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1
Department of Radiology, Hadassah University Hospital, P. O. Box 12227,
Jerusalem, Israel, 91121.
2
Department of Oncology, Hadassah University Hospital, Jerusalem, Israel,
91121.
Received July 19, 2000;
accepted after revision April 11, 2001.
Address correspondence to T. Sella.
Abstract
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MATERIALS AND METHODS. The radiologic follow-up of 127 women with metatastic ovarian carcinoma who had undergone surgery and chemotherapy between 1985 and 1996 was reviewed. In reviewing each patient's medical record, we determined whether a chest CT scan had been obtained, and if so, how many had been obtained during the patient's follow-up period. For patients with a chest CT scan, an analysis of the presence of disease in the thorax and its relation to disease in the abdomen and pelvis, as revealed on CT images, was performed.
RESULTS. Of the patients whose cases were examined, 82 (65%) had had at least one chest CT scan obtained, with more than 50% having had three or more scans. Thirty-two (39%) patients had no radiologic evidence of disease. Twenty-eight (34%) showed disease in the abdomen or pelvis but no disease in the chest. Eighteen (22%) had both chest and abdominal or pelvic CT scans that indicated disease. In all of these patients, abdominal or pelvic disease had appeared on scans before spreading to the chest. Four (5%) of the patients had isolated chest disease. The rate of lung metastases from ovarian carcinoma in our series was 6%. In all of these patients, pulmonary metastases were preceded either by abdominal or pelvic disease or by a rise in tumor markers.
CONCLUSION. Pulmonary metastases in ovarian carcinoma are rare and usually preceded by recurrence of carcinoma in the abdomen or pelvis. We suggest that chest CT scanning could be eliminated in the routine follow-up of patients who have been treated for ovarian carcinoma; yet it should be performed for those patients with elevated serum tumor markers but without evidence of abdominal or pelvic disease.
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We undertook a retrospective study to examine the frequency with which chest CT scanning was used as part of the routine follow-up of patients with metastatic ovarian carcinoma. In addition, we assessed the value of chest CT scans by measuring the incidence of thoracic metastasis and its temporal relationship to the appearance of metastatic disease in the abdomen or pelvis.
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Data of patients who had at least one chest CT scan, as well as abdominal and pelvic CT scans, available for review were further analyzed to assess the following parameters: the stage of disease during the review period; the number of CT scans obtained of the chest and of the abdomen and pelvis; the presence of metastatic disease and its characterization at each anatomic site; the temporal relationship between the appearance of metastatic disease at different sites; and chronologic correlation of the serum tumor marker (CA-125 and carcinoembryonic antigen) measurements with the presence of metastatic disease visible on CT images. Patients who did not have at least one chest CT scan were excluded from this analysis.
The most recent CT examination in which a chest CT scan had been included was reviewed for each patient, and the status of disease in the chest, abdomen, and pelvis on the date of that examination was assessed. Two independent radiologists reviewed the CT examinations of each patient. Clinical charts relating to the relevant dates were also reviewed.
Thoracic disease was reported as pleural effusion, parenchymal nodules, or both. Abdominal or pelvic disease was defined as the presence of ascites, local recurrence, lymphadenopathy, or omental or hepatic metastases, and was recorded as present or absent. Each patient's data were reviewed and scored as positive or negative for disease at each site according to these criteria. Abdominal and pelvic diseases were grouped together.
After reviewing all data, we categorized the patients into one of four groups: no radiologic evidence of disease in the chest, abdomen, or pelvis (group 1); no radiologic evidence of thoracic disease but evidence of disease in the abdomen or pelvis (group 2); radiologic evidence of both thoracic and abdominal or pelvic disease (group 3); or radiologic evidence of thoracic disease but no evidence of abdominal or pelvic disease (group 4). In a patient with pulmonary metastases present, we reviewed all the chest CT scans dating back to the time before the nodules appeared. We assessed abdominal and pelvic disease and serum tumor markers present in the patient at that time.
Results were calculated as proportions with a 95% confidence interval (CI).
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Of the 82 women for whom at least one chest CT scan had been obtained,
there were 32 (39%) in group 1, 28 (34%) in group 2, 18 (22%) in group 3, and
four (5%) in group 4. Interobserver agreement in assigning a group to a
patient was 100% (
= 1). The incidence of thoracic involvement was 27%
(groups 3 and 4). Of these, 16 women had pleural disease (effusion or nodules)
alone, two had pulmonary nodules with effusion, and four had pulmonary nodules
alone. Only six patients had evidence of lung metastases. One of these was a
patient with concomitant ovarian and breast carcinoma whose chest CT scan
showed an isolated metastasis. The results of a needle biopsy showed the
metastasis to be adenocarcinoma of the breast. Therefore, only five of the 82
patients in our series had pulmonary metastases from ovarian carcinoma. These
five patients represent 6% of our patient population (95% CI, 2-13%). These
results are summarized in Tables
2 and
3.
