Staging ovarian cancer: role of imaging

EANM guideline on the role of 2-[18F]FDG PET/CT in diagnosis, staging, prognostic value, therapy assessment and restaging of ovarian cancer, endorsed by the American College of Nuclear Medicine (ACNM), the Society of Nuclear Medicine and Molecular Imaging (SNMMI) and the International Atomic Energy Agency (IAEA)

In most patients with ovarian carcinoma, the diagnosis is reached when the disease is long past the initial stages, presenting already an advanced stage, and they usually have a very bad prognosis. Cytoreductive or debulking surgical procedures, platinum-based chemotherapy and targeted agents are key therapeutic elements. However, around 7 out of 10 patients present recurrent disease within 36 months from the initial diagnosis. The metastatic spread in ovarian cancer follows three pathways: contiguous dissemination across the peritoneum, dissemination through the lymphatic drainage and, although less importantly in this case, through the bloodstream. Radiological imaging, including ultrasound, CT and MRI, are the main imaging techniques in which management decisions are supported, CT being considered the best available technique for presurgical evaluation and staging purposes. Regarding 2-[¹⁸F]FDG PET/CT, the evidence available in the literature demonstrates efficacy in primary detection, disease staging and establishing the prognosis and especially for relapse detection. There is limited evidence when considering the evaluation of therapeutic response. This guideline summarizes the level of evidence and grade of recommendation for the clinical indications of 2-[¹⁸F]FDG PET/CT in each disease stage of ovarian carcinoma.

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.

Evaluation of Computed Tomography Scan and CA 125 Response in Predicting Operability in Advanced Ovarian Cancer and Assessing Survival Outcome in Interval Cytoreductive Surgery

The study aims at the prediction of optimal cytoreduction (OCR) in patients undergoing interval cytoreduction (ICR) in advanced epithelial ovarian cancer (AEOC) based on CT imaging and CA 125 values and assessing the survival pattern of these patients after ICR. This is a prospective observational study of patients with stage III C ovarian cancer who underwent ICR in our institution after neoadjuvant chemotherapy (NACT). All consecutive patients operated from April 2016 to October 2017 were included in the study. From their medical records, their demographic details and clinical variables were recorded. The CA 125 value and CT scan findings before and after chemotherapy were documented. A Bristow's predictive score (BS) was calculated based on the radiological parameters. After ICR, the outcome of the surgery was documented. Optimal cytoreduction (OCR) was defined as no gross residual disease after surgery. The surgical outcome was correlated with the CA 125 difference pre and post chemotherapy and Bristow's predictive score pre and post chemotherapy. The patients were followed up and their survival at 6 and 12 months was assessed. Univariate and multivariate analysis was done to identify factors predicting OCR. 51 patients were included in the study. Age group of the women ranged from 31 to 74 years with a mean of 52 years. Majority of the patients (70.6%) were postmenopausal. Of the 51 women, OCR could be achieved in 31 patients (60.8%). Post-chemotherapy, 36 patients had elevated CA125 above baseline of which 50% attained OCR. Forty six patients had CA 125 response post chemotherapy of which 67.4% attained OCR. Forty five patients had reduction in Bristow Score compared to the pre chemo values of which 64.4% attained OCR which was not found to be statistically significant. Overall survival was 100% survival at 6 months and 92.8% at 12 months in those who achieved OCR. Those with residual disease 0.1-1 cm had survival of 74.1% at 6 and 12 months. Those with residual disease > 1 cm had a survival of 50% at 6 and 12 months. CA125 response has a significant role in predicting OCR while CT evaluation using the BS was not useful in predicting OCR during ICR for AEOC.

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.

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.

Potential Application of Dual-Energy CT in Gynecologic Cancer: Initial Experience

OBJECTIVE

The purpose of this article is to review the use of dual-energy CT (DECT) in the assessment of gynecologic cancer.

CONCLUSION

DECT has the potential to improve diagnostic performance, may improve the ability to differentiate between simple cystic lesions and primary ovarian cancer, and may also improve the detection of musculoskeletal and liver metastases. Additional studies will be needed to determine the direction of future developments and the degree to which DECT will affect the imaging and management of gynecologic cancer.

