A prospective trial of computed tomography in the staging of ovarian malignancy

Summary. Thirty patients, thought clinically to have ovarian tumours, were studied prospectively by pre-operative computed tomographic (CT) scans of the abdomen and pelvis. In six patients (20%) small metastases in mesentery, omentum and on subdiaphragmatic peritoneum were not detected by the scans. CT did not improve the accuracy of staging or assist the surgeons by drawing their attention to disease which they might otherwise have missed. Although CT gives an elegant demonstration of anatomy, it is not an alternative to extended laparotomy in patients with ovarian tumours.     

The value of computed tomography in staging cervical carcinoma

The purpose of our study was to determine the value of computed tomography (CT) in relation to the local extension of cervical carcinoma and the possible spread in the peritoneal and the retroperitoneal space. Sixty-five patients treated for cervical carcinoma during the period 1980-1986 were included in the study. Histologic diagnosis of the disease was done by punch cervical biopsy and diagnostic curettage. The investigation of all patients included intravenous pyelography, barium enema, bone and liver scanning and CT. Our results demonstrate a correlation between CT and pathologic data in 75-78.5% depending on stage. CT may be considered as a dependable method for staging of cervical carcinoma.     

Appendectomy in primary and secondary staging operations for ovarian malignancy

Appendectomy was performed at primary or secondary staging operations in 100 patients with ovarian malignancies. Of 80 patients who underwent appendectomy at the time of their primary surgery, 25 (31.2%) had appendiceal metastases. Among 47 patients who were believed to have disease limited to the pelvis at the time of surgery--stage I (N = 34), II (N = 7), IIIA (N = 5), and those designated stage IIIC solely on the basis of microscopic para-aortic nodal metastasis (N = 1)--the appendix was involved with disease in only two patients (4.3%). However, among 33 patients with advanced disease--stage IIIB (N = 6), IIIC except those designated IIIC solely on the basis of microscopic paraaortic nodal metastasis (N = 19), and IV (N = 8)--the appendix was involved with disease in 23 patients (69.7%) (P less than .001). Poorly differentiated tumors and serous histologic cell types more frequently metastasized to the appendix (64, 15, 6, and 8% for grades 3, 2, and 1 and borderline histology, respectively; P less than .001; and 48, 13, and 8% for serous, endometrioid, and mucinous; P less than .001). Of 20 patients who underwent appendectomy at their secondary staging procedure, two had metastases. Metastatic disease in the appendix was microscopic in nine of 27 patients. Because the frequency of appendiceal metastasis is similar to that of other metastatic sites in stages I and II ovarian cancer, it should be removed at primary staging procedures. Appendectomy should also be performed in patients with advanced ovarian malignancies if it contributes to cytoreduction or at the time of secondary staging procedures.     

Role of X-ray computed tomography in the staging of cervical carcinoma

X-ray computed tomography (CT) was performed in 132 cases of untreated cervical carcinoma, and the CT findings were compared with operative findings and pathological specimens in surgically treated cases, and with post-therapeutic CT findings in irradiated cases. The results were as follows: 1) The cervical image was significantly (p less than 0.01) enlarged in the group in which the diameter of the cancer in the specimen was greater than 2.0 cm. Accordingly, a cervical area exceeding 12.6 cm2 was classified as enlargement of the cervix. 2) With respect to parametrial invasion in surgically proven cases (176 parametrial), the diagnostic value of CT was indicated by a sensitivity of 58%, a specificity of 90%, and an accuracy of 83%. 3) In detecting paravaginal and vesical involvement, CT was superior to conventional diagnostic methods, and the accuracy of CT in the detection of vesical involvement was 96% in surgically treated cases. 4) The diagnostic value of CT in evaluating lymph node metastases in surgically confirmed cases was indicated by a specificity of 100%, and an accuracy of 88%; although the sensitivity was only 29%, when lymph node images with a maximum diameter exceeding 2.0 cm were regarded as metastases. The above findings indicate that CT provides greater accuracy in the staging of cervical carcinoma, when used with conventional methods.     

Abdominopelvic computed tomography in the preoperative evaluation of suspected ovarian masses

To evaluate the efficacy of computed tomography (CT) in 175 patients scheduled to undergo surgery for a suspected ovarian mass, we compared preoperative CT findings with the findings at surgery and histology. At surgery, 115 patients were found to have epithelial ovarian malignancies (20 stage 1, 7 stage II, 50 stage III and 38 stage IV) while 60 had benign pelvic tumors. CT findings were suggestive of malignancy in 4 (7%) of 60 patients with benign tumors and suggestive of benign disease in 3 (3%) of 115 patients with malignant ovarian tumors; 30% of all scans were inconclusive. The sensitivity of CT for predicting pelvic or para-aortic lymph node involvement in 42 patients who underwent lymphadenectomy was 62 and 70%, respectively; the specificity was 100%. The results of this series suggest that the routine use of CT in the preoperative evaluation of patients does not seem justified.     

