بسم هللا الرحمن الرحيم. Prof soha Talaat

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Francine Fowler
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1 بسم هللا الرحمن الرحيم

3 Ovarian tumors The leading indication for gynecologic surgery. Preoperative characterization of complex solid and cystic adnexal masses is crucial for informing patients about possible surgical strategies.

4 Ovarian cancer It is a leading cause of death among women It is the second most common gynecological cancer after cancer cervix It is the fifth most common cancer in women after (lung, breast, colorectal, and pancreatic cancers)

5 Ovarian cancer Approximately 75% 80% of ovarian cancers are diagnosed at stages II IV. Patients with stage IA or IB disease have a 90% 95% 5-year survival rate following surgery alone whereas patients with stage IV disease have a dismal prognosis, with a 10% 5-year survival rate despite aggressive multimodality treatment.

6 Borderline ovarian tumors Comprise up to 15 20% of ovarian epithelial neoplasms. Borderline ovarian tumors are histologically characterized as epithelial tumors with a stratified growth pattern but without destructive stromal invasion. Serous and mucinous neoplasms constitute the majority of borderline tumors and occur mostly in women of reproductive age Acs G. Serous and mucinous borderline (low malignant potential) tumors of the ovary. Am J Clin Pathol2005 ; 123[suppl]:S13 S57

7 Proper management depends on: Clinical examination OECs are notoriously difficult to diagnose in the early stages. Even patients with advanced disease may present with nonspecific abdomino-pelvic symptoms. Laboratory tests Although CA 125 is a useful biomarker, elevated CA-125 levels are seen in only 50% 60% of mucinous or clear cell variants and early-stage cancers. Radiological assessment

8 Pelvic & TVS with CFM The initial diagnostic modality of choice.

TVS Colour Doppler & 3D Combining morphologic

allowed accurate assessments, the overall

intermediate, rather than determining vascular

Improves the detection of morphologic abnormalities

9 TVS Colour Doppler & 3D Combining morphologic assessment with TVS with color Doppler features has allowed accurate assessments, the overall vascularity was classified as high, low, or intermediate, rather than determining vascular indices. Improves the detection of morphologic abnormalities indicative of neoplastic ovarian masses. In particular, small papillary projections or focal wall (mural) irregularities.

10 Role of Cross-sectional Imaging Diagnosis, Characterization, and Surveillance Assessment of primary tumours. The pattern of extra-ovarian spread may be (a) extraovarian intrapelvic (stage II). (b) extrapelvic intraabdominal (stage III). (c) Intra-abdominal with intrahepatic parenchymal deposits or extra-abdominal with distant metastasis (stage IV).

11 The emerging role of functional imaging techniques Radioimmunoscintigraphy, PET/CT, diffusionweighted MRI, dynamic contrast-enhanced MRI, and magnetic resonance spectroscopy in staging ovarian cancer and assessing treatment response. Diffusion MRI The combination of functional information with conventional anatomical visualization holds promise to accurately characterize peritoneal disease, and provides noninvasive biomarkers of therapeutic performance and patient prognosis.

12 Conventional MRI : Contrast-enhanced MRI may be helpful in cases of complex ultrasound findings MR Imaging protocol: Sagittal T2 Axial T2 Axial T1 Axial T1 SPAIR DWI (b: 0, 500, 1000, and 1500) Coronal T2 Axial T1 post contrast Coronal T1 post contrast

13 Interpretation of images: A)Conventional images Appearance of the tumor ; whether cystic, solid or mixed. Involvement of one or both ovaries Signal intensity Enhancement Wall thickness Presence of vegetations Ascites Lymph nodes Other pelvic organs Peritoneal and omental deposit

14 One of the new functional MRI techniques is DWI Tissue microstructures affect the random motion of water molecules

15 Tissues with low cellularity free water diffusion (Low signal) Tissues with high cellularity restriction of water diffusion (high signal)

16 B) DWI Qualitatively, regarding the signal Restricted diffusion = DW+ ADC Quantitatively, regarding the ADC values ADC maps generated from different b values ROI measured manually, over the largest possible area for the solid and cystic tumors ADC value 1.25 x 10-3 mm2/s may be an optimal cutoff value (Li et al, 2011)

17 What are the different clinical applications? Characterization of primary lesion

18 Peritoneal deposits

19 Lymph node assessment

20 Differentiating residual and Recurrent Disease from Post operative Change

21 A study was performed on ovarian tumors (Soha Talaat,Safaa saif, sahar mansour,2011) ADC for cystic component Minimum Maximum Mean +/-SD p-value ADC ( x 10-3 ) in malignant tumors (± 0.37) ADC ( x 10-3 )in benign tumors (± 0.56)

