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 treatmenttreatment

6. PET-CT in Recurrence surgerychemotherapy

7. PET-CT in Recurrence CT alonePET-CT Sensitivity92%97% Specificity60%80% Kappa0.290.63 Sebastian S et al. Abdom Imaging 2008. 33:112 53 patients with epithelial ovarian cancer Concurrent diagnostic CT and PET-CT scans

8. 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

9. 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 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 Hylton N. J Clin Oncol 2006. 24:3293 DCE MRI SER map prepost 1 cyclepost chemo

12. 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

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 = 0.96AUC = 0.84 Will O et al. Lancet Oncol 2005. 7:52

16. 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 2006. 238:272 ^ Kitajima K et al. Am J Roentgenol 2008. 190:1652

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

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 Radiofrequency generator 60-250 W Coagulation necrosis 55-100 o C Grounding Pad Power Source

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 hydrodissectionablation

23. Followup PET-CT 1 month 1 year

24. High Grade Muellerian Ablation Pre-RFRF

25. Three Year Followup 3 months3 years