Abstract
Objective
To design clear guidelines for the staging and follow-up of patients with ovarian cancer, and to provide the radiologist with a framework for use in multidisciplinary conferences.
Methods
Guidelines for ovarian cancer staging and follow-up were defined by the female imaging subcommittee of the ESUR (European Society of Urogenital Radiology) based on the expert consensus of imaging protocols of 12 leading institutions and a critical review of the literature.
Results
Computed tomography (CT) with coverage of the base of the lungs to the inguinal region is regarded as the imaging technique of choice for preoperative staging. Critical diagnostic criteria are presented and the basis for a structured report for preoperative staging is outlined. Following primary treatment for ovarian cancer, clinical assessment and CA-125 are routinely used to monitor patients. For suspected recurrence, CT remains the imaging modality of choice, with positron emission tomography (PET)/CT emerging as the optimal imaging technique for suspected recurrence, particularly in patients with negative CT or magnetic resonance imaging (MRI).
Conclusions
CT is the imaging modality of choice for preoperative staging and detection of recurrence in patients with ovarian cancer.
References
Royal College of Radiologists (2007) Making the best use of clinical radiology services, 6th edn. Royal College of Radiologists, London
Spencer JA, Forstner R, Cunha TM, Kinkel K (2010) ESUR guidelines for MR imaging of the sonographically indeterminate adnexal mass: an algorithmic approach. Eur Radiol 20:25–35
Spencer JA (2005) A multidisciplinary approach to ovarian cancer at diagnosis. Br J Radiol 78:S94–S102
Spencer JA, Forstner R, Hricak H (2008) Investigating women with suspected ovarian cancer. Gynecol Oncol 108:262–264
Togashi K (2003) Ovarian cancer: the role of US, CT and MRI. Eur Radiol 13(Suppl 4):L87–L104
Vorgias G, Iavazzo C, Savvopoulos P et al (2009) Can the preoperative Ca-125 level predict optimal cytoreduction in patients with advanced ovarian carcinoma?: a single institution cohort study. Gynecol Oncol 112:11–15
Forstner R (2007) Radiological staging of ovarian cancer: imaging findings and contribution of CT and MRI. Eur Radiol 17:3223–3235
Tempany CM, Zou KH, Silverman SG et al (2000) Staging of advanced ovarian cancer: comparison of imaging modalities-report from the Radiology Oncology Group. Radiology 215:761–767
Kurtz AB, Tsimikas JV, Tempany CMC et al (1999) Diagnosis and staging of ovarian cancer: comparative values of Doppler and conventional US, CT, and MR imaging correlated with surgery and histopathologic analysis-report of the Radiology diagnostic oncology group. Radiology 212:19–27
Thomsen HS (2007) ESUR guideline: gadolinium-based contrast media and nephrogenic fibrosis. Eur Radiol 17:2692–2706
Low RN, Sebrechts CP, Barone RB, Muller W (2009) Diffusion-weighted MRI of peritoneal tumors: comparison with conventional MRI and surgical and histopathologic findings- a feasibility study. AJR Am J Roentgenol 193:461–470
Spencer JA Swift SE, Wilkinson N, et al (2001) Peritoneal carcinomatosis: image guided peritoneal core biopsy for tumour type and patient management 221:173-177
Griffin N, Grant LA, Freeman S et al (2009) Image guided biopsy in patients with suspected ovarian carcinoma: a safe and effective technique? Eur Radiol 19:230–235
Yoshida Y, Kurokawa T, Tsuchida T et al (2004) The incremental benefits of FDG positron emission tomography over CT alone for the preoperative staging of ovarian cancer. AJR Am J Roentgenol 182:227–233
Kitajima K, Murakami K, Yamasaki E et al (2008) Diagnostic accuracy of integrated FDG-PET/contrast enhanced CT in staging ovarian cancer: comparison with enhanced CT. Eur J Nucl Med Mol Imaging 35:1912–1920
Holloway BJ, Gore ME, A’Hern RP et al (1997) The significance of paracardiac lymph node enlargement in ovarian cancer. Clin Radiol 52:692–697
