Ovarian Carcinoma

Ovarian Carcinoma

Todd M. Blodgett, MD

Alex Ryan, MD

Hesham Amr, MD

Axial graphic shows a heterogeneous pelvic mass with areas of central necrosis and peripheral areas of nodularity image, compatible with ovarian carcinoma.

Axial fused PET/CT shows the areas of peripheral nodularity image with intense activity.


Abbreviations and Synonyms

  • Ovarian carcinoma, carcinoma of the ovary, ovarian cancer


  • Primary malignancy of ovary

    • Epithelial (90%)

      • Arises from germinal epithelium on outside of ovary

    • Stromal (6%)

      • Arises from connective tissue

      • Low rate of metastasis

    • Germ cell (3%)

      • Teens/young women

      • Highly curable

  • Staging of ovarian cancer

    • Stage I: Confined to one or both ovaries

    • Stage II: Spread to uterus/fallopian tube, within pelvis

    • Stage III: Lymph nodes, abdominal cavity

    • Stage IV: Outside abdomen, intrahepatic metastases


General Features

  • Best diagnostic clue: Solid or complex cystic mass arising from ovary ± ascites

  • Location

    • Primary generally found in ovary

    • Metastases most common to peritoneum, omentum

    • Rare intrahepatic metastases

    • Three main routes of lymphatic spread

      • Accompanying ovarian blood vessels cranially to para-aortic and paracaval nodes

      • Following subovarian plexus in broad ligament to obturator and pelvic nodes

      • Following round ligament to external iliac and inguinal nodes

  • Size

    • Variable

      • However, most ovarian carcinoma detected late, so tumors tend to be large

Imaging Recommendations

  • Best imaging tool

    • Most common: Transvaginal ultrasound followed by MR &/or CT for evaluation of metastasis

      • Risk of malignancy index (RMI) calculated using transvaginal ultrasound results, CA-125 blood level, menopausal status

    • Consider PET/CT for most complete staging

      • Especially use PET/CT for suspected recurrence, particularly with mild rise in CA-125

  • Protocol advice: Consider using contrast-enhanced CT as part of the PET/CT scan

CT Findings

  • Primary lesion usually complex cystic mass with mural nodularity

  • In general, malignancy suggested by thickness and irregularity of cavity walls, septae, enhancing nodules

  • Sensitivity 92% for peritoneal metastases

  • GI contrast especially helpful for distinguishing pelvic viscera from intestinal tract

  • Primary use of CT scanning is to evaluate metastatic disease, not ovarian mass

    • For evaluation of the ovarian mass, ultrasonography and MR are more valuable

  • CT scanning is helpful in diagnosing cystic teratomas, 93% of which contain fat and 56% of which are calcified

    • If a large (> 10 cm) soft tissue mass is present, malignant transformation should be suspected

  • Serous cystadenoma has an attenuation similar to that of water

    • But mucinous cystadenoma has an attenuation closer to that of soft tissue

  • CT imaging has much greater sensitivity than techniques used previously

    • Detects 2-3 mm lesions in the lungs and solid viscera

  • Scans with contrast yield high-quality information about retroperitoneal lymph nodes and ureters

  • Low contrast between peritoneal tumors and adjacent soft tissues limits overall sensitivity

    • MR sensitivity in this case 91%

      • But limited in depiction of small calcified peritoneal implants, which are common in patients with serous carcinoma

  • NECT

    • Cystic adnexal mass with septations and soft tissue density papillary projections

  • CECT

    • Solid mural nodules demonstrate enhancement

    • May facilitate detection of peritoneal implants and distant metastases

  • CT angiogram: Can be used to assess vascular invasion

Nuclear Medicine Findings

  • Initial diagnosis

    • FDG PET almost never used to evaluate an adnexal mass or to evaluate for primary ovarian carcinoma

    • Pure mucinous adenocarcinoma more likely to be falsely negative by standard SUV criteria, due to low cellularity and better differentiation properties

  • Staging

    • Not currently covered by Medicare

    • Three lymph node stations with high rate of false positives: Axillary, inguinal, hilar

    • PET limited in detecting lymph node micrometastases

      • In one study, PET/CT failed to identify microscopic disease in 59% of pathologically positive lymph nodes

    • Also limited for differentiating peritoneal tumors from adjacent soft tissue or bowel activity

  • Restaging

    • PET/CT: Sensitivity > 95%, specificity 80-93%, and positive predictive value of 83-94% for detection of recurrence

    • PET has 6-8 mm limit of resolution

      • Limited in detection of small disseminated lesions (e.g., peritoneal carcinosis and mesenteric or omental recurrences)

    • Degenerative change in pelvis, such as sacroiliac arthritis, has been mistaken for recurrence

      • Active degenerative change in bone can have ↑ FDG activity

    • For detection of ovarian cancer recurrence mean sensitivity, specificity, and accuracy each 83%

    • In one study of patients with primarily subcentimeter lesions, sensitivity of FDG PET for recurrence was only 10%

      • With mean lesion size of 1.1 cm, patient-based sensitivity 81%

  • Response to therapy

    • Paucity of studies in the literature; not currently covered or recommended for evaluating response to therapy


