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From the Archives of the AFIP

Radiologic Staging of Ovarian Carcinoma with Pathologic Correlation¹

¹ From the Departments of Radiologic Pathology (P.J.W.) and GYN and Breast Pathology (J.S.S.), Armed Forces Institute of Pathology, 14th St at Alaska Ave, Bldg 54, Rm M-121, Washington, DC 20306-6000; and the Department of Diagnostic Radiology, University of Maryland Medical System, Baltimore (K.H.). Received July 31, 2003; revision requested September 10 and received September 30; accepted October 1. All authors have no financial relationships to disclose. Address correspondence to P.J.W. (e-mail: woodwardp@afip.osd.mil).

View larger version (95K): [in a new window]   Figure 1a.  Diagrams illustrate stage IA (a) and stage IB (b) ovarian carcinoma. (Adapted from reference 12.)

View larger version (94K): [in a new window]   Figure 1b.  Diagrams illustrate stage IA (a) and stage IB (b) ovarian carcinoma. (Adapted from reference 12.)

View larger version (163K): [in a new window]   Figure 2a.  Stage IA ovarian carcinoma. (a) Transverse ultrasonographic (US) image of the left ovary (cursors) shows a complex left ovarian mass with both cystic and solid components. (b) Intraoperative photograph shows the enlarged left ovary (arrow) posterior to the uterus. The capsule was intact, and there was no intraperitoneal spread of disease.

View larger version (124K): [in a new window]   Figure 2b.  Stage IA ovarian carcinoma. (a) Transverse ultrasonographic (US) image of the left ovary (cursors) shows a complex left ovarian mass with both cystic and solid components. (b) Intraoperative photograph shows the enlarged left ovary (arrow) posterior to the uterus. The capsule was intact, and there was no intraperitoneal spread of disease.

View larger version (158K): [in a new window]   Figure 3a.  Ascites in a patient with ovarian cancer. (a) Axial CT scan shows marked ascites and serosal implants on the bowel (arrows). (b) Photograph of cut autopsy specimens of the diaphragm shows confluent, tan deposits of tumor along the inferior margin (arrows) that occluded lymphatic transport of fluid.

View larger version (82K): [in a new window]   Figure 3b.  Ascites in a patient with ovarian cancer. (a) Axial CT scan shows marked ascites and serosal implants on the bowel (arrows). (b) Photograph of cut autopsy specimens of the diaphragm shows confluent, tan deposits of tumor along the inferior margin (arrows) that occluded lymphatic transport of fluid.

View larger version (95K): [in a new window]   Figure 4a.  Drawings illustrate stage IIA (a) and stage IIB (b) ovarian cancer. (Adapted from reference 12.)

View larger version (88K): [in a new window]   Figure 4b.  Drawings illustrate stage IIA (a) and stage IIB (b) ovarian cancer. (Adapted from reference 12.)

View larger version (167K): [in a new window]   Figure 5a.  Local spread of ovarian carcinoma in a 77-year-old woman. (a) Transverse US image through the pelvis shows an enlarged, predominantly solid left ovary (arrow). (b) Axial CT image shows an irregular interface between the left ovary and the uterus (black arrow), a finding that suggests direct invasion. Irregular nodularity seen in the surrounding soft tissues (curved arrow) and a small amount of ascites (straight white arrow) are suggestive of stage IIC or higher disease. (c) Photograph of the uterus shows extensive implants involving the serosal surface (cf the normal uterine serosal surface in Fig 2). (d) Low-power photomicrograph (original magnification, x2; hematoxylin-eosin stain) of serous papillary carcinoma involving the paratubal and paraovarian soft tissues shows a prominent papillary growth pattern lined by cytologically malignant serous epithelium with destructive stromal invasion. The fallopian tube is seen in cross section (arrow).

