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Multidetector CT of Peritoneal Carcinomatosis from Ovarian Cancer¹

¹ From the Russell H. Morgan Department of Radiology and Radiological Science (H.K.P., E.K.F.) and Kelly Gynecologic Oncology Service (R.E.B., F.J.M.), Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21287. Recipient of a Certificate of Merit award for an education exhibit at the 2001 RSNA scientific assembly. Received May 23, 2002; revision requested July 9 and received September 20; accepted September 23. Address correspondence to H.K.P. (e-mail: hpannu@jhmi.edu).

View larger version (163K): [in a new window]   Figure 1a.  Normal abdominopelvic anatomy in a 59-year-old woman with a history of ovarian cancer. Intravenously administered contrast material-enhanced CT was performed. (a) Coronal reformatted image of the anterior abdomen and pelvis shows both hemidiaphragms (arrowheads), the liver surface (short arrow), and the paracolic gutters (long arrows). (b) Oblique reformatted image (superior view) shows the rectum (R), levator muscle (arrowheads), internal iliac vessels (short arrow), and vaginal cuff (long arrows). The image also shows the expected location of the uterosacral ligaments, which extend from the vaginal cuff to the sacrum (S).

View larger version (143K): [in a new window]   Figure 1b.  Normal abdominopelvic anatomy in a 59-year-old woman with a history of ovarian cancer. Intravenously administered contrast material-enhanced CT was performed. (a) Coronal reformatted image of the anterior abdomen and pelvis shows both hemidiaphragms (arrowheads), the liver surface (short arrow), and the paracolic gutters (long arrows). (b) Oblique reformatted image (superior view) shows the rectum (R), levator muscle (arrowheads), internal iliac vessels (short arrow), and vaginal cuff (long arrows). The image also shows the expected location of the uterosacral ligaments, which extend from the vaginal cuff to the sacrum (S).

View larger version (149K): [in a new window]   Figure 2.  Normal anatomy in a 74-year-old woman with a history of ovarian cancer. Intravenous contrast-enhanced CT of the abdomen and pelvis was performed. Sagittal volume-rendered image shows the bladder (B), rectosigmoid (R), vaginal cuff (V), and cul-de-sac (long arrow) as well as presacral fat (short arrow).

View larger version (141K): [in a new window]   Figure 3a.  Relationship of a primary ovarian mass to the pelvic viscera in a 58-year-old woman with ovarian cancer. (a) Axial intravenous contrast-enhanced CT scan demonstrates mixed cystic and solid masses in the adnexa bilaterally (arrows). U = uterus. (b) Sagittal reformatted image obtained to the left of midline shows a left ovarian mass (M) that is inseparable (long arrow) from a small segment of the anterior rectosigmoid (S). Note also the tumor plaque in the omentum abutting the anterior abdominal wall (short arrow). Arrowhead indicates the levator plate. (c) Sagittal reformatted image obtained to the right of midline shows that the tumor (T) is inseparable from the superior bladder wall (arrow), a finding that suggests involvement of the overlying peritoneal reflection. B = bladder, U = uterus.

View larger version (163K): [in a new window]   Figure 3b.  Relationship of a primary ovarian mass to the pelvic viscera in a 58-year-old woman with ovarian cancer. (a) Axial intravenous contrast-enhanced CT scan demonstrates mixed cystic and solid masses in the adnexa bilaterally (arrows). U = uterus. (b) Sagittal reformatted image obtained to the left of midline shows a left ovarian mass (M) that is inseparable (long arrow) from a small segment of the anterior rectosigmoid (S). Note also the tumor plaque in the omentum abutting the anterior abdominal wall (short arrow). Arrowhead indicates the levator plate. (c) Sagittal reformatted image obtained to the right of midline shows that the tumor (T) is inseparable from the superior bladder wall (arrow), a finding that suggests involvement of the overlying peritoneal reflection. B = bladder, U = uterus.

View larger version (170K): [in a new window]   Figure 3c.  Relationship of a primary ovarian mass to the pelvic viscera in a 58-year-old woman with ovarian cancer. (a) Axial intravenous contrast-enhanced CT scan demonstrates mixed cystic and solid masses in the adnexa bilaterally (arrows). U = uterus. (b) Sagittal reformatted image obtained to the left of midline shows a left ovarian mass (M) that is inseparable (long arrow) from a small segment of the anterior rectosigmoid (S). Note also the tumor plaque in the omentum abutting the anterior abdominal wall (short arrow). Arrowhead indicates the levator plate. (c) Sagittal reformatted image obtained to the right of midline shows that the tumor (T) is inseparable from the superior bladder wall (arrow), a finding that suggests involvement of the overlying peritoneal reflection. B = bladder, U = uterus.

