Imaging in Ovarian Cancer

8/18/2019 Imaging in Ovarian Cancer

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Imaging in ovarian cancer

Ovarian cancer affects mainly post-menopausal women but is not uncommon in pre-menopausal women.

•.

The presentation of ovarian cancer is usually delayed,

and therefore early detection of disease is important.

•.

Imaging has an important role in the detection and

characterisation of adnexal masses with the

primaryimaging modality being transvaginal ultrasound.

•.

Cross-sectional imaging is useful to assess the extent ofdisease prior to surgery, for monitoring treatment

response and for detecting recurrence.

Ovarian cancer is the fifth most common cancer affecting women in the UK and is associated with a worse prognosis

than other forms of gynaecological malignancy. There are increasing numbers of women presenting with ovarian

cancer over the age of 65 years. The diagnosis of ovarian cancer is often delayed, owing to the lack of symptoms and

the nonspecific nature of the disease, particularly in the early stages. The prognosis of advanced ovarian cancer is

poor in the later stages, making early detection of malignancy important. On current classification systems, the

staging of ovarian cancer remains surgical but the role of imaging is contributory throughout the management of

ovarian cancer which defines disease burden. The primary imaging modality for detection of ovarian disease is

transvaginal ultrasound, and !T imaging is predominantly used in the staging of ovarian cancer with "#$ being

reserved as a problemsolving techni%ue, especially in younger women where benign disease is more likely. &ewer

modalities such as positron emission tomography !T are increasingly being recognised in ovarian cancer where

recurrent disease can be diagnosed more %uickly with subse%uent treatment. The role of imaging is discussed with

reference to the different imaging modalities available in the assessment of ovarian malignancy.

Ovarian cancer is the second most common gynaecological cancer and is associated with higher mortality rates

compared with other forms of gynaecological malignancy. The incidence of ovarian cancer is appro'imately ()))

cases per year in the UK *+. The ma-ority of cases occur in women aged over 6) years, but appro'imately +) of

cases occur in younger women. #isk factors for ovarian cancer include nulliparity, early menarche, childbirth after /5years, late menopause and hereditary cancer syndromes. Ovarian stimulation drugs may slightly increase the risk of

ovarian cancer *0, but the use of the oral contraceptive pill is thought to be protective.

1atients are usually asymptomatic in the early stages and may present in the late stages with abdominal distension,

shortness of breath, fatigue or bony pain. 2elayed diagnosis means a poorer prognosis with a survival rate of 530)

in 4tage $$$ or $ ovarian cancer compared with appro'imately ) at 4tage $ */. The overall survival rate in ovarian

cancer has gradually increased but has not significantly changed in latestage ovarian cancer, despite developments

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in diagnosis and treatment */. 7arly detection re%uires a multidisciplinary approach, with a thorough clinical

assessment combined with appropriate imaging techni%ues and tumour markers.

Investigation4ection8

1atients should initially undergo a pelvic bimanual e'amination, after which serum cancer antigen +05 9!:+05;

levels and a pelvic ultrasound may be performed. !:+05 is a poor marker for screening as only 5) of 4tage $

tumours will elevate !:+05 *


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Ovarian tumours are graded as well 9+);, moderately 905; and poorly differentiated 965; *+


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:bout ()3(5 of patients with ovarian cancer have tumour spread beyond the pelvis at the time of diagnosis *0.

4pread in ovarian cancer occurs primarily by intraperitoneal dissemination due to tumour cells shedding into the

peritoneum and being distributed in a clockwise fashion. The commonest sites for spread are the pouch of 2ouglas,

the right subphrenic space and the omentum */). :typical sites include the ligamentum teres, gastrosplenic,

gastrohepatic ligaments and splenic hilum */+. Eocal spread occurs within the pelvis, to the opposite ovary, uterus,fallopian tubes, bladder, rectum and pelvic side wall. &odal metastases spread via the lymphatics to the paraaortic

chain, along the ovarian vessels and via the broad ligament to the internal iliac, obturator and e'ternal iliac nodes.

