The role of CT, PET-CT, and MRI in ovarian cancer

The develop of persistent luminescence nanoparticles with excellent performances in cancer targeted bioimaging and killing: a review

The use of fluorescent nanomaterials in tumor imaging and treatment effectively avoids the original limitations of traditional tumor clinical diagnostic methods. The PLNPs emitted persistent luminescence after the end of excitation light. Owing to their superior optical properties, such as a reduced laser irradiation dose, spontaneous fluorescence interference elimination, and near-infrared imaging, PLNPs show great promise in tumor imaging. Moreover, they also achieve excellent anti-tumor therapeutic effects through surface modification and drug delivery. However, their relatively large size and limited surface modification capacity limit their ability to kill tumors effectively enough for clinical applications. Thus, this article reviews the synthesis and modification of PLNPs and the research progress in targeted tumor imaging and tumor killing. We also discuss the challenges and prospects of their future applications in these fields. This review has value for accelerating the design of PLNPs based platform for cancer diagnosis and treatment.

A Meta-analysis of 68Ga-FAPI PET in Assessment of Ovarian Cancer

RATIONALE AND OBJECTIVES

The objective of this research is to carry out a systematic review and meta-analysis to detect the diagnostic efficacy of 68Ga-FAPI Positron Emission Tomography (PET) Computed Tomography/Magnetic Resonance (CT/MR) in total of the lesions as well as different aspects of metastasis in individuals with ovarian cancers (OC).

MATERIALS AND METHODS

The PubMed, Embase, Cochrane library, and Web of Science databases were thoroughly searched until the cut-off date of July 23, 2024. The assessment of 68Ga-FAPI PET CT/MR of OC was presented by the included studies. Bivariate random effects models were utilized to compute the sensitivity and specificity of 68Ga-FAPI PET CT/MR in OC. The I-square index (I2) was utilized to measure heterogeneity and sensitivity analysis were employed to test it.

RESULTS

The pooled sensitivity as well as specificity for 68Ga-FAPI PET CT/MR in OC were 0.90 (95% CI: 0.84-0.95) as well as 0.95 (95% CI: 0.91-0.97), correspondingly. In the subanalysis for metastatic lesions (lymph node [LN] metastases and peritoneal involvement), the pooled sensitivity and specificity of 68Ga-FAPI PET CT/MR were 0.94 (95% CI: 0.74-0.99) and 0.95 (95% CI: 0.84-0.99) for identifying metastatic LNs as well as 0.93 (95% CI: 0.81-0.97) and 0.96 (95% CI: 0.89-0.99) about peritoneal carcinomatosis evaluation, correspondingly. In the head-to-head comparison with 18F-FDG PET/CT, 68Ga-FAPI PET CT/MR exhibited a better sensitivity in identifying peritoneal metastases (P=.0004).

CONCLUSION

68Ga-FAPI PET CT/MR displayed a high overall diagnostic effectiveness in OC. When evaluating metastatic peritoneal lesions of OC, 68Ga-FAPI PET CT/MR displayed a superior pooled sensitivity.

Analysis of endometrial liquid‑based cytology samples to detect somatic mutations and classify ovarian cancer

Ovarian cancer has a poor prognosis, and screening methods have not been established. Biomarkers based on molecular genetic characteristics must be identified to develop diagnostic and therapeutic strategies for all cancer types, particularly ovarian cancer. The present study aimed to evaluate the usefulness of genetic analysis of cervical and endometrial liquid-based cytology (LBC) specimens for detecting somatic mutations in patients with ovarian cancer. The data of 19 patients with ovarian cancer treated between August 2019 and July 2022 were analyzed. LBC specimens from the cervix and endometrium of patients with preoperatively suspected ovarian cancer were collected, and genomic DNA was extracted from these LBC specimens and surgically removed cancer tissue sections for genetic analysis. Next-generation sequencing (NGS) analysis of cervical and endometrial LBC revealed genetic mutations similar to those in formalin-fixed, paraffin-embedded (FFPE) tissues in 42% of ovarian cancer cases, including negative cervical and endometrial cytology cases and early-stage cases. The pathogenic variants detected were PIK3CA (n=1), RB1 (n=1) and TP53 (n=6). In high-grade serous carcinoma (HGSC) cases, the diagnosis rate was 54.5%, which was higher than that of other histological types. In univariate analysis of patients with HGSC, the presence of serous tubal intraepithelial carcinoma tended to be associated with the detection of somatic mutations in LBC samples. NGS analysis of cervical and endometrial LBC samples revealed genetic variants similar to those in FFPE tissues from ovarian cancer cases and may be useful as a noninvasive screening method for detecting somatic mutations and classifying ovarian cancer.

A clinicoradiological model based on clinical and CT features for preoperative prediction of histological classification in patients with epithelial ovarian cancers: a two-center study

OBJECTIVES

To develop and validate a clinicoradiological model integrating clinical and computed tomography (CT) features to preoperative predict histological classification in patients with epithelial ovarian cancers (EOCs).

METHODS

This retrospective study included 470 patients who were pathologically proven EOCs and performed by contrast enhanced CT before treatment from center I (training cohort, N = 329; internal test cohort, N = 141) and 83 EOC patients who were included as an external test cohort from center II. The univariate analysis and multivariate logistic regression analysis were used to select significant clinical and CT features. The significant clinical model was developed based on clinical characteristics. The significant radiological model was established by CT features. The significant clinical and CT features were used to construct the clinicoradiological model. Model performances were evaluated using the area under the receiver operating characteristic curve (AUC), calibration curve, the Brier score and decision curve analysis (DCA). The AUCs were compared by net reclassification index (NRI) and integrated discrimination improvement (IDI).

RESULTS

The significant clinical and CT parameters including age, transverse diameter, morphology, margin, ascites and lymphadenopathy were incorporated to build the clinicoradioligical model. The clinicoradiological model showed relatively satisfactory discrimination between type I and type II EOCs with the AUC of 0.841 (95% confidence interval [CI] 0.797-0.886), 0.874 (95% CI 0.811-0.937) and 0.826 (95% CI 0.729-0.923) in the training, internal and external test cohorts, respectively. The NRI and IDI showed the clinicoradiological model significantly performed than those of the clinical model (all P < 0.05). No statistical significance was found between radiological and clinicoradiological model. The clinicoradiological model demonstrated optimal classification accuracy and clinical application value.

