Detection of Recurrent Ovarian Cancer at MRI: Comparison With Integrated PET/CT

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.

Evaluation of follow-up strategies for women with epithelial ovarian cancer following completion of primary treatment

BACKGROUND

This is an update of a previous Cochrane Review, last updated in 2014. Ovarian cancer is the eighth most common cancer and seventh most common cause of death due to cancer in women worldwide. Traditionally, most women who have been treated for cancer undergo long-term follow-up in secondary care. However, it has been suggested that the use of routine review may not be effective in improving survival, or health-related quality of life (HRQOL), or relieving anxiety. In addition, traditional follow-up may not be cost-effective.

OBJECTIVES

To compare the potential effects of different strategies of follow-up in women with epithelial ovarian cancer, following completion of primary treatment.

SEARCH METHODS

For this update, we searched the Cochrane Gynaecological Cancer Group Trials Register, CENTRAL 2022, Issue 11, MEDLINE, and Embase from August 2013 to November 2022. We also searched review articles and contacted experts in the field.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that evaluated follow-up strategies for women with epithelial ovarian cancer following completion of primary treatment.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology. Two review authors independently selected potentially relevant trials, extracted data, and assessed risk of bias. They compared results, and resolved disagreements by discussion. We assessed the certainty of evidence, using the GRADE approach, for the outcomes of interest: overall survival (OS), health-related quality of life (HRQOL), psychological effects, and cost analysis.

MAIN RESULTS

For this update, we included one new RCT, including 112 women with ovarian, fallopian tube, or peritoneal cancer, who had completed primary treatment by surgery, with or without chemotherapy. This study reported the effect of individualised, i.e. individually tailored, nurse-led follow-up versus conventional medical follow-up on HRQOL, psychological outcomes, and cost-analysis. Individualised follow-up improved HRQOL in one of the two scales, with a decrease in mean difference (MD) in the QLQ-C30 discomfort scale following 12 months of individualised treatment compared to 12 months of conventional treatment (MD -5.76 points, 95% confidence interval (CI) -10.92 to -0.60; 1 study, 112 participants; low-certainty evidence; minimal important difference 4 to 10 points). There may be little or no difference in the other HRQOL scale (QLQ-Ov28, MD -0.97 points, 95% CI -2.57 to 0.63; 1 study, 112 participants: low-certainty evidence); psychological outcome, measured with the hospital anxiety and depression scale (HADS; MD 0.10 point, 95% CI -0.81 to 1.02; 1 study, 112 participants: low-certainty evidence), or cost analysis (MD -GBP 695.00, 95% CI -1467.23 to 77.23; 1 study, 112 participants: moderate-certainty evidence). Our previous review included one RCT, with 529 women in a confirmed remission, with normal CA125 concentration and no radiological evidence of disease, after surgery and first-line chemotherapy for ovarian cancer. This study evaluated immediate treatment of ovarian cancer relapse following a rise of serum CA125 levels versus delaying treatment until symptoms developed for OS, and HRQOL. There was little or no difference in OS between the immediate and delayed arms after a median follow-up of 56.9 months (unadjusted hazard ratio (HR) 0.98, 95% CI 0.80 to 1.20; 1 study, 529 participants; moderate-certainty evidence). Time from randomisation to first deterioration in global health score or death was shorter in the immediate treatment group than in the delayed treatment group (HR 0.71, 95% CI 0.58 to 0.88).

AUTHORS' CONCLUSIONS

Limited evidence from one trial suggests that routine surveillance with CA125 in asymptomatic women and treatment at CA125-defined relapse does not seem to offer survival advantage when compared to treatment at symptomatic relapse. However, this study pre-dates the use of PARPi maintenance treatment and the increased use of secondary cytoreductive surgery, so the results may be limited in their applicability to current practice. Limited evidence from one trial suggests that individualised nurse-led follow-up may improve HRQOL in women with ovarian cancer following completion of primary treatment. Large RCTs are needed to compare different types of follow-up, looking at survival, HRQOL, psychological effects, and cost as outcomes.

Meta-analysis of the diagnostic value of 18F-FDG PET/CT in the recurrence of epithelial ovarian cancer

BACKGROUND

Ovarian cancer is the leading cause of cancer-related death among gynecologic malignancies. With much evidence suggesting that 18F-FDG PET/CT may be an excellent imaging test for the diagnosis of epithelial ovarian cancer recurrence, we conducted a systematic review and meta-analysis to summarize relevant studies and evaluate the accuracy and application value of 18F-FDG PET/CT in the diagnosis of recurrence of epithelial ovarian cancer.

