| [Objective]1. To assess the clinical value of 18F-FDG PET/CT in preliminary diagnosing of endometrial cancer;2. To assess the clinical value of 18F-FDG PET/CT in the surveillance of postoperative recurrence and metastasis in patients with endometrial cancer.[Materials and Methods]1. Study objective1.1 Patients with preliminary diagnosing as endometrial cancer:29 patients who were clinical highly suspected or diagnosed as endometrial cancer from January 2004 to October 2015. They were enrolled in this study, aged from 22-76 years old, with a mean age of 54 years old. Endometrial cancer was diagnosed by histopathology examination of surgical or Fractional curettage surgery. Regional lymph node metastasis was established based on pathological examination in patients treated with surgery and based on Ultrasound, CT, MRI, bone SPECT, PET/CT imaging and clinical follow-up in those cases which didn’t treated with surgery, the diagnosis of distant metastasis was identified based on all clinical information including laboratory tests, clinical examination, and kinds of imaging examination. All of patients were followed-up for more than 6 months.1.2 patients with endometrial cancer after therapy:83 patients, who with endometrial cancer after therapy underwent whole body 18F-FDG PET/CT examination from March 2004 to September 2015.They were enrolled in this study, aged from 28-78 years old, with a mean age of 54 years old. All patients were performed uterine cut and ovaries removed completely.79 cases for endometrial adenocarcinoma, squamous carcinoma in 2 cases,1 gland scale cancer, clear cell carcinoma in 1 cases. Simple surgical treatment of 51 cases, surgery and (or)chemotherapy in 32 cases. FIGO stage:Ⅰ 39 cases, Ⅱ 13cases, Ⅲ 27 cases, IV 4 cases.83 cases of postoperative patients with intrauterine membrane, line 1 time of PET/CT examination in 69 patients, line 2 times and more than 2 times 14 cases of PET/CT examination. All patients with primary tumors confirmed by curettage scraping or surgical pathology, recurrence and metastases according to the pathological biopsy, laboratory examination, a variety of imaging and long-term followed-up data.2. Imaging instrument and imaging agentThe examinations were carried out using a GE Discovery LS PET/CT scanner (GE, Healthcare, and Waukesha, WI) and Biography mCTx128 Scanner (Siemens, Germany). The positron emitter was produced using the cyclotron of PET tracer (GE, Healthcare).The tracer 18F-FDG was manufactured automated by the tracer synthesis system of FDG Micro lab (GE, Healthcare), with a radiochemical purity> 95%.3. Imaging methods and conditionsThe patient take the supine, the head slightly back, by CT position set a bit later, set the scan starting place, The image acquisition included non-enhanced CT scan and PET scan covered the range from the head to the middle thigh, if necessary, add to sweep the lower limbs, collection of 6 to 8 beds. GE Discovery LS PET/CT scanner:140KV voltage, current 160mA, pitch0.75,bulb lap spin time0.8S,layer thickness 5mm, PET emission with a 2 D acquisition,3min/Bed. mCTxl28 Scanner: 120KV voltage and current for automatic, pitch of 0.55, ball tube single rotation time of 1.0s, layer thickness 3mm, PET emission with a 3D acquisition,2min/Bed. when necessary, the injunctions Sammy (furosimide) promote row after pelvic delayed imaging in order to eliminate the interference of bladder urine radioactive. Patients with suspected intracranial metastases should be collected by the method of three-dimensional model of cerebral, emission scanning 5min/beds.4. Image reconstruction and fusionPET images were reconstructed by using a standard iterative algorithm (ordered subset expectation maximization) with CT data being used for attenuation correction. The CT images were reconstructed by using a standard method.The thickness of each slice of PET and CT after reconstruction was 4.25mm (Discovery LS PET/CT) and 2.0mm (Siemens Biograph mCTx). The acquired images of PET and CT were sent to the Xeleris (GE Medical Systems) and Syngo MMWP workstation for image registration and fusion.5. PET/CT Image analysis5.1 Qualitative analysisPET, CT and PET/CT images were interpreted independently by three experienced senior physicians of nuclear medicine and three experienced senior physicians of CT diagnosis. After visually examining all images on the workstation, the reviewers reached a final diagnosis based mainly on fusion images of PET, CT and clinical.5.1.1 Diagnostic criteria for primary tumors of endometrial cancerThe 18F-FDG PET/CT imaging see the endometrial has lump, massive, local and irregular nodular radioactive uptake