Staging of advanced ovarian cancer: comparison of imaging modalities--report from the Radiological Diagnostic Oncology Group

Applying Quantitative CT Image Feature Analysis to Predict Response of Ovarian Cancer Patients to Chemotherapy

RATIONALE AND OBJECTIVES

The study aimed to investigate the role of applying quantitative image features computed from computed tomography (CT) images for early prediction of tumor response to chemotherapy in the clinical trials for treating ovarian cancer patients.

MATERIALS AND METHODS

A dataset involving 91 patients was retrospectively assembled. Each patient had two sets of pre- and post-therapy CT images. A computer-aided detection scheme was applied to segment metastatic tumors previously tracked by radiologists on CT images and computed image features. Two initial feature pools were built using image features computed from pre-therapy CT images only and image feature difference computed from both pre- and post-therapy images. A feature selection method was applied to select optimal features, and an equal-weighted fusion method was used to generate a new quantitative imaging marker from each pool to predict 6-month progression-free survival. The prediction accuracy between quantitative imaging markers and the Response Evaluation Criteria in Solid Tumors (RECIST) criteria was also compared.

RESULTS

The highest areas under the receiver operating characteristic curve are 0.684 ± 0.056 and 0.771 ± 0.050 when using a single image feature computed from pre-therapy CT images and feature difference computed from pre- and post-therapy CT images, respectively. Using two corresponding fusion-based image markers, the areas under the receiver operating characteristic curve significantly increased to 0.810 ± 0.045 and 0.829 ± 0.043 (P < 0.05), respectively. Overall prediction accuracy levels are 71.4%, 80.2%, and 74.7% when using two imaging markers and RECIST, respectively.

CONCLUSIONS

This study demonstrated the feasibility of predicting patients' response to chemotherapy using quantitative imaging markers computed from pre-therapy CT images. However, using image feature difference computed between pre- and post-therapy CT images yielded higher prediction accuracy.

Peritoneal Carcinomatosis in Primary Ovarian Cancer: Ultrasound Detection and Comparison with Computed Tomography

We retrospectively compared detection rates and consistency for diagnosis of peritoneal carcinomatosis (PC) of primary ovarian cancer (OC) between ultrasound (US) and computed tomography (CT) scans in 41 patients whose PC of OC (stages IIC-IV) had been diagnosed by histopathology findings. Compared with CT detection rates, those for US were significantly higher for metastases to the pelvic area (92.3% vs. 43.6%, p < 0.001) and bowel surface (64.0% vs. 16.0%, p = 0.002); however, they did not significantly differ for other sites: omentum, diaphragm, lateral peritoneum, mesenteric, hepatic and splenic surfaces. Diagnostic consistency between US and CT scans were fair to moderate for splenic (κ = 0.806), hepatic (κ = 0.485), lateral peritoneum (κ = 0.450) and diaphragm (κ = 0.338) surfaces, but poorly consistent for other parts (κ = 0.144-0.229). In summary, US can complement CT scans, especially for detecting PC of primary OC metastases in pelvic and bowel surfaces.

Advanced Primary Epithelial Ovarian and Peritoneal Carcinoma-Does Diagnostic Accuracy of Preoperative CT Scan for Detection of Peritoneal Metastatic Sites Reflect into Prediction of Suboptimal Debulking? A Prospective Study

Ovarian cancer is the seventh most common cancer in females worldwide. Optimal debulking is the standard treatment but possible only in 30-85% of advanced stages. Knowing exactly the disease extent preoperatively may predict suboptimal debulking. We analyzed diagnostic accuracy of preoperative CT scan in disease mapping and prediction of suboptimal debulking in a prospective observational study from March 2013 to May 2015 in a tertiary hospital. Adults below the age of 75 years with ECOG PS-0, 1, 2, clinically/radiologically newly diagnosed stage IIIc epithelial ovarian (EOC), and primary peritoneal carcinoma (PPC) were included. Neoadjuvant chemotherapy recipients were excluded. Preoperative multidetector CT (MDCT) scan showing deposits at 19 predetermined abdominopelvic sites were compared with the same sites seen at laparotomy and corresponding accuracies of CT scan calculated. Primary debulking surgery was done to achieve debulking to nil or less than 1-cm residual disease. Stepwise logistic regression models were used to determine the frequent suboptimal debulking sites and the predictive performance of the clinical and CT scan findings. A total of 36 patients were enrolled. The optimal debulking rate was 50%. The CT scan could detect the disease-bearing sites with overall sensitivity of 68.29%, specificity of 89%, accuracy of 78.07%, and positive and negative predictive values of 99 and 50.1%, respectively. Upon multivariate analysis, bowel mesentery (p 0.011) and omental extension (p 0.025) were associated with suboptimal debulking. CT scan accuracy at these sites (predictive performance) was 86.1%. We identified small bowel mesentery and omental extension (to spleen/stomach/colon) as sites associated with suboptimal debulking. MDCT accurately depicts peritoneal metastases, although sensitivity is reduced in certain areas of significance for optimal debulking. Further validation with more number of patients is warranted.

The Emerging Role of PET/MR Imaging in Gynecologic Cancers

This article summarizes recent advances in PET/MR imaging in gynecologic cancers and the emerging clinical value of PET/MR imaging in the management of the 3 most common gynecologic malignancies: cervical, endometrial, and ovarian cancers. PET/MR imaging offers superior soft tissue contrast, improved assessment of primary tumor involvement because of high-resolution multiplanar reformats, and functional MR techniques such as diffusion-weighted MR imaging and dynamic contrast-enhanced MR imaging. This article discusses the challenges, future directions, and technical advances of PET/MR imaging, and the emerging new multimodality, multiparametric imaging techniques for integrating morphologic, functional, and molecular imaging data.

Ultrasound in preoperative assessment of pelvic and abdominal spread in patients with ovarian cancer: a prospective study

OBJECTIVE

To analyze the accuracy of ultrasound in assessing pelvic and intra-abdominal spread in patients with ovarian cancer.

