Dott. Giovanni CARBOGNIN - Sacro...

Dott. Giovanni CARBOGNIN

Dipartimento di Radiologia Diagnostica

Ospedale “Sacro Cuore – Don Calabria” Negrar (VR)

IL CARCINOMA OVARICO: APPROCCIO MULTIDISCIPLINARE E

PROSPETTIVE TERAPEUTICHE

CONSIDERAZIONI PRELIMINARI

Ovarian cancer is the seventh most common malignancy among women

worldwide, accounting for 3.7% of all cases of cancer in women.

The incidence of ovarian cancer is highest in developed nations, where it

remains the most lethal gynecologic malignancy

Mohaghegh P, Rockall AG. Imaging Strategy for Early Ovarian Cancer: Characterization of Adnexal Masses with

Conventional and Advanced Imaging Techniques. RadioGraphics, 2012, 32: 1751–1773

The high mortality rates of ovarian cancer are partly due to its

late detection, with 67% of patients presenting with advanced

disease

Kosary CL. Cancer of the Ovary. In: , Ries LAG, Young JL, Keel GE, et al., eds. , SEER Survival Monograph.

Cancer Survival Among Adults: U.S. SEER Program, 1988-2001—Patient and Tumor Characteristics. National

Cancer Institute, SEER Program, NIH Pub. No. 07-6215, Bethesda, Md; 200

CARCINOMA OVARICO: RUOLO DELL’IMAGING

CONSIDERAZIONI PRELIMINARI

Mohaghegh P, Rockall AG. Imaging Strategy for Early Ovarian Cancer: Characterization of Adnexal Masses with

Conventional and Advanced Imaging Techniques. RadioGraphics, 2012, 32: 1751–1773

Adnexal masses (which encompass ovarian and tubal

lesions) are relatively common, but only a small number are

malignant.

Unlike many lesions that occur in other parts of the body,

biopsy should not be performed in adnexal masses that

demonstrate no evidence of peritoneal disease because it

may cause spillage of cystic contents, potentially leading to

iatrogenic up-staging of what may have been a malignant

tumor that was limited to the ovary. Therefore, the clinical and

imaging assessment of adnexal masses influences further

management decisions and specialty referrals.


Ovarian cancer may be incidentally found at

any cross-sectional imaging modality, but

especially at ultrasonography (US),

performed for other reasons.

US represents also the “first-line” modality for

investigating a suspected adnexal mass.

US NELLA DIAGNOSI DI K OVARICO


- irregular solid mass

- irregular multilocular cystic mass

- solid components or papillary vegetations

on the cyst wall

- high flow within solid components on

color Doppler images

- ascites

- peritoneal nodules

- other evidence of metastases

Timmerman D, Testa AC, Bourne T, et Al.. Simple ultrasound-based rules for the diagnosis of

ovarian cancer. Ultrasound Obstet Gynecol 2008;31(6): 681–690

MORPHOLOGIC US FEATURES SUGGESTIVE OF MALIGNANCY

All features are most accurately assessed at transvaginal US




Fleischer AC, Lyshchik A, Hirari M, Moore RD, Abramson RG, Fishman DA. Early Detection of Ovarian Cancer with Conventional

and Contrast-Enhanced Transvaginal Sonography: Recent Advances and Potential Improvements. J Oncol. 2012;2012:302858.

Aree solide irregolari nel

cistoadenocarcinoma mucinoso






Escrescenze papillari nel

carcinoma a cellule chiare






Noduli parietali nel carcinoma

endometrioide






Pseudosetti e lesioni ecogene di

aspetto solido nel teratoma immaturo



DOPPLER NELLA CARATTERIZZAZIONE DELLE

LESIONI OVARICHE

ALTRE TECNICHE US NELLA DIAGNOSI


“TV-CDS provides

depiction of the

macrovascularity (over

200 μ) of tumors (but

does not delineate

microscopic/capillary

tumor neovascularity.”



CEUS NELLA CARATTERIZZAZIONE DELLE

LESIONI OVARICHE

ALTRE TECNICHE US NELLA DIAGNOSI


“With enhancement of the

blood signal by using

encapsulated gas

microbubbles, it is now

possible to detect blood flow at

the microvascular level, such

as in tissue perfusion.”



È NECESSARIA LA CARATTERIZZAZIONE ISTOLOGICA?



