2025+ACR适宜性标准：卵巢癌的分期及随访（更新版）

ACR Appropriateness Criteria® Staging and Follow-Up of Ovarian Cancer:2025 Update

Expert Panel on GYN and OB Imaging: Erica B. Stein, MDa, Aradhana M. Venkatesan, MDb,Esma A. Akin, MDc, Emily Barrows, MDd, Parul Barry, MDe, Nicole M. Hindman, MDf,Chenchan Huang, MDg, Gaiane M. Rauch, MD, PhD, Madeleine Sertic, MB, BChi,Krista Suarez-Weiss, MD $^{j}$ , Jason D. Wright, MD $^{k}$ , Ashish P. Wasnik, MD $^{l}$

Abstract

Ovarian cancer remains the sixth most common cause of cancer mortality in women in the United States and is a leading cause of mortality among patients with gynecologic malignancies. Imaging plays an important role in pretreatment staging of epithelial ovarian cancers, the evaluation of posttreatment response, and follow-up. Accurate pretreatment imaging is integral to determine appropriate first-line therapy. By delineating the extent of disease, imaging can assist decision making regarding the likelihood of optimal primary cytoreduction or need for neoadjuvant chemotherapy when optimal cytoreduction is not felt to be achievable. Contrast-enhanced CT serves as a mainstay modality for the pretreatment assessment of ovarian cancer, with MRI, PET/CT, and, in some instances, PET/MRI used in the pretreatment setting. CT and PET/CT are also integral to assessing response, including in the suspected recurrence setting, with MRI and PET/MRI being used in select cases.

${}^{a}$ University of Michigan Medical Center, Ann Arbor, Michigan.

${ }^{b}$ Panel Chair, The University of Texas MD Anderson Cancer Center, Houston, Texas.

‘George Washington University Hospital, Washington, District of Columbia;ACR Commission on Nuclear Medicine and Molecular Imaging.

$^{-}$ Virginia Commonwealth University Health/Virginia Commonwealth University School of Medicine, Richmond, Virginia; American College of Obstetrics and Gynecologists.

‘University of Pittsburgh Medical Center Hillman Cancer Center, Pitts-burgh, Pennsylvania; Commission on Radiation Oncology.

`New York University School of Medicine, New York, New York`.

${}^{8}$ New York University Langone Medical Center, New York, New York.

${ }^{10}$ The University of Texas MD Anderson Cancer Center, Houston, Texas.Massachusetts General Hospital and Harvard Medical School, Boston,Massachusetts.

‘Brown University Health, Providence, Rhode Island.

${ }^{3}$ Columbia University Vagellos College of Physicians and Surgeons, New York, New York; Society of Gynecologic Oncology.

${}^{3}$ Specialty Chair, University of Michigan, Ann Arbor, Michigan,Corresponding author: Eric B. Stein, MD, University of Michigan Medical Center, 1500 E Medical Center Drive, UH B1 D502, Ann Arbor,MI 48109-5030; e-mail: estr@med.umich.edu.

The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.Reprint requests to: publications@acr.org.

Parul Barry, MD, reports a relationship with Elsevier Pathways that in-cludes consulting or advisory; relationships with Beckwith Institute Grant,Pitsburgh Foundation Grant, American Society for Radiation Oncology Breast Cancer Research Foundation Grant, Silverlon Grant,5UGl233184-186 for share include funding grants; reports previous service on the ACR Oncology Board; is a current member of ARS Board that includes board membership; and is Senior Associate Editor of Rare Tumors Review and is Editor for Frontiers in Oncology, Radiation Oncology Sec-tion. Adrhana M. Venkatesan, MD, reports a relationship with Siemens Healthiners AG that includes funding grants and a relationship with Elsevier Ltd that includes honorarium. Ashish P. Wasnik, MD, reports,unrelated to the submitted work, grants from National Institutes of Health & Sequana Medical Inc through University of Michigan; royalties from Elsevier Inc and Applied Morphomics Inc through University of Michi-gan; US. Parent 10,918/326; leadership roles as Director, Division of Abdominal Radiology at the University of Michigan, Ann Arbor, Michi-gan, and Depuytic Editora. Academic Radiology. Jason D. Wright, MD, re-ports a relationship with Merck & Co Inc that includes funding grants; a relationship with UptoDate Inc that includes consulting or advisory; and a relationship with American College of Obstetricians and Gynecologists that includes consulting or advisory. The other authors state that they have no conflict of interest related to the material discussed in this article. All authors are nonpartner/nonpartnership track/employees.

The ACR Appropriateness Criteria documents are updated regularly.Please go to the ACR website at http://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria to confirm that you are accessing the most current content.

Discipline: The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment.Generally, the complexity and severity of a patient's clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient's condition are ranked. Other imaging studies necessary to evaluate other co-existence differences or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.

The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RANDU/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Key Words: Appropriaten Criteria, Appropriate Use Criteria, AUC, imaging evaluation, ovarian cancer, recurrence, staging

J Am Coll Radiol 2025;22:S689-S698. © 2025 American College of Radiology. Published by Elsevier Inc. All rights are reserved, including those for text and data mining, Al training, and similar technologies.

ACR Appropriateness Criteria® Staging and Follow-Up of Ovarian Cancer: 2025 Update. Variants 1 to 4 and Tables 1 and 2.

