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Diagnostic value of PET/CT is similar to that of conventional MRI and even better for detecting small peritoneal implants in patients with recurrent ovarian cancer. February 24, 2012

Posted by patoconnor in cancer, gynecological cancer, ovarian cancer, tubal cancer, Uncategorized, uterine cancer, vaginal cancer.
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Diagnostic value of PET/CT is similar to that of conventional MRI and even better for detecting small peritoneal implants in patients with recurrent ovarian cancer.

Feb 2012

Sanli YTurkmen CBakir BIyibozkurt COzel SHas DYilmaz ETopuz SYavuz EUnal SNMudun A.


Departments of aNuclear Medicine bRadiology cObstetrics and Gynecology dBiostatistics and Medical Informatics ePathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.



The aim of this study was to evaluate the diagnostic value of 2-(fluorine-18)-fluoro-2-deoxy-D-glucose (F-FDG) PET/CT in comparison with MRI for the detection of recurrent ovarian cancer.


Forty-seven patients with suspected ovarian cancer recurrence after total ablative or cytoreductive surgery, as well as neoadjuvant or adjuvant chemotherapy, who had undergone F-FDG PET/CT imaging were recruited for the present study. All patients also underwent MRI within a month of F-FDG PET/CT for the same purpose. Recurrent cancer in the abdomen and pelvis was evaluated in each of the 47 patients and classified as either distant metastasis or local pelvic recurrence involving the vaginal stump, peritoneal implants, supradiaphragmatic region, and/or abdominal and pelvic lymph nodes. Special attention was paid to peritoneal implants. These were divided into five groups according to size of the implants: less than 0.5 cm (group 1), 0.5-1 cm (group 2), 1-2 cm (group 3), 2-3 cm (group 4), and larger than 3 cm (group 5). PET/CT findings were compared with abdominopelvic MR findings. Statistical analysis was carried out using the Wilcoxon signed rank test.


Thirty-nine of 47 patients were found to have recurrent ovarian cancer. Both PET/CT and MRI were negative for recurrence in six patients. Overall sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of PET/CT were 97.5, 100, 100, 87.5, and 97.8%, respectively, whereas those of MRI were 95, 85.7, 97.4, 75, and 93.6%, respectively. For the peritoneal implants in groups 2 and 3, the sensitivity, negative predictive value, and diagnostic accuracy values of PET/CT were significantly better than those of MRI (P<0.05).


The present study revealed that PET/CT is similar to conventional MRI for the detection of recurrent ovarian cancer. PET/CT has greater accuracy in the detection of small-to-medium-sized (<2 cm) peritoneal implants compared with MRI. This may affect surgical decision making.



How Is Ovarian Cancer Diagnosed? November 16, 2008

Posted by patoconnor in cancer, gynecological cancer, ovarian cancer, tubal cancer, uterine cancer, vaginal cancer.
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How Is Ovarian Cancer Diagnosed?

From the American Cancer Society

Consultation with a specialist

If your pelvic exam or other tests suggest that you may have ovarian cancer, you will need a doctor or surgeon who specializes in treating women with this type of cancer. A gynecologic oncologist is an obstetrician/gynecologist who is specially trained in treating cancers of the female reproductive system.

Imaging studies

Imaging methods such as computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and ultrasound studies can confirm whether a pelvic mass is present. Although these studies cannot confirm that the mass is a cancer, they are useful if your doctor is looking for spread of ovarian cancer to other tissues and organs.


Ultrasound (ultrasonography) is the use of sound waves to create an image on a video screen. Sound waves are released from a small probe placed in the woman’s vagina or on the surface of her abdomen. The sound waves create echoes as they enter the ovaries and other organs. The same probe detects the echoes that bounce back, and a computer translates the pattern of echoes into a picture. Because ovarian tumors and normal ovarian tissue often reflect sound waves differently, this test may be used to find tumors and determine whether a mass is solid or a fluid-filled cyst.