increased,CT in the corresponding position on the same soft tissue nodules or masses.5.1.2 Diagnostic criteria for regional lymph node metastasisFor the lymph node with 18F-FDG uptake higher than that of the blood pool and without density increased significantly and calcification, no matter the size of lymph nodes it was diagnosed to be positive.5.1.3 Diagnostic criteria for distant metastasis of endometrial carcinomaPET/CT imaging in distant organs or tissues see article nodular, flake or massive radioactive thick shadow, lesion distribution of radioactive higher than that of the surrounding normal tissues, excluding the physiological uptake, typical inflammation or postoperative changes; Multiple nodules in lungs showed on CT images were diagnosed as pulmonary metastases if the nodules were rounded, soft tissue density, smooth edges. Whether the lesion had 18F-FDG uptake or not, it just was a reference, not a necessary condition for the diagnosis.5.1.4 Diagnostic criteria for recurrence of postoperative endometrial carcinomaPET in vaginal stump see radioactive concentration in shadow, and higher than that of the surrounding normal tissues, CT in the corresponding position on the same soft tissue nodules or masses.5.2 Semi-quantitative AnalysisLesion with abnormal 18F-FDG uptake was identified by three experienced senior physicians of PET/CT. The maximum standardized uptake value (SUVmax) was calculated automatically by the workstation by setting the regions of interest (ROI) on the lesion. The calculation method of the SUV is:The standardized values taken (SUV)=the lesion activity per unit volume (Bq/ml)/[imaging agent dose (Bq)/patient weight (kg)]6.The clinical stages of endometrial cancerUsing international Federation of Gynecology and Obstetrics (FIGO) which revised in 2009,according the surgery pathological staging method.7. Statistical analysisStatistical Package SPSS20.0 were used for statistical analysis. The size and SUVmax of the primary lesion was expressed as mean±standard deviation (X±S), with clinical diagnostic test and evaluation methods, calculation the sensitivity, specificity, accuracy, positive predictive value and negative predictive value of 18F-FDG PET/CT in diagnosing the primary lesions, recurrence, regional lymph node metastasis and distant metastasis of endometrial cancer. Comparing the recurrence and metastasis rate of endometrial cancer in 2 years and 2 years more and different treatment used the Pearson Chi-square. The relationship between the recurrence and metastasis of endometrial cancer and CA125 use Fisher exact probability. The relationship between primary tumor SUVmax and tumor size, FIGO staging, muscular infiltration depth and the cervical interstitial infiltrates using two independent samples t test. All statistical tests P<0.05 was considered statistically significant.[Results]1.Patients with preliminary diagnosing as endometrial cancer1.118F-FDG PET/CT imaging for diagnosis of endometrial cancer primary lesions27 cases confirmed by curettage scraping and postoperative pathology of endometrial carcinoma.The endometrial lesions in PET/CT for the block and massive were 16 cases, nodular 6 cases and 7 cases of irregular shape.18F-FDG PET/CT imaging positive 28 cases, the diagnosis of endometrial carcinoma by pathological examination of 26 cases, endometrial cancer were different degree oven higher radioactivity uptake, SUVmax is13.4±8.5. the other 2 cases of false positive, 1 case endometrial simple hyperplasia and another 1 case endometrial tuberculosis. false negative in 1 cases(less than 1.0 cm in diameter), la stage endometrial adenocarcinoma.1.2 The relationship between primary endometrial carcinoma SUVmax and different factors27 patients with endometrial cancer, according to the statistics analysis results, the SUVmax value of primary tumor lesions associated with tumor size and muscular infiltration depth (P value were 0.001 and 0.013).the SUVmax value of diameter greater than 4 was obviously higher than that of less than 4,the SUVmax value of muscle layer infiltration depth more thanl/2 significantly higher than the infiltration depth less than 1/2,but FIGO staging and cervical stoma infiltration have nothing with the SUVmax values (P value were 0.200 and 0.065)1.318F-FDG PET/CT imaging in the diagnosis lymph node metastasis of endometrial carcinoma27 patients with endometrial carcinoma, with lymph node metastasis in 9 cases, 6 cases confirmed by surgery and pathology, the other 3 cases by clinical and laboratory examination, a variety of imaging examination and clinical follow-up of 6 months or more. pelvic lymph node 8 cases.7 cases of