Variant 1. Adult. Ovarian cancer. Pretreatment staging.

|Procedure|Appropriateness Category|Relative Radiation Level| |---|---|---| |CT abdomen and pelvis with IV contrast|Usually Appropriate|888| |CT chest with IV contrast|Usually Appropriate|888| |MRI abdomen and pelvis without and with IV contrast|May Be Appropriate|0| |MRI abdomen and pelvis without IV contrast|May Be Appropriate|888| |CT abdomen and pelvis without IV contrast|May Be Appropriate|888| |CT chest without IV contrast|May Be Appropriate|888| |FDG-PET/MRI skull base to mid-thigh|May Be Appropriate|888| |FDG-PET/CT skull base to mid-thigh|May Be Appropriate|888| |US abdomen and pelvis transabdominal|Usually Not Appropriate|0| |US pelvis transavaginal|Usually Not Appropriate|0| |CT chest without and with IV contrast|Usually Not Appropriate|888| |CT abdomen and pelvis without and with IV contrast|Usually Not Appropriate|888| |CT abdomen and pelvis without and with IV contrast|Usually Not Appropriate|888|

Variant 2. Adult. Ovarian cancer. Posttreatment response evaluation.

|Procedure|Appropriateness Category|Relative Radiation Level| |---|---|---| |CT abdomen and pelvis with IV contrast|Usually Appropriate|$$\begin{array}{l}\\ \\ \\ \\ \\ \\ \\ \end{array}$$| |CT chest with IV contrast|Usually Appropriate|$$\begin{array}{l}\\ \\ \\ \\ \\ \end{array}$$| |FDG-PET/CT skull base to mid-thigh|Usually Appropriate|$$\begin{array}{l}\\ \\ \\ \end{array}$$| |MRI abdomen and pelvis without and IV contrast|May Be Appropriate|0| |MRI abdomen and pelvis without IV contrast|May Be Appropriate|0| |CT abdomen and pelvis without IV contrast|May Be Appropriate|0| |CT chest without IV contrast|May Be Appropriate|0| |FDG-PET/MRI skull base to mid-thigh|May Be Appropriate|0| |US silica transvaginal|Usually Not Appropriate|0| |CT chest without and with IV contrast|Usually Not Appropriate|0| |CT abdomen and pelvis without and with IV contrast|May Not Appropriate|0|

Variant 3. Adult. Ovarian cancer. Posttreatment routine surveillance. Asymptomatic patient, no suspected recurrence.

|Procedure|Appropriateness Category|Relative Radiation Level| |---|---|---| |MRI abdomen and pelvis without and with IV contrast|May Be Appropriate|O| |MRI abdomen and pelvis without IV contrast|May Be Appropriate|O| |CT abdomen and pelvis with IV contrast|May Be Appropriate|8| |CT abdomen and pelvis without IV contrast|May Be Appropriate|8| |CT chest with IV contrast|May Be Appropriate|8| |CT chest without IV contrast|May Be Appropriate|8| |FDG-PET/MRI skull base to mid-thigh|May Be Appropriate|8| |FDG-PET/CT skull base to mid-thigh|May Be Appropriate|8| |US abdomen and pelvis transabdominal|Usually Not Appropriate|O| |US pelvis transvaginal|Usually Not Appropriate|O| |CT chest without and with IV contrast|Usually Not Appropriate|8| |CT abdomen and pelvis without and with IV contrast|Usually Not Appropriate|8| |CT distance without IV contrast|Usually Not Appropriate|8|

Variant 4. Adult. Ovarian cancer. Posttreatment evaluation. Suspected or known recurrence.

|Procedure|Appropriateness Category|Relative Radiation Level| |---|---|---| |CT abdomen and pelvis with IV contrast|Usually Appropriate|888| |CT chest with IV contrast|Usually Appropriate|888| |FDG-PET/CT skull base to mid-thigh|Usually Appropriate|888| |MRI abdomen and pelvis without and with IV contrast|May Be Appropriate|0| |MRI abdomen and pelvis without IV contrast|May Be Appropriate|0| |CT abdomen and pelvis without IV contrast|May Be Appropriate|888| |CT chest without IV contrast|May Be Appropriate|888| |FDG-PET/MRI skull base to mid-thigh|May Be Appropriate|888| |US abdomen and pelvis transabdominal|Usually Not Appropriate|0| |US pelvis transvaginal|Usually Not Appropriate|0| |CT chest without and with IV contrast|Usually Not Appropriate|888| |CT abdomen and pelvis without and with IV contrast|Usually Not Appropriate|888| |CT abdomen and pelvis without and with IV contrast|May Not Appropriate|888|

Table 1. Appropriateness category names and definitions

|Appropriateness Category|Appropriateness Rating|Appropriateness Category Definition| |---|---|---| |Usually Appropriate|7,8, or 9|The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.| |May Be Appropriate|4, 5, or 6|The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.| |May Be Appropriate (Disagreement)|5|The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel's recommendation. "May be appropriate" is the rating category and a rating of 5 is assigned.| |Usually Not Appropriate|1,2, or 3|The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.|

Table 2. Relative radiation level designations

|RRL|Adult Effective Dose Estimate Range (mSv)|Pediatric Effective Dose Estimate Range (mSv)| |---|---|---| |0|0|0| |8|<0.1|<0.03| |8|0.1-1|0.03-0.3| |8|1-10|0.3-3| |8|10-30|3-10| |8|30-100|10-30|

Note: Relative radiation level (RRL) assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (eg, region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as "varies."

