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Background  The low sensitivity of F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) for the evaluation of metastatic lymph nodes (LNs) is mainly due to the partial volume effect in patients with rectal cancer. This retrospective study evaluated the diagnostic accuracy of F-18 FDG PET/CT with optimal cut-off values of the maximum standardized uptake value (SUV max ), according to LN size, for the evaluation of regional LN in rectal cancer patients.    Methods  This study included 176 patients with rectal cancer who underwent F-18 FDG PET/CT for initial staging. Patients were classified based on the long-axis diameter of the regional LN on CT images as small (≤ 7 mm;  n  = 118) and large (> 7 mm;  n  = 58) LN groups. The optimal cut-off value of SUV max  was determined for each group, using receiver operating characteristic curve analysis. Areas under the curve (AUC) were compared by C-statistics using two methods: the cut-off value of SUV max  optimized according to LN size, and a fixed SUV max  cut-off value of 2.5.    Results  The optimal cut-off values of SUV max  for the small and large LN groups were 1.1, and 2.1, respectively. The sensitivity, specificity, and accuracy of F-18 FDG PET/CT using the optimal cut-off values were 90.6, 70.9, and 76.3% in the small LN group, and 68.6, 78.3, and 72.4% in the large LN group. The sensitivity, specificity, and accuracy of F-18 FDG PET/CT using the fixed cut-off value were 18.8, 100, and 78.0% in the small LN group, and 51.4, 87.0, and 65.5% in the large LN group. The AUC was significantly higher using the optimal cut-off values than the fixed cut-off value (0.808 vs. 0.594,  p  = 0.005) in the small LN group, but not in the large LN group (0.734 vs. 0.692,  p  = 0.429).    Conclusions  Application of the lower cut-off value of SUV max  improves the diagnostic performance of F-18 FDG PET/CT for the evaluation of small regional LNs in patients with rectal cancer.    Electronic supplementary material  The online version of this article (10.1186/s40644-018-0165-5) contains supplementary material, which is available to authorized users.

cancer imaging

Accuracy of F-18 FDG PET/CT with optimal cut-offs of maximum standardized uptake value according to size for diagnosis of regional lymph node metastasis in patients with rectal cancer