Ovarian Carcinomatosis: How the Radiologist Can Help Plan the Surgical Approach

Abstract

Ovarian carcinoma is the most common cause of death due to gynecologic malignancy. Peritoneal involvement is present in approximately 70% of patients at the time of initial diagnosis. The disease spreads abdominally by direct extension, exfoliation of tumor cells into the peritoneal space, and dissemination of tumor cells along lymphatic pathways. Carcinomatosis characterizes an advanced stage of disease in which peritoneal disease has spread throughout the upper abdomen (stage IIIC) or in which diffuse peritoneal disease is accompanied by malignant pleural infiltration or visceral metastases (stage IV). Common sites of intraperitoneal seeding of ovarian carcinoma include the pelvis, omentum, paracolic gutters, liver capsule, and diaphragm. Soft-tissue thickening, nodularity, and enhancement are all signs of peritoneal involvement. Advanced-stage disease is treated either with initial cytoreductive surgery (debulking) followed by adjuvant chemotherapy, or with initial neoadjuvant chemotherapy followed by debulking. Radiologic imaging plays an important role in the selection of patients who may benefit from neoadjuvant chemotherapy before debulking. However, accurate interpretation of the imaging findings is challenging and requires a detailed knowledge of the complex peritoneal anatomy, directionality of flow of peritoneal fluid, and specific disease sites that are likely to present particular difficulties with regard to surgical access and technique. Although there is as yet no clear consensus on the criteria for resectability of peritoneal lesions, extensive involvement of the small bowel or mesenteric root, involved lymph nodes superior to the celiac axis, pleural infiltration, pelvic sidewall invasion, bladder trigone involvement, and hepatic parenchymal metastases or implants near the right hepatic vein are considered indicative of potential nonresectability. Implants larger than 2 cm in diameter in the diaphragm, lesser sac, porta hepatis, intersegmental fissure, gallbladder fossa, or gastrosplenic or gastrohepatic ligament also may represent nonresectable disease.

Imaging of peritoneal deposits in ovarian cancer: A pictorial review

“…Pelvis: Pelvic side wall invasion should be commented upon in the structured report. Mass extension within 3 mm or encasing more than 90% of iliac vessel circumference confirms the pelvic side wall invasion [1] (Figure 4). …”

“…Lymph nodes: Involvement of suprarenal lymph nodes including epiphrenic should be documented as it makes the disease prone to suboptimal resection and warrants neoadjuvant chemotherapy [1] . Pelvis: Pelvic side wall invasion should be commented upon in the structured report.…”

“…Radiologic imaging helps in proper selection of treatment, determine resectability of lesion and prognosticate the case. Accurate interpretation of imaging findings help surgeons in planning the mana gement [1,2] . Here we attempt to present a comprehensive in-depth review of extraovarian imaging manifestations of advanced ovarian carcinoma.…”

Assessment of Relapse in Patients with Peritoneal Carcinomatosis after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy using F-18-FDG-PET/CT

“…Monitoring disease-free survival (DFS) after HIPEC poses several challenges for any available imaging modality. Due to the extensive surgical procedure, a variety of postsurgical tissue alterations are found including nodules and adhesions due to scar tissue as well as thickening and variably increased glucose uptake of the bowel wall due to inflammatory reaction [28]. The aim is to differenti- ate between these postsurgical alterations and remaining or recurring tumor manifestations after HIPEC [29].…”

Tumor sensitive matching flow: A variational method to detecting and segmenting perihepatic and perisplenic ovarian cancer metastases on contrast-enhanced abdominal CT

“…Microarray images are primary data sources for early detection and segmentation of ovarian-cancer related epithelial cells, stroma, or vascular markers from ovary tissue samples (Janowczyk et al, 2009; Signolle et al, 2008). In this paper, we focus on detecting and segmenting perihepatic and perisplenic ovarian cancer metastases (outside and adjacent to liver and spleen) on contrast-enhanced CT images, two common locations of ovarian cancer metastases in the peritoneum and presenting in approximately 70% of patients at the time of initial diagnosis (Nougaret et al, 2012). …”