SUMMARY OF LITERATURE REVIEW

Introduction/Background

Ovarian cancer remains the sixth most common cause of cancer mortality in women in the United States and is a leading cause of cancer mortality among patients with gy-necologic malignancies [1]. Ovarian cancer can affect anyone who has ovaries, including cisgender females as well as transgender men and nonbinary gender-identifying groups who have ovaries.

There are several different histopathologic subtypes of ovarian cancer, with epithelial ovarian cancer being the most common and accounting for approximately 90% of all ma-lignant ovarian neoplasms [2]. Most of the information in this document regarding imaging use for staging and recurrence applies to epithelial ovarian cancers. There are two major subtypes of epithelial ovarian cancers that are distinguished by molecular, genetic, and morphologic characteristics. Type I is the more indolent form that includes low-grade serous,low-grade endometrioid, mucinous tumors, and clear cell carcinomas. Type II includes aggressive neoplasms, such as

<EndOfPara>high-grade serous or endometrioid, and undifferentiated cancer [3].The aggressive, or type II ovarian cancers, typically present in advanced stages (stage III-IV), after the disease has spread beyond the pelvis [4,5].

This document largely applies to staging and follow-up for type II ovarian cancers. Diagnostic imaging plays a major role in characterizing ovarian mass(es), determining presurgical disease extent, predicting tumor resectability,evaluating response to chemotherapy, and evaluating for posttreatment recurrence [2,5-11].

Although surgical staging is the reference standard in ovarian cancer, initial management recommendations rely on presurgical imaging to assess disease extent. Pretreatment imaging can assess the likelihood of optimal primary cytoreduction, which is the surgical removal of macroscopic disease but small sites of visible disease $<1 ~cm$ in size may remain [12]. In addition to disease extent, preoperative imaging can also identify sites of disease that are deemed potentially unresectable or challenging to resect; for example, disease involving the small bowel mesentery or

porta hepatitis and suprarenal lymph node metastases [12]. If complete or optimal cytoreduction is not felt to be achievable, then neoadjuvant chemotherapy may be considered prior to interval debulking surgery.

DISCUSSION OF PROCEDURES BY VARIANT

Variant 1: Adult. Ovarian cancer.

Pretreatment staging

The goal of imaging is to appropriately stage ovarian cancer in treatment-naive patients. Imaging plays a crucial role in guiding the most appropriate therapeutic interventions,thereby optimizing patient outcomes and overall manage-ment of the disease.

CT Abdomen and Pelvis With IV Contrast. Contrast-enhanced CT is the most useful procedure in the preop-erative evaluation of ovarian cancer [13]. It can provide clinically relevant information, including assessment of locoregional tumor extent and distant sites of disease including peritoneum, omentum, mesentery, liver, and lymph nodes. Contrast-enhanced CT has a reported accu-racy for ovarian cancer staging of up to 94% [14], and accurate abdominopelvic disease assessment can predict successful surgical cytoreduction [13]. The sensitivity of CT staging varies depending on the anatomical location being examined. One of the significant drawbacks of CT in staging ovarian cancer is its limited ability to consistently identify tumor implants on the bowel surface,mesentery, or peritoneum that are smaller than 5 mm,particularly in in the absence of ascites [6,15-17].

The addition of oral contrast on CT imaging, typically performed with positive oral contrast, can help differentiate peritoneal implants from adjacent bowel. Rectal contrast administration can increase the sensitivity in detecting rectosigmoid serosal implants[2].

CT imaging can be instrumental in planning biopsies of the onumert or other abdominopelvic tumor sites when preoperative histology is necessary [18-21].

CT Abdomen and Pelvis Without and With IV Contrast. There is no relevant literature to support the use of CT of the abdomen and pelvis without and with intra-venous (IV) contrast for ovarian cancer staging.

CT Abdomen and Pelvis Without IV Contrast. CT of the abdomen and pelvis without IV contrast can be considered in certain clinical settings but offers limited ability to identify small peritoneal or mesenteric implants or lymphadenopathy from bowel or adjacent organs.

CT Chest With IV Contrast. CT of the chest with IV contrast is a useful modality for detecting pulmonary me-tastases during the baseline staging of ovarian cancer.

Presence of pleural metastases and pleural effusions may suggest transdiaphragmatic tumor spread. Presence of a moderate-to-large pleural effusion on preoperative CT is a predictor of poor posttreatment outcome and may impact decisions to pursue neoadjuvant chemotherapy over pri-mary cytoreductive surgery[22].

CT Chest Without and With IV Contrast. There is no relevant literature to support the use of CT of the chest without and with IV contrast for ovarian cancer staging.

CT Chest Without IV Contrast. CT of the chest without IV contrast may be useful for staging evaluation.CT of the chest without IV contrast can detect small pul-monary nodules; however, pleural metastases may be diffi-cult to delineate without IV contrast.

FDG-PET/CT Skull Base to Mid-Thigh. Fluorine-18-2-fluoro-2-deoxy-D-glucose(FDG)-PET, when combined with CT, is a valuable tool for staging advanced ovarian cancer. Although this modality has a limited role for locregional staging, it is helpful in identifying sites of distant metastatic disease, such as peritoneal and lymph node metastases when lesion characterization may alter clinical management. A recent meta-analysis showed no statistical difference in sensitivity between CT with IV contrast and FDG-PET/CT in the detection of stage III ovarian cancer; however, there was improved specificity with FDG-PET/CT [23].