Magnetic Resonance Imaging of Gynecological Malignancies: Role in Personalized Management

Gynecological malignancies are a leading cause of mortality and morbidity in women and pose a significant health problem around the world. Currently used staging systems for management of gynecological malignancies have unresolved issues, the most important being recommendations on the use of imaging. Although not mandatory as per the International Federation of Gynecology and Obstetrics recommendations, preoperative cross-sectional imaging is strongly recommended for adequate and optimal management of patients with gynecological malignancies. Standardized disease-specific magnetic resonance imaging protocols help assess disease spread accurately and avoid pitfalls. Multiparametric imaging holds promise as a roadmap to personalized management in gynecological malignancies. In this review, we will highlight the role of magnetic resonance imaging in cervical, endometrial, and ovarian carcinomas.

[Gynecological tumors of the true pelvis: Radiological diagnosis for pelvic tumors made simple]

Tumors of the reproductive organs are among the most common female tumors. Computed tomography (CT) and magnetic resonance imaging (MRI) are used for establishing the differential diagnosis, for staging and increasingly for treatment stratification. Sonography is the first line imaging modality for assessing benign and malignant tumors of the uterus as well as ovarian and adnexal lesions. In sonographically indeterminate masses MRI is used for clarification as it allows not only a prediction of the dignity but also in most cases a specific diagnosis. The MRI examination is also superior to CT in the assessment of tumors resembling benign pelvic lesions. Whereas MRI has become established as the modality of choice for local staging and treatment planning in cancers of the uterine cervix and endometrial cancer, CT is used for staging of ovarian cancer due to the propensity for peritoneal spread outside the pelvis at the time of initial diagnosis.

Imaging Features of Uncommon Gynecologic Cancers

OBJECTIVE

The role of imaging in patients with suspected gynecologic malignancies is to provide an accurate diagnosis to achieve the best and most tailored treatment plan. Uncommon cancers pose a distinct challenge, because current knowledge of these diseases is still limited. Our purpose is to highlight the role of cross-sectional imaging techniques, including ultrasound, CT, MRI, and PET/CT, in the diagnosis and pretreatment stratification of patients with rare gynecologic cancers.

CONCLUSION

This review shows the relevance of imaging findings for diagnosis, staging, and treatment planning in patients with uncommon uterine, cervical, vaginal, vulvar, and ovarian cancers.

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.

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.

The added role of MR imaging in treatment stratification of patients with gynecologic malignancies: what the radiologist needs to know

Many treatment options are available to patients with endometrial, cervical, or ovarian cancer. Magnetic resonance (MR) imaging plays an important role in the patient journey from the initial evaluation of the extent of the disease to appropriate treatment selection and follow-up. The purpose of this review is to highlight the added role of MR imaging in the treatment stratification and overall care of patients with endometrial, cervical, or ovarian cancer. Several MR imaging techniques used in evaluation of patients with gynecologic malignancies are described, including both anatomic MR imaging sequences (T1- and T2-weighted sequences) and pulse sequences that characterize tissue on the basis of physiologic features (diffusion-weighted MR imaging), dynamic contrast agent-enhanced MR imaging, and MR spectroscopy. MR imaging findings corresponding to the 2009 revised International Federation of Gynecology and Obstetrics staging of gynecologic malignancies are also described in detail, highlighting possible pearls and pitfalls of staging. With the growing role of the radiologist as a core member of the multidisciplinary treatment planning team, it is crucial for imagers to recognize that MR imaging has become central in tailoring treatment options and therapy in patients with gynecologic malignancies.

Diagnosis and management of peritoneal metastases from ovarian cancer

The management and the outcome of peritoneal metastases or recurrence from epithelial ovarian cancer are presented. The biology and the diagnostic tools of EOC peritoneal metastasis with a comprehensive approach and the most recent literatures data are discussed. The definition and the role of surgery and chemotherapy are presented in order to focuse on the controversial points. Finally, the paper discusses the new data about the introduction of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of advanced epithelial ovarian cancer.

[Radiological diagnostics of ovarian cancer]

Ovarian cancer is diagnosed in stages FIGO III/IV in up to 75% of cases. Despite medical advances the 5-year survival rate has only been moderately increased to 44% during recent years. The initial evaluation is performed using transvaginal ultrasound (US) (sensitivity 90-96%, specificity 98-99% for detection of ovarian lesions). Probably benign findings will be followed-up sonographically or will be laparoscopically excised. Magnetic resonance imaging (MRI) allows a definitive diagnosis in more than 90% of sonographically indeterminate lesions. Malignant lesions require computer tomography (CT) staging and treatment in gynecology centers in a multidisciplinary setting. Peritoneal implants larger than 1 cm are detected equally by CT and MRI. Detection of ascites which is associated with peritoneal carcinomatosis in up to 80% of cases is equally feasible by US, CT and MRI.

