24 Ovarian Cancer

(1)

History

73-year-old female who has a history of ovarian cancer, who is also status post right gluteal resection for sarcoma. Her recent CA-125 is 71 and a new right iliac mass was found on the recent CT study. The patient is evaluated for extent of disease.

Findings

There is a moderately intense focus of hypermetabolism in the right gluteal soft tissue consistent with locally recurrent sarcoma (Figures 24.1.1 and 24.1.2). This cor- responds with the recent enhanced CT clearly delineating the soft tissue density within the water density collection in the area of resection. The right psoas muscle is also hypermetabolically active (Figure 24.1.3) in the region of the common iliac vessels indi- cating metastases. The bladder is displaced by the feces-ﬁlled rectum and is extending to the right psoas area. The right colonic activity is prominent but probably physiologic. The tongue uptake is also probably physiologic. No other active lesions are noted above the diaphragm.

Impression

1. Interval multifocal gluteal recurrence consistent with the enhanced gluteal lesions on CT.

2. Interval appearance of bulky right psoas muscle metastasis consistent with mass on CT.

Pearls and Pitfalls

• PET has the sensitivity of 80% to 90%, speciﬁcity of 92% to 100%, and accuracy of 79% to 92% for detecting recurrent ovarian tumor.^2,6,7,8

• PET has the ability to change patient management by 40%.

Discussion

A PET negative exam tends to have a longer relapse-free interval than a positive PET study. This patient has a recurrent tumor. Most authorities recommend a followup post chemotherapy in 6 months with imaging.

24 Ovarian Cancer

Hossein Jadvar

Case 24.1

250

(2)

FIGURE24.1.2. FIGURE24.1.3.

(3)

History

74-year-old female who has a history of ovarian cancer with elevated CA-125 at 2522.

Patient underwent hysterectomy, bilateral salpingo-oophorectomy, and omentectomy.

Pelvic washing was positive for cancer. She was treated with chemotherapy. Her last CT revealed some residual paraaortic adenopathy and a right pelvic lymphocele. Her most current CA-125 was 19. Evaluation for residual disease is requested.

Findings

There are multiple extensive sites of lymphadenopathy along the left para-aortic (Figures 24.2.1 and 24.2.2) and left iliac chains (Figure 24.2.3). Another intense focus of hypermetabolism is also noted in the left lower cervical node (Figure 24.2.4). These ﬁndings are consistent with metastasis. There is photopenia (Figure 24.2.5) in the right superior aspect of the bladder consistent with the right pelvic lymphocyst seen on the CT. The symmetric activity in the vocal cord (Figure 24.2.6) is physiologic. No other adenopathy seen above or below the diaphragm. Moderately intense tubular shaped uptake in the right abdomen may be related to either normal bowel uptake or metastatic serosal/omental tumor implants.

Impression

1. Evidence for distant metastasis in a lower cervical lymph node.

2. Extensive lymphadenopathy in the left para-aortic and left iliac chain.

3. Photopenic right lymphocyst as noted on CT.

• PET has a sensitivity of 73%, speciﬁcity of 92%, and accuracy of 86% for detecting lymph node involvement.^3,4

• The positive predictive value and negative predictive value are 89% and 86%

respectively.^1,3,4

• The sensitivity of CT for detecting lymph node involvement ranges from 40% to 63%;

the speciﬁcity of CT for detecting the same ranges from 81% to 83%.^1,3,4 252 Part II Clinical Cases

Case 24.2

FIGURE24.2.1.

(4)

(5)

Discussion

CA-125 is a serum marker to monitor recurrent tumor. The sensitivity of CA-125 is 90% to 100%. However, it can be falsely negative in 25% to 50% of the cases. Also, it does not provide the site of recurrence.

254 Part II Clinical Cases

FIGURE24.2.6.

History

69-year-old female who has a history of ovarian cancer currently on Cytoxan therapy.

The patient is being evaluated for using CA-125 level and disease recurrence.

Findings

There are retroperitoneal (Figures 24.3.1 and 24.3.2), common iliac (Figures 24.3.3 and 24.3.4), and distal external iliac nodes. There is a left paracolic gutter peritoneal implant (Figure 24.3.5). There are multiple hypermetabolic liver metastases (Figures 24.3.6 and 24.3.7), some with calciﬁcation, indicating mucinous histology.

Impression

Metastatic mucinous ovarian carcinoma to the liver parenchyma, retroperitoneum, and peritoneum.

Case 24.3

(6)

(7)

(8)

• FDG PET has a sensitivity of 71%, speciﬁcity of 100%, positive predictive value of 100%, negative predictive value of 76%, and an accuracy of 85% in the detection of peritoneal carcinomatosis.⁵

• Calcifying metastases is typical of mucinous cystadenocarcinoma histology.

Discussion

Early detection of recurrent disease is a reliable indicator for a second-line therapy.

PET can detect an intra-abdominal relapse with peritoneal carcinomatosis in 40% to 60% of the cases. Most recurrent ovarian carcinomas present with peritoneal seeding from para-arotic or peritoneal lymphatics. Unfortunately, false-positive examinations can occur with associated nonmalignancy physiology including inﬂammatory adnexal mass or corpus luteum. Urine activity can also potentially mask the lesions. Some institutions recommend the use of bladder lavage in order to minimize this artifact.