Update on Imaging of Ovarian Cancer

Imaging of Peritoneal Metastases in Ovarian Cancer Using MDCT, MRI, and FDG PET/CT: A Systematic Review and Meta-Analysis

This review aims to compare the diagnostic performance of multidetector CT (MDCT), MRI, including diffusion-weighted imaging, and FDG PET/CT in the detection of peritoneal metastases (PMs) in ovarian cancer (OC). A comprehensive search was performed for articles published from 2000 to February 2023. The inclusion criteria were the following: diagnosis/suspicion of PMs in patients with ovarian/fallopian/primary peritoneal cancer; initial staging or suspicion of recurrence; MDCT, MRI and/or FDG PET/CT performed for the detection of PMs; population of at least 10 patients; surgical results, histopathologic analysis, and/or radiologic follow-up, used as reference standard; and per-patient and per-region data and data for calculating sensitivity and specificity reported. In total, 33 studies were assessed, including 487 women with OC and PMs. On a per-patient basis, MRI (p = 0.03) and FDG PET/CT (p < 0.01) had higher sensitivity compared to MDCT. MRI and PET/CT had comparable sensitivities (p = 0.84). On a per-lesion analysis, no differences in sensitivity estimates were noted between MDCT and MRI (p = 0.25), MDCT and FDG PET/CT (p = 0.68), and MRI and FDG PET/CT (p = 0.35). Based on our results, FDG PET/CT and MRI are the preferred imaging modalities for the detection of PMs in OC. However, the value of FDG PET/CT and MRI compared to MDCT needs to be determined. Future research to address the limitations of the existing studies and the need for standardization and to explore the cost-effectiveness of the three imaging modalities is required.

Association between the quantitative characteristics of dual-energy spectral CT and cytoreduction surgery outcome in patients with advanced epithelial ovarian cancers: A prospective observational study

This study aimed to explore the association between the quantitative characteristics of dual-energy spectral CT and cytoreduction surgery outcome in patients with advanced epithelial ovarian carcinoma (EOC). In this prospective observational study, patients with advanced EOC (federation of gynecology and obstetrics stage III-IV) treated in the Department of Gynecological Oncology at our Hospital between June 2021 and March 2022 were enrolled. All participants underwent dual-energy spectral computed tomography (DECT) scanning 2 weeks before cytoreductive surgery. The quantitative data included peritoneal cancer index (PCI) determined by DECT, CT value at 70 keV, normalized iodine concentration, normalized water concentration, effective atomic number (effective-Z), and slopes of the spectral attenuation curves (slope λ Hounsfield unit). Fifty-five participants were included. The patients were 57.2 ± 9.8 years of age, and 72.7% were menopausal. The maximal diameter of tumors was 8.6 (range, 2.9-19.7) cm, and 76.4% were high-grade serous carcinomas. Optimal cytoreduction was achieved in 43 patients (78.2%). Compared with the optimal cytoreductive group, the suboptimal cytoreductive group showed a higher PCI (median, 21 vs 6, P < .001), higher 70 keV CT value (69.5 ± 16.6 vs 57.1 ± 13.0, P = .008), and higher slope λ Hounsfield unit (1.89 ± 0.66 vs 1.39 ± 0.60, P = .015). The multivariable analysis showed that the PCI (OR = 1.74, 95%CI: 1.24-2.44, P = .001) and 70 keV CT value (OR = 1.07, 95%CI: 1.01-1.13, P = .023) were independently associated with a suboptimal cytoreductive surgery. The area under the receiver operating characteristics curve of PCI and 70 keV CT value was 0.903 (95%CI: 0.805-1.000, P = .000) and 0.740 (95%CI: 0.581-0.899, P = .012), respectively. High PCI and 70 keV CT value are independently associated with suboptimal cytoreductive surgery in patients with advanced EOC. The PCI determined by DECT might be a better predictor for suboptimal cytoreduction.

Initial Experience with the Radiotracer 18F-Fluciclovine PET/CT in Ovarian Cancer

OBJECTIVE

Early and accurate staging of ovarian cancer is paramount to disease survival. Conventional imaging including FDG PET/CT are limited in the evaluation of small metastatic lesions. 18F-Fluciclovine has minimal urine and bowel excretion allowing optimal visualization of the abdomen and pelvis. This study examines 18F-fluciclovine uptake in known primary and recurrent ovarian cancer.

METHODS

Seven patients with a confirmed diagnosis of epithelial ovarian cancer underwent 18F-fluciclovine PET/CT imaging. Forty-one (41) lesions were identified with 18F-fluciclovine and confirmed to be true positive (n = 41). We aim to explore if 18F-fluciclovine uptake in ovarian lesions were greater than background uptake of bone marrow, blood pool, and bladder. Quantification analysis was performed to determine max and mean standard uptake values (SUVmax and SUVmean) of known and suspected lesions compared to SUVmean uptake of background structures.

RESULTS

18F-Fluciclovine demonstrated 100% sensitivity (41/41) for uptake in known ovarian lesions. The average SUVmax (±SD) uptake of known ovarian lesions was 5.9 (±2.6) and 5.1 (±2.0) on early and delayed images, respectively. The average tumor SUVmax to SUVmean of background (±SD) (T:B) ratios on early and delay were 1.9 (±0.8), 2.1 (±0.9) for marrow; 3.8 (±1.8), 3.4 (±1.5) for aorta; and 8.4 (±4.3), 1.5 (±1.7) for bladder, respectively.

CONCLUSION

18F-Fluciclovine uptake in malignant ovarian lesions was above background levels suggesting its feasibility in the imaging of ovarian cancer. Due to increasing tracer washout via the urinary bladder over time, early imaging at 4 min post injection is favorable.

HE4 and CA-125 kinetics to predict outcome in patients with recurrent epithelial ovarian carcinoma: the META4 clinical trial

HE4 and CA-125 are used for epithelial ovarian cancer (EOC) screening, diagnosis, and follow-up. Our objective was to study HE4 and CA-125 kinetics in patients treated for recurrent EOC. Serum samples were prospectively collected before the first chemotherapy cycle and every 3 months until disease progression. Data from 89/101 patients could be analyzed. At baseline, the median CA-125 and HE4 concentrations were 210 IU/L (7-10,310) and 184 pM (31-4,836). Among the 12 patients (13%) with normal CA-125 (<35 IU/L) concentration, eight had HE4 concentration ≥75 pM, and among the 16 patients with normal HE4 concentration (18%), 12 had increased CA-125 concentration. The median nadir concentrations were 31 IU/L (3-8,744) for CA-125 and 75 pM (20-4,836) for HE4. The median times to nadir were 14 (0-130) weeks for CA-125 and 12 (0-52) weeks for HE4. In multivariate analysis, CA-125 and HE4 nadir concentrations (<35 IU/L, HR 0.35, 95% CI: 0.17-0.72 and<75 pM, HR 0.40, 95% CI: 0.20-0.79) and time to CA-125 and HE4 nadir (>14 weeks, HR 0.37, 95% CI: 0.20-0.70 and >12 weeks, HR 0.43, 95% CI: 0.23-0.83) were prognostic factors of progression-free survival. More investigations on HE4 kinetics could help to better monitor patients with CA-125 concentration within normal values.