Common primary tumours of the abdomen and pelvis and their patterns of tumour spread as seen on multi-detector computed tomography

BACKGROUND: Multidetector computed tomography (MDCT) has become the main investigation of choice for staging of many cancers. AIM: The purpose of this pictorial review is to discuss the imaging appearances on CT of some of the more common cancers arising within the abdomen and pelvis and to describe their typical sites of local, nodal and haematogenous tumour spread. METHODS: Cancers arising from the stomach, pancreas, colon, kidney, ovary and prostate will be reviewed. RESULTS: Awareness of the characteristic sites of tumour spread is important to allow accurate identification of all sites of disease. CONCLUSION: This will clearly have an impact on both patient management and prognosis.

The Value of Postoperative/Preadjuvant Chemotherapy Computed Tomography in the Management of Patients With Ovarian Cancer

Objective:

The objectives of the study were to compare the operative assessment of residual disease with the postoperative computed tomography (CT) findings in patients with ovarian cancer who underwent primary surgical cytoreduction or interval debulking surgery to residual disease 1 cm or less and to assess the effect of potential prognostic factors on patient survival.

Methods:

Patients scheduled for surgery and with an available postoperative CT were eligible for the study. Images were retrospectively analyzed in consensus by 2 radiologists. A 5-point qualitative scoring system was used to evaluate the CT findings (1 = tumor definitely absent, 2 = tumor probably absent, 3 = tumor possibly present, 4 = tumor probably present, 5 = tumor definitely present).

Results:

Between September 2005 and December 2008, 206 consecutive patients were enrolled; 51 were eligible. In 30 cases (59%), the postoperative CT findings correlated with the surgeon's assessment of residual disease. For the univariate analyses, the only significant prognostic factors associated with overall survival were no residual disease versus residual disease of less than 1 cm as assessed by the surgeon (hazard ratio [HR], 3.06; 95% confidence interval [CI], 1.29-7.27;P= 0.011) and no residual disease versus residual disease greater than 1 cm on CT (HR, 2.57; 95% CI, 1.02-6.48;P= 0.045). The interaction of surgical residual disease and stage 3 was significant (HR, 3.40; 95% CI, 1.42-8.16;P= 0.006) in the multivariate Cox model.

Conclusions:

There was only 59% correlation between the surgical assessment and postoperative CT findings of residual disease in patients reported to have undergone optimal surgery. Stage and residual disease as assessed by the surgeon were significant prognostic factors for overall survival. The value for postoperative CT may lie in those cases with small-volume residual disease (visible but reported as <1 cm) at surgery.

Pre-operative evaluation of peritoneal deposits using multidetector computed tomography in ovarian cancer

OBJECTIVE

In the management of epithelial ovarian cancer (EOC), the identification of peritoneal deposits is the most important prognostic factor. We conducted a prospective study to evaluate the role of multidetector CT (MDCT) in identifying peritoneal deposits pre-operatively.

METHODS

38 previously untreated patients (median age 50 years; range 26-70 years) were evaluated with contrast-enhanced MDCT of the abdomen and pelvis. All CT scans were performed on a four-slice MDCT scanner with thin-slice image acquisition. Multiplanar coronal, sagittal or oblique images were constructed and all images were reviewed by at least two radiologists. The extent of disease was determined and mapped for all areas of the abdomen and pelvis. CT scans were reviewed and compared with surgical findings. Peritoneal deposits and thickening were separately noted for each of the nine segments of the abdomen and pelvis (i.e. bilateral hypochondria, bilateral lumbar, bilateral iliac fossa, epigastrium, umbilical region and hypogastrium) and were mainly used to determine the accuracy of MDCT in the depiction of peritoneal carcinomatosis.

RESULTS

Sensitivity, specificity, positive and negative predictive values and accuracy of CT in the detection of peritoneal deposits were similar to those reported in the literature. The most common anatomical sites to have peritoneal deposits were the pouch of Douglas (18 cases) and the right subdiaphragmatic region (18 cases).

CONCLUSION

Despite the improved scanning technology, image reconstruction and viewing ability of MDCT, its overall accuracy for the detection of peritoneal deposits is not significantly improved when compared with conventional CT; however, MDCT is useful in the assessment of disease at specific locations in the abdomen and pelvis.