METHODS

This prospective study enrolled all consecutive patients referred to a single gynecological oncology center for suspected ovarian cancer. We analyzed only data from patients with histologically confirmed primary ovarian cancer who were evaluated following predefined preoperative ultrasound, intraoperative and pathology protocols. We evaluated the agreement of depth of infiltration of the rectosigmoid wall, tumor spread in different peritoneal compartments and presence of metastatic retroperitoneal and inguinal lymph nodes, as determined at ultrasound, with intraoperative and histopathological findings.

RESULTS

In total, 578 patients were enrolled between March 2008 and January 2013, of whom 394 met the study inclusion criteria and were analyzed; 74% of these suffered from advanced-stage cancer. Our results showed excellent agreement between ultrasound and histology in assessment of rectosigmoid wall infiltration (kappa value, 0.812; area under the receiver-operating characteristics curve, 0.898). The overall accuracy in evaluating different peritoneal compartments, retroperitoneal and inguinal lymph nodes and depth of rectosigmoid wall infiltration was 85.3%, 84.8%, 99.7% and 91.1%, respectively. Ultrasound showed high sensitivity only in the assessment of rectosigmoid wall infiltration (83.1%), peritoneal spread into the pelvis (81.4%) and omentum (67.3%), and inguinal metastatic lymph nodes (100%). The specificity of ultrasound in detection of all evaluated parameters was > 90%.

CONCLUSION

This is the largest imaging study to date on ovarian cancer staging. Ultrasound can be used as the method of choice to plan rectosigmoid wall resection and dissection of infiltrated inguinal lymph nodes. In assessing different peritoneal and retroperitoneal compartments, ultrasound was accurate and highly specific. However, similar to other modern imaging techniques, it had relatively low sensitivity, further supporting the role of comprehensive surgical staging. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Multimodal Magnetic Resonance and Near-Infrared-Fluorescent Imaging of Intraperitoneal Ovarian Cancer Using a Dual-Mode-Dual-Gadolinium Liposomal Contrast Agent

The degree of tumor removal at surgery is a major factor in predicting outcome for ovarian cancer. A single multimodality agent that can be used with magnetic resonance (MR) for staging and pre-surgical planning, and with optical imaging to aid surgical removal of tumors, would present a new paradigm for ovarian cancer. We assessed whether a dual-mode, dual-Gadolinium (DM-Dual-Gd-ICG) contrast agent can be used to visualize ovarian tumors in the peritoneal cavity by multimodal MR and near infra-red imaging (NIR). Intraperitoneal ovarian tumors (Hey-A8 or OVCAR3) in mice enhanced on MR two days after intravenous DM-Dual Gd-ICG injection compared to controls (SNR, CNR, p < 0.05, n = 6). As seen on open abdomen and excised tumors views and confirmed by optical radiant efficiency measurement, Hey-A8 or OVCAR3 tumors from animals injected with DM-Dual Gd-ICG had increased fluorescence (p < 0.05, n = 6). This suggests clinical potential to localize ovarian tumors by MR for staging and surgical planning, and, by NIR at surgery for resection.

Early prediction of clinical benefit of treating ovarian cancer using quantitative CT image feature analysis

BACKGROUND

In current clinical trials of treating ovarian cancer patients, how to accurately predict patients' response to the chemotherapy at an early stage remains an important and unsolved challenge.

PURPOSE

To investigate feasibility of applying a new quantitative image analysis method for predicting early response of ovarian cancer patients to chemotherapy in clinical trials.

MATERIAL AND METHODS

A dataset of 30 patients was retrospectively selected in this study, among which 12 were responders with 6-month progression-free survival (PFS) and 18 were non-responders. A computer-aided detection scheme was developed to segment tumors depicted on two sets of CT images acquired pre-treatment and 4-6 weeks post treatment. The scheme computed changes of three image features related to the tumor volume, density, and density variance. We analyzed performance of using each image feature and applying a decision tree to predict patients' 6-month PFS. The prediction accuracy of using quantitative image features was also compared with the clinical record based on the Response Evaluation Criteria in Solid Tumors (RECIST) guideline.

RESULTS

The areas under receiver operating characteristic curve (AUC) were 0.773 ± 0.086, 0.680 ± 0.109, and 0.668 ± 0.101, when using each of three features, respectively. AUC value increased to 0.831 ± 0.078 when combining these features together. The decision-tree classifier achieved a higher predicting accuracy (76.7%) than using RECIST guideline (60.0%).

CONCLUSION

This study demonstrated the potential of using a quantitative image feature analysis method to improve accuracy of predicting early response of ovarian cancer patients to the chemotherapy in clinical trials.

CT in ovarian cancer staging: how to review and report with emphasis on abdominal and pelvic disease for surgical planning

CT of the abdomen and pelvis is the first line imaging modality for staging, selecting treatment options and assessing disease response in ovarian cancer. The staging CT provides disease distribution, disease burden and is the imaging surrogate for surgico-pathological FIGO staging. Optimal cyto-reductive surgery offers patients’ the best chance for disease control or cure, but sub-optimal resection confers no advantage over chemotherapy and adversely increases the risk of post surgical complications. Although there is extensive literature comparing performance of CT against laparoscopy and surgery, for the staging abdominal and pelvic CT, there are currently no accepted guidelines for interpretation or routinely used minimum data set templates for reporting these complex CT scans often with extensive radiological findings. This review provides a systematic approach for identifying the important radiological findings and highlighting important sites of disease within the abdomen and pelvis, which may alter or preclude surgery at presentation or after adjuvant chemotherapy. The distribution of sites and volume of disease can be used to categorize patients as suitable, probably suitable or not suitable for optimal cyto-reductive surgery. This categorization can potentially assist oncological surgeons and oncologists as a semi objective assessment tool useful for selecting patient treatment, streamlining multi disciplinary discussion and improving the reproducibility and correlation of CT with surgical findings. The review also highlights sites of disease and complications of ovarian cancer which should be included as part of the radiological report as these may require additional surgical input from non gynaecological surgeons or influence treatment selection.