View larger version (157K): [in a new window]   Figure 5b.  Local spread of ovarian carcinoma in a 77-year-old woman. (a) Transverse US image through the pelvis shows an enlarged, predominantly solid left ovary (arrow). (b) Axial CT image shows an irregular interface between the left ovary and the uterus (black arrow), a finding that suggests direct invasion. Irregular nodularity seen in the surrounding soft tissues (curved arrow) and a small amount of ascites (straight white arrow) are suggestive of stage IIC or higher disease. (c) Photograph of the uterus shows extensive implants involving the serosal surface (cf the normal uterine serosal surface in Fig 2). (d) Low-power photomicrograph (original magnification, x2; hematoxylin-eosin stain) of serous papillary carcinoma involving the paratubal and paraovarian soft tissues shows a prominent papillary growth pattern lined by cytologically malignant serous epithelium with destructive stromal invasion. The fallopian tube is seen in cross section (arrow).

View larger version (114K): [in a new window]   Figure 5c.  Local spread of ovarian carcinoma in a 77-year-old woman. (a) Transverse US image through the pelvis shows an enlarged, predominantly solid left ovary (arrow). (b) Axial CT image shows an irregular interface between the left ovary and the uterus (black arrow), a finding that suggests direct invasion. Irregular nodularity seen in the surrounding soft tissues (curved arrow) and a small amount of ascites (straight white arrow) are suggestive of stage IIC or higher disease. (c) Photograph of the uterus shows extensive implants involving the serosal surface (cf the normal uterine serosal surface in Fig 2). (d) Low-power photomicrograph (original magnification, x2; hematoxylin-eosin stain) of serous papillary carcinoma involving the paratubal and paraovarian soft tissues shows a prominent papillary growth pattern lined by cytologically malignant serous epithelium with destructive stromal invasion. The fallopian tube is seen in cross section (arrow).

View larger version (152K): [in a new window]   Figure 5d.  Local spread of ovarian carcinoma in a 77-year-old woman. (a) Transverse US image through the pelvis shows an enlarged, predominantly solid left ovary (arrow). (b) Axial CT image shows an irregular interface between the left ovary and the uterus (black arrow), a finding that suggests direct invasion. Irregular nodularity seen in the surrounding soft tissues (curved arrow) and a small amount of ascites (straight white arrow) are suggestive of stage IIC or higher disease. (c) Photograph of the uterus shows extensive implants involving the serosal surface (cf the normal uterine serosal surface in Fig 2). (d) Low-power photomicrograph (original magnification, x2; hematoxylin-eosin stain) of serous papillary carcinoma involving the paratubal and paraovarian soft tissues shows a prominent papillary growth pattern lined by cytologically malignant serous epithelium with destructive stromal invasion. The fallopian tube is seen in cross section (arrow).

View larger version (153K): [in a new window]   Figure 6a.  Direct uterine invasion. (a, b) Axial T2-weighted MR images show a complex, mixed cystic and solid mass of the ovary (a), which has invaded the myometrium (arrows) (b). (c) Photograph of the uterus shows irregular thickening of the myometrium in the area of invasion (arrow).

View larger version (150K): [in a new window]   Figure 6b.  Direct uterine invasion. (a, b) Axial T2-weighted MR images show a complex, mixed cystic and solid mass of the ovary (a), which has invaded the myometrium (arrows) (b). (c) Photograph of the uterus shows irregular thickening of the myometrium in the area of invasion (arrow).

View larger version (116K): [in a new window]   Figure 6c.  Direct uterine invasion. (a, b) Axial T2-weighted MR images show a complex, mixed cystic and solid mass of the ovary (a), which has invaded the myometrium (arrows) (b). (c) Photograph of the uterus shows irregular thickening of the myometrium in the area of invasion (arrow).

View larger version (128K): [in a new window]   Figure 7.  Bilateral serous cystadenocarcinomas with encasement of the right external iliac vessels. Axial CT image shows the irregular interface between the tumor and the vessels (white arrow) and the extension to the opposite side (black arrow), indicating encasement.

View larger version (64K): [in a new window]   Figure 8.  Drawing illustrates stage III ovarian carcinoma. Metastases may be on the liver capsule (peritoneal seeding) but not within the parenchyma (hematogenous metastases). (Adapted from reference 12.)