Diagnostic performance of noninvasive imaging using computed tomography, magnetic resonance imaging, and positron emission tomography for the detection of ovarian cancer: a meta-analysis

OBJECTIVE

The aim of this meta-analysis was to compare the diagnostic value of noninvasive imaging methods computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) in the detection of ovarian cancer (OC).

METHODS

PubMed, Embase, and Ovid were comprehensively searched from the date of inception to 31st, March, 2022. Pooled sensitivity, specificity, positive likelihood ratio (+ LR), negative likelihood ratio (- LR), diagnostic odds ratio (DOR), and area under the curve (AUC) of summary receiver operating characteristic (SROC) with their respective 95% confidence intervals (CIs) were calculated.

RESULTS

Sixty-one articles including 4284 patients met the inclusion criteria of this study. Pooled estimates of sensitivity, specificity, and AUC of SROC with respective 95% CIs of CT on patient level were 0.83 (0.73, 0.90), 0.69 (0.54, 0.81), and 0.84 (0.80, 0.87). The overall sensitivity, specificity, SROC value with respective 95% CIs of MRI were 0.95 (0.91, 0.97),0.81 (0.76, 0.85), and 0.90 (0.87, 0.92) on patient level. Pooled estimates of sensitivity, specificity, SROC value of PET/CT on patient level were 0.92 (0.88, 0.94), 0.88 (0.83, 0.92), and 0.96 (0.94, 0.97).

CONCLUSION

Noninvasive imaging modalities including CT, MRI, PET (PET/CT, PET/MRI) yielded favorable diagnostic performance in the detection of OC. Hybrid implement of different tools (PET/MRI) is more accurate for identifying metastatic OC.

Added Value of FDG PET/MRI in Gynecologic Oncology: A Pictorial Review

Fluorine 18-fluorodeoxyglucose (FDG) PET and MRI independently play a valuable role in the management of patients with gynecologic malignancies, particularly endometrial and cervical cancer. The PET/MRI hybrid imaging technique combines the metabolic information obtained from PET with the excellent soft-tissue resolution and anatomic details provided by MRI in a single examination. MRI is the modality of choice for assessment of local tumor extent in the pelvis, whereas PET is used to assess for local-regional spread and distant metastases. The authors discuss the added value of FDG PET/MRI in imaging gynecologic malignancies of the pelvis, with a focus on the role of FDG PET/MRI in diagnosis, staging, assessing treatment response, and characterizing complications. PET/MRI allows better localization and demarcation of the extent of disease, characterization of lesions and involvement of adjacent organs and lymph nodes, and improved differentiation of benign from malignant tissues, as well as detection of the presence of distant metastasis. It also has the advantages of decreased radiation dose and a higher signal-to-noise ratio of a prolonged PET examination of the pelvis contemporaneous with MRI. The authors provide a brief technical overview of PET/MRI, highlight how simultaneously performed PET/MRI can improve stand-alone MRI and PET/CT in gynecologic malignancies, provide an image-rich review to illustrate practical and clinically relevant applications of this imaging technique, and review common pitfalls encountered in clinical practice. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

In Vivo Ultrasound Molecular Imaging in the Evaluation of Complex Ovarian Masses: A Practical Guide to Correlation with Ex Vivo Immunohistochemistry

Ovarian cancer is the fifth leading cause of cancer-related deaths in women and the most lethal gynecologic cancer. It is curable when discovered at an early stage, but usually remains asymptomatic until advanced stages. It is crucial to diagnose the disease before it metastasizes to distant organs for optimal patient management. Conventional transvaginal ultrasound imaging offers limited sensitivity and specificity in the ovarian cancer detection. With molecularly targeted ligands addressing targets, such as kinase insert domain receptor (KDR), attached to contrast microbubbles, ultrasound molecular imaging (USMI) can be used to detect, characterize and monitor ovarian cancer at a molecular level. In this article, the authors propose a standardized protocol is proposed for the accurate correlation between in- vivo transvaginal KDR-targeted USMI and ex vivo histology and immunohistochemistry in clinical translational studies. The detailed procedures of in vivo USMI and ex vivo immunohistochemistry are described for four molecular markers, CD31 and KDR with a focus on how to enable the accurate correlation between in vivo imaging findings and ex vivo expression of the molecular markers, even if not the entire tumor could can be imaged by USMI, which is not an uncommon scenario in clinical translational studies. This work aims to enhance the workflow and the accuracy of characterization of ovarian masses on transvaginal USMI using histology and immunohistochemistry as reference standards, which involves sonographers, radiologists, surgeons, and pathologists in a highly collaborative research effort of USMI in cancer.

Prediction of Surgical Outcome in Advanced Ovarian Cancer by Imaging and Laparoscopy: A Narrative Review

Maximal-effort upfront or interval debulking surgery is the recommended approach for advanced-stage ovarian cancer. The role of diagnostic imaging is to provide a systematic and structured report on tumour dissemination with emphasis on key sites for resectability. Imaging methods, such as pelvic and abdominal ultrasound, contrast-enhanced computed tomography, whole-body diffusion-weighted magnetic resonance imaging and positron emission tomography, yield high diagnostic performance for diagnosing bulky disease, but they are less accurate for depicting small-volume carcinomatosis, which may lead to unnecessary explorative laparotomies. Diagnostic laparoscopy, on the other hand, may directly visualize intraperitoneal involvement but has limitations in detecting tumours beyond the gastrosplenic ligament, in the lesser sac, mesenteric root or in the retroperitoneum. Laparoscopy has its place in combination with imaging in cases where ima-ging results regarding resectability are unclear. Different imaging models predicting tumour resectability have been developed as an adjunctional objective tool. Incorporating results from tumour quantitative analyses (e.g., radiomics), preoperative biopsies and biomarkers into predictive models may allow for more precise selection of patients eligible for extensive surgery. This review will discuss the ability of imaging and laparoscopy to predict non-resectable disease in patients with advanced ovarian cancer.

Current Update on PET/MRI in Gynecological Malignancies-A Review of the Literature

Early detection of gynecological malignancies is vital for patient management and prolonging the patient's survival. Molecular imaging, such as positron emission tomography (PET)/computed tomography, has been increasingly utilized in gynecological malignancies. PET/magnetic resonance imaging (MRI) enables the assessment of gynecological malignancies by combining the metabolic information of PET with the anatomical and functional information from MRI. This article will review the updated applications of PET/MRI in gynecological malignancies.

