radiologic diagnosis of ovarian...

Christina Coleman, HMS IIIGillian Lieberman, MD

Radiologic Diagnosis and Radiologic Diagnosis and Staging of Staging of

Ovarian CancerOvarian CancerChristina ColemanChristina Coleman

Harvard Medical School Year IIIHarvard Medical School Year IIIGillian Lieberman, MDGillian Lieberman, MD

January 2006


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OutlineOutline•• Typical Patient PresentationTypical Patient Presentation•• Epidemiology of Ovarian CancerEpidemiology of Ovarian Cancer•• Menu of Test AvailableMenu of Test Available•• UltrasoundUltrasound•• MRIMRI•• Computed TomographyComputed Tomography


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Common Patient PresentationCommon Patient PresentationMs. D is a 49 Ms. D is a 49 yoyo F who presented to the ED complaining of F who presented to the ED complaining of

diffuse abdominal pain and bloating. Her pain is slightly diffuse abdominal pain and bloating. Her pain is slightly relieved with bowel movements. She denies relieved with bowel movements. She denies nausea/vomiting, fever/chills, nausea/vomiting, fever/chills, hematocheziahematochezia, , melenamelena, , diarrhea or constipation.diarrhea or constipation.

PMH is significant for recent diagnosis of H. Pylori infection PMH is significant for recent diagnosis of H. Pylori infection being treated with being treated with prevpacprevpac

Physical exam revealed mild abdominal distention and mild Physical exam revealed mild abdominal distention and mild tenderness of RUQ and tenderness of RUQ and epigastriumepigastrium. . GuaiacGuaiac positive positive stoolstool

Labs were normal except for HctLabs were normal except for Hct--34.4 and LDH34.4 and LDH--301301


Patient had abdominal Patient had abdominal ultrasound to evaluate her for ultrasound to evaluate her for

acute cholecystitisacute cholecystitis


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Abdominal US of LiverAbdominal US of Liver

PACS BIDMC


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Differential Diagnosis of AscitesDifferential Diagnosis of Ascites•• Elevated Lymphatic PressureElevated Lymphatic Pressure

•• CirrhosisCirrhosis•• Heart FailureHeart Failure

•• Obstruction of Obstruction of LymphaticsLymphatics, Portal Vein or IVC, Portal Vein or IVC•• NeoplasticNeoplastic

•• LymphomaLymphoma•• Benign tumorBenign tumor•• Metastatic Disease Metastatic Disease –– Gastric carcinoma, ovarian carcinomaGastric carcinoma, ovarian carcinoma

•• InfectionInfection•• SchistosomiasisSchistosomiasis•• SarcoidosisSarcoidosis•• TuberculosisTuberculosis

•• Thrombosis of IVC or Portal VeinThrombosis of IVC or Portal Vein•• Infection or Inflammation (Peritonitis)Infection or Inflammation (Peritonitis)

•• AbscessAbscess•• PancreatitisPancreatitis•• Pelvic Inflammatory DiseasePelvic Inflammatory Disease•• Rupture of hollow Rupture of hollow viscusviscus

•• HypoalbuminemiaHypoalbuminemia


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Additional Patient HistoryAdditional Patient History•• Our patient also complained of a weight loss of Our patient also complained of a weight loss of

about 8 about 8 –– 10 lbs over the last couple of months. 10 lbs over the last couple of months. Her appetite has been waning.Her appetite has been waning.

•• Family Family HxHx: mother diagnosed w/ ovarian cancer : mother diagnosed w/ ovarian cancer at age 49, sister had breast cancer at age 35at age 49, sister had breast cancer at age 35

•• now 5 years postnow 5 years post--menopause, with one sonmenopause, with one son

•• Further labs revealed CAFurther labs revealed CA--125 elevated 174125 elevated 174


Any patient with unexplained Any patient with unexplained ascites and a positive family ascites and a positive family history of breast and ovarian history of breast and ovarian

cancer in addition to elevated CAcancer in addition to elevated CA-- 125 needs to be worked125 needs to be worked--up for up for

Ovarian Carcinoma.Ovarian Carcinoma.