View larger version (143K): [in a new window]   Figure 9a.  (a) Low-power photomicrograph (original magnification, x4; hematoxylin-eosin stain) of an omental biopsy specimen shows a noninvasive implant from a serous tumor of low malignant potential. Psammoma bodies (arrows) are present within the fibrous bands that track between adipose lobules. (b) Photograph of a surgical specimen shows small omental implants from clear cell carcinoma (arrows). These examples represent clinically important disease that would be difficult or impossible to detect with imaging.

View larger version (115K): [in a new window]   Figure 9b.  (a) Low-power photomicrograph (original magnification, x4; hematoxylin-eosin stain) of an omental biopsy specimen shows a noninvasive implant from a serous tumor of low malignant potential. Psammoma bodies (arrows) are present within the fibrous bands that track between adipose lobules. (b) Photograph of a surgical specimen shows small omental implants from clear cell carcinoma (arrows). These examples represent clinically important disease that would be difficult or impossible to detect with imaging.

View larger version (130K): [in a new window]   Figure 10a.  Stage III endometrioid carcinoma. (a, b) Axial CT images through the upper abdomen (a at a higher level than b) show multiple implants along the diaphragm (curved arrow) and liver capsule (straight arrows). Note how visualization and tumor localization is aided by the presence of ascites. (c) Axial CT image through the pelvis shows more peritoneal involvement (arrows) and bilateral ovarian tumors.

View larger version (132K): [in a new window]   Figure 10b.  Stage III endometrioid carcinoma. (a, b) Axial CT images through the upper abdomen (a at a higher level than b) show multiple implants along the diaphragm (curved arrow) and liver capsule (straight arrows). Note how visualization and tumor localization is aided by the presence of ascites. (c) Axial CT image through the pelvis shows more peritoneal involvement (arrows) and bilateral ovarian tumors.

View larger version (124K): [in a new window]   Figure 10c.  Stage III endometrioid carcinoma. (a, b) Axial CT images through the upper abdomen (a at a higher level than b) show multiple implants along the diaphragm (curved arrow) and liver capsule (straight arrows). Note how visualization and tumor localization is aided by the presence of ascites. (c) Axial CT image through the pelvis shows more peritoneal involvement (arrows) and bilateral ovarian tumors.

View larger version (151K): [in a new window]   Figure 11a.  Stage III ovarian carcinoma. (a) Axial CT image shows a fine reticulonodular pattern of the omentum (curved arrow) and an abnormally thickened, nodular loop of bowel (straight arrow). (b) Photograph of serial sections taken through the omentum shows multiple firm, tan, metastatic nodules. (c) Photograph of the resected small bowel loop, which was described as "stiff and leathery," demonstrates the irregular, "shaggy" appearance of the serosal surface, secondary to studding with tumor implants (arrows).

View larger version (134K): [in a new window]   Figure 11b.  Stage III ovarian carcinoma. (a) Axial CT image shows a fine reticulonodular pattern of the omentum (curved arrow) and an abnormally thickened, nodular loop of bowel (straight arrow). (b) Photograph of serial sections taken through the omentum shows multiple firm, tan, metastatic nodules. (c) Photograph of the resected small bowel loop, which was described as "stiff and leathery," demonstrates the irregular, "shaggy" appearance of the serosal surface, secondary to studding with tumor implants (arrows).

View larger version (60K): [in a new window]   Figure 11c.  Stage III ovarian carcinoma. (a) Axial CT image shows a fine reticulonodular pattern of the omentum (curved arrow) and an abnormally thickened, nodular loop of bowel (straight arrow). (b) Photograph of serial sections taken through the omentum shows multiple firm, tan, metastatic nodules. (c) Photograph of the resected small bowel loop, which was described as "stiff and leathery," demonstrates the irregular, "shaggy" appearance of the serosal surface, secondary to studding with tumor implants (arrows).

