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Diagnostic PET/CT for detecting malignant lymph nodes in patients with cervical cancer Stage IB1

Cervical cancer is the fourth most frequent cancer among women and a common cause of death in the female population [1]. Approximately 30% of patients with cervical cancer develop recurrent disease, most within two years after therapy completion [2]. After the initial diagnosis of cervical cancer, all patients treated at Rigshospitalet, University Hospital Copenhagen, Denmark underwent clinical staging under general anesthesia in accordance with the FIGO classification. Patients with greater than Stage 1A underwent a PET/CT scan to evaluate possible spread to lymph nodes and distant metastatic disease. Patients with Stage IB1 disease were usually surgically treated. If PET-positive lymph nodes were detected, a diagnostic laparoscopy was performed to remove the lymph nodes for histological examination. Nodal status is not included in the FIGO staging system, but was used for treatment guidance [3-5]. In the literature, FDG-PET was superior to conventional imaging methods for detecting metastatic lymph nodes and metastatic disease [6-9]. Tumor volume and lymph node involvement determined by FDG-PET were predictors of overall survival [10]. The presence of metastatic para-aortic lymph nodes was the most important prognostic factor for recurrence and death and generally indicated a poor prognosis. Postsurgical stage was a better indicator of prognosis than clinical FIGO stage [6, 8, 11-13]. PET/CT has been used at Rigshospitalet in cervical cancer for over ten years [14]. A retrospective study evaluated 65 selected cervical cancer (Stage IB-IVA) patients treated there from 2006 to 2011. They all underwent diagnostic laparoscopy due to PET-positive lymph nodes. Thirty-five percent of the patients had false-positive lymph nodes, indicating no sign of malignancy at conclusive histological examination [15]. The reason for false-positive results may be benign tumours (histiocytosis), infection, and inflammation. The female abdomen is difficult to evaluate due to FDG-activity in ovaries, ureters, and intestines [14]. The objective of this study was to evaluate results of initial PET/CT in patients with cervical cancer Stage IB1. The authors hypothesized that the positive predictive value was high, i.e. the rate of false-positive lymph nodes on PET/CT was low. The present authors believed that their skills improved with experience in the assessment of PET/CT.