Clinical and molecular evaluation of patients with ovarian cancer in the context of drug resistance to chemotherapy

The present study aimed to evaluate changes in the expression patterns at the gene and protein levels associated with drug resistance. The study group included 48 women who had a histopathologically confirmed diagnosis of stage I-IV ovarian cancer, they were divided into two subgroups (groups A and B). In group A, there were 36 patients in whom surgical treatment was supplemented with first-line chemotherapy according to current standards. Within this patient group, 5 had stage I (14%), 5 had stage II (14%), 25 had stage III (69%), and 1 had stage IV ovarian cancer (3%). Drug resistance was found after the third cycle of chemotherapy in 17 patients (71%) and after the sixth cycle in 7 patients (29%). Group B included 12 women with type I ovarian cancer, including 11 with stage I and 1 patient with stage IV ovarian cancer. The oncological treatment required only surgery. The control group (C) included 50 women in whom the uterus and adnexa were surgically removed for non-oncological reasons. Significantly higher levels of carcinoma antigen 125 CA-125 and human epididymis protein 4 HE4 were observed in group A and in menopausal women. Moreover, drug resistance was associated with significantly higher levels of CA-125 (p < 0.05). The genes UBA2, GLO1, STATH, and TUFT1 were differentiated in test samples from control samples. Moreover, drug resistance was associated with significantly higher expression of GLO1. The results of these assessments indicated the strong link between UBA2 and hsa-miR-133a-3p and hsa-miR-133b; GLO1 and hsa-miR-561-5p; STATH and hsa-miR-137-3p and hsa-miR-580-3p; and TUFT1 and hsa-miR-1233-3p and hsa-miR-2052. Correlation analysis showed a significant correlation between CA-125 and HE4 levels. Moreover, a significant correlation between TUFT1 mRNA and UBA2, GLO1, STATH (negative correlation), and TUFT1 in relation to CA-125 and HE4 (p < 0.05) was noted in all patients. In view of the lack of screening tests for ovarian cancer, the occurrence of the described correlation may be inscribed as an attempt to establish an assay that meets the criteria of a screening test and thus increase the early diagnosis of ovarian cancer.

Multidetector computed tomography in diagnosing peritoneal metastases in ovarian carcinoma

Multidetector computed tomography (MDCT) of the abdomen is currently the imaging examination of choice for the staging and follow-up of ovarian carcinoma (OC). Peritoneal metastases (PMs) represent the most common pathway for the metastatic spread of OC. MDCT scanners, due to several advantages-including increased volume coverage, reduced scanning time, acquisition of thin slices and creation of multiplanar reformations, and three-dimensional reconstructions-provide useful information regarding the early and accurate detection of PMs. Detailed mapping of peritoneal carcinomatosis is feasible, with improved detection of sub-centimeter peritoneal implants and thorough evaluation of curved peritoneal surfaces.

Clues to the diagnosis of borderline ovarian tumours: An imaging guide

Borderline Ovarian Tumours (BOTs) are an interesting subset of epithelial neoplasms defined histologically by atypical epithelial proliferation without stromal invasion. These tumours typically affect young women in the reproductive age group and have a good prognosis. Although ultrasonography is the primary screening imaging technique in the evaluation of any suspected adnexal mass, grey-scale and colour Doppler have limited value in characterizing BOTs. Thus, a pelvic magnetic resonance imaging (MRI) is recommended for further characterization on account of its multiplanar capabilities, excellent soft-tissue contrast and high spatial resolution. BOTs histological subtypes display specific features on MRI that are useful in differential diagnosis. However, the final diagnosis and staging of BOTs require pathologic evaluation after surgical excision. Therefore, the purpose of this review is to describe, illustrate and compare the imaging characteristics of the different subtypes of BOTs - serous, mucinous and seromucinous - focusing on MRI, as well as to correlate with pathology findings considering the recent 2020 World Health Organization (WHO) classification, in order to improve the accuracy of preoperative diagnosis and facilitate optimal patient management.

A multidisciplinary approach remains the best strategy to improve and strengthen the management of ovarian cancer (Review)

Ovarian cancer represents one of the most aggressive female tumors worldwide. Over the decades, the therapeutic options for the treatment of ovarian cancer have been improved significantly through the advancement of surgical techniques as well as the availability of novel effective drugs able to extend the life expectancy of patients. However, due to its clinical, biological and molecular complexity, ovarian cancer is still considered one of the most difficult tumors to manage. In this context, several studies have highlighted how a multidisciplinary approach to this pathology improves the prognosis and survival of patients with ovarian cancer. On these bases, the aim of the present review is to present recent advantages in the diagnosis, staging and treatment of ovarian cancer highlighting the benefits of a patient‑centered care approach and on the importance of a multidisciplinary team for the management of ovarian cancer.

Preoperative Prediction of Metastasis for Ovarian Cancer Based on Computed Tomography Radiomics Features and Clinical Factors

Background

There is urgent need for an accurate preoperative prediction of metastatic status to optimize treatment for patients with ovarian cancer (OC). The feasibility of predicting the metastatic status based on radiomics features from preoperative computed tomography (CT) images alone or combined with clinical factors were investigated.

Methods

A total of 101 OC patients who underwent primary debulking surgery were enrolled. Radiomics features were extracted from the tumor volumes contoured on CT images with LIFEx package. Mann-Whitney U tests, least absolute shrinkage selection operator (LASSO), and Ridge Regression were applied to select features and to build prediction models. Univariate and regression analysis were applied to select clinical factors for metastatic prediction. The performance of models generated with radiomics features alone, clinical factors, and combined factors were evaluated and compared.

Results

Nine radiomics features were screened out from 184 extracted features to classify patients with and without metastasis. Age and cancer antigen 125 (CA125) were the two clinical factors that were associated with metastasis. The area under curves (AUCs) for the radiomics signature, clinical factors model, and combined model were 0.82 (95% CI, 0.66-0.98; sensitivity = 0.90, specificity = 0.70), 0.83 (95% CI, 0.67-0.95; sensitivity = 0.71, specificity = 0.8), and 0.86 (95% CI, 0.72-0.99, sensitivity = 0.81, specificity = 0.8), respectively.

Conclusions

Radiomics features alone or radiomics features combined with clinical factors are feasible and accurate enough to predict the metastatic status for OC patients.

Progression-free survival by investigator versus blinded independent central review in newly diagnosed patients with high-grade serous ovarian cancer: Analysis of the VELIA/GOG-3005 trial

OBJECTIVE

In the phase 3 VELIA/GOG-3005 trial, veliparib added to carboplatin-paclitaxel and continued as maintenance improved progression-free survival (PFS) compared to carboplatin-paclitaxel alone in patients with newly diagnosed ovarian carcinoma. Primary analysis of PFS was by investigator (INV) assessment, with a supplemental analysis of PFS by blinded independent central review (BICR).

METHODS

Patients received veliparib or placebo with carboplatin-paclitaxel (6 cycles) and as maintenance (30 additional cycles). The primary analysis compared PFS in the veliparib-throughout arm to the carboplatin-paclitaxel only arm in the BRCA mutation (BRCAm), homologous recombination deficiency (HRD), and intention-to-treat (ITT) populations. Exploratory analyses of PFS in BRCA wildtype (BRCAwt), homologous recombination proficient (HRP), and HRD + BRCAwt populations were also performed. PFS per BICR and overall concordance rates between INV and BICR assessments were analyzed.

RESULTS

Hazard ratios for PFS by INV and BICR were consistent in each of the primary analysis and exploratory populations. In the ITT population, median PFS per INV was 23.5 months in the veliparib-throughout arm versus 17.3 months in the control arm (hazard ratio [HR] 0.683, 95% confidence interval [CI] 0.562-0.831; P < 0.001). Median PFS by BICR was 29.3 months versus 19.2 months (HR 0.687, 95% CI 0.504-0.806). In the ITT population, the overall concordance rates between INV and BICR were 78% and 75% for the veliparib-throughout and control arms, respectively.