4pread to superficial and deep inguinal nodes is via the round ligament. 2istant metastases are rare at the time of

diagnosis, but metastatic sites include the liver, spleen, pleura, lung, adrenals and, less commonly, the skeleton and

brain.

4taging remains surgical and is performed in accordance with $nternational Federation of ynecology and Obstetrics

9F$O; staging system 9Table +; */0. 4tage $ refers to tumour confined to the ovaries, 4tage $$ to ovarian cancer with

peritoneal metastases confined to the true pelvis, 4tage $$$ to e'trapelvic peritoneal or abdominopelvic metastases

and 4tage $ to metastases outside the abdomen and pelvis. The surgical procedure aims to stage regions according

to the spread of cancer and involves aspiration of ascites or washings of the pelvis and paracolic gutters. : total

hysterectomy and bilateral oophorectomy is usually performed. Fertility preservation can only be considered in

patients with 4tage $: disease, where dilatation and curettage, unilateral oophorectomy and inspection of

the contralateral ovary are undertaken. :ll organs and peritoneal surfaces are visualised for disease spread. :n

infracolic omentatectomy and biopsies of the pelvic peritoneum, culdesac, bladder reflection, paracolic gutters and

diaphragm are performed *0. :ny suspicious lymph nodes are e'cised, although some authors advocate systematic

e'cision of bilateral obturator, left renal vein and retroperitoneal nodes *//. :ppendectomy is recommended in

suspected mucinous tumours */


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a4ource8 KurtL :B, Tsimakas, Tempany !"!, Damper U", :rger 1D, Bree #E, et al. 2iagnosis and staging of

ovarian cancer8 comparative values of doppler and conventional U4, !T and "#imagingcorrelated with surgery and

histopathologic analysisMreportof the#adiology 2iagnostic Oncology roup.Radiology +C0+08+30(.

Treatment4ection8

The standard management of ovarian carcinoma is primary debulking surgery 9124; followed by chemotherapy.

4tages $3$$$ are primarily treated with surgical cytoreduction and 4tage $ is managed with chemotherapy. 124 refers

to initial resection of all tumour sites leaving no macroscopic residual disease. $n advanced cases, complete surgical

resection may not be possible and optimal disease reduction with residual sites of less than +30 cm is considered

acceptable */(. 124 should be performed by a trained gynaeoncology surgeon, preferably in a cancer centre */>.

4urgical disease volume reduction facilitates the response to chemotherapeutic agents */ by reduction in tumour

bulk, which responds more effectively and improves overall survival *


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Ultrasound

The ma-ority of patients with suspected ovarian cancer will undergo a pelvic ultrasound, which includes both

transabdominal and TU4. Transabdominal scans evaluate larger pelvic masses and focused ultrasound with TU4

due to the close pro'imity of the probe allows a more focussed assessment of the ovaries and adne'al masses. The

siLe and morphology of the ovaries and the relationship of any pelvic masses to the ovaries and uterus can be

assessed. The internal composition of a mass can be determined and whether it is predominantly solid or cystic,unilocular or multilocular. The vascularity of solid components and the presence of calcification or internal septae can

be demonstrated well on ultrasound. 4imple follicular cysts, corpus luteal cysts, endometriomas and benign cystic

teratomas can be identified confidently with ultrasound and will obviate the need for furtherimaging 9Figure +;. 4imple

cysts @5 cm are likely to be benign, especially in premenopausal women *


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Figure 3. : solid mass within the left ovary clearly demonstrating central internal blood flow in a comple' cystic mass withabnormal doppler indices 9pulsatility inde' @+, resist ive inde' @).>3+)) and specificity of 6036 *5>.