FDG-PET/MRI Skullal Base to Mid-Thigh. FDG-PET,when combined with MRI, is a diagnostic alternative to more established imaging modalities, such as contrast-enhanced CT and FDG-PET/CT, and may be useful for pretreatment staging. MRI allows for high contrast and spatial resolution of soft tissues as compared with CT,and when paired with the functional capabilities of FDG it may offer improved diagnostic performance compared with FDG-PET/CT [24-26]. FDG-PET/MRI can better resolve sites of physiologic FDG activity in the pelvis(eg, pelvic ureters), distinguishing them from peritoneal deposits, which is an advantage over FDG-PET/CT[27].

MRI Abdomen and Pelvis Without and With IV Contrast. MRI of the abdomen and pelvis can be used for ovarian cancer staging, specifically in certain clinical settings such as in patients with a history of fertility preservation for borderline tumors and/or inconclusive CT findings [28,29]. MRI has shown similar accuracy to CT for initial staging and has been shown to predict peritoneal tumor volume comparable to surgery [30,31].Limitations in the use of MRI for ovarian cancer staging include nonroutine use of intraluminal gastrointestinal

contrast agents and greater likelihood of patient motion due to examination length.

MRI Abdomen and Pelvis Without IV Contrast. MRI of the abdomen and pelvis without IV contrast has a limited role in baseline ovarian cancer staging, but it can offer better soft tissue resolution when compared with CT abdomen pelvis without IV contrast.

US Abdomen and Pelvis Transabdominal. Trans-abdominal ultrasound (US) of the abdomen and pelvis is not useful for pretreatment ovarian cancer staging. A recent meta-analysis observed that although US had a good diag-nostic performance in detecting disease in certain anatomical sites (eg, rectosigmoid), it had low diagnostic performance in other anatomical sites (eg, root of the mesentery) [32].Although few studies have shown sensitivity comparable to that of CT [33], the use of US in ovarian cancer staging does not reflect universal practice or experience. National Comprehensive Cancer Network (NCCN) guidelines state that in patients with newly diagnosed ovarian cancer after recent surgical procedure that imaging with US can be used as clinically indicated [2].

US Pelvis Transvaginal. There is no relevant literature to support the use of transvaginal pelvis US for ovarian cancer staging. Transvaginal pelvis US is helpful to determine site of origin of a pelvis mass, characterize the lesion, and assist in image-guided core biopsy [34].

Variant 2: Adult. Ovarian cancer.

Posttreatment response evaluation

The goal of imaging is to assess the posttreatment response evaluation in ovarian cancer. With the relevant imaging information, an appropriate clinical and follow-up plan can be determined.

CT Abdomen and Pelvis With IV Contrast. CT of the abdomen and pelvis with IV and oral contrast is the most useful procedure to assess disease extent following treatment[35]. NCCN guidelines state that contrast-enhanced CT of the abdomen and pelvis can be performed for monitoring and follow-up of tumor burden[2].

CT Abdomen and Pelvis Without and With IV Contrast. There is no relevant literature to support the use of CT of the abdomen and pelvis without and with IV contrast for posttreatment ovarian cancer response evaluation.

CT Abdomen and Pelvis Without IV Contrast. CT of the abdomen and pelvis without IV contrast can be considered in certain clinical settings but offers limited ability to identify metastases, especially differentiating small peritoneal or mesenteric implants, or lymphadenopathy from bowel or adjacent organs.

<EndOfPara>CT Chest With IV Contrast. CT of the chest with IV contrast is a useful modality to assess posttreatment response in patients with ovarian cancer[2].

CT Chest Without and With IV Contrast. There is no relevant literature to support the use of CT of the chest without and with IV contrast for posttreatment ovarian cancer response evaluation.

CT Chest Without IV Contrast. CT of the chest without IV contrast may be considered to assess postreat-ment response. CT of the chest without IV contrast can detect small pulmonary nodules; however, pleural metas-tases may be difficult to delineate without IV contrast.

FDG-PET/CT Skull Base to Mid-Thigh. FDG-PET/CT may be useful in the posttreatment response evaluation of ovarian cancer [2]. Resolution or regression of neoplastic implants with concomitant reduction in metabolic activity indicates a favorable response to therapy.

FDG-PET/MRI Skull Base to Mid-Thigh. FDG-PET/MRI may be useful in the posttreatment response evalua-tion of ovarian cancer. In postoperative patients, FDG-PET/MRI is at least equivalent to FDG-PET/CT and provides additional diagnostic benefits, such as higher soft tissue resolution [27,36].

MRI Abdomen and Pelvis Without and With IV Contrast. MRI of the abdomen and pelvis may be useful in the posttreatment response evaluation of ovarian cancer[2].

MRI Abdomen and Pelvis Without IV Contrast. MRI of the abdomen and pelvis without IV contrast may be considered in the posttreatment response evaluation of ovarian cancer and may offer improved soft tissue contrast compared with CT without IV contrast.

US Abdomen and Pelvis Transabdominal. There is no relevant literature to support the use of transabdominal US of the abdomen and pelvis in evaluating posttreatment response.