MATERIALS AND METHODS

Clinical trials of 18F-FDG PET/CT for the diagnosis of recurrence of epithelial ovarian cancer were systematically searched in PubMed, Embase, Cochrane Library, Web of Science and OVID database. The relevant literature was searched until May 22, 2022. Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used to evaluate the quality of the included original studies, and the meta-analysis was performed using a bivariate mixed-effects model and completed in Stata 15.0.

RESULTS

A total of 17 studies on 18F-FDG PET/CT for the diagnosis of epithelial ovarian cancer recurrence were included in this systematic review, involving 639 patients with epithelial ovarian cancer. Meta-analysis showed that the sensitivity, specificity and area under the curve of 18F-FDG PET/CT for the diagnosis of epithelial ovarian cancer recurrence were 0.88 (95% CI: 0.79 - 0.93), 0.89 (95% CI: 0.72 - 0.96) and 0.94 (95% CI: 0.91- 0.96), respectively. Subgroup analysis showed higher diagnostic efficacy in prospective studies than in retrospective studies, and no significant publication bias was observed in Deeks' funnel plot, with sensitivity analysis revealing the stability of results. Meta regression shows that the heterogeneity of this study comes from study type.

CONCLUSION

18F-FDG PET/CT has good diagnostic value in the recurrence of epithelial ovarian cancer.

Magnetic Fields and Cancer: Epidemiology, Cellular Biology, and Theranostics

Humans are exposed to a complex mix of man-made electric and magnetic fields (MFs) at many different frequencies, at home and at work. Epidemiological studies indicate that there is a positive relationship between residential/domestic and occupational exposure to extremely low frequency electromagnetic fields and some types of cancer, although some other studies indicate no relationship. In this review, after an introduction on the MF definition and a description of natural/anthropogenic sources, the epidemiology of residential/domestic and occupational exposure to MFs and cancer is reviewed, with reference to leukemia, brain, and breast cancer. The in vivo and in vitro effects of MFs on cancer are reviewed considering both human and animal cells, with particular reference to the involvement of reactive oxygen species (ROS). MF application on cancer diagnostic and therapy (theranostic) are also reviewed by describing the use of different magnetic resonance imaging (MRI) applications for the detection of several cancers. Finally, the use of magnetic nanoparticles is described in terms of treatment of cancer by nanomedical applications for the precise delivery of anticancer drugs, nanosurgery by magnetomechanic methods, and selective killing of cancer cells by magnetic hyperthermia. The supplementary tables provide quantitative data and methodologies in epidemiological and cell biology studies. Although scientists do not generally agree that there is a cause-effect relationship between exposure to MF and cancer, MFs might not be the direct cause of cancer but may contribute to produce ROS and generate oxidative stress, which could trigger or enhance the expression of oncogenes.

Past, Present, and Future of Serum Tumor Markers in Management of Ovarian Cancer: A Guide for the Radiologist

The ability to accurately detect early ovarian cancer and subsequently monitor treatment response is essential to improving survival for patients with ovarian malignancies. Several serum tumor markers (STMs)-including cancer antigen 125 (CA-125), human epididymis protein 4 (HE4), cancer antigen 19-9 (CA 19-9), and carcinoembryonic antigen (CEA)-have been used as a noninvasive method of identifying ovarian cancer in conjunction with imaging. Although current guidelines do not recommend use of STMs as screening tools for ovarian cancer, these markers have clinical utility in both diagnosis and surveillance for women with ovarian cancer. CA-125 is the most commonly used STM; its level may be elevated in several types of ovarian cancer, including epithelial cell tumors, carcinosarcoma, teratomas, and secondary ovarian malignancies. An elevated level of CA 19-9 is associated with clear cell tumors, teratomas, and secondary malignancies. CEA is most commonly associated with mucinous ovarian cancers. Finally, HE4 is being increasingly used to identify certain subtypes of epithelial ovarian cancers, particularly serous and endometrioid tumors. Diagnosis of ovarian cancers relies on a combination of CA-125 levels and US findings, which include a large adnexal mass or high-risk features, including septa and increased vascularity. CT is preferred for staging and is used along with PET and STM monitoring for surveillance. Increasingly, MRI is being used to characterize ovarian lesions that are indeterminate at US or CT. The future of STM testing involves development of "liquid biopsies," in which plasma samples are analyzed for evidence of tumors, including circulating tumor DNA or tumor cells and tumor micro-RNA. When combined with traditional imaging techniques, liquid biopsies may lead to earlier diagnosis and improved survival. An invited commentary by Shinagare is available online. ^©RSNA, 2021.