Cystosonography in the staging of gynecological malignancy

Summary Five patients with carcinoma of the cervix and one with carcinoma of the vagina were examined by both cystoscopy and endosonography. Both techniques revealed malignant infiltration of the bladder in 4 patients. In the other 2 cystocopy showed an intact bladder mucosa despite cystosonographic evidence of invasion of the bladder wall by tumor.     

Diagnosis of puerperal ovarian vein thrombophlebitis by computed tomography

A case of puerperal ovarian vein thrombophlebitis diagnosed by computed tomography is presented. Resolution after treatment with antibiotics and anticoagulation is demonstrated. The obstetrician must be aware of the role of computed tomography in making a prompt and accurate diagnosis in such cases.     

Prediction of suboptimal primary cytoreduction in primary ovarian cancer with combined positron emission tomography/computed tomography--a prospective study

ObjectiveThe treatment of FIGO stage IB2 cervical cancer is controversial. Our aim was to assess treatment patterns, outcomes, and complications in patients with stage IB2 cervical cancer.MethodsA retrospective study of patients with stage IB2 cervical carcinoma at a single institution between January 1982 and September 2006 was performed. To adequately control treatment variables, we only included patients who underwent their entire treatment at our institution. Toxicity was assessed using NCI Common Toxicity Criteria (CTC).ResultsWe identified 82 patients, of whom 47 met the strict inclusion criteria. Of these, 27 patients (57%) underwent primary radical hysterectomy (RH) and 20 (43%) were treated with definitive radiation/chemoradiation therapy (RT/CRT). Patients selected for RT/CRT had a higher American Society of Anesthesiologist (ASA) score than those selected for surgery (P = 0.037). The 3-year progression free survival rate was 52% for the RH group and 55% for the RT/CRT group (P = 0.977). The 3-year overall survival rates were 72% and 55%, respectively (P = 0.161). Overall, 52% of patients in the RH group received postoperative radiation therapy as part of their adjuvant treatment. CTC grade 3, 4, and 5 complications affected 5 patients (19%) in the RH group and 3 (15%) in the RT/CRT group.ConclusionBoth RH and definitive RT/CRT are adequate management strategies for patients with FIGO stage IB2 cervical cancer. However, there was a subset of patients in whom RH as monotherapy was appropriate. Further studies are needed to evaluate the role of new preoperative models that will accurately identify these patients.     

Combined positron emission tomography and computed tomography for the detection of recurrent ovarian mucinous adenocarcinoma

BACKGROUND: The role of combined positron emission tomography and computed tomography (PET-CT) in the diagnosis of recurrent ovarian mucinous adenocarcinoma is uncertain because of previous reports that PET has limited sensitivity in the detection of mucinous neoplasms. CASE: A 71-year-old white woman presented with complaints of right lower quadrant pain and a palpable adnexal mass. Physical examination and transvaginal ultrasonography revealed a 12 x 13 cm cystic mass in the left side of the pelvis. Exploratory laparotomy, optimal tumor-reductive surgery, total abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy, and omentectomy were performed. The diagnosis was FIGO stage IIIC well-differentiated ovarian mucinous adenocarcinoma. The patient was treated with 6 cycles of carboplatin and paclitaxel. Four months after completing chemotherapy, the patient was noted to have an elevated serum CA125 level (72 U/mL), being otherwise asymptomatic. Findings on abdominal and pelvic CT were compatible with postsurgical changes. PET-CT was performed and revealed increased metabolism along the posterior aspect of the right rectus abdominis muscle and abutting the anterior wall of an adjacent loop of bowel. CONCLUSION: PET-CT may identify clinically occult recurrent ovarian mucinous adenocarcinoma.     

A case of primary ovarian adenomyoma mimicking ovarian malignancy

Adenomyoma is a benign tumor composed of smooth muscle and benign endometrium. These tumors typically originate within the uterus. An extrauterine adenomyoma is an extremely rare entity. After an extensive literature search, only four cases of primary ovarian adenomyoma appear to have thus far been reported. Here, we report a case of ovarian adenomyoma in a 39-year-old woman mimicking malignant neoplasma of the ovary, along with a brief literature review.     

Can computed tomography substitute for second-look operation in ovarian carcinoma?