US Pelvis Transvaginal. There is no relevant literature to support the use of transvaginal US of the pelvis for the evaluation of posttreatment response.

Variant 3: Adult. Ovarian cancer.

Posttreatment routine surveillance.

Asymptomatic patient, no suspected recurrence

The goal of imaging is to identify disease recurrence in asymptomatic patients on surveillance with a history of treated ovarian cancer. With the relevant imaging

information, early and unexpected recurrence can be identified, thus improving patient outcomes.

The role for routine surveillance with imaging is unclear in patients considered to be in clinical remission. Imaging has limited sensitivity for the detection of small tumor deposits in the abdomen and pelvis, with or without monitoring of cancer antigen 125 (CA-125) levels [4,39].NCCN guidelines for follow-up after primary treatment include scheduled clinical visits, imaging when clinically indicated (CT of the chest, abdomen, and pelvis; MRI;FDG-PET/CT; or PET), and CA-125 monitoring if initial elevation was present [2].

Surveillance imaging may be warranted in asymptom-atic patients under circumstances in which tumor markers are deemed unreliable, physical examinations are incon-clusive, or there is a significant risk of recurrence [2].

The patient population defined in this scenario is an asymptomatic patient in whom no recurrence is suspected(eg, no concerning physical examination findings and no elevation of serum tumor markers).

CT Abdomen and Pelvis With IV Contrast. The use of surveillance with CT of the abdomen and pelvis with IV contrast is unclear in those patients considered to be in clinical remission. In one study with CT surveillance, a higher rate of optimal secondary cytoreductive surgery and improved overall survival was reported in those with asymptomatic recurrences compared with patients with symptomatic recurrences [38,40]. However, in another study of 412 patients, recurrence in 80\% of the patient population was detected by either physical examination(15%), imaging (27%), CA-125 level (23%), or CA-125 level combined with imaging (35%) [4,38]. In this same study, no difference in overall survival was shown between asymptomatic and symptomatic patients with recurrence.

CT Abdomen and Pelvis Without and With IV Contrast. There is no relevant literature to support the use of CT of the abdomen and pelvis without and with IV contrast in asymptomatic patients without suspected recurrence.

CT Abdomen and Pelvis Without IV Contrast. In instances for which CT of the abdomen and pelvis is clinically indicated, CT of the abdomen and pelvis without IV contrast may be considered in some clinical instances.

CT Chest With IV Contrast. Surveillance with CT of the chest with IV contrast is unclear in patients without suspected recurrence. Per NCCN guidelines, CT of the chest may be considered as part of monitoring and follow-up, as clinically useful[2].

CT Chest Without and With IV Contrast. There is no relevant literature to support the use of CT of the chest

without and with IV contrast in asymptomatic patients without suspected recurrence.

CT Chest Without IV Contrast. The utility of surveil-lance imaging is unclear in those patients considered to be in clinical remission. Per NCCN guidelines, CT of the chest may be considered as part of monitoring and follow-up, as clinically indicated [2].

FDG-PET/CT Skull Base to Mid-Thigh. The use of surveillance FDG-PET/CT is unclear in those patients considered to be in clinical remission. Per NCCN guide-lines, PET/CT or PET may be considered as part of monitoring and follow-up, as clinically indicated [2].

FDG-PET/MRI Skull Base to Mid-Thigh. There is no relevant literature to support the use of FDG-PET/MRI in asymptomatic patients without suspected recurrence.

MRI Abdomen and Pelvis Without and With IV Contrast. Per NCCN guidelines, MRI may be considered as part of monitoring and follow-up for patients with ovarian cancer in the posttreatment routine surveillance setting, as clinically indicated [2]. As such, MRI of the abdomen without and with IV contrast may be useful.

MRI Abdomen and Pelvis Without IV Contrast. Per NCCN guidelines, MRI may be considered as part of monitoring and follow-up for patients with ovarian cancer in the Pelvis Without IV Contrast. Per NCCN guidelines, MRI may be considered as part of monitoring and follow-up for patients with ovarian cancer in the posttreatment routine surveillance setting, as clini-cally indicated [2]. As such, MRI of the abdomen and pelvis without IV contrast may be useful.

US Abdomen and Pelvis Transabdominal. There is no evidence to support the use of transabdominal US of the abdomen and pelvis vs posttreatment surveillance in asymptomatic patients.

US Pelvis Transvaginal. There is no evidence to support the use of transvaginal US of the pelvis for posttreatment surveillance in asymptomatic patients with a history of treated ovarian cancer.

Variant 4: Adult. Ovarian cancer.Posttreatment evaluation. Suspected or known recurrence

The goal of imaging is to identify sites of disease recurrence in patients with a history of treated ovarian cancer with suspected or known recurrence. The relevant imaging in-formation can inform treatment planning and specifically guide decisions related to surgical or medical treatment.

In the evaluation for recurrence and extent of disease,imaging of the chest, abdomen, and pelvis plays a key role.The suspicion of recurrence after treatment may arise from clinical symptoms, findings during physical examination, or

an increase in CA-125 levels, which would then prompt the need for imaging to evaluate for recurrence.