Computed tomography

The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, like a conventional x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body. The machine will take pictures of multiple slices of the part of your body that is being studied.

This test can help tell if the cancer has spread into your liver or other organs. CT scans are useful in showing how large the tumor is, what other organs it may be invading, whether lymph nodes are enlarged and if your kidneys or bladder are affected.

You may be asked to drink 1 to 2 pints of a liquid before the CT scan called “oral contrast.” This helps outline the intestine so that certain areas are not mistaken for tumors. You may also receive an IV (intravenous) line through which a different kind of contrast dye is injected. This helps better outline structures in your body.

The injection can cause some flushing (redness and warm feeling that may last hours to days). A few people are allergic to the dye and get hives. Rarely, more serious reactions like trouble breathing and low blood pressure can occur. Medicine can be given to prevent and treat allergic reactions. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays.

CT scans are not usually used to to biopsy (see biopsy in the section “Other tests”) an ovarian tumor, but they can be used to biopsy a suspected metastasis. For this procedure, called a CT-guided needle biopsy, the patient stays on the CT scanning table, while a radiologist moves a biopsy needle toward the location of the mass. CT scans are repeated until the doctors are confident that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ½ inch long and less than 1/8 inch in diameter) is removed and examined under a microscope.

CT scans take longer than regular x-rays and you need to lie still on a table while they are being done. But just like other computerized devices, they are getting faster and the most modern ones take only seconds.

Barium enema x-ray

This is a test to see whether the cancer has invaded the colon (large intestine) or rectum (it is also used to look for colorectal cancer). After taking laxatives the day before, the radiology technician puts barium sulfate, a chalky substance, into the rectum and colon. Because barium is impermeable to x-rays (impossible for x-rays to go through), it outlines the colon and rectum on x-rays of the abdomen. This test is rarely used now in women with ovarian cancer. Colonoscopy may be done instead.

Magnetic resonance imaging

MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Not only does this produce cross sectional slices of the body like a CT scanner, it can also produce slices that are parallel with the length of the body. A contrast material might be injected into a vein (same as with a CT scan). MRI scans are not used often to look for ovarian cancer.

MRI scans are particularly helpful to examine the brain and spinal cord. MRI scans take longer than CT scans, — often up to 30 minutes or more. Also, you have to be placed inside a tube, which is confining and can upset people with claustrophobia (fear of enclosed spaces). The machine also makes a thumping noise that you may find disturbing. Some places will provide headphones with music to block the sound.

Chest x-ray

This procedure may be done to determine whether ovarian cancer has spread (metastasized) to the lungs. This spread may cause one or more tumors in the lungs and often causes fluid to collect around the lungs. This fluid, called a pleural effusion, can be seen with chest x-rays.

Positron emission tomography (PET scan)

In this test radioactive glucose (sugar) is given to look for the cancer. Because cancers use glucose (sugar) at a higher rate than normal tissues, the radioactivity will tend to concentrate in the cancer. A scanner can spot the radioactive deposits. This test has can be helpful for spotting small collections of cancer cells. In some instances this test has proved useful in finding ovarian cancer that has spread. It is even more valuable when combined with a CT scan (PET/CT scan). Although PET scans can help find cancer when it has spread, they are expensive and many insurance companies will not cover the cost.


This procedure uses a thin, lighted tube through which a doctor can look at the ovaries and other pelvic organs and tissues in the area around the bile duct. The tube is inserted through a small incision (cut) in the lower abdomen and sends the images of the pelvis or abdomen to a video monitor. Laparoscopy provides a view of organs that can help plan surgery or other treatments and can help doctors confirm the stage (how far the tumor has spread) of the cancer. Also, doctors can manipulate small instruments through the laparascopic incision(s) to perform biopsies.