The increasing use of computerized tomography as a noninvasive means of evaluating pelvic and abdominal malignancy was investigated as an adjunct to a second-look operation in patients with ovarian carcinoma. In order to fully evaluate the abdominal and pelvic contents enhanced CT examinations were done in 18 patients. There were 3 “true positives” and 12 “true negatives.” The 3 “false negative” CT scans demonstrated multiple small implants at operation. It appears that the use of the CT scan in evaluating ovarian carincoma is restricted because of the diffuse nature and small implants associated with ovarian cancer. The absence of disease by CT scan evaluation was not an adequate reason to defer the second-look operation.     

Role of computed axial tomography of the chest in staging patients with nonmetastatic gestational trophoblastic disease

Thirty-nine women with nonmetastatic gestational trophoblastic disease as determined by conventional staging studies were prospectively evaluated with computed axial tomography (CAT) of the lungs. Sixteen patients (41%) had pulmonary micrometastases detected by CAT, which were not detected by routine chest x-ray. Eight patients (20.5%) had indeterminate scans, and only 15 patients (38%) had negative scans. Eight of 16 patients (50%) with pulmonary micrometastases failed initial therapy with methotrexate-folinic acid rescue while one of eight (12.5%) patients in the indeterminate group and one of 15 (6.7%) patients in the true nonmetastatic group failed initial therapy (P less than .006). All patients who failed methotrexate-folinic acid rescue ultimately achieved prolonged remission with actinomycin D. Time to remission was significantly decreased in patients without evidence of pulmonary micrometastases (P = .03), but the total number of courses of chemotherapy was not significantly different (P = .06). No life-threatening toxicity occurred. Pulmonary micrometastases detected by CAT but not chest x-ray are predictive of an increased risk of methotrexate-folinic acid therapy failure. Computed axial tomography of the lungs identifies a group of patients at high risk for failure of methotrexate-folinic acid rescue, and, therefore, may be indicated for routine staging of patients with otherwise nonmetastatic gestational trophoblastic disease.     

Usefulness of computed tomography in predicting cytoreductive surgical outcomes for ovarian cancer

Purpose

The objective of this study was to identify features of preoperative computed tomography (CT) scans that can best predict outcomes of primary cytoreductive surgery in ovarian cancer patients.

Methods

Preoperative CT scans of 98 patients were evaluated retrospectively. Multiple logistic regression analysis was used to develop two models.

Results

Although optimal surgical reduction was attempted in 98 patients, 12 had suboptimal results. Having tumor implants on the small or large bowel mesenteries (any size) or at other sites (cutoff index: ??1?cm) was found to be significant (p?<?0.001) for predicting a suboptimal cytoreduction outcome. Two predictive models were created using multiple logistic regression analysis; both consider diffuse peritoneal thickening (DPT), infrarenal para-aortic or pelvic lymph node involvement, a bowel encasement tumor (??2?cm), and any tumor implants in the cul-de-sac as significant. Model 1 adds consideration to any tumors in the pelvic or retroperitoneum and has an accuracy of 90.8% for predicting a suboptimal surgery. Model 2 (accuracy of 93.9%) adds to the core of predictors the presence of tumor implants on the bowel mesenteries (??2?cm), omental caking (??2?cm), and ascites fluid.

Conclusion

Using specific CT findings from patients with ovarian cancer, we have devised two predictive models that have an accuracy of greater than 90% for predicting whether cytoreductive surgery will completely remove all tumor tissue, which should greatly aid in the differential decision-making as to whether to attempt cytoreductive surgery first, or to advance directly to neoadjuvant chemotherapy.     

A case of ovarian sarcoidosis mimicking malignancy

We present a case of systemic sarcoidosis with ovarian and peritoneal involvement. The atypical clinical presentation of the disease has lead to a problem of the differential diagnosis with ovarian cancer. A 72-year-old female was admitted because of low grade fever, fatigue and dilatation of the abdomen. Clinical and laboratory evaluation of the patient revealed moderate right pleural effusion, ascites, diffuse ovarian infiltration, presence of enlarged intraabdominal lymph nodes and a substantially high value of serum CA 125. Histological examination after laparotomy was indicative of ovarian sarcoidosis.     

A comparison of findings at second-look laparotomy with preoperative computed tomography in patients with ovarian cancer

Prior to undergoing second-look laparotomy, 57 patients with ovarian cancer were evaluated with computed axial tomography (CT). All patients were clinically free of disease following chemotherapy. At laparotomy, 25 patients had visible evidence of disease, 9 had microscopic disease only, and 23 were free of cancer. Tumor was correctly identified on CT in 9 of the 25 patients (36%) with macroscopic disease. Tumors smaller than 2 cm in size were not detected by CT. CT suggested disease in 8 of the 32 patients (25%) who were free of macroscopic disease. CT provides useful information when it is abnormal. Fine needle aspiration of suspicious areas can spare some patients laparotomy. However, CT has a significant false-negative rate due to its inability to detect small volume disease. Patients with negative CT will continue to require reexploration and tissue confirmation to assess the need for further therapy.     