CONCLUSION

The easily accessible nomogram based on the clinicoradiologic model showed favorable performance in distinguishing between type I and type II EOCs and could therefore be used to improve the clinical management of EOC patients.

Prognostic Value of Pretreatment 18F-FDG-PET/CT Metabolic Parameters in Advanced High-Grade Serous Ovarian Cancer

AIM

To assess the prognostic value of pretreatment 18F-FDG-PET/CT quantitative metabolic parameters in patients with advanced high-grade serous ovarian cancer (HGSOC).

METHODS

A review of 47 patients diagnosed with advanced HGSOC between 2012 and 2020 in our center was performed, evaluating pretreatment 18F-FDG-PET/CT metabolic parameters: maximum standardized uptake value (SUVmax), total lesion glycolysis (TLG) and metabolic tumoral volume (MTV). Two experienced nuclear medicine physicians evaluated the images, thereby obtaining quantitative parameters semiautomatically classifying the volume of interest (VOI) as the target (t): VOI with the highest SUVmax normalized by lean body mass (SUVmax(lbm)), non target (nt) and total (sum of target and non-target VOIs). The disease-free survival (DFS) and overall survival (OS) were calculated. Optimal cutoff values with ROC curves/median values were used. The Correlation between metabolic parameters and DFS/OS was determined using univariate and survival-curves analysis.

RESULTS

The median DFS was 18 months (2.5-55) and the OS 33.6 months (2.5-92). The MTVtotal, MTV(t), TLGtotal and TLG(t) were significantly associated with DFS (p = 0.005, 0.01, 0.04 and 0.04, respectively). The patients with MTVtotal > 427.8 cm3 and MTVtarget > 434 cm3 had shorter DFS than the patients with lower values (18.8 versus 31 months and 15.6 versus 30, p = 0.02 and 0.01, respectively). The patients with higher TLGtotal and TLG(t) values tended to have worse DFS (p = 0.26 and 0.31, respectively). In a multivariate analysis, the MTVtotal was statistically significantly associated with DFS (p = 0.003). No correlation was found with OS.

CONCLUSIONS

Pretreatment MTVtotal and MTV(t) appear to be predictive of relapse in patients with advanced HGSOC.

Comparison of 68Ga-FAPI PET CT/MRI and 18F-FDG PET/CT in metastatic lesions of gynecological cancers: a systematic review and head-to-head meta-analysis

Background68Ga-labled fibroblast activating protein inhibitor (68Ga-FAPI) represents a new and exciting positron emission tomography-computed tomography/magnetic resonance (PET-CT/MR) radiotracer.PurposeTo compare the diagnostic efficacy of 68Ga-FAPI PET CT/MR and 18F-fluorodeoxyglucose (18F-FDG) PET/CT in metastatic lesions of gynecological cancers (GCs).Material and MethodsThe PubMed, Embase, and Web of Science databases were thoroughly investigated from inception until 22 December 2023. A head-to-head contrast between 18F-FDG PET/CT as well as 68Ga-FAPI PET CT/MR for the assessment of GCs was presented by the included studies. A random variable model was employed to examine the sensitivity in detection of lymph node (LN) and peritoneal metastases (PM).ResultsThe pooled sensitivity for 68Ga-FAPI PET CT/MR and 18F-FDG PET/CT in lymph node metastases (LNM) of GC were 0.98 (95% confidence interval [CI] = 0.86-1) and 0.85 (95% CI = 0.65-0.98), respectively, while the results about peritoneal metastases in ovarian cancer were 0.98 (95% CI = 0.93-1) and 0.71 (95% CI = 0.55-0.86). Compared with 18F-FDG PET/CT, 68Ga-FAPI PET CT/MR exhibited a better sensitivity in peritoneal involvement of ovarian cancer with a relative risk of 0.24 (95% CI = 0.09-0.40) and P = 0.002.Conclusion68Ga-FAPI PET CT/MR displayed a superior sensitivity over 18F-FDG PET/CT in detecting metastatic lesions of ovarian cancer. However, there was insufficient evidence to favor the superiority of 68Ga-FAPI PET CT/MR in LNM of CC. Further studies are needed for evaluating primary and metastatic lesions of 68Ga-FAPI PET CT/MR in different GC.

An Assessment of the Effectiveness of Preoperative İmaging Modalities (MRI, CT, and 18F-FDG PET/CT) in Determining the Extent of Disease Spread in Epithelial Ovarian-Tubal-Peritoneal Cancer (EOC)

Background and Objectives: Epithelial ovarian-tubal-peritoneal cancer (EOC) is the most common type of ovarian cancer. Optimal cytoreductive surgery is the most important prognostic factor in its management. When complete cytoreduction is anticipated to be challenging, neoadjuvant systemic chemotherapy (NACT) becomes an alternative. Imaging modalities are utilized in the decision-making process for primary treatment. The purpose of this study is to evaluate the diagnostic performance and accuracy of preoperative MRI, CT, and 18F-FDG PET/CT in detecting the extent of EOC. Materials and Methods: Between 2017 and 2018, 24 patients with primary (with or without neoadjuvant chemotherapy) or recurrent EOC diagnosed at the Department of Gynecologic Oncology, Istanbul University, Istanbul Faculty of Medicine, were enrolled in this study. These 24 women underwent preoperative imaging modalities within 7 days prior to surgery. The results were compared with histopathological findings, considered the gold standard. Results: We evaluated 24 anatomic regions most commonly involved in EOC. The sensitivity of MRI, CT, and PET/CT in detecting ≥ 0.5 cm implants was 95%, 84%, and 86%, respectively. However, when including implants < 0.5 cm, sensitivity decreased significantly to 40%, 38%, and 42%, respectively. The calculated area under the curve (AUC) for tumors, including those < 0.5 cm, was evaluated as weak for all three modalities (MRI: 0.689, CT: 0.678, PET/CT: 0.691), with PET/CT detecting the largest area. For detecting tumors ≥ 0.5 cm, the AUCs were 0.974, 0.921, and 0.923 for MRI, CT, and PET/CT, respectively. The largest AUC was calculated with MRI, and the AUCs for all three methods were evaluated as excellent. Accuracy was comparable among all three imaging modalities, and no statistically significant differences were found (p < 0.05). Conclusions: While imaging modalities are valuable tools for evaluating abdominal spread in epithelial ovarian cancer (EOC), they have demonstrated limited success in detecting miliary disease. The risk of false negatives for miliary tumors on PET/CT may be mitigated by combining it with other imaging modalities such as MRI or CT. Further investigations are necessary to identify more accurate imaging techniques for this challenging clinical scenario.