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What is Ovarian Cancer?What is Ovarian Cancer?•• 8080--90% of tumors arise from the surface epithelial90% of tumors arise from the surface epithelial--

stromalstromal layers of the ovary, usually in the form of a layers of the ovary, usually in the form of a cystadenocarcimacystadenocarcima. . HistologicHistologic subtypes:subtypes:

•• serous serous cystadenocarcinomacystadenocarcinoma (50%)(50%)•• mucinous mucinous cystadenocarcinomacystadenocarcinoma (20%)(20%)•• endometrioidendometrioid carcinoma (20%)carcinoma (20%)•• clear cell carcinoma (10%)clear cell carcinoma (10%)•• undifferentiated (1%)undifferentiated (1%)

•• GranulosaGranulosa cell tumorscell tumors•• Germ cell tumors: Germ cell tumors: dysgerminomasdysgerminomas, , immmatureimmmature

teratomasteratomas, , endodermalendodermal sinus tumorssinus tumors•• Metastases from breast or gastric carcinomaMetastases from breast or gastric carcinoma


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Ovarian Cancer EpidemiologyOvarian Cancer Epidemiology

•• 55thth leading cause of cancer death in leading cause of cancer death in womenwomen

•• ~25,000 new cases each year and 14,500 ~25,000 new cases each year and 14,500 deathsdeaths

•• Overall 5Overall 5--year survival rate is 53%year survival rate is 53%•• Stage I/II: 80Stage I/II: 80--90% survival rate90% survival rate•• Stage III/IV: 5Stage III/IV: 5--50% survival rate50% survival rate

•• 80% of patients present in an advanced 80% of patients present in an advanced stage of diseasestage of disease


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Risk FactorsRisk Factors•• 10% of cases are hereditary10% of cases are hereditary

•• BRCA1 mutation 40BRCA1 mutation 40--60% lifetime risk of 60% lifetime risk of developing ovarian cancerdeveloping ovarian cancer

•• BRCA2 mutation 10BRCA2 mutation 10--20% lifetime risk20% lifetime risk

•• 90% sporadic90% sporadic•• older ageolder age•• early menarche or late menopauseearly menarche or late menopause•• nulliparitynulliparity•• HRT increases risk 1.8x for 10yrs of useHRT increases risk 1.8x for 10yrs of use


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Menu of Tests Available to Menu of Tests Available to Diagnose and Stage Ovarian Diagnose and Stage Ovarian

CancerCancer

•• Pelvic UltrasoundPelvic Ultrasound•• MRIMRI•• CTCT•• FDGFDG--PETPET


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Pelvic UltrasoundPelvic Ultrasound•• TransabdominalTransabdominal and/or and/or TransvaginalTransvaginal US is US is

the standard for identification and the standard for identification and characterization of an characterization of an adnexaladnexal massmass

•• 6060--97% sensitivity in detecting masses97% sensitivity in detecting masses•• 9393--97% of masses can be 97% of masses can be chararacterizedchararacterized

by by sonographicsonographic morphology alonemorphology alone•• 95% positive predictive value for benignity95% positive predictive value for benignity•• 5050--94% positive predictive value for 94% positive predictive value for

malignancymalignancy


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US Features of Malignancy US Features of Malignancy vsvs Benign CystBenign Cyst

•• Ovary volume > 20cmOvary volume > 20cm3 3 premenopausal or > 8premenopausal or > 8-- 10cm10cm33 postmenopausalpostmenopausal

•• Solid component within massSolid component within mass•• Mural thickeningMural thickening•• SeptationsSeptations > 3mm> 3mm•• NodularityNodularity•• Papillary projectionsPapillary projections•• Bilateral massesBilateral masses

All are indications of malignancyAll are indications of malignancy


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Comparative Patient Comparative Patient TransvaginalTransvaginal US of US of Normal Premenopausal OvaryNormal Premenopausal Ovary

PACS BIDMC

Follicles


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Comparative Patient Comparative Patient TransvaginalTransvaginal US US of Ovarian Cystof Ovarian Cyst


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TransvaginalTransvaginal US of Our PatientUS of Our Patient’’s s Right OvaryRight Ovary

Nodular

PACS BIDMC


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TransvaginalTransvaginal US of PatientUS of Patient’’ss Left OvaryLeft Ovary

PACS BIDMC


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Doppler Ultrasound Helps Distinguish Doppler Ultrasound Helps Distinguish Malignant Malignant vsvs Benign MassesBenign Masses

•• Provides information about vascular compliance, vessel Provides information about vascular compliance, vessel density and distribution of vessels within an identified density and distribution of vessels within an identified massmass

