Correlation Between FDG Uptake by PET/CT and the Expressions of Glucose Transporter Type 1 and Hexokinase II in Cervical Cancer

Tong, Seo-Yun MD,PhD*; Lee, Jong-Min MD,PhD*; Ki, Kyung-Do MD,PhD*; Choi, Young-Joon MD,PhD*; Seol, Hyun-Joo MD,PhD*; Lee, Seon-Kyung MD,PhD*; Huh, Chu-Yeop MD,PhD*; Kim, Gou-Young MD,PhD; Lim, Sung-Jig MD,PhD

International Journal of Gynecological Cancer:
doi: 10.1097/IGC.0b013e31824864e6
Cervical Cancer

Background: The aim of this study was to explore the association between 2-deoxy-2-F18-fluoro-D-glucose uptake and the expressions of glucose transporter type 1 (GLUT-1) and hexokinase II (HK-II) in the lymph nodes of patients with cervical cancer.

Methods: This prospective study included 20 women with International Federation of Gynecology and Obstetrics stage IB to stage IIA cervical cancer who underwent positron emission tomography (PET)–computed tomography (CT) (PET/CT) before surgical treatment. In 333 dissected lymph nodes (LNs) obtained, we examined the size, tumor involvement, and expressions of GLUT-1 and HK-II. These characteristics were compared with PET/CT and pathological findings.

Results: Pathological analysis found that 21% (70) of the 333 surgically dissected LNs were metastatic. Positron emission tomography/CT detected metastasis with 22.8% sensitivity and 98.5% specificity. The levels of GLUT-1 and HK-II expression in false-positive LNs were higher than those in pathologically confirmed negative nodes (P = 0.015 and P = 0.001, respectively). In metastatic LNs, PET/CT-positive nodes were significantly different from PET/CT-negative nodes in mean size (P = 0.043), tumor involvement (P = 0.008), and proportion of GLUT-1–positive tumor cells (P = 0.042).

Conclusions: Our results indicate that overexpression of GLUT-1 and HK-II may be related to 2-deoxy-2-F18-fluoro-D-glucose uptake in false-positive tissues on PET/CT. In metastatic lymph nodes, the ability of PET/CT to detect cancer may depend on tumor involvement, lymph node size, and GLUT-1 expression.

Author Information

*Department of Obstetrics and Gynecology, and †Department of Pathology, School of Medicine, Kyung Hee University, Seoul, South Korea.

Address correspondence and reprint requests to Jong-Min Lee, MD, PhD, Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, #149 Sangil-Dong, Gangdong-Gu, Seoul 134-727, Korea. E-mail:

This study was supported by the Kyung Hee University research fund in 2010 (KHU-20100767).

The authors declare no conflict of interest.

Received November 16, 2011

Accepted December 27, 2011

Article Outline

Uterine cervical cancer often disseminates via lymphatic spread. It is generally accepted that pelvic lymphadenectomy be conducted systematically at the time of radical hysterectomy, as it provides valuable prognostic information.1–3 Currently, cervical cancer is clinically staged according to International Federation of Gynecology and Obstetrics (FIGO) recommendations. Therefore, in the pretreatment evaluation, the detection of lymph node (LN) involvement and distant metastasis determines the prognosis and the course of treatment.4–6 Although computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and PET/CT are widely used pretreatments to detect metastatic LNs in patients with cervical cancer, recent studies have shown that PET and PET/CT have higher diagnostic significance than does CT or MRI.5,7–10

Positron emission tomography, which uses the glucose analog 2-deoxy-2-F18-fluoro-D-glucose (FDG), is a noninvasive functional imaging modality used to detect primary tumors, plan and monitor therapy, and detect metastasis and recurrence.11,12 The combination of PET with CT increases its specificity and helps localize hot spots through software imaging fusion. However, FDG uptake is not specific for malignancy and is less accurate in detecting lesions smaller than 1.5 cm.4,13

In cancer, higher FDG uptake compared to that of noncancerous cells has been attributed to increased metabolic turnover and increased glycolytic activity with up-regulation of glycolysis-associated genes.14 At the molecular level, expression of the facilitative glucose transporter (GLUT) proteins, especially GLUT-1, has been shown to be a good predictor of FDG uptake in various cancers, such as colorectal, lung, ovarian, and cervical cancers15–18; whereas GLUT-1 is undetectable in most normal epithelial tissues and benign epithelial tumors.19 Glucose phosphorylation enzyme type II (hexokinase II [HK-II]) is also known to be the most important subtype for glucose metabolism in cancer cells.20,21

In this study, our objectives were to determine whether GLUT-1 or HK-II expression is related to FDG uptake in lesions identified as false positive or false negative on PET/CT, in addition to the factors affecting these relationships. To pursue these objectives, we explored the association of FDG uptake with the expressions of GLUT-1 and HK-II in metastatic cervical cancer LNs, as well as LNs pathologically confirmed as negative.