AI-enhanced PET/CT image synthesis using CycleGAN for improved ovarian cancer imaging

Purpose

Ovarian cancer is the fifth fatal cancer among women. Positron emission tomography (PET), which offers detailed metabolic data, can be effectively used for early cancer screening. However, proper attenuation correction is essential for interpreting the data obtained by this imaging modality. Computed tomography (CT) imaging is commonly performed alongside PET imaging for attenuation correction. This approach may introduce some issues in spatial alignment and registration of the images obtained by the two modalities. This study aims to perform PET image attenuation correction by using generative adversarial networks (GANs), without additional CT imaging.

Material and methods

The PET/CT data from 55 ovarian cancer patients were used in this study. Three GAN architectures: Conditional GAN, Wasserstein GAN, and CycleGAN, were evaluated for attenuation correction. The statistical performance of each model was assessed by calculating the mean squared error (MSE) and mean absolute error (MAE). The radiological performance assessments of the models were performed by comparing the standardised uptake value and the Hounsfield unit values of the whole body and selected organs, in the synthetic and real PET and CT images.

Results

Based on the results, CycleGAN demonstrated effective attenuation correction and pseudo-CT generation, with high accuracy. The MAE and MSE for all images were 2.15 ± 0.34 and 3.14 ± 0.56, respectively. For CT reconstruction, such values were found to be 4.17 ± 0.96 and 5.66 ± 1.01, respectively.

Conclusions

The results showed the potential of deep learning in reducing radiation exposure and improving the quality of PET imaging. Further refinement and clinical validation are needed for full clinical applicability.

Ovarian cancer staging and follow-up: updated guidelines from the European Society of Urogenital Radiology female pelvic imaging working group

OBJECTIVE

To provide up-to-date European Society of Urogenital Radiology (ESUR) guidelines for staging and follow-up of patients with ovarian cancer (OC).

METHODS

Twenty-one experts, members of the female pelvis imaging ESUR subcommittee from 19 institutions, replied to 2 rounds of questionnaires regarding imaging techniques and structured reporting used for pre-treatment evaluation of OC patients. The results of the survey were presented to the other authors during the group's annual meeting. The lexicon was aligned with the Society of American Radiology (SAR)-ESUR lexicon; a first draft was circulated, and then comments and suggestions from the other authors were incorporated.

RESULTS

Evaluation of disease extent at diagnosis should be performed by chest, abdominal, and pelvic CT. The radiological report should map the disease with specific mention of sites that may preclude optimal cytoreductive surgery. For suspected recurrence, CT and [18F]FDG PET-CT are both valid options. MRI can be considered in experienced centres, as an alternative to CT, considering the high costs and the need for higher expertise in reporting.

CONCLUSIONS

CT is the imaging modality of choice for preoperative evaluation and follow-up in OC patients. A structured radiological report, including specific mention of sites that may preclude optimal debulking, is of value for patient management.

KEY POINTS

Question Guidelines were last published for ovarian cancer (OC) imaging in 2010; here, guidance on imaging techniques and reporting, incorporating advances in the field, are provided. Findings Structured reports should map out sites of disease, highlighting sites that limit cytoreduction. For suspected recurrence, CT and 18FDG PET-CT are options, and MRI can be considered. Clinical relevance Imaging evaluation of OC patients at initial diagnosis (mainly based on CT), using a structured report that considers surgical needs is valuable in treatment selection and planning.

Intratumoral and peritumoral MRI-based radiomics for predicting extrapelvic peritoneal metastasis in epithelial ovarian cancer

OBJECTIVES

To investigate the potential of intratumoral and peritumoral radiomics derived from T2-weighted MRI to preoperatively predict extrapelvic peritoneal metastasis (EPM) in patients with epithelial ovarian cancer (EOC).

METHODS

In this retrospective study, 488 patients from four centers were enrolled and divided into training (n = 245), internal test (n = 105), and external test (n = 138) sets. Intratumoral and peritumoral models were constructed based on radiomics features extracted from the corresponding regions. A combined intratumoral and peritumoral model was developed via a feature-level fusion. An ensemble model was created by integrating this combined model with specific independent clinical predictors. The robustness and generalizability of these models were assessed using tenfold cross-validation and both internal and external testing. Model performance was evaluated by the area under the receiver operating characteristic curve (AUC). The Shapley Additive Explanation method was employed for model interpretation.

RESULTS

The ensemble model showed superior performance across the tenfold cross-validation, with the highest mean AUC of 0.844 ± 0.063. On the internal test set, the peritumoral and ensemble models significantly outperformed the intratumoral model (AUC = 0.786 and 0.832 vs. 0.652, p = 0.007 and p < 0.001, respectively). On the external test set, the AUC of the ensemble model significantly exceeded those of the intratumoral and peritumoral models (0.843 vs. 0.750 and 0.789, p = 0.008 and 0.047, respectively).

CONCLUSION

Peritumoral radiomics provide more informative insights about EPM than intratumoral radiomics. The ensemble model based on MRI has the potential to preoperatively predict EPM in EOC patients.

CRITICAL RELEVANCE STATEMENT

Integrating both intratumoral and peritumoral radiomics information based on MRI with clinical characteristics is a promising noninvasive method to predict EPM to guide preoperative clinical decision-making for EOC patients.

KEY POINTS

Peritumoral radiomics can provide valuable information about extrapelvic peritoneal metastasis in epithelial ovarian cancer. The ensemble model demonstrated satisfactory performance in predicting extrapelvic peritoneal metastasis. Combining intratumoral and peritumoral MRI radiomics contributes to clinical decision-making in epithelial ovarian cancer.

Preoperative CECT-Based Multitask Model Predicts Peritoneal Recurrence and Disease-Free Survival in Advanced Ovarian Cancer: A Multicenter Study

RATIONALE AND OBJECTIVES

Peritoneal recurrence is the predominant pattern of recurrence in advanced ovarian cancer (AOC) and portends a dismal prognosis. Accurate prediction of peritoneal recurrence and disease-free survival (DFS) is crucial to identify patients who might benefit from intensive treatment. We aimed to develop a predictive model for peritoneal recurrence and prognosis in AOC.