CONCLUSIONS

Hazard ratios for PFS per BICR and per INV were consistent, with no suggestion of investigator bias. These findings support the reliability of PFS by INV in ovarian cancer trials.

Diagnostic performance of PET/CT and PET/MR in the management of ovarian carcinoma-a literature review

Ovarian cancer is a challenging disease. It often presents at an advanced stage with frequent recurrence despite optimal management. Accurate staging and restaging are critical for improving treatment outcomes and determining the prognosis. Imaging is an indispensable component of ovarian cancer management. Hybrid imaging modalities, including positron emission tomography/computed tomography (PET/CT) and PET/magnetic resonance imaging (MRI), are emerging as potential non-invasive imaging tools for improved management of ovarian cancer. This review article discusses the role of PET/CT and PET/MRI in ovarian cancer.

Low-grade serous epithelial ovarian cancer: a comprehensive review and update for radiologists

Low-grade serous carcinoma (LGSC) is an infrequent subtype of ovarian cancer, corresponding to 5% of epithelial neoplasms. This subtype of ovarian carcinoma characteristically has molecular features, pathogenesis, clinical behaviour, sensitivity to chemotherapy, and prognosis distinct to high-grade serous carcinoma (HGSC). Knowing the difference between LGSC and other ovarian serous tumours is vital to guide clinical management, which currently is only possible histologically. However, imaging can provide several clues that allow differentiating LGSC from other tumours and enable precise staging and follow-up of ovarian cancer treatment. Characteristically, LGSC appears as mixed lesions with variable papillary projections and solid components, usually in different proportions from those detected in serous borderline tumour and HGSC. Calcified extracellular bodies, known as psammoma bodies, are also a common feature of LGSC, frequently detectable within lymphadenopathies and metastases associated with this type of tumour. In addition, the characterisation of magnetic resonance imaging enhancement also plays an essential role in calculating the probability of malignancy of these lesions. As such, in this review, we discuss and update the distinct radiological modalities features and the clinicopathologic characteristics of LGSC to allow radiologists to be familiarised with them and to narrow the differential diagnosis when facing this type of tumour.

Gastric linitis plastica due to signet-ring cell carcinoma with Krukenberg tumors diagnosed by endoscopic ultrasound-guided fine-needle aspiration

Gastric linitis plastica is a rare condition characterized by the stiffening and thickening of the gastric wall, presenting a "leather bottle" appearance. It is generally associated with infiltration of poorly differentiated gastric cancer cells, but similar findings can arise due to metastases from other cancers and benign inflammatory processes. Despite advances in imaging modalities, pathological evaluation is required for diagnosis. As endoscopic mucosal biopsies may not be diagnostic, endoscopic ultrasound-guided fine-needle aspiration of the thickened stomach wall presents a potential diagnostic option. We report a case which presented with bilateral ovarian tumors and was ultimately diagnosed as gastric signet-ring cell carcinoma with Krukenberg tumors by endoscopic ultrasound-guided fine-needle aspiration of the stomach wall. The preoperative diagnosis allowed the patient to avoid surgery and to start chemotherapy for gastric cancer. We also review the existing literature on endoscopic ultrasound-guided fine-needle aspiration in the context of gastric linitis plastica.

Non-contrast MRI can accurately characterize adnexal masses: a retrospective study

Objective

To determine the accuracy of interpretation of a non-contrast MRI protocol in characterizing adnexal masses.

Methods and materials

Two hundred ninety-one patients (350 adnexal masses) who underwent gynecological MRI at our institution between the 1^st of January 2008 and the 31^st of December 2018 were reviewed. A random subset (102 patients with 121 masses) was chosen to evaluate the reproducibility and repeatability of readers’ assessments. Readers evaluated non-contrast MRI scans retrospectively, assigned a 5-point score for the risk of malignancy and gave a specific diagnosis. The reference standard for the diagnosis was histopathology or at least one-year imaging follow-up. Diagnostic accuracy of the non-contrast MRI score was calculated. Inter- and intra-reader agreement was analyzed with Cohen’s kappa statistics.

Results

There were 53/350 (15.1%) malignant lesions in the whole cohort and 20/121 (16.5%) malignant lesions in the random subset. Good agreement between readers was found for the non-contrast MRI score (к = 0.73, 95% confidence interval [CI] 0.58–0.86) whilst the intra-reader agreement was excellent (к = 0.81, 95% CI 0.70–0.88). The non-contrast MRI score value of ≥ 4 was associated with malignancy with a sensitivity of 84.9%, a specificity of 95.9%, an accuracy of 94.2% and a positive likelihood ratio of 21 (area under the receiver operating curve 0.93, 95% CI 0.90–0.96).

Conclusion

Adnexal mass characterization on MRI without the administration of contrast medium has a high accuracy and excellent inter- and intra-reader agreement. Our results suggest that non-contrast studies may offer a reasonable diagnostic alternative when the administration of intravenous contrast medium is not possible.

Key Points

• A non-contrast pelvic MRI protocol may allow the characterization of adnexal masses with high accuracy.

• The non-contrast MRI score may be used in clinical practice for differentiating benign from malignant adnexal lesions when the lack of intravenous contrast medium precludes analysis with the O–RADS MRI score.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-07737-9.

Computed Tomography Based Radiomics as a Predictor of Survival in Ovarian Cancer Patients: A Systematic Review

Simple Summary

Ovarian cancer represents the most lethal gynecological malignancy. Since many new drugs have been recently introduced as adjunctive treatments for this pathology, an early prediction of outcome might be helpful to further improve outcomes. Radiomics represents a recent advancement, relying on extraction of quantitative features from imaging examinations. Indeed, clinical images, such as computed tomography images, may contain quantitative information, reflecting the underlying pathophysiology of a tumoral tissue. Radiomic analyses can be performed in tumor regions and metastatic lesions, as well as in normal tissues. The radiomic process relies on quantitative features, usually extracted by dedicated software, and then culminates in analysis and model building, according to a defined clinical question. This systematic review aims to evaluate association between radiomics based on computed tomography images and survival (in terms of overall survival and progression free survival) in ovarian cancer patients.

Abstract

The objective of this systematic review was to assess the results of radiomics for prediction of overall survival (OS) and progression free survival (PFS) in ovarian cancer (OC) patients. A secondary objective was to evaluate the findings of papers that based their analyses on inter-site heterogeneity. This systematic review was conducted according to the PRISMA statement. After the initial retrieval of 145 articles, the final systematic review comprised six articles. Association between radiomic features and OS was evaluated in 3/6 studies (50%); all articles showed a significant association between radiomic features and OS. Association with PFS was evaluated in 5/6 (83%) articles; the period of follow-up ranged between six and 36 months. All the articles showed significant association between radiomic models and PFS. Inter-site textural features were used for analysis in 2/6 (33%) articles. They demonstrated that high levels of inter-site textural heterogeneity were significantly associated with incomplete surgical resection in breast cancer gene-negative patients, and that lower heterogeneity was associated with complete resectability. There were some differences among papers in methodology; for example, only 3/6 (50%) articles included validation cohorts. In conclusion, radiomic models have demonstrated promising results as predictors of survival in OC patients, although larger studies are needed to allow clinical applicability.