A colonoscopy is a way to examine the inside of the large intestine (colon). After the large intestine has been cleaned with laxatives, the doctor inserts a fiberoptic tube into the rectum and passes it through the entire colon. The images are sent to a video monitor. This allows the doctor to see the inside and detect any abnormalities. Colonoscopy can be uncomfortable, so the patient is sedated before the procedure. This test is more commonly used to look for colorectal cancer.


The only way to determine for certain if a growth is cancer is to remove a sample of the growth from the suspicious area and examine it under a microscope. This procedure is called a biopsy. For ovarian cancer, the biopsy is most commonly done by removing the tumor at surgery. It can be also be done during a laparoscopy procedure or with a needle placed directly into the tumor through the skin of the abdomen. Usually the needle will be guided by either ultrasound or CT scan. A needle biopsy is sometimes used instead of surgery if the patient cannot have surgery because of advanced cancer or some other serious medical condition.

In patients with ascites (collection of fluid inside the abdomen), samples of fluid can also be used to diagnose the cancer. In this procedure, called paracentesis, the skin of the abdomen is numbed and a needle attached to a syringe is passed through the abdomen wall into the fluid in the abdominal cavity. The fluid is sucked up into the syringe and then sent for analysis.

In all these procedures, the tissue obtained is sent to the pathology laboratory. There it is examined under the microscope by a pathologist, a doctor who specializes in diagnosing and classifying diseases by examining cells under a microscope and using other lab tests.

Blood tests

Your doctor will order blood counts to make sure you have enough red blood cells, white blood cells and platelets (cells that help stop bleeding). There will also be tests to measure your kidney and liver function as well as your general health status. Finally the doctor will order a CA-125 test. If the test result is elevated, consultation with a gynecologic oncologist is recommended.

American Cancer Society

Ovarian Cancer Facts November 14, 2008

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The ovaries

The ovaries are two small, oval-shaped organs that are part of the female reproductive system. They are in the lower part of the tummy (abdomen), which is known as the pelvis. Other organs are very close to the ovaries (see diagrams below). These include:

  • The ureters, which drain urine from the kidneys to the bladder.
  • The bladder.
  • The back passage (rectum).
  • The lower part of the small bowel.
  • The omentum (a membrane which surrounds all of the pelvic and abdominal organs and keeps them in place). It is also called the peritoneum.
  • Groups of lymph nodes.

Each month, in women of childbearing age, one of the ovaries produces an egg. The egg passes down the fallopian tube to the womb (uterus). If the egg is not fertilised by a sperm it passes out of the womb and is shed, along with the lining of the womb, as part of the monthly period.

The ovaries also produce the female sex hormones, oestrogen and progesterone. As a woman nears the menopause (‘change of life’) the ovaries make less of these hormones and periods gradually stop.




Types of Ovarian Cancer

Most ovarian cancers are a type called epithelial cancer. Epithelial ovarian cancer means the cancer has started in the cells that cover the surface of the ovary. There are several types of epithelial cancers of the ovary. The most common types are:

  • serous
  • endometrioid.

Less common types of epithelial ovarian cancer are:

  • mucinous
  • clear cell
  • undifferentiated or unclassifiable.

They are currently all treated in a similar way.

There are also less common types of ovarian cancer. These include germ cell tumours (ovarian teratomas) and sarcomas. Germ cell tumours tend to affect younger women and behave very differently to other types of ovarian cancer.

Risk factors and causes of ovarian cancer

Each year, about 6600 women in the UK are diagnosed with ovarian cancer. The causes are not yet completely understood. The risk of developing ovarian cancer is very low in young women and increases as women get older. Over eight out of ten (85%) ovarian cancers occur in women over the age of 50. Most ovarian cancers occur in women who have had their menopause.

Some factors are known to affect a woman’s chance of developing ovarian cancer – they may increase the risk or decrease it. These are described below.

