Management of persistent post-treatment cervical FDG-avidity after definitive chemoradiation for locally advanced cervical cancer

Fluorodeoxyglucose positron emission tomography with computed tomography (FDG-PETCT) imaging is recommended to assess the response after completion of definitive chemoradiation for the treatment of locally advanced cervical cancer. False-positive residual avidity is common and may lead to further workup or interventions. We aim to describe a cohort of patients treated with definitive chemoradiation for locally advanced cervical cancer with cervical avidity on post treatment PETCT; in particular the patterns of cervical recurrence and concordance with PETCT FDG avidity. This is a retrospective review of patients between 2015–2021 at a safety-net hospital system who underwent definitive chemoradiation for stage IB2–IVA cervical cancer, underwent post-treatment PETCT, and had post-treatment avidity in the cervix. 145 patients were included, of which 79 (55%) patients had post-treatment avidity in the cervix. The median cervical standardized uptake value (SUV) measurement was 5. The work up of these 79 patients with residual cervical avidity varied including biopsy, repeat imaging, or placement on surveillance. 16 (20.5%) patients in the cohort ultimately were diagnosed with persistent or progressive disease. No patients with SUV <5 (49%) had persistent cervical disease. The majority of the recurrences were not detected until more than 11 months after treatment completion in our patient population Persistent cervical FDG-avidity is common after treatment with definitive chemoradiation for locally advanced cervical cancer. However, persistent disease is less common. To triage further work up, our data suggests that patients with SUV <5 are unlikely to have persistent cervical disease and can be considered for repeat imaging alone. Those with cervical SUV of 5 or higher could consider repeat biopsy or exam under anesthesia based on physical exam, versus close follow-up with repeat imaging. The average time to recurrence of almost 1 year makes close surveillance for the two years after treatment crucial.

Cervical cancer; Persistent FDG avidity; Chemoradiation

[1] Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians. 2021; 71: 209–249.

[2] Raut A, Chopra S, Mittal P, Patil G, Mahantshetty U, Gurram L, et al. FIGO classification 2018: validation study in patients with locally advanced cervix cancer treated with chemoradiation. International Journal of Radiation Oncology, Biology, Physics. 2020; 108: 1248–1256.

[3] National Comprehensive Cancer Network. Cervical cancer 2023. Available at: https://www.nccn.org/professionals/physician_gls/pdf/cervical.pdf (Accessed: 16 April 2023).

[4] Rosenbaum SJ, Lind T, Antoch G, Bockisch A. False-positive FDG PET uptake—the role of PET/CT. European Radiology. 2006; 16: 1054–1065.

[5] Chung HH, Jo H, Kang WJ, Kim JW, Park NH, Song YS, et al. Clinical impact of integrated PET/CT on the management of suspected cervical cancer recurrence. Gynecologic Oncology. 2007; 104: 529–534.

[6] Gandy N, Arshad MA, Park WE, Rockall AG, Barwick TD. FDG-PET imaging in cervical cancer. Seminars in Nuclear Medicine. 2019; 49: 461–470.

[7] Peters PN, Pierson WE, Chen LM, Westphalen AC, Chapman JS, Hsu IC. PET-detected asymptomatic recurrence is associated with improved survival in recurrent cervical cancer. Abdominal Radiology. 2021; 46: 341–350.

[8] Markus M, Sartor H, Bjurberg M, Trägårdh E. Metabolic parameters of [18F]FDG PET-CT before and after radiotherapy may predict survival and recurrence in cervical cancer. Acta Oncologica. 2023; 62: 180–188.

[9] Kim YJ, Han S, Kim YS, Nam JH. Prognostic value of post-treatment 18F-fluorodeoxyglucose positron emission tomography in uterine cervical cancer patients treated with radiotherapy: a systematic review and meta-analysis. Journal of Gynecologic Oncology. 2019; 30: e66.

[10] Michaan N, Wenkert A, Even-Sapir E, Kerzhner K, Rabin T, Safra T, et al. Prognostic significance of delayed complete metabolic response on PET/CT after primary chemoradiation treatment of cervical cancer. International Journal of Gynecologic Cancer. 2023; 33: 1695–1701.