abdominal aorta, supraclavicular fossa in 5 cases, the lymph node, metastasis in 2 cases, mediastinal lymph node metastasis in 1 cases, neck in 2 cases and diaphragm feet deep in 2 cases.18F-FDG PET/CT imaging for positive regional lymph node was 13 cases,4 cases of lymph nodes for false positive, respectively in the mediastinum and neck each 1 cases, next into the iliac blood vessels inside and outside in 2 cases, all confirmed by Follow-up for lymph node inflammation. Regional lymph node 18F-FDG PET/CT imaging was true negative 14 cases.18F-FDG PET/CT imaging For regional lymph node metastases in the diagnosis of sensitivity, specificity, accuracy, positive predictive value and negative predictive value was 90.9%(10/11),81.3% (13/16),85.2%(23/27),76.9%(10/13) and 92.9%(13/14) respectively.1.3 18F-FDG PET/CT imaging in the diagnosis distant metastasis of endometrial carcinoma27 cases patients of endometrial cancer, pathology and clinical follow-up confirmed with distant metastasis is 8 cases,5 cases confirmed by pathological examination, while 2 cases for clinical follow-up confirmed. of lung metastases,3 cases of bone metastases,4 cases of peritoneal metastasis in 4 cases, pancreatic metastasis in 1 cases,2 cases of adrenal metastasis and muscle transfer in 1 cases. taking cases as the research unit,18F-FDG PET/CT imaging positive was 7 cases, imaging negative 20 cases, false negative in 1 cases(bone metastases).18F-FDG PET/CT imaging for diagnosis of blood vessel metastases of endometrial cancer,the sensitivity, specificity and accuracy were 87.5%(7/8),100%(19/19)and 95.2% (26/27) respectively.1.518F-FDG PET/CT imaging for endometrial cancer clinical treatment decisions27 cases patients of endometrial cancer,18F-FDG PET/CT imaging,44.4%(12/27) patients by PET/CT images clearly show the scope of tumor invasion or find metastases and amend or change the clinical decision making. For infringement of the cervical or vaginal poster medial endometrial carcinoma and fat the gap between the adjacent to the bladder, PET/CT change operation method in 5 cases. due to found the pelvic and abdominal aorta beside lymph node metastases in increased postoperative radiotherapy in 9 cases, by finding the distant organ metastases,8 cases change with the treatment plan. at the same time,18F-FDG PET/CT imaging of endometrial cancer and lung diffuse large B double carcinoma 1 cases of lymphoma, which change the treatment plan in time.1 cases of retroperitoneal lymph node metastases and 1 example of the primary lesions of endometrial cancer expansion of oppression urethra and renal pelvis and prompt clinical attention should be paid to protect renal function.2 cases(1 cases found no bone metastasis,1 cases found no ovaries infiltrating), the 18F-FDG PET/CT imaging was negative, then without prompt clinical stage changes.2.The follow-up group of endometrial cancer2.118F-FDG PET/CT imaging in the diagnosis of endometrial carcinoma postoperative recurrence and metastasis83 cases of postoperative patients with endometrial carcinoma,40 cases were confirmed by biopsy pathology and clinical follow-up for recurrence and metastasis, 16 cases confirmed by biopsy pathology, the rest of the 24 cases on the basis of laboratory test results, a variety of imaging examination and clinical long-term follow-up results of judgement.18F-FDG PET/CT imaging was positive 46 cases,6 cases false positive, imaging negative 28 cases and no false negative. in the 6 cases of false positive,2 cases of vaginal stump lesion (1 case of postoperative changes and 1 cases of inflammation). the other 4 cases respectively muscle metastases (neurofibromatosis),brain metastasis (transitional meningiomas), bone metastases (follow-up confirmed bone injury) and lymph node metastases (follow-up for lymph node inflammation). taking patients as the search unit,18F-FDG PET/CT imaging for endometrial cancer postoperative recurrence and metastasis diagnostic sensitivity, specificity, accurancy, positive predictive value and negative predictive value was 97.5%(39/40),82.4%(28/34),90.5%(67/74),86.7%(39/45) and 96.6% (28/29).there were 9 cases found a second primary lung cancer.7 cases were found after 2 years of the first primary cancer, with an average of 65 months, the other 2 cases 6 months and 9 months.7 cases confirmed by pathology,respectively,2 cases of gastric carcinoma,2 cases of lung cancer, pancreatic cancer and rectal sarcoma, ovarian serous papillary cystadenocarcinoma in 1 case, the rest 2 cases confirmed by a variety of imaging and clinical follow-up 2 months for pancreatic cancer and carcinoma of renal pelvis. taking patients as the search