Imaging Questions in Ovarian Cancer Susanna I. Lee, MD, PhD.
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Transcript of Imaging Questions in Ovarian Cancer Susanna I. Lee, MD, PhD.
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
CT alone PET-CT
Sensitivity 92% 97%
Specificity 60% 80%
Kappa 0.29 0.63
Sebastian S et al. Abdom Imaging 2008. 33:112
• 53 patients with epithelial ovarian cancer
• Concurrent diagnostic CT and PET-CT scans
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
Ktrans
ep= Ktrans/e
e=
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
Hylton N. J Clin Oncol 2006. 24:3293
DCE MRI
SER map
pre post 1 cycle post chemo
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 = 0.96AUC = 0.84
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 NodesEndometrial 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
• Radiofrequency generator 60-250 W
• Coagulation necrosis 55-100oC
GroundingPad
Power Source
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-CT1 month 1 year
High Grade Muellerian AblationPre-RF RF
Three Year Followup3 months 3 years