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Review
. 2018 Apr;13(2):165-177.
doi: 10.1016/j.cpet.2017.11.004. Epub 2018 Feb 3.

[18F]-2-Fluoro-2-Deoxy-D-glucose-PET Assessment of Cervical Cancer

Chitra Viswanathan  1 , Silvana Faria  2 , Catherine Devine  2 , Madhavi Patnana  2 , Tara Sagebiel  2 , Revathy B Iyer  2 , Priya R Bhosale  2
Affiliations
Review

[18F]-2-Fluoro-2-Deoxy-D-glucose-PET Assessment of Cervical Cancer

Chitra Viswanathan et al. PET Clin. 2018 Apr.

Abstract

This article provides an overview of PET in cervical cancer, primarily with regard to the use of 18F-2-fluoro-2-deoxy-d-glucose-PET/computed tomography. A brief discussion of upcoming technologies, such as PET/MR imaging, is presented.

Keywords: Cancer staging; Cervical cancer; PET/CT; PET/MR imaging; Treatment planning.

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Figures

Figure 1
Figure 1
PET/CT in initial evaluation of cervical cancer primary tumor. 46-year-old female with stage IIB squamous cell carcinoma of cervix. A–C. Axial (A), coronal (B), and sagittal (C) fused PET/CT images show an intensely FDG-avid cervical mass with SUVmax 15.5, MTV 70.64 ml, and TLG 623 ml.
Figure 1
Figure 1
PET/CT in initial evaluation of cervical cancer primary tumor. 46-year-old female with stage IIB squamous cell carcinoma of cervix. A–C. Axial (A), coronal (B), and sagittal (C) fused PET/CT images show an intensely FDG-avid cervical mass with SUVmax 15.5, MTV 70.64 ml, and TLG 623 ml.
Figure 1
Figure 1
PET/CT in initial evaluation of cervical cancer primary tumor. 46-year-old female with stage IIB squamous cell carcinoma of cervix. A–C. Axial (A), coronal (B), and sagittal (C) fused PET/CT images show an intensely FDG-avid cervical mass with SUVmax 15.5, MTV 70.64 ml, and TLG 623 ml.
Figure 2
Figure 2
PET/CT in initial evaluation of cervical cancer primary tumor and lymph nodes. 57-year-old female with stage IV squamous cell carcinoma of the cervix. A. Axial fused FDG PET/CT shows cervical tumor (T) with posterior bladder (B) involvement along with anterior rectal invasion and extension to bilateral uterosacral ligaments and upper 1/3 of vagina. Also note left pelvic sidewall lymphadenopathy (N). B. Axial fused PET/CT shows bilateral pelvic sidewall lymphadenopathy (N), consisting of 2.7 cm left external iliac node and 2.8 cm right external iliac node. C. Axial fused PET/CT shows 1 cm left common iliac node (N). As a result of the PET/CT findings, the patient will be treated with definitive chemoradiation to include the pelvis and retroperitoneum. D. Axial T2-weighted MRI better shows the rectal and bladder involvement by cervical tumor (T).
Figure 2
Figure 2
PET/CT in initial evaluation of cervical cancer primary tumor and lymph nodes. 57-year-old female with stage IV squamous cell carcinoma of the cervix. A. Axial fused FDG PET/CT shows cervical tumor (T) with posterior bladder (B) involvement along with anterior rectal invasion and extension to bilateral uterosacral ligaments and upper 1/3 of vagina. Also note left pelvic sidewall lymphadenopathy (N). B. Axial fused PET/CT shows bilateral pelvic sidewall lymphadenopathy (N), consisting of 2.7 cm left external iliac node and 2.8 cm right external iliac node. C. Axial fused PET/CT shows 1 cm left common iliac node (N). As a result of the PET/CT findings, the patient will be treated with definitive chemoradiation to include the pelvis and retroperitoneum. D. Axial T2-weighted MRI better shows the rectal and bladder involvement by cervical tumor (T).
Figure 2
Figure 2
PET/CT in initial evaluation of cervical cancer primary tumor and lymph nodes. 57-year-old female with stage IV squamous cell carcinoma of the cervix. A. Axial fused FDG PET/CT shows cervical tumor (T) with posterior bladder (B) involvement along with anterior rectal invasion and extension to bilateral uterosacral ligaments and upper 1/3 of vagina. Also note left pelvic sidewall lymphadenopathy (N). B. Axial fused PET/CT shows bilateral pelvic sidewall lymphadenopathy (N), consisting of 2.7 cm left external iliac node and 2.8 cm right external iliac node. C. Axial fused PET/CT shows 1 cm left common iliac node (N). As a result of the PET/CT findings, the patient will be treated with definitive chemoradiation to include the pelvis and retroperitoneum. D. Axial T2-weighted MRI better shows the rectal and bladder involvement by cervical tumor (T).
Figure 2
Figure 2