CT Abdomen and Pelvis With IV Contrast. CT of the abdomen and pelvis with IV and oral contrast is the most useful procedure for confirming recurrent disease and determining the extent in patients with suspected or known recurrence(based on clinical symptoms, physical examina-tion, or CA-125 level) [38]. Contrast-enhanced CT has a reported sensitivity ranging from 58% to 84% and a specificity in the range of 59% to 100% in identifying tu-mor recurrence [41-43]. Recurrent disease often presents as peritoneal implants, both within the peritoneal cavity and along the surface of visceral organs. A limitation with CT is detecting peritoneal, mesenteric, or serosal lesions that are <5 mm in size [40].

CT Abdomen and Pelvis Without and With IV Contrast. There is no relevant literature to support the use of CT of the abdomen and pelvis without and with IV contrast in the evaluation of suspected or known ovarian cancer recurrence.

CT Abdomen and Pelvis Without IV Contrast. CT of the abdomen and pelvis without IV contrast offers limited ability to identify small peritoneal or mesenteric implants,or lymphadenopathy among bowel loops and other adjacent organs.

CT Chest With IV Contrast. CT of the chest with IV contrast is the most useful modality in evaluating recurrent or metastatic disease in the thorax.

CT Chest Without and With IV Contrast. There is no relevant literature to support the use of CT of the chest without and with IV contrast in the evaluation of suspected or known ovarian cancer recurrence.

CT Chest Without IV Contrast. CT of the chest without IV contrast is not typically useful in this setting.

FDG-PET/CT Skull Base to Mid-Thigh. FDG-PET/CT can be used in the evaluation of recurrent ovarian cancer [2]. In a recent meta-analysis, FDG-PET/CT showed a sensitivity of 88% and a specificity of 89% in diagnosing recurrent epithelial ovarian cancer [44]. FDG-PET/CT can also be used as an adjunct imaging study when there is a high clinical suspicion for recurrence but CT is indeterminate [45]. Certain limitations of FDG-PET/CT including poor detection of subcentimeter me-tastases due to suboptimal spatial resolution of PET, high concentration of excreted FDG obscuring lesions near the bladder, and metabolic activity on or between bowel loops, particularly after surgery when adhesions or inflammation are present, may be difficult to assess [44,45].

FDG-PET/MRI Skull All Base to Mid-Thigh. In specific patient scenarios, FDG-PET/MRI may be useful in the suspected recurrence. Example scenarios include those pa-tients with high clinical suspicion (such as rising CA-125 levels or worsening clinical symptoms) but indeterminate CT findings [27].

MRI Abdomen and Pelvis Without and With IV Contrast. MRI of the abdomen and pelvis may be useful as a problem-solving tool in those patients with suspected or known disease recurrence and when CT is indeterminate.

MRI Abdomen and Pelvis Without IV Contrast. MRI without IV contrast may be considered in those patients with suspected or known disease recurrence of ovarian cancer and when CT is indeterminate. However, IV contrast is preferable for the detection and characterization of lesions suspected to represent tumor deposits.

US Abdomen and Pelvis Transabdominal. There is no relevant literature to support the use of transabdominal US of the abdomen and pelvis in the evaluation of suspected or known ovarian cancer recurrence.

US Pelvis Transvaginal. There is no relevant literature to support the routine use of pelvic US in the evaluation of sus-pected or known ovarian cancer recurrence following treatment.

SUMMARY OF HIGHLIGHTS

This is a summary of the key recommendations from the variant tables. Refer to the complete narrative document for more information.

■Variant 1: For initial pretreatment staging of ovarian cancer, CT abdomen and pelvis with IV contrast and CT chest with IV contrast are recommended complementary studies to stage the tumor and evaluate for distant metastases. MRI abdomen and pelvis without and with IV contrast, MRI abdomen and pelvis without IV contrast, CT abdomen and pelvis without IV contrast, CT chest without IV contrast, FDG-PET/MRI, and FDG-PET/CT may be appropriate in staging ovarian cancer prior to treatment.

■Variant 2:For follow-up imaging evaluation following treatment for ovarian cancer, CT abdomen and pelvis with IV contrast, CT chest with IV contrast, and FDG-PET/CT are recommended complementary studies to evaluate the posttreatment response. MRI abdomen and pelvis without and with IV contrast,MRI abdomen and pelvis without IV contrast, CT abdomen and pelvis without IV contrast, CT chest

without IV contrast, and FDG-PET/MRI may be appropriate in the posttreatment response evaluation.

■Variant 3: For posttreatment imaging evaluation in asymptomatic patients without suspected recurrence,the role of imaging is unclear in those patients considered to be in clinical remission. CT abdomen and pelvis with or without IV contrast, CT chest with or without IV contrast, MRI abdomen and pelvis without and with IV contrast, MR abdomen and pelvis without IV contrast, FDG-PET/MRI, and FDG-PET/CT may be appropriate, as clinically indicated.

Variant 4: For follow-up imaging evaluation following treatment for ovarian cancer in patients with suspected or known recurrence, CT abdomen and pelvis with IV contrast, CT chest with IV contrast, and FDG-PET/CT are recommended complementary studies to evaluate for local recurrence and metastatic disease. MRI abdomen and pelvis without and IV contrast, MRI abdomen and pelvis without IV contrast, CT abdomen and pelvis without IV contrast, CT chest without IV contrast, and FDG-PET/MRI may be appropriate in the posttreatment evaluation of patients with suspected or known recurrence.