View larger version (164K): [in a new window]   Figure 4a.  Relationship of a primary ovarian mass to the pelvic vessels and sidewall in a 58-year-old woman with ovarian cancer. Intravenous contrast-enhanced CT of the abdomen and pelvis was performed. (a) Coronal reformatted image shows ovarian masses (M) that abut the external iliac veins (short arrows), which are patent and normal in caliber. Long arrow indicates the pubic symphysis. (b) On an oblique reformatted image of the pelvis (superior view), the ovarian masses (M) lie adjacent to the internal iliac vessels (long arrows) and in proximity to the pelvic sidewall (short arrow).

View larger version (127K): [in a new window]   Figure 4b.  Relationship of a primary ovarian mass to the pelvic vessels and sidewall in a 58-year-old woman with ovarian cancer. Intravenous contrast-enhanced CT of the abdomen and pelvis was performed. (a) Coronal reformatted image shows ovarian masses (M) that abut the external iliac veins (short arrows), which are patent and normal in caliber. Long arrow indicates the pubic symphysis. (b) On an oblique reformatted image of the pelvis (superior view), the ovarian masses (M) lie adjacent to the internal iliac vessels (long arrows) and in proximity to the pelvic sidewall (short arrow).

View larger version (127K): [in a new window]   Figure 5a.  Implants of the diaphragm and liver in a 60-year-old woman with ovarian cancer. (a) Axial intravenous contrast-enhanced arterial phase CT scan of the abdomen shows a rind of tumor (long arrow) at the dome of the liver (L). There is dense contrast material in the aorta (A), minimal contrast material in the inferior vena cava (short arrow), and no contrast material in the hepatic veins (arrowhead). (b) Axial intravenous contrast-enhanced venous phase CT scan of the abdomen shows greater enhancement of the normal liver parenchyma (L), which can be clearly distinguished from the surface tumor deposit (long arrow). The inferior vena cava (short arrow) also demonstrates greater enhancement, and contrast material is now seen in the hepatic veins (arrowhead). (c) Sagittal reformatted image shows thickening of the right hemidiaphragm by tumor plaque (arrows). A right pleural effusion (arrowhead) is also seen. L = liver.

View larger version (127K): [in a new window]   Figure 5b.  Implants of the diaphragm and liver in a 60-year-old woman with ovarian cancer. (a) Axial intravenous contrast-enhanced arterial phase CT scan of the abdomen shows a rind of tumor (long arrow) at the dome of the liver (L). There is dense contrast material in the aorta (A), minimal contrast material in the inferior vena cava (short arrow), and no contrast material in the hepatic veins (arrowhead). (b) Axial intravenous contrast-enhanced venous phase CT scan of the abdomen shows greater enhancement of the normal liver parenchyma (L), which can be clearly distinguished from the surface tumor deposit (long arrow). The inferior vena cava (short arrow) also demonstrates greater enhancement, and contrast material is now seen in the hepatic veins (arrowhead). (c) Sagittal reformatted image shows thickening of the right hemidiaphragm by tumor plaque (arrows). A right pleural effusion (arrowhead) is also seen. L = liver.

View larger version (139K): [in a new window]   Figure 5c.  Implants of the diaphragm and liver in a 60-year-old woman with ovarian cancer. (a) Axial intravenous contrast-enhanced arterial phase CT scan of the abdomen shows a rind of tumor (long arrow) at the dome of the liver (L). There is dense contrast material in the aorta (A), minimal contrast material in the inferior vena cava (short arrow), and no contrast material in the hepatic veins (arrowhead). (b) Axial intravenous contrast-enhanced venous phase CT scan of the abdomen shows greater enhancement of the normal liver parenchyma (L), which can be clearly distinguished from the surface tumor deposit (long arrow). The inferior vena cava (short arrow) also demonstrates greater enhancement, and contrast material is now seen in the hepatic veins (arrowhead). (c) Sagittal reformatted image shows thickening of the right hemidiaphragm by tumor plaque (arrows). A right pleural effusion (arrowhead) is also seen. L = liver.

View larger version (123K): [in a new window]   Figure 6a.  Diaphragmatic implants in a 65-year-old woman with ovarian cancer. (a) Axial intravenous contrast-enhanced CT scan shows soft-tissue implants (arrows) along the right hemidiaphragm and a tumor that is isoattenuating relative to the liver (L) but that can be detected due to surrounding ascites. (b) Sagittal reformatted image shows a clear separation (long arrow) between the diaphragmatic tumor (short arrow) and the dome of the liver (L).