View larger version (163K): [in a new window]   Figure 12.  Axial CT image shows marked thickening of the omentum referred to as "omental cake" (white arrow). Also note thickening along the peritoneum and mesentery (black arrows).

View larger version (68K): [in a new window]   Figure 13.  Drawing illustrates stage IV ovarian carcinoma. There are distant metastases present, including in the hepatic parenchyma. (Adapted from reference 12.)

View larger version (107K): [in a new window]   Figure 14a.  Hepatic metastases from stage III versus stage IV ovarian carcinoma. (a) Axial CT image of stage III disease shows multiple, biconvex low-attenuation masses along the capsule of the liver. Some extend along the expected course of the falciform ligament (arrow), a finding that could be confused with intraparenchymal metastases. There is also a small implant on the spleen (arrowhead). (b) Axial CT image shows obvious intraparenchymal liver metastases, representing stage IV disease.

View larger version (116K): [in a new window]   Figure 14b.  Hepatic metastases from stage III versus stage IV ovarian carcinoma. (a) Axial CT image of stage III disease shows multiple, biconvex low-attenuation masses along the capsule of the liver. Some extend along the expected course of the falciform ligament (arrow), a finding that could be confused with intraparenchymal metastases. There is also a small implant on the spleen (arrowhead). (b) Axial CT image shows obvious intraparenchymal liver metastases, representing stage IV disease.

View larger version (164K): [in a new window]   Figure 15a.  Stage IV ovarian cancer. (a) Longitudinal US image through the midline of the pelvis shows a large, complex, cystic ovarian mass. Curved arrow = uterus. (b) Longitudinal US image of the right paracolic gutter demonstrates several peritoneal implants (arrows). (c) Axial US image at the level of the right hemidiaphragm shows multiple solid pleural masses (arrow) and an effusion.

View larger version (141K): [in a new window]   Figure 15b.  Stage IV ovarian cancer. (a) Longitudinal US image through the midline of the pelvis shows a large, complex, cystic ovarian mass. Curved arrow = uterus. (b) Longitudinal US image of the right paracolic gutter demonstrates several peritoneal implants (arrows). (c) Axial US image at the level of the right hemidiaphragm shows multiple solid pleural masses (arrow) and an effusion.

View larger version (151K): [in a new window]   Figure 15c.  Stage IV ovarian cancer. (a) Longitudinal US image through the midline of the pelvis shows a large, complex, cystic ovarian mass. Curved arrow = uterus. (b) Longitudinal US image of the right paracolic gutter demonstrates several peritoneal implants (arrows). (c) Axial US image at the level of the right hemidiaphragm shows multiple solid pleural masses (arrow) and an effusion.

View larger version (152K): [in a new window]   Figure 16a.  Stage III serous cystadenocarcinoma. (a-c) Axial CT images (obtained at successively lower levels) show diffuse calcifications of peritoneal metastases, including those in a prominent omental cake (arrow in b). (d) Medium-power photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows a noninvasive omental implant with prominent dark purple-staining psammoma bodies (cf Fig 9a).

View larger version (169K): [in a new window]   Figure 16b.  Stage III serous cystadenocarcinoma. (a-c) Axial CT images (obtained at successively lower levels) show diffuse calcifications of peritoneal metastases, including those in a prominent omental cake (arrow in b). (d) Medium-power photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows a noninvasive omental implant with prominent dark purple-staining psammoma bodies (cf Fig 9a).

View larger version (154K): [in a new window]   Figure 16c.  Stage III serous cystadenocarcinoma. (a-c) Axial CT images (obtained at successively lower levels) show diffuse calcifications of peritoneal metastases, including those in a prominent omental cake (arrow in b). (d) Medium-power photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows a noninvasive omental implant with prominent dark purple-staining psammoma bodies (cf Fig 9a).

View larger version (195K): [in a new window]   Figure 16d.  Stage III serous cystadenocarcinoma. (a-c) Axial CT images (obtained at successively lower levels) show diffuse calcifications of peritoneal metastases, including those in a prominent omental cake (arrow in b). (d) Medium-power photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows a noninvasive omental implant with prominent dark purple-staining psammoma bodies (cf Fig 9a).

