Abstract
The utilization of 2-[fluorine 18] fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) in combination with computed tomography (CT) in the assessment of gynecologic malignancies has been rapidly growing in recent years; however, its role in clinical practice has yet to be established. A number of pitfalls are commonly encountered, including normal physiologic activity in bowel loops and blood vessels, or focal retained activity in ureters and urinary bladder. Increased uptake has also been reported in many benign pelvic processes and in premenopausal patients; endometrial activity changes cyclically, whereas increased ovarian uptake may be functional. FDG PET–CT has an emerging role in staging nodal disease and in the evaluation of local recurrence or peritoneal spread of gynecologic malignancies and is also useful in monitoring response to therapy and in long-term follow-up. FDG PET–CT is most suitable in patients with high tumor markers and negative or uncertain conventional imaging data. Patient preparation, proper scanning protocol, combined assessment of PET and CT data, and the evaluation of conventional imaging findings are essential to define disease and to avoid diagnostic pitfalls.
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References
Wahl RL (2004) Why nearly all PET of abdominal and pelvic cancers will be performed as PET/CT. J Nucl Med 45:82S–95S
Koyama K, Okamura T, Kawabe J, et al. (2003) Evaluation of 18F-FDG PET with bladder irrigation in patients with uterine and ovarian tumors. J Nucl Med 44(3):353–358
Sugawara Y, Eisbruch A, Kosuda S, et al. (1999) Evaluation of FDG PET in patients with cervical cancer. J Nucl Med 40(7):1125–1131
Lai CH, Huang KG, See LC, et al. (2004) Restaging of recurrent cervical carcinoma with dual-phase [18F]fluoro-2-deoxy-d-glucose positron emission tomography. Cancer 100(3):544–552
Kim SK, Kang KW, Roh JW, et al. (2005) Incidental ovarian 18F-FDG accumulation on PET: correlation with the menstrual cycle. Eur J Nucl Med Mol Imaging 32(7):757–763
Nishizawa S, Inubushi M, Okada H (2005) Physiological 18F-FDG uptake in the ovaries and uterus of healthy female volunteers. Eur J Nucl Med Mol Imaging 32(5):549–556
Lerman H, Metser U, Grisaru D, et al. (2004) Normal and abnormal 18F-FDG endometrial and ovarian uptake in pre- and postmenopausal patients: assessment by PET/CT. J Nucl Med 45(2):266–271
Hempling RE (1996) Handbook of gynecologic oncology, 2nd edn. Boston: Little Brown, pp 103–130
Toita T, Nakano M, Higashi M, et al. (1995) Prognostic value of cervical size and pelvic lymph node status assessed by computed tomography for patients with uterine cervical cancer treated by radical radiation therapy. Int J Radiat Oncol Biol Phys 33(4):843–849
Yen TC, See LC, Lai CH, et al. (2004) 18F-FDG uptake in squmous cell carcinoma of the cervix is correlated with glucose transporter 1 expression. J Nucl Med 45(1):22–29
Nicolet V, Carignan L, Bourdon F, et al. (2000) MR imaging of cervical carcinoma: a practical staging approach. Radiographics 20(6):1539–1549
Scheidler J, Hricak H, Yu KK, et al. (1997) Radiological evaluation of lymph node metastases in patients with cervical cancer. A meta-analysis. JAMA 278(13):1096–1101
Sugawara Y, Eisbruch A, Kosuda S, et al. (1999) Evaluation of FDG PET in patients with cervical cancer. J Nucl Med 40(7):1125–1131
Rose PG, Adler LP, Rodriguez M, et al. (1999) Positron emission tomography for evaluating para-aortic nodal metastasis in locally advanced cervical cancer before surgical staging: a surgicopathologic study. J Clin Oncol 17(1):41–45
Reinhardt MJ, Ehritt-Braun C, Vogelgesang D, et al. (2001) Metastatic lymph nodes in patients with cervical cancer: detection with MR imaging and FDG PET. Radiology 218(3):776–782
