. SUVmean showed 100% sensitivity for prediction of LNMS but with relatively fair specificity, 62.50%. TLG had the highest AUC with a considerably accepted sensitivity 88.89% and specificity 83.33%. Also, the pooled mean difference of all 18F-FDG PET/CT parameters was found to be statistically significant in all the studied risk categories (tumor grade, MI, LVSI, and risk stratification). Several studies suggested the value of 18F-FDG PET/CT in EC, with different sensitivity and specificity, three previous meta-analyses supported the results of this study specially indicating high specificity of this technique for detection of LNMs in EC [16, 33, 34]. They suggest that the relatively high pooled specificity of 18F-FDG PET/CT for detection of LNMS in EC could safely argue the replacement of surgical lymphadenectomy in low-risk patients. Still, these meta-analyses found the pooled sensitivity of 18F-FDG PET/CT to be much lower than the suggested by this study reaching maximum 73%. They suggested an explanation for this that the avidity of 18F-FDG PET/CT depends on the presence of sufficient malignant cells to produce an increase in glucose metabolism, and the spatial resolution might be not reliable enough to detect small tumors or micro-metastasis with no established threshold for LN size in EC for 18F-FDG PET/CT to detect LNMs [33, 34].

Still, 18F-FDG PET/CT might be a preoperative solution for patients with high surgical risk and early stage EC where omitting lymphadenectomy might be an excellent alternative and even vaginal hysterectomy using regional anesthesia might be the ideal management for these patients thus alleviating both the surgical and anesthetic risk. This was supported by the statistically significant difference between the mean values of all 18F-FDG PET/CT metabolic parameters in patients with stage IA EC and those with higher stage.

Still, this study has different limitations, the retrospective design of the study and the relatively small number of cases, this was attributed to the fact that 18F-FDG PET/CT is still an evolving diagnostic tool in EC where not all clinicians are still aware of its importance which made it difficult to construct a prospective study and to attain larger number of cases which are still needed to validate the results of this study. Also, this study did not compare this technique with the value of other techniques as dynamic post-contrast magnetic resonance imaging (MRI) using diffusion/ADC map and perfusion data which even seems to superior in detection of LNMs according to few reports [35, 36]. Third, none of the included cases had para-aortic lymphadenectomy which is especially important in high-grade EC and is reported to be present in 2.7% of EC with absent pelvic LNMs [37]. Also, the retrospective nature of the study hindered the possibility of node-by-node or region-by-region evaluation, which would have provided valuable information, and the study of the prognostic value of 18F-FDG PET/CT in EC and the study of disease survival and recurrence due to unavailability of data.

Conclusion

18F-FDG PET/CT has high accuracy in risk stratification of EC patients, TLG and SUVmax showed highest AUC for detection of MI > 50% and risk stratification with highest sensitivity and specificity, while TLG showed the highest AUC for detection of LVSI and LNMs with highest sensitivity and specificity. Thus, preoperative 18F-FDG PET/CT can aid in omitting surgical lymphadenectomy in low-risk early stage EC, sparing these women the surgical risk and morbidity. Still, larger prospective studies are needed to validate these results.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

EC:

Endometrial cancer

FIGO:

International Federation of Gynecology and Obstetrics

LVSI:

Lymphovascular space invasion

LNMs:

Lymph node metastasis

18F-FDG PET/CT:

18F-fluorodeoxyglucose positron emission tomography/computed tomography

FEC PET/CT:

Fluoro-ethyl-choline positron emission tomography/computed tomography

SUVmax :

Maximum standardized uptake value

PET:

Positron emission tomography

TLG:

Total lesion glycolysis

MTV:

Metabolic tumor volume

TAH + BSO:

Hysterectomy and bilateral salpingo-oophorectomy

VOIs:

Volume of interests

SUVmean :

Mean standardized uptake value

MI:

Myometrial invasion

AUC:

Area under the curve

CT:

Computed tomography

MRI:

Magnetic resonance imaging

DW-MRI:

Diffusion-Weighted magnetic resonance imaging

FES-PET:

Female EStrogen- positron emission tomography/computed tomography

References

  1. Siegel R, Naishadham D, Jemal A (2013) Cancer statistics, 2013. CA Cancer J Clin 63(1):11–30

    Article  Google Scholar 

  2. Walentowicz-Sadlecka M, Malkowski B, Walentowicz P, Sadlecki P, Marszalek A, Pietrzak T, Grabiec M (2014) 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 2014:234813

    Article  Google Scholar 

  3. Bi FF, Li D, Yang Q (2013) Hypomethylation of ETS transcription factor binding sites and upregulation of PARP1 expression in endometrial cancer. BioMed Res Int 2013:946268