Ultrasound has a lower detection rate for peritoneal metastases than !T or "#$ *5 and certain tumours such as

borderline ovarian tumours may be more difficult to assess accurately, although the presence of papillae or multiple

septae is suggestive 9Figure


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Figure ". 9a; :'ial T + weighted fast spin echo "#$ showing a welldefined comple' pelvic mass containing highsignalmaterial superiorly. 9b; T + weighted fatsuppressed se%uences demonstrate signal dropout in the superior aspect of thismass 9star;, indicating the presence of macroscopic fat, which is consistent with a benign cystic teratoma.

Figure #. : tubulocystic mass in the pouch of 2ouglas is demonstrated well on a'ial and sagittal "#$images. Theappearances are those of a haematosalpin'. The structure is hyperintense on the a'ialT + weighted images and becomes

more conspicuous on fatsuppressed se%uences. &ot the intermediate signal intensity on the sagittal T 0

weighted se%uence.

"#$ is not widely used in ovarian cancer in some centres and may relate to cost issues, lack of availability and the

variability of study %uality. Both !T and "#$ are superior to ultrasound in the assessment of the nature of ovarian

masses, with the highest accuracy for "#$ *66. "#$ is useful in the assessment of local tumour invasion and for

evaluating local spread to the uterus, bladder, rectum or pelvic sidewall. 4imilar to !T, it can be used to detect tumour

residuum or recurrence. 2ue to the lack of ionising radiation, "#$ is indicated in patients who are allergic to iodinated

contrast, pregnant patients and younger women. $t has a higher specificity than ultrasound *66, and is helpful in

characterising lesions where ultrasound and !T e'aminations have been inconclusiveC it is most useful in those with

a low likelihood of malignancy where surgery can be avoided *6(, 6>. $ts multiplanar capability and better soft tissue

characterisation relating to tissue signal characteristics make it more useful than !T or ultrasound in helping to

confirm benign disease 9Figure 6;. Dowever, it is not suitable for all patients, such as those with claustrophobia, a

large body habitus and those with "#$incompatible metallic implants or difficulties with breathholding.

The features that increase the suspicion for malignancy on "#$ are similar to those found on ultrasound with solid

nonfatty, nonfibrous tissue or cysts with thick walls, septations and papillary pro-ections. 1apillary pro-ections are

seen in 0 of malignant tumours *6+. The most predictive features for malignancy are enhancing tissue 9Figure (;,

vegetations in a cystic lesion, a diameter of more than 6 cm and necrosis *6, (). 1elvic organ invasion, implants,

ascites and enlarged lymph nodes increase the likelihood of malignancy. Uterine invasion is identified as distortionof

the uterine contour, an irregular interface between the tumour and the myometrium and increased signal intensityof

the myometrium. Eoss of the fat plane between the solid component of the tumour and the ad-acent bowel

orbladder can indicate local invasion. 1elvic wall invasion can be diagnosed when tumour reaches the sidewall to

within / mm or when iliac vessels are surrounded and distorted *(+.

Figure $. : comple' cystic pelvic mass in a /6yearold woman. The internal septum and the nodule 9arrow; demonstrateenhancement following intravenous gadolinium and is therefore highly suggestive of malignancy.

$n a prospective study of adne'al masses, "#$ showed a sensitivity of +)) and specificity of and peritoneal metastases, but "#$ is more accurate for lymph node metastases *6+, local disease and

liver metastases.

%T4ection8

!hoose

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!T is widely available and allows rapid evaluation of the whole abdomen and pelvis. Oral contrast may be helpful to

opacify the small bowel and colon to facilitate the differentiation of adne'al structures from bowel loops and pelvic

structures *(+. 1atients with calcified peritoneal disease may have metastases obscured by positive oral contrast and

therefore re%uire oral water 9Figure >;. 1atients are re%uired to have a full bladder and are usually given + l of dilute

9/; astrografin 9Bracco, "ilan, $taly; at least + h prior to the scan. The use of intravenous contrast helps to

characterise the internal structure of adne'al masses and to make peritoneal disease more conspicuous. $ts mainstay

is in assessing e'traovarian and distant disease, and disease that may be less amenable to surgery. 1articular siteswhere surgical resection may be more difficult are supradiaphragmatic 9Figure ;, subdiaphragmatic recesses 9Figure

+);, liver parenchyma, supracolic omentum, suprarenal lymph nodes and small bowel mesentery 9Figure ++;.