The utility of multi-detector computed tomography in the diagnosis of malignant pleural effusion in the patients with ovarian cancer

PURPOSE

The purpose of this study was to retrospectively assess possible clinical predictors of malignant pleural effusion in patients with ovarian cancer.

MATERIALS AND METHODS

This review was performed on 38 ovarian cancer patients that showed pleural effusion in a CT scan and who underwent thoracocentesis before treatment. CT scans were obtained using a 4-channel multi-detector CT scanner. Fisher's exact test was used to determine the probability of malignant pleural effusion as a function of; amount of ascites, lymph node enlargement, amount of pleural effusion, pleural nodules, and pleural thickening.

RESULTS

Sixteen (42.1%) of the 38 patients had malignant pleural effusion and malignant pleural effusion amounts were greater than those with nonmalignant effusion. Pleural nodules were more frequently found in the malignant pleural effusion group (eight [50%] patients) than in the nonmalignant group (zero [0%] patient) (p<0.001). Supradiaphragmatic lymph node enlargement (with short axis diameter 1cm or more) was more frequent in malignant group (12 [75%] patients) than in the nonmalignant group (two [9.1%] patients) (p<0.001).

CONCLUSION

The probability of malignant pleural effusion in patients with ovarian cancer was found to be correlated with the amount of pleural effusion, the presence of pleural nodules, and supradiaphragmatic lymph node enlargement.

Diagnostic accuracy of integrated FDG-PET/contrast-enhanced CT in staging ovarian cancer: comparison with enhanced CT

PURPOSE

The purpose of the study is to evaluate the accuracy of integrated positron emission tomography and computed tomography (PET/CT) with (18)F-fluorodeoxyglucose (FDG) with IV contrast for preoperative staging of ovarian cancer, in comparison with enhanced CT, using surgical and histopathological findings as the reference standard.

MATERIALS AND METHODS

Forty patients with ovarian cancer underwent FDG-PET/contrast-enhanced CT scans for staging before primary debulking surgery. PET/CT and the CT component separately, were interpreted by two experienced radiologists by consensus for each investigation. Status with regard to lesion inside and outside the pelvis was determined on the basis of histopathology. The significance of differences between the two imaging modalities was determined using the McNemar test.

RESULTS

Staging revealed stage I in 18 patients (IA, n=9; IB, n=3; IC, n=6), stage II in seven (IIA, n=2; IIB, n=3; IIC, n=2), stage III in 14 (IIIA, n=1; IIIB, n=3; IIIC, n=10), and stage IV in one. The results of CT and PET/CT were concordant with the final pathological staging in 22 out of 40 (55%) and 30 out of 40 (75%) cases, respectively. The overall lesion-based sensitivity improved from 37.6% (32 out of 85) to 69.4% (59 out of 85), specificity from 97.1% (578 out of 595) to 97.5% (580 out of 595), and accuracy from 89.7% (610 out of 680) to 94.0% (639 out of 680) between CT and PET/CT. There were significant differences in sensitivity and accuracy, with p values of 5.6 x 10(-7) and 1.2 x 10(-7), respectively.

CONCLUSION

Integrated FDG-PET/contrast-enhanced CT is a more accurate imaging modality for staging ovarian cancer and useful for selecting appropriate treatment than enhanced CT.

MR imaging in ovarian cancer

Magnetic resonance (MR) imaging is increasingly being used in patients with gynaecological disorders due to its high contrast resolution compared to computed tomography (CT) and ultrasound. In women presenting with an adnexal mass, ultrasound remains the primary imaging modality in the detection and characterisation of such lesions. However, in recent years overwhelming evidence has accumulated for the use of MR imaging in patients with indeterminate adnexal masses particularly in younger women and where disease markers are unhelpful. In staging ovarian cancer and for evaluating therapeutic response MR imaging is as accurate as CT but CT remains the imaging modality of choice because it is more widely available and quicker. This article reviews that evidence and outlines a place for the use of MR imaging in ovarian cancer.