Hormonal Factors

  • Women who have not had children are slightly more likely to develop ovarian cancer than women who have, although the risk is still very low. Having two or more children may provide more protection than just one.
  • Breast feeding your children may slightly decrease your risk.
  • Starting your periods early or having a late menopause slightly increases your risk of ovarian cancer.
  • Women who take the contraceptive pill are less likely to develop ovarian cancer.
  • Using oestrogen-only hormone replacement therapy (HRT) can slightly increase the risk. When HRT is stopped the risk of ovarian cancer gradually reduces to the same level as women who haven’t taken HRT.
  • Infertility and fertility treatments

    Research has shown that infertility treatment may slightly increase the risk of developing ovarian cancer. However, other research doesn’t support this.

    Health Factors

    Having endometriosis may increase your risk of ovarian cancer.

    Lifestyle factors

    Being overweight may increase your risk of developing ovarian cancer.

    Eating a diet high in animal fats and low in fresh fruit and vegetables may increase your risk.

    Genetic factors

  • About 5–10 in 100 (5–10%) ovarian cancers are caused by an inherited faulty gene in the family.
  • Women who have had breast cancer have an increased risk of ovarian cancer. This is because breast and ovarian cancer can be caused by the same faulty genes.
  • If any of the following are present in one side of your family, it is possible that there may be an inherited faulty gene:

    • Ovarian cancer in at least two close relatives (mother, sisters or daughters).
    • One close relative with ovarian cancer and one close relative with breast cancer diagnosed when they were under the age of 50 (or both cancers in the same person).
    • Ovarian cancer in one close relative and breast cancer in two family members diagnosed when they were under the age of 60.
    • Three close relatives with colon (bowel) or womb (endometrial) cancer, and one relative with ovarian cancer.

    Having one elderly relative with ovarian cancer doesn’t necessarily increase your risk of ovarian cancer.

    Women who are worried that they may have an increased risk of developing ovarian cancer, because of cancer in their family, can be referred to a genetic counselling clinic. Contact your GP or our information service for more details about genetic counselling clinics. The clinics are based in hospitals and you will be seen by a genetics specialist who can check your family history to see whether you are likely to be at increased risk.

    If two or more of your close relatives have had ovarian cancer you may want to consider having testing (screening) for ovarian cancer. However, it is not yet known how effective screening is at detecting ovarian cancer (screening).

    Screening for ovarian cancer

    Research trials are being carried out to see whether ovarian cancers can be detected early so that they can be treated more effectively. The trials are testing women who have no symptoms of ovarian cancer, to see if testing can detect a cancer at an early stage. This is known as screening. Currently it is not known whether screening can help to detect ovarian cancers at an earlier stage, so there is no national screening programme for ovarian cancer in the UK.

    Women who may have an increased risk of ovarian cancer can ask their GP to refer them to take part in an ovarian cancer screening research trial.

    A recent research study is looking at the benefits of screening postmenopausal women with either a blood test for a protein called CA125 or a vaginal ultrasound (see diagnosis). The aim of the trial is to see if either of these tests will help doctors diagnose women with ovarian cancer when their cancer is at an early stage. The trial has recently closed and it will be a few years before we know the results.

    Symptoms of ovarian cancer

    Most women with early-stage cancer of the ovary don’t have any symptoms for a long time. When symptoms occur they may include any of the following:

    • loss of appetite
    • vague indigestion, nausea, excessive gas (wind) and a bloated, full feeling
    • unexplained weight gain
    • swelling in the abdomen – this may be due to a build up of fluid (ascites), which can cause shortness of breath
    • pain in the lower abdomen
    • changes in bowel or bladder habits, such as constipation, diarrhoea or needing to pass urine more often
    • lower back pain
    • pain during sex
    • abnormal vaginal bleeding, although this is rare.

    If you have any of the above symptoms it is important to have them checked by your doctor, but remember they are common to many other conditions and most women with these symptoms will not have cancer.