Patterns and Prognostic Importance of Hepatic Involvement in Patients with Serous Ovarian Cancer: A Single-Institution Experience with 244 Patients

Purpose To evaluate the frequency, patterns, and prognostic importance of metastatic hepatic involvement in serous ovarian cancer. Materials and Methods This institutional review board-approved retrospective study, with waived informed consent, included 244 patients with pathologically proven serous ovarian cancer (mean age ± standard deviation, 59 years ± 10.7; range 19-93 years). Electronic medical records and all available imaging studies over a median follow-up of 44 months (interquartile range [IQR], 27-70) were reviewed to identify the frequency of liver parenchymal invasion (LPI) from perihepatic peritoneal metastasis and hematogenous liver metastases. The associations and prognostic importance of LPI and hematogenous metastases were studied by using univariate and multivariate Cox proportional analysis. Results Eighty-four of 244 patients (34%) developed perihepatic metastases, of whom 55 (23%) developed LPI after median of 43 months (IQR, 25-63). Hematogenous hepatic metastases developed in 38 of 244 patients (16%) after median of 42 months (IQR, 26-64). At multivariate analysis, age (P = .008; hazard ratio [HR]: 1.03; 95% confidence interval [CI]: 1.009, 1.07) and suboptimal cytoreduction (P = .03; HR, 2.13; 95% CI: 1.12, 4.07) were associated with LPI. Increasing age (P = .01; HR, 1.04; 95% CI: 1.008, 1.08), high-grade tumor (P = .01; HR, 6.75; 95% CI: 1.44, 120.5), and advanced stage (P = .03; HR, 3.16; 95% CI: 1.94, 4.56) were associated with hematogenous metastases. Overall survival with and without LPI was similar (median, 80 months; IQR, 50-not reached vs 123 months; IQR, 49-279; P = .6). Hematogenous metastases were associated with significantly shorter survival at univariate (median 63 months, IQR 43-139 vs 145 months, IQR 50-not reached; P = .006) and multivariate analyses (P = .03; HR, 1.88; 95% CI: 1.14, 3.28). Conclusion Differentiating hematogenous metastases and LPI is important for radiologists; hematogenous metastases are associated with shorter survival, while LPI does not adversely affect survival and prognostically behaves like peritoneal disease. ^© RSNA, 2016.

A prospective study evaluating diffusion weighted magnetic resonance imaging (DW-MRI) in the detection of peritoneal carcinomatosis in suspected gynecologic malignancies

OBJECTIVES

To evaluate and compare the ability of DW-MRI and CT to detect sites of peritoneal dissemination in gynecologic malignancies. The reproducibility of DW-MRI and CT interpretation between radiologists was also assessed.

METHODS

Single institution prospective cohort study of women with suspected advanced gynecologic cancer who underwent surgical staging from 2010 to 2013. Participants underwent both DW-MRI and contrast-enhanced CT prior to surgery. Radiologists and surgeons were blinded, respectively, to surgical and DW-MRI results. The area under the receiver operator characteristic curve (AUC) was calculated for each disease site for CT and DW-MRI and compared to surgical findings. Kappa statistics quantified interobserver agreement between both radiologists.

RESULTS

Twenty seven patients were enrolled. Mean age at surgery was 59years. Ninety percent of participants had stage IIIC/IV disease. For right diaphragm disease, the AUC for DW-MRI was 0.95 compared to 0.81 for CT. For left diaphragm disease, the AUC was 0.89 for DW-MRI compared to 0.74 for CT. The AUC was similar for DW-MRI and CT for omental disease (0.79 versus 0.64); the liver surface (0.61 versus 0.67); bowel mesentery (0.73 versus 0.64); and cul de sac (0.75 versus 0.64). Interobserver agreement for DW-MRI was greater than CT for omental, Morrison's pouch, liver surface, and right diaphragm disease.

CONCLUSIONS

DW-MRI detects right diaphragmatic disease found at surgery with greater accuracy than CT. For other disease sites key to surgical planning, DW-MRI is equivalent to CT. Interobserver agreement was superior for a majority of disease sites evaluated by DW-MRI compared to CT.

Ovarian Cancer, the Revised FIGO Staging System, and the Role of Imaging

OBJECTIVE

It is now recognized that ovarian cancer includes a heterogeneous group of malignant epithelial tumors originating from the ovaries, fallopian tubes, or peritoneum. This development has prompted the International Federation of Gynecology and Obstetrics (FIGO) to issue a revised staging system that can provide prognostic information and guidance on personalized management of ovarian cancer.

CONCLUSION

We review the epidemiology of ovarian cancer, the new FIGO staging system, and the role of imaging in the assessment, staging, and follow-up of ovarian cancer.

[Modern imaging of renal tumors - application in diagnostics and therapy. Characterization, operation planning and therapy monitoring of renal lesions]

This article elucidates the various tools used for the diagnostics and characterization of renal lesions. The advantages and limitations of ultrasound, contrast-enhanced ultrasound (CEUS), computed tomography (CT) and magnetic resonance imaging (MRI) are presented and discussed. In addition, modern imaging features of CT and MRI, such as iodine quantification in CT as well as diffusion-weighted and perfusion imaging in MRI are presented. Lastly, recent developments in standardized reporting of renal tumors regarding the intraoperative surgical risk are presented.