Narayan K, Hicks RJ, Jobling T, et al. (2001) A comparison of MRI and PET scanning in surgically staged loco-regionally advanced cervical cancer: potential impact on treatment. Int J Gynecol Cancer 11(4):263–271
Sun SS, Chen TC, Yen RF, et al. (2001) Value of whole body 18F-fluoro-2-deoxyglucose positron emission tomography in the evaluation of recurrent cervical cancer. Anticancer Res 21(4B):2957–2961
Yeh LS, Hung YC, Shen YY, et al. (2002) Detecting para-aortic lymph nodal metastasis by positron emission tomography of 18F-fluorodeoxyglucose in advanced cervical cancer with negative magnetic resonance imaging findings. Oncol Rep 9(6):1289–1292
Lin WC, Hung YC, Yeh LS, et al. (2003) Usefulness of (18)F-fluorodeoxyglucose positron emission tomography to detect para-aortic lymph nodal metastasis in advanced cervical cancer with negative computed tomography findings. Gynecol Oncol 89(1):73–76
Ma SY, See LC, Lai CH, et al. (2003) Delayed (18)F-FDG PET for detection of paraaortic lymph node metastases in cervical cancer patients. J Nucl Med 44(11):1775–1783
Havrilesky LJ, Kulasingam SL, Matchar DB, et al. (2005) FDG-PET for management of cervical and ovarian cancer. Gynecol Oncol 97(1):183–191
Choi HJ, Roh JW, Seo SS, et al. (2006) 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 106(4):914–922
Roh JW, Seo SS, Lee S, et al. (2005) Role of positron emission tomography in pretreatment lymph node staging of uterine cervical cancer: a prospective surgicopathologic correlation study. Eur J Cancer 41(14):2086–2092
Wright JD, Dehdashti F, Herzog TJ, et al. (2005) Preoperative lymph node staging of early-stage cervical carcinoma by [18F]-fluoro-2-deoxy-d-glucose-positron emission tomography. Cancer 104(11):2484–2491
Wong TZ, Jones EL, Coleman RE (2004) Positron emission tomography with 2-deoxy-2-[(18)F]fluoro-d-glucose for evaluating local and distant disease in patients with cervical cancer. Mol Imaging Biol 6(1):55–62
DiSaia PJ, Creasman WT (2002) Clinical gynecologic oncology, 6th edn. Mosby: St Louis
Park DH, Kim KH, Park SY (2000) Diagnosis of recurrent uterine cervical cancer: computed tomography versus positron emission tomography. Korean J Radiol 1(1):51–55
Sun SS, Chen TC, Yen RF, et al. (2001) Value of whole body 18F-fluoro-2-deoxyglucose positron emission tomography in the evaluation of recurrent cervical cancer. Anticancer Res 21(4B):2957–2961
Ryu SY, Kim MH, Choi SC, et al. (2003) Detection of early recurrence with 18F-FDG PET in patients with cervical cancer. J Nucl Med 44(3):347–352
Nakamoto Y, Eisbruch A, Achtyes ED, et al. (2002) Prognostic value of positron emission tomography using F-18-fluorodeoxyglucose in patients with cervical cancer undergoing radiotherapy. Gynecol Oncol 84(2):289–295
Havrilesky LJ, Wong TZ, Secord AA, et al. (2003) The role of PET scanning in the detection of recurrent cervical cancer. Gynecol Oncol 90(1):186–90
Lai CH, Huang KG, See LC, et al. (2004) Restaging of recurrent cervical carcinoma with dual-phase [18F]fluoro-2-deoxy-d-glucose positron emission tomography. Cancer 100(3):544–552
Grigsby PW, Siegel BA, Dehdashti F (2001) Lymph node staging by positron emission tomography in patients with carcinoma of the cervix. J Clin Oncol 19(17):3745–3749
Horowitz NS, Dehdashti F, Herzog TJ, et al. (2004) Prospective evaluation of FDG-PET for detecting pelvic ana paraortic lymph node matastasis in uterine corpus cancer. Gynecol Oncol 95(3):546–551
Lentz SS (2002) Endometrial carcinoma diagnosed by positron emission tomography: a case report. Gynecol Oncol 86(2):223–224
Nakahara T, Fujii H, Ide M, et al. (2001) F-18 FDG uptake in endometrial cancer. Clin Nucl Med 26(1):82–83
