CT of Ovarian Cancer for Primary Treatment Planning: What the Surgeon Needs to Know- Radiology In Training

Abstract

A 60-year-old woman presented with intermittent abdominal pain, an elevated serum CA-125 level, and an abnormal CT examination and was ultimately diagnosed with advanced-stage high-grade serous ovarian cancer. Key tumor locations on CT scans that should be highlighted by the radiologist to guide treatment selection are discussed.

Dr Fernandes is currently a nuclear oncology fellow in the Molecular Imaging and Therapy Service, Radiology Department, Memorial Sloan Kettering Cancer Center in New York, New York. She completed her radiology residency in the Universidade Federal do Rio de Janeiro, Brazil, and abdominal imaging fellowship at the Centro de Imagem Rede D’Or, Rio de Janeiro, Brazil, followed by a body oncologic imaging fellowship at Memorial Sloan Kettering.

Dr Lakhman is an associate attending radiologist in the Body Imaging Service, Radiology Department, Memorial Sloan Kettering Cancer Center. She is an active member of the gynecologic oncologic disease management team and a director of gynecologic imaging. Dr Lakhman is enthusiastic about educating residents and fellows and participating in collaborative research.

Figure 1:

Contrast-enhanced CT images demonstrate multisite peritoneal carcinomatosis. (A) Axial image shows implant in the fissure for ligamentum venosum (arrow). (B) Axial image demonstrates implants in the falciform ligament (arrow), hepatorenal recess (black arrowhead), and lesser sac (white arrowhead). (C) Axial image illustrates implants in the central mesentery (arrow). (D) Axial image shows implants in the small bowel mesentery (arrow) and bowel serosa (★). (E) Coronal image demonstrates implants in the right subdiaphragmatic region (black arrow), large bowel serosa (white arrows), and sigmoid mesentery (★). (F) Coronal image shows implants in the central small bowel mesentery (arrows) and large bowel serosa (stars). No abnormal findings were seen in the chest.

Figure 2:

Illustration shows the International Federation of Gynecology and Obstetrics staging system for ovarian cancer. LN = lymph node.

Figure 3:

Algorithm for triaging patients with suspected advanced ovarian cancer to primary treatment (ie, primary debulking surgery vs neoadjuvant chemotherapy followed by interval debulking surgery). CEA = carcinoembryonic antigen, iv = intravenous, OC = ovarian cancer.

Figure 4:

Chart shows disease locations and likelihood of resectability. No universally accepted resectability criteria exist and, thus, there is significant variability across centers.

Figure 5:

Diagram illustrates the peritoneal spaces. The peritoneal cavity is divided into the greater peritoneal cavity and lesser sac (omental bursa). The greater omentum is a multilayered fold of peritoneum that extends down from the greater curvature of the stomach. The gastrocolic ligament is a portion of greater omentum between the stomach and transverse colon. The lesser omentum is a multilayered fold of peritoneum that extends from the lesser curvature of the stomach and proximal duodenum to the liver. A pelvic peritoneal recess between the uterus and rectum (rectouterine recess) is known as the cul-de-sac or pouch of Douglas.

Figure 6:

Diagram illustrates the lesser sac and its borders. The lesser sac is bordered anteriorly by the liver, stomach, and greater omentum and posteriorly by the pancreas, left adrenal gland, and left kidney; on the left side by the splenorenal and gastrosplenic ligaments and on the right side by the lesser omentum. The lesser omentum joins the stomach and proximal duodenum to the liver, includes hepatogastric and hepatoduodenal ligaments, and encloses the porta hepatis. Splenic ligaments include the splenorenal, gastrosplenic, and splenocolic ligaments (latter not illustrated). Tumor implants in the perihepatic region, porta hepatis, lesser sac, and splenic hilum are shown in purple.

Figure 7:

Diagram illustrates the relationship between the extent of small bowel mesenteric and/or serosal involvement and feasibility of complete cytoreduction. The small bowel mesentery is a large fat-laden peritoneal reflection that attaches the jejunum and ileum to the posterior abdominal wall via the root of small bowel mesentery. The root runs on a diagonal from the duodenojejunal junction to the ileocecal region and contains superior mesenteric vessels, nerves, and lymphatics.

Figure 8:

Diagram illustrates the supradiaphragmatic and retrocrural lymph node groups. Supradiaphragmatic lymph nodes are divided into two major groups: anterior and middle. The anterior group is located posterior to the xiphoid process and just behind the anterior seventh rib costochondral junction. The middle group is usually present on the right side and absent on the left side. Retrocrural lymph nodes are situated posterior to each crus of the diaphragm.