View larger version (153K): [in a new window]   Figure 6b.  Diaphragmatic implants in a 65-year-old woman with ovarian cancer. (a) Axial intravenous contrast-enhanced CT scan shows soft-tissue implants (arrows) along the right hemidiaphragm and a tumor that is isoattenuating relative to the liver (L) but that can be detected due to surrounding ascites. (b) Sagittal reformatted image shows a clear separation (long arrow) between the diaphragmatic tumor (short arrow) and the dome of the liver (L).

View larger version (143K): [in a new window]   Figure 7a.  (a) Diaphragmatic disease in a 58-year-old woman with a new diagnosis of ovarian cancer. Sagittal reformatted image from intravenous contrast-enhanced abdominal CT clearly depicts the diaphragm (long arrow), allowing differentiation of pleural fluid (arrowhead) from a minimal amount of ascites (short arrow) below the diaphragm. (b) Diaphragmatic disease in a 74-year-old woman with ovarian cancer. Coronal reformatted image from intravenous contrast-enhanced abdominal CT shows calcified tumor plaque at the right hemidiaphragm (short arrow) and along the right lobe of the liver (long arrow).

View larger version (142K): [in a new window]   Figure 7b.  (a) Diaphragmatic disease in a 58-year-old woman with a new diagnosis of ovarian cancer. Sagittal reformatted image from intravenous contrast-enhanced abdominal CT clearly depicts the diaphragm (long arrow), allowing differentiation of pleural fluid (arrowhead) from a minimal amount of ascites (short arrow) below the diaphragm. (b) Diaphragmatic disease in a 74-year-old woman with ovarian cancer. Coronal reformatted image from intravenous contrast-enhanced abdominal CT shows calcified tumor plaque at the right hemidiaphragm (short arrow) and along the right lobe of the liver (long arrow).

View larger version (106K): [in a new window]   Figure 8.  Localization of a liver surface implant in a 58-year-old woman with a history of ovarian cancer. Intravenous contrast-enhanced abdominal CT was performed. Coronal reformatted image shows a tumor as it would appear at surgery. There is scalloping of the anteroinferior left lobe of the liver (arrow).

View larger version (115K): [in a new window]   Figure 9a.  Tumor scalloping of the liver surface in a 60-year-old woman with ovarian cancer. Intravenous contrast-enhanced abdominal CT was performed. Axial (a) and sagittal (b) reformatted images show scalloping of the posterior liver surface by tumor implants (arrows). There is also a large amount of ascites.

View larger version (134K): [in a new window]   Figure 9b.  Tumor scalloping of the liver surface in a 60-year-old woman with ovarian cancer. Intravenous contrast-enhanced abdominal CT was performed. Axial (a) and sagittal (b) reformatted images show scalloping of the posterior liver surface by tumor implants (arrows). There is also a large amount of ascites.

View larger version (141K): [in a new window]   Figure 10a.  (a) Splenic implants in a 63-year-old woman with ovarian cancer. Intravenous contrast-enhanced thin-section abdominal CT scan shows a small, hypoattenuating tumor nodule (arrowhead) anterior to the spleen. Minimal tumor nodularity (arrow) is seen in the fat adjacent to the splenic flexure of the colon. (b) Splenic implants in a 40-year-old woman with ovarian cancer. Axial intravenous contrast-enhanced abdominal CT scan shows tumor scalloping of the spleen (arrow). Ascites and liver parenchymal metastases are also seen.

View larger version (121K): [in a new window]   Figure 10b.  (a) Splenic implants in a 63-year-old woman with ovarian cancer. Intravenous contrast-enhanced thin-section abdominal CT scan shows a small, hypoattenuating tumor nodule (arrowhead) anterior to the spleen. Minimal tumor nodularity (arrow) is seen in the fat adjacent to the splenic flexure of the colon. (b) Splenic implants in a 40-year-old woman with ovarian cancer. Axial intravenous contrast-enhanced abdominal CT scan shows tumor scalloping of the spleen (arrow). Ascites and liver parenchymal metastases are also seen.