Dual energy CT in gland tumors: a comprehensive narrative review and differential diagnosis

Dual energy CT (DECT)with image acquisition at two different photon X-ray levels allows the characterization of a specific tissue or material/elements, the extrapolation of virtual unenhanced and monoenergetic images, and the quantification of iodine uptake; such special capabilities make the DECT the perfect technique to support oncological imaging for tumor detection and characterization and treatment monitoring, while concurrently reducing the dose of radiation and iodine and improving the metal artifact reduction. Even though its potential in the field of oncology has not been fully explored yet, DECT is already widely used today thanks to the availability of different CT technologies, such as dual-source, single-source rapid-switching, single-source sequential, single-source twin-beam and dual-layer technologies. Moreover DECT technology represents the future of the imaging innovation and it is subject to ongoing development that increase according its clinical potentiality, in particular in the field of oncology. This review points out recent state-of-the-art in DECT applications in gland tumors, with special focus on its potential uses in the field of oncological imaging of endocrine and exocrine glands.

Glycolytic phenotypes in an evaluation of ovarian carcinoma based on carcinogenesis and BRCA mutation

BACKGROUNDS

Recently, a dualistic carcinogenesis model of ovarian cancer has emerged. We aimed to investigate differences in the glycolytic phenotypes of type I and type II ovarian carcinoma on the basis of FDG uptake and in the pathological features according to tumour grade and histology.

MATERIALS AND METHODS

In total, 386 epithelial ovarian carcinoma patients underwent debulking surgery, and the histopathological results of the patients were retrospectively reviewed from 2003 to 2017. Among these patients, 170 patients had histopathological data that were available due to primary cytoreductive surgery and could be analysed regarding FDG avidity in type I and type II ovarian cancer. The FDG uptake of the tumour (SUVmax), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) were analysed according to the tumour grade, histology and type of ovarian carcinogenesis (type I and II) and prognosis.

RESULTS

Among the 386 patients, there was a significant difference in SUVmax among ovarian cancer subtypes. There was a significant increase in SUVmax as the tumour grade increased (8.08 ± 0.63, 10.5 ± 0.40, and 12.7 ± 0.38 for grades I, II and III, respectively, Kruskal-Wallis test, p < 0.0001). Among the 90 type I and 80 type II ovarian carcinoma patients, there was a significant difference in SUVmax (type I and II, 9.47 ± 0.54 and 12.97 ± 0.70, respectively, Mann-Whitney test, p = 0.0003). However, no significant change in SUVmax was observed between BRCA-positive and BRCA-negative patients (N = 80, 13.8 ± 5.78 and 12.4 ± 6.30, Student's t-test, p = 0.3075). Among clinicopathologic and metabolic parameters, type of ovarian cancer, MTV and CA125 were significant factors in the prediction of recurrence.

CONCLUSIONS

The glycolytic phenotype was related to tumour grade and histological subtype, with significant differences between type I and II ovarian cancer. SUVmax of the ovarian cancer would be considered in the differentiation of type I and II ovarian cancer.

miR-197-3p reduces epithelial-mesenchymal transition by targeting ABCA7 in ovarian cancer cells

The present study was designed to explore the role of microRNA-197-3p in regulating the epithelial-mesenchymal cellular transition in ovarian cancer. The results showed that miR-197 to be significantly (P < 0.05) downregulated in human ovarian cancer tissues and cell lines. Overexpression of miR-197 significantly (P < 0.05) reduced the proliferation of OVACAR-3 cancer cells. Additionally, the colony formation of the OVACAR-3 cells was inhibited by 59% relative to control. The migration and invasion of the OVACAR-3 cells was inhibited by 64% and 72%, respectively, upon miR-197 overexpression. Western blot analysis showed miR-197 was found to upregulate the expression of E-cadherin, while the expression of N-cadherin, vimentin, and snail proteins was found to decrease significantly (P < 0.05). TargetScan analysis together with dual luciferase assay revealed that miR-197 exerts its effects by targeting ABCA7 in ovarian cancer. ABCA7 was significantly (P < 0.05) overexpressed in ovarian cancer tissues and cell lines. However, silencing of ABCA7 resulted in significant inhibition of cell proliferation, migration, and invasion. Nonetheless, overexpression of ABCA7 could abolish the tumor-suppressive effects of miR-197 on the OVACAR-3 cells. Taken together, miR-197 acts a tumor-suppressive in ovarian cancer and points towards its therapeutic implications in the treatment of ovarian cancer.

Epithelial ovarian cancer: a review of preoperative imaging features indicating suboptimal surgery

Epithelial ovarian cancer has been traditionally treated with cytoreductive surgery and chemotherapy. Optimal surgery is the key to improving the prognosis, and, thus, preoperative imaging should be carefully assessed to determine if the involvement of gastrointestinal, vascular, or thoracic surgeons is necessary to achieve this. Consequently, gynecologists should be able to recognize which imaging features suggest optimal or suboptimal resection. The aim of this review was to present the preoperative imaging features indicating suboptimal resection of epithelial ovarian cancer.

Does dual-energy CT differentiate benign and malignant ovarian tumours?

AIM

To assess the ability of dual-energy computed tomography (DECT) to distinguish benign from malignant ovarian tumours (OTs).

MATERIALS AND METHODS

Following approval of the institutional review board, the institutional database was mined for treatment-naive patients who underwent primary cytoreduction for OT. Thirty-seven patients were included and divided into those with benign OTs (n = 11) and malignant OTs (n = 26), including high-grade (n = 20) and low-grade (n = 6) malignant OTs. Advanced processing and region of interest delineation on the ovarian mass were performed using the preoperative staging DECT examination using the Advantage Workstation. The pixel-level data of the CT attenuation values at 50, 70, and 120 keV and the effective atomic number (Z_eff), water content (WC), and iodine content (IC) in the ovarian mass were recorded. The Wilcoxon rank-sum test was used to compare CT attenuation data at different voltages, Z_eff, and WC and IC levels between benign and malignant OTs and between high- and low-grade malignant OTs. Simple logistic regression was used to correlate the imaging characteristics with malignant status and grade.

RESULTS

Malignant OTs had significantly higher Z_eff and IC compared with benign OTs. The threshold values for the diagnosis of malignant OT were IC≥9.74 (100 μg/cm³) with 81% sensitivity and 73% specificity and Z_eff ≥8.16 with 85% sensitivity and 73% specificity. High-grade OTs had significantly higher WC compared with low-grade OTs, and a threshold of ≥1,013.92 mg/cm³ differentiated them with 80% sensitivity and 83% specificity.

CONCLUSION

DECT may be a tool to help distinguish malignant and benign OTs and predict tumour grade.

Cardiophrenic lymph node resection in cytoreduction for primary advanced or recurrent epithelial ovarian carcinoma: a cohort study

OBJECTIVES

To evaluate the clinical outcomes of epithelial ovarian carcinoma patients who underwent cardiophrenic lymph node resection.