Pathways of lymphatic spread in gynecologic malignancies

Precise radiologic evaluation of regional adenopathic involvement in pelvic gynecologic tumors is fundamental to clinical practice because of its prognostic and therapeutic significance. Likewise, the identification of metastatic adenopathies at posttreatment imaging is essential for assessing response and detecting recurrence. Similar to urologic neoplasms, gynecologic neoplasms most often spread regionally to the pelvic and retroperitoneal lymph nodes, following the normal drainage pathways of the pelvic organs. Familiarity with routes of dissemination, treatment options, and means of analyzing lymph node characteristics is crucial to determine the extent of disease. Two staging systems can be used in characterizing gynecologic malignancies: the FIGO (International Federation of Gynecology and Obstetrics) system, which is the most commonly and universally used, and the TNM (tumor, node, metastasis) system, which is based on clinical and/or pathologic classification. Anatomic assessment with multidetector computed tomography (CT) and magnetic resonance (MR) imaging is still the most commonly used technique for the detection of lymph node spread, which is mainly based on morphologic criteria, the most important of which is nodal size. However, size has limited diagnostic specificity. Consequently, functional imaging techniques such as diffusion-weighted MR imaging, positron emission tomography combined with CT, lymphoscintigraphy, and sentinel lymph node mapping, which are based on molecular and physiologic activity and allow more precise evaluation, are often incorporated into diagnostic imaging protocols for staging of gynecologic malignancies.

Functional MR Imaging in Gynecologic Cancer

Dynamic-contrast enhanced (DCE) and diffusion-weighted (DW) MR imaging are invaluable in the detection, staging, and characterization of uterine and ovarian malignancies, for monitoring treatment response, and for identifying disease recurrence. When used as adjuncts to morphologic T2-weighted (T2-W) MR imaging, these techniques improve accuracy of disease detection and staging. DW-MR imaging is preferred because of its ease of implementation and lack of need for an extrinsic contrast agent. MR spectroscopy is difficult to implement in the clinical workflow and lacks both sensitivity and specificity. If used quantitatively in multicenter clinical trials, standardization of DCE- and DW-MR imaging techniques and rigorous quality assurance is mandatory.

Correlation of Radiologic with Surgical Peritoneal Cancer Index Scores in Patients with Pseudomyxoma Peritonei and Peritoneal Carcinomatosis: How Well Can We Predict Resectability?

INTRODUCTION

Pseudomyxoma peritonei (PMP) and peritoneal carcinomatosis (PC) arises from primary or secondary peritoneal cancer and can be treated with complete surgical removal of disease. Suitability for surgery is based on a peritoneal cancer index (PCI), with a PCI ≥ 20 representing unresectable disease.

AIMS

Compare preoperative imaging with surgical findings based on PCI.

METHODS

All cases of patients with PMP and PC undergoing cytoreductive surgery ± hyperthermic intraperitoneal chemotherapy (HIPEC) between 2010 and 2014 were included. Two staff radiologists blinded to surgical PCI scores retrospectively reviewed imaging studies to calculate corresponding radiologic PCI scores for each patient. Correlation between radiologic PCI and surgical PCI, as obtained from operative reports, was assessed using Spearman's rho correlation coefficients. Preoperative assessment of a PCI cutoff of 20 on imaging was compared with actual surgical PCI using sensitivity, specificity, and positive and negative predictive values.

RESULTS

Forty-two patients had a mean surgical PCI ± SEM score of 15.1 ± 1.3 and mean radiologic PCI of 15.5 ± 1.5. The most common tumor histologies were appendiceal (60 %) and colon (33 %) adenocarcinoma and were of low tumor grade (67 %). Correlation between individual radiologists and surgical PCI was 0.59 and 0.62, respectively (all p < 0.001). When mean radiologic PCI was used, this correlation with surgical PCI improved to 0.64 and to 0.65 when good quality studies only were considered (all p < 0.001). Radiologic PCI score had a sensitivity of 76 %, a specificity of 69 %, positive predictive value of 85 %, and a negative predictive value of 56 % when compared with the surgical PCI. In patients with a radiologic PCI score ≥ 20, 6/13 (46 %) still achieved adequate cytoreduction.

CONCLUSIONS

Good quality cross-sectional imaging, combined with overreading and formal assessment of all components of the PCI score yields the best correlation with actual surgical findings. Although preoperative assessment of PCI ≥ 20 was reasonably accurate, using this cutoff to assess resectability is problematic as almost half of these patients were still able to undergo adequate cytoreduction. Better assessment of resectability is needed preop, either by refinement of the PCI criteria or routine staging laparoscopy.

Low 25-OH vitamin D levels at time of diagnosis and recurrence of ovarian cancer

The objective of this study was to evaluate the correlation between 25-OH vitamin D and ovarian cancer as a diagnostic marker or recurrence disease marker. We studied the following: (1) 61 women without gynecologic diseases, (2) 45 women affected by benign ovarian disease, (3) 46 women with recent diagnosis of ovarian cancer, (4) 26 follow-up women with recurrent ovarian cancer, and (5) 32 follow-up women with stable ovarian cancer. The 25-OH vitamin D was quantified with LUMIPULSE® G 25-OH vitamin D on LUMIPULSE® G 1200 (Fujirebio, Japan). As a threshold value, identified by ROC curve analysis, 20.2 ng/mL (sensitivity 73.3 %, specificity 84 %) was chosen corresponding to the limit between sufficient and insufficient 25-OH vitamin D according to the WHO. Low 25-OH vitamin D levels were observed in 26 % of women without gynecologic diseases, in 80 % of women with recent diagnosis of ovarian cancer and in 24 % women affected by benign ovarian diseases (p < 0.001). The follow-up study showed an insufficient level of 25-OH vitamin D in 73 % women with recurrent ovarian cancer and in 47 % women with stable ovarian cancer (p < 0.0003). This study showed that patients with ovarian cancer are often insufficient in 25-OH vitamin D compared to women with benign ovarian diseases. The women with recurrent ovarian cancer presented more often low levels compared to women with stable ovarian cancer. This study suggests that 25-OH vitamin D, due to its antiproliferative properties, can be a good marker for ovarian cancer also.

PSMA PET/CT with Glu-urea-Lys-(Ahx)-[⁶⁸Ga(HBED-CC)] versus 3D CT volumetric lymph node assessment in recurrent prostate cancer

Purpose

PET/CT with the PSMA ligand is a powerful new method for the early detection of nodal metastases in patients with biochemical relapse. The purpose of this retrospective investigation was to evaluate the volume and dimensions of nodes identified by Glu-urea-Lys-(Ahx)-[⁶⁸Ga(HBED-CC)] (⁶⁸Ga-PSMA-11) in the setting of recurrent prostate cancer.