    Usually you begin by seeing your GP, who will examine you and arrange for you to have any tests (usually ultrasound scans and/or blood tests) that may be necessary. If your GP suspects that you have ovarian cancer they will refer you to a cancer centre to be seen by a specialist gynaecology cancer team for the tests and for specialist advice and treatment.

    At the hospital

    At the hospital, the gynaecologist (specialist in women’s illnesses) will ask you about your general health and any previous medical problems, before examining you. This will include an internal (vaginal) examination to check for any lumps or swellings.

    The specialist may arrange for you to have a blood test and chest x-ray to check your general health.

    You may have a specific blood test to check whether there are higher than normal levels of the CA125 protein in your blood. CA125 is a protein that most women have in their blood. The level may be higher in women with ovarian cancer, as it is sometimes produced by ovarian cancer cells. However, CA125 is not specific to ovarian cancer, and the level can also be raised in women who have other non-cancerous conditions.

    Several tests may be used to diagnose cancer of the ovary. The tests may also show the stage of the cancer – whether or not it has spread to other parts of the body. These tests help your doctor to know the best way to treat the cancer.

    Ultrasound scan          

    An ultrasound uses sound waves to build up a picture of the inside of the abdomen, the liver and the pelvis. It will be done in the hospital scanning department.

    If you have a pelvic ultrasound you will be asked to drink plenty of fluids so that your bladder is full. This helps to give a clearer picture. Once you are lying comfortably on your back a gel is spread onto your abdomen. A small device, which produces sound waves, is then rubbed over the area. The sound waves are converted into a picture by a computer.

    If you have a vaginal ultrasound scan, a probe with a rounded end is put into your vagina. The probe produces sound waves, which are then converted into a picture by a computer. Although this type of ultrasound scan may sound uncomfortable, many women find it more comfortable than having a pelvic ultrasound, as it is not necessary to have a full bladder.

    Pelvic or vaginal ultrasound can be used to check for any enlargement or abnormalities of the ovaries which may be due to a cyst or tumour. It can also be used to show the size and position of a cancer.

    CT scan

    A CT (computerised tomography) scan takes a series of x-rays which builds up a three-dimensional picture of the inside of the body. The scan is painless but takes from 10 to 30 minutes. CT scans use a small amount of radiation, which will be very unlikely to harm you and will not harm anyone you come into contact with. You will be asked not to eat or drink for at least four hours before the scan.

    You may be given a drink or injection of a dye which allows particular areas to be seen more clearly. For a few minutes, this may make you feel hot all over. If you are allergic to iodine or have asthma you could have a more serious reaction to the injection, so it is important to let your doctor know beforehand. You will probably be able to go home as soon as the scan is over.

    MRI scan

    An MRI (magnetic resonance imaging) scan is similar to a CT scan, but uses magnetic fields instead of x-rays to build up a series of cross-sectional pictures of the body. During the test you will be asked to lie very still on a couch inside a metal cylinder that is open at both ends. The whole test may take up to an hour and is painless – although the machine is very noisy. You will be given earplugs or headphones to wear.

    The cylinder is a very powerful magnet, so before going into the room you should remove all metal belongings. You should also tell your doctor if you have ever worked with metal or in the metal industry or if you have any metal inside your body (for example, a cardiac monitor, pacemaker, surgical clips, or bone pins). You may not be able to have an MRI because of the magnetic fields.

    Some people are given an injection of dye into a vein in the arm, but this usually does not cause any discomfort. You may feel claustrophobic inside the cylinder, but you may be able to take someone with you into the room to keep you company. It may also help to mention to the staff beforehand if you do not like enclosed spaces. They can then offer extra support during your test.

    Abdominal fluid aspiration

    If there has been a build up of fluid in the abdomen, a sample of the fluid can be taken to check for any cancer cells. The doctor will use a local anaesthetic to numb the area before passing a small needle through the skin. Some fluid is drawn off into a syringe and examined under a microscope.