Eisenhauer E, Therasse P, Bogaerts J et al (2009) New response evaluation criteria in solid tumours: Revised RECIST guideline (version 1.1). Eur J Cancer 45:228–247
Quayyum A, Coakley FV, Westphalen AC et al (2005) Role of CT and MRI in predicting optimal cytoreduction of newly diagnosed primary epithelial ovarian cancer. Gynecol Oncol 96:301–306
Kim SH, Kim SH, Yang DM et al (2004) Unusual causes of tubo-ovarian abscess CT and MR imaging findings. Radiographics 24:1575–1589
Pickhardt PJ, Bhalla S (2005) Unusual nonneoplastic peritoneal and subperitoneal conditions: CT findings. Radiographics 25:719–730
Coakley FV, Choi PH, Gougoutas CA et al (2002) Peritoneal metastases: detection with spiral CT in patients with ovarian cancer. Radiology 223:495–499
Woodward PJ, Hosseinzadeh K, Saenger JS (2004) Radiologic staging of ovarian carcinoma with pathologic correlation. From the archives of the AFIP. Radiographics 24:225–246
Akin O, Sala E, Chaya S et al (2008) Perihepatic metastases from ovarian cancer: sensitivity and specificity of CT for the detection of metastases with and those without liver parenchymal invasion. Radiology 248:511–517
Young RH, Scully RE (2002) Metastatic tumors of the ovary. In: Kurmann RJ (ed) Blausteins’s pathology of the female genital tract, 5th edn. Springer, New York, pp 1063-1101
Choi HJ, Lee JH, Kang S et al (2006) Contrast-enhanced CT for differentiation of ovarian metastasis from gastrointestinal tract cancer: stomach cancer versus colon cancer. AJR Am J Roentgenol 187:741–745
Gadducci A, Cosio S (2009) Surveillance of patients after initial treatment of ovarian cancer. Crit Rev Oncol Hematol 71:43–52
Funt AS, Hricak HH (2003) Ovarian malignancies. Top Magn Reson Imaging 14:329–338
Gu P, Pan LL, Wu SQ et al (2009) CA-125, PET alone, PET-CT. CT and MRI in diagnosing recurrent ovarian carcinoma A systematic review Eur J Radiol 71:164–174
Funt SA, Hricak H, Abu-Rustum N et al (2004) Role of CT in the management of recurrent ovarian cancer. AJR Am J Roentgenol 182:393–398
Rustin GJ, van der Burg ME, on behalf of MRC and EORTC collaborators (2009) A randomized trial in ovarian cancer (OC) of early treatment of relapse based on CA 125 level alone versus delayed treatment based on conventional clinical indicators (MRC OVO5/EORTC 55955 trials). J Clin Oncol 27(15 Suppl):5S, Abstract 1
www.ctu.mrc.ac.uk/news_and_press_releases/news_archive/ov05_trial_asco_may_2009.aspx
Dachmann AH, Visweswaran A, Battula R et al (2001) Role of chest CT in the follow-up of ovarian adenocarcinoma. AJR Am J Roentgenol 176:701–705
Sella T, Rosenbaum E, Edelmann DZ et al (2001) Value of chest CT scans in routine ovarian carcinoma follow-up. AJR Am J Roentgenol 177:857–859
Pannu HK, Bristow RE, Montz FJ et al (2003) Multidetector CT of peritoneal carcinomatosis from ovarian cancer. Radiographics 23:687–701
Kopka L, Rogalla P, Hamm B (2002) Multislice CT of the abdomen—current indications and future trends. Rofo 174:273–282
Kalra MK, Maher MM, Toth TL et al (2004) Techniques and applications of automatic tube current modulation for CT. Radiology 233:649–657
Johnson W, Taylor MB, Carrington BM, Bonington SC, Swindell R (2007) The value of hyoscine butylbromide in pelvic MRI. Clin Radiol 62:1087–1093
Fujii S, Matsusue E, Kanasaki Y et al (2008) Detection of peritoneal dissemination in gynaecological malignancy: evaluation by diffusion-weighted MR imaging. Eur Radiol 18:18–23
Forstner R, Hricak H, Occhipinti K et al (1995) Ovarian cancer: staging with CT and MRI. Radiology 197:619–626
Benedet JL, Bender H, Jones H et al (2000) FIGO classification and clinical practice guidelines in the management of gynaecologic cancers: FIGO Committee on Gynecologic Oncology. Int J Gynaecol Obstet 70:209–262
Acknowledgements
We are grateful to the following members of the female imaging subcommittee who contributed discussion of the guidelines and responded to a questionnaire about current practice in their institutions: C. Balleguier, M. Bazot, M.T. Cunha, F. Danza, B. Hamm, R. Kubik, G. Sallustio and A.C. Tsili.