    PubMed  PubMed Central  Google Scholar 

  4. Amant F, Moerman P, Neven P, Timmerman D, Van Limbergen E, Vergote I (2005) Endometrial cancer. Lancet 366(9484):491–505

    Article  Google Scholar 

  5. Bakkum-Gamez JN, Gonzalez-Bosquet J, Laack NN, Mariani A, Dowdy SC (2008) Current issues in the management of endometrial cancer. Mayo Clin Proc 83:97–112

    Article  Google Scholar 

  6. Kikuchi A, Yanase T, Sasagawa M, Honma S (2017) The role of para-aortic lymphadenectomy in stage IIIC endometrial cancer: a single-institute study. J Obstet Gynaecol 37(4):510–513

    Article  Google Scholar 

  7. Todo Y, Takeshita S, Okamoto K, Yamashiro K, Kato H (2017) Implications of para-aortic lymph node metastasis in patients with endometrial cancer without pelvic lymph node metastasis. J Gynecol Oncol 28(5):e59

    Article  Google Scholar 

  8. Atri M, Zhang Z, Dehdashti F, Lee SI, Marques H, Ali S, Koh WJ, Mannel RS, DiSilvestro P, King SA, Pearl M, Zhou X, Plante M, Moxley KM, Gold M (2017) Utility of PET/CT to evaluate retroperitoneal lymph node metastasis in high-risk endometrial cancer: results of ACRIN 6671/GOG 0233 trial. Radiology 283(2):450–459

    Article  Google Scholar 

  9. Lee HJ, Lee JJ, Park JY, Kim JH, Kim YM, Kim YT, Nam JH (2017) Prognostic value of metabolic parameters determined by preoperative 18F-FDG PET/CT in patients with uterine carcinosarcoma. J Gynecol Oncol 28(4):e43

    Article  Google Scholar 

  10. Lindqvist E, Wedin M, Fredrikson M, Kjølhede P (2017) Lymphedema after treatment for endometrial cancer—a review of prevalence and risk factors. Eur J Obstet Gynecol Reprod Biol 211:112–121

    Article  Google Scholar 

  11. Pulman KJ, Dason ES, Philp L, Bernardini MQ, Ferguson SE, Laframboise S, Atenafu EG, May T (2017) Comparison of three surgical approaches for staging lymphadenectomy in high-risk endometrial cancer. Int J Gynaecol Obstet 136(3):315–319

    Article  Google Scholar 

  12. Bae HS, Lim MC, Lee JS, Lee Y, Nam BH, Seo SS, Kang S, Chung SH, Kim JY, Park SY (2016) Postoperative lower extremity edema in patients with primary endometrial cancer. Ann Surg Oncol 23(1):186–195

    Article  Google Scholar 

  13. Mariani A, Webb MJ, Keeney GL, Haddock MG, Calori G, Podratz KC (2000) Low-risk corpus cancer: is lymphadenectomy or radiotherapy necessary? Am J Obstet Gynecol 182(6):1506–1519

    CAS  Article  Google Scholar 

  14. Tsujikawa T, Yoshida Y, Kudo T, Kiyono Y, Kurokawa T, Kobayashi M, Tsuchida T, Fujibayashi Y, Kotsuji F, Okazawa H (2009) Functional images reflect aggressiveness of endometrial carcinoma: estrogen receptor expression combined with 18F-FDG PET. J Nucl Med 50(10):1598–1604

    CAS  Article  Google Scholar 

  15. Chung HH, Nam BH, Kim JW, Kang KW, Park NH, Song YS, Chung JK, Kang SB (2010) Preoperative [18F]FDG PET/CT maximum standardized uptake value predicts recurrence of uterine cervical cancer. Eur J Nucl Med Mol Imaging 37:1467–1473

    Article  Google Scholar 

  16. Ghooshkhanei H, Treglia G, Sabouri G, Davoodi R, Sadeghi R (2014) Risk stratification and prognosis determination using 18F-FDG PET imaging in endometrial cancer patients: a systematic review and meta-analysis. Gynecol Oncol 132(3):669–676

    Article  Google Scholar 

  17. Lee HJ, Ahn BC, Hong CM, Song BI, Kim HW, Kang S, Jeong SY, Lee SW, Lee J (2011) Preoperative risk stratification using (18)F-FDG PET/CT in women with endometrial cancer. Nuklearmedizin 50(5):204–213

    CAS  Article  Google Scholar 

  18. Husby JA, Reitan BC, Biermann M, Trovik J, Bjørge L, Magnussen IJ, Salvesen ØO, Salvesen HB, Haldorsen IS (2015) Metabolic tumor volume on 18F-FDG PET/CT improves preoperative identification of high-risk endometrial carcinoma patients. J Nucl Med 56(8):1191–1198

