Computed tomography imaging of ovarian peritoneal carcinomatosis: a pictorial review

Role of Computed Tomography in the Evaluation of Peritoneal Carcinomatosis

Peritoneal carcinomatosis (PC) refers to metastatic spread of tumor into the peritoneal cavity. Earlier, PC was thought to be associated with grave clinical outcome. However, various advances in treatment options including cytoreductive surgery and heated intraperitoneal chemotherapy or early post-operative chemotherapy can prolong survival of patients with peritoneal carcinomatosis. These treatment options are associated with high morbidity and mortality. The purpose of this article is to acquaint the radiologist about various appearances of peritoneal carcinomatosis in order to help clinicians in selecting candidates for surgery and avoid unnecessary potentially debilitating surgeries in patients with unresectable PC.

Spectral CT in peritoneal carcinomatosis from ovarian cancer: a tool for differential diagnosis of small nodules?

The detection of peritoneal carcinomatosis in patients with ovarian cancer is crucial to establish the correct therapeutic planning (debulking surgery versus neoadjuvant chemotherapy).

Often, however, the nodules of peritoneal carcinomatosis are very small in size or have a reticular appearance that can mimic the fat stranding that is typical of acute inflammation conditions. Our hypothesis is that the use of dual-layer spectral computed tomography with its applications, such as virtual monoenergetic imaging and Z-effective imaging, might improve the detection and the characterisation of peritoneal nodules, increasing sensitivity and diagnostic accuracy, as recently described for other oncological diseases.

Impact of no residual disease on postoperative computed tomography on survival in patients with optimally debulked advanced high-grade serous ovarian cancer during upfront surgery

OBJECTIVE

We sought to investigate the impact of size of residual tumors as determined by postoperative computed tomography (CT) on survival of patients with advanced, high-grade serous ovarian carcinoma (HGSC) who achieved residual disease less than 1 cm after primary debulking surgery (PDS).

METHODS

We collected data of patients with stage III HGSC who had residual tumor less than 1 cm after PDS between 2013 and 2018. Surgeon-assessed residual disease during surgery was defined as sR0 (no gross residual) or sR1 (gross residual <1 cm), and radiologist-assessed residual disease on postoperative CT was defined as rR0 (no evidence of disease) or rRany (existing residual disease). All patients were classified into the following groups: sR0/rR0, sR1/rR0, sR0/rRany, and sR1/rRany.

RESULTS

A total of 436 patients was placed into the sR0/rR0 (n = 187, 42.9%), sR1/rR0 (n = 59, 13.5%), sR0/rRany (n = 79, 18.1%), or sR1/rRany group (n = 111, 25.5%). Discrepancies between surgical and radiological assessments were recorded for 176 patients (40.4%) including 38 cases of sR1/rRany group with discordant residual tumor location indicated between two methods. During multivariate analysis, patients with ascites on preoperative CT, sR0/rRany group inclusion, and sR1/rRany group inclusion showed unfavorable progression-free and overall survival.

CONCLUSIONS

The incorporation of surgical and radiological evaluations for determining the size of residual tumors was more accurate than surgical evaluation only for predicting survival among patients with advanced ovarian cancer who underwent PDS to residual disease less than 1 cm.

CT imaging of peritoneal carcinomatosis with surgical correlation: a pictorial review

Cytoreductive surgery in combination with hyperthermic intraperitoneal chemotherapy has revolutionized the survival and the quality of life in selected patients with peritoneal carcinomatosis. Preoperative CT is important for the selection of patients that may benefit from cytoreductive surgery and is useful for surgical planning. There are several tasks for the radiologist during CT interpretation: to describe cancerous implants on a "site-by-site" basis in the peritoneum, ligaments, mesenteries and visceral surfaces, to analyze patterns of involvement and to estimate the disease burden. Knowledge of the correlation between the CT and the surgical findings enhances the understanding of the disease and facilitates the communication between radiologists and surgeons.

Performance of Multiparametric Functional Imaging to Assess Peritoneal Tumor Burden in Ovarian Cancer

PURPOSE

The aim of the study was to evaluate the clinical utility of pretreatment 18F-FDG PET/CT with quantitative evaluation of peritoneal metabolic cartography in relation to staging laparoscopy for ovarian carcinomatosis.

PATIENTS AND METHODS

A retrospective review of prospectively collected data from 84 patients with FIGO (International Federation of Gynecology and Obstetrics) stage IIIC to IV ovarian cancer was carried out. All patients had a double-blinded 18F-FDG PET/CT review. Discriminant capacity of metabolic parameters to identify peritoneal carcinomatosis in the 13 abdominal regions according to the peritoneal cancer index was estimated with area under the receiver operating characteristic curve (AUC).

RESULTS

The metabolic parameter showing the best trade-off between sensitivity and specificity to predict peritoneal extension compared with peritoneal cancer index score was the metabolic tumor volume (MTV), with a Spearman ρ equal to 0.380 (P < 0.001). The AUC of MTV to diagnose peritoneal involvement in the upper abdomen (regions 1, 2, and 3) ranged from 0.740 to 0.765. MTV AUC values were lower in the small bowel regions (9-12), ranging from 0.591 to 0.681, and decreased to 0.487 in the pelvic region 6. 18F-FDG PET/CT also improved the detection of extra-abdominal disease, upstaging 35 patients (41.6%) from stage IIIC to IV compared with CT alone and leading to treatment modification in more than one third of patients.

CONCLUSIONS

18F-FDG PET/CT metrics are highly accurate to reflect peritoneal tumor burden, with variable diagnostic value depending on the anatomic region. MTV is the most representative metabolic parameter to assess peritoneal tumor extension.

Ovarian cancer staging: What the surgeon needs to know

Ovarian cancer (OC) is the leading cause of gynecological cancer death, and most cases are diagnosed at advanced stages due to a nonspecific and insidious clinical presentation. Radiologists play a critical role in the decision of which patients are candidates for primary debulking surgery and who may benefit from neoadjuvant chemotherapy. This pictorial review summarizes the dissemination patterns of OC, main imaging findings of metastatic disease, and which findings may alter the treatment plan or predict suboptimal tumor resection.