unit,18F-FDG PET/CT imaging for endometrial cancer postoperative malignant tumors (including the recurrence and metastasis and second primary cancer) diagnostic sensitivity, specificity, accurancy, positive predictive value and negative predictive value was 98.0%(48/49),82.4%(28/34),91.6%(76/83),88.9%(48/54) and 96.6% (28/29)2.2 vaginal stump recurrence in lesions74 cases of postoperative patients with endometrial cancer, confirmed by pathology and clinical follow-up of vaginal stump relapse in 11 cases,18F-FDG PET/CT imaging was 18 cases,7 cases of false positive (5 cases of postoperative changes and 2 cases of inflammation),imaging negative 56 cases and without false negative. vaginal stump lesion in 3 patients by Sammy promote row after lesions showed clearly.18F-FDG PET/CT imaging for detection sensitivity specificity and accuracy of vaginal stump recurrence in lesions were 91.7%(11/12),88.7%(55/62) and 89.2%(66/74).vaginal stump of recurrent lesions in SUVmax is 8.82±6.34.2.3 lymph node metastases74 cases of postoperative patients with endometrial cancer, confirmed by pathology and clinical follow-up with lymph node metastasis30 cases, with pelvic lymph node metastasis by 21 cases,12 cases for both the pelvic lymph node and the abdominal aorta,3 cases of inguinal lymph node metastasis, mediastinal lymph node 4 cases,6 patients with supraclavicular fossa lymph node metastasis and neck lymph node metastasis 3 cases.18F-FDG PET/CT imaging was 31 cases,l cases of false positive, confirmed by follow-up for supraclavicular lymph node caused by inflammation.4 cases of retroperitoneal region and 2 cases of common iliac blood vessels near the lymph node metastases invasion, oppression urethra obstruction.18F-FDG PET/CT imaging for detection sensitivity and specificity of lymph node metastasis were 93.5%(29/31),97.7%(42/43),95.9%(71/74),96.7% (29/30) and 95.5%(42/44).2.4 distant metastases74 cases of postoperative patients with endometrial cancer, confirmed by pathology and clinical follow-up with distant metastasis.30 cases, peritoneal metastasis 9 cases,12 cases pulmonary metastasis, bone metastasis in 11 cases, hepatic metastasis in 5 cases, muscle transfer 3 cases,1 cases spleen metastases,1 cases of adrenal metastasis, brain metastasis in 1 case, ovarian metastasis in 1 case, and renal transfer in 1 case. taking cases as the research unit,18F-FDG PET/CT imaging true positive 27 cases,4 cases were false positive, true negative 40 cases, false negative in 3 case.18F-FDG PET/CT imaging for distant metastases in the diagnosis of sensitivity, specificity were 90.0%(27/30)and 90.1%(40/44).4 cases of false positive lesion were respectively muscle inflammation, bone trauma, transitional meninggiomas and muscle nerve fibroma.3 false negative lesions of liver metastasis, lung metastasis and bone metastases,18F-FDG PET/CT imaging in false negative mainly related to the lesion is too small.2.5 The performance of 18F-FDG PET/CT imaging for detecting the relationship between endometrial cancer recurrence and metastasis lesions and CA125 results.33 (44.6%) patients has serum CA125 results before 18F-FDG PET/CT imaging. 12 cases with CA125 increased,10 cases with 18F-FDG PET/CT imaging detected one or more malignant lesions, and confirmed by clinical follow-up for tumor recurrence and metastasis.CA125 of the 21 patients within the normal range,PET/CT found positive lesions only 1 patients, confirmed by clinical and transfer for recurrence. In CA125 positive group and negative group, the positive rate of PET/CT were 83.3% vs.4.76%(chi-square=21.214 P=0.000),difference was statistically significant, the PET/CT in patients with elevated CA125 Positive rate is higher than no rise.[Conclusions]1.18F-FDG PET/CT can increase the accuracy of diagnosis and staging of endometrial cancer, and it is useful to make the more reasonable treatment plans2.18F-FDG PET/CT has obvious advantages for detecting the distant metastases3.For follow-up of patients with endometrial cancer,18F-FDG PET/CT imaging can be detected early recurrence and metastases, improve the prognosis of patients, ureteral obstruction in time at the same time, to prevent kidney damage.4.1nflammation and postoperative change is main causes of false positive in 18F-FDG PET/CT imaging. It should be paid attention during the diagnosis combined with related history, pay attention to identify tumor metastases and physiological concentration and inflammatory reaction caused by false positive lesions.5.18F-FDG PET/CT imaging helps detect double cancer of postoperative patients with endometrial carcinoma. |
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