View larger version (140K): [in a new window]   Figure 17a.  Mucinous tumor of low malignant potential. (a) Longitudinal US image of the abdomen demonstrates a large cystic mass with multiple loculi of varying echogenicities. (b) Axial CT scan shows a massive tumor filling the abdomen with loculi of varying attenuation.

View larger version (127K): [in a new window]   Figure 17b.  Mucinous tumor of low malignant potential. (a) Longitudinal US image of the abdomen demonstrates a large cystic mass with multiple loculi of varying echogenicities. (b) Axial CT scan shows a massive tumor filling the abdomen with loculi of varying attenuation.

View larger version (120K): [in a new window]   Figure 18a.  Pseudomyxoma peritonei. (a, b) Axial CT images show low-attenuation material throughout the abdomen, with mass effect and distortion and scalloping of the liver margin, particularly involving the left lobe (arrows in a). The bowel is matted posteriorly, and there are subtle septations (arrows in b). (c) Intraoperative photograph shows thick, gelatinous material exuding from the incision site. (d) Medium-power photomicrograph (original magnification, x40; hematoxylin-eosin stain) shows pools of acellular mucin dissecting through bands of fibrous tissue, an appearance compatible with the clinical diagnosis of pseudomyxoma peritonei.

View larger version (136K): [in a new window]   Figure 18b.  Pseudomyxoma peritonei. (a, b) Axial CT images show low-attenuation material throughout the abdomen, with mass effect and distortion and scalloping of the liver margin, particularly involving the left lobe (arrows in a). The bowel is matted posteriorly, and there are subtle septations (arrows in b). (c) Intraoperative photograph shows thick, gelatinous material exuding from the incision site. (d) Medium-power photomicrograph (original magnification, x40; hematoxylin-eosin stain) shows pools of acellular mucin dissecting through bands of fibrous tissue, an appearance compatible with the clinical diagnosis of pseudomyxoma peritonei.

View larger version (116K): [in a new window]   Figure 18c.  Pseudomyxoma peritonei. (a, b) Axial CT images show low-attenuation material throughout the abdomen, with mass effect and distortion and scalloping of the liver margin, particularly involving the left lobe (arrows in a). The bowel is matted posteriorly, and there are subtle septations (arrows in b). (c) Intraoperative photograph shows thick, gelatinous material exuding from the incision site. (d) Medium-power photomicrograph (original magnification, x40; hematoxylin-eosin stain) shows pools of acellular mucin dissecting through bands of fibrous tissue, an appearance compatible with the clinical diagnosis of pseudomyxoma peritonei.

View larger version (157K): [in a new window]   Figure 18d.  Pseudomyxoma peritonei. (a, b) Axial CT images show low-attenuation material throughout the abdomen, with mass effect and distortion and scalloping of the liver margin, particularly involving the left lobe (arrows in a). The bowel is matted posteriorly, and there are subtle septations (arrows in b). (c) Intraoperative photograph shows thick, gelatinous material exuding from the incision site. (d) Medium-power photomicrograph (original magnification, x40; hematoxylin-eosin stain) shows pools of acellular mucin dissecting through bands of fibrous tissue, an appearance compatible with the clinical diagnosis of pseudomyxoma peritonei.

View larger version (158K): [in a new window]   Figure 19a.  Poorly differentiated adenocarcinoma. (a) Axial CT scan through the pelvis shows bilateral ovarian masses. (b) Axial CT image through the level of the kidneys shows significant retroperitoneal adenopathy (arrow) but no obvious intraperitoneal disease.

View larger version (163K): [in a new window]   Figure 19b.  Poorly differentiated adenocarcinoma. (a) Axial CT scan through the pelvis shows bilateral ovarian masses. (b) Axial CT image through the level of the kidneys shows significant retroperitoneal adenopathy (arrow) but no obvious intraperitoneal disease.

View larger version (162K): [in a new window]   Figure 20.  