    CAS  Article  Google Scholar 

  19. Pak K, Cheon GJ, Nam HY, Kim SJ, Kang KW, Chung JK, Kim EE, Lee DS (2014) Prognostic value of metabolic tumor volume and total lesion glycolysis in head and neck cancer: a systematic review and metaanalysis. J Nucl Med 55(6):884–890

    CAS  Article  Google Scholar 

  20. Colombo N, Creutzberg C, Amant F, Bosse T, González-Martín A, Ledermann J, Marth C, Nout R, Querleu D, Mirza MR, Sessa C, ESMO-ESGO-ESTRO Endometrial Consensus Conference Working Group (2016) ESMO-ESGO-ESTRO Consensus Conference on endometrial cancer. Ann Oncol 27:16–41

    CAS  Article  Google Scholar 

  21. Bristow RE, Zahurak ML, Alexander CJ, Zellars RC, Montz FJ (2003) FIGO stage IIIC endometrial carcinoma: resection of macroscopic nodal disease and other determinants of survival. Int J Gynecol Cancer 13(5):664–672

    CAS  Article  Google Scholar 

  22. Winer I, Ahmed QF, Mert I, Bandyopadhyay S, Cote M, Munkarah AR, Hussein Y, Al-Wahab Z, Elshaikh MA, Alosh B, Schultz DS, Mahdi H, Nucci MR, Van de Vijver KK, Morris RT, Oliva E, Ali-Fehmi R (2015) Significance of lymphovascular space invasion in uterine serous carcinoma: what matters more; extent or presence? Int J Gynecol Pathol 34(1):47–56

    CAS  Article  Google Scholar 

  23. Gee MS, Atri M, Bandos AI, Mannel RS, Gold MA, Lee SI (2018) Identification of distant metastatic disease in uterine cervical and endometrial cancers with FDG PET/CT: analysis from the ACRIN 6671/GOG 0233 multicenter trial. Radiology 287(1):176–184

    Article  Google Scholar 

  24. Concin N, Matias-Guiu X, Vergote I, Cibula D, Mirza MR, Marnitz S, Ledermann J, Bosse T, Chargari C, Fagotti A, Fotopoulou C, Gonzalez Martin A, Lax S, Lorusso D, Marth C, Morice P, Nout RA, O’Donnell D, Querleu D, Raspollini MR, Sehouli J, Sturdza A, Taylor A, Westermann A, Wimberger P, Colombo N, Planchamp F, Creutzberg CL (2021) ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma. Int J Gynecol Cancer 31(1):12–39

    Article  Google Scholar 

  25. Shen G, Zhou H, Jia Z, Deng H (2015) Diagnostic performance of diffusion-weighted MRI for detection of pelvic metastatic lymph nodes in patients with cervical cancer: a systematic review and meta-analysis. Br J Radiol 88(1052):20150063

    Article  Google Scholar 

  26. Antonsen SL, Jensen LN, Loft A, Berthelsen AK, Costa J, Tabor A, Qvist I, Hansen MR, Fisker R, Andersen ES, Sperling L, Nielsen AL, Asmussen J, Høgdall E, Fagö-Olsen CL, Christensen IJ, Nedergaard L, Jochumsen K, Høgdall C (2013) MRI, PET/CT and ultrasound in the preoperative staging of endometrial cancer—a multicenter prospective comparative study. Gynecol Oncol 128(2):300–308

    CAS  Article  Google Scholar 

  27. Kim HJ, Cho A, Yun M, Kim YT, Kang WJ (2016) Comparison of FDG PET/CT and MRI in lymph node staging of endometrial cancer. Ann Nucl Med 30(2):104–113

    Article  Google Scholar 

  28. Fasmer KE, Gulati A, Dybvik JA, Ytre-Hauge S, Salvesen Ø, Trovik J, Krakstad C, Haldorsen IS (2020) Preoperative 18F-FDG PET/CT tumor markers outperform MRI-based markers for the prediction of lymph node metastases in primary endometrial cancer. Eur Radiol 30(5):2443–2453

    Article  Google Scholar 

  29. Wang T, Sun H, Guo Y, Zou L (2019) 18F-FDG PET/CT quantitative parameters and texture analysis effectively differentiate endometrial precancerous lesion and early-stage carcinoma. Mol Imaging 18:1536012119856965

    Article  Google Scholar 

  30. Trousil S, Lee P, Pinato DJ, Ellis JK, Dina R, Aboagye EO, Keun HC, Sharma R (2014) Alterations of choline phospholipid metabolism in endometrial cancer are caused by choline kinase alpha overexpression and a hyperactivated deacylation pathway. Cancer Res 74(23):6867–6877