Methods

All PET/CT images were acquired 60 ± 10 min after intravenous injection of ⁶⁸Ga-PSMA-11 (mean dose 176 MBq). In 21 patients with recurrent prostate cancer and rising PSA, 49 PSMA-positive lymph nodes were identified. Using semiautomated lymph node segmentation software, node volume and short-axis and long-axis dimensions were measured and compared with the maximum standardized uptake values (SUVmax). Round nodes greater than or equal to 8 mm were considered positive by morphological criteria alone. The percentage of nodes identified by elevated SUVmax but not by conventional morphological criteria was determined.

Results

The mean volume of ⁶⁸Ga-PSMA-11-positive nodes was 0.5 ml (range 0.2 – 2.3 ml), and the mean short-axis diameter was 5.8 mm (range 2.4 – 13.3 mm). In 7 patients (33.3 %) with 31 PSMA-positive nodes only 11 (36 %) were morphologically positive based on diameters >8 mm on CT. In the remaining 14 patients (66.7 %), 18 (37 %) of PSMA positive lymph nodes had short-axis diameters <8 mm with a mean short-axis diameter of 5.0 mm (range 2.4 – 7.9 mm). Thus, in this population, ⁶⁸Ga-PSMA-11 PET/CT detected nodal recurrence in two-thirds of patients who would have been missed using conventional morphological criteria.

Conclusion

⁶⁸Ga-PSMA-11 PET/CT is more sensitive than CT based 3D volumetric lymph node evaluation in determining the node status of patients with recurrent prostate cancer, and is a promising method of restaging prostate cancers in this setting.

Gynecologic oncologic imaging with PET/CT

FDG-PET/CT has been evaluated in a variety of gynecologic malignancies in a variety of settings and is approved by the Centers for Medicare & Medicaid Services for the initial and subsequent treatment strategies of these malignancies. Cervical cancer is typically very FDG avid, and FDG-PET/CT appears to be most valuable for initial staging, radiation therapy planning, and detection of recurrent disease. For ovarian cancer, the most value of FDG-PET/CT appears to be for detecting recurrent disease in the setting of rising CA-125 level and negative or equivocal anatomical imaging studies. Initial studies evaluating response to therapy are promising and further work in this area is needed. FDG uptake in both nonmalignant and physiological processes in the pelvis can make interpretation of FDG-PET/CT in this region challenging and knowledge of these entities and patterns can avoid misinterpretation. Some of the most common findings relate to the cyclic changes that occur as part of the menstrual cycle in premenopausal women. Mucinous tumors and low-volume or peritoneal carcinomatosis are causes of false-negative results on FDG-PET/CT studies. As new tracers are developed, comparisons with patient outcomes and standards of care (eg, FDG-PET/CT) will be needed.

Role of imaging in the pretreatment evaluation of common gynecological cancers

Different treatment options are available for patients with gynecological cancers. Imaging plays an important role in assessment of patients with common cancers involving uterine body, cervix and ovaries, from detection to evaluation of the extent of disease. The purpose of this review is to highlight the role of cross-sectional imaging techniques in treatment stratification and overall management of patients with endometrial, cervical and ovarian cancers. Several imaging techniques used are described, including ultrasound, computed tomography (CT), MRI and PET/CT. Specific imaging appearances of the most common uterine, cervical and ovarian cancers are discussed. Imaging findings corresponding to the 2009 revised International Federation of Gynecology and Obstetrics (FIGO) staging of gynecologic malignancies are also described. In the multidisciplinary evaluation of patients with gynecologic malignancies, the role of the radiologist has become central for accurate diagnosis and evaluation of extent of disease to achieve better treatment selection and planning.

Diagnostic Performance of Computed Tomography for Preoperative Staging of Patients with Non-endometrioid Carcinomas of the Uterine Corpus

PURPOSE

The aim of this study was to assess the diagnostic performance of computed tomography (CT) for initial staging of non-endometrioid carcinomas of the uterine corpus.

MATERIALS AND METHODS

Waiving informed consent, the Institutional Review Board approved this Health Insurance Portability and Accountability Act (HIPAA)-compliant retrospective study of 193 women with uterine papillary serous carcinomas, clear cell carcinomas, and carcinosarcomas, who underwent surgical staging between May 1998 and December 2011 and had preoperative CT within 6 weeks before surgery. Two radiologists (R1, R2) independently reviewed all CT images. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and area under the curve were calculated using operative notes and surgical pathology as the reference standard.

RESULTS

The respective sensitivities and specificities achieved by R1/R2 were 0.79/0.64 and 0.87/0.75 for detecting deep myometrial invasion (MI) on CT; 0.56/0.63 and 0.93/0.79 for detecting cervical stromal invasion; 0.52/0.45 and 0.95/0.93 for detecting pelvic nodal metastases; and 0.45/0.30 and 0.98/0.98 for detecting para-aortic nodal metastases. Although CT had suboptimal sensitivity for the detection of omental disease, it had high PPV for omental seeding at surgical exploration (1.00 for R1 and 0.92 for R2). Inter-observer agreement ranged from moderate in the detection of deep MI (κ = 0.42 ± 0.06) to almost perfect in the detection of para-aortic nodal metastases (κ = 0.88 ± 0.08).

CONCLUSION

In patients with uterine non-endometrioid carcinomas, CT is only moderately accurate for initial staging but may provide clinically valuable information by 'ruling-in' isolated para-aortic lymph node metastases and omental dissemination.