METHODS

In this retrospective multi-institution study of 515 patients, an end-to-end multi-task convolutional neural network (MCNN) comprising a segmentation convolutional neural network (CNN) and a classification CNN was developed and tested using preoperative CT images, and MCNN-score was generated to indicate the peritoneal recurrence and DFS status in patients with AOC. We evaluated the accuracy of the model for automatic segmentation and predict prognosis.

RESULTS

The MCNN achieved promising segmentation performances with a mean Dice coefficient of 84.3% (range: 78.8%-87.0%). The MCNN was able to predict peritoneal recurrence in the training (AUC 0.87; 95% CI 0.82-0.90), internal test (0.88; 0.85-0.92), and external test set (0.82; 0.78-0.86). Similarly, MCNN demonstrated consistently high accuracy in predicting recurrence, with an AUC of 0.85; 95% CI 0.82-0.88, 0.83; 95% CI 0.80-0.86, and 0.85; 95% CI 0.83-0.88. For patients with a high MCNN-score of recurrence, it was associated with poorer DFS with P < 0.0001 and hazard ratios of 0.1964 (95% CI: 0.1439-0.2680), 0.3249 (95% CI: 0.1896-0.5565), and 0.3458 (95% CI: 0.2582-0.4632).

CONCLUSION

The MCNN approach demonstrated high performance in predicting peritoneal recurrence and DFS in patients with AOC.

Status of and Challenges in Therapy of Mucinous Ovarian Cancer Associated with Pseudomyxoma Peritonei Syndrome: Review of Current Options and Future Treatment Trends

OBJECTIVE

Pseudomyxoma peritonei (PP) is a rare condition, and differentiating between primary and secondary ovarian causes is crucial for determining the appropriate oncological therapy. Given the resistance of ovarian mucinous carcinoma to standard platinum-based chemotherapy, the objective of this review is to present the current therapeutic approaches and summarize the emerging trends in the treatment of this disease.

METHODS

The authors conducted an exhaustive evaluation of studies published over a 14-year period (June 2010-May 2024) concerning pseudomyxoma peritonei, mucinous ovarian carcinoma, ovarian causes of PP, and ovarian cancer using the following databases: PubMed, Scopus, and Science Direct. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The results were organized into seven subchapters and analyzed.

RESULTS

The analyzed studies present surgery followed by HIPEC as the current therapy with the best long-term survival results. However, the oncological treatment is unsatisfactory, and the choice of therapy depending on the primary origin of the tumor becomes particularly important. For the differential diagnosis between pseudomyxoma due to a gastrointestinal cause and that of ovarian origin, genetic analyses are recommended; these include the characteristics of the mucin present in the lesion, as the therapeutic response can have contradictory results depending on the primary origin of the tumor.

CONCLUSIONS

Surgery followed by HIPEC remains the standard for resectable cases. However, oncological treatment has controversial results in the case of mucinous ovarian carcinoma compared to other types of ovarian cancer and to metastatic ovarian tumors associated with pseudomyxoma of the peritoneum. Based on the articles included in this review, it was found that the current trend is the study of mucin as a resistance factor against chemotherapy based on platinum products and the targeting of oncological therapy according to the tumor's genetic characteristics.

Using ultrasound to identify adnexal masses

ABSTRACT

This article describes the use of ultrasound in the initial diagnosis of a patient with a pelvic mass. CT commonly is used to detect ovarian cancer, especially when the patient has nonspecific symptoms; ultrasound also can be used as a follow-up procedure after an abdominal ultrasound reveals suspicious findings.

Addressing the Contrast Media Recognition Challenge: A Fully Automated Machine Learning Approach for Predicting Contrast Phases in CT Imaging

OBJECTIVES

Accurately acquiring and assigning different contrast-enhanced phases in computed tomography (CT) is relevant for clinicians and for artificial intelligence orchestration to select the most appropriate series for analysis. However, this information is commonly extracted from the CT metadata, which is often wrong. This study aimed at developing an automatic pipeline for classifying intravenous (IV) contrast phases and additionally for identifying contrast media in the gastrointestinal tract (GIT).

MATERIALS AND METHODS

This retrospective study used 1200 CT scans collected at the investigating institution between January 4, 2016 and September 12, 2022, and 240 CT scans from multiple centers from The Cancer Imaging Archive for external validation. The open-source segmentation algorithm TotalSegmentator was used to identify regions of interest (pulmonary artery, aorta, stomach, portal/splenic vein, liver, portal vein/hepatic veins, inferior vena cava, duodenum, small bowel, colon, left/right kidney, urinary bladder), and machine learning classifiers were trained with 5-fold cross-validation to classify IV contrast phases (noncontrast, pulmonary arterial, arterial, venous, and urographic) and GIT contrast enhancement. The performance of the ensembles was evaluated using the receiver operating characteristic area under the curve (AUC) and 95% confidence intervals (CIs).

RESULTS

For the IV phase classification task, the following AUC scores were obtained for the internal test set: 99.59% [95% CI, 99.58-99.63] for the noncontrast phase, 99.50% [95% CI, 99.49-99.52] for the pulmonary-arterial phase, 99.13% [95% CI, 99.10-99.15] for the arterial phase, 99.8% [95% CI, 99.79-99.81] for the venous phase, and 99.7% [95% CI, 99.68-99.7] for the urographic phase. For the external dataset, a mean AUC of 97.33% [95% CI, 97.27-97.35] and 97.38% [95% CI, 97.34-97.41] was achieved for all contrast phases for the first and second annotators, respectively. Contrast media in the GIT could be identified with an AUC of 99.90% [95% CI, 99.89-99.9] in the internal dataset, whereas in the external dataset, an AUC of 99.73% [95% CI, 99.71-99.73] and 99.31% [95% CI, 99.27-99.33] was achieved with the first and second annotator, respectively.

CONCLUSIONS

The integration of open-source segmentation networks and classifiers effectively classified contrast phases and identified GIT contrast enhancement using anatomical landmarks.

