Recurrent Ovarian Cancer: Use of Contrast-enhanced CT and PET/CT to Accurately Localize Tumor Recurrence and to Predict Patients’ Survival

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Our results suggest that the number, size, and maximum standardized uptake value of peritoneal deposits and distant lymph node metastases at imaging may be used to predict the patients’ survival.


To compare accuracy and interobserver variability in the detection and localization of recurrent ovarian cancer with contrast material–enhanced (CE) computed tomography (CT) and positron emission tomography (PET)/CT and determine whether imaging findings can be used to predict survival.

Materials and Methods

Waiving informed consent, the institutional review board approved this HIPAA-compliant, retrospective study of 35 women (median age, 54.4 years) with histopathologically proven recurrent ovarian carcinoma who underwent CE CT and PET/CT before exploratory surgery. All CE CT and PET/CT scans were independently analyzed. Tumor presence, number of lesions, and the size and maximum standardized uptake value (SUVmax) of the largest lesion were recorded for patient and region. Surgical histopathologic findings constituted the reference standard. Areas under the receiver operating characteristic curves (AUCs), κ statistics, and hazard ratios were calculated.


Readers’ AUCs in detection of recurrence for region were 0.85 (95% confidence interval [CI]: 0.81, 0.90) and 0.78 (95% CI: 0.72, 0.83) for CE CT and 0.84 (95% CI: 0.79, 0.89) and 0.74 (95% CI: 0.67, 0.81) for PET/CT (P = .76); 12 patients died. At PET/CT, size, number, and SUVmax of peritoneal deposits were significantly associated with poor survival for readers 1 and 2 (P ≤ .01and ≤ .05, respectively), as were long- and short-axis diameters, number, and SUVmax of distant lymph nodes for reader 1 (P ≤ .001). With CE CT, size (reader 1) and number (readers 1 and 3) of peritoneal deposits were significantly associated with poor survival (P ≤ .01), as were long- and short-axis diameters and number of distant lymph nodes for reader 1 (P ≤ .01). Interobserver agreement ranged from fair (patient, κ = 0.30) to moderate (region, κ = 0.55) for CE CT and fair (patient, κ = 0.24) to substantial (region, κ = 0.63) for PET/CT.


Preliminary data suggest that CE CT and PET/CT may have similar accuracy in detection of recurrent ovarian cancer. Tumor size, number, and SUVmax may have potential as prognostic biomarkers for patients with recurrent ovarian cancer.