Evaluation of gynecologic cancer with MR imaging, 18F-FDG PET/CT, and PET/MR imaging

MR imaging and (18)F-FDG PET/CT play central and complementary roles in the care of patients with gynecologic cancer. Because treatment often requires combinations of surgery, radiotherapy, and chemotherapy, imaging is central to triage and to determining prognosis. This article reviews the use of the 2 imaging modalities in the initial evaluation of 3 common cancers: uterine cervical, uterine endometrial, and epithelial ovarian. Imaging features that affect management are highlighted, as well as the relative strengths and weaknesses of the 2 modalities. Use of imaging after initial therapy to assess for recurrence and to plan salvage therapy is described. Newer functional and molecular techniques in MR imaging and PET are evaluated. Finally, we describe our initial experience with PET/MR imaging, an emerging technology that may prove to be a mainstay in personalized gynecologic cancer care.

Diagnosis of Peritoneal Metastases with Abdominal Malignancies: Role of ADC Measurement on Diffusion Weighted MRI

OBJECTIVE

The purpose of our study was to evaluate the utility of the apparent diffusion coefficient (ADC) value measurement in the diagnosis of peritoneal metastases on diffusion weighted magnetic resonance imaging.

MATERIALS AND METHODS

Diffusion weighted imaging with conventional magnetic resonance imaging sequences was performed on twenty consecutive oncology patients (group I) with peritoneal metastases. The ADC values of the metastases, the peritoneal fat around the metastases (group I) and the peritoneal fat in patients with no malignancy (group II) at b(0-100), b(0-600), and (b 0-1000) s/mm(2) gradients were measured and compared.

RESULTS

The apparent diffusion coefficient values of three gradients in peritoneal metastases (2.27±0.4; 1.67±0.7 and 1.09±0.4×10(-3) mm(2)/s at b 100, 600 and 1000 gradients, respectively) were significantly lower than the ADC values of the peritoneal fat around metastases (3.07±0.4; 2.07±0.4; 1.33±0.3×10(-3) mm(2)/s at b 100, 600 and 1000 gradients, respectively) (p<0.05). There was no significant difference between the ADC values of peritoneal fat in the patients of group I and group II at the 3 diffusion gradients (p>0.05).

CONCLUSION

The measurement of ADC values may be used as a complementary diagnostic method in differentiating peritoneal metastases from peritoneal fat on Diffusion Weighted MRI (DWMRI DWMRI).

Toward operative in vivo fluorescence imaging of the c-Met proto-oncogene for personalization of therapy in ovarian cancer

BACKGROUND

Standard biomarker testing of a single macroscopic disease site is unlikely to be sufficient because of tumor heterogeneity. A focus on examining global biomarker expression or activity, particularly in microscopic residual chemotherapy-resistant disease, is needed for the appropriate selection of targeted therapies. This study was aimed at establishing a technique for the assessment of biomarkers of ovarian cancer peritoneal spread.

METHODS

An in-house developed fluorescent imaging device was used to detect the expression of the c-Met oncogene in ovarian cancer. A modified cyanine 5-tagged peptide, GE137, with a high in vitro affinity for the human c-Met protein, was tested in a panel of ovarian cancer cell lines. Finally, the feasibility of detecting submillimeter ovarian cancer cell peritoneal metastases in vivo was tested through the intravenous injection of GE137 into mice with tumor xenografts.

RESULTS

Using optical imaging it was possible to detect c-Met expression in submillimeter peritoneal metastases that were freshly excised from a human high-grade serous ovarian cancer. GE137 selectively bound to the c-Met tyrosine kinase without activating survival signaling pathways (AKT or extracellular signal-regulated kinase phosphorylation) downstream of c-Met. GE137 specifically accumulated in SKOv3 ovarian cancer cells expressing c-Met via clathrin-mediated endocytosis and emitted a fluorescent signal that lasted for at least 8 hours in tumor xenografts in vivo with a sustained high signal-to-noise ratio.

CONCLUSIONS

Our results suggest that intraoperative optical imaging could provide a new paradigm for selecting cancer patients for appropriate targeted therapies, particularly after initial chemotherapy.

Management of epithelial ovarian cancer from diagnosis to restaging: an overview of the role of imaging techniques with particular regard to the contribution of 18F-FDG PET/CT

Epithelial ovarian carcinoma is a major form of cancer affecting women in the western world. The silent nature of this disease results in late presentation at an advanced stage in many patients. It is therefore important to assess the role of imaging techniques in the management of these patients. This article presents a review of the literature on the role of (18)F-FDG-PET/CT in the different stages of management of epithelial ovarian cancer. Moreover, a comparison with other imaging techniques has been made and the relationship between (18)F-PET/CT and the assay of serum CA-125 levels has been discussed.

Value of (18)F-FDG PET/CT in the Detection of Ovarian Malignancy

PURPOSE

Ovarian cancer is a leading cause of gynecologic malignancy. As symptoms of ovarian cancer are nonspecific, only 20 % of ovarian cancers are diagnosed while they are still limited to the ovaries. Thus, early and accurate detection of disease is important for an improved prognosis. For the accurate and effective diagnosis of ovarian malignancy on (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography/computed tomography (PET/CT), we analyzed several parameters, including visual assessment.

METHOD

A total of 51 peritoneal lesions in 19 patients who showed ovarian masses with diffuse peritoneal infiltration were enrolled. Twelve patients were confirmed to have ovarian malignancy and seven patients with benign disease by pathologic examination. All patients were examined by (18)F-FDG PET/CT, and an additional 2-h delayed (18)F-FDG PET/CT was also performed for 15 patients with 42 peritoneal lesions. We measured semiquantitative parameters including maximum and mean standardized uptake values (SUVmax, SUVmean), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) on a 1-h initial (18)F-FDG PET/CT image (Parameter1) and on a 2-h delayed image (Parameter2). Additionally, retention indices of each parameter were calculated, and each parameter among the malignant and benign lesions was compared by Mann-Whitney U test. We also assessed the visual characteristics of each peritoneal lesion, including metabolic extent, intensity, shape, heterogeneity, and total visual score. Associations between visual grades and malignancy were analyzed using linear by linear association methods. Moreover, a receiver operating characteristic (ROC) curve was analyzed to compare the effectiveness of significant parameters.