Ecological and evolutionary dynamics to design and improve ovarian cancer treatment

Ovarian cancer ecosystems are exceedingly complex, consisting of a high heterogeneity of cancer cells. Development of drugs such as poly ADP-ribose polymerase (PARP) inhibitors, targeted therapies and immunotherapies offer more options for sequential or combined treatments. Nevertheless, mortality in metastatic ovarian cancer patients remains high because cancer cells consistently develop resistance to single and combination therapies, urging a need for treatment designs that target the evolvability of cancer cells. The evolutionary dynamics that lead to resistance emerge from the complex tumour microenvironment, the heterogeneous populations, and the individual cancer cell's plasticity. We propose that successful management of ovarian cancer requires consideration of the ecological and evolutionary dynamics of the disease. Here, we review current options and challenges in ovarian cancer treatment and discuss principles of tumour evolution. We conclude by proposing evolutionarily designed strategies for ovarian cancer, with the goal of integrating such principles with longitudinal, quantitative data to improve the treatment design and management of drug resistance. KEY POINTS/HIGHLIGHTS: Tumours are ecosystems in which cancer and non-cancer cells interact and evolve in complex and dynamic ways. Conventional therapies for ovarian cancer inevitably lead to the development of resistance because they fail to consider tumours' heterogeneity and cellular plasticity. Eco-evolutionarily designed therapies should consider cancer cell plasticity and patient-specific characteristics to improve clinical outcome and prevent relapse.

A metabolite-based liquid biopsy for detection of ovarian cancer

Serial CA125 and second line transvaginal ultrasound (TVS) screening in the UKCTOCS indicated a shift towards detection of earlier stage ovarian cancer (OvCa), but did not yield a significant mortality reduction. There remains a need to establish additional biomarkers that can complement CA125 for even earlier and at a larger proportion of new cases. Using a cohort of plasma samples from 219 OvCa cases (59 stage I/II and 160 stage III/IV) and 409 female controls and a novel Sensitivity Maximization At A Given Specificity (SMAGS) method, we developed a blood-based metabolite-based test consisting of 7 metabolites together with CA125 for detection of OvCa. At a 98.5% specificity cutpoint, the metabolite test achieved sensitivity of 86.2% for detection of early-stage OvCa and was able to capture 64% of the cases with low CA125 levels (< 35 units/mL). In an independent test consisting of 65 early-stage OvCa cases and 141 female controls, the metabolite panel achieved sensitivity of 73.8% at a 91.4% specificity and captured 13 (44.8%) out of 29 early-stage cases with CA125 levels < 35 units/mL. The metabolite test has utility for ovarian cancer screening, capable of improving upon CA125 for detection of early-stage disease.

Predicting Complete Cytoreduction with Preoperative [18F]FDG PET/CT in Patients with Ovarian Cancer: A Systematic Review and Meta-Analysis

The cornerstone of ovarian cancer treatment is complete surgical cytoreduction. The gold-standard option in the absence of extra-abdominal metastases and intra-abdominal inoperable circumstances is primary cytoreductive surgery (CRS). However, achieving complete cytoreduction is challenging, and only possible in a selected patient population. Preoperative imaging modalities such as [18F]FDG PET/CT could be useful in patient selection for cytoreductive surgery. In our systematic review and meta-analysis, we aimed to evaluate the role of preoperative [18F]FDG PET/CT in predicting complete cytoreduction in primary and secondary debulking surgeries. Publications were pooled from two databases (PubMed, Mendeley) with predefined keywords "(ovarian cancer) AND (FDG OR PET) AND (cytoreductive surgery)". The quality of the included studies was assessed with the Prediction model Risk Of Bias Assessment Tool (PROBAST). During statistical analysis, MetaDiSc 1.4 software and the DerSimonian-Laird method (random effects models) were used. Primary and secondary cytoreductive surgeries were evaluated. Pooled sensitivities, specificities, positive predictive values (PPVs), and negative predictive values (NPVs) were calculated and statistically analyzed. Results were presented in forest plot diagrams and summary receiver operating characteristic (SROC) curves. Overall, eight publications were included in our meta-analysis. Four publications presented results of primary, three presented results of secondary cytoreductions, and two presented data related to both primary and secondary surgery. Pooled sensitivities, specificities, and positive and negative predictive values were the following: in the case of primary surgeries: 0.65 (95% CI 0.60-0.71), 0.73 (95% CI 0.66-0.80), 0.82 (95% CI 0.77-0.87), 0.52 (95% CI 0.46-0.59); and in the case of secondary surgeries: 0.91 (95% CI 0.84-0.95), 0.48 (95% CI 0.30-0.67), 0.88 (95% CI 0.81-0.93), 0.56 (95% CI 0.35-0.75), respectively. The PPVs of [18F]FDG PET/CT proved to be higher in cases of secondary debulking surgeries; therefore, it can be a valuable predictor of complete successful secondary cytoreduction.

Ovarian cancer

ABSTRACT

Ovarian cancer, a leading cause of cancer deaths, poses challenges due to insidious development and vague signs and symptoms. Risk factors include age, reproductive history, genetic mutations, and environmental factors. Treatment involves surgery, chemotherapy, and targeted therapy, with nursing interventions focusing on symptom management and supportive care.

Current development of theragnostic nanoparticles for women's cancer treatment

In the biomedical industry, nanoparticles (NPs-exclusively small particles with size ranging from 1-100 nanometres) are recently employed as powerful tools due to their huge potential in sophisticated and enhanced cancer theragnostic (i.e. therapeutics and diagnostics). Cancer is a life-threatening disease caused by carcinogenic agents and mutation in cells, leading to uncontrolled cell growth and harming the body's normal functioning while affecting several factors like low levels of reactive oxygen species, hyperactive antiapoptotic mRNA expression, reduced proapoptotic mRNA expression, damaged DNA repair, and so on. NPs are extensively used in early cancer diagnosis and are functionalized to target receptors overexpressing cancer cells for effective cancer treatment. This review focuses explicitly on how NPs alone and combined with imaging techniques and advanced treatment techniques have been researched against 'women's cancer' such as breast, ovarian, and cervical cancer which are substantially occurring in women. NPs, in combination with numerous imaging techniques (like PET, SPECT, MRI, etc) have been widely explored for cancer imaging and understanding tumor characteristics. Moreover, NPs in combination with various advanced cancer therapeutics (like magnetic hyperthermia, pH responsiveness, photothermal therapy, etc), have been stated to be more targeted and effective therapeutic strategies with negligible side effects. Furthermore, this review will further help to improve treatment outcomes and patient quality of life based on the theragnostic application-based studies of NPs in women's cancer treatment.

Surgical evidence-based comparison of [68Ga]Ga-FAPI-04 PET and MRI-DWI for assisting debulking surgery in ovarian cancer patients

PURPOSE

Imaging assessment of abdominopelvic tumor burden is crucial for debulking surgery decision in ovarian cancer patients. This study aims to compare the efficiency of [68Ga]Ga-FAPI-04 FAPI PET and MRI-DWI in the preoperative evaluation and its potential impact to debulking surgery decision.

