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 :2155

PET-CT in Recurrence no treatmenttreatment

PET-CT in Recurrence surgerychemotherapy

PET-CT in Recurrence CT alonePET-CT Sensitivity92%97% Specificity60%80% Kappa Sebastian S et al. Abdom Imaging : 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 K trans  ep = K trans /  e ee = Volume transfer constant Flux rate constant Tofts PS et al. J Magn Reson Imaging :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 – neoadjuvant breast cancer –ACRIN 6677/RTOG0265 – recurrent glioblastoma

Neoadjuvant Breast Cancer Hylton N. J Clin Oncol :3293 DCE MRI SER map prepost 1 cyclepost 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 : 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 :52

What About the Small Nodes? Any size<10 mm Unenhanced MRI63%NA USPIO MRI88%70% PET-CT (cervical ca)*72%37% PET-CT (endometrial ca)^53%40% *Sironi S et al. Radiology :272 ^ Kitajima K et al. Am J Roentgenol :1652

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

Percutaneous Tumor Ablation Thermal – frictional heating –Radiofrequency (460 kHz) –Microwave ( 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 W Coagulation necrosis o C Grounding Pad 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 hydrodissectionablation

Followup PET-CT 1 month 1 year

High Grade Muellerian Ablation Pre-RFRF

Three Year Followup 3 months3 years