Abstract
Hypoxia in cervical cancer has been associated with a poor prognosis. Over the years 68Ga labelled nitroimidazoles have been studied and have shown improved kinetics. We present our initial experience of hypoxia Positron Emission Tomography (PET) imaging in cervical cancer with 68Ga-Nitroimidazole derivative and the correlation with 18F-FDG PET/CT and immunohistochemistry. Twenty women with cervical cancer underwent both 18F-FDG and 68Ga-Nitroimidazole PET/CT imaging. Dual-point imaging was performed for 68Ga-Nitroimidazole PET. Immunohistochemical analysis was performed with hypoxia inducible factor-1α (HIF-1α). We documented SUVmax, SUVmean of the primary lesions as well as tumor to muscle ratio (TMR), tumor to blood (TBR), metabolic tumor volume (MTV) and hypoxic tumor volume (HTV). There was no significant difference in the uptake of 68Ga-Nitroimidazole between early and delayed imaging. Twelve patients had uptake on 68Ga-Nitroimidazole PET. Ten patients demonstrated varying intensities of HIF-1α expression and six of these also had uptake on 68Ga-Nitroimidazole PET. We found a strong negative correlation between HTV and immunohistochemical staining (r = −0.660; p = 0.019). There was no correlation between uptake on PET imaging and immunohistochemical analysis with HIF-1α. Two-thirds of the patients demonstrated hypoxia on 68Ga-Nitroimidazole PET imaging.
Highlights
Despite widespread awareness programs and improvements in screening, cervical cancer continues to be a major cause of morbidity and mortality amongst women in lowand middle-income states [1]
Most patients were referred for a scan with an initial clinical impression of locally advanced disease, some of the patients were upstaged by the 18 F-FDG Positron Emission Tomography (PET)/CT
When considering the hypoxia score, we found that five of the seven patients considered positive for hypoxia on immunohistochemistry, displayed uptake above background on the 68 Ga-Nitroimidazole scan
Summary
Despite widespread awareness programs and improvements in screening, cervical cancer continues to be a major cause of morbidity and mortality amongst women in lowand middle-income states [1]. Some of the challenges related to the management include late presentation, access to treatment and poor response to therapy [2,3]. Hypoxia is a common phenomenon linked to resistance to most forms of therapy in various malignancies including cervical cancer [4,5,6,7]. Strategies to overcome hypoxia have been the subject of investigations over the years as treatment becomes more personalized. Several methods have been implemented to try and overcome hypoxia including intensity modulated radiation therapy (IMRT) which is closely linked to dose-painting, and hypoxia sensitizing drugs [10,11]. Detection of hypoxia in cancer lesions may help aid treatment planning
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