METHODS

Thirty-six patients with suspected/confirmed ovarian cancer were enrolled and underwent integrated [68Ga]Ga-FAPI-04 PET/MRI. Nineteen patients (15 stage III-IV and 4 I-II stage) who underwent debulking surgery were involved in the diagnostic efficiency analysis. The images of [68Ga]Ga-FAPI-04 PET and MRI-DWI were visually analyzed respectively. Immunohistochemistry on FAP was performed in metastatic lesions to investigate the radiological missing of [68Ga]Ga-FAPI-04 PET as well as its different performance in primary debulking surgery (PDS) and interval debulking surgery (IDS) patients. Potential imaging impact on management was also studied in 35 confirmed ovarian cancer patients.

RESULTS

[68Ga]Ga-FAPI-04 PET displayed higher sensitivity (76.8% vs.59.9%), higher accuracy (84.9% vs. 80.7%), and lower missing rate (23.2% vs. 40.1%) than MRI-DWI in detecting abdominopelvic metastasis. The diagnostic superiority of [68Ga]Ga-FAPI-04 PET is more obvious in PDS patients but diminished in IDS patients. [68Ga]Ga-FAPI-04 PET outperformed MRI-DWI in 70.8% abdominopelvic regions (17/24), which contained seven key regions that impact the resectability and surgical complexity. MRI-DWI hold advantage in the peritoneal surface of the bladder and the central tendon of the diaphragm. Of the contradictory judgments between the two modalities (14.9%), [68Ga]Ga-FAPI-04 PET correctly identified more lesions, particularly in PDS patients (73.8%). In addition, FAP expression was independent of lesion size and decreased in IDS patients. [68Ga]Ga-FAPI-04 PET changed 42% of surgical planning that was previously based on MRI-DWI.

CONCLUSION

[68Ga]Ga-FAPI-04 PET is more efficient in assisting debulking surgery in ovarian cancer patients than MRI-DWI. Integrated [68Ga]Ga-FAPI-04 PET/MR imaging is a potential method for planning debulking surgery in ovarian cancer patients.

Application of PET/MRI in Gynecologic Malignancies

The diagnosis, treatment, and management of gynecologic malignancies benefit from both positron emission tomography/computed tomography (PET/CT) and MRI. PET/CT provides important information on the local extent of disease as well as diffuse metastatic involvement. MRI offers soft tissue delineation and loco-regional disease involvement. The combination of these two technologies is key in diagnosis, treatment planning, and evaluating treatment response in gynecological malignancies. This review aims to assess the performance of PET/MRI in gynecologic cancer patients and outlines the technical challenges and clinical advantages of PET/MR systems when specifically applied to gynecologic malignancies.

Diagnostic Performance of Magnetic Resonance Imaging for Pediatric Ovarian Neoplasms: A Multi-Institutional Review

STUDY OBJECTIVE

To assess the diagnostic performance of MRI to predict ovarian malignancy alone and compared with other diagnostic studies.

METHODS

A retrospective analysis was conducted of patients aged 2-21 years who underwent ovarian mass resection between 2009 and 2021 at 11 pediatric hospitals. Sociodemographic information, clinical and imaging findings, tumor markers, and operative and pathology details were collected. Diagnostic performance for detecting malignancy was assessed by calculating sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for MRI with other diagnostic modalities.

RESULTS

One thousand and fifty-three patients, with a median age of 14.6 years, underwent resection of an ovarian mass; 10% (110/1053) had malignant disease on pathology, and 13% (136/1053) underwent preoperative MRI. MRI sensitivity, specificity, PPV, and NPV were 60%, 94%, 60%, and 94%. Ultrasound sensitivity, specificity, PPV, and NPV were 31%, 99%, 73%, and 95%. Tumor marker sensitivity, specificity, PPV, and NPV were 90%, 46%, 22%, and 96%. MRI and ultrasound concordance was 88%, with sensitivity, specificity, PPV, and NPV of 33%, 99%, 75%, and 94%. MRI sensitivity in ultrasound-discordant cases was 100%. MRI and tumor marker concordance was 88% with sensitivity, specificity, PPV, and NPV of 100%, 86%, 64%, and 100%. MRI specificity in tumor marker-discordant cases was 100%.

CONCLUSION

Diagnostic modalities used to assess ovarian neoplasms in pediatric patients typically agree. In cases of disagreement, MRI is more sensitive for malignancy than ultrasound and more specific than tumor markers. Selective use of MRI with preoperative ultrasound and tumor markers may be beneficial when the risk of malignancy is uncertain.

CONCISE ABSTRACT

This retrospective review of 1053 patients aged 2-21 years who underwent ovarian mass resection between 2009 and 2021 at 11 pediatric hospitals found that ultrasound, tumor markers, and MRI tend to agree on benign vs malignant, but in cases of disagreement, MRI is more sensitive for malignancy than ultrasound.

Shortening Acquisition Time and Improving Image Quality for Pelvic MRI Using Deep Learning Reconstruction for Diffusion-Weighted Imaging at 1.5 T

RATIONALE AND OBJECTIVES

To determine the impact on acquisition time reduction and image quality of a deep learning (DL) reconstruction for accelerated diffusion-weighted imaging (DWI) of the pelvis at 1.5 T compared to standard DWI.

MATERIALS AND METHODS

A total of 55 patients (mean age, 61 ± 13 years; range, 27-89; 20 men, 35 women) were consecutively included in this retrospective, monocentric study between February and November 2022. Inclusion criteria were (1) standard DWI (DWIS) in clinically indicated magnetic resonance imaging (MRI) at 1.5 T and (2) DL-reconstructed DWI (DWIDL). All patients were examined using the institution's standard MRI protocol according to their diagnosis including DWI with two different b-values (0 and 800 s/mm2) and calculation of apparent diffusion coefficient (ADC) maps. Image quality was qualitatively assessed by four radiologists using a visual 5-point Likert scale (5 = best) for the following criteria: overall image quality, noise level, extent of artifacts, sharpness, and diagnostic confidence. The qualitative scores for DWIS and DWIDL were compared with the Wilcoxon signed-rank test.