Back to Top | Article Outline


Back to Top | Article Outline

This prospective study involved 20 women with histopathologically confirmed FIGO stage IB to stage IIA invasive cervical cancer, as determined by a conventional workup that included pelvic and rectovaginal examination, routine laboratory testing, chest radiography, cystoscopy, and sigmoidoscopy. All patients underwent a preoperative workup, including both MRI and PET/CT scans. The patients were recruited between June 2007 and May 2009, and they ranged in age from 32 to 68 years (mean, 49 years). The patients had no contraindications to the surgical procedure, had no evidence of distant metastases, and had a Gynecological Oncology Group (GOG) performance status of 0 to 1. We excluded those women who did not want to undergo preoperative PET/CT (n = 4). The institutional review board of our institute approved the study protocol, and informed consent was obtained from all patients participating in the study.

Back to Top | Article Outline

Positron emission tomography/CT was performed on a dual-slice Philips Gemini System (Philips, Eindhoven, The Netherlands). After the patients had fasted for at least 6 hours, 4.0-MBq/kg body weight of fluorine-18-fluorodeoxyglucose (18F-FDG) was administered at a normal blood glucose level. A low-dose CT scan was acquired for attenuation correction at a 120-kV tube potential with 30 mA s current, covering a range from the skull base to the thighs. Positron emission scans were acquired with a 15.5-cm field of view for 3 minutes per table position using a 3-dimensional acquisition mode, and an average of 8 to 10 table positions were required to cover the range. The subsequent diagnostic CT scan was acquired during a single breath-hold of 70 seconds after administration of 120 mL of nonionic contrast material (Ultravist, 623 mg/mL of Iopromide, Bayer Schering, Berlin, Germany) at a tube current of 160 mA s. Positron emission tomography data were reconstructed with attenuation correction, and both CT and PET data were reconstructed in 5-mm slices. Computed tomography and PET data sets were reviewed on a postprocessing workstation in axial, coronal, and sagittal orientations and were fused with a color-coded superimposition of the PET onto the CT image.

Back to Top | Article Outline
Image Analysis

The images were preoperatively reviewed by an experienced nuclear medicine physician. The presence of abnormally increased FDG uptake was noted, and its exact anatomic location was indicated on the CT. In the report, the readers indicated the presence or absence of elevated specific uptake values, which increase the suspicion of distant metastases. Positron emission tomography/CT images were interpreted as negative when no areas of abnormal FDG uptake were seen. The presence of abnormal FDG uptake was indicated when accumulation of the tracer was moderately to markedly increased relative to the uptake in comparable normal structures or surrounding tissue, with the exclusion of physiological bowel, vessel, and urinary activity. The classification of LNs on PET/CT images as cancer positive was based on the presence of focally increased FDG uptake on the PET images in a location that corresponded to an LN chain on the CT images. Lymph nodes with increased tracer uptake were considered positive for metastasis, even if they were smaller than 1 cm in the short-axis diameter.

Back to Top | Article Outline
Surgical Technique

All patients underwent surgery with the same instruments and techniques performed by 2 experienced gynecologic oncologists with knowledge of the PET/CT results. All patients underwent radical hysterectomy with pelvic and para-aortic lymphadenectomy. All harvested LNs were grouped according to the name of the adjacent vessel (abdominal aorta, both common iliac arteries, both external iliac arteries, and both internal iliac and obturator arteries). For nodal matching, each surgical specimen was labeled according to site and side.

Back to Top | Article Outline
Immunohistochemical Staining for GLUT-1 and HK-II

The surgical specimens were fixed in buffered formalin and embedded in paraffin, and sections 3-μm in thickness were stained with hematoxylin and eosin in an autostainer (Bond MAX, Vision BioSystems Ltd, Mount Waverley, Australia). Formalin-fixed, paraffin-embedded tissue sections were immunostained with rabbit anti–GLUT-1 polyclonal antibody (1:50, Neomarkers, Fremont, CA) and goat anti–HK-II antibody (1:100, Santa Cruz Biotechnology, Santa Cruz, CA).

