Ovarian Cancer

Because of paucity of symptoms in early stages, approximately 60% to 75% of patients with ovarian cancer present with advanced disease.93,114 Ovarian cancer is staged surgically according to the FIGO staging system. The FIGO system reflects the three primary mechanisms of disease spreads of ovarian cancer, including local, peritoneal, and lymphatic.

In most centers, endovaginal ultrasound is the primary imaging modality used for screening for ovarian cancer and evaluation of an adnexal mass. Because most patients with ovarian cancer present with adnexal or pelvic masses and the majority of adnexal and pelvic masses are benign, differentiation between benign and malignant ovarian tumor is clinically important.

In patients with ovarian cancer, imaging can be used to determine the extent of primary disease before surgical staging and debulking. Imaging is also used to assess for recurrence, especially in symptomatic patients. The primary disease can be staged with CT or MRI, which are equivalent for detecting peritoneal metastases.115-118 In a study of 118 women with pelvic malignancies, the sensitivity for peritoneal disease was 92% for CT and 95% for MRI.118

The major role of MRI in evaluation of adnexal masses includes determining if a mass is truly ovarian in origin, to accurately diagnose certain benign lesions, such as dermoid cyst and endometrial cyst, and to more precisely define the internal architecture of ovarian masses. MRI is reported to be a cost-effective next step when the results of the ultrasound are indeterminate.114

On MRI, the presence of solid components or nodules in a cystic tumor, necrosis in a solid tumor, thick, irregular walls or septations, larger lesion size, enhancement of internal structure as well as presence of ascites, peritoneal disease, or adenopathy increase the possibility of malignancy.119 The

figure 31.13. Ovarian cancer. (A) Axial CT of the pelvis obtained after intravenous contrast material injection shows mixed cystic and solid masses in the bilateral adnexae. U, uterus. (B) Coronal reformatted image obtained after intravenous contrast material injection shows cystic ovarian masses abutting the bilateral external iliac veins (short arrows). Large arrow indicates the pubic symphysis. (C) Sagittal reformatted image of the right upper abdomen obtained after intra-

figure 31.13. Ovarian cancer. (A) Axial CT of the pelvis obtained after intravenous contrast material injection shows mixed cystic and solid masses in the bilateral adnexae. U, uterus. (B) Coronal reformatted image obtained after intravenous contrast material injection shows cystic ovarian masses abutting the bilateral external iliac veins (short arrows). Large arrow indicates the pubic symphysis. (C) Sagittal reformatted image of the right upper abdomen obtained after intra-

venous contrast material injection shows thickening of the right hemidiaphragm by tumor deposits along the liver surface (large arrows). Arrowhead indicates a right pleural effusion. (D) Sagittal reformatted image of the left upper abdomen obtained after intravenous contrast material injection shows tumor (T) invading the superior portion of the spleen. Short arrows indicate left hemi-diaphragm. (From Pannu et al.,124 by permission of RadioGraphics.)

venous contrast material injection shows thickening of the right hemidiaphragm by tumor deposits along the liver surface (large arrows). Arrowhead indicates a right pleural effusion. (D) Sagittal reformatted image of the left upper abdomen obtained after intravenous contrast material injection shows tumor (T) invading the superior portion of the spleen. Short arrows indicate left hemi-diaphragm. (From Pannu et al.,124 by permission of RadioGraphics.)

accuracy of MRI for the diagnosis of malignancy has been reported to range from 83% to 86% without contrast enhancement and from 78% to 95% with contrast enhancement.

CT is usually performed as it is a rapid test and readily available. The peritoneum, retroperitoneum, and viscera are assessed for metastases. Evaluation includes sites that are difficult to evaluate at surgery, such as the diaphragm, splenic hilum, stomach, lesser sac, liver, mesenteric root, and suprarenal paraaortic nodes (Figure 31.13).120,121 Optimal debulking of disease at sites, such as the bowel mesentery and porta hepatis may also be difficult. With a successful debulk-ing procedure, residual tumor implants are subcentimeter in size. Preoperative localization of the sites of peritoneal metastases and retroperitoneal adenopathy aids in surgical planning. Preoperative imaging also helps identify patients who may benefit from neoadjuvant chemotherapy to reduce disease volume before surgical debulking. CT and clinical parameters have been used to develop scoring systems to predict the success of surgery.116,120,122