RESULTS

The overall image quality was evaluated to be significantly superior in DWIDL compared to DWIS for b = 0 s/mm2, b = 800 s/mm2, and ADC maps by all readers (P < .05). The extent of noise was evaluated to be significantly less in DWIDL compared to DWIS for b = 0 s/mm2, b = 800 s/mm2, and ADC maps by all readers (P < .001). No significant differences were found regarding artifacts, lesion detectability, sharpness of organs, and diagnostic confidence (P > .05). Acquisition time for DWIS was 2:06 minutes, and simulated acquisition time for DWIDL was 1:12 minutes.

CONCLUSION

DL image reconstruction improves image quality, and simulation results suggest that a reduction in acquisition time for diffusion-weighted MRI of the pelvis at 1.5 T is possible.

Management of retroperitoneal high-grade serous carcinoma of unknown origin: A case report

BACKGROUND

Retroperitoneal high-grade serous carcinoma (HGSC) of unknown origin is a sporadic tumor that can originate from ovarian cancer. Herein, we report the case of a woman with retroperitoneal HGSC of unknown origin and describe how she was diagnosed and treated.

CASE SUMMARY

A 71-year-old female presented with the tumor marker CA125 elevated to 1041.9 U/mL upon a regular health examination. Computed tomography revealed retroperitoneal lymph node enlargement. Subsequently, positron emission tomography scanning revealed lesions with increased F-18 fluorodeoxyglucose uptake at the nodes. As a result, she underwent laparoscopic lymph node resection, and pathology revealed metastatic adenocarcinoma with CK7(+), PAX8(+), WT1(+), PR(-), and p53 mutational loss of expression, indicating that the origin may be from the adnexa. The patient was admitted to our ward and underwent laparoscopic staging; however, the pathological results were negative. Under the suspicion of retroperitoneal HGSC of unknown origin, chemotherapy and targeted therapy were initiated. Tumor marker levels decreased after treatment.

CONCLUSION

We present a case of HGSC of unknown origin managed using retroperitoneal lymphadenectomy, staging surgery, chemotherapy, and targeted therapy.

An Unusual Presentation: High-Grade Serous Carcinoma of the Fallopian Tube Manifesting With Altered Mental Status Secondary to a Single Brain Metastasis-A Case Report and Review of the Literature

Epithelial ovarian and fallopian cancers are aggressive lesions that rarely metastasize to the central nervous system. Brain metastases usually occur in the setting of known primary disease or widespread metastatic disease. However, in extremely rare cases, an isolated intracranial neoplasm may be the first presentation of fallopian cancer. To the best of our knowledge, only one such case has been reported previously. We present an illustrative case with multimodality imaging and histopathologic correlation of a fallopian tube carcinoma first presenting with altered mental status secondary to an isolated brain metastasis. A 64-year-old female with no pertinent medical history presented with altered mentation. Initial workup identified a 1.6 cm avidly enhancing, solitary brain lesion at the gray-white junction with associated vasogenic edema concerning for either central nervous system lymphoma or metastatic disease. Additional imaging identified a 7.5 × 3 cm left adnexal lesion, initially thought to be a hydrosalpinx with hemorrhage, but magnetic resonance imaging suggested gynecologic malignancy. No lesions elsewhere in the body were identified. Given the lack of locoregional or systemic disease, the intracranial and pelvic lesions were assumed to represent synchronous but distinct processes. The intracranial lesion was biopsied. Preliminary results were suggestive of lymphoma, but further analysis was consistent with high-grade serous carcinoma of müllerian origin. Positron emission tomography/computed tomography was performed to evaluate for other neoplastic lesions, only highlighting the intracranial and pelvic lesions. At this point, a diagnosis of metastatic fallopian cancer was made. The patient was taken for robot-assisted laparoscopy with surgical debulking of the pelvic neoplasm, pathology demonstrating high-grade serous carcinoma of the fallopian tube, matching that of the intracranial lesion. Even though rare, metastatic fallopian cancer should be considered in patients with isolated brain lesions and adnexal lesions, even in the absence of locoregional or systemic disease.

Unlocking the 'ova'-coming power: immunotherapy's role in shaping the future of ovarian cancer treatment

Ovarian cancer is a prominent cancer worldwide with a relatively low survival rate for women diagnosed. Many individuals are diagnosed in the late stage of the disease and are prescribed a wide variety of treatment options. Current treatment options are primarily a combination of surgery and chemotherapy as well as a new but promising treatment involving immunotherapy. Nevertheless, contemporary therapeutic modalities exhibit a discernible lag in advancement when compared with the strides achieved in recent years in the context of other malignancies. Moreover, many surgery and chemotherapy options have a high risk for recurrence due to the late-stage diagnosis. Therefore, there is a necessity to further treatment options. There have been many new advancements in the field of immunotherapy. Immunotherapy has been approved for 16 various types of cancers and has shown significant treatment potential in many other cancers as well. Researchers have also found many promising outlooks for immunotherapy as a treatment for ovarian cancer. This review summarizes many of the new advancements in immunotherapy treatment options and could potentially offer valuable insights to gynecologists aimed at enhancing the efficacy of their treatment approaches for patients diagnosed with ovarian cancer.

Current Status and Controversies in Neoadjuvant Chemotherapy for Advanced Stage Ovarian Cancer: A Review

Objective: To evaluate the role of neoadjuvant chemotherapy (NACT) in the management of advanced ovarian cancer (AOC), with a focus on patient eligibility, pre-NACT diagnosis, treatment, timing of interval cytoreductive surgery (ICS) and the target of ICS, challenges in ICS, response assessment, changes in the tumor microenvironment during NACT, platinum resistance. Mechanism: NACT precedes cytoreductive surgery and shrinks tumors, thereby improving surgical success. Findings in Brief: NACT shows promising results for improving tumor reduction rates and improve prognosis. Conclusions: NACT has emerged as a promising treatment strategy for AOC.

18F-FDG PET/MRI and 18F-FDG PET/CT for the Management of Gynecological Malignancies: A Comprehensive Review of the Literature

OBJECTIVE

Positron emission tomography with 2-deoxy-2-[fluorine-18] fluoro- D-glucose integrated with computed tomography (18F-FDG PET/CT) or magnetic resonance imaging (18F-FDG PET/MRI) has emerged as a promising tool for managing various types of cancer. This review study was conducted to investigate the role of 18F- FDG PET/CT and FDG PET/MRI in the management of gynecological malignancies.

SEARCH STRATEGY

We searched for relevant articles in the three databases PubMed/MEDLINE, Scopus, and Web of Science.

