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Imaging Questions in Ovarian Cancer

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

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Imaging Questions in Ovarian Cancer

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  1. Imaging Questions in Ovarian Cancer Susanna I. Lee, MD, PhD

  2. 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

  3. 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

  4. PET Impact on Management Hillner BE et al. J Clin Oncol 2008. 26:2155

  5. PET-CT in Recurrence no treatment treatment

  6. PET-CT in Recurrence surgery chemotherapy

  7. PET-CT in Recurrence • 53 patients with epithelial ovarian cancer • Concurrent diagnostic CT and PET-CT scans Sebastian S et al. Abdom Imaging 2008. 33:112

  8. Emerging Technologies • PET-CT • Perfusion imaging • Dynamic contrast enhanced CT (DCE-CT) • Dynamic contrast enhanced MRI (DCE MRI) • Nodal imaging • Ultrasmallsuperparamagnetic iron oxide (USPIO) MRI • Diffusion weighted imaging (DWI) MRI • Percutaneous tumor ablation

  9. DCE MRI Tracer Kinetic Model ue = Ktrans Volume transfer constant kep= Ktrans/ue Flux rate constant Tofts PS et al. J Magn Reson Imaging 1999. 10:223

  10. 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

  11. Neoadjuvant Breast Cancer pre post 1 cycle post chemo DCE MRI SER map Hylton N. J Clin Oncol 2006. 24:3293

  12. Emerging Technologies • PET-CT • Perfusion imaging • Dynamic contrast enhanced CT (DCE-CT) • Dynamic contrast enhanced MRI (DCE MRI) • Nodal imaging • Ultrasmallsuperparamagnetic iron oxide (USPIO) MRI • Diffusion weighted imaging (DWI) MRI • Percutaneous tumor ablation

  13. 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

  14. USPIO MRI Endometrial Cancer benign malignant

  15. 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

  16. What About the Small Nodes? *Sironi S et al. Radiology 2006. 238:272 ^ Kitajima K et al. Am J Roentgenol 2008. 190:1652

  17. USPIO and Small Nodes Endometrial ca with 5 mm node PET USPIO

  18. 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

  19. Radiofrequency Ablation Power Source • Radiofrequency generator 60-250 W • Coagulation necrosis 55-100oC Grounding Pad

  20. 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

  21. Clear Cell Ovary Recurrence

  22. Radiofrequency Ablation hydrodissection ablation

  23. Followup PET-CT 1 year 1 month

  24. High Grade Muellerian Ablation Pre-RF RF

  25. Three Year Followup 3 months 3 years

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