Comparison of diagnostic values between CA125 combined with CA199 and ultrasound combined with CT in ovarian cancer

Application values of CA125 combined with CA199 and ultrasound combined with computed tomography (CT) in the clinical diagnosis of ovarian cancer were compared. A retrospective analysis was performed on 168 ovarian cancer patients admitted to the Department of Gynecology in Jining No.1 People's Hospital from July 2013 to March 2016. Of the patients 107 with malignant tumors were in the malignant group, and 61 patients with benign tumors were in the benign group. Another 98 healthy controls in the same period were in the normal group. Chemiluminescence was used for the detection of levels of tumor markers CA125 and CA199 in the serum of all patients. CA125 combined with CA199 and color Doppler ultrasound combined with CT scan were used to diagnose and analyze the sensitivity, specificity, accuracy, and positive detection rate of ovarian cancer patients at different stages. The sensitivity, specificity and diagnostic coincidence rate of ultrasound combined with CT in the diagnosis of ovarian cancer were 97.20, 80.32 and 91.07%, respectively, which were significantly higher than the 92.52, 73.77 and 85.71% of serum CA125 combined with CA199. The positive detection rate of ultrasound combined with CT in the early diagnosis of ovarian cancer was 93.55%, higher than 83.87% of CA125 combined with CA199. The sensitivity, specificity, coincidence rate and positive detection rate of ultrasound combined with CT in the diagnosis were higher than those of CA125 combined with CA199. In the actual diagnosis process, these two diagnostic schemes can be selectively and comprehensively applied, so as to make a correct diagnosis, which is of great significance for reducing patient mortality.

Imaging strategy in recurrent ovarian cancer: a practical review

Ovarian cancer is one of the most aggressive gynaecologic malignancies in women worldwide. The lack of proper screening programs and the characteristic abdominal spreading with minimal clinical symptoms give rise of its high lethality. Most patients show advanced disease at diagnosis and have a poor prognosis. The surveillance of ovarian cancer patients after initial treatment is a challenging question in clinical practice and there is no consensus in literature about the most appropriate follow-up strategy for these women. The role of Imaging has become increasingly important, allowing to properly monitor patients, distinguishing the different relapse patterns, thus guiding the correct management and therapy. In this review, we report and analyze the scientific evidence about the role of the different imaging modalities now available in the follow-up strategy and management of Epithelial Ovarian Cancer patients with recurrent disease.

The Role of 18F-FDG PET/CT in Detecting Ovarian Cancer Recurrence in Patients with Elevated CA-125 Levels

Objectives:

To investigate the role of ¹⁸F-FDG positron emission tomography/computed tomography (PET/CT) in detection of recurrence in ovarian cancer patients with increased CA-125 levels.

Methods:

Fifty-two patients (30-80 years old, mean: 58.5±10.6 years) who had been histopathologically diagnosed with ovarian cancer, underwent ¹⁸F-FDG PET/CT imaging for re-staging due to elevation of CA-125 levels were included in this retrospective study. ¹⁸F-FDG PET/CT findings were compared with histopathological, radiological and clinical follow-up results.

Results:

CA-125 levels ranged between 35.2-2740 U/mL (N: 0-35 U/mL). Recurrent disease was detected in 45 of 52 patients on PET/CT imaging. There were three false negative and one false positive result. In addition to abdominal and pelvic lesions, 14 distant metastatic lesions (brain, lung, liver and bone metastasis) were identified correctly on PET/CT imaging. Sensitivity, specificity, positive and negative predictive value and accuracy of ¹⁸F-FDG PET/CT were calculated as 94%, 75%, 98%, 50% and 96%, respectively.

Conclusion:

¹⁸F-FDG PET/CT is a useful imaging method that can be used in detection of ovarian cancer recurrence in patients with elevated CA-125 levels. Since this modality offers whole body imaging, distant metastases could be detected in addition to abdominal and pelvic lesions thus contributing to patient management.

Diagnostic value of positron emission tomography (PET) and PET/computed tomography in recurrent/metastatic ovarian cancer: A meta-analysis

AIM

The study was conducted to assess and compare the overall diagnostic value of positron emission tomography (PET) alone and PET/computed tomography (CT) for the detection of recurrent/metastatic ovarian cancer.

METHODS

A systematic literature search in PubMed, EMBASE and Chinese literature databases (CNKI, VIP and Wanfang) up to August 2014 was performed to identify relevant articles. The diagnostic performance of PET alone or PET/CT was assessed in terms of the following evaluation indexes: summary sensitivity, specificity, positive and negative likelihood ratio, diagnostic odds ratio and area under the curve summary receiver operating characteristics.

RESULTS

Sixty-four studies with 3722 patients were included in this meta-analysis. Favorable results were obtained for both PET/CT and PET alone with similar sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio and area under the curve in diagnosing recurrent/metastatic ovarian cancer (P > 0.05). However, the sensitivity of PET/CT was significantly higher than PET alone in European patients.