METHODS

We retrospectively reviewed the records of all surgically treated patients with advanced epithelial ovarian carcinoma (stages IIIC-IV) who underwent cardiophrenic lymph node resection between 2002 and 2018. Only those in whom cardiophrenic lymph node involvement was the only detectable extra-abdominal disease were included. Patients with suspected cardiophrenic lymph node metastasis on staging images underwent a transdiaphragmatic incision to access the para-cardiac space after complete abdominal cytoreduction achievement. Data on disease-free survival, overall survival, and surgical procedures performed concurrently with cardiophrenic lymph node resection were collected.

RESULTS

Of the total 456 patients, 29 underwent cardiophrenic lymph node resection; of these, 24 patients met the inclusion criteria. Twenty-two, one, and one patients had high grade serous epithelial ovarian carcinoma, low grade epithelial ovarian carcinoma, and ovarian carcinosarcoma, respectively. Ten patients had recurrent disease (recurrence group). Fourteen patients underwent cytoreduction during primary treatment (primary debulking group); four underwent cytoreduction after neoadjuvant chemotherapy. Cardiophrenic lymph node resection was performed on the right side in 19 patients, left side in three, and bilaterally in two. The average procedural duration was 28 minutes, with minimal blood loss and no severe complications. Twenty-one patients had cardiophrenic lymph node positivity. The median disease-free intervals were 17 and 12 months in the recurrent and primary debulking surgery groups, respectively. The mediastinum was the first recurrence site in 10 patients. Five patients developed brain metastases. Five patients had an overall survival beyond 50 months.

CONCLUSIONS

Although rare, the cardiophrenic lymph nodes may be a site of metastasis of ovarian cancer. Although their presence might indicate future recurrence, some patients may achieve long-term survival. Resection should be considered in cases of suspicious involvement to confirm extra-abdominal disease and achieve complete cytoreduction.

MicroRNAs in ovarian cancer and recent advances in the development of microRNA-based biosensors

Ovarian cancer is the most aggressive of all gynaecological malignancies and is the leading cause of cancer-associated mortality worldwide.

Pre-operative evaluation of epithelial ovarian cancer patients: Role of whole body diffusion weighted imaging MR and CT scans in the selection of patients suitable for primary debulking surgery. A single-centre study

PURPOSE

to evaluate the accuracy of Whole Body MRI including Diffusion-Weighted Imaging sequences (WB DWI MR) in the assessment of sites of disease in epithelial ovarian cancer (EOC), in comparison to CT; to evaluate whether a clinical-radiological score may predict suboptimal cytoreductive surgery.

METHODS

patients with suspected EOC who underwent pre-operative WB DWI MR were included; CT scans were recorded. Data recorded included: age, staging, dates of examinations and surgery; tumour markers; sites of disease at imaging scans and at surgery. For calculation of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of WB DWI MR and CT, surgical evaluation represented the gold standard. The accuracy of WB DWI MR and CT was compared. The association between clinical and radiological criteria with sub-optimal cytoreduction was tested to identify a final model to predict sub-optimal cytoreduction.

RESULTS

92 patients were included; 77/92 (83.7 %) were optimally cytoreduced. Sixty-six CT and 92 MR examinations were evaluated. WB DWI MR showed overall higher accuracy than CT in assessing all sites, but it performed significantly better than CT specifically for involvement of mesentery, lumbo-aortic lymph nodes, pelvis, large bowel, sigmoid-rectum. The predicting score for suboptimal cytoreduction included: mesenteric carcinomatosis; mesenteric retraction; large bowel carcinomatosis.

CONCLUSIONS

In pre-operative evaluation of EOC patients, WB DW MRI is accurate for assessment of multiple sites and it is significantly more accurate than CT for specific unresectable sites. In our series, significant sites of disease for suboptimal cytoreduction were mesenteric carcinomatosis, mesenteric retraction and large bowel carcinomatosis.

Management Driven Structured Reporting in Ovarian Cancer

Since majority (80%) of ovarian cancer patients present at an advanced stage, imaging performed on these patients have numerous findings. The combination of multiple findings on imaging, complexity of anatomical structures which are involved in ovarian cancer, and the need to perceive certain subtle imaging features which would impact management often makes it challenging to systematically review images of these patients. Similarly, it is difficult to effectively communicate these findings in radiology reports. Structured reporting that is geared toward clinical decision-making has been an area of recognized need. An understanding of the review areas, which aid clinical decision-making in a multidisciplinary team setting at our institution led us to the proposed structured reporting template for ovarian cancer. Through this review, the authors would like to share this reporting template with examples.

An update on preoperative assessment of the resectability of advanced ovarian cancer

The best prognosis for advanced ovarian cancer is provided by no residual disease after primary cytoreductive surgery. It is thus important to be able to predict resectability that will result in complete cytoreduction, while avoiding unnecessary surgery that may leave residual disease. No single procedure appears to be sufficiently accurate and reliable to predict resectability. The process should include a preoperative workup based on clinical examination, biomarkers, especially tumor markers, and imaging, for which computed tomography, as well as sonography, magnetic resonance imaging and positron-emission tomography, can be used. This workup should provide sufficient information to determine whether complete cytoreduction is possible or if not, to propose neoadjuvant chemotherapy which is preferable in this case. For the remaining patients, laparoscopy is broadly recommended as an ultimate triage step. However, its modalities are still debated, and several scores have been proposed for standardization and improving accuracy. The risk of false negatives requires a final assessment of resectability as the first stage of cytoreductive surgery by laparotomy. Composite models, consisting of several criteria of workup and, sometimes, laparoscopy have been proposed to improve the accuracy of the predictive process. Regardless of the modality, the process appears to be accurate and reliable for predicting residual disease but less so for predicting complete cytoreduction and thus avoiding unnecessary surgery and an inappropriate treatment strategy. Overall, the proposed procedures are heterogeneous, sometimes unvalidated, or do not consider advances in surgery. Future techniques and/or models are still needed to improve the prediction of complete resectability.

Magnetic resonance imaging findings for discriminating clear cell carcinoma and endometrioid carcinoma of the ovary

BACKGROUND

Common cancerous histological types associated with endometriosis are clear cell carcinoma (CCC) and endometrioid carcinoma (EC). CCC is regarded as an aggressive, chemoresistant histological subtype. Magnetic resonance imaging (MRI) offers some potential advantages to diagnose ovarian tumors compared with ultrasonography or computed tomography. This study aimed to identify MRI features that can be used to differentiate between CCC and EC.

METHODS

We searched medical records of patients with ovarian cancers who underwent surgical treatment at Nara Medical University Hospital between January 2008 and September 2018; we identified 98 patients with CCC or EC who had undergone preoperative MRI. Contrasted MRI scans were performed less than 2 months before surgery. Patients were excluded from the study if they had no pathology, other pathological subtype of epithelial ovarian cancer, and/or salvage treatment for recurrence and metastatic ovarian cancer at the time of study initiation. Clinically relevant variables that were statistically significant by univariate analysis were selected for subsequent multivariate regression analysis to identify independent factors to distinguish CCC from EC.