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This report is made on behalf of the ESUR Female Imaging Sub-Committee (eight collaborators)
Appendices
Appendix 1
CT imaging technique
Ideally, patients fast for 4 h.
Bowel opacification, usually applied orally with 1,000 ml of diluted contrast media or alternatively water 1 h before the CT study, is generally recommended. Water facilitates differentiation of bowel loops from tiny calcifications, but small peritoneal implants may be better visualised with positive opacified bowel loops [34]. Rectal opacification aids in assessing local invasion, particularly in large tumours but is reserved for problem solving. Alternatively, an aliquot of oral contrast medium may be given at 6-8 h before examination to aid colonic opacification. It is taken at bedtime for a morning examination and on rising for an afternoon examination.
The use of intravenous contrast medium is mandatory for staging. A portal venous phase examination (at 70-90 s) is suggested, as solid enhancing components and papillary projections in adnexal masses and in implants may be missed in an early phase. The value of a dual-phase (arterial and portal venous) protocol has not been assessed. It may, however, be useful for large adnexal masses [35].
Reformatted images, using 3- to 5-mm slice thickness at 3- to 4-mm intervals in transaxial, coronal and sagittal planes allow assessment of morphology and local extent of ovarian cancer and of peritoneal carcinomatosis. As radiation protection is a concern, techniques with tube modulation and automatic current settings are recommended in imaging of the pelvis in general, and particularly in women with extensive subcutaneous fat [36].
Appendix 2
MRI technique
The use of antiperistaltic agents is recommended to optimise image quality, particularly in assessing peritoneal implants and for diffusion-weighted imaging [37]. Bowel preparation with diluted barium sulphate may be performed, however at the expense of increased imaging time [11]. Imaging sequences include a T1W sequence, T2-weighted (W) sequences of the pelvis in axial, sagittal and coronal planes, and T2W with fat saturation (FS) and T1W with gadolinium and FS for the whole examination field, the latter at least in two planes. Slice thickness should not exceed 6 mm in the pelvis and 10 mm in the upper abdomen.
DW-MRI seems a new promising technique as it provides a new contrast mechanism in assessing peritoneal carcinomatosis [11]. The optimal b value is not yet established and reported b values for diagnosing peritoneal implants range from 400-500 to 800-1,000 s/mm2 [38]. DW-MRI combined with conventional imaging sequences seems most accurate for the depiction of peritoneal metastases [11].
Contrast-enhanced MRI should be performed not longer than 10 min after contrast medium application, because contrast medium diffusion into ascites may occur. In patients with renal insufficiency, the use of gadolinium-based contrast media has to be cautiously estimated [10]. In these patients, thin-slice T2W imaging with FS and transaxial DWI will provide depiction of implants at least of more than 1-2 cm in size.
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Forstner, R., Sala, E., Kinkel, K. et al. ESUR guidelines: ovarian cancer staging and follow-up. Eur Radiol 20, 2773–2780 (2010). https://doi.org/10.1007/s00330-010-1886-4
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DOI: https://doi.org/10.1007/s00330-010-1886-4