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Imaging Questions in
Ovarian Cancer
Susanna I. Lee, MD, PhD
Emerging Technologies
• PET-CT
• Perfusion imaging
– Dynamic contrast enhanced CT (DCE-CT)
– Dynamic contrast enhanced MRI (DCE MRI)
• Nodal imaging
– Ultrasmall superparamagnetic iron oxide (USPIO) MRI
– Diffusion weighted imaging (DWI) MRI
• Percutaneous tumor ablation
• 22,975 studies from 1,178 centers over 1 year
• 15% patients with gynecologic cancers
– 2,096 ovarian
– 1,198 uterine corpus
– 434 cervix
• Query referring physician on intended patient
management before and after PET-CT
PET Impact on Management
Hillner BE et al. J Clin Oncol 2008. 26:2155
PET-CT in Recurrence
no treatment
treatment
PET-CT in Recurrence
surgery
chemotherapy
PET-CT in Recurrence
• 53 patients with epithelial ovarian cancer
• Concurrent diagnostic CT and PET-CT scans
CT alone
PET-CT
Sensitivity
92%
97%
Specificity
60%
80%
Kappa
0.29
0.63
Sebastian S et al. Abdom Imaging 2008. 33:112
Emerging Technologies
• PET-CT
• Perfusion imaging
– Dynamic contrast enhanced CT (DCE-CT)
– Dynamic contrast enhanced MRI (DCE MRI)
• Nodal imaging
– Ultrasmall superparamagnetic iron oxide (USPIO) MRI
– Diffusion weighted imaging (DWI) MRI
• Percutaneous tumor ablation
DCE MRI Tracer Kinetic Model
ue =
Ktrans
kep= Ktrans/ue
Volume transfer constant
Flux rate constant
Tofts PS et al. J Magn Reson Imaging 1999. 10:223
DCE MRI As a Biomarker
• Correlate with pathologic prognostic indicators
– Tumor grade, microvessel density, VEGF expression
• Predict clinical response to therapy
– Anti-VEGF antibody, tyrosine kinase inhibitor
• Prospectively acquired DCE MRI databases
with corresponding clinical outcome
– ACRIN 6657/CALGB 150007 – neoadjuvant breast cancer
– ACRIN 6677/RTOG0265 – recurrent glioblastoma
Neoadjuvant Breast Cancer
pre
post 1 cycle
post chemo
DCE MRI
SER map
Hylton N. J Clin Oncol 2006. 24:3293
Emerging Technologies
• PET-CT
• Perfusion imaging
– Dynamic contrast enhanced CT (DCE-CT)
– Dynamic contrast enhanced MRI (DCE MRI)
• Nodal imaging
– Ultrasmall superparamagnetic iron oxide (USPIO) MRI
– Diffusion weighted imaging (DWI) MRI
• Percutaneous tumor ablation
USPIO MRI
• Paramagnetic core in dextran
• Half life ~25-30 h
• Nanoparticles dark on T2*
• Macrophage accumulation
– Normal nodes = dark
– Tumor replaced nodes = bright
Harisinghani MG et. al. N Eng J Med 2003. 348: 2491
USPIO MRI Endometrial Cancer
benign
malignant
USPIO MRI for Nodal Metastases
• 631 patients, 3004 nodes with histology
• Summary ROC for per lymph node data
AUC = 0.84
AUC = 0.96
Will O et al. Lancet Oncol 2005. 7:52
What About the Small Nodes?
Any size
<10 mm
Unenhanced MRI
63%
NA
USPIO MRI
88%
70%
PET-CT (cervical ca)*
72%
37%
PET-CT (endometrial ca)^
53%
40%
*Sironi S et al. Radiology 2006. 238:272
^ Kitajima K et al. Am J Roentgenol 2008. 190:1652
USPIO and Small Nodes
Endometrial ca with 5 mm node
USPIO
PET
Percutaneous Tumor Ablation
• Thermal – frictional heating
– Radiofrequency (460 kHz)
– Microwave (900-2450 MHz)
• Cryo – freeze thaw cycles
• High intensity focused ultrasound (HIFU)
– Acoustic lens to focus ultrasound for power deposition
– Thermonecrosis
– No applicator tract
Radiofrequency Ablation
Power Source
Grounding
Pad
• Radiofrequency generator 60-250 W
• Coagulation necrosis 55-100oC
Radiofrequency Ablation
• Indications
–
–
–
–
Medically inoperable patients or bridge to transplant
Liver – hepatocellular carcinoma, colon cancer
Kidney – renal cell ca
Lung – NSCLC, metastases
• Lesion selection criteria
–
–
–
–
Percutaneous approach available
< 5.5 cm
Adjacent structures
Heat sink effect
Clear Cell Ovary Recurrence
Radiofrequency Ablation
hydrodissection
ablation
Followup PET-CT
1 month
1 year
High Grade Muellerian Ablation
Pre-RF
RF
Three Year Followup
3 months
3 years