RESULTS

MRI of CCC and EC showed a large cystic heterogeneous mixed mass with mural nodules protruding into the cystic space. Univariate logistic regression analysis revealed that the growth pattern (broad-based nodular structures [multifocal/concentric sign] or polypoid structures [focal/eccentric sign]), surface irregularity (a smooth/regular surface or a rough/irregular/lobulated surface), "Width" of mural nodule, "Height-to-Width" ratio (HWR), and presence of preoperative ascites were factors that significantly differed between CCC and EC. In the multivariate logistic regression analysis, the growth pattern of the mural nodule (odds ratio [OR] = 0.69, 95% confidence interval [CI]: 0.013-0.273, p = 0.0004) and the HWR (OR = 3.71, 95% CI: 1.128-13.438, p = 0.036) were independent predictors to distinguish CCC from EC.

CONCLUSIONS

In conclusion, MRI data showed that the growth pattern of mural nodules and the HWR were independent factors that could allow differentiation between CCC and EC. This finding may be helpful to predict patient prognosis before operation.

Imaging in the pre-operative staging of ovarian cancer

The main prognostic factor in ovarian cancer is the stage of disease at diagnosis. The staging system in use (FIGO classification, updated in 2014) is based on the surgical-pathological findings. Although surgical staging is the gold standard in ovarian cancer, the initial patient management depends on the imaging-based pre-surgical staging assessment, in order to identify unresectable or difficult to resect disease. Radiologists need to be aware of the strengths of the available imaging modalities, as well as the imaging pitfalls. Clear understanding of pattern of disease spread and review areas are critical for accurate staging and treatment planning. The current standard of care for pre-surgical staging is CT of the thorax, abdomen, and pelvis. This allows a rapid evaluation of disease extent and is fairly accurate in identifying bulky disease but has definite limitations in assessing the extent of small volume disease and in the confirmation of certain sites of disease beyond the abdomen. Functional MRI has been reported to be superior in detecting small peritoneal deposits. PET/CT may be used as a problem-solving tool in some patients where determination remains unclear, particularly in confirmation of advanced stage beyond the abdomen.

Low-grade epithelial ovarian cancer: what a radiologist should know

Ovarian cancer accounts for the death of over 100,000 females every year and is the most lethal gynecological malignancy. Low-grade serous ovarian carcinoma (LGSOC) and high-grade serous ovarian carcinoma (HGSOC) have been found to represent two distinct entities based on their molecular differences, clinical course, and response to chemotherapy. Currently, all ovarian cancers are staged according to the revised staging system of the International Federation of Gynecology and Obstetrics (FIGO). Imaging plays an integral role in the diagnosis, staging, and follow-up of ovarian cancers. This review will be based on the two-tier grading system of epithelial ovarian cancers, with the main emphasis on serous ovarian cancer, and the role of imaging to characterize low-grade vs high-grade tumors and monitor disease recurrence during follow-up.

Pre-operative assessment of intra-abdominal disease spread in epithelial ovarian cancer: a comparative study between ultrasound and computed tomography

Objective

To compare the diagnostic performance of ultrasound and computed tomography (CT) for detecting pelvic and abdominal tumor spread in women with epithelial ovarian cancer.

Methods

An observational cohort study of 93 patients (mean age 57.6 years) with an ultrasound diagnosis of adnexal mass suspected of malignancy and confirmed histologically as epithelial ovarian cancer was undertaken. In all cases, transvaginal and transabdominal ultrasound as well as CT scans were performed to assess the extent of the disease within the pelvis and abdomen prior to surgery. The exploration was systematic, analyzing 12 anatomical areas. All patients underwent surgical staging and/or cytoreductive surgery with an initial laparoscopy for assessing resectability. The surgical and pathological findings were considered as the 'reference standard'. Sensitivity and specificity of ultrasound and CT scanning were calculated for the different anatomical areas and compared using the McNemar test. Agreement between ultrasound and CT staging and the surgical stage was estimated using the weighted kappa index.

Results

The tumorous stage was International Federation of Gynecology and Obstetrics (FIGO) stage I in 26 cases, stage II in 11 cases, stage III in 47 cases, and stage IV in nine cases. Excluding stages I and IIA cases (n=30), R0 (no macroscopic residual disease) was achieved in 36 women (62.2%), R1 (macroscopic residual disease <1 cm) was achieved in 13 women (25.0%), and R2 (macroscopic residual disease >1 cm) debulking surgery occurred in three women (5.8%). Eleven patients (11.8%) were considered not suitable for optimal debulking surgery during laparoscopic assessment. Overall sensitivity of ultrasound and CT for detecting disease was 70.3% and 60.1%, respectively, and specificity was 97.8% and 93.7%, respectively. The agreement between radiological stage and surgical stage for ultrasound (kappa index 0.69) and CT (kappa index 0.70) was good for both techniques. Overall accuracy to determine tumor stage was 71% for ultrasound and 75% for CT.

Conclusion

Detailed ultrasound examination renders a similar diagnostic performance to CT for assessing pelvic/abdominal tumor spread in women with epithelial ovarian cancer.

Fluorescent Nanoparticles for the Guided Surgery of Ovarian Peritoneal Carcinomatosis

Complete surgical resection is the ideal cure for ovarian peritoneal carcinomatosis, but remains challenging. Fluorescent guided surgery can be a promising approach for precise cytoreduction when appropriate fluorophore is used. In the presence paper, we review already developed near- and short-wave infrared fluorescent nanoparticles, which are currently under investigation for peritoneal carcinomatosis fluorescence imaging. We also highlight the main ways to improve the safety of nanoparticles, for fulfilling prerequisites of clinical application.

The Clearance of Serum Human Epididymis Protein 4 Following Primary Cytoreductive Surgery for Ovarian Carcinoma

OBJECTIVE

The aim of this study was to examine the clearance of serum human epididymis protein 4 (HE4) in the immediate postoperative period in patients undergoing maximal effort cytoreductive surgery for ovarian carcinoma.

METHODS

The study was performed at a tertiary gynecologic oncology center. The surgery was performed by accredited gynecological oncologists.

RESULTS

Preoperative and serial postoperative venous blood samples at 4, 8, 24, 48, 72, 96, and 120 hours were taken from 10 sequential patients. Pretreatment HE4 is considered elevated at greater than 70 pmol/L. Human epididymis protein 4 was greater than 70 pmol/L in 7 patients, including all patients with high-grade serous carcinoma. Patients with preoperative elevation of serum HE4 and complete cytoreduction cleared more than 80% of serum HE4 in the first 4 hours and more than 88% within 5 days of surgery. One patient with incomplete cytoreduction of high-grade serous carcinoma had 66% clearance at 4 hours and a plateau thereafter.

CONCLUSIONS

Human epididymis protein 4 derived from ovarian carcinoma had a short half-life of less than 4 hours in the circulation when cytoreductive surgery was complete. Sustained low HE4 following surgery could be a useful indicator of the completeness of cytoreduction. Plateau or rise in serum HE4 could suggest persistent disease. Comparison of values on day 1 and day 4 or 5 might have value in assessing the completeness of cytoreduction.