Figure &. :'ial !T section through the lower abdomen showing calcified omental disease in a patient with mucinouscystadenocarcinoma. This is distinguished from ad-acent bowel, which contains a negative oral contrast agent.

Figure '. &umerous paracardiac or cardiophrenic lymph nodes 9arrow; in a patient with 4tage $$$ ovarian cancer.

Figure 1(. &odular thickening of the right hemidiaphragm due to subdiaphragmatic disease. &ote the peritoneal diseasemedial to the spleen 9arrow;.

Figure 11. $lldefined streaky soft tissue opacity in the root of the small bowel mesentery due to peritoneal disease 9arrow;.There is also ascites in the right paracolic gutter.

The specific features of ovarian malignancy on !T are pelvic masses greater than < cm, cystic masses of variable

density, wall irregularity, thick septa 9N/ mm;, vegetations and solid enhancing components within adne'al masses.

1eritoneal disease is highly suggestive of malignancy and is demonstrated as thickening, nodularity and abnormal

enhancement of the peritoneum. !alcified deposits within the peritoneum may be seen in serous cyst

adenocarcinomas *(0. 1eritoneal disease is commonly seen in the paracolic gutter, omentum, bowel serosa 9Figure

+0;, liver surface, subphrenic spaces and mesentery. $t is important to review deposits close to the diaphragm on

coronal reformats 9Figure +/; as deposits ad-acent to the liver can be difficult to discriminate from subcapsular

deposits, which are 4tage $$$ disease, and liver parenchymal involvement, which is 4tage $ disease 9Figures

+


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Figure 12. 7'tensive thickening and serosal disease of the sigmoid colon 9arrow; with further peritoneal disease seen alongthe right pelvic side wall.

Figure 13. !oronal reformats can help to identify subdiaphragmatic and subcapsular disease more easily. &ote thesubdiaphragmatic disease inferior to the right hemidiaphragm 9arrow;.

Figure 14. There is an invasive subcapsular deposit in the posterior part of the right lobe of liver 9arrow;, which should notbe mistaken for a parenchymal metastasis. 4ignificantly enlarged periportal lymphadenopathy 9star; is also seen in thispatient with 4tage $$$ ovarian cancer.

Figure 1". : parenchymal metastasis in a patient with 4tage $ ovarian cancer. &ote the periportal lymphadenopathy andleft adrenal metastasis.

1elvic ascites, although suggestive of malignancy, is not specific for malignancy, and may be present in ovarian

torsion, pelvic inflammatory disease and benign ovarian fibromas *(


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and can be used along with other forms of crosssectional imaging such as "#$ and newer modalities such as

positron emission tomography 917T;=!T.

)ositron emission tomography %T4ection8

17T=!T can detect e'trapelvic disease and distant metastases, and is an alternative to !T imaging for the evaluation

of hypermetabolic implants, especially on the subdiaphragmatic, subhepatic, serosal and subcapsular surfaces

9Figure +6;. Fluorodeo'yglucose 9F2; 17T=!T combines metabolic information with the anatomical information

obtained from !T to increase the accuracy of imaging *(>. :lthough 17T=!T can serve as both a primary staging tool

and for evaluating recurrence, its strength lies in detecting recurrence, where it is particularly useful in distinguishing

later stages of ovarian cancer, with an accuracy of 5 *(, >). 4tudies have reported low sensitivities and

specificities for detecting primary ovarian cancer *>+, >0.

Figure 1#. : subcapsular liver deposit is shown as a highly metabolic lesion on coronal positron emissiontomography=!T images 9arrow;. There is also left hydronephrosis.