    This operation allows the doctor to look at the ovaries, fallopian tubes, the womb and the surrounding area. It’s done under a general anaesthetic. Most women usually go home the same day but you may have to stay in hospital overnight.

    While you are under anaesthetic, the doctor makes 3–4 small cuts, approximately 1cm (½ inch) in length, in the skin and muscle of the lower abdomen. A thin fibre-optic tube (laparoscope) is then inserted. By looking through the laparoscope the doctor can look at the ovaries and take a small sample of tissue (biopsy) for examination under a microscope.

    During the operation, carbon dioxide gas is passed into the abdominal cavity and this can cause uncomfortable wind and/or shoulder pains. The pain is often eased by walking about or by taking sips of peppermint water. If the pain continues when you are at home you should contact the hospital for advice.

    After a laparoscopy you will have one or two stitches in your lower abdomen. You should be able to get up as soon as the effects of the anaesthetic have worn off.

    Eploratory laparotomy                 

    Sometimes cancer of the ovary cannot be diagnosed before a full operation (laparotomy) is carried out.

    It will probably take several days for the results of your tests to be ready and a follow-up appointment will be arranged for you before you go home. Obviously, this waiting period is an anxious time and it may help you to talk things over with a close friend, a relative, the hospital specialist nurse, or a support organisation.

    Staging and grading of ovarian cancer


    The stage of a cancer is a term used to describe its size and whether it has spread beyond its original area of the body. Knowing the extent of the cancer and the grade helps the doctors to decide on the most appropriate treatment. It’s often not possible to stage an ovarian cancer before a laparotomy is done and the results of any biopsies are known (see diagnosis). A commonly used staging system is described below.

    Borderline tumours are made up of low-grade cells that are unlikely to spread. They are usually completely cured by surgery and rarely require further treatment.

    Stage 1 ovarian cancer only affects the ovaries. This stage is divided into three sub-groups:

    • Stage 1a The cancer is only in one ovary
    • Stage 1b There are tumours in both ovaries.
    • Stage 1c The cancer is either at stage 1a or 1b, and there are cancer cells on the surface of one of the ovaries, or in the fluid taken from within the abdomen during surgery, or the ovary has burst (ruptured) before or during surgery.

    Stage 2 ovarian cancer has begun to spread outside the ovaries within the pelvis. There are three sub-groups:

    • Stage 2a The cancer has spread to the womb or fallopian tubes.
    • Stage 2b The tumour has spread to other structures within the pelvis, such as the rectum or bladder.
    • Stage 2c The cancer is either at stage 2a or 2b, and there are cancer cells on the surface of one of the ovaries, or in the fluid taken from within the abdomen during surgery, or the ovary has burst (ruptured) before or during surgery.

    Stage 3 The cancer has spread beyond the pelvis to the lining of the abdomen (a fatty membrane called the omentum), and/or to abdominal organs such as the lymph nodes in the abdomen, or the upper part of the bowel.

    • Stage 3a The tumours in the abdomen are very small and cannot be seen except under a microscope.
    • Stage 3b The tumours in the abdomen can be seen but they are smaller than 2cm.
    • Stage 3c The tumours in the abdomen are larger than 2cm.

    Stage 4 The cancer has spread to other parts of the body such as the liver, lungs, or distant lymph nodes (for example in the neck).

    If the cancer comes back after initial treatment this is known as recurrent cancer.


    Grading refers to the appearance of the cancer cells when they are looked at under the microscope. The grade gives an idea of how quickly the cancer may develop. There are three grades: grade 1 (low-grade), grade 2 (moderate-grade) and grade 3 (high-grade).

    • Low-grade means that the cancer cells look very like the normal cells of the ovary. They usually grow slowly and are less likely to spread.
    • Moderate-grade means that the cells look more abnormal than low-grade cells.
    • High-grade means that the cells look very abnormal. They are likely to grow more quickly and are more likely to spread.