Fludeoxyglucose F 18 PET/CT Assessment of Ovarian Cancer

Ovarian cancer is one of the most common gynecologic cancers and one of the leading causes of cancer death in women. It is often asymptomatic in early stages, and thus most patients are diagnosed when it is of advanced stage. For these reasons, the role of biomarkers and tomographic imaging is crucial. Fludeoxyglucose F 18 PET/CT is a useful imaging modality in different clinical settings of the disease, overcoming some limits of conventional imaging and influencing prognosis and therapeutic approaches. PET/MR imaging is an emerging modality, and its potential role remains to be explored.

The Diagnostic and Prognostic Potential of microRNAs in Epithelial Ovarian Carcinoma

Ovarian cancer causes more than 100,000 deaths globally per year. Despite intensive research efforts, there has been little improvement in the overall survival of patients over the past three decades. Most patients are not diagnosed until the cancer is at an advanced stage, by which time their chances of still being alive after 5 years are appallingly low. Attempts to extend life in these patients have been, for the most part, unsuccessful. This owes partly to the lack of suitable biomarkers for stratifying patients at the molecular level, into responders and non-responders. This would lead to more drugs being shown to have a clinical benefit and being approved for use in subgroups of patients. There is also a desperate need for improved biomarkers for earlier detection of ovarian cancer; if the disease is detected sooner there is a significantly improved outlook. In this review, we outline the evidence that microRNAs are deregulated in ovarian cancer, what this can tell us about tumour progression and how it could be used to improve patient stratification in clinical trials. We also describe the potential for circulating microRNAs, both associated with proteins or carried in vesicles, to be used as diagnostics for earlier detection or as biomarkers for informing clinicians on the prognosis and best treatment of ovarian cancer.

Preliminary application of multiple parameters spectral CT in the diagnosis of ovarian cancer

The aim of the study was to evaluate the effectiveness of spectral CT in the diagnosis of ovarian cancer. We retrospectively analyzed the data of 22 patients with spectral CT enhanced scan. The patients were divided into 2 groups: ovarian cancer group (n = 11) and benign tumor group (n = 11), according to the pathologic results. CT values at 40 keV, iodine concentration (IC), water concentration (WC) and spectral curve slope (λHU) of arterial phase and venous phase in the tumors of 2 groups were measured with gemstone spectral imaging (GSI) post-processing software. The independent samples t test was used to compare these multiple parameters above between 2 groups. For the parameters which showed statistically different, the ROC curves were further generated to calculate their diagnostic effectiveness respectively. According to the results, CT values at 40 keV, IC and λHU measured in arterial and venous phases were higher in ovarian cancer group than those in benign tumor group. There were significant differences between these 2 groups (P < 0.05). While WC had no significant difference in these 2 groups (P > 0.05). CT values at 40 keV, IC and λHU had high effectiveness to the diagnosis of ovarian cancer according to ROC curves. The optimal parameter among them was IC in arterial phase with AUC of 0.90. Using 10.92 (100 ug/cm3) as a threshold value, the sensitivity and specificity for diagnosis were 88.9% and 94.7%. Thus, we concluded that spectral CT with multiple parameters was valuable in the diagnosis of ovarian cancer.

Diagnostic value of whole body diffusion-weighted MRI compared to computed tomography for pre-operative assessment of patients suspected for ovarian cancer

BACKGROUND

Despite excellent per-lesion performance for peritoneal staging, the additional clinical value of diffusion-weighted magnetic resonance imaging (DWI/MRI) compared to computed tomography (CT) remains to be established in ovarian cancer. Our purpose was to evaluate whole body (WB)-DWI/MRI for diagnosis, staging and operability assessment of patients suspected for ovarian cancer compared to CT.

METHODS

One hundred and sixty-one patients suspected for ovarian carcinoma underwent 3 T WB-DWI/MRI and contrast-enhanced CT. WB-DWI/MRI and CT were compared for confirmation of the malignant nature and primary origin of the ovarian mass, Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) staging and prediction of incomplete resection using institutional operability criteria. Interobserver agreement between two readers was determined for WB-DWI/MRI and CT.

RESULTS

WB-DWI/MRI showed a significantly higher accuracy than CT (93 versus 82%, p = 0.001) to confirm the malignant nature of the ovarian mass and correctly identified 26 of 32 (81%) cancers of non-ovarian origin compared to 10/32 (31%) for CT (p < 0.001). WB-DWI/MRI assigned more ovarian carcinoma patients to the correct FIGO stage (82/94, 87%) compared with CT (33/94, 35%). For prediction of incomplete resection, WB-DWI/MRI showed significantly higher sensitivity (94 versus 66%), specificity (97.7 versus 77.3%) and accuracy (95.7 versus 71.3%) compared to CT (p < 0.001). Interobserver agreement was almost perfect (κ = 0.90) for WB-DWI/MRI and moderate (κ = 0.52) for CT for prediction of incomplete resection.

CONCLUSIONS

WB-DWI/MRI was superior to CT for primary tumour characterisation, staging and prediction of incomplete resection in patients suspected for ovarian cancer.

Ovarian Sertoli-Leydig cell tumours: How typical is their typical presentation?

Ovarian Sertoli-Leydig cell tumours (OSLCT) are rare and typically present with androgenic manifestations in women of the 2nd-3rd decade. Out of 228 diagnoses of ovarian sex cord-stromal tumours recorded at an academic institution during a 14-year period, eight women were surgically treated for OSLCT. Patient mean age was 54.8 years (range 19-81), five women being in the postmenopausal stage (62.5%). Only one woman presented with androgenic manifestations (12.5%), four with abnormal/postmenopausal uterine bleeding (50%), and three with abdominal pain (37.5%). Fertility sparing or radical surgery was performed depending on patient age and stage of disease. The only patient with an advanced disease (FIGO stage IV) was referred to palliative care postoperatively. The other seven were at FIGO stage I. Five of them were free from disease at a mean follow-up of 67 months, while the remaining two were lost at follow-up. The youngest woman of the series, treated with fertility-preserving unilateral salpingo-oophorectomy at the age of 19, had two spontaneous pregnancies and deliveries of healthy babies during a 10-year follow-up period. In conclusion, our single institution 14-year experience demonstrates that the diagnosis of OSLCT is particularly challenging since many patients are older than expected and lack androgenic manifestations. Impact statement • What is already known on this subjectOvarian Sertoli-Leydig cell tumours (OSLCT) are rare and are thought to typically present with androgenic manifestations in women of the 2nd-3rd decade. • What the results of this study addOur single institution 14-year experience shows that a high proportion of women with ovarian Sertoli-Leydig cell tumours may not present with androgenic manifestations, and many of them also are in the postmenopausal stage. Most patients have a good prognosis and fertility-preserving surgery in younger women can lead to spontaneous pregnancies and deliveries of healthy children after treatment. • What are the implications of these findings for clinical practice and/or further researchThe diagnosis of OSLCT is particularly challenging and therefore not reached before surgery in most of the cases. However, while hysterectomy with bilateral salpingo-oophorectomy and surgical staging are recommended for women with higher stage or no fertility wish, fertility-sparing surgery should be considered in younger women with early disease. Therefore, further research should focus on non-invasive diagnosis possibly by means of laboratory or imaging techniques.