CONCLUSIONS

Both PET and PET/CT have promising diagnostic value in recurrent/metastatic ovarian cancer. The diagnostic performance of PET/CT may be superior to PET alone in European patients.

Applications of PET/MR Imaging in Urogynecologic and Genitourinary Cancers

Positron emission tomograph (PET)-magnetic resonance (MR) is a new modality combining PET and MR. In gynecologic cancers it can be used for staging of cervical and endometrial cancer, planning of radiation therapy in cervical cancer, assessing response to chemotherapy in ovarian cancer, and detection of recurrence in most gynecologic cancers. It is being explored for prostate cancer and other genitourinary cancers, but is still in experimental stages.

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

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

Correlation of pre-operative CT findings with surgical & histological tumor dissemination patterns at cytoreduction for primary advanced and relapsed epithelial ovarian cancer: A retrospective evaluation

OBJECTIVES

Computed tomography (CT) is an essential part of preoperative planning prior to cytoreductive surgery for primary and relapsed epithelial ovarian cancer (EOC). Our aim is to correlate pre-operative CT results with intraoperative surgical and histopathological findings at debulking surgery.

METHODS

We performed a systematic comparison of intraoperative tumor dissemination patterns and surgical resections with preoperative CT assessments of infiltrative disease at key resection sites, in women who underwent multivisceral debulking surgery due to EOC between January 2013 and December 2014 at a tertiary referral center. The key sites were defined as follows: diaphragmatic involvement(DI), splenic disease (SI), large (LBI) and small (SBI) bowel involvement, rectal involvement (RI), porta hepatis involvement (PHI), mesenteric disease (MI) and lymph node involvement (LNI).

RESULTS

A total of 155 patients, mostly with FIGO stage IIIC disease (65%) were evaluated (primary=105, relapsed=50). Total macroscopic cytoreduction rates were: 89%. Pre-operative CT findings displayed high specificity across all tumor sites apart from the retroperitoneal lymph node status, with a specificity of 65%. The ability however of the CT to accurately identify sites affected by invasive disease was relatively low with the following sensitivities as relating to final histology: 32% (DI), 26% (SI), 46% (LBI), 44% (SBI), 39% (RI), 57% (PHI), 31% (MI), 63% (LNI).

CONCLUSION

Pre-operative CT imaging shows high specificity but low sensitivity in detecting tumor involvement at key sites in ovarian cancer surgery. CT findings alone should not be used for surgical decision making.

PET/MRI Evaluation of Gynecologic Malignancies and Prostate Cancer

PET combined with cross-sectional anatomical imaging is an essential part of workup for most malignancies, in which CT or MRI provides anatomical context to the functional information from PET. Hybrid imaging with PET/CT has been extensively researched and implemented clinically in the evaluation and management of patients with gynecologic malignancies. Lately, integrated PET/MR scanners have become available. This new technology is fast gaining a role in clinical applications in the fields of oncology, neurology, and cardiology. MRI provides excellent soft tissue contrast especially in the pelvis and has been proven very useful for imaging prostate and female genital pathologies. The ability of PET to provide accurate functional imaging data with high sensitivity combined with the strength of MRI to provide accurate depiction of anatomy with high contrast and spatial resolution renders combined PET/MRI a desirable method for evaluation of gynecologic malignancies and other pelvic cancers such as prostate cancer. The goal of this article is to provide an overview of the published literature using PET/MRI in gynecologic and prostate cancers.

Gynecologic oncologic imaging with PET/CT

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

Massive peritoneal cavity calcification in the course of advanced ovarian cancer: a case report

Ovarian cancer usually does not give any clinical signs until it reaches a large size. This condition is often associated with the occurrence of metastases within the peritoneal cavity, pelvic and abdominal cavities. Ovarian cancer can spread by intraperitoneal implantation, by way of the lymphatic system, and also through the systemic circulation. Even when the tumor reaches a large size, the symptoms are not specific and may resemble other ailments. Therefore, ovarian cancer is detected in most cases only in the third and fourth level of advancement. Peritoneal calcification occurs in many diseases. The degree of calcium deposits is usually small and does not give clinical symptoms. In the reported case, computed tomography of the abdomen showed numerous scattered peritoneal calcifications of irregular shape as well as massive calcification in the uterus and appendages. In the detection of changes associated with calcification, multidetectory computed tomography shows a very high sensitivity. It makes the precise location and assessment of the extent of changes possible.