•• Tumors have low resistance flow patterns with high Tumors have low resistance flow patterns with high systolic to diastolic flowsystolic to diastolic flow

•• Resistive Index (RI) = peak systolic velocity Resistive Index (RI) = peak systolic velocity –– end diastolic velocityend diastolic velocitypeak systolic velocitypeak systolic velocity

< 0.4 abnormal< 0.4 abnormal

•• PulsatilePulsatile Index (PI) = peak systolic velocity Index (PI) = peak systolic velocity –– end diastolic velocityend diastolic velocitymean velocitymean velocity

< 1.0 abnormal< 1.0 abnormal


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Color Doppler US of Our PatientColor Doppler US of Our Patient’’ss Right OvaryRight Ovary

PACS BIDMC


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Ultrasound Diagnosis of Ms DUltrasound Diagnosis of Ms D’’s s ovarian massesovarian masses

•• LargeLarge complexcomplex rightright ovarianovarian massmass with with heterogenousheterogenous echogenicityechogenicity and and hyperechoichyperechoic solid components. Abnormal solid components. Abnormal vascularityvascularity seen on color seen on color dopplerdoppler. There . There is also a 4 by 3cm left ovarian mass. is also a 4 by 3cm left ovarian mass. Evidence is highly suspicious for Evidence is highly suspicious for malignancy.malignancy.

•• DDX: primary ovarian tumor, metastases DDX: primary ovarian tumor, metastases


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MRIMRI

•• Rarely used for initial diagnosis of ovarian cancerRarely used for initial diagnosis of ovarian cancer•• Used to characterize masses that are Used to characterize masses that are indeterminantindeterminant or or

poorly visualized by ultrasoundpoorly visualized by ultrasound•• Diagnostic predictive value of malignancy is 87Diagnostic predictive value of malignancy is 87--99%99%•• Ovaries are evaluated with axial T1, axial T2, and Ovaries are evaluated with axial T1, axial T2, and

sagittalsagittal T2T2--weighted imagesweighted images•• Gadolinium increases detection of malignant massesGadolinium increases detection of malignant masses•• Fat saturation can help distinguish blood from fat on T1Fat saturation can help distinguish blood from fat on T1•• MRI is also good for detecting local invasion of the MRI is also good for detecting local invasion of the

cancercancer


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Comparative Patient MRI of Comparative Patient MRI of Right Ovarian MassRight Ovarian Mass

PACS BIDMC

Heterogenous signal is suspicious for malignancy


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Comparative Patient MRI of Comparative Patient MRI of MyometrialMyometrial InvasionInvasion

http://radiographics.rsnajnls.org/cgi/content/figsonly/24/1/225

Mixed cystic tumor Myometrial

Invasion



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Comparative Patient MR Images showing enhanced Comparative Patient MR Images showing enhanced metastasis detection with fatmetastasis detection with fat--saturation and gadoliniumsaturation and gadolinium


Axial CT Axial T2-weighted, fat-suppressed MR image

Axial gadolinium-enhanced, T1-weighted, fat-suppressed MR



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Computed TomographyComputed Tomography•• Primary modality used for Primary modality used for stagingstaging ovarian cancerovarian cancer•• Conventional CT: sensitivity 63Conventional CT: sensitivity 63--79%, specificity 79%, specificity

82% for detection of peritoneal implants82% for detection of peritoneal implants•• Helical CT: sensitivity 85Helical CT: sensitivity 85--93%, specificity 9193%, specificity 91--

96%96%•• Evaluates extent of tumor, peritoneal implants, Evaluates extent of tumor, peritoneal implants,

lymphadenopathylymphadenopathy, and solid organ metastases, and solid organ metastases•• Oral contrast helps to differentiate bowel from Oral contrast helps to differentiate bowel from

serosalserosal and mesenteric metsand mesenteric mets•• Caveats:Caveats:

•• Cannot visualize implants < 1cmCannot visualize implants < 1cm•• IV contrast may obscure visualization of calcified metsIV contrast may obscure visualization of calcified mets


Before Looking at the staging of ovarian Before Looking at the staging of ovarian cancer by CT criteria, we much first cancer by CT criteria, we much first understand how the tumor spreads.understand how the tumor spreads.