SUPPORTING DOCUMENTS

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The ap-pendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness of criteria methodology and other supporting documents,visit www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

GENDER EQUALITY AND INCLUSIVITY CLAUSE

The ACR acknowledges the limitations in applying inclu-sive language when citing research studies that pre-dates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diversse. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health[46].

RELATIVE RADIATION LEVEL INFORMATION

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting

the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL)indication has been included for each imaging examination.The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total ra-diation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life ex-pectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table 2). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria $\odot$ Radiation Dose Assessment Introduction document [47].

ACKNOWLEDGMENTS

The ACR is the sole funding source of the ACR AC.

REFERENCES

1. Siegel RL, Giaquinto AN, Jemal A. Cancer statistics, 2024. CA Cancer J Clin 2024;74:12-49.

2. NCCN Clinical Practice Guidelines in Oncology. Ovarian Cancer,Including Fallojan Tube Cancer and Primary Pertoneal Cancer.Version 2,2024. Available at: https://www.nccn.org/professionals/physician_gls/pdf/ovarian.pdf.Accessed March 31,2025.

3.Kurman RJ, Shih Ie M. The origin and pathogenesis of epithelial ovarian cancer: a proposed unifying theory. Am J Surg Pathol 2010;34:433-43.

4. Gadducci A, Fuso L, Cosio S, et al. Are surveillance procedures of clinical benefit for patients treated for ovarian cancer? A retrospective Italian multicentric study. Int J Gynecol Cancer 2009;19:367-74.

5. Lutz AM, Willmann JK, Drescher CW, et al. Early diagnosis of ovarian carcinoma: is a solution in sight? Radiology 2011;259:329-45.

6. Chandrashekhar SH, Thulkar S, Srivastava DN, et al. Pre-operative evaluation of peritoneal deposits using multidetector computed to-mography in ovarian cancer. Br J Radiol 2011;84:38-43.

7.Jeong YY,Outwater EK,Kang HK.Imaging evaluation of ovarian masses. Radiographics 2000;20:1445-70.

8. Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST. CT and MR imaging of ovarian tumors with emphasis on differential diagnosis.Radiographics 2002;22:1305-25.

9. Liu J, Xu Y, Wang J. Ultrasonography, computed tomography and magnetic resonance imaging for diagnosis of ovarian carcinoma. Eur J Radiol 2007;62:328-34.

10. Rettenmaier NB, Rettenmaier CR, Wojciechowski T, et al.The utility and cost of routine follow-up procedures in the surveillance of ovarian and primary peritoneal carcinoma: a 16-year institutional review. Br J Cancer 2010;103:1657-62.

11. Son H, Khan SM, Rahaman J, et al. Role of FDG PET/CT in staging of recurrent ovarian cancer. Radiographics 2011;31:569-83.

12.Castellani F,Nganga EC,Dumas L,Banerjee S, Rockall AG.Imaging in the pre-operative staging of ovarian cancer. Abdom Radiol (NY)2019;44:685-96.

13.Schmidt S, Meuli RA, Achtari C, Prior JO. Peritoneal carcinomatosis in primary ovarian cancer staging: comparison between MDCT,MRI, and 18F-FDG PET/CT. Clin Nucl Med 2015;40:371-7.

14. Forstner R, Hricak H, Occhipinti KA, Powell CB, Frankel SD,Tern J. Ovarian cancer: staging with CT and MR imaging. Radi-ology 1995;197:619-26.

15. Ghossain MA, Buy JN, Ligneres C, et al. Epithelial tumors of the ovary: comparison of MR and CT findings. Radiology 1991;181:863-70.

16. Hynninen J, Kemppainen M, Letónius M, et al. A prospective com-parison of integrated FDG-PET/contrast-enhanced CT and contrast-enhanced CT for pretreatment imaging of advanced epithelial ovarian cancer. Gynecol Oncol 2013;131:389-94.

17. Pannu HK, Horton KM, Fishman EK. Thin section dual-phase multidetector-row computed tomography detection of peritoneal metastases in gynecologic cancers. J Comput Assist Tomogr 2003;27:333-40.

18. Griffin N, Grant LA, Freeman SJ, et al. Image-guided biopsy in pa-tients with suspected ovarian carcinoma: a safe and effective tech-nique? Eur Radiol 2009;19:230-5.

19. Hewitt MJ, Anderson K, Hall GD, et al. Women with peritoneal carcinomosis of unknown origin: efficacy of image-guided biopsy to determine site-specific diagnosis. BJOG 2007;114:46-50.

20. Souza FF, Mortele KJ, Cibas ES, Eurbur SM, Silverman SG. Pre-dictive value of percutaneous imaging-guided biopsy of peritoneal and omental masses: results in 111 patients. AJR Am J Roentgenol 2009;19:231-6.

21. Spencer JA, Weston MJ, Said SA, Wilkinson N, Hall GD. Clinical utility of image-guided peritoneal and ontal biopsy. Nat Rev Clin Oncol 2010;7:623-31.

22. Mironov O, Ishill NM, Mironov S, et al. Pleural diffusion detected at CT prior to primary ycorodulation for stage III or IV ovarian carci-noma: effect on survival. Radiology 2011;258:776-84.

23. Wilson MP, Souror S, Bao B, et al. Diagnostic accuracy of contrast-enhanced CT versus PET/CT for advanced ovarian cancer staging: a comparative systematic review and meta-analysis. Abdom Radiol(NY) 2024;49:2135-44.