Ak I, Ozalp S, Yalcin OT, Zor E, et al. (2004) Uptake of 2-[18F]fluoro-2-deoxy-d-glucose in uterine leiomyoma: imaging of four patients by coincidence positron emission tomography. Nucl Med Commun 25(9):941–945
Torizuka T, Nakamura F, Takekuma M, et al. (2006) FDG PET for the assessment of myometrial infiltration in clinical stage I uterine corpus cancer. Nucl Med Commun 27(6):481–487
Horowitz NS, Dehdashti F, Herzog TJ, et al. (2004) Prospective evaluation of FDG-PET for detecting pelvic and para-aortic lymph node metastasis in uterine corpus cancer. Gynecol Oncol 95(3):546–551
Chao A, Chang TC, Ng KK, et al. (2006) 18F-FDG PET in the management of endometrial cancer. Eur J Nucl Med Mol Imaging 33(1):36–44
Belhocine T, De Barsy C, Hustinx R, et al. (2002) Usefulness of (18)F-FDG PET in the post-therapy surveillance of endometrial carcinoma. Eur J Nucl Med Mol Imaging 29(9):1132–1139
Saga T, Higashi T, Ishimori T, et al. (2003) Clinical value of FDG-PET in the follow up of post-operative patients with endometrial cancer. Ann Nucl Med 17(3):197–203
Lamoreaux WT, Grigsby PW, Dehdashti F, et al. (2005) FDG-PET evaluation of vaginal carcinoma. Int J Radiat Oncol Biol Phys 62(3):733–737
Cohn DE, Dehdashti F, Gibb RK, et al. (2002) Prospective evaluation of positron emission tomography for the detection of groin node metastases from vulvar cancer. Gynecol Oncol 85(1):179–184
Lin LL, Dehdashti F, Siegel BA, et al. (2007) PET and PET-CT of tumors of the female genital tract. In: von Schulthess GK (ed) Molecular anatomic imaging. PET-CT and SPECT-CT integrated modality imaging, 2nd edn. Philadelphia: Lippincott Williams & Wilkins, pp 427–442
Kawahara K, Yoshida Y, Kurokawa T, et al. (2004) Evaluation of positron emission tomography with tracer 18-fluorodeoxyglucose in addition to magnetic resonance imaging in the diagnosis of ovarian cancer in selected women after ultrasonography. J Comput Assist Tomogr 28(4):505–516
Kumar R, Alavi A (2004) PET imaging in gynecologic malignancies. Radiol Clin N Am 42(6):1155–1167
Hubner KF, McDonald TW, Niethammer JG, et al. (1993) Assessment of primary and metastatic ovarian cancer by positron emission tomography (PET) using 2-[18F]deoxyglucose (2-[18F]FDG). Gynecol Oncol 51(2):197–204
Romer W, Avril N, Dose J, et al. (1997) Metabolic characterization of ovarian tumors with positron-emission tomography and F-18 fluorodeoxyglucose. Rofo 166(1):62–68
Schroder W, Zimny M, Rudlowski C, et al. (1999) The role of 18F-fluoro-deoxyglucose positron emission tomography (18F-FDG PET) in diagnosis of ovarian cancer. Int J Gynecol Cancer 9(2):117–122
Grab D, Flock F, Stohr I, et al. (2000) Classification of asymptomatic adnexal masses by ultrasound, magnetic resonance imaging, and positron emission tomography. Gynecol Oncol 77(3):454–459
Lieberman G, MacLean AB, Buscombe JR, et al. (2001) The clinical application of a dual head gamma camera with coincidence detection in 20 women with suspected ovarian cancer. BJOG 108(12):1229–1236
Fenchel S, Grab D, Nuessle K, et al. (2002) Asymptomatic adnexal masses: correlation of FDG PET and histopathologic findings. Radiology 223(3):780–788
Kawahara K, Yoshida Y, Kurokawa T, et al. (2004) Evaluation of positron emission tomography with tracer 18-fluorodeoxyglucose in addition to magnetic resonance imaging in the diagnosis of ovarian cancer in selected women after ultrasonography. J Comput Assist Tomogr 28(4):505–516
Zimny M (2004) Ovarian cancer. In: Oehr P, Biersack HJ, Coleman RE (eds) PET and PET-CT in oncology. Berlin: Springer-Verlag, pp 227–235
Kubik-Huch RA, Dorffler W, von Schulthess GK, et al. (2000) Value of (18F)-FDG positron emission tomography, computed tomography, and magnetic resonance imaging in diagnosing primary and recurrent ovarian carcinoma. Eur Radiol 10(5):761–767