→ Imaging aims to identify patients unfit for

surgery, either by diagnosing a primary tumour

other than ovarian cancer, or by depicting

disease volume and/or extent beyond the reach

of surgery

Forstner R, Sala E, Kinkel K, Spencer JA (2010) ESUR guidelines: ovarian cancer staging

and follow-up. Eur Radiol 20:2773–2780

Timmerman D, Testa AC, Bourne T, et Al.. Simple ultrasound-based rules for the diagnosis of

ovarian cancer. Ultrasound Obstet Gynecol 2008;31(6): 681–690

PANORAMICITÁ DELL’APPROCCIO SOVRAPUBICO

Aspetto “solido” e peduncoli

vascolari

Versamento ascitico




“Contrast-enhanced CT is the standard modality used to stage suspected ovarian

cancers seen at US”

TCDM NELLA DIAGNOSI DI K OVARICO

- Consente stadiazione completa

- meno importante nella prima diagnosi

Mubarak F, Alam MS, Akhtar W, Hafeez S, Nizamuddin N. Role of multidetector computed tomography (MDCT)

in patients with ovarian masses. Int J Womens Health. 2011, 5 (3):123-6.

Lesione eterogenea solida/liquida


- Migliore (oggettiva)

definizione della sede;

- Soddisfacente analisi delle

caratteristiche della lesione



Useful morphologic information may be gained from the use of intravenous contrast material–enhanced CT,

such as the presence of a complex cystic mass with enhancing solid components or ancillary features such

as ascites and omental or peritoneal deposits in a malignancy.



No study has specifically investigated the use of CT as a tool for depicting early

ovarian cancer, and there is currently no evidence to support such a study. The

nature of a solitary adnexal mass may often remain unclear at CT, unless specific

features are clearly demonstrated.

Pickhardt PJ, Hanson ME. Incidental adnexal masses detected at low-dose unenhanced CT in asymptomatic women age

50 and older: implications for clinical management and ovarian cancer screening. Radiology 2010;257(1):144–150



CARATTERIZZAZIONE DI LESIONE (BENIGNO VS MALIGNO)

RM NELLA DIAGNOSI DI K OVARICO

100% sensitivity,

50% specificity

94% accuracy

NPV of 100%

PPV of 93%

Michielsen, K., Vergote, I., Op de beeck, K. et Al. Whole-body MRI with diffusion-weighted sequence for staging of

patients with suspected ovarian cancer: a clinical feasibility study in comparison to CT and FDG-PET/CT. Eur Radiol

(2014) 24: 889-991

Assenza di radiazioni ionizzanti e tossicità da mdc

Elevatissima risoluzione tissutale

Acquisizioni multiplanari dirette e ricostruzioni 3D

Esame “whole body”

Ricerca di localizzazioni secondarie sulla base di

differenti modalità di interazione con il tessuto

patologico



I VANTAGGI DELL’INDAGINE RM



Più elevata risoluzione tissutale / caratterizzazione strutturale



For overall peritoneal staging, the

sensitivity and specificity of WB-

DWI/MRI were significantly higher than

CT and PET/CT (P < 0.00001)

Michielsen, K., Vergote, I., Op de beeck, K. et Al. Whole-body MRI with diffusion-weighted sequence for staging of

patients with suspected ovarian cancer: a clinical feasibility study in comparison to CT and FDG-PET/CT. Eur Radiol

(2014) 24: 889-991



Michielsen, K., Vergote, I., Op de beeck, K. et Al. Whole-body MRI with diffusion-weighted sequence for staging of patients with

suspected ovarian cancer: a clinical feasibility study in comparison to CT and FDG-PET/CT. Eur Radiol (2014) 24: 889-991

WB-DWI/MRI allowed more accurate tumour characterisation and detection of

peritoneal, mesenterial and serosal metastases than CT or FDG-PET/CT. With

similar performance to FDG-PET/CT, WB-DWI/MRI significantly improved the

detection of thoracic lymphadenopathies compared with CT. The ability to

simultaneously and accurately determine the extent of peritoneal and distant

metastatic disease — pivotal in determining the operability of ovarian cancer —

suggests the potential value of WB-DWI/MRI for presurgical staging of ovarian

cancer.

Vergote I, Du Bois A, Amant F, Heitz F, Leunen K, Harter P. Neoadjuvant chemotherapy in advanced ovarian

cancer: On what do we agree and disagree? Gynecol Oncol (2013) 128:6–11

“TAKE HOME”


Il carcinoma ovarico costituisce più spesso riscontro

occasionale

Quando associato a sintomatologia è più spesso in stadio

avanzato

Obiettivo dell’IMAGING è identificare Pz che possono

beneficiare di intervento curativo

L’indagine RM, soprattutto con tecnica DIFFUSION “Whole

Body”, è preferibile nella stadiazione (e nella selezione dei

Pazienti)

[email protected]

GRAZIE PER L’ATTENZIONE!

STADIAZIONE CARCINOMA DEL COLON METASTATICO: QUALI ESAMI?

Dott. Giovanni CARBOGNIN - Sacro...

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