Radiological staging of ovarian cancer: imaging findings and contribution of CT and MRI

Ovarian cancer is the most lethal among the gynecologic malignancies with approximately 70% of patients presenting with advanced tumor stage. The prognosis of patients with ovarian cancer is directly related to the tumor stage and residual tumor burden after cytoreductive surgery. Exploratory laparotomy has been the cornerstone in the management of ovarian cancer, as it offers staging and tumor debulking. Understaging at initial laparotomy, however, is a problem in up to 30%, mainly due to insufficient technique and unexpected peritoneal spread outside the pelvis. Sites difficult to assess intraoperatively including the posterior aspect of the liver and the dome of the diaphragm can be well demonstrated with multiplanar imaging. CT and alternatively MRI have been accepted as adjunct imaging modalities for preoperative staging ovarian cancer. Of these, multidetector CT is the imaging modality of choice for staging ovarian cancer. In a multidisciplinary team approach patient management may be guided towards an individualized treatment plan. The contribution of imaging includes (1) surgery planning including referral practice, (2) selection of candidates for primary chemotherapy by demonstration of non (optimally) resectable disease, and (3) tissue sampling in peritoneal carcinomatosis.

Magnetic resonance imaging-based prospective detection of intraperitoneal human ovarian carcinoma xenografts treatment response

The feasibility of applying magnetic resonance imaging (MRI) for conducting prospective studies of intraperitoneal (i.p.) tumor treatment response to chemotherapy and resultant effects on survival in human ovarian carcinoma/nude mouse orthotopic xenograft models was evaluated. Female nude mice were implanted i.p. with either NMP-1 or SKOV-3ip. human ovarian carcinoma cells on day 0. Initial T2-weighted magnetic resonance (MR) images of the abdomens of NMP-1-implanted mice were obtained on day 7 to confirm the presence of nascent tumors; similar confirmations were made on day 14 with mice bearing SKOV-3ip. xenografts. On the initial imaging days, a multiple-dose regimen of cisplatin (CDDP; qd7 x3) was commenced, using 4 or 6 mg/kg treatments with the NMP-1 model and using 6 mg/kg treatments with the SKOV-3ip. model. Mice were reimaged multiple times, 2 days following each CDDP injection and at later times as well, depending on host survival. The images for each mouse from the last imaging day (day 30 for NMP-1, day 44 for SKOV-3ip.) were used in a blinded fashion to attempt to visually distinguish control from treated mice and to determine whether MRI could predict a survival benefit. For SKOV-3ip. mice, ten out of ten mice were correctly segregated into the control or the CDDP treatment group based solely on these blinded, nonquantified MR results. In this model, the 6 mg/kg multiple-dose regimen achieved a modest response, improving life span by approximately 24%. However, for the NMP-1 mice, only six out of nine evaluable mice were correctly segregated into the control or one of the treatment groups by similar MRI criteria, a virtually random distribution; further, neither CDDP treatment regimen achieved a significant improvement in survival in this model. In another study, NMP-1-implanted mice were treated on day 7 after tumor implantation with a single injection of a hyaluronic acid-paclitaxel copolymer. Control and treated mice were MR imaged on day 28, which revealed marked reductions in tumor burden in treated mice, correlating well with a subsequently observed improved survival of approximately 40%. Our results suggest that MRI can be used to serially and noninvasively monitor treatment response and predict ongoing treatment effects on survival.

Adnexal fascioliasis masquerading as ovarian cancer

BACKGROUND

Preoperative diagnosis of ovarian cancer is still problematic as multiple disease processes may present with pelvic mass. Fascioliasis is a parasitic disease producing unique clinical manifestations.

CASE REPORT

A 49-year-old female patient admitted to our hospital with the complaint of occasional abdominal pain. Pelvic examination revealed a right adnexal mass. Serum CA-125 level was elevated. Explorative laparotomy was performed with the initial diagnosis of ovarian tumor. Final diagnosis was adnexal fascioliasis.

CONCLUSION

In the setting of a newly diagnosed pelvic mass, care should be taken when interpreting an elevated CA-125 level. While ovarian cancer is high on the list of differential diagnoses, atypical clinical presentation of fasciola may give rise to a misdiagnosis of malignancy.

Treated Ovarian Cancer: MR Imaging, Laparotomy Reassessment, and Serum CA-125 Values Compared with Clinical Outcome at 1 Year

PURPOSE

To compare retrospectively the use of magnetic resonance (MR) imaging, laparotomy reassessment, and serum CA-125 values in predicting the presence of residual tumor in women who have been treated for ovarian cancer.