View larger version (130K): [in a new window]   Figure 11a.  Implants of the spleen and diaphragm in an 84-year-old woman with ovarian cancer. (a) Axial intravenous contrast-enhanced abdominal CT scan shows a soft-tissue mass in the left upper abdomen (arrow) that creates an impression on the stomach. (b) On a sagittal reformatted image, a tumor (T) is seen to invade the superior portion of the spleen. The left hemidiaphragm is thin anteriorly and posteriorly (short arrows) but thick at the level of the tumor (long arrow). The tumor is contiguous with both the diaphragm and the spleen.

View larger version (165K): [in a new window]   Figure 11b.  Implants of the spleen and diaphragm in an 84-year-old woman with ovarian cancer. (a) Axial intravenous contrast-enhanced abdominal CT scan shows a soft-tissue mass in the left upper abdomen (arrow) that creates an impression on the stomach. (b) On a sagittal reformatted image, a tumor (T) is seen to invade the superior portion of the spleen. The left hemidiaphragm is thin anteriorly and posteriorly (short arrows) but thick at the level of the tumor (long arrow). The tumor is contiguous with both the diaphragm and the spleen.

View larger version (174K): [in a new window]   Figure 12a.  (a) Porta hepatis implants in a 40-year-old woman with ovarian cancer. Coronal reformatted image from intravenous contrast-enhanced abdominal CT shows enlarged periportal nodes (short arrow), liver metastases, and ascites. Long arrow indicates the portal vein. (b) Gallbladder fossa implants in a 74-year-old woman with metastatic ovarian cancer. Coronal oblique reformatted image from intravenous contrast-enhanced abdominal CT demonstrates several implants at the gallbladder fossa (arrows), which are easily seen due to calcification.

View larger version (149K): [in a new window]   Figure 12b.  (a) Porta hepatis implants in a 40-year-old woman with ovarian cancer. Coronal reformatted image from intravenous contrast-enhanced abdominal CT shows enlarged periportal nodes (short arrow), liver metastases, and ascites. Long arrow indicates the portal vein. (b) Gallbladder fossa implants in a 74-year-old woman with metastatic ovarian cancer. Coronal oblique reformatted image from intravenous contrast-enhanced abdominal CT demonstrates several implants at the gallbladder fossa (arrows), which are easily seen due to calcification.

View larger version (152K): [in a new window]   Figure 13a.  (a) Peritoneal implants in a 74-year-old woman with a history of ovarian cancer. Coronal oblique reformatted image from intravenous contrast-enhanced abdominal CT demonstrates a partially calcified mass (long arrow) along the greater curvature of the stomach. Additional calcified implants are seen in the abdomen (short arrows), and ascites is also evident. (b, c) Peritoneal implants in a 47-year-old woman with ovarian cancer. (b) Axial intravenous contrast-enhanced abdominal CT scan shows tiny nodules in the gastrohepatic ligament (short arrows) and in the inferior portion of the falciform ligament (long arrow). (c) Axial intravenous contrast-enhanced abdominal CT scan obtained inferior to b shows additional nodules in the lesser sac (arrows).

View larger version (114K): [in a new window]   Figure 13b.  (a) Peritoneal implants in a 74-year-old woman with a history of ovarian cancer. Coronal oblique reformatted image from intravenous contrast-enhanced abdominal CT demonstrates a partially calcified mass (long arrow) along the greater curvature of the stomach. Additional calcified implants are seen in the abdomen (short arrows), and ascites is also evident. (b, c) Peritoneal implants in a 47-year-old woman with ovarian cancer. (b) Axial intravenous contrast-enhanced abdominal CT scan shows tiny nodules in the gastrohepatic ligament (short arrows) and in the inferior portion of the falciform ligament (long arrow). (c) Axial intravenous contrast-enhanced abdominal CT scan obtained inferior to b shows additional nodules in the lesser sac (arrows).

View larger version (117K): [in a new window]   Figure 13c.  (a) Peritoneal implants in a 74-year-old woman with a history of ovarian cancer. Coronal oblique reformatted image from intravenous contrast-enhanced abdominal CT demonstrates a partially calcified mass (long arrow) along the greater curvature of the stomach. Additional calcified implants are seen in the abdomen (short arrows), and ascites is also evident. (b, c) Peritoneal implants in a 47-year-old woman with ovarian cancer. (b) Axial intravenous contrast-enhanced abdominal CT scan shows tiny nodules in the gastrohepatic ligament (short arrows) and in the inferior portion of the falciform ligament (long arrow). (c) Axial intravenous contrast-enhanced abdominal CT scan obtained inferior to b shows additional nodules in the lesser sac (arrows).

