A comprehensive review of anatomy, pathways of metastatic spread and scan findings

1. FDG PET/CT Utility in Gynecologic Malignancies: A comprehensive review of
anatomy, pathways of metastatic spread and scan findings
Nicholas Plaxton, MD1 , Aruna Polsani, MD1, Raghuveer Halkar, MD1, Karen Godette, MD1 , Barron, Bruce, MD1,2
1Emory University School of Medicine, 2 Atlanta Veterans Affairs Medical Center
LEARNING OBJECTIVES PELVIC ANATOMY CERVICAL OVARIAN ENDOMETRIAL VAGINAL
Uterine fundus • 150,000 Deaths annually • 2nd most common gynecological cancer
1. Pictorial review of clinical features of major • Most common gynecological cancer • Cervical cancer extension or recurrence into
Fallopian tube  4000 in US • Most common death from gynecologic cancer
gynecologic cancers including cervical, • 142,000 women per year the vagina is most common tumor
ovarian, endometrial, vaginal, and vulvar
Infundibulum
Fimbria  11,000 new cases in US • 22,000 new cases and 14,000 deaths in US • 4TH most common malignancy in US women • Primary vaginal cancer is less than 3% of all
Ovary
• PET/CT is more accurate in assessing nodal • Nonspecific symptoms – bloating, distention
malignancies and demonstrate the role of Uterine Body • Most cases in post menopause gynecological malignancies
Ascending branch of uterine artery
spread than CT and MRI (sensitivity 89% vs 39%) • 75 % present with stage III or IV disease
FDG PET/CT. Internal iliac • Highest incidence in 7TH decade of life • Squamous type (HPV , 60 – 80 yrs)
artery
• SUV negatively correlates to treatment response • Residual tumor > 2cm survival of 12-16 months • Abnormal uterine bleeding common symptom • Adenocarcinoma type ( DES use, 12 – 30 yrs)
Cervix Uterine artery
External Os • Positive PET has positive predictive value of 90% • Tumor < 2 cm survival is 40-45 months
2. Illustrate and correlate anatomic and Vaginal branch of uterine artery
• 5 year survival 80% • Lymphatic spread in distal 1/3 to inguinal nodes
Vaginal canal • PET has high rate of false negatives • Debulking surgery is mainstay of treatment
conventional imaging features of • Dependent on stage, myometrial involvement • Lymphatic spread in proximal 2/3 to pelvic and
• Limited sensitivity in early stage IA and IIA • Preoperative imaging achieves optimal debulking
gynecologic malignancies. and histological type para-arotic nodes (PALN)
• Try to minimize urine FDG activity (Foley, voiding) • PET improves accuracy in staging
Coronal Illustration • Poor prognosis in advanced or recurrent disease
• Primary spread of tumor via lymph node paths • Staging concordant with clinical pathology in 69%
3. Demonstrate the integration of FIGO 1. obturator, internal iliac, external iliac, and common iliac
• Lymphatic spread to pelvic or para-arotic nodes
scoring and treatment planning to improve 2. direct to common iliac
for PET vs. 53% for CT • Hematogenous spread to lung, liver, bones or
accuracy of staging. 3. common iliac, pre-sacral and para-arotic • Mucinous type represents 12-15% of ovarian vagina
Perimetrium • Inguinal /axillary nodes reactive in HIV, not mets cancers and usual is not FDG avid
INTRODUCTION Myometrium
Rectouterine pouch
• Liver metastasis in a third of recurrent disease • Ovarian cancer tends to spread via peritoneal
Vaginal metastasis before and after treatment
Cervix of Douglas
In the United States in 2007,* 80,976 women Fundus
Endometrium
Body
were diagnosed with gynecologic cancer, and
27,739 succumbed to the disease. Our Vesicouterine pouch
of Meiring
objective was to review the five major
gynecologic cancers (cervical, ovarian, Primary uterine cancer
T2 Weighted MRI pelvis Virchow’s Node
uterine, vaginal, and vulvar) and demonstrate
the role of FDG PET/CT in diagnosis,
surveillance, FIGO staging and treatment Cervical cancer with pyometra Bilateral Ovarian Cancer Vaginal melanoma Vaginal cancer
strategy. We selected FDG PET/CT cases
done at Emory University with strong key
Right ovary
with cysts Left ovary
VULVAR
Internal iliac artery
• 4% all women genital cancers originate in vulva
Right internal
representative findings for each of these iliac artery Left iliacus muscle
gynecological cancers for presentation. • 2/100,000 women per year
Psoas muscle
Endometrial cancer with malignant effusion • 40-60% in premenopause associated with HPV
Understanding of key findings in
gynecological malignancies is crucial for early • HPV negative more common in post-menopausal
diagnosis, treatment strategy and assessment • Growth and infiltration with direct involvement of
of treatment response. the vagina, urethra, perineum, and /or anus
Upper pelvis axial CT with contrast
• Lymphatic spread to inguinal and femoral nodes
CONTACT Sister Mary Peritoneal Caking • 1-7% involve Bartholin’s gland
Solitary Cervical cancer with Joseph node • FIGO changes based on invasion and size and
Nicholas A. Plaxton M.D. hepatic obstructed os the number of involved lymph nodes
Depart of Radiology and Imaging Sciences External iliac artery metastasis • FDG PET sens and spec of 80 and 90%
Division of Nuclear Medicine • More accurate in detecting extranodal metastases
Round ligaments
Email: nickplaxton@emory.edu Planning Target Volume for
Phone: 404 712 4868 External iliac vein
radiation treatment
Bladder
References and FIGO classification available Uterus
upon request.
Thanks to Eric Jablonowski for illustration. Lower pelvis axial CT with contrast
Poster Design & Printing by Genigraphics® - 800.790.4001
Cervical cancer with HIV and lymphadenapathy Peritoneal Implants Endometrial cancer with multiple metastases Vulvar cancer