Preoperative staging of ovarian cancer: comparison between ultrasound, CT and whole‐body diffusion‐weighted MRI (ISAAC study)

Abstract

Objectives To compare the performance of transvaginal and transabdominal ultrasound with that of the first‐line staging method (contrast‐enhanced computed tomography (CT)) and a novel technique, whole‐body magnetic resonance imaging with diffusion‐weighted sequence (WB‐DWI/MRI), in the assessment of peritoneal involvement (carcinomatosis), lymph‐node staging and prediction of non‐resectability in patients with suspected ovarian cancer. Methods Between March 2016 and October 2017, all consecutive patients with suspicion of ovarian cancer and surgery planned at a gynecological oncology center underwent preoperative staging and prediction of non‐resectability with ultrasound, CT and WB‐DWI/MRI. The evaluation followed a single, predefined protocol, assessing peritoneal spread at 19 sites and lymph‐node metastasis at eight sites. The prediction of non‐resectability was based on abdominal markers. Findings were compared to the reference standard (surgical findings and outcome and histopathological evaluation). Results Sixty‐seven patients with confirmed ovarian cancer were analyzed. Among them, 51 (76%) had advanced‐stage and 16 (24%) had early‐stage ovarian cancer. Diagnostic laparoscopy only was performed in 16% (11/67) of the cases and laparotomy in 84% (56/67), with no residual disease at the end of surgery in 68% (38/56), residual disease ≤ 1 cm in 16% (9/56) and residual disease > 1 cm in 16% (9/56). Ultrasound and WB‐DWI/MRI performed better than did CT in the assessment of overall peritoneal carcinomatosis (area under the receiver‐operating‐characteristics curve (AUC), 0.87, 0.86 and 0.77, respectively). Ultrasound was not inferior to CT (P = 0.002). For assessment of retroperitoneal lymph‐node staging (AUC, 0.72–0.76) and prediction of non‐resectability in the abdomen (AUC, 0.74–0.80), all three methods performed similarly. In general, ultrasound had higher or identical specificity to WB‐DWI/MRI and CT at each of the 19 peritoneal sites evaluated, but lower or equal sensitivity in the abdomen. Compared with WB‐DWI/MRI and CT, transvaginal ultrasound had higher accuracy (94% vs 91% and 85%, respectively) and sensitivity (94% vs 91% and 89%, respectively) in the detection of carcinomatosis in the pelvis. Better accuracy and sensitivity of ultrasound (93% and 100%) than WB‐DWI/MRI (83% and 75%) and CT (84% and 88%) in the evaluation of deep rectosigmoid wall infiltration, in particular, supports the potential role of ultrasound in planning rectosigmoid resection. In contrast, for the bowel serosal and mesenterial assessment, abdominal ultrasound had the lowest accuracy (70%, 78% and 79%, respectively) and sensitivity (42%, 65% and 65%, respectively). Conclusions This is the first prospective study to document that, in experienced hands, ultrasound may be an alternative to WB‐DWI/MRI and CT in ovarian cancer staging, including peritoneal and lymph‐node evaluation and prediction of non‐resectability based on abdominal markers of non‐resectability. © 2021 International Society of Ultrasound in Obstetrics a...

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

“…The recent European and international guidelines acknowledged that ultrasound imaging quality has improved in recent decades and, if carried out by an experienced sonographer, ultrasound has an invaluable role in estimating the malignant potential and histopathological features of ovarian tumours, as well as assessing tumour extent in the abdomen and pelvis [ 11 , 31 ]. Multiple prospective studies on large cohorts of patients showed good diagnostic performance in the assessment of ovarian cancer spread in the abdomen but also in the prediction of non-resectability [ 55 , 79 , 102 , 103 , 104 ]. Furthermore, ultrasound-guided tru-cut biopsy is possible in patients unfit for surgery or in whom secondary (metastatic) ovarian cancer is suspected ( Table 4 ) [ 105 , 106 , 107 ].…”

“…Thoracic percutaneous ultrasound has limitations in visualizing mid-/upper mediastinal or lung parenchymal metastases, but convex array or linear array probes can visualize parietal pleural carcinomatosis and fluidothorax or cardiophrenic lymph nodes (anterior paracardiac lymph nodes ( Figure 5 and Figure 6 ). Moreover, transabdominal ultrasound has a lower accuracy (compared to intraoperative findings) in the identification of small-size peritoneal implants [ 79 , 103 ]. To improve detection of small-volume carcinomatosis, laparoscopy prior to laparotomy was suggested as an addition to ultrasound examination in the preoperative assessment of ovarian cancer patients in cases with unclear resectability (for example, if bowel serosa and its mesentery seem uninvolved on preoperative imaging, but the loops are retracted to the mesentery with irregular dilatation and impaired peristalsis) [ 79 , 102 ].…”

“…Moreover, transabdominal ultrasound has a lower accuracy (compared to intraoperative findings) in the identification of small-size peritoneal implants [ 79 , 103 ]. To improve detection of small-volume carcinomatosis, laparoscopy prior to laparotomy was suggested as an addition to ultrasound examination in the preoperative assessment of ovarian cancer patients in cases with unclear resectability (for example, if bowel serosa and its mesentery seem uninvolved on preoperative imaging, but the loops are retracted to the mesentery with irregular dilatation and impaired peristalsis) [ 79 , 102 ].…”

“…To assess critical sites, Fischerova et al evaluated the performance of transvaginal/transabdominal ultrasound, CT and WB-DWI/MRI to preoperatively assess ESMO-ESGO markers of non-resectability in the abdomen ( Figure 2 ) [ 79 ]. All the three imaging methods yielded similar accuracy (85–90%), but ultrasound showed higher sensitivity than WB-DWI/MRI and CT (63%, 50% and 56%, respectively) for predicting non-resectability using ESMO-ESGO-specific markers.…”

“…Abdominal CT has been recommended over the past few years as the modality of choice for staging ovarian cancer ( Figure 7 ) [ 108 ]. To assess the peritoneal carcinomatosis, the sensitivity of CT ranges from 58% to 90%, specificity from 58% to 94% and accuracy from 76% to 90% ( Table 5 ) [ 53 , 54 , 79 , 102 , 104 , 109 ]. CT is a widely available technique with the advantage of short examination time ( Table 4 ).…”