Back to Top | Article Outline
Evaluation of Stained Sections

Cancer involvement, the sizes of individual LNs (millimeter), and tumor proportions (percent) within LNs were assessed. The proportions (percent) of GLUT-1– and HK-II–positive tumor cells in tumors and normal tissue were also simultaneously evaluated by an experienced pathologist. Staining intensities were graded as follows: zero, negative; 1, weak; 2, medium; and 3, intense. The staining intensity of red blood cells was defined as grade 3.

Back to Top | Article Outline
Statistical Analysis

We performed node-based analyses and calculated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy using standard statistical formulas. Independent Student t tests were used to compare the sizes of LNs, the tumor proportions within LNs, and the proportions of immunostain-positive cells in tumor and normal tissues. The Mann-Whitney nonparametric 2-sample test was used to assess differences in the staining grades of both GLUT-1 and HK-II. All statistical analyses were performed using SPSS version 12.0 and were considered significant at P < 0.05.

Back to Top | Article Outline


Table 1 summarizes the characteristics of patients in this study. Of the 20 patients, 16 had a diagnosis of squamous cell carcinoma, 3 patients had adenocarcinoma, and the remaining patient had a diagnosis of adenosquamous cell carcinoma. Clinical FIGO stage was IB1 in 6 patients, IB2 in 9 patients, and IIA in 5 patients. On histopathological analysis, 70 of the 333 LNs were positive for metastasis. For LN metastasis, PET/CT was true positive in 16 of the 70 metastatic nodes and true negative in 259 of the 263 nonmetastatic nodes. Thus, the overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of PET/CT on node-based analysis were 22.8%, 98.5%, 80%, 82.7%, and 82.6%, respectively (Table 2).

We analyzed the patterns of GLUT-1 and HK-II expression in both the cell membrane and cytoplasm (Fig. 1). In cancer cells, positive staining was present mainly around the necrotic area; the intensity of expression was heterogeneous within the tumor. The mean percentage of GLUT-1–positive cells in pathologically confirmed negative LNs was higher in PET-positive nodes than it was in PET-negative nodes (mean [SD]; 3.75% [2.99%] vs. 1.01% [2.2%]; P = 0.015). Similarly, the mean percentage of HK-II-positive cells in pathologically negative LNs was higher in PET-positive nodes than it was in PET-negative nodes (mean [SD]; 2.25% [1.5%] vs. 0.72% [0.94%], P = 0.001). However, the mean staining intensities of GLUT-1 and HK-II in pathologically negative nodes were not significantly different between PET-positive and PET-negative nodes (Table 3).

In LNs pathologically proven as metastatic, there were statistically significant differences between PET-negative and PET-positive LNs in size, tumor involvement (percent), and percentage of GLUT-1–positive cells (Table 4). The LN diameters of PET-negative and PET-positive nodes were 8.22 and 11.88 mm, respectively (P = 0.043). The proportion of tumor cells was 40.0% and 63.75% in PET-negative and PET-positive nodes, respectively (P = 0.008). The mean percentage of GLUT-1-positive tumor cells was higher in PET-positive nodes than it was in PET-negative nodes (P = 0.042). The mean GLUT-1 staining intensity was greater in PET-positive nodes than it was in PET-negative nodes, although the difference was not statistically significant (P = 0.052). However, no significant difference was observed between FDG uptake and HK-II expression in pathologically confirmed metastatic LNs.

Back to Top | Article Outline


A recent meta-analysis by Choi et al10 reported that PET and PET/CT had higher diagnostic performances than did CT or MRI in detecting metastatic LNs in patients with cervical cancer. However, FDG uptake is not specific to cancer and can be taken up by some benign tumors, infections, inflammatory cells, and normal tissue. Images of the abdomen and female pelvis can be especially difficult to interpret owing to FDG uptake in the ovaries, intestines, and ureters.In addition, false-negative analysis may result from small metastaticLNs or micrometastases.22 Although the image fusion of function and anatomy in a PET/CT scan increases the diagnostic accuracy, pitfalls still exist.23,24

2-Deoxy-2-F18-fluoro-D-glucose uptake in cancer cells is associated with the following: (1) facilitated diffusion through glucose transport proteins, (2) subsequent phosphorylation by HK isoforms that produce FDG-6-phosphate, and (3) decreased dephosphorylation.25 Therefore, the association between FDG uptake and the expressions of GLUT-1 and HK-II has been evaluated in many other cancers, such as lung cancer,25 cholangiocellular carcinoma,26 lymphoma,27 pancreatic cancer,28 ovarian cancer,18 and cervical cancer.17

