Nghiên cứu giá trị của chụp cộng hưởng từ trong chẩn đoán ung thư buồng trứng tt tiếng anh

MINISTRY OF EDUCATION MINISTRY OF HEATH Hanoi medical university dOAN TIEN LUU STUDY THE VALUE OF MR IMAGING IN OVARIAN CANCER DIAGNOSIS Specilised : Radiology Code : 62720166 Summarise of thesis of Philosophy doctor Hanoi - 2019 Thesis made in hannoi medical university THESIS SUPERVISORS: Ass Prof BUI VAN LENH Ass Prof VU BA QUYET Reviewer 1: Ass Prof Thai Khac Chau Reviewer 2: Ass Prof Nguyen Dinh Tuan Reviewer 3: Ass Prof Lam Khanh Thesis will be protected in congress university level of Hanoi Medical University 2019 Thesis will be found in: - National library - Library of Hanoi medical university Researchs publised concerning to the thesis Đoàn Tiến Lưu, Bùi Văn Lệnh, Vũ Bá Quyết (2019), “Nghiên cứu áp dụng thang điểm cộng hưởng từ chẩn đốn khả ác tính u buồng trứng”, Tạp chí Y học thực hành, số tháng năm 2019 (1089), trang 86 - 90 Đoàn Tiến Lưu, Bùi Văn Lệnh, Vũ Bá Quyết (2019), “Nghiên cứu giá trị xung cộng hưởng từ động học sau tiêm thuốc đối quang từ chẩn đoán phân biệt u buồng trứng ác tính với u buồng trứng lành tính”, Tạp chí Y học thực hành, số tháng năm 2019 (1098), trang 23 – 27 INTRODUCTION Ovarian cancer is the third most common cancer, after cervical cancer and endometrial cancer, but is the leading cause of death among female genital cancers The disease has a poor prognosis because the majority of cases are detected late Most cases have pelvic invasion and peritoneal metastases when detected To change the prognosis, early detection and proper treatment should be made Recently, with the development of new magnetic resonance pulse chains (CHT), it has faster shooting time, better resolution of images, analysis of many characteristics of tumor tissue, differentiating cancer tissue from benign tissue At the same time, it is easier to surveyed the entire abdominal cavity to detect peritoneal metastases, lymph node metastasis Magnetic resonance (MR) imaging is increasingly showing advantages in definitive diagnosis and diagnosis of ovarian cancer stage There have been studies of the value of MR imaging in the diagnosis of ovarian cancer in developed countries However, in Vietnam, there are no studies, especially studies on MR machines with advanced software for diagnosing ovarian cancer So we conducted a research on the topic "Study the value of MR imaging in diagnosing ovarian cancers" with the following three research objectives: Describe the MR imaging characteristics of ovarian cancer Evaluate the value of MR imaging in the differential diagnosis of ovarian cancer with benign ovarian tumors Evaluate the value of MR imaging in the diagnosis of ovarian cancer stage * Urgency of the project: Finding out a medical imaging modality which has hight value in diagnosis of ovarian cancers and staging ovarian cancers MR imaging with 1,5T machines, many new sequences, has hight potential in accurately differentiating between ovarian cancers and benign ovarian tumors, in staging ovarian cancers * New contributions of the thesis: This thesis is the first Vietnamese research of values of MR imaging in diagnosis of ovarian cancers The study outcomes showed efficacy of MR imaging in diffentiating between ovarian cancers and benign ovarian tumors, and in staging ovarian cancer Ovarian cancer’s tissues are always restricted diffusion (hight intensity on DW-b1000) Cutt-off of ADC value ≤ 1,26x10-3 mm2/s has moderate value in diffentiating between ovarian cancers and benign ovarian tumors Ovarian tumor’s tissue with enhanced curve type II or type III is the most important characteristics in diagnosis of ovarian cancers Diffusion imaging (DW-b1000) has hight sensitive in discovering peritoneal metastases THESIS OUTLINE This thesis covers 131 pages, including: preamle (2 pages), chapter 1: The Overview (37 pages), chapter 2: Material and method (19 pages), chapter 3: Study outcomes (28 pages), chapter 4: Discussion (42 pages), Conclusions (2 pages), Recommendation (1 page) The thesis consists of 35 tables, charts, diagram, 29 figures There are 105 references, of which in Vietnamese and 100 in English CHAPTER 1: OVERVIEW 1.1 GENERAL ON OVARIAN CANCERS 1.1.1 Epidemiology of ovarian cancers Ovarian cancer represents the sixth most commonly diagnosed cancer among women in the world, and causes more deaths per year than any other cancer of the female reproductive system it accounts for about 4% of all cancers in women It is the third common after cervical cancer and endometrial cancer An estimated in 70 women in the United States will develop ovarian cancer in their lifetime On a worldwide basis, an estimated 204,000 