Yen RF, Sun SS, Shen YY, et al. (2001) Whole body positron emission tomography with 18F-fluoro-2-deoxyglucose for the detection of recurrent ovarian cancer. Anticancer Res 21(5):3691–3694
Zimny M, Siggelkow W, Schroder W, et al. (2001) 2-[Fluorine-18]-fluoro-2-deoxy-d-glucose positron emission tomography in the diagnosis of recurrent ovarian cancer. Gynecol Oncol 83(2):310–315
Cho SM, Ha HK, Byun JY, et al. (2002) Usefulness of FDG PET for assessment of early recurrent epithelial ovarian cancer. AJR Am J Roentgenol 179(2):391–395
Chang WC, Hung YC, Kao CH, et al. (2002) Usefulness of whole body positron emission tomography (PET) with 18F-fluoro-2-deoxyglucose (FDG) to detect recurrent ovarian cancer based on asymptomatically elevated serum levels of tumor marker. Neoplasma 49(5):329–333
Torizuka T, Nobezawa S, Kanno T, et al. (2002) Ovarian cancer recurrence: role of whole-body positron emission tomography using 2-[fluorine-18]-fluoro-2-deoxy-D-glucose. Eur J Nucl Med Mol Imaging 29(6):797–803
Bristow RE, del Carmen MG, Pannu HK, et al. (2003) Clinically occult recurrent ovarian cancer: patient selection for secondary cytoreductive surgery using combined PET/CT. Gynecol Oncol 90(3):519–528
Pannu HK, Cohade C, Bristow RE, et al. (2004) PET-CT detection of abdominal recurrence of ovarian cancer: radiologic-surgical correlation. Abdom Imaging 29(3):398–403
Nanni C, Rubello D, Farsad M, et al. (2005) (18)F-FDG PET/CT in the evaluation of recurrent ovarian cancer: a prospective study on forty-one patients. Eur J Surg Oncol 31(7):792–797
Takekuma M, Maeda M, Ozawa T, et al. (2005) Positron emission tomography with 18F-fluoro-2-deoxyglucose for the detection of recurrent ovarian cancer. Int J Clin Oncol 10(3):177–181
Pannu HK, Bristow RE, Cohade C, et al. (2004) PET-CT in recurrent ovarian cancer: initial observations. Radiographics 24(1):209–223
Havrilesky LJ, Kulasingam SL, Matchar DB, et al. (2005) FDG-PET for management of cervical and ovarian cancer. Gynecol Oncol 97(1):183–191
Garcia Velloso MJ, Boan Garcia JF, Villar Luque LM, et al. (2003) F-18-FDG positron emission tomography in the diagnosis of ovarian recurrence. Comparison with CT scan and CA 125. Rev Esp Med Nucl 22(4):217–223
Simcock B, Neesham D, Quinn M, et al. (2006) The impact of PET/CT in the management of recurrent ovarian cancer. Gynecol Oncol 103(1):271–276
Avril N, Sassen S, Schmalfeldt B, et al. (2005) Prediction of response to neoadjuvant chemotherapy by sequential F-18-fluorodeoxyglucose positron emission tomography in patients with advanced-stage ovarian cancer. J Clin Oncol 23(30):7445–7453
Blake MA, Singh A, Setty BN, et al. (2006) Pearls and pitfalls in interpretation of abdominal and pelvic PET-CT. Radiographics 26(5):1335–1353
Cohade C, Osman M, Nakamoto Y, et al. (2003) Initial experience with oral contrast in PET-CT: phantom and clinical studies. J Nucl Med 44(3):412–416
Antoch G, Freudenberg LS, Egelhof T, et al. (2002) Focal tracer uptake: a potential artifact in contrast-enhanced dual-modality PET-CT scans. J Nucl Med 43(10):1339–1342
Yau YY, Chan WS, Tam YM, et al. (2005) Application of intravenous contrast in PET/CT: does it really introduce significant attenuation correction error? J Nucl Med 46(2):283–291
Subhas N, Patel PV, Pannu HK, et al. (2005) Imaging of pelvic malignancies with in-line FDG PET-CT: case examples and common pitfalls of FDG PET. Radiographics 25(4):1031–1043
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De Gaetano, A.M., Calcagni, M.L., Rufini, V. et al. Imaging of gynecologic malignancies with FDG PET–CT: case examples, physiolocic activity, and pitfalls. Abdom Imaging 34, 696–711 (2009). https://doi.org/10.1007/s00261-008-9457-8
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DOI: https://doi.org/10.1007/s00261-008-9457-8