Prediction of Surgical Outcome in Advanced Ovarian Cancer by Imaging and Laparoscopy: A Narrative Review

Abstract

Maximal-effort upfront or interval debulking surgery is the recommended approach for advanced-stage ovarian cancer. The role of diagnostic imaging is to provide a systematic and structured report on tumour dissemination with emphasis on key sites for resectability. Imaging methods, such as pelvic and abdominal ultrasound, contrast-enhanced computed tomography, whole-body diffusion-weighted magnetic resonance imaging and positron emission tomography, yield high diagnostic performance for diagnosing bulky disease, but they are less accurate for depicting small-volume carcinomatosis, which may lead to unnecessary explorative laparotomies. Diagnostic laparoscopy, on the other hand, may directly visualize intraperitoneal involvement but has limitations in detecting tumours beyond the gastrosplenic ligament, in the lesser sac, mesenteric root or in the retroperitoneum. Laparoscopy has its place in combination with imaging in cases where ima-ging results regarding resectability are unclear. Different imaging models predicting tumour resectability have been developed as an adjunctional objective tool. Incorporating results from tumour quantitative analyses (e.g., radiomics), preoperative biopsies and biomarkers into predictive models may allow for more precise selection of patients eligible for extensive surgery. This review will discuss the ability of imaging and laparoscopy to predict non-resectable disease in patients with advanced ovarian cancer.

First external validity study of the Fagotti score in ovarian cancer

“…Laparoscopy may directly visualize intraperitoneal involvement, but it has inherent limitations when investigating tumours behind the gastrosplenic ligament, in the lesser sac, mesenteric root or when exploring the retroperitoneum. The major benefit of laparoscopy appears as an ultimate triage step in situations where the imaging diagnosis is uncertain regarding resectability and the presence of diffuse small-volume carcinomatosis 22 .…”

Staging by imaging in gynecologic cancer and the role of ultrasound: an update of European joint consensus statements

“…124 125 Several models and imaging scoring systems have been developed for predicting surgical outcome and residual disease, but studies have frequently failed to provide sufficient external validation of their results. 119 Nowadays, a thorough and structured imaging assessment of critical sites for ovarian cancer surgery remains the most useful approach (Online Supplemental Appendix S5). 126 Using this approach, the results of an international ISAAC interim analysis showed that transvaginal/transabdominal ultrasound was non-inferior to both CECT (p value=0.029) or whole-body diffusion-weighted MRI (p value=0.036) for predicting surgical non-resectability.…”

“…In general, all imaging modalities have high specificity for predicting residual disease (remaining visible cancer tissue at the end of debulking surgery), but low sensitivity for detecting small-volume carcinomatosis, potentially resulting in unnecessary surgical explorations due to non-resectable disease (Figure 8, Online Supplemental Video S8). 119 Laparoscopy, on the other hand, offers direct visualization of the peritoneal parietal, visceral, omental, and mesenteric surfaces but may miss retroperitoneal spread, tumors behind the gastrosplenic ligament or the lesser sac, as described in the recent review by Pinto et al 119 Laparoscopy can be considered in cases of uncertain resectability or to exclude small-volume carcinomatosis which may not be seen on imaging, such as on the bowel serosa or mesentery (Figure 8).…”

Neglected Anatomical Areas in Ovarian Cancer: Significance for Optimal Debulking Surgery

“…A cut-off value of 10 was applied. Mesenteric retraction was excluded from the score [130][131][132]. Moreover, the score was also implemented for patients undergoing interval debulking surgery [129].…”