General overview on the use of PET

imaging in gynecological oncology

Dr Andrew Tan EH
Consultant Nuclear Physician
Raffles Hospital, Singapore
 Gynecological Cancers
• Cervical cancers
• Ovarian cancers
• Endometrial cancers
 Cervical Cancer
• 4th most common cancer in women worldwide
• 85% of cases occurring in developing countries
• Introduction of cervical cancer screening and HPV
vaccination have reduced incidences and mortality
• 80% squamous cell carcinoma
• 20% adenocarcinoma and adenosquamous
carcinoma
• Cervical cancer generally highly metabolically active
 Stage Description Illustration

I The carcinoma is strictly confined to the cervix

IA Invasive cancer identified only microscopically.
IA1 Measured invasion of stroma ≤3.0 mm in depth and ≤7.0 mm width.
IA2 Measured invasion of stroma >3.0 mm and < 5.0 mm in depth and ≤ 7 mm width.

IB Clinical lesions confined to the cervix or preclinical lesions greater than stage IA.

IB1 Clinical lesions no greater than 4 cm in size.

IB2 Clinical lesions >4 cm in size.
II The carcinoma extends beyond the uterus but not extended onto the pelvic wall or to the lower
third of the vagina.

IIA Involvement of up to the upper 2/3 of the vagina. No obvious parametrial involvement

IIA1 Clinically visible lesion ≤4.0 cm.

IIA2 Clinically visible lesion >4.0 cm.
IIB Obvious parametrial involvement but not onto the pelvic sidewall.
III The carcinoma has extended onto the pelvic sidewall or lower third of vagina or hydronephrosis

IIIA Involvement of the lower vagina but no extension onto pelvic sidewall.
IIIB Extension onto the pelvic sidewall, or hydronephrosis/non-functioning kidney.

IV The carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the
bladder and/or rectum.
 Cervical Cancer - Staging
• FIGO is predominantly a clinical staging
• Despite advances in diagnostic techniques, the
staging system in largely unchanged because the
highest incidences are in developing countries
• LN status and metastases not included in FIGO
• FIGO has maintained that its staging was intended
for comparison purposes, and not as a guide for
therapy
 Nodal Staging
• FDG PET/CT is more accurate than CT or MRI for
detection of nodal disease.
• But detection of micro metastases is low

Sensitivity Specificity Accuracy

MRI 30.3% 92.6% 72.7%

PET 57.6% 92.6% 85.1%

Choi HJ et al. Cancer. 2006 Feb 15;106(4):914-22.

Nodal Staging Impact
Nodal status on PET is the major predictor of
outcome in locally advanced cervix cancer
and was superior to FIGO staging

PET imaging aids in the selection of patients

for surgery and helps avoid multimodality
therapy and its associated morbidity.

Narayan et al. International Journal of Gynecological

Cancer 2009; 19(5): 912-918

Goyal Bhupesh K et al. International Journal of

Gynecological Cancer 2010; 20(6): 1041-1045
 Distant Metastases
• FDG PET is particularly sensitive for distant
metastases
• Reported sensitivity 100%, specificity 90% and
accuracy 94%

Wong TZ et al. Mol Imaging Biol 2004; 6(1): 55-62

Response and Relapse Assessment
PET sensitivity, specificity and accuracy for
detecting recurrence was 90.3%, 81.0% and
86.5%. Changed management in 23.1%

Provides reliable long term prognostic

information for patients undergoing
treatment, and guides additional therapy

Chung HH et al. Gynecol Oncol 2007; 104(3): 529-34

Schwart JK et al. J Nucl Med 2009; 50(S1): 64S-73S

 Summary
Purpose Value

Staging Moderate sensitivity for nodal micro metastases

Good accuracy for distant metastases
Superior compared to clinical staging or anatomical imaging for N and
M assessment
Therapy Planning Influences management decisions and avoids multimodality
treatment
Response Provides long term prognostication information

Recurrence Good accuracy for recurrent disease

 Ovarian Cancer
• 5th most common type of cancer in women
and 4th most common cause of death
• Estimated lifetime risk of 1 in 54
• Predominantly affects post menopausal
women
• 90% epithelial origin (serous, mucinous,
endometroid, clear cell, Brenner, mixed,
undifferentiated)
 Stage Description

I Growth limited to the ovaries

IA Growth limited to one ovary; no ascites present containing malignant cells. No tumour on the external surface; capsule
intact
IB Growth limited to both ovaries; no ascites present containing malignant cells. No tumour on the external surfaces;
capsules intact

IC Tumour either stage IA or IB, but with tumour on surface of one or both ovaries, or with capsule ruptured, or with
ascites present containing malignant cells, or with positive peritoneal washings

II Growth involving one or both ovaries with pelvic extension

IIA Extension and/or metastases to the uterus and/or tubes

IIB Extension to other pelvic tissues

IIC Tumour either stage IIA or IIB, but with tumour on surface of one or both ovaries, or with capsule(s) ruptured, or with
ascites present containing malignant cells, or with positive peritoneal washings

III Tumour involving one or both ovaries with histologically confirmed peritoneal implants outside the pelvis and/or
positive regional lymph nodes. Superficial liver metastases equal stage III. Tumour is limited to the true pelvis, but with
histologically proven malignant extension to small bowel or omentum
IIIA Tumour grossly limited to the true pelvis, with negative nodes, but with histologically confirmed microscopic seeding of
abdominal peritoneal surfaces, or histologically proven extension to small bowel or mesentery
IIIB Tumour of one or both ovaries with histologically confirmed implants, peritoneal metastasis of abdominal peritoneal
surfaces, none exceeding 2 cm in diameter; nodes are negative
IIIC Peritoneal metastasis beyond the pelvis >2 cm in diameter and/or positive regional lymph nodes
IV Growth involving one or both ovaries with distant metastases. If pleural effusion is present, there must be positive
cytology to allot a case to stage IV. Parenchymal liver metastasis equals stage IV
 Primary Ovarian Cancer
• In differentiating benign from malignant ovarian
lesion, reported sensitivity (82.4 – 100%) and
specificity (76.9 – 92.5%)

• High diagnostic value in differentiating malignant

from benign tissue
• Low diagnostic value in differentiating borderline
and benign tumors
Kitajima K et al. Nucl Med Commun 2011; 32(7): 549-53
Signe Risum et al. Gynecologic Oncology 2007; 105: 145-149
 Ovarian Cancer - Staging
• Staging allocates patients into groups with similar prognostic
outlooks
• 5 year survival (Stage I: 75%, Stage II-III: 20-40%, Stage IV: <10%)
• Best survival: Early diagnosis and optimal surgical debulking
• Important negative prognostic factor: residual tumor post
surgery
Van der Burg ME et al. N Engl J Med 1995; 332: 629-634
du Bois A et al. Cancer 2009; 115: 1234-1244

• Role of imaging is accurate staging, to guide the surgical

process or to identify distant metastases that excludes
surgery
 Peritoneal Disease
• In detecting peritoneal lesions, reported
sensitivity 91%, specificities 91%, true positive
77%, false negative 23%

L Funicelli et al.Abdom Imaging 2010; 35(6): 701-7

Rubini G et al. Recenti Prog Med 2012; 103(11): 510-4
 Stage Migration
• FDG imaging staging shows significant stage
migration when done after FIGO staging

S Risum et al. Gynecol Oncol 2010; 116(3): 395-8

 Disease Relapse
• Incidence of relapse
– Early stage: 20-30%
– Advanced stage: 50-75%

• In detecting relapse, FDG PET/CT has the highest

sensitivity (91%), in comparison with Ca-125, CT
and MRI, while Ca-125 had highest specificity
(93%)

Gu P et al. Eur J Radiol 2009; 71(1): 164-74

 Summary
Purpose Value

Staging More accurate than conventional imaging in nodal and distant

metastases detection
Therapy Planning Restages diseases in significant proportion of cases, guides treatment
planning
Response To assess for residual disease. This is an important prognostic factor

Recurrence Useful in assessment upon biochemical (Ca-125) recurrence

 Endometrial Cancer
• 6th most common malignancy in females
• >80% occur in post menopausal women
• Type 1 (80%). Estrogen dependent
endometroid adenocarcinoma
• Type 2 (20%). Estrogen independent clear cell
type
 Stage Description

I Tumour confined to the corpus uteri

IA NO or less than half myometrial invasion
IB Invasion equal to or more than half of the myometrium
II Tumour invades cervical stroma, but does not extend beyond the uterus

III Local and/or regional spread of the tumour

IIIA Tumour invades the serosa of the corpus uteri and/or adnexae
IIIB Vaginal and/or parametrial involvement
IIIC Metastasis to pelvic and/or para-aortic lymph nodes

IIIC1 Positive pelvic nodes

IIIC2 Positive para-aortic lymph nodes with or without positive pelvic lymph nodes
IV Tumour invades bladder and/or bowel mucosa, and/or distant metastases
IVA Tumour invasion of bladder and/or bowel mucosa
IVB Distant metastases, including intra-abdominal metastases and/or inguinal lymph nodes
 Endometrial Cancer - Prognosis
• Endometrial cancer is generally associated
with a favorable prognosis. Age adjusted 5
year survival is approximately 80%
• Most cases are diagnosed at an early stage

• Tumor stage is important for both prognosis

and adjuvant treatment
 Staging
• Most endometrial cancers are FDG avid
• Nodal disease sensitivity (57%) and specificity (100%)
• Distant metastases sensitivity (100%) and specificity
(96%)
Picchio M et al. Nucl Med Commun 2010; 31(6): 506-12

The main use is for the detection of distant

metastases, which would obviate surgical staging
 Recurrence
• Most recurrences are known to develop within 2
years
• Early detection allows an earlier opportunity for
salvage therapy, which improves prognosis
• FDG PET reported sensitivity (96%), specificity (78%),
positive predictive value (89%), and negative
predictive value (91%)
• In 35% of cases, management was altered by PET
findings (by detecting unsuspected disease)

Belhocine T et al. Eur J Nucl Med Mol Imaging 2002; 29(9): 1132-9
 Summary
Purpose Value

Staging Utility in detecting distant metastases, which alters prognosis and

management
Recurrence Good surveillance tool for high risk patients.
Thank You