Our results indicate that DWI and DCE sequences provide additional information and can be useful in EOC. We conducted our measurements in a single plane with the aim being to develop a method that would be easy to apply also in clinical practice, as previously shown for breast cancer (Bickel et al., 2017). It is straightforward to incorporate DWI into conventional imaging and it is already being used in the estimation of recurrence. Michielsen et al. showed that imaging with DWI was superior to CT in OC staging. While including DCE sequences into imaging, it will slightly increase the duration of the imaging session; on the other hand, it will provide additional information that may be clinically important. Semi-quantitative and quantitative perfusion parameters showed promising results in our study. Ktrans significantly detected HGSOC and was predictive for the results of cytoreductive surgery. In addition, Ktrans and Kep were associated with hypoxia specific marker (HIF-1α). WashIn and WashOut parameters were indicative of the patient’s platinum sensitivity. Our results could be helpful in treatment planning in OC; however, they will need to be verified in large cohorts.
New MRI modalities are under continuous development for oncological imaging.
Techniques such as Sodium MR imaging (23Na-MRI), Phosphorus spectroscopic imaging (31P-MRSI), Chemical exchange saturation transfer imaging (CEST), Blood oxygen level-dependent imaging (BOLD MRI) and Hyperpolarized imaging (HP MRI) are under active investigation. In addition, hybrid imaging with positron emission tomography/MRI has been developed to overcome the individual limitations of morphological and functional imaging techniques. It is possible to include different tracers in addition to the traditional 18F (FDG) radiotracer e.g. the hypoxia tracers 18F EF5 or 18F fluoromisonidazole (FMISO) in hybrid imaging.
To conclude, this thesis reveals that both DWI and DCE MRI are useful tools for assessing the prognosis of the patient with EOC. In our results, a large ROI placement proved to be more reliable than a small ROI, when cystic and necrotic areas were meticulously avoided. A multiparametric MRI variable, a combination of lower ADC values and DCE parameters indicative of a disease that is more aggressive, was also
predictive for recurrence-free survival. Because medicine is becoming more individualized, also OC imaging may change in the future. Functional MRI holds the potential to enhance significantly our understanding of tumour biology. In multiparametric imaging of breast and prostate cancers, analyses of the DWI and DCE, time intensity curve shapes are already a part of diagnostic imaging. In addition, in the diagnostic imaging of gliomas, even DCE perfusion parameters are already in widespread clinical use. It is not surprising that perfusion parameters were initially first exploited in neurological imaging because all functional imaging has its origins in the brain. It is relatively straightforward to stabilize the head for imaging and furthermore, breathing and other artefacts are less of a problem in comparison to abdominal imaging. The rapid advances in imaging technologies have meant that functional imaging is becoming more common and its validation is underway in abdominal imaging. We live in an era of artificial intelligence and in the future, genome analysis may be combined with functional imaging. Nonetheless, at present, we have to be satisfied with the encouraging results emerging from this thesis: it is predicted that multiparametric MRI will be an important tool enabling personalized medicine in patients with OC.
8 CONCLUSIONS
I
DWI is a valuable tool in the characterization of ovarian cancer. Reduced ADC values were associated with histopathological prognostic factors and a worse outcome in EOC.
In our cohort, ADC values measured from a large ROI, covering the whole solid lesion in a single plane (cystic and necrotic areas were meticulously avoided), were superior to those assessed from a small ROI, which concentrated on the brightest area in a DW imaging sequence. Our results suggest that a whole lesion covering ROI is sufficient for use as a prognostic biomarker in the DWI-MRI of EOC.
II
DCE-MRI parameters may represent an imaging biomarker for predicting tumor aggressiveness and prognosis in OC. One DCE parameter, Ktrans, was higher in high-grade serous histology than in other types of EOC. Higher Ktrans values predicted also a better outcome in cytoreductive surgery. WashIn and WashOut parameters were predictive of platinum sensitivity. Multiparametric MRI variables were predictive of recurrence-free survival.
III
Our study indicates that the hypoxia specific marker, HIF-1α was associated with DCE pharmacokinetic perfusion parameters Ktrans and Kep, and thus DCE imaging may represent a noninvasive method for clinical use to allow the physician to estimate preoperatively if hypoxia is present.
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