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All five patients with pulmonary metastases had previous chest CT scans available for review along with the abdominal and pelvic scans obtained on correlating dates. In three of these patients, abdominal or pelvic recurrence had appeared before thoracic disease and had been documented at a previous time when findings of the chest CT scan had been normal. In the two additional patients, pulmonary metastasis was an isolated finding. In both, a rise in serum tumor markers had been noted weeks earlier, at a time when findings of the chest CT scan had been normal. Hence, all cases of pulmonary metastases in our study were preceded either by abdominal or pelvic disease or by a rise in tumor markers.
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Standard procedure is to follow up patients who have had ovarian carcinoma with periodic CT examinations using one of various protocols. The protocol used at our institution includes an initial abdominal and pelvic CT examination at diagnosis; a baseline CT examination after surgery but before chemotherapy; a CT examination after 3 months if any residual disease was present after surgery; and a CT examination at the end of routine treatment (usually six courses of chemotherapy). If the patient's disease was initially assessed as stage IV, these examinations are followed by a CT examination at 3 months; otherwise, 6-month, 1-year, and 2-year follow-up CT scans are obtained. This protocol, however, does not state when to include chest CT scanning as part of the follow-up. To our knowledge, the literature provides no clear guidelines on when to perform chest CT in patients who have had ovarian carcinoma. A recent study by Dachman et al. [12] is the first attempt to address this issue; the researchers state that the contribution of chest CT to the follow-up of these patients is small.
Our study shows that in our institution, despite the use of a standard protocol, the frequency with which chest CT scanning was performed varied greatly. Thirty-five percent of patients did not have a chest CT scan obtained at any time, whereas 5% of the patients each had eight or more scans obtained. Twenty-three patients had undergone only one chest CT scanning during their follow-up, possibly performed because of clinical concern about the appearance of suspicious symptoms. Of those patients who had been examined using chest CT, most (55%) had had between two and five scans obtained. This wide variation in practice likely reflects a degree of confusion among the referring physicians concerning when to request chest CT scanning for these patients. Therefore, clear guidelines are warranted.
By the end of the follow-up period (average follow-up period, 3.5 years), only 39% of the women in the study group had remained free of disease. Of the 50 patients (61%) with recurrent or metastatic disease, 27% had diseases involving the chest. The majority of these women (82%) had a pleural effusion. Only four patients had isolated pulmonary metastases, just 8% of all those with recurring disease, with an upper 95% confidence value of 19%. The remaining 46 patients had experienced either coinciding abdominal or pelvic disease or pleural disease, all of which could have been detected on a standard abdominal CT examination. A recent study of thoracic involvement in patients with metastatic ovarian carcinoma found that 77.8% of such disease was located in the lower thorax [12].
Because of the retrospective nature of our study, some bias toward patients with pulmonary disease may exist. Even so, only five patients in our study group had pulmonary metastases from ovarian carcinoma. This finding, together with that cited from the literature, suggests that parenchymal pulmonary metastases are rare in patients who have been treated for ovarian carcinoma. Furthermore, in the patients in our study, all cases of pulmonary metastases were preceded either by recurrent abdominal or pelvic disease that was detectable on CT images or by a rise in serum tumor markers. This finding correlates with those of Dachman et al. [12] who found progression of chest disease without previous progression of abdominal or pelvic disease in the findings of only 2.7% of CT scans of 40 patients with metastatic ovarian carcinoma. The coexistence of pulmonary metastases with recurrent or metastatic abdominal or pelvic disease does not necessitate a change in therapeutic strategy.
On the basis of our results, we suggest that routine chest CT scanning may be eliminated in the follow-up of patients who have been treated for ovarian carcinoma. This practice adds significant cost and exposes the patient to unnecessary discomfort and radiation. Thoracic CT scanning is definitely indicated in the patients with an elevation in serum tumor markers but without evidence of recurrent or metastatic abdominal or pelvic disease. A patient who experiences onset of new respiratory symptoms may also need a chest CT scan so that any pulmonary metastases or other possible thoracic diseases may be diagnosed.
In conclusion, the most common thoracic involvement in patients who have been treated for ovarian carcinoma is pleural effusion, which can easily be revealed on abdominal CT images performed according to standard protocols. Pulmonary metastases are rare and usually are preceded by recurrence of disease in the abdomen or pelvis. Therefore, we suggest that chest CT scanning may be eliminated from the routine follow-up protocol of patients who have had ovarian carcinoma and should be reserved for those patients with elevated serum tumor markers but without evidence of abdominal or pelvic disease. To establish the efficacy of our proposed change, a prospective study using a standardized protocol is warranted.
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