MATERIALS AND METHODS

This study was approved by the institutional review board, and informed consent was waived. The study was compliant with the Health Insurance Portability and Accountability Act. Seventy-six women (mean age, 59 years) with treated ovarian cancer underwent preoperative MR imaging of the abdomen and pelvis with intravenous gadolinium-based and intraluminal barium contrast material. MR findings were compared with surgical and histopathologic findings, serial and static serum CA-125 values, and clinical follow-up results. Tumor absence was proved with normal surgical results and by following up patients for at least 1 year, with no evidence of residual tumor at serial CA-125 analysis or subsequent laparotomy. McNemar test for correlated proportions was used for statistical analysis.

RESULTS

Sixty-eight women had residual tumor proved at laparotomy and biopsy or at clinical follow-up. Eight patients had no evidence of residual tumor. Gadolinium-enhanced MR imaging depicted residual tumor in 61 patients (sensitivity, 90%; specificity, 88%; accuracy, 89%) compared with laparotomy, which demonstrated residual tumor in 60 patients (sensitivity, 88%; specificity, 100%; accuracy, 89%) and CA-125 values, which demonstrated residual tumor in 44 patients (sensitivity, 65%; specificity, 88%; accuracy, 67%) (P < .01). The positive predictive values for MR imaging, laparotomy, and serum CA-125 values were 98%, 100%, and 98%, respectively, whereas the corresponding negative predictive values were 50%, 50%, and 23%, respectively. In 14 patients, there was a discrepancy between the results of MR imaging and those of laparotomy. In seven patients, MR imaging depicted residual tumor that was not found at laparotomy but was proved at subsequent biopsy or clinical and imaging follow-up, with an increasing serum CA-125 level. In six patients, MR findings were normal, and subsequent laparotomy revealed small-volume residual tumor. Residual tumor was incorrectly predicted with MR imaging in one patient who had no surgical or clinical evidence of residual tumor for 1 year.

CONCLUSION

Gadolinium-enhanced spoiled gradient-echo MR imaging depicts residual tumor in women with treated ovarian cancer, with an accuracy, positive predictive value, and negative predictive value that are comparable to those of laparotomy and superior to those of serum CA-125 values alone.

Role of CT and MR imaging in predicting optimal cytoreduction of newly diagnosed primary epithelial ovarian cancer

OBJECTIVE

To determine the relative accuracy of CT or MR imaging in the detection of inoperable tumor sites prior to cytoreductive surgery in a large series of patients with newly diagnosed primary epithelial ovarian cancer.

METHODS

One hundred thirty-seven women with newly diagnosed primary epithelial ovarian cancer underwent CT (n = 91) or MR imaging (n = 46) prior to cytoreductive surgery. The following imaging criteria were used to identify inoperable tumor sites: (1) peritoneal implants greater than 2 cm in maximum diameter in the porta hepatis, intersegmental fissure, gall bladder fossa, subphrenic space, gastrohepatic ligament, gastrosplenic ligament, lesser sac, or root of the small bowel mesentery; (2) retroperitoneal adenopathy greater than 2 cm in maximum diameter above the renal hila; (3) hepatic metastases or abdominal wall invasion. Imaging results were compared with operability at surgery.

RESULTS

Cytoreductive surgery was suboptimal in 21 of the 137 (15%) patients. Sixteen of these patients had inoperable tumor on preoperative imaging, while one additional patient had apparently inoperable tumor on imaging but was optimally debulked at surgery. The sensitivity, specificity, positive predictive value, and negative predictive value of preoperative imaging for the prediction of suboptimal debulking were 76% (16/21), 99% (115/116), 94% (16/17), and 96% (115/120), respectively. CT and MR imaging were equally effective (P = 1.0) in the detection of inoperable tumor.

CONCLUSION

Preoperative CT and MR imaging are equally accurate in the detection of inoperable tumor and the prediction of suboptimal debulking in newly diagnosed epithelial ovarian cancer. This suggests imaging may help select patients who might be more appropriately managed by neoadjuvant chemotherapy.

Coccidioidomycosis Mimicking Ovarian Cancer

BACKGROUND

Dissemination of coccidioidomycosis to the abdominal cavity is rare. No previous case of peritoneal coccidioidomycosis has presented as an adnexal mass.

CASE

We report a case of peritoneal coccidioidomycosis mimicking ovarian carcinoma. The patient presented with a complex ovarian mass, ascites, omental caking, and an elevated CA 125. The ultimate diagnosis was not made until frozen section histopathology was performed at staging laparotomy.