24. Queiroz MA, Kubik-Huch RA, Hauser N, et al. PET/MRI and PET/CT in advanced gynecological tumours: initial experience and comparison. Eur Radiol 2015;25:2222-30.

25. Tsuyoshi H, Tsujikawa T, Yamada S, Okazawa H, Yoshida Y.Diagnostic value of[(18)F)FDG PET/MRI for staging in patients with ovarian cancer. EJNMMI Res 2020;10:117.

26. Zheng M, Xie D, Pan C, Xu Y, Yu W. Diagnostic value of 18F-FDG PET/MRI in recurrent pelvis malignancies of female patients: a sys-tematic review and meta-analysis. Nucl Med Commun 2018;39:479-85.

27. Tarcha Z, Konstantinoff KS, Ince S, et al. Added Value of FDG PET/MRI in gynecologic oncology: a pictorial review. Radiographics 2023;43:e230006.

28. Mironov S, Akin O, Pandit-Taskar N, Hann LE. Ovarian cancer.Radiol Clin North Am 2007;45:149-66.

29.Woodward PJ, Hosseinzadeh K, Saenger JS. From the archives of the AFIP: radiologic staging of ovarian carcinoma with pathologic cor-relation. Radiographics 2004;22:245-26.

30. Low RN, Barone RM. Combined diffusion-weighted and gadolinium-enhanced MRI can accurately predict the peritoneal cancer index preferatively in patients being considered for cyto-ductive surgical procedures. Ann Surg Oncol 2012;19:1394-401.

31. Tempany CM, Zou KH, Silverman SG, Brown DL, Kurtz AB,McNeil BJ. Staging of advanced ovarian cancer: comparison of im-aging modalities-report from the Radiological Diagnostic Oncology Group. Radiology 2000;215:761-7.

32. Luis Alcazar J, Ramon Perez-Vidal J, Tameish S, Chacon E,Manzour N, Angel Minguez J. Ultrasound for assessing tumor spread in ovarian cancer. A systematic review of the literature and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2024;292:194-200.

33. Alcazar JL, Caparro A, Arraiza M, et al. Pre-operative assessment of intra-abdominal disease spread in epithelial ovarian cancer: a comparative study between ultrasound and computed tomography.Int J Gynecol Cancer 2019;29:227-33.

34. Conway C, Zalud I, Dilena M, et al. Simple cyst in the post-menopausal patient: detection and management. J Ultrasound Med 1998;17:369-72. quiz 73-4.

35. Forstner R, Sala E, Kinkel K, Spencer JA. ESUR guidelines: ovarian cancer staging and follow-up. Eur Radiol 2010;20:2773-80.

36. Ponisio MR, Fowler KJ, Dehdashti F. The emerging role of PET/MR imaging in gynecologic cancers. PET Clin 2016;11:425-40.

37. Gadducci A, Cosio S. Surveillance of patients after initial treatment of ovarian cancer. Crit Rev Oncol Hematol 2009;71:43-52.

38. Salani R, Khanna N, Frimer M, Bristow RE, Chen LM. An update on post-treatment surveillance and diagnosis of recurrence in women with gynecologic malignancies: Society of Gynecologic Oncology(SGO) recommendations. Gynecol Oncol 2017;146:3-10.

39. Sala E, Mannelli L, Yamamoto K, et al. The value of postoperative/preadvuant chemotherapy computed tomography in the manage-ment of patients with ovarian cancer. Int J Gynecol Cancer 2011;21:296-301.

40. Tanner EJ, Chi DS, Eisenhauer EL, Diaz-Montes TP, Santillan A,Bristow RE. Surveillance for the detection of recurrent ovarian cancer: survival impact or lead-time bias? Gynecol Oncol 2010;117:336-40.

41. Kitajima K, Murakami K, Yamasaki E, et al. Performance of inte-grated 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;35:1439-48.

42. Meyer JI, Kennedy AW, Friedman R, Ayoub A, Zepp RC. Ovarian carcinoma: value of CT in predicting success of debulking surgery.AJR Am J Roentgenol 1995;165:875-8.

43. Tawakol A, Abdelhafe YG, Osama A, Hamada E, El Refaei S.Diagnostic performance of 18F-FDG PET/contrast-enhanced CT versus contrast-enhanced CT alone for post-treatment detection of ovarian malignancy. Nutl Med Commun 2016;37:453-60.

44. Wang X, Yang L, Wang Y. Meta-analysis of the diagnostic value of(18)F-FDG PET/CT in the recurrence of epithelial ovarian cancer Front Oncol 2022;12:1003465.

45. Salani R, Backes FJ, Furng MF, et al. Posttreatment surveillance and diagnosis of recurrence in women with gynecologic malignancies:Society of Gynecologic Oncologists recommendations. Am J Obstet Gynecol 2011;204:466-78.

46. National Academies of Sciences. Engineering, and Medicine; Division of Behavioral and Social Sciences and Education; Committee on National Statistics; Committee on Measuring Sex, Gender Identity, and Sexual Orientation. Measuring sex, gender identity, and sexual orientation. In: Becker T, Chin M, Bates N, eds. Measuring sex,gender identity, and sexual orientation. Washington, DC: National Academies Press; 2022.

47. American College of Radiology. ACR Appropriateness Criteria radiation dose assessment introduction. Available at: https://edge.sciteodcloud.io/americanoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf. Accessed March 31,2025.