View larger version (141K): [in a new window]   Figure 14a.  Peritoneal thickening secondary to metastases in a 63-year-old woman with a history of ovarian cancer. (a) Axial intravenous contrast-enhanced abdominal CT scan reveals a small soft-tissue implant (arrowhead) that abuts the descending colon and mimics colonic contents. (b) Coronal reformatted image shows peritoneal thickening along the entire length of the left paracolic gutter (arrows at right). There is minimal thickening and nodularity in the right paracolic gutter (arrow at left). A = ascending colon, D = descending colon.

View larger version (174K): [in a new window]   Figure 14b.  Peritoneal thickening secondary to metastases in a 63-year-old woman with a history of ovarian cancer. (a) Axial intravenous contrast-enhanced abdominal CT scan reveals a small soft-tissue implant (arrowhead) that abuts the descending colon and mimics colonic contents. (b) Coronal reformatted image shows peritoneal thickening along the entire length of the left paracolic gutter (arrows at right). There is minimal thickening and nodularity in the right paracolic gutter (arrow at left). A = ascending colon, D = descending colon.

View larger version (145K): [in a new window]   Figure 15.  Large-volume peritoneal implants in a 60-year-old woman with ovarian cancer. Abdominopelvic CT was performed. Sagittal reformatted image obtained to the left of midline shows a rind of tumor in the left paracolic gutter (arrow). D = descending colon.

View larger version (133K): [in a new window]   Figure 16.  Omental caking in a 58-year-old woman with ovarian cancer. Abdominopelvic CT was performed. Coronal reformatted image shows large omental implants (arrows) as they would appear at surgery.

View larger version (157K): [in a new window]   Figure 17.  Necrotic bowel implant in a 66-year-old woman with ovarian cancer. Coronal reformatted image shows a necrotic tumor implant (long arrow) on the bowel (B) in the left upper abdomen. The lesion is not connected to any bowel loops, and there is stranding of the adjacent mesentery as well as small satellite nodules (short arrow).

View larger version (155K): [in a new window]   Figure 18a.  (a) Vaginal cuff implants in an 84-year-old woman with a history of ovarian cancer and hysterectomy. Sagittal reformatted image from intravenous contrast-enhanced abdominopelvic CT demonstrates air in the vagina (arrowhead). The wall of the vagina is thickened, and there is a mass at the apex (arrow), a finding that is compatible with recurrent tumor. (b) Uterosacral ligament implants in a 64-year-old woman with recurrent ovarian cancer. Axial reformatted image from abdominopelvic CT shows a soft-tissue nodule (arrow) to the right of the sigmoid colon (S). A tumor involving the uterosacral ligament was found at surgery. (c) Bladder implants in a 45-year-old woman with ovarian cancer. Sagittal reformatted image from pelvic CT shows a small calcified implant (short arrow) on the peritoneal reflection superior to the bladder (long arrow).

View larger version (134K): [in a new window]   Figure 18b.  (a) Vaginal cuff implants in an 84-year-old woman with a history of ovarian cancer and hysterectomy. Sagittal reformatted image from intravenous contrast-enhanced abdominopelvic CT demonstrates air in the vagina (arrowhead). The wall of the vagina is thickened, and there is a mass at the apex (arrow), a finding that is compatible with recurrent tumor. (b) Uterosacral ligament implants in a 64-year-old woman with recurrent ovarian cancer. Axial reformatted image from abdominopelvic CT shows a soft-tissue nodule (arrow) to the right of the sigmoid colon (S). A tumor involving the uterosacral ligament was found at surgery. (c) Bladder implants in a 45-year-old woman with ovarian cancer. Sagittal reformatted image from pelvic CT shows a small calcified implant (short arrow) on the peritoneal reflection superior to the bladder (long arrow).

View larger version (138K): [in a new window]   Figure 18c.  (a) Vaginal cuff implants in an 84-year-old woman with a history of ovarian cancer and hysterectomy. Sagittal reformatted image from intravenous contrast-enhanced abdominopelvic CT demonstrates air in the vagina (arrowhead). The wall of the vagina is thickened, and there is a mass at the apex (arrow), a finding that is compatible with recurrent tumor. (b) Uterosacral ligament implants in a 64-year-old woman with recurrent ovarian cancer. Axial reformatted image from abdominopelvic CT shows a soft-tissue nodule (arrow) to the right of the sigmoid colon (S). A tumor involving the uterosacral ligament was found at surgery. (c) Bladder implants in a 45-year-old woman with ovarian cancer. Sagittal reformatted image from pelvic CT shows a small calcified implant (short arrow) on the peritoneal reflection superior to the bladder (long arrow).