Our study found that false-positive LNs on PET/CT had higher percentages of GLUT-1– and HK-II–positive cells than did true-negative LNs. However, the expressions of GLUT-1 and HK-II were significantly lower in pathologically negative LNs than those in metastatic LNs. About metastatic LNs, PET/CT-positive nodes had a higher proportion of GLUT-1–positive cells and stronger GLUT-1 staining intensity than did PET/CT-negative nodes, whereas HK-II expression was not correlated with FDG uptake. These results suggest that GLUT-1 plays a role in FDG uptake on PET/CT evaluation in cervical cancer. In addition, the mean tumor size was significantly larger in PET/CT-positive nodes than it was in PET/CT-negative metastatic LNs. Finally, tumor involvement was significantly higher in PET/CT-positive nodes than in PET/CT-negative metastatic LNs (64% vs 40%; P = 0.008). This suggests that tumor involvement is an important factor associated with the PET/CT positivity of metastatic LNs in cervical cancer.

This study has several limitations. First, the surgicopathological localization of PET/CT-positive LNs is difficult. We attempted to minimize this limitation by adopting a mapping system for LN classification.8 Second, our results show a lower sensitivity (22.8%) for PET/CT compared to that in a previously reported meta-analysis (54%).10 It has been reported that PET/CT has low sensitivity in LN evaluation of patients with early-stage cervical cancer (FIGO stage ≤IB1)4 and high false-negative rates with small or early nodal involvement.8,29 Although the sensitivity was not different between stage IB and IIA in this study, compared to previous reports,29,30 our study had smaller negative LNs (mean [SD] size, 6.68 [4.98] mm) and metastatic LNs (mean [SD] size, 9.06 [6.37] mm), which may explain the low sensitivity of PET/CT.

In conclusion, the positivity of PET/CT in metastatic LNs of cervical cancer was related to the node size, tumor involvement, and GLUT-1 expression.