22 ADC for solid component Minimum Maximum Mean +/-SD p-value ADC ( x 10-3 ) in malignant tumors (± 0.11) ADC ( x 10-3 )in benign tumors (± 0.67)

23 100% 90% 80% 100% 83.30% 85.70% 85% 80% 78.60% 70% 60% 50% 40% MRI DW 30% 20% 10% 0% SENSITIVITY SPECIFICITY ACCURACY

24 case 1 Female patient 21 year old complaining of abdominal enlargement.us showed solid pelvi-abdominal mass with increased vascularity on Doppler examination

25 Case 1

26 case 1 Pathological diagnosis Granulosa cell tumor DWI High signal on DWI Low signal on ADC maps ADC value 0.68 x 10-3mm2/s

27 case 2 47 year old female patient came complaining of abdominal pain, US showed multilocular adnexal mass

28 Case 2 Conventional MRI Benign looking, likely serous cystadenoma Minimal free pelvic ascites

29 Case 2 DWI High Signal On DWI(T2 shine through) High signal on ADC maps ADC value 2.01 x 10-3mm2/s Pathological diagnosis Serous cystadenoma

30 case 3 Female patient 35 year old complained of abdominal pain, TVUS showed a deeply seated rounded right solid ovarian mass, Marked vascularity on Doppler examination

31 case 4

32 case 4 No abnormal high signal on DWI High signal on ADC map ADC value 0.98 x 10-3mm2/s Pathological diagnosis Ovarian Fibroma

33 case 4 Female patient 34 year old complaining of abdominal discomfort, US revealed complex adnexal mass with multiple papillary projections

34 case 5

35 case 4 DWI Papillary projections moderate high signal Low signal on ADC maps ADC values 1.03 x 10-3mm2/s Pathological diagnosis Borderline papillary serous cystadenoma

36 case 5 Female patient 42 year old came complaining of dull aching pelvic pain,us revealed two masses(pelvic and left lumbar) with echogenic foci

37 6 case

38 case 6

39 case 5 DWI Nodular part showed foci of restricted diffusion Marked low ADC values for both masses (0.39 x 10-3 mm2/s) and(0.64 x 10-3 mm2/s) Pathological diagnosis Bilateral mature cystic teratomas Mature cystic teratomas showed restriction may be attributed to keratinoid substance and Rokitansky protuberance

40 case 6 Pregnant Female 25 year old came complaining of dull aching right hypochondrial pain

44 case 7 Female patient, 40 years old, pregnant (32 wks),complaining of severe diffuse pelvi-abdominal pain and intermittent attacks of vaginal bleeding

49 Cervical& upper vaginalmass Mass Diffusion ADC

50 Limitations DWI interpretation should be in conjunction with other morphological criteria in conventional MRI sequences Recommendations Study with large number of cases with special concern for BOTs Cases of mature cystic teratomas better to be excluded as their DWI findings are misleading and can give false results

51 DWI is one of the new functional MRI techniques When properly indicated, it can help increasing the specificity of MRI DWI implies using: Completely noninvasive technique No radiation exposure Might be an alternative for contrast (pregnancy) Increases the radiologist s confidence in image interpretation DWI interpretation should be done in conjugation with the conventional MRI

Ovarian lesions detected by US Functional

cystic (with no solid parts) Complex cystic and

for characterization (T1, T2, fat suppression)

contrast, DWI ) contrast, DWI ) complicat ed or

favor of benignity High signal in T2, and DWI in

52 Ovarian lesions detected by US Functional anechoic cyst less than or equal 5 cm Complex cystic (with no solid parts) Complex cystic and solid Purely solid repeated follow up by US MRI for characterization (T1, T2, fat suppression) MRI for staging (T1, T2, fat suppression, post contrast, DWI ) MRI for staging (T1, T2, fat suppression, post contrast, DWI ) complicat ed or increased in size low signal in T2, and DWI in favor of benignity High signal in T2, and DWI in favor of malignanc y MRI

Terminology Estimate the risk of malignancy in adnexal masses - Overview

Terminology Estimate the risk of malignancy in adnexal masses - Overview Understanding the IOTA (International Ovarian Tumor Analysis) terminology & Classification Using the IOTA simple rules to estimate the risk of malignancy in women with adnexal masses Elisabeth Epstein,