• Tumor invades dependent portions of the pelvis

• Peritoneal fluid is seeded by the cancer and spreads it along the abdominal cavity

• Peritoneal fluid flows predominantly on the right, so the right side of the abdomen typically has more metastases

• Blockage of the diaphragmatic lymphatics causes malignant ascites


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FIGO Staging CriteriaFIGO Staging Criteria

Stage I: tumor confined to ovaries Stage II: Local spread of tumor confined to the pelvis




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FIGO Staging CriteriaFIGO Staging Criteria

Stage III: peritoneal metastases outside the pelvis or abdomino- pelvic nodal mets

Stage IV: metastasis outside the abdomen, or hematogenesis spread




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Potential CT FindingsPotential CT Findings•• Cystic mass lateral to uterus, often bilateral (If lesion is solCystic mass lateral to uterus, often bilateral (If lesion is solid, id,

necrosis suggests malignancy)necrosis suggests malignancy)•• Local spread: pelvic side wall, rectum, sigmoid colon, bladderLocal spread: pelvic side wall, rectum, sigmoid colon, bladder•• Peritoneal spread (Present in 70% of patients at initial diagnosPeritoneal spread (Present in 70% of patients at initial diagnosis):is):

•• AscitesAscites•• Thickened Thickened OmentumOmentum ((OmentalOmental Cake)Cake)•• PlaquePlaque--like enhancing soft tissue masses in pouch of Douglas, like enhancing soft tissue masses in pouch of Douglas, paracolicparacolic

gutters, gutters, subphrenicsubphrenic space, surface of liver, and surface of small and space, surface of liver, and surface of small and large bowellarge bowel

•• Calcified metastasesCalcified metastases•• Nodal spread: 3 routesNodal spread: 3 routes

•• Retroperitoneal nodes along ovarian vesselsRetroperitoneal nodes along ovarian vessels•• Internal iliac and Internal iliac and obturatorobturator nodes near broad ligamentnodes near broad ligament•• External iliac and inguinal nodes near round ligamentExternal iliac and inguinal nodes near round ligament

•• Metastases: liver parenchyma, lungs, kidneyMetastases: liver parenchyma, lungs, kidney


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Returning to Our Patient, Ms D:Returning to Our Patient, Ms D:

After her ultrasound confirmed bilateral After her ultrasound confirmed bilateral ovarian masses, highly ovarian masses, highly suspicoussuspicous for for

malignancy, she had a pelvic and malignancy, she had a pelvic and abdominal CT for preabdominal CT for pre--operative staging.operative staging.


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PatientPatient’’s Axial CT s Axial CT –– Liver LevelLiver Level

Ascites

Peritonealimplant

PACS BIDMC


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Comparative Patient CT of Comparative Patient CT of SubphrenicSubphrenic ImplantsImplants

Not visualized on our Patient’s CT but noted during surgery

PACS BIDMC


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PatientPatient’’s CT s CT –– Kidney LevelKidney LevelOmental

Mass

PACS BIDMC

OmentalCake

Encasement of bowel by tumor


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PatientPatient’’s CT a little lower downs CT a little lower downLymphadenopathy

(>1cm suggestive of metastasis)

PACS BIDMC

More omental cake


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PatientPatient’’s CT of Left Ovarys CT of Left OvaryLt Cystic mass

Rt Cystic Mass

Thickened Bowel Loops

PACS BIDMC


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PatientPatient’’s CT of s CT of RtRt OvaryOvary

Rt Ovarian Mass

PACS BIDMC

Sigmoid colon, rectum and uterus encased by tumor


After the CT, Ms D underwent After the CT, Ms D underwent exploratory exploratory laparotomylaparotomy and and complete surgical staging.complete surgical staging.


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FDG PETFDG PET•• Positron Emission Tomography with Positron Emission Tomography with flourinatedflourinated

deoxydeoxy glucoseglucose•• Not used for characterization, diagnosis or Not used for characterization, diagnosis or

staging of ovarian massesstaging of ovarian masses•• Sensitivity 83Sensitivity 83--86%, Specificity 5486%, Specificity 54--86%86%•• False positives with inflammatory processes, False positives with inflammatory processes,

some benign tumors, and gastrointestinal some benign tumors, and gastrointestinal activityactivity

•• Useful for disease recurrence in patients that Useful for disease recurrence in patients that have rising CAhave rising CA--125 but negative CT or MRI 125 but negative CT or MRI findingsfindings