Utilizing spatial and spectral features of photoacoustic imaging for ovarian cancer detection and diagnosis

A composite set of ovarian tissue features extracted from photoacoustic spectral data, beam envelope, and co-registered ultrasound and photoacoustic images are used to characterize malignant and normal ovaries using logistic and support vector machine (SVM) classifiers. Normalized power spectra were calculated from the Fourier transform of the photoacoustic beamformed data, from which the spectral slopes and 0-MHz intercepts were extracted. Five features were extracted from the beam envelope and another 10 features were extracted from the photoacoustic images. These 17 features were ranked by their p-values from t -tests on which a filter type of feature selection method was used to determine the optimal feature number for final classification. A total of 169 samples from 19 ex vivo ovaries were randomly distributed into training and testing groups. Both classifiers achieved a minimum value of the mean misclassification error when the seven features with lowest p-values were selected. Using these seven features, the logistic and SVM classifiers obtained sensitivities of 96.39 ± 3.35% and 97.82 ± 2.26%, and specificities of 98.92 ± 1.39% and 100%, respectively, for the training group. For the testing group, logistic and SVM classifiers achieved sensitivities of 92.71 ± 3.55% and 92.64 ± 3.27%, and specificities of 87.52 ± 8.78% and 98.49 ± 2.05%, respectively.

[(18)F]FDG PET/MRI vs. PET/CT for whole-body staging in patients with recurrent malignancies of the female pelvis: initial results

PURPOSE

To evaluate the diagnostic potential of PET/MRI with [(18)F]FDG in recurrent ovarian and cervical cancer in comparison to PET/CT.

METHODS

A group of 19 patients with suspected recurrence of pelvic malignancies (ovarian cancer, 11 patients; cervical cancer, 8 patients) scheduled for an [(18)F]FDG PET/CT were subsequently enrolled for a PET/MRI. The scan protocol comprised: (1) a T1-W axial VIBE after contrast agent adminstration, (2) an axial T2-W HASTE, (3) a coronal TIRM, (4) an axial DWI, and dedicated MR sequences of the female pelvis including (5) a T1-W VIBE before contrast agent adminstration, (6) a sagittal T2-W TSE, and (7) a sagittal T1-W dynamic VIBE. The datasets (PET/CT, PET/MRI) were rated separately by two readers regarding lesion count, lesion localization, lesion conspicuity (four-point scale), lesion characterization (benign/malignant/indeterminate) and diagnostic confidence (three-point scale). All available data (histology, prior examinations, PET/CT, PET/MRI, follow-up examinations) served as standard of reference. Median values were compared using the Wilcoxon rank sum test.

RESULTS

Metastatic lesions were present in 16 of the 19 patients. A total of 78 lesions (malignant, 58; benign, 20) were described. Both PET/CT and PET/MRI allowed correct identification of all malignant lesions and provided equivalent conspicuity (3.86 ± 0.35 for PET/CT, 3.91 ± 0.28 for PET/MRI; p > 0.05). Diagnostic confidence was significantly higher for PET/MRI in malignant (p < 0.01) and benign lesions (p < 0.05).

CONCLUSION

Both PET/CT and PET/MRI offer an equivalently high diagnostic value for recurrent pelvic malignancies. PET/MRI offers higher diagnostic confidence in the discrimination of benign and malignant lesions. Considering the reduced radiation dose and superior lesion discrimination, PET/MRI may serve as a powerful alternative to PET/CT in the future.

Evaluation of follow-up strategies for patients with epithelial ovarian cancer following completion of primary treatment

BACKGROUND

Ovarian cancer is the sixth most common cancer and seventh commonest cause of death in women worldwide. Traditionally, many people who have been treated for cancer undergo long-term follow-up in secondary care. However, it has been suggested that the use of routine review may not be effective in improving survival, quality of life (QoL), or relieving anxiety, or both. In addition, traditional follow-up may not be cost-effective.

OBJECTIVES

To compare the potential benefits of different strategies of follow-up in patients with epithelial ovarian cancer following completion of primary treatment.

SEARCH METHODS

For this update we searched the Cochrane Gynaecological Cancer Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 7, 2013, MEDLINE and EMBASE from November 2010 to July 2013. We also searched reference lists of review articles and contacted experts in the field.

SELECTION CRITERIA

All relevant randomised controlled trials (RCTs) that evaluated follow-up strategies for women with epithelial ovarian cancer following completion of primary treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias.