RESULT

In a comparison between the malignant and benign groups in the analysis of 51 total peritoneal lesions, SUVmax1, SUVmean1, and TLG1 showed significant differences. Also, in the analysis of 42 peritoneal lesions that underwent an additional 2-h (18)F-FDG PET/CT examination, SUVmax1,2, SUVmean1,2, TLG2, and the RI of TLG showed significant differences between the malignant and benign groups. MTV did not show significant differences in either the analysis of 51 peritoneal lesions or of 42 lesions. Regarding visual assessments, metabolic intensity, shape, heterogeneity, and total visual score showed an association with malignancy. In the ROC analysis, the AUC of the visual score was larger than the AUC of other parameters in both the analyses of 51 peritoneal lesions and of 42 lesions.

CONCLUSION

Although further study with a larger patient population is needed, the visual assessment of (18)F-FDG PET/CT imaging has a primary role in the detection of malignancy in ovarian cancer patients with assistance from other semi-quantitative parameters.

[Ovarian tumors in postmenopausal women: report of 100 cases and review of the literature]

Le but de notre travail est d’étudier les particularités de prise en charge des tumeurs de l'ovaire chez la femme ménopausée. L’étude rétrospective porte sur 100 patientes opérées pour des tumeurs ovariennes en post ménopause durant une période de 5 ans. L’âge moyen des patientes était de 61,3 ans (extrêmes: 47- 84 ans). L'aspect échographique était liquidien pur dans 40% des cas, mixte ou solide dans 30% des cas. Le dosage de CA 125 était élevé dans 25% des cas. Un traitement chirurgical a été pratiqué chez toutes les patientes: Laparotomie de première intention dans 43 cas,cœliochirurgie dans 51 cas, cœlioscopie puis laparotomie dans 6 cas. L'examen anatomopathologique définitif a révélé 22% de tumeurs malignes et 10% de kystes fonctionnels. Le geste chirurgical était une annexectomie bilatérale pour la majorité des tumeurs bénignes et carcinologique en cas de tumeurs malignes. La stratégie diagnostique des tumeurs ovariennes en post ménopause reste de nos jours basée sur la clinique, l’échographie et les marqueurs tumoraux. Les bénéfices de la cœlioscopie sont indiscutables. L'attitude à opérer systématiquement les kystes uniloculaires ayant les critères de bénignité est actuellement révisée.

Gynecologic tumors: how to communicate imaging results to the surgeon

Gynecologic cancers are a leading cause of morbidity and mortality for female patients, with an estimated 88,750 new cancer cases and 29,520 deaths in the United States in 2012. To offer the best treatment options to patients it is important that the radiologist, surgeon, radiation oncologist, and gynecologic oncologist work together with a multidisciplinary approach. Using the available diagnostic imaging modalities, the radiologist must give appropriate information to the surgeon in order to plan the best surgical approach and its timing.

Whole-body MRI with diffusion-weighted sequence for staging of patients with suspected ovarian cancer: a clinical feasibility study in comparison to CT and FDG-PET/CT

OBJECTIVES

To evaluate whole-body MRI with diffusion-weighted sequence (WB-DWI/MRI) for staging and assessing operability compared with CT and FDG-PET/CT in patients with suspected ovarian cancer.

METHODS

Thirty-two patients underwent 3-T WB-DWI/MRI, (18) F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) and CT before diagnostic open laparoscopy (DOL). Imaging findings for tumour characterisation, peritoneal and retroperitoneal staging were correlated with histopathology after DOL and/or open surgery. For distant metastases, FDG-PET/CT or image-guided biopsies were the reference standards. For tumour characterisation and peritoneal staging, WB-DWI/MRI was compared with CT and FDG-PET/CT. Interobserver agreement for WB-DWI/MRI was determined.

RESULTS

WB-DWI/MRI showed 94 % accuracy for primary tumour characterisation compared with 88 % for CT and 94 % for FDG-PET/CT. WB-DWI/MRI showed higher accuracy of 91 % for peritoneal staging compared with CT (75 %) and FDG-PET/CT (71 %). WB-DWI/MRI and FDG-PET/CT showed higher accuracy of 87 % for detecting retroperitoneal lymphadenopathies compared with CT (71 %). WB-DWI/MRI showed excellent correlation with FDG-PET/CT (κ = 1.00) for detecting distant metastases compared with CT (κ = 0.34). Interobserver agreement was moderate to almost perfect (κ = 0.58-0.91).

CONCLUSIONS

WB-DWI/MRI shows high accuracy for characterising primary tumours, peritoneal and distant staging compared with CT and FDG-PET/CT and may be valuable for assessing operability in ovarian cancer patients.

KEY POINTS

• Whole-body MRI with diffusion weighting (WB-DWI/MRI) helps to assess the operability of suspected ovarian cancer. • Interobserver agreement is good for primary tumour characterisation, peritoneal and distant staging. • WB-DWI/MRI improves mesenteric/serosal metastatic spread assessment compared with CT and FDG-PET/CT. • Retroperitoneal/cervical-thoracic nodal staging using qualitative DWI criteria was reasonably accurate. • WB-DWI/MRI and FDG-PET/CT showed the highest diagnostic impact for detecting thoracic metastases.

The special role of ultrasound for screening, staging and surveillance of malignant ovarian tumors: distinction from other methods of diagnostic imaging

Ovarian cancer is the most aggressive gynecologic malignancy, with a 5-year survival rate ranging around 40%. A crucial factor influencing the prognosis is early detection of a suspicious mass and referral to a gynecologic oncology center for further diagnosis, staging and debulking surgery. Here, we present the different imaging methods ultrasound (US), magnetic resonance imaging, computer tomography (CT) and 18F-fluoro-deoxyglucose positron emission tomography (PET)/CT that are used for the characterization, diagnosis, staging and surveillance of ovarian cancer. In this review, we focus on US and discuss in detail the advantages and the limitations, as well as the appropriate indications for each of the individual imaging techniques.