    CAS  Article  Google Scholar 

  31. Rockall AG, Barwick TD, Wilson W, Singh N, Bharwani N, Sohaib A, Nobbenhuis M, Warbey V, Miquel M, Koh DM, De Paepe KN, Martin-Hirsch P, Ghaem-Maghami S, Fotopoulou C, Stringfellow H, Sundar S, Manchanda R, Sahdev A, Hackshaw A, Cook GJ, MAPPING Study Group (2021) Diagnostic accuracy of FEC-PET/CT, FDG-PET/CT, and diffusion-weighted MRI in detection of nodal metastases in surgically treated endometrial and cervical carcinoma. Clin Cancer Res 27(23):6457–6466

    CAS  Article  Google Scholar 

  32. FESPET Study: Female EStrogen recePtor in Endometrial Cancer Treatment (FESPET). https://clinicaltrials.gov/ct2/show/NCT03489473.

  33. Chang MC, Chen JH, Liang JA, Yang KT, Cheng KY, Kao CH (2012) 18F-FDG PET or PET/CT for detection of metastatic lymph nodes in patients with endometrial cancer: a systematic review and meta-analysis. Eur J Radiol 81(11):3511–3517

    Article  Google Scholar 

  34. Bollineni VR, Ytre-Hauge S, Bollineni-Balabay O, Salvesen HB, Haldorsen IS (2016) High diagnostic value of 18F-FDG PET/CT in endometrial cancer: systematic review and meta-analysis of the literature. J Nucl Med 57(6):879–885

    CAS  Article  Google Scholar 

  35. Kitajima K, Suenaga Y, Ueno Y, Kanda T, Maeda T, Takahashi S, Ebina Y, Miyahara Y, Yamada H, Sugimura K (2013) Value of fusion of PET and MRI for staging of endometrial cancer: comparison with 18F-FDG contrast-enhanced PET/CT and dynamic contrast-enhanced pelvic MRI. Eur J Radiol 82(10):1672–1676

    Article  Google Scholar 

  36. Bian LH, Wang M, Gong J, Liu HH, Wang N, Wen N, Fan WS, Xu BX, Wang MY, Ye MX, Meng YG (2019) Comparison of integrated PET/MRI with PET/CT in evaluation of endometrial cancer: a retrospective analysis of 81 cases. PeerJ 7:e7081

    Article  Google Scholar 

  37. Ayhan A, Tuncer R, Tuncer ZS, Yüce K, Küçükali T (1994) Correlation between clinical and histopathologic risk factors and lymph node metastases in early endometrial cancer (a multivariate analysis of 183 cases). Int J Gynecol Cancer 4(5):306–309

    Article  Google Scholar 

Download references

Acknowledgements

Ain Shams University, Helwan University, and Misr Radiology Center (MRC).

Funding

The authors did not receive any external funding in the study.

Author information

Authors and Affiliations

  1. Department of Radiology, Helwan University, Cairo, 16646, Egypt

    Mostafa M. Abdelkawi & Eman A. NasrElDin

  2. Department of Obstetrics and Gynecology, Ain Shams University, Cairo, Egypt

    Mohamed S. Sweed & Mohamed A. Ali

Authors
  1. Mostafa M. Abdelkawi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mohamed S. Sweed
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mohamed A. Ali
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Eman A. NasrElDin
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

MA helped design the study, supervised the undertaking of the trial, undertook the analysis, edited the final manuscript and shared in funding the study. MS helped design the study, supervised the undertaking of the trial, undertook the analysis, wrote the first draft of the manuscript and shared in funding the study. MA helped design the study, shared in undertaking of the trial, assisted with data analysis, gave editorial feedback to versions of the manuscript and shared in funding the study. EN shared in undertaking of the trial, provided advice during the running of the trial, collected data for analysis, gave editorial feedback to versions of the manuscript, and shared in funding the study. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Eman A. NasrElDin.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Research Ethics Committee for Human and Animal Research at the Faculty of Medicine, Helwan University (REC-FMHU) with approval number 35-2021.

Consent for publication

All patients included in this research gave written informed consent to publish the data contained within this study.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Abdelkawi, M.M., Sweed, M.S., Ali, M.A. et al. Risk stratification of endometrial cancer and lymph node metastases prediction using 18F-FDG PET/CT: role of metabolic tumor volume and total lesion glycolysis. Egypt J Radiol Nucl Med 53, 49 (2022). https://doi.org/10.1186/s43055-022-00716-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s43055-022-00716-0

Keywords

  • Endometrial neoplasms
  • Positron emission tomography computed tomography
  • Lymphatic metastasis
  • Risk assessment
  • Tumor burden