MAIN RESULTS

The authors did not identify any new studies that were eligible for inclusion in this update of the review. The search for the original review identified only one RCT that met the inclusion criteria, which included 529 women. This study reported data on immediate treatment of ovarian cancer relapse following rise of serum CA125 levels versus delaying treatment until symptoms developed. All the women participating had previous confirmation of remission, with normal CA125 concentration and no radiological evidence of disease, after surgery and first-line chemotherapy for ovarian cancer.Overall survival between the immediate and delayed arms showed no difference after a median follow-up of 56.9 months (unadjusted hazard ratio (HR) 0.98, 95% confidence interval (CI) 0.80 to 1.20; P value 0.85). Time from randomisation to first deterioration in global health score or death was shorter in the immediate treatment group than in the delayed treatment group (HR 0.71, 95% CI 0.58 to 0.88; P value < 0.01). The trial was at low risk of bias.

AUTHORS' CONCLUSIONS

Limited evidence from a single trial suggests that routine surveillance with CA125 in asymptomatic patients and treatment at CA125 relapse does not seem to offer survival advantage when compared to treatment at symptomatic relapse. RCTs are needed to compare different types of follow-up, looking at survival, QoL, cost and psychological effects as outcomes.

Which imaging technique should we use in the follow up of gynaecological cancer?

Follow-up routines after gynaecological cancer vary. The optimal approach is unknown, and no randomised-controlled trials comparing surveillance protocols have been published. In this chapter, we summarise the diagnostic performance of ultrasound, computed tomography, and magnetic resonance imaging in the follow up of women treated for ovarian or uterine cancers. Computed tomography is today the standard imaging method for the follow up of women treated for endometrial, cervical, or ovarian cancer. Six-monthly or annual follow-up examinations have not been shown to positively affect survival. Instead, a combination of transvaginal and transabdominal ultrasound examination with clinical examination might be a more cost-effective strategy for early detection of recurrence. Positron-emission tomography might play a role in women with clinical or serological suspicion of recurrence but without evidence of disease at conventional diagnostic imaging. To create guidelines, more studies, preferably randomised-controlled trials, on follow-up strategies are needed.

Cancer survivorship, a unique and growing cohort in medical practice: radiology perspective

The unique medical and psychologic burdens of cancer survivorship have only recently been recognized. This rapidly expanding cohort of patients will be seen increasingly by non-oncology physicians who must consider medical issues related to their cancer or its therapy for any presenting symptoms. Appropriate use of clinical imaging is essential for diagnosing treatment-related complications, recurrent tumor, or emergence of second primaries. This article will review clinical imaging in common medical problems uniquely found in cancer survivors.

CA-125-indicated asymptomatic relapse confers survival benefit to ovarian cancer patients who underwent secondary cytoreduction surgery

Background

There is no consensus regarding the management of ovarian cancer patients, who have shown complete clinical response (CCR) to primary therapy and have rising cancer antigen CA-125 levels but have no symptoms of recurrent disease. The present study aims to determine whether follow-up CA-125 levels can be used to identify the need for imaging studies and secondary cytoreductive surgery (CRS).

Methods

We identified 410 ovarian cancer patients treated at The University of Texas MD Anderson Cancer Center between 1984 and 2011. These patients had shown CCR to primary therapy. Follow-up was conducted based on the surveillance protocol of the MD Anderson Cancer Center. We used the Cox proportional hazards model and log-rank test to assess the associations between the follow-up CA-125 levels and secondary CRS and survival duration.

Results

The CA-125 level of 1.68 × nadir was defined as the indicator of recurrent disease (p < 0.001). The specificity and sensitivity of this criterion were 82.9% and 85.6%, respectively, and the median lead-time of the CA-125 biochemical progression prior to clinically-defined relapse was 31 days (ranging from 1 to 391 days). The median number of the negative imaging studies for the clinical relapse findings in patients with a CA-125 level of < 1.68 × nadir was 3 (ranging from 0 to 24 times). The increase of CA-125 level at relapse was an independent predictor of overall and progression free survival in patients who had shown CCR to primary therapy (p = 0.04 and 0.02 respectively). The overall and progression free survival durations in patients with a CA-125 level ≤ 1.68 × nadir at relapse (69.4 and 13.8 months) were longer than those with a CA-125 level > 1.68 × nadir at relapse (55.7 and 10.4 months; p = 0.04 and 0.01, respectively). The overall and progression free survival duration of patients with asymptomatic relapse and underwent a secondary CRS was longer than that of patients with symptomatic relapse (p = 0.02 and 0.04 respectively).

Conclusions

The increase of serum CA-125 levels is an early warning of clinical relapse in ovarian cancer. Using CA-125 levels in guiding the treatment of patients with asymptomatic recurrent ovarian cancer, who have shown CCR to primary therapy, can facilitate optimal secondary CRS and extend the survival duration of the patients.