Clinical features and outcomes of neck lymphatic metastasis in ovarian epithelial carcinoma

Background

Neck lymph node metastasis (NLNM) in epithelial ovarian cancer (EOC) is rare and treated as advanced stage cancer. However, ovarian cancer with lymphatic metastasis may manifest a different clinical course from peritoneal carcinomatosis.

Methods

The authors retrospectively assessed 20 patients with EOC and pathologically diagnosed as NLNM between January 2001 and December 2010. The patients were divided into two groups according to the time of NLNM identification. Statistical methods included Kaplan-Meier, log-rank, and Cox regression analysis.

Results

Eleven patients were diagnosed with NLNM at the same time of surgical exploration of EOC (Group A) and nine patients at cancer recurrence 43.3 months after initial surgery (Group B). In Group A, patients with tumors confined to the pelvic cavity had no recurrence or had isolated lymph node recurrence (ILNR), and survived longer than patients with abdominal tumor spreading (P = 0.0007). In Group B, 2 patients showed ILNR. The median survival time after NLNM was 42 months in Group A and 6 months in Group B (P = 0.01). Cox model demonstrated that non-serous histology, brain metastasis, and NLNM identified at cancer recurrence were major predictors for poor overall survival (Hazard ratio [HR] = 18.67, 6.93, and 4.52; P = 0.01, 0.02, and 0.04, respectively).

Conclusions

A subgroup of EOC patients with NLNM who presented limited pelvic cancer had much better overall survival than patients who had cancer spreading beyond the pelvic cavity or were diagnosed with NLNM at cancer recurrence.

Computed tomography adnexal mass score to estimate risk for ovarian cancer

OBJECTIVE

We wish to develop a CT scan-based scoring system which estimates the probability of adnexal mass malignancy.

METHODS

Patients (324) undergoing adnexal mass surgery were recruited into the study from June 1, 2002, to January 1, 2009. All study patients had a preoperative CT scan and serum CA-125 test. CT scan abnormalities included any solid tumor components, ascites, and pelvic or abdominal lymphadenopathy and omental caking.

RESULTS

There were 225 (70%) benign and 99 (30%) malignant ovarian masses. Using logistic regression with the area under the curve of the receiver operating curve of 82%, the cancer probability was determined by the equation. e(-3.6372+0.0306*(A)+0.001*(C)+1.551*(D)+1.7377*(E)+2.76*(F)) / 1+e(-3.6372+0.0306*(A)+0.001*(B)+0.876*(C)+1.551*(D)+1.7377*(E)+2.76*(F)) where A = age, B = CA-125, C = solid adnexal mass is 1 and cystic is 0, D = ascites is 1, E = omental caking is 1 and absence is 0, F = node size ≥1 cm is 1 and <1 cm is 0 value. The natural logarithm e is a constant [2.718281828]. For example, for a woman of age 60, CA-125 = 50 U/mL, with solid adnexal mass, ascites, omental caking, and lymphadenopathy, the probability is 0.994. Hence, this woman has a 99.4% probability of having cancer.

CONCLUSION

The computed tomography adnexal mass score combines CT scan findings, CA-125, and patient age into an equation to predict the malignant probability of an adnexal mass.

Role of 18F-FDG PET/CT in diagnosing peritoneal carcinomatosis in the restaging of patient with ovarian cancer as compared to contrast enhanced CT and tumor marker Ca-125

OBJECTIVES

To investigate the role of whole-body fluorine-18-2-deoxy-2-fluoro-d-glucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) in the identification of peritoneal carcinomatosis in patients with ovarian cancer (OC).

MATERIAL AND METHODS

Seventy-nine patients with histologically proven stages III-IV OC who underwent (18)F-FDG PET/CT were studied retrospectively. We considered group A as 51 patients who also underwent computed-tomography with contrast-enhancement (CECT), and group B as 35 patients who had also been tested for biomarker Ca-125. Sensitivity, specificity, accuracy, positive predictive values (PPV) and negative predictive values (NPV) of (18)F-FDG PET/CT as compared to CECT and to Ca-125 were evaluated.

RESULTS

(18)F-FDG PET/CT' sensitivity, specificity, accuracy, PPV and NPV for all 79 patients were: 85%, 92.31%, 88.61%, 91.89% and 85.71%, respectively. (18)F-FDG PET/CT sensitivity in group A was 78.6%, while it was 53.6% for CECT. (18)F-FDG PET/CT specificity, calculated in the same group, was 91.3%, while that of CECT was 60.9% (statistically significant difference, McNemar 4, P=0.039). Accuracy was 84.3% and 56.9%, respectively. (18)F-FDG PET/CT' sensitivity in group B was 86.4%, while that of Ca-125 was 81.8% (no statistical difference, McNemar 0, P=1). (18)F-FDG PET/CT specificity in group B was 84.6% while that of Ca-125 was 38.5% (clear but not statistically significant difference, McNemar 3.12, P=0.070). Accuracy calculated in the same group was 85.7% for (18)F-FDG PET/CT and 65.7% for Ca-125.

CONCLUSION

(18)F-FDG PET/CT is a useful diagnostic tool when peritoneal biopsy cannot be performed and it can better select those who are candidates for adjuvant chemotherapy.

MRI of ovarian masses

MRI provides exquisite views of the pelvic anatomy through its high spatial resolution and tissue contrast, and as such plays a key role in the work up of ovarian lesions, identifying features that distinguish benign and malignant lesions. In the case of primary tumors it enables local staging and detection of metastatic disease to help guide management options such as complex surgery or the consideration of neoadjuvant chemotherapy. Functional MRI techniques such as diffusion-weighted MRI (DW-MRI), dynamic contrast-enhanced MRI (DCE-MRI) and tumor-selective molecular imaging are currently being evaluated as possible predictive and prognostic biomarkers in the context of ovarian malignancy, and may play a larger role in routine clinical practice in the future. Herein we provide an overview of the conventional and advanced MRI techniques used to characterize ovarian masses and of the role that MR plays in the staging, treatment selection and follow up of patients with ovarian cancer.