Imaging Ovarian Cancer and Peritoneal Metastases—Current and Emerging Techniques

In This Article

Abstract and Introduction


Peritoneal metastases are often the first presentation of ovarian malignancy. Evaluating the extent of disease critically determines tumor resectability and can also predict outcome. Standard CT, however, frequently fails to identify small sites of peritoneal spread. Moreover, it does not provide a quantitative index of disease response to cytotoxic therapy as it relies on macroscopic morphological changes in tumor volume, and does not reflect preceding molecular events in the microenvironment of the tumor. We describe the emerging role of functional imaging techniques, such as radioimmunoscintigraphy, PET/CT, diffusion-weighted MRI, dynamic contrast-enhanced MRI, and magnetic resonance spectroscopy in staging ovarian cancer and assessing treatment response. 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.


Ovarian cancer is the second most common gynecological malignancy after endometrial cancer in developed countries, but accounts for more deaths than the remaining gynecological cancers added together.[1] The high mortality reflects advanced stage at presentation, either with extrapelvic peritoneal disease and/or abdominopelvic lymphadenopathy (FIGO [International Federation of Gynecology and Obstetrics] stage III), or parenchymal metastases (FIGO stage IV).[2] Ovarian cancer can spread by intraperitoneal seeding, direct invasion or through the lymphatic and vascular circulation. Peritoneal seeding is the most common route of dissemination, and stage III disease is associated at best with a 5-year survival rate of 32–47%.[2]

The extent and anatomical location of peritoneal involvement determines the feasibility of cytoreductive surgery and predicts the surgical result. Imaging of the peritoneum in previously treated patients with rising levels of serum CA125 is crucial in order to detect sites of relapse and to designate surgical versus chemotherapeutic management options. Staging of ovarian cancer has been routinely practiced by means of contrast-enhanced CT. The sensitivity of this technique depends on the size and location of peritoneal implants, owing to their similar density and, therefore, poor contrast to adjacent normal structures, particularly in the absence of ascites. Moreover, purely anatomical imaging uses only size criteria when assessing the impact of cytotoxic therapy and does not recognize the functional alterations that occur within tissue before any changes in tumor volume. Thus, there has been a growing awareness of the potential of functional imaging to improve staging accuracy and quantify early treatment response. This Review describes the principles and techniques of functional imaging modalities currently employed in ovarian cancer in the clinical and experimental setting. It also discusses their advantages and limitations compared with conventional imaging, and their prospective role in patient management.


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