Impact of FDG-PET and -PET/CT imaging in the clinical decision-making of ovarian carcinoma: an evidence-based approach

The most definitive role of fluorodeoxyglucose (FDG)-PET/computed tomography (CT) at present is surveillance and detecting recurrence in patients who have completed primary therapy but demonstrate a rising serum tumor marker (e.g., CA-125 levels). In this scenario, PET/CT demonstrates high sensitivity and accuracy in detecting lesions that are otherwise challenging, and appears superior (with less interobserver variability) compared with CT alone. Despite the fact that peritoneal deposits may be missed by PET/CT, the overall performance is better than CT alone. FDG-PET does not play a significant additional role in the primary diagnosis of ovarian cancers; however, the role of combined PET/CT modality has recently begun to be re-explored for initial disease staging, particularly because PET/CT can pick up small unsuspected lesions and thereby provide a better disease assessment of the whole body in a single examination. The baseline PET/CT also subserves an important role for future monitoring of therapy response. Therapy monitoring by PET could help to optimize neoadjuvant therapy protocols and to avoid ineffective therapy in nonresponders early in its course, although PET/CT has cost-effectiveness issues that need further evaluation. The prognostic value of FDG-PET/CT has been investigated in the following areas: in the preoperative setting to predict optimal cytoreduction; to assess the value of a positive FDG-PET following primary surgery; and when employed as a replacement for second-look laparotomy following completion of primary surgery and chemotherapy. The data, although promising, are still sparse in all the three domains for a definite recommendation.

Clinical trials in recurrent ovarian cancer

The 4th Ovarian Cancer Consensus Conference of the Gynecologic Cancer InterGroup was held in Vancouver, Canada, in June 2010. Representatives of 23 cooperative research groups studying gynecologic cancers gathered to establish international consensus on issues critical to the conduct of large randomized trials. Group C, 1 of the 3 discussion groups, examined recurrent ovarian cancer, and we report the consensus reached regarding 4 questions. These included the following: (1) What is the role of cytoreductive surgery for recurrent ovarian cancer? (2) How do we define distinct patient populations in need of specific therapeutic approaches? (3) Should end points for trials with recurrent disease vary from those of first-line trials? (4) Is CA-125 progression alone sufficient for entry/eligibility into clinical trials?

Evaluation of follow-up strategies for patients with epithelial ovarian cancer following completion of primary treatment

BACKGROUND

Ovarian cancer is the sixth most common cancer and seventh cause of cancer death in women worldwide. Traditionally, many patients who have been treated for cancer undergo long-term follow up in secondary care. Recently however it has been suggested that the use of routine review may not be effective in improving survival, quality of life (QoL), and relieving anxiety. In addition, it may not be cost effective.

OBJECTIVES

To compare the potential benefits of different strategies of follow up in women with epithelial ovarian cancer following completion of primary treatment.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010, Issue 4), MEDLINE and EMBASE (to November 2010). We also searched CINAHL, PsycLIT, registers of clinical trials, abstracts of scientific meetings, reference lists of review articles, and contacted experts in the field.

SELECTION CRITERIA

All relevant randomised controlled trials (RCTs) that evaluated follow-up strategies for patients with epithelial ovarian cancer following completion of primary treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias.

MAIN RESULTS

We found only one RCT (Rustin 2010) that met our inclusion criteria. This trial included 529 women and reported data on immediate treatment versus delayed treatment in women with confirmation of remission and with normal CA125 concentration and no radiological evidence of disease after surgery and first-line chemotherapy.Overall survival showed no significant difference between the immediate and delayed arms after a median follow up of 56.9 months (unadjusted hazard ratio (HR) = 0·98, 95% confidence interval (CI) 0·80 to 1·20; P = 0·85). Time from randomisation to first deterioration in global health score or death was significantly shorter in the early group compared with the delayed group (HR 0·71, 95% CI 0·58 to 0·88; P < 0·01). The trial was at low risk of bias.

AUTHORS' CONCLUSIONS

There is a lack of randomised studies on most aspects of follow-up care after treatment for epithelial ovarian cancers. Limited evidence from a single trial suggests that routine surveillance with CA125 in asymptomatic patients, with treatment at CA125 relapse, does not seem to offer survival advantage when compared to treatment at symptomatic relapse. Randomised controlled trials are needed to compare different types of follow up on the outcomes of survival, quality of Life, cost and psychological effects.