new cases are diagnosed and 125,000 women die of ovarian cancer annually In 2007, approximately 22,430 new cases of ovarian cancer will be diagnosed and 15,280 ovarian cancer-related deaths are expected in the United States Mortality is high because women typically present with late-stage disease when the overall 5-year relative survival rate is 45% Thus, the public health burden is significant Ovarian cancer affects women in the age 20 - 80 years and older more frequently than younger women More than 80% of all ovarian cancers occur in women in the age more than 40 years old 1.1.2 Hispathology of ovarian cancers - Over 90% of ovarian neoplasms arise from the epithelial surface of the ovary, the rest from germ cells or stromal cells The epithelial neoplasms are classified as serous (30–70%), endometrioid (10–20%), mucinous (5–20%), clear cell (3–10%), and undifferentiated (1%) - 5% - 10% of ovarian cancers are of germ cell origin, included dysgerminoma, endodermal sinus tumor, embryonal carcinoma, choriocarcinoma, malignant teratoma - Sex cord-stromal are rare, 10 mm IIIA2 Microscopic, extrapelvic (above the brim) peritoneal involvement ± positive retroperitoneal lymph nodes - IIIB Macroscopic, extrapelvic, peritoneal metastasis ≤ cm ± positive retroperitoneal lymph nodes Includes extension to capsule of liver/spleen - IIIC Macroscopic, extrapelvic, peritoneal metastasis > cm ± positive retroperitoneal lymph nodes Includes extension to capsule of liver/spleen Stage IV: Distant metastasis excluding peritoneal metastasis - IVA Pleural effusion with positive cytology - IVB Hepatic and/or splenic parenchymal metastasis, metastasis to extraabdominal organs (including inguinal lymph nodes and lymph nodes outside of the abdominal cavity) 1.2 MR PROTOCOL MR imaging is performed with a closed-configuration superconducting 1.5-T system (Signa HDxT; GE Healthcare) MR imaging is performed with the patient lying in the supine position (feet first) MR sequences: - Localizer sequence in the three spatial planes; Axial T2-weighted single-shot fast spin-echo (SSFSE) sequence, section thickness mm, interslice gap 0.6 mm, used as second localiser to identify the longitudinal axis of the uterus in the case of laterally deviated uterus - Sagittal T2-weighted fast spin-echo (FSE) sequence parallel to the longitudinal axis of the uterus (identified on the previous SSFSE sequence), section thickness mm, interslice gap mm Oblique coronal T2-weighted FSE sequence parallel to the longitudinal axis of the uterus, section thickness mm, interslice gap mm - Oblique axial T2-weighted FSE sequence perpendicular to the longitudinal axis of the uterus, section thickness mm, interslice gap mm - Axial oblique fat suppressed T2-weighted FSE sequence, section thickness mm; interslice gap mm - Axial T1-weighted gradient-echo (GRE) sequence in-out (chemicalshift imaging), section thickness mm; interslice gap 0,6 mm - Axial DWI SE EPI (TR/TE 3000/74,1; flip angle 90°; section thickness mm; interslice gap mm - Axial oblique T1-weighted 3D gradient-echo liver acquisition with volume acquisition (LAVA) sequence with fat suppression, section thickness 3.4 mm; overlap locations −1.7 mm After i.v administration of 0.1 mmol/kg paramagnetic contrast agent (Dotarem) at a flow rate of ml/s, followed by 20 ml of saline solution at the same flow rate, the following sequences are acquired: - Dynamic axial T1-weighted 3D gradient-echo LAVA with fat suppression, section thickness 3.4 mm, overlap locations −1.7 mm, 10 sequences acquired in minutes after contrast administration CHAPTER 2: OBJECTS AND METHOD 2.1 Materials Objects included 184 patients with ovarian tumors (93 patients with ovarian cancers and 91 patients with benign ovarian tumors) All the patients got pelvis and abdominal MR imaging to diagnose ovarian cancers at Radiology department of Hanoi University Hospital, operated at Oncology department of Hanoi University Hospital and National hospital of obstetrics and gynecology, from November 2013 to August 2017 2.2 Study methods Prospective, descriptive cross-sectional study 2.2.1 Study equipments - MR system 1.5T Signa X (GE Healthcare) - Paramagnetic contrast agent (Dotarem) 0,5mmol/1ml 2.2.2 Study design - Select eligible patients - Various MR criterias were evaluated on the basis of several previously published terms: + A purely cystic lesion was defined by the absence of solid tissue and the absence of internal enhancement after injection and corresponded to a unilocular cyst or hydrosalpinx, both of which have low T1-weighted and high T2-weighted MR signal intensities + A purely endometriotic mass was defined as a lesion that displayed