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Attendees at ECR 2011 state of the art session on ovarian cancer will learn more about the trend towards individualised patient treatment with high-quality imaging and detailed pathologic analysis based on information provided by an image-guided biopsy.

The role of radiologists is growing rapidly in the investigation and monitoring of suspected ovarian cancer. New diagnostic and interventional techniques, together with changes in clinical management and the validation of emerging areas such as MRI of adnexal mass and imageguided peritoneal core biopsy, offer new challenges and opportunities.

Ovarian cancer is the leading cause of death from genitourinary cancer in women. Due to its nonspecific clinical features, it may present to any radiologist involved in abdomino-pelvic imaging. Attendees at European Society of Radiology 's ECR 2011 state of the art session on ovarian cancer will learn more about the trend towards individualised patient treatment with high-quality imaging and detailed pathologic analysis based on information provided by an image-guided biopsy. In the future, the timing and extent of surgery may be specific for each patient and the chemotherapy regimen may be selected for the different pathologic types of ovarian cancer.

Dr. John Spencer, consultant radiologist at St. James University Hospital in Leeds, U.K., stressed that although ovarian cancer screening remains experimental, the trend towards cross-sectional imaging for evaluation of common gastrointestinal and genitourinary tract problems has a significant rate of discovery of incidental findings of adnexal masses and other gynaecological abnormalities. He added that some findings, such as peritoneal carcinomatosis, are clearly relevant. After further clarification, most adnexal masses that are discovered as incidental findings turn out to be ‘nuisance’ lesions, but he remarked that this results in significant costs and increased patient anxiety. Spencer suggested that MRI can benefit patient care because of its ability to make specific non-invasive diagnoses and define masses as benign or malignant.

PET/CT can improve the accuracy of staging in patients with ovarian cancer, especially by detecting metastases in normal-size lymph nodes and unsuspected extra-abdominal nodal sites of disease. Experts are also excited about the potential of diffusion-weighted MRI (DW-MRI) as a diagnostic tool for improved accuracy of ovarian cancer detection with peritoneal spread.

“Radiology will play an increasingly crucial role in staging of ovarian cancer,” said Dr. Evis Sala, university lecturer and honorary consultant radiologist at Addenbrooke’s Hospital, Cambridge, U.K. “Furthermore, we are likely to see an increase in the use of PET/CT and potentially MRI (with added DW-MRI sequences) for primary staging of ovarian cancer. However, well-designed studies with histopathology as standard of reference are required to evaluate and compare the accuracy of PET/CT and DWI in staging of ovarian cancer.”

Although imaging already plays a vital role in staging and treatment planning in ovarian cancer by assuring an appropriate selection of patients for primary surgery versus neo-adjuvant chemotherapy, other benefits can result, particularly for the surgeon. Sala indicated that imaging provides the surgeon with a map of distribution of the disease prior to either primary or interval debulking surgery. Additionally, it is routinely used to monitor the response to chemotherapy and detect tumour recurrence.

Contrast-enhanced CT remains the gold standard for staging of ovarian cancer because it is easier to interpret (due to less intra-observer variability), and it is also more widely available and cheaper than MRI and PET/CT . A combination of clinical examinations, together with serum CA 125 measurement and imaging features, may be useful, but ultimately a diagnosis is made by histopathologic evaluation of tumour tissue obtained from surgery, laparoscopy, or image-guided core biopsy.

Because of the unique properties of peritoneal spread in ovarian cancer (large surface development at a relatively small depth), the potential use of intraoperative or laparoscopic imaging is an important development. This technique exploits the refraction of light or emission of fluorescence in order to image sub-surface tissue at a depth of approximately 2mm. Preliminary data have confirmed the promise of the technique for improved detection of peritoneal seeding.

Dr. Isabelle Thomassin-Naggara, from the department of radiology at Hôpital Tenon in Paris, emphasised the potential value of combining ultrasound with MRI, including perfusion and diffusion sequences. She suggested that because of the high diagnostic performance of these techniques (up to 96% for characterising complex adnexal masses), this is likely to be the way forward. She agreed with Sala regarding the benefits to the surgeon of using these techniques, which should help influence a surgical decision and treatment. “Because the most important prognostic factor for ovarian cancer is the absence of residual tissue after the first surgery, all imaging modalities have the potential to assist surgeons when deciding on best treatment options,” she noted.

She identified ultrasound as the gold standard for detection of adnexal masses, MRI for characterisation of complex adnexal masses, and spiral CT for ovarian cancer extension. In the future, high-field MR may improve the feasibility and the accuracy of MR spectroscopy for the characterisation of adnexal masses. She suggested considering ultrasound in the first instance for exploring adnexal masses.

Dr. Rosemarie Forstner, from the department of radiology at Paracelsus Private Medical University, Salzburg, Austria, agreed that where adnexal masses are indeterminate following ultrasound, a complementary MR examination may be warranted because it may contribute to improved patient management by influencing specialist referral, surgical approach, and other therapeutic options. She added that in patients with an unequivocal malignant mass with or without peritoneal spread, preoperative staging by CT helps optimise therapy planning, and radiology reports should provide detailed information about findings that are crucial for treatment planning, including the primary tumour and its dissemination. Radiologists should also include details about tumour sites that may be difficult to assess intraoperatively, as well signs that are indicative of suboptimal debulking in extensive tumour load.

To determine appropriate chemotherapy, evaluation of tumour extent using multidetector CT and image-guided biopsy looks set to ensure imaging remains the mainstay of assessment of treatment response. Therefore, working in a multidisciplinary team in gynaecological cancer will give radiologists a central patient management role.

Source: ESR

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