© RSNA, 2010


  • 1 American Cancer Society. Cancer facts & figures 2009. Atlanta, Ga: American Cancer Society, 2009. Google Scholar
  • 2 Jemal A, Siegel R, Ward E, Hao Y, Xu J, Thun MJ. Cancer statistics, 2009. CA Cancer J Clin 2009;59(4):225–249. Crossref, MedlineGoogle Scholar
  • 3 Omura GA, Brady MF, Homesley HD, et al.. Long-term follow-up and prognostic factor analysis in advanced ovarian carcinoma: the Gynecologic Oncology Group experience. J Clin Oncol 1991;9(7):1138–1150. Crossref, MedlineGoogle Scholar
  • 4 Rose PG. Surgery for recurrent ovarian cancer. Semin Oncol 2000;27(3 suppl 7):17–23. MedlineGoogle Scholar
  • 5 Folk JJ, Botsford M, Musa AG. Monitoring cancer antigen 125 levels in induction chemotherapy for epithelial ovarian carcinoma and predicting outcome of second-look procedure. Gynecol Oncol 1995;57(2):178–182. Crossref, MedlineGoogle Scholar
  • 6 Patsner B, Orr JW, Mann WJ, Taylor PT, Partridge E, Allmen T. Does serum CA-125 level prior to second-look laparotomy for invasive ovarian adenocarcinoma predict size of residual disease? Gynecol Oncol 1990;38(3):373–376. Crossref, MedlineGoogle Scholar
  • 7 Rubin SC, Hoskins WJ, Hakes TB, et al.. Serum CA 125 levels and surgical findings in patients undergoing secondary operations for epithelial ovarian cancer. Am J Obstet Gynecol 1989;160(3):667–671. Crossref, MedlineGoogle Scholar
  • 8 Forstner R, Hricak H, Powell CB, Azizi L, Frankel SB, Stern JL. Ovarian cancer recurrence: value of MR imaging. Radiology 1995;196(3):715–720. LinkGoogle Scholar
  • 9 Kubik-Huch RA, Dörffler W, von Schulthess GK, et al.. Value of (18F)-FDG positron emission tomography, computed tomography, and magnetic resonance imaging in diagnosing primary and recurrent ovarian carcinoma. Eur Radiol 2000;10(5):761–767. Crossref, MedlineGoogle Scholar
  • 10 Kurtz AB, Tsimikas JV, Tempany CM, et al.. Diagnosis and staging of ovarian cancer: comparative values of Doppler and conventional US, CT, and MR imaging correlated with surgery and histopathologic analysis—report of the Radiology Diagnostic Oncology Group. Radiology 1999;212(1):19–27. LinkGoogle Scholar
  • 11 Tempany CM, Zou KH, Silverman SG, Brown DL, Kurtz AB, McNeil BJ. Staging of advanced ovarian cancer: comparison of imaging modalities—report from the Radiological Diagnostic Oncology Group. Radiology 2000;215(3):761–767. LinkGoogle Scholar
  • 12 Coakley FV, Choi PH, Gougoutas CA, et al.. Peritoneal metastases: detection with spiral CT in patients with ovarian cancer. Radiology 2002;223(2):495–499. LinkGoogle Scholar
  • 13 Gu P, Pan LL, Wu SQ, Sun L, Huang G. CA 125, PET alone, PET-CT, CT and MRI in diagnosing recurrent ovarian carcinoma: a systematic review and meta-analysis. Eur J Radiol 2009;71(1):164–174. Crossref, MedlineGoogle Scholar
  • 14 Kitajima K, Murakami K, Yamasaki E, et al.. Performance of integrated FDG-PET/contrast-enhanced CT in the diagnosis of recurrent ovarian cancer: comparison with integrated FDG-PET/non-contrast-enhanced CT and enhanced CT. Eur J Nucl Med Mol Imaging 2008;35(8):1439–1448. Crossref, MedlineGoogle Scholar
  • 15 Nanni C, Rubello D, Farsad M, et al.. (18)F-FDG PET/CT in the evaluation of recurrent ovarian cancer: a prospective study on forty-one patients. Eur J Surg Oncol 2005;31(7):792–797. Crossref, MedlineGoogle Scholar
  • 16 Sironi S, Messa C, Mangili G, et al.. Integrated FDG PET/CT in patients with persistent ovarian cancer: correlation with histologic findings. Radiology 2004;233(2):433–440. LinkGoogle Scholar
  • 17 Thrall MM, DeLoia JA, Gallion H, Avril N. Clinical use of combined positron emission tomography and computed tomography (FDG-PET/CT) in recurrent ovarian cancer. Gynecol Oncol 2007;105(1):17–22. Crossref, MedlineGoogle Scholar
  • 18 Fulham MJ, Carter J, Baldey A, Hicks RJ, Ramshaw JE, Gibson M. The impact of PET-CT in suspected recurrent ovarian cancer: a prospective multi-centre study as part of the Australian PET Data Collection Project. Gynecol Oncol 2009;112(3):462–468. Crossref, MedlineGoogle Scholar
  • 19 Simcock B, Neesham D, Quinn M, Drummond E, Milner A, Hicks RJ. The impact of PET/CT in the management of recurrent ovarian cancer. Gynecol Oncol 2006;103(1):271–276. Crossref, MedlineGoogle Scholar
  • 20 Soussan M, Wartski M, Cherel P, et al.. Impact of FDG PET-CT imaging on the decision making in the biologic suspicion of ovarian carcinoma recurrence. Gynecol Oncol 2008;108(1):160–165. Crossref, MedlineGoogle Scholar
  • 21 Vinnicombe SJ, Norman AR, Nicolson V, Husband JE. Normal pelvic lymph nodes: evaluation with CT after bipedal lymphangiography. Radiology 1995;194(2):349–355. LinkGoogle Scholar
  • 22 Obuchowski NA. Nonparametric analysis of clustered ROC curve data. Biometrics 1997;53(2):567–578. Crossref, MedlineGoogle Scholar
  • 23 Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457–481. CrossrefGoogle Scholar
  • 24 Zhou XH, Obuchowski NA, McClish DK. Statistical methods in diagnostic medicine. New York, NY: Wiley-Interscience, 2002. CrossrefGoogle Scholar
  • 25 Bristow RE, Giuntoli RL, Pannu HK, Schulick RD, Fishman EK, Wahl RL. Combined PET/CT for detecting recurrent ovarian cancer limited to retroperitoneal lymph nodes. Gynecol Oncol 2005;99(2):294–300. Crossref, MedlineGoogle Scholar
  • 26 Chung HH, Kang WJ, Kim JW, et al.. Role of [18F]FDG PET/CT in the assessment of suspected recurrent ovarian cancer: correlation with clinical or histological findings. Eur J Nucl Med Mol Imaging 2007;34(4):480–486. Crossref, MedlineGoogle Scholar
  • 27 Hauth EA, Antoch G, Stattaus J, et al.. Evaluation of integrated whole-body PET/CT in the detection of recurrent ovarian cancer. Eur J Radiol 2005;56(2):263–268. Crossref, MedlineGoogle Scholar
  • 28 Mangili G, Picchio M, Sironi S, et al.. Integrated PET/CT as a first-line re-staging modality in patients with suspected recurrence of ovarian cancer. Eur J Nucl Med Mol Imaging 2007;34(5):658–666. Crossref, MedlineGoogle Scholar
  • 29 Pannu HK, Bristow RE, Cohade C, Fishman EK, Wahl RL. PET-CT in recurrent ovarian cancer: initial observations. RadioGraphics 2004;24(1):209–223. LinkGoogle Scholar
  • 30 Sebastian S, Lee SI, Horowitz NS, et al.. PET-CT vs. CT alone in ovarian cancer recurrence. Abdom Imaging 2008;33(1):112–118. Crossref, MedlineGoogle Scholar
  • 31 Chi DS, McCaughty K, Diaz JP, et al.. Guidelines and selection criteria for secondary cytoreductive surgery in patients with recurrent, platinum-sensitive epithelial ovarian carcinoma. Cancer 2006;106(9):1933–1939. Crossref, MedlineGoogle Scholar

Article History

Received December 2, 2009; revision requested January 8, 2010; final revision received March 30; accepted April 14; final version accepted May 10.
Published online: Oct 2010
Published in print: Oct 2010