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Combining positron emission tomography/computed tomography, radiomics, and sentinel lymph node mapping for nodal staging of endometrial cancer patients
  1. Cinzia Crivellaro1,
  2. Claudio Landoni1,2,
  3. Federica Elisei1,
  4. Alessandro Buda3,
  5. Manuela Bonacina4,
  6. Tommaso Grassi3,
  7. Lavinia Monaco4,
  8. Daniela Giuliani3,
  9. Irene Gotuzzo4,
  10. Sonia Magni4,
  11. Giampaolo Di Martino3,
  12. Martina Delle Marchette4,
  13. Luca Guerra1,2,
  14. Fabio Landoni2,3,
  15. Robert Fruscio2,3,
  16. Cristina Messa4,5 and
  17. Elisabetta De Bernardi2
  1. 1Nuclear Medicine Department, ASST di Monza San Gerardo Hospital, Monza, Lombardia, Italy
  2. 2School of Medicine and Surgery, University of Milan-Biocca, Monza, Lombardia, Italy
  3. 3Gynaecologic Oncology Surgical Unit, Obstetrics and Gynaecology Department, ASST-Monza, San Gerardo Hospital, Milano, Lombardia, Italy
  4. 4University of Milan–Bicocca, Milano, Lombardia, Italy
  5. 5Tecnomed Foundation, University of Milan–Bicocca, Milano, Lombardia, Italy
  1. Correspondence to Dr Cinzia Crivellaro, Nuclear Medicine, ASST di Monza, Monza, Lombardia 20900, Italy; cinzia.crivellaro{at}


Objective To evaluate the combination of positron emission tomography/computed tomography (PET/CT) and sentinel lymph node (SLN) biopsy in women with apparent early-stage endometrial carcinoma. The correlation between radiomics features extracted from PET images of the primary tumor and the presence of nodal metastases was also analyzed.

Methods From November 2006 to March 2019, 167 patients with endometrial cancer were included. All women underwent PET/CT and surgical staging: 60/167 underwent systematic lymphadenectomy (Group 1) while, more recently, 107/167 underwent SLN biopsy (Group 2) with technetium-99m +blue dye or indocyanine green. Histology was used as standard reference. PET endometrial lesions were segmented (n=98); 167 radiomics features were computed inside tumor contours using standard Image Biomarker Standardization Initiative (IBSI) methods. Radiomics features associated with lymph node metastases were identified (Mann-Whitney test) in the training group (A); receiver operating characteristic (ROC) curves, area under the curve (AUC) values were computed and optimal cut-off (Youden index) were assessed in the test group (B).

Results In Group 1, eight patients had nodal metastases (13%): seven correctly ridentified by PET/CT true-positive with one false-negative case. In Group 2, 27 patients (25%) had nodal metastases: 13 true-positive and 14 false-negative. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of PET/CT for pelvic nodal metastases were 87%, 94%, 93%, 70%, and 98% in Group 1 and 48%, 97%, 85%, 87%, and 85% in Group 2, respectively. On radiomics analysis a significant association was found between the presence of lymph node metastases and 64 features. Volume-density, a measurement of shape irregularity, was the most predictive feature (p=0001, AUC=0,77, cut-off 0.35). When t

esting cut-off in Group B to discriminate metastatic tumors, PET false-negative findings were reduced from 14 to 8 (-43%).

Conclusions PET/CT demonstrated high specificity in detecting nodal metastases. SLN and histologic ultrastaging increased false-negative PET/CT findings, reducing the sensitivity of the technique. PET radiomics features of the primary tumor seem promising for predicting the presence of nodal metastases not detected by visual analysis.

  • endometrial neoplasms
  • sentinel lymph node

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  • CC and CL are joint first authors.

  • Editor's note This paper will feature in a special issue on sentinel lymph node mapping in 2020.

  • Contributors CC, EDeB, AB: data analysis and draft preparation. FE, LG, CL: evaluation of PET/CT images. LM, TG, DG, SM, MDelle M, GDiM: surgery and data collection. MB, IG: data analysis. RF, FL, CM: manuscript revision.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.