Back to Top | Article Outline


1. Girardi F, Pickel H, Winter R. Pelvic and parametrial lymph nodes in the quality control of the surgical treatment of cervical cancer. Gynecol Oncol. 1993; 50: 330–333.
2. Sakuragi N, Satoh C, Takeda N, et al.. Incidence and distribution pattern of pelvic and paraaortic lymph node metastasis in patients with stages IB, IIA, and IIB cervical carcinoma treated with radical hysterectomy. Cancer. 1999; 85: 1547–1554.
3. Lee JM, Lee KB, Lee SK, et al.. Pattern of lymph node metastasis and the optimal extent of pelvic lymphadenectomy in FIGO stage IB cervical cancer. J Obstet Gynaecol Res. 2007; 33: 288–293.
4. Magne N, Chargari C, Vicenzi L, et al.. New trends in the evaluation and treatment of cervix cancer: the role of FDG-PET. Cancer Treat Rev. 2008; 34: 671–681.
5. Son H, Kositwattanarerk A, Hayes MP, et al.. PET/CT evaluation of cervical cancer: spectrum of disease. Radiographics. 2010; 30: 1251–1268.
6. Lee DW, Kim YT, Kim JH, et al.. Clinical significance of tumor volume and lymph node involvement assessed by MRI in stage IIB cervical cancer patients treated with concurrent chemoradiation therapy. J Gynecol Oncol. 2010; 21: 18–23.
7. Sugawara Y, Eisbruch A, Kosuda S, et al.. Evaluation of FDG PET in patients with cervical cancer. J Nucl Med. 1999; 40: 1125–1131.
8. Choi HJ, Roh JW, Seo SS, et al.. Comparison of the accuracy of magnetic resonance imaging and positron emission tomography/computed tomography in the presurgical detection of lymph node metastases in patients with uterine cervical carcinoma: a prospective study. Cancer. 2006; 106: 914–922.
9. Kim SK, Choi HJ, Park SY, et al.. Additional value of MR/PET fusion compared with PET/CT in the detection of lymph node metastases in cervical cancer patients. Eur J Cancer. 2009; 45: 2103–2109.
10. Choi HJ, Ju W, Myung SK, et al.. Diagnostic performance of computer tomography, magnetic resonance imaging, and positron emission tomography or positron emission tomography/computer tomography for detection of metastatic lymph nodes in patients with cervical cancer: meta-analysis. Cancer Sci. 2010; 101: 1471–1479.
11. Oriuchi N, Higuchi T, Ishikita T, et al.. Present role and future prospects of positron emission tomography in clinical oncology. Cancer Sci. 2006; 97: 1291–1297.
12. Gambhir SS. Molecular imaging of cancer with positron emission tomography. Nat Rev Cancer. 2002; 2: 683–693.
13. Grigsby PW. The contribution of new imaging techniques in staging cervical cancer. Gynecol Oncol. 2007; 107 (1 suppl 1): S10–S12.
14. Pauwels EK, Sturm EJ, Bombardieri E, et al.. Positron emission tomography with [18F]fluorodeoxyglucose. Part I. Biochemical uptake mechanism and its implication for clinical studies. J Cancer Res Clin Oncol. 2000; 126: 549–559.
15. Gu J, Yamamoto H, Fukunaga H, et al.. Correlation of GLUT-1 overexpression, tumor size, and depth of invasion with 18F-2-fluoro-2-deoxy-D-glucose uptake by positron emission tomography in colorectal cancer. Dig Dis Sci. 2006; 51: 2198–2205.
16. de Geus-Oei LF, van Krieken JH, Aliredjo RP, et al.. Biological correlates of FDG uptake in non–small cell lung cancer. Lung Cancer. 2007; 55: 79–87.
17. Yen TC, See LC, Lai CH, et al.. 18F-FDG uptake in squamous cell carcinoma of the cervix is correlated with glucose transporter 1 expression. J Nucl Med. 2004; 45: 22–29.
18. Kurokawa T, Yoshida Y, Kawahara K, et al.. Expression of GLUT-1 glucose transfer, cellular proliferation activity and grade of tumor correlate with [F-18]-fluorodeoxyglucose uptake by positron emission tomography in epithelial tumors of the ovary. Int J Cancer. 2004; 109: 926–932.
19. Younes M, Lechago LV, Somoano JR, et al.. Wide expression of the human erythrocyte glucose transporter Glut1 in human cancers. Cancer Res. 1996; 56: 1164–1167.
20. Mathupala SP, Rempel A, Pedersen PL. Aberrant glycolytic metabolism of cancer cells: a remarkable coordination of genetic, transcriptional, post-translational, and mutational events that lead to a critical role for type II hexokinase. J Bioenerg Biomembr. 1997; 29: 339–343.
21. Haberkorn U, Ziegler SI, Oberdorfer F, et al.. FDG uptake, tumor proliferation and expression of glycolysis associated genes in animal tumor models. Nucl Med Biol. 1994; 21: 827–834.
22. Chung HH, Kang KW, Cho JY, et al.. Role of magnetic resonance imaging and positron emission tomography/computed tomography in preoperative lymph node detection of uterine cervical cancer. Am J Obstet Gynecol. 2010; 203: 156 e151–156 e155.
23. Subhas N, Patel PV, Pannu HK, et al.. Imaging of pelvic malignancies with in-line FDG PET-CT: case examples and common pitfalls of FDG PET. Radiographics. 2005; 25: 1031–1043.
24. Loft A, Berthelsen AK, Roed H, et al.. The diagnostic value of PET/CT scanning in patients with cervical cancer: a prospective study. Gynecol Oncol. 2007; 106: 29–34.
25. Mamede M, Higashi T, Kitaichi M, et al.. [18F]FDG uptake and PCNA, Glut-1, and Hexokinase-II expressions in cancers and inflammatory lesions of the lung. Neoplasia. 2005; 7: 369–379.
26. Paudyal B, Oriuchi N, Paudyal P, et al.. Expression of glucose transporters and hexokinase II in cholangiocellular carcinoma compared using [18F]-2-fluro-2-deoxy-D-glucose positron emission tomography. Cancer Sci. 2008; 99: 260–266.
27. Shim HK, Lee WW, Park SY, et al.. Expressions of glucose transporter types 1 and 3 and hexokinase-II in diffuse large B-cell lymphoma and other B-cell non-Hodgkin’s lymphomas. Nucl Med Biol. 2009; 36: 191–197.
28. Higashi T, Tamaki N, Honda T, et al.. Expression of glucose transporters in human pancreatic tumors compared with increased FDG accumulation in PET study. J Nucl Med. 1997; 38: 1337–1344.
29. Park W, Park YJ, Huh SJ, et al.. The usefulness of MRI and PET imaging for the detection of parametrial involvement and lymph node metastasis in patients with cervical cancer. Jpn J Clin Oncol. 2005; 35: 260–264.
30. Wright JD, Dehdashti F, Herzog TJ, et al.. Preoperative lymph node staging of early-stage cervical carcinoma by [18F]-fluoro-2-deoxy-D-glucose-positron emission tomography. Cancer. 2005; 104: 2484–2491.

Cervical cancer; Lymph node metastasis; PET/CT; Glucose transporter 1; Hexokinase II

Copyright © 2012 by IGCS and ESGO