CT diagnosis of intrasplenic metastasis from ovarian carcinoma

Intrasplenic metastases from ovarian carcinoma cannot be always demonstrated intraoperatively. CT is the most important imaging modality of choice for staging and follow-up ovarian cancer; in this study we searched CT appearances of intrasplenic metastases from ovarian carcinoma. We retrospectively reviewed imaging histories of the patients with ovarian cancer from the radiology information system, and found 12 patients with intrasplenic metastasis. All patients underwent abdominal CT with 16-MDCT. We searched number, density and maximum diameters of splenic metastasis. The growing rate of three lesions, which were followed up by CT, was calculated. Serum cancer antigen (CA) 125 levels were noted. We also evaluated clinical history and pathology reports of all patients. Splenic metastases, solitary or multiple, were detected most frequently during the follow-up (1-14 years after initial diagnosis) and most were associated with other sites of recurrence. The diameters of lesions ranged from 4 to 85mm. All lesions appeared hypodense except for one lesion with dense calcification. Densities of lesions ranged from 12 to 208 Hounsfield units (mean, 49±51HU). Most lesions appeared as solid well-defined nodules; however some lesions had lobulated and irregular contours with an infiltrative pattern. The growing rates of three lesions were 0.72mm/month, 1.75mm/month and 2.70mm/month. Eight patients had elevated serum CA 125 levels (40-1256U/mL). We concluded that CT can demonstrate intraparenchymal and infiltrative splenic metastasis in patients with ovarian cancer even in the absence of increased CA 125 levels.

Use of FDG-PET/CT for peritoneal carcinomatosis before hyperthermic intraperitoneal chemotherapy

BACKGROUND

Peritoneal carcinomatosis (PC) is associated with a very poor prognosis. Complete cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy has been shown to improve survival rates of PC. However, this treatment is beneficial for patients if the complete cytoreductive surgery is macroscopically completed before implementing hyperthermic intraperitoneal chemotherapy. Even so, a strict selection of patients is of fundamental importance because of the invasive nature of the intervention. The aim of this study was to assess the performance of FDG-PET/CT examinations for the diagnosis and evaluation of the extent of PC.

METHODS

A retrospective analysis was conducted on 28 consecutive patients with suspected PC, scheduled for a complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, and who underwent an FDG-PET/CT examination. We compared the results of PET examinations with histological and intraoperative findings. The extent of PC was assessed precisely using a simplified 'peritoneal cancer index', within the three modalities (PET, surgery and histology).

RESULTS

Of 28 patients, 23 had histological PC. The sensitivity and specificity of the PET examination for the diagnosis of PC were, respectively, 82 and 100%. Even if the extent of PC was underestimated by PET, there was a good correlation when compared with histology and intraoperative results.

CONCLUSION

PET presented a good performance level in the diagnosis and evaluation of the extent of PC. PET/CT examinations could be useful to avoid unnecessary surgery.

Present and future of FDG-PET/CT in ovarian cancer

Integrated FDG-PET/CT has been used successfully for the diagnosis, staging, restaging, therapy monitoring and prognostic prediction of ovarian cancer as well as various other malignant tumors. Compared with conventional PET/non-contrast CT images, combined PET/contrast-enhanced CT images with intravenous iodine contrast medium and sufficient radiation dose may contribute to a more accurate diagnosis with higher confidence. In the future, tracers other than FDG and integrated PET/MRI will be realized. We herein review the place and role of FDG-PET/CT in the management of ovarian cancer, discussing its usefulness and limitations in the imaging of these patients.

Surveillance of patients after initial treatment of ovarian cancer

The surveillance of ovarian cancer patients after initial treatment is a challenging question in clinical practice. Serum CA 125 assay, physical examination, and imaging examinations have been employed with different time schedules for the follow-up of asymptomatic patients. Rising serum CA 125 levels may precede the clinical detection of relapse in 56-94% of cases with a median lead time of 3-5 months. An ongoing randomised phase III European trial is comparing the benefits of early administration of chemotherapy based on serum CA 125 assay alone versus delaying treatment until clinical or radiological detection of recurrent disease. Physical examination, with or without ultrasound, is very useful for the surveillance of these patients, since approximately 25-50% of relapses involve the pelvis. Additional radiological imaging techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI), are usually performed in asymptomatic patients with rising CA 125 levels as well as in patients with suspicious symptoms or signs. Integrated positron emission tomography (PET) and CT scanners (PET/CT) can identify recurrent disease in tissues that appear normal at CT imaging as well as metastatic lesions intimately associated with the bowel wall that are difficult to detect with CT or MRI, so that in most series PET/CT has a higher diagnostic reliability than that of conventional imaging techniques. Moreover, PET/CT can disclose unusual supra-diaphragmatic spreading of the disease and may be very helpful for treatment planning, especially for the selection of patients suitable for secondary surgical cytoreduction. A prospective, randomised trial of therapeutic interventions based on stratification by PET/CT disease status could elucidate the real impact of this diagnostic procedure in the management of patients with recurrent ovarian cancer.