A study performed in the late 1990s on 64 patients presenting with ovarian cancer found that the overall sensitivity of single-detector CT for detecting peritoneal metastases was 85% to 93% and the sensitivity for subcentimeter lesions was 25% to 50%.123 There have been significant improvements in CT technology in the past few years with newer multidetec-tor row scanners replacing older single-detector scanners and increasing number of detector rows. These changes allow thin slices of large volumes of anatomy to be obtained in a few seconds. Thin slices optimize visualization of subcentimeter structures and can be used to generate images in multiple planes to evaluate structures, such as the diaphragm and pelvis (see Figure 31.13).124,125

Patients who are suspected to have recurrent disease based on symptoms or biochemical markers can be imaged with CT, MRI, or PET. Detection of lesions on all modalities is dependent on size. For CT, detection is greater for implants greater than 5 to 10mm than for smaller lesions.123,126 Sensitivity of single-detector CT is more than 50% for detecting implants at most sites, except the small bowel and mesentery, where lesions can be difficult to appreciate because of partial volume averaging.116 Implants are easier to visualize when surrounded by ascites. The sensitivity of multidetector row CT for detecting tumor recurrence is not established. The sensitivity of MRI was 91% for detecting recurrence in 64 women with ovarian cancer.127 Implants less than 2 cm were present in false-negative cases. Peritoneal, mesenteric, and bowel metastases can be effectively detected with MRI.128 Although CT and MRI are usually performed to evaluate patients for recurrence, small implants can be difficult to detect on visceral surfaces by anatomic imaging. The lesions may not be appreciated because of lack of significant contrast difference between tumor and normal viscera. An advantage of functional imaging with PET is that lesions are conspicuous as there is increased uptake in tumor and minimal background activity. The sensitivity of PET for recurrent tumor is higher in patients with suspected relapse compared with those without clinical disease.129 Sensitivities ranging from 80% to 100% have been reported in four series with a total of 113 patients.129-132 However, similar to CT and MRI, lesion detection is dependent on size and is less likely for lesions less than 1 to 2 cm in size than for larger masses.129,130,133,134 Omental carcinomatosis with subcentimeter lesions may not show sufficient uptake to be detected on PET although it is evident on CT.134 In 22 patients with primarily subcentime-ter lesions, including microscopic disease, the sensitivity of PET for detecting tumor recurrence was 10%.135 In a study of 31 patients with a mean lesion size of 1.1cm, the patient-based sensitivity of PET for disease recurrence was 81% and lesion-based sensitivity was 45%.134 The specificity of PET for recurrent ovarian cancer ranges from 42% to 100%.129-132,134,135 Three studies that compared PET findings with surgery found specificities of 93%, 42%, and 50%, respectively.130,134,135 High specificities of 83% and 100% were reported in two studies comparing PET with surgical or clinical follow-up.129,131 Increased uptake can be seen in postsurgical inflammation and in normal bowel and urinary tract.

However, PET may play a role in assessing patients when CT and MRI are negative and tumor markers are rising.131,136-138 It has been suggested as a complementary test to anatomic imaging.131,134,138,139 Sensitivity is improved when both CT and PET are performed.140 There is also improved correlation with surgical findings if the findings on CT and PET are combined.141 Detection of omental implants and malignant retroperitoneal nodes is improved. PET/CT scanners may play a more significant role in the future in evaluating patients with ovarian cancer. CT images as well as PET images are generated and fused for localization of abnormal activity on PET and characterization of malignant potential in masses seen on CT.142,143 However, as currently performed, the CT obtained as part of a PET/CT study is technically limited as the tube current is lower and images are noisier, there is respiratory motion artifact, there is artifact from the patient's arms, and bowel or intravenous contrast are typically not given.

In summary, CT or MRI can be used to detect extraovar-ian spread of primary tumor and recurrent disease. CT is usually performed due to ease of study and ready availability. Lesion conspicuity is high on PET, and it has been suggested as a complementary test to anatomic imaging for detecting tumor spread. The new fused PET/CT scanners combine the benefits of functional and anatomic imaging and have the potential to more accurately determine disease extent. Sub-centimeter lesions are difficult to detect by all imaging modalities.

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