CONCLUSION

Peritoneal coccidioidomycosis can present with the clinical, radiographic, and serologic features of ovarian cancer. Although essential for diagnosis and staging, radiographic studies and tumor markers have limited specificity. Coccidioidomycosis now joins other benign conditions that comprise the differential diagnosis of patients who present with what seems to be advanced ovarian carcinoma. Infectious diseases consultation is recommended for the management of peritoneal coccidioidomycosis.

From the archives of the AFIP: radiologic staging of ovarian carcinoma with pathologic correlation

Ovarian cancer is the deadliest gynecologic malignancy, with approximately 70% of patients having peritoneal involvement at the time of diagnosis. It spreads predominantly by direct invasion and intraperitoneal dissemination. The staging system is surgically based, with stage I disease being limited to one or both ovaries. In stage II disease, there is extraovarian spread of tumor, but it does not extend beyond the pelvis. Stages III and IV disease are considered advanced, with stage III ovarian cancer including diffuse peritoneal disease involving the upper abdomen and stage IV disease having distant metastases including hepatic lesions. Common sites of intraperitoneal seeding include the omentum, paracolic gutters, liver capsule, and diaphragm. Thickening, nodularity, and enhancement are all signs of peritoneal involvement. Although computed tomography is the most common imaging modality used to stage ovarian cancer, magnetic resonance imaging has been shown to be equally accurate. Currently, however, no imaging modality allows microscopic spread of disease to be ruled out, and a full staging laparotomy is always required. Early ovarian cancer is treated with comprehensive staging laparotomy, whereas advanced but operable disease is treated with primary cytoreductive surgery (debulking) followed by adjuvant chemotherapy. Patients with unresectable disease may benefit from neoadjuvant (preoperative) chemotherapy before debulking.

Incremental Benefits of FDG Positron Emission Tomography over CT Alone for the Preoperative Staging of Ovarian Cancer

OBJECTIVE

The purpose of this study was to determine whether the addition of positron emission tomography (PET) with the radiotracer FDG to cross-sectional imaging, such as CT, increases accuracy in the detection of tumor spread. SUBJECTS AND METHODS. Fifteen patients who were thought to have ovarian cancer on the basis of the results of physical examination, sonography findings, and level of serum cancer antigen 125 were enrolled over an 11-month period. After screening, patients underwent two imaging examinations-abdominopelvic CT and whole-body FDG PET- within 2 weeks before surgery. Also before surgery, staging accuracy was assessed separately using CT with or without FDG PET (which was based on modifications of the International Federation of Gynecology and Obstetrics [FIGO] criteria). The results of the histology and surgery findings were used to assess the accuracy of the scanning findings.

RESULTS

Staging revealed stage III disease in seven patients (IIIC, n = 6; IIIB, n = 1), stage II in three (IIC, n = 2; IIB, n = 1), and stage I in five (IC, n = 3; IA, n = 2), according to the FIGO criteria. Although CT staging correlated with postoperative staging in eight (53%) of 15 patients, consensus evaluation of CT with FDG PET staging improved correlation with postoperative staging in 13 (87%) of 15 patients.

CONCLUSION

The addition of FDG PET to CT increases accuracy in staging of ovarian cancer.

Thin section dual-phase multidetector-row computed tomography detection of peritoneal metastases in gynecologic cancers

PURPOSE

To determine the sensitivity, specificity, and accuracy of multidetector-row computed tomography (CT) using thin sections and multiplanar reconstruction for the detection of peritoneal implants in patients with ovarian cancer.

METHOD

Seventeen thin section dual-phase multidetector-row CT scans were performed on 17 women with potential peritoneal metastases from ovarian cancer, which scans were then followed by surgery. Axial and multiplanar images from the CT scans were reviewed by 2 observers, and the results were compared with the operative and clinical notes.

RESULTS

Peritoneal metastases were detected by both readers in all 7 patients presenting with ovarian cancer and disease at laparotomy. Metastases were detected in 5/6 patients with recurrent tumor by observer 1 and in 4/6 patients by observer 2. Sensitivity, specificity, and accuracy for detecting peritoneal metastases at individual sites in the abdomen and pelvis were improved when both axial and multiplanar images were reviewed. Sensitivities were highest for the paracolic gutters and infracolic omentum (>70%). Approximately 50% of liver and diaphragmatic lesions were detected. Specificities approached 100% for all sites and accuracies were >80% for most sites of disease.

CONCLUSION

The sensitivity, specificity, and accuracy of CT for peritoneal metastases in patients is high using thin slices and axial and multiplanar review of the data.