Pelvic Inflammatory Disease

  • CT findings nonspecific

  • Disrupted fat planes

  • Thickened fascial planes

Tubo-Ovarian Abscess

  • Commonly depicted as regular mass with debris similar to that seen with endometrioma or hemorrhagic cyst

Complex Functional Cysts

  • May have intense FDG activity

Benign Ovarian Tumors

  • Includes cystadenoma, dermoid tumors

Borderline Ovarian Tumors

  • Pathologically difficult to differentiate between benign and malignant

  • Low malignant potential

Normal Physiologic FDG Activity

  • Mostly in younger premenopausal women

  • Helpful if bilateral physiologic activity present

  • Look for CT findings of corpus luteal cyst: Rind of enhancement in an otherwise normal-appearing ovary


General Features

  • General path comments

    • Ovarian cancer spreads primarily intraperitoneally as well as to lymph nodes

      • Peritoneal fluid flows upward from pelvis to paracolic gutters and subphrenic regions, carrying tumor cells that implant on abdominal viscera

    • Common sites of metastatic implantation

      • Pelvis

      • Right hemidiaphragm

      • Perihepatic

      • Right paracolic gutter

      • Bowel

      • Omentum

    • Distant lymph nodes are involved in approximately 7% of cases of serous ovarian adenocarcinoma

  • Genetics

    • 10% of patients with ovarian cancer appear to have genetic predisposition

    • These patients may develop cancer early, between ages 30 and 50

    • One study suggested patients with BRCA gene have 60% risk of developing ovarian cancer

  • Etiology

    • Unknown

    • Number of reproductive cycles appears to be related to risk

    • Ovulation suppression may decrease cancer incidence

  • Epidemiology

    • Leading cause of death among women with gynecological malignancies

    • Third most common cancer of female reproductive organs

Microscopic Features

  • Most common histologies are papillary serous adenocarcinoma and endometrioid type

  • Serous adenocarcinoma comprises 40% of epithelial ovarian cancers

  • Psammoma bodies may be present

    • Ovarian cancer with multiple psammoma bodies may have better prognosis



  • Most common signs/symptoms

    • Early stage: Nonspecific, pelvic pain

      • Often attributed to other causes (e.g., menstruation, irritable bowel syndrome)

    • With metastases: Abdominal/pelvic bloating, pain, pressure, early satiety, nausea/vomiting, frequent urination, feeling similar to pregnancy

  • Other signs/symptoms

    • CA-125 has accuracy of 79-95% for recurrence; increase precedes apparent recurrence by 3-6 months

    • Doubling of CA-125 above normal limit has been shown to have sensitivity of 85.9% and specificity of 91.3% for detection of recurrence


  • Age: Average age at diagnosis 57 years

  • Ethnicity: More common among Caucasians than African-Americans

Natural History & Prognosis

  • Most patients asymptomatic until disease is in advanced stage

  • In 75-80% of patients, cancer has spread beyond ovary at diagnosis

  • Overall survival approximately 35%

  • Despite clinical advances and improved surgery, overall survival has not changed because the disease presents at advanced stage

    • 75% of patients are diagnosed in stage III/IV, and in this group the 5 year survival rate is 17%

  • Up to 85% of women ultimately relapse

  • Well-known that patients with advanced ovarian cancer have better outcome when neoadjuvant chemotherapy is performed before surgery

  • Up to 24% of ovarian tumors in premenopausal women are malignant and up to 60% in postmenopausal women


  • Surgery, chemotherapy, radiation therapy; depends on stage of disease, institution where treated

    • Surgery for earlier stages: Total abdominal hysterectomy, bilateral oophorectomy, omentectomy, biopsy of lymph nodes/tissues

    • Surgery for later stages: Early stage surgery plus tumor debulking

    • Chemotherapy: Paclitaxel &/or platinum-based drugs

    • Radiation therapy: Stage II

  • Exploratory laparotomy done for high suspicion of malignancy

    • Only 1 ovarian cancer detected for every 8-9 benign cyst operations

  • Benefit of optimal primary cytoreductive debulking surgery is well established

  • Following debulking surgery, stage IV patients have same median survival as stage III patients

  • 75% of women have complete clinical response, but the majority of these will experience recurrence



  • Benign increased FDG uptake in ovaries can mimic ovarian primary malignancy

    • Look for other signs of ovarian malignancy (ascites, peritoneal implants, lymphadenopathy)

  • PET/CT valuable in patient with rising CA-125, negative anatomic imaging

    • Some claim PET is as valuable for detection of recurrence as second-look surgery and may be substituted as noninvasive option

  • PET/CT valuable to distinguish post-surgical change from recurrence

Image Interpretation Pearls

  • Serous adenocarcinoma may contain microcalcifications that can be confused with old granulomatous disease

  • Incidence of groin metastases less than 3%; isolated inguinal nodal metastasis without other nodal involvement very rare


1. Hillner BE et al: Impact of positron emission tomography/computed tomography and positron emission tomography (PET) alone on expected management of patients with cancer: initial results from the National Oncologic PET Registry. J Clin Oncol. 26(13):2155-61, 2008

2. Reinhardt MJ: Gynecologic tumors. Recent Results Cancer Res. 170:141-50, 2008

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Sep 22, 2016 | Posted by in MAGNETIC RESONANCE IMAGING | Comments Off on Ovarian Carcinoma

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