high T1- weighted signal intensity that was greater than or equal to that of subcutaneous fat, shading on T2-weighted MR images, and no solid tissue + A purely fatty mass was defined as a lesion that displayed high T1weighted signal intensity that decreased after fat saturation and that displayed no solid tissue + Readers also recorded enhancement of the cyst wall, bi- or multilocularity, and the presence of thickened regular septa or grouped septa 10 + The presence of a solid tissue and its morphology (solid portion, vegetation, thickened irregular septa) were also evaluated Then, T2weighted signal intensity within the solid tissue (low or intermediate compared with that of the outer myometrium) and b = 1000 sec/mm2– weighted signal intensity within the solid tissue (high b = 1000 sec/mm2– weighted signal intensity compared with that of serous fluid [urine in the bladder or cerebrospinal fluid]) were analyzed As previously demonstrated, we described lesions that displayed both low T2 and b = 1000 sec/mm2–weighted signal intensity within the solid tissue + Finally, readers analyzed the perfusion-weighted images at a standard workstation by using the breast or prostate perfusion tool and selecting two regions of interest—one in the external myometrium and one in the most enhancing part of any solid tissue We classified the enhancement of the solid tissue by using a previously published time– signal intensity curve classification A gradual increase in the signal intensity of the solid tissue, without a well-defined “shoulder,” was defined as curve type A moderate initial increase in the signal intensity of solid tissue relative to that of myometrium, followed by a plateau, was defined as curve type An initial increase in the signal intensity of solid tissue that was steeper than that of myometrium was defined as curve type + The presence of free fluid in peritoneal cavity + Peritoneal implants was also noted: Nodular thickening of the peritoneum that is restricted diffusion (hight intensisty on DW-b1000) and enhances after gadolinium chelate injection + Pelvis invasion: Normally, there is a hight intensity interface on T2W between ovarian tumors and rectum, uterus, blader and pelvis wall When we can not see this interface or the interface is irregular or retracted, it is said that there is pelvis invasion + Metastases lymph nodes: Oval or round in shape, transverse diameter over 8mm, hyperintensity on DW-b1000, enhances after gadolinium chelate injection, beside to pelvis vessels and aorta, vena cava and superior mesenteric vessels 13 Table 3.1: Multivariate analysis of MR characteristics for diagnosing malignant ovarian tumors Malignant Malignant Benign characteristics Univariate analysis OR (CI p 95%) 0,001 2,680 (1,474 4,873) 0,002 2,546 (1,376 4,714) 0,001 3,210 (1,698 6,067) 0,001 4,704 (2,470 8,956) 0,001 43,784 (12,875 148,896) 0,001 64,138 (18,711 219,849) 0,001 22,032 (9,889 49,086) 0,001 96,806 (35,630 263,020) 0,001 +∞ Size of tumor ≥ 80mm 54/93 (58,1%) 31/91 (34,1%) Multilocularity 68/93 (73,1%) 47/91 (51,6%) Wall thickness ≥ 3mm 72/93 (77,4%) 47/91 (51,6%) Vegetations 53/93 (57,0%) 20/91 (22,0%) Solid portion 90/93 (96,8%) 37/91 (40,7%) High intensity tissue on DW 90/93 (96,8%) 29/91 (31,9%) Tissue’s ADC ≤ 1,26x10-3 mm2/s Curve type or 68/93 (73,1%) 10/91 (11,0%) 85/93 (91,4%) 9/91 (9,9%) Peritoneal metastases Peritoneal cavity’s fluid 29/93 (31,2%) 56/93 (60,2%) 0/91 (0,0%) 16/91 0,001 (17,6%) 7,095 (3,59114,018) Multivariate analysis p aOR (CI 95%) 0,117 0,266 (0,051- 1,393) 0,120 3,461 (0,722 – 16,585) 3,730 (0,766 – 18,157) 0,356 (0,076 – 1,670) 1,338 (0,181 – 9,913) 3,432 (0,526 – 22,377) 4,067 (0,878 – 18,845) 59,211 (10,047 – 334,845) 873212193,7 0,103 0,190 0,776 0,197 0,073 0,001 0,001 0,874 1,126 (0,259 – 4,899) When analyzing univariate, the MR characteristics of ovarian tumors, size of tumor ≥ 80mm, multilocularity, wall thickness ≥ 3mm, vegetations, tissues increase signal on DW-b1000, tissue’s ADC value ≤ 14 1,26x10-3 mm2 / s, enhancement with curve type or type 3, peritoneal metastases, peritoneal cavity’s fluid, all have value in diagnosis of malignant ovarian tumors.The malignant ratio of tumors with one of the above characteristics is higher than the malignant ratio of tumors with no corresponding characteristics, the difference is statistically significant p However, when analyzing multi-variable Regression Multinomial Logistic, there are only two characteristics, contrast-enhanced tissue with curve type or and peritoneal metastases, that are valuable for diagnosis of malignant tumor, malignancy aOR very high, dynamic range of odds ratio (CI 95%) always > 1, with p