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Surgical StagingSurgical Staging•• Murky brown ascitesMurky brown ascites•• MiliaryMiliary tumor studding right tumor studding right

hemidiaphragmhemidiaphragm•• OmentumOmentum replaced by 5cm thick replaced by 5cm thick

tumortumor•• SerosalSerosal surfaces of the transverse surfaces of the transverse

colon, appendix and small bowel colon, appendix and small bowel were involvedwere involved

•• Tumor coated peritoneum of Tumor coated peritoneum of bladder, uterus, bladder, uterus, adnexaadnexa and culand cul-- dede--sacsac

•• Multiple loops of bowel fixed in Multiple loops of bowel fixed in the pelvisthe pelvis

Stage IIIC grade 3 papillary serous ovarian carcinomahttp://www.cancerfacts.com/GeneralContent/Ovarian/images/Ovar_SrgclStgng.gif

http://www.cancerfacts.com/GeneralContent/Ovarian/images/Ovar_SrgclStgng.gif


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SummarySummaryIf history and physical exam are suspicious for ovarian If history and physical exam are suspicious for ovarian

carcinoma, then the following imaging workcarcinoma, then the following imaging work--up is up is recommended:recommended:

•• Pelvic US: proven to be sensitive and specific enough to Pelvic US: proven to be sensitive and specific enough to detect 60detect 60--97% of ovarian masses and characterize them 97% of ovarian masses and characterize them as benign or malignantas benign or malignant

•• MRI: reserved for MRI: reserved for indeterminantindeterminant US. It can be used for US. It can be used for staging, but is more expensive than CT and difficult to staging, but is more expensive than CT and difficult to assess bowel due to motion artifact. Better visualization assess bowel due to motion artifact. Better visualization of invasion than CT.of invasion than CT.

•• CT: primary modality for staging. Can evaluate tumor CT: primary modality for staging. Can evaluate tumor invasion, peritoneal metastases, invasion, peritoneal metastases, lymphadenopathylymphadenopathy, and , and distant metastasisdistant metastasis

•• FDG PET: reserved for diagnosing recurrence of diseaseFDG PET: reserved for diagnosing recurrence of disease


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North America: WomenNorth America: Women’’s Imaging, An Oncologic Focuss Imaging, An Oncologic Focus. WB Saunders . WB Saunders Company, Philadelphia, May 2002. 40:3:609Company, Philadelphia, May 2002. 40:3:609--636636

FuntFunt SA, SA, HannHann LG. Detection and Characterization of LG. Detection and Characterization of AdnexalAdnexal Masses. Masses. Radiologic Clinics of North America: WomenRadiologic Clinics of North America: Women’’s Imaging, An Oncologic s Imaging, An Oncologic FocusFocus. WB Saunders Company, Philadelphia, May 2002. 40:3:591. WB Saunders Company, Philadelphia, May 2002. 40:3:591--608608

Reeder, Maurice MD. Reeder, Maurice MD. GamutsGamuts in Radiology: Comprehensive Lists of Roentgen in Radiology: Comprehensive Lists of Roentgen Differential Diagnosis 4Differential Diagnosis 4thth EditionEdition. Springer 2003. Springer 2003

Stomper PC. Stomper PC. Cancer Imaging ManualCancer Imaging Manual. J.B. Lippincott Company, Philadelphia . J.B. Lippincott Company, Philadelphia 19931993

Woodward PJ, Woodward PJ, HosseinzadehHosseinzadeh K. From the Archives of AFIP: Radiologic Staging K. From the Archives of AFIP: Radiologic Staging of Ovarian Carcinoma with Pathologic Correlation. of Ovarian Carcinoma with Pathologic Correlation. RadiographicsRadiographics. Jan . Jan 2004; 24:2252004; 24:225--46.46.

http://radiographics.rsnajnls.org/cgi/content/figsonly/24/1/225http://radiographics.rsnajnls.org/cgi/content/figsonly/24/1/225

http://www.cancerfacts.com/GeneralContent/Ovarian/images/Ovar_Srhttp://www.cancerfacts.com/GeneralContent/Ovarian/images/Ovar_SrgclStgng.gifgclStgng.gif





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AcknowledgementsAcknowledgements

•• Riley Riley BoveBove•• Darren Brennan, MDDarren Brennan, MD•• Erik Erik StienStien, MD, MD•• Gillian Lieberman, MDGillian Lieberman, MD•• Pamela LepkowskiPamela Lepkowski•• Larry Larry BarbarasBarbaras, Webmaster, Webmaster

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