The usefulness of 17T=!T may be limited in premenopausal women, where high rates of falsepositive results can

occur with benign disease and high falsenegative results with borderline tumours, lowgrade and early

adenocarcinomas *>/. 1hysiological uptake in the pelvis due to superimposed bladder and bowel activity can make

assessment of the pelvis challenging. Benign conditions such as endometriosis, hydrosalpinges, pedunculated

fibroids and benign ovarian tumours are associated with high uptake 9Figure +(; *>; *>5. Ovarian

tracer uptake should therefore be correlated carefully with menstrual status and phase. : study by !astellucci

suggests that a standard uptake value 94U; of / or more is positive for malignancy and a 4U of up to 0.( is

considered benign *>). $ncidental avid ovarian uptake in a postmenopausal woman should be investigated further

with TU4 and correlated with !:+05 as uptake is unlikely to be physiological. :bnormal lymph nodes are better

detected on 17T=!T as conventional imaging relies on siLe criteria to distinguish pathological nodes, but 17T=!T

adds functional information 9Figure +;. !T is traditionally very sensitive for detecting peritoneal implants but small

peritoneal implants less than ( mm may be difficult to identify on 17T=!T. 4tudies report high a sensitivity of >( and

specificity of +)) *>6, although it is not the preferred techni%ue of staging it is comparable in accuracy to !T. $n

addition to !T, it can evaluate e'trapelvic disease and distant metastases more easily demonstrated compared with

!T alone 9Figure 0); *>(. $t has been shown to more significantly influence the management of patients with

suspected disease recurrence where other studies have been negative or inconclusive *>>.

Figure 1$. : fused a'ial positron emission tomography=!T image showing no uptake in a benign cystic teratoma. &ormalbowel uptake is noted around the teratoma.

!hoose

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Figure 1&. 9a; Benign physiological uptake in both ovaries indicated by bilateral faint uptake. 9b; "arked bilateral uptakewithin the ovaries in a patient with ovarian metastases secondary to melanoma.

Figure 1'. 9a; There is a single enlarged aortocaval node shown on !T 9arrows; in a patient with known ovarian cancer. 9b;This node shows avid uptake on positron emission tomography=!T, indicating metastatic involvement. $t was resected andconfirmed to represent recurrent disease.

Figure 2(. 9a; : metastatic lesion in the spleen in a patient with 4tage $ ovarian cancer. 9b; This lesion shows markeduptake on the corresponding positron emission tomography=!T image.

7arly diagnosis of disease relapse is important as up to (5 of patients with ovarian cancer will relapse *>, and

although !:+05 is a sensitive marker for relapse, relevant sites of recurrence need to be identified early 9Figure 0);.

17T=!T performs better than !T or "#$ in the detection of recurrence *), with high sensitivity for disease

recurrence 9sensitivity +, specificity >>; *+. Falsepositives can occur in assessing patients following surgery,with inflammatory change or fibrosis and in tumours less than / weeks post chemotherapy *0. 17T=!T can modify

treatment planning and is an important tool for patients with suspected recurrent disease where !T and "# have

been negative or inconclusive */.

%onclusion4ection8

There are multiple imaging modalities available for the radiologist in assessing ovarian cancer. Ultrasound is useful

as a firstline investigation for suspected malignancy and identifying the need for further imaging. "#$ can

characterise adne'al masses with more accuracy and may prevent surgery in those with benign pathology especially

in younger women. !T and "#$ have a similar accuracy in the assessment of e'trapelvic disease, but the wider

availability and reproducibility of !T makes it more useful in the preoperative setting. Both !T and 17T=!T are

utilised in assessing response to treatment, and detecting disease progression and relapse. 17T=!T is less readily

available and is currently being implemented in specific settings such as detection of recurrence or for clarification of

disease in patients being considered for secondary debulking surgery.

!e*erences4ection8

. Cancer 4esearch 56. Cancer incidence for common cancers. &778 9cited & :ovember &7;.)vailablefrom* http*


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)vailable from* http*


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Imaging in Ovarian Cancer