A prospective, randomized trial of integrative medicine for women with ovarian cancer

Objectives

Despite increased use of integrative medicine in cancer therapy, little data exist on its efficacy. This prospective, randomized, pilot trial sought to evaluate the feasibility of combined modality integrative medicine (CM-IM) in women with ovarian cancer (OvCA) and evaluate its effects on quality of life (QoL), chemotherapy toxicity and immunologic profiles.

Methods

Women with newly diagnosed OvCA requiring chemotherapy were offered enrollment. Those randomized to the experimental arm received hypnosis, therapeutic massage and healing touch with each cycle of chemotherapy. The control arm received chemotherapy without CM-IM. All patients completed QoL questionnaires prior to cycles 1, 3 and 6, and 6-months after chemotherapy. Immunologic profiles were measured. Statistical analysis was based on intent-to-treat. Student's t-test and Fischer's exact-test were used to determine differences.

Results

Forty-three women enrolled. All women randomized to CM-IM were successfully treated. There were no statistical differences between the groups in age, stage, grade, histologic cell type, CA125 levels, or surgical cytoreductive status. There was no difference in overall QoL measurements. Re-hospitalization rates, treatment delays, anti-emetic use, and infection rates were similar. Immunologic profiles revealed no difference between arms for WBC or salivary IgA levels. Women receiving CM-IM had consistently higher levels of CD4, CD8 and NK cells, although this did not reach statistical significance.

Conclusions

Prospective clinical evaluation of integrative medicine for women with gynecologic malignancy is feasible. This first, pilot study of CM-IM in gynecologic oncology demonstrated no improvement in QoL or chemotherapy toxicity. Integrative medicine-associated improvements in immunologic profiles warrant further investigation.     

A multicenter prospective trial evaluating the ability of preoperative computed tomography scan and serum CA-125 to predict suboptimal cytoreduction at primary debulking surgery for advanced ovarian,fallopian tube,and peritoneal cancer

Objective

To assess the ability of preoperative computed tomography (CT) scan of the abdomen/pelvis and serum CA-125 to predict suboptimal (> 1 cm residual disease) primary cytoreduction in advanced ovarian, fallopian tube, and peritoneal cancer.

Methods

This was a prospective, non-randomized, multicenter trial of patients who underwent primary cytoreduction for stage III–IV ovarian, fallopian tube, and peritoneal cancer. A CT scan of the abdomen/pelvis and serum CA-125 were obtained within 35 and 14 days before surgery, respectively. Four clinical and 20 radiologic criteria were assessed.

Results

From 7/2001 to 12/2012, 669 patients were enrolled; 350 met eligibility criteria. The optimal debulking rate was 75%. On multivariate analysis, three clinical and six radiologic criteria were significantly associated with suboptimal debulking: age ≥ 60 years (p = 0.01); CA-125 ≥ 500 U/mL (p < 0.001); ASA 3–4 (p < 0.001); suprarenal retroperitoneal lymph nodes > 1 cm (p < 0.001); diffuse small bowel adhesions/thickening (p < 0.001); and lesions > 1 cm in the small bowel mesentery (p = 0.03), root of the superior mesenteric artery (p = 0.003), perisplenic area (p < 0.001), and lesser sac (p < 0.001). A ‘predictive value score’ was assigned for each criterion, and the suboptimal debulking rates of patients who had a total score of 0, 1–2, 3–4, 5–6, 7–8, and ≥ 9 were 5%, 10%, 17%, 34%, 52%, and 74%, respectively. A prognostic model combining these nine factors had a predictive accuracy of 0.758.

Conclusions

We identified nine criteria associated with suboptimal cytoreduction, and developed a predictive model in which the suboptimal rate was directly proportional to a predictive value score. These results may be helpful in pretreatment patient assessment.     

Impact of positron emission tomography/computed tomography in the management of patients with epithelial ovarian carcinoma after treatment

Purpose  

The aims of this study were to compare the usefulness and reliability of integrated whole-body positron emission tomography/computed tomography (PET/CT) using ¹⁸F-fluorodeoxyglucose (FDG) with those of contrast-enhanced multidetector CT during regular follow-up in patients after initial treatment of ovarian cancer, to assess the impact of FDG–PET/CT on the confirmation of recurrence, restaging, and clinical management of patients, and to determine the incremental information provided by PET/CT.