SELECTION CRITERIA

All studies reporting data on the FDG PET/CT and FDG PET MRI in the management of gynecological cancer, performed anywhere in the world and published exclusively in the English language, were included in the present study.

DATA COLLECTION AND ANALYSIS

We used the EndNote software (EndNote X8.1, Thomson Reuters) to list the studies and screen them on the basis of the inclusion criteria. Data, including first author, publication year, sample size, clinical application, imaging type, and main result, were extracted and tabulated in Excel. The sensitivity, specificity, and diagnostic accuracy of the modalities were extracted and summarized.

MAIN RESULTS

After screening 988 records, 166 studies published between 2004 and 2022 were included, covering various methodologies. Studies were divided into the following five categories: the role of FDG PET/CT and FDG-PET/MRI in the management of: (a) endometrial cancer (n = 30); (b) ovarian cancer (n = 60); (c) cervical cancer (n = 50); (d) vulvar and vagina cancers (n = 12); and (e) gynecological cancers (n = 14).

CONCLUSIONS

FDG PET/CT and FDG PET/MRI have demonstrated potential as non-invasive imaging tools for enhancing the management of gynecological malignancies. Nevertheless, certain associated challenges warrant attention.

Imaging ovarian cancer - from baseline characteristics to high-risk image factors

BACKGROUND

Imaging ovarian cancer (OC) includes evaluating peritoneal carcinomatosis (PC) and enlarged cardio phrenic lymph nodes (CPLN) by computed tomography (CT), and thorough evaluation is tedious work. A "CT short score" with high-risk CT parameters might be a more pragmatic approach, but it is not known if such a short score associates with aggressive OC subtypes and impaired OC survival. Further, it is not known if certain established OC risk factors are linked to high-risk CT-findings which would be important in image evaluation. Herein, we investigate a CT short score and its relation to baseline characteristics, OC subtypes, and survival.

METHODS

The Malmö Diet and Cancer Study is a prospective cohort that included 17,035 women (1991-1996). Baseline characteristics and tumor information on 159 OC and information on OC specific survival (last follow-up, 2017-12-31) was registered. A CT short score (CPLN and PC-index (PCI) in seven regions) was registered and associations with clinical stage [stage I vs. advanced stage (II-IV), histological type/grade (high grade serous and endometrioid vs. other subtypes], and OC-specific survival were analyzed with logistic and Cox regression, respectively. Parity and menopausal status were analyzed in relation to short score and PCI.

RESULTS

There was an association between higher short score and advanced clinical stage (adjusted OR 2.76 (1.42-5.38)), adjusted for age at diagnosis and histological type/grade. Higher short score was associated with impaired OC specific survival (adjusted HR 1.17 (1.01-1.35)), adjusted for age at diagnosis, histological type/grade, and clinical stage. There were no significant associations between parity, menopausal status, and short score/PCI.

CONCLUSIONS

CT short score was significantly associated with advanced clinical stages and impaired OC survival. A pragmatic approach (based on CT) to evaluate high risk image findings in OC could help reduce radiologists' workload and at the same time provide structured reports to surgeons and oncologists involved in OC care.

Response to treatment and prognostic significance of supradiaphragmatic disease in patients with high-grade serous ovarian cancer

OBJECTIVES

This study was designed to investigate the response to chemotherapy of supradiaphragmatic disease diagnosed by preoperative imaging. As secondary objectives, oncologic outcomes of patients affected by supradiaphragmatic disease and their pattern of recurrence were also evaluated.

METHODS

Data of consecutive patients with newly diagnosed FIGO stage IV (for supradiaphragmatic disease) epithelial ovarian cancer undergoing either primary debulking surgery or neoadjuvant chemotherapy plus interval debulking surgery between 2004 and 2021, were retrospectively collected. All patients were preoperatively evaluated by chest/abdominal CT scan or ¹⁸F-FDG PET/CT preoperatively and at follow-up to evaluate response to chemotherapy. At follow-up visits, site of recurrence diagnosed by imaging techniques was systematically recorded as it occurred. Progression-free and overall survival were measured by using Kaplan-Meier and Cox models.

RESULTS

A total of 130 patients was included in this study with a median (range) follow-up of 32.9 (12.8-176.7) months. Complete or partial response was achieved in most of the patients after 3 cycles (77.7%) and 6 cycles (85.4%) of chemotherapy. At follow-up, recurrence occurred in 96 (73.8%) patients and the main site of recurrence was abdomen only in 64 (66.7%) patients. At multivariate analysis, residual disease after surgery was the only variable influencing survival outcomes.

CONCLUSIONS

Supradiaphragmatic disease respond to chemotherapy in most patients affected by advanced EOC and recurrence mainly occurs in the abdomen. Results from this study confirms that abdominal optimal cytoreduction is the main surgical goal in the treatment of women affected by FIGO stage IV EOC.

Effect of Two-Port Laparoscopic Surgery on Pregnancy Outcomes of Patients with Concurrent Adnexal Masses

Adnexal masses are common in pregnancy, with 2–10% of pregnancies presenting with an ovarian mass and approximately 1–6% of these masses being malignant. For suspected malignancy or masses with symptoms, surgery must be performed as early as possible. We retrospectively investigated the effect of two-port laparoscopic surgery on the outcomes of patients with concurrent adnexal masses between 2012 and 2019 (including large mucinous tumor, large teratoma, serous borderline tumor, and heterotopic pregnancy). Laparoscopic right partial oophorectomy was performed for a 27 cm ovarian mucinous tumor at a gestational age (GA) of 21 weeks, laparoscopic right oophorocystectomy for an 18 cm teratoma at a GA of 10 weeks, and laparoscopic left salpingo-oophorectomy for a 7 cm serous borderline tumor at a GA of 7 weeks after ultrasonographic confirmation of an intrauterine gestational sac with a fetal heartbeat. Laparoscopic excision of a tubal pregnancy was performed in a heterotopic pregnancy at a GA of 12 weeks with massive internal bleeding. Laparoscopic surgery is easier and safe to perform during early pregnancy because a smaller uterus allows for superior visualization. All of these patients had optimal postoperative recovery and normal spontaneous delivery at term. We discussed several aspects of treatment and delivery, namely treatment option (expectant management or surgery), surgery timing (early or advanced pregnancy), surgery type (laparoscopy or laparotomy), and delivery route (normal spontaneous delivery or cesarean section), in patients with concurrent adnexal tumors and their effects on pregnancy outcomes.