PET/CT in initial evaluation of cervical cancer primary tumor and lymph nodes. 57-year-old female with stage IV squamous cell carcinoma of the cervix. A. Axial fused FDG PET/CT shows cervical tumor (T) with posterior bladder (B) involvement along with anterior rectal invasion and extension to bilateral uterosacral ligaments and upper 1/3 of vagina. Also note left pelvic sidewall lymphadenopathy (N). B. Axial fused PET/CT shows bilateral pelvic sidewall lymphadenopathy (N), consisting of 2.7 cm left external iliac node and 2.8 cm right external iliac node. C. Axial fused PET/CT shows 1 cm left common iliac node (N). As a result of the PET/CT findings, the patient will be treated with definitive chemoradiation to include the pelvis and retroperitoneum. D. Axial T2-weighted MRI better shows the rectal and bladder involvement by cervical tumor (T).
Figure 3
Figure 3
PET/CT in evaluation of metastatic disease. 46-year-old female with stage IVB poorly differentiated cervical carcinoma. A. Axial fused FDG PET/CT shows primary cervical tumor (arrow). B. Axial fused PET/CT shows FDG-avid left common iliac node (arrow). C. Axial fused PET/CT through upper pelvis shows stranding in left omental fat with mild FDG uptake (arrow), in keeping with peritoneal disease. D. Axial fused PET/CT shows an FDG-avid left lung nodule (arrow). E. Axial fused PET/CT shows an FDG-avid left supraclavicular node (arrow).
Figure 3
Figure 3
PET/CT in evaluation of metastatic disease. 46-year-old female with stage IVB poorly differentiated cervical carcinoma. A. Axial fused FDG PET/CT shows primary cervical tumor (arrow). B. Axial fused PET/CT shows FDG-avid left common iliac node (arrow). C. Axial fused PET/CT through upper pelvis shows stranding in left omental fat with mild FDG uptake (arrow), in keeping with peritoneal disease. D. Axial fused PET/CT shows an FDG-avid left lung nodule (arrow). E. Axial fused PET/CT shows an FDG-avid left supraclavicular node (arrow).
Figure 3
Figure 3
PET/CT in evaluation of metastatic disease. 46-year-old female with stage IVB poorly differentiated cervical carcinoma. A. Axial fused FDG PET/CT shows primary cervical tumor (arrow). B. Axial fused PET/CT shows FDG-avid left common iliac node (arrow). C. Axial fused PET/CT through upper pelvis shows stranding in left omental fat with mild FDG uptake (arrow), in keeping with peritoneal disease. D. Axial fused PET/CT shows an FDG-avid left lung nodule (arrow). E. Axial fused PET/CT shows an FDG-avid left supraclavicular node (arrow).
Figure 3
Figure 3
PET/CT in evaluation of metastatic disease. 46-year-old female with stage IVB poorly differentiated cervical carcinoma. A. Axial fused FDG PET/CT shows primary cervical tumor (arrow). B. Axial fused PET/CT shows FDG-avid left common iliac node (arrow). C. Axial fused PET/CT through upper pelvis shows stranding in left omental fat with mild FDG uptake (arrow), in keeping with peritoneal disease. D. Axial fused PET/CT shows an FDG-avid left lung nodule (arrow). E. Axial fused PET/CT shows an FDG-avid left supraclavicular node (arrow).
Figure 3
Figure 3
PET/CT in evaluation of metastatic disease. 46-year-old female with stage IVB poorly differentiated cervical carcinoma. A. Axial fused FDG PET/CT shows primary cervical tumor (arrow). B. Axial fused PET/CT shows FDG-avid left common iliac node (arrow). C. Axial fused PET/CT through upper pelvis shows stranding in left omental fat with mild FDG uptake (arrow), in keeping with peritoneal disease. D. Axial fused PET/CT shows an FDG-avid left lung nodule (arrow). E. Axial fused PET/CT shows an FDG-avid left supraclavicular node (arrow).
Figure 4
Figure 4
PET/CT in evaluation of osseous metastatic disease. 40-year-old female with stage IIA poorly differentiated adenocarcinoma of the cervix. A. Axial fused FDG PET/CT shows primary cervical tumor (arrow). B. Axial fused PET/CT shows FDG-avid right rib lesion (arrow). C. Coronal PET maximum intensity projection (MIP) image shows multiple FDG-avid osseous lesions compatible with widespread bone marrow metastases.
Figure 4
Figure 4
PET/CT in evaluation of osseous metastatic disease. 40-year-old female with stage IIA poorly differentiated adenocarcinoma of the cervix. A. Axial fused FDG PET/CT shows primary cervical tumor (arrow). B. Axial fused PET/CT shows FDG-avid right rib lesion (arrow). C. Coronal PET maximum intensity projection (MIP) image shows multiple FDG-avid osseous lesions compatible with widespread bone marrow metastases.
Figure 4
Figure 4
PET/CT in evaluation of osseous metastatic disease. 40-year-old female with stage IIA poorly differentiated adenocarcinoma of the cervix. A. Axial fused FDG PET/CT shows primary cervical tumor (arrow). B. Axial fused PET/CT shows FDG-avid right rib lesion (arrow). C. Coronal PET maximum intensity projection (MIP) image shows multiple FDG-avid osseous lesions compatible with widespread bone marrow metastases.
Figure 5
Figure 5
PET/CT in tumor response: complete metabolic response to therapy. 47-year-old female with stage IIB squamous cell carcinoma of the cervix. A–B. Axial (A) and coronal (B) fused FDG PET/CT images show mass with intense FDG uptake in the cervix with SUVmax 19.6 (arrow). C–E. Follow-up axial (C) and coronal (D) fused PET/CT images after treatment with definitive chemoradiation using external beam radiation therapy and brachytherapy show complete metabolic and anatomic response after therapy (SUVmax 3.4) with radiation fiducial marker in place (arrow). Coronal (E) fused PET/CT shows FDG uptake in brown fat in the neck and chest (arrows).
Figure 5
Figure 5
PET/CT in tumor response: complete metabolic response to therapy. 47-year-old female with stage IIB squamous cell carcinoma of the cervix. A–B. Axial (A) and coronal (B) fused FDG PET/CT images show mass with intense FDG uptake in the cervix with SUVmax 19.6 (arrow). C–E. Follow-up axial (C) and coronal (D) fused PET/CT images after treatment with definitive chemoradiation using external beam radiation therapy and brachytherapy show complete metabolic and anatomic response after therapy (SUVmax 3.4) with radiation fiducial marker in place (arrow). Coronal (E) fused PET/CT shows FDG uptake in brown fat in the neck and chest (arrows).
Figure 5
Figure 5
PET/CT in tumor response: complete metabolic response to therapy. 47-year-old female with stage IIB squamous cell carcinoma of the cervix. A–B. Axial (A) and coronal (B) fused FDG PET/CT images show mass with intense FDG uptake in the cervix with SUVmax 19.6 (arrow). C–E. Follow-up axial (C) and coronal (D) fused PET/CT images after treatment with definitive chemoradiation using external beam radiation therapy and brachytherapy show complete metabolic and anatomic response after therapy (SUVmax 3.4) with radiation fiducial marker in place (arrow). Coronal (E) fused PET/CT shows FDG uptake in brown fat in the neck and chest (arrows).
Figure 5
Figure 5
PET/CT in tumor response: complete metabolic response to therapy. 47-year-old female with stage IIB squamous cell carcinoma of the cervix. A–B. Axial (A) and coronal (B) fused FDG PET/CT images show mass with intense FDG uptake in the cervix with SUVmax 19.6 (arrow). C–E. Follow-up axial (C) and coronal (D) fused PET/CT images after treatment with definitive chemoradiation using external beam radiation therapy and brachytherapy show complete metabolic and anatomic response after therapy (SUVmax 3.4) with radiation fiducial marker in place (arrow). Coronal (E) fused PET/CT shows FDG uptake in brown fat in the neck and chest (arrows).
Figure 5
Figure 5
PET/CT in tumor response: complete metabolic response to therapy. 47-year-old female with stage IIB squamous cell carcinoma of the cervix. A–B. Axial (A) and coronal (B) fused FDG PET/CT images show mass with intense FDG uptake in the cervix with SUVmax 19.6 (arrow). C–E. Follow-up axial (C) and coronal (D) fused PET/CT images after treatment with definitive chemoradiation using external beam radiation therapy and brachytherapy show complete metabolic and anatomic response after therapy (SUVmax 3.4) with radiation fiducial marker in place (arrow). Coronal (E) fused PET/CT shows FDG uptake in brown fat in the neck and chest (arrows).
Figure 6
Figure 6
PET/CT in recurrent cervical cancer. 39-year-old female with FIGO stage IB adenocarcinoma of the cervix initially diagnosed 2 years prior and treated with radical hysterectomy and bilateral pelvic lymph node dissection. Although the lymph nodes were negative, there was deep cervical involvement and radiation therapy was implemented. Follow-up PET/CT was obtained due to symptoms and elevated CEA levels. A. Axial fused FDG PET/CT shows an FDG avid focus in the left pelvis in the region of the radiation marker, representing recurrent disease (arrow). B. Axial fused PET/CT also shows an FDG-avid left supraclavicular lymph node (arrow) suspicious for metastasis. Biopsy was obtained to exclude metastatic disease, with no evidence of malignancy noted on pathology.
Figure 6
Figure 6
PET/CT in recurrent cervical cancer. 39-year-old female with FIGO stage IB adenocarcinoma of the cervix initially diagnosed 2 years prior and treated with radical hysterectomy and bilateral pelvic lymph node dissection. Although the lymph nodes were negative, there was deep cervical involvement and radiation therapy was implemented. Follow-up PET/CT was obtained due to symptoms and elevated CEA levels. A. Axial fused FDG PET/CT shows an FDG avid focus in the left pelvis in the region of the radiation marker, representing recurrent disease (arrow). B. Axial fused PET/CT also shows an FDG-avid left supraclavicular lymph node (arrow) suspicious for metastasis. Biopsy was obtained to exclude metastatic disease, with no evidence of malignancy noted on pathology.
Figure 7
Figure 7
PET/MRI in primary evaluation. 53-year-old female with stage IVA squamous cell carcinoma of the cervix. A. Axial fused FDG PET/MRI shows FDG-avid large circumferential cervical tumor involving the left parametrium (arrow), lower one third of vagina, uterus, and urinary bladder (B). Significant thickening is seen in the distal portions of bilateral ureters (right ureter labeled U), likely representing tumor extension. The patient had bilateral ureteral stents in place. B. Axial T2-weighted MRI at the same level of fused PET/MRI shows the primary cervical tumor and local extension into the surrounding tissues as described in (A) with improved conspicuity, demonstrating the value of MRI in local tumor evaluation. C. Sagittal T2-weighted MRI shows the full extent of cervical tumor, along with extension into the posterior urinary bladder and into the vagina. D. Sagittal ADC map MRI reveals low signal intensity of the primary cervical tumor, in keeping with restricted diffusion.
Figure 7
Figure 7
PET/MRI in primary evaluation. 53-year-old female with stage IVA squamous cell carcinoma of the cervix. A. Axial fused FDG PET/MRI shows FDG-avid large circumferential cervical tumor involving the left parametrium (arrow), lower one third of vagina, uterus, and urinary bladder (B). Significant thickening is seen in the distal portions of bilateral ureters (right ureter labeled U), likely representing tumor extension. The patient had bilateral ureteral stents in place. B. Axial T2-weighted MRI at the same level of fused PET/MRI shows the primary cervical tumor and local extension into the surrounding tissues as described in (A) with improved conspicuity, demonstrating the value of MRI in local tumor evaluation. C. Sagittal T2-weighted MRI shows the full extent of cervical tumor, along with extension into the posterior urinary bladder and into the vagina. D. Sagittal ADC map MRI reveals low signal intensity of the primary cervical tumor, in keeping with restricted diffusion.
Figure 7
Figure 7
PET/MRI in primary evaluation. 53-year-old female with stage IVA squamous cell carcinoma of the cervix. A. Axial fused FDG PET/MRI shows FDG-avid large circumferential cervical tumor involving the left parametrium (arrow), lower one third of vagina, uterus, and urinary bladder (B). Significant thickening is seen in the distal portions of bilateral ureters (right ureter labeled U), likely representing tumor extension. The patient had bilateral ureteral stents in place. B. Axial T2-weighted MRI at the same level of fused PET/MRI shows the primary cervical tumor and local extension into the surrounding tissues as described in (A) with improved conspicuity, demonstrating the value of MRI in local tumor evaluation. C. Sagittal T2-weighted MRI shows the full extent of cervical tumor, along with extension into the posterior urinary bladder and into the vagina. D. Sagittal ADC map MRI reveals low signal intensity of the primary cervical tumor, in keeping with restricted diffusion.
Figure 7
Figure 7
PET/MRI in primary evaluation. 53-year-old female with stage IVA squamous cell carcinoma of the cervix. A. Axial fused FDG PET/MRI shows FDG-avid large circumferential cervical tumor involving the left parametrium (arrow), lower one third of vagina, uterus, and urinary bladder (B). Significant thickening is seen in the distal portions of bilateral ureters (right ureter labeled U), likely representing tumor extension. The patient had bilateral ureteral stents in place. B. Axial T2-weighted MRI at the same level of fused PET/MRI shows the primary cervical tumor and local extension into the surrounding tissues as described in (A) with improved conspicuity, demonstrating the value of MRI in local tumor evaluation. C. Sagittal T2-weighted MRI shows the full extent of cervical tumor, along with extension into the posterior urinary bladder and into the vagina. D. Sagittal ADC map MRI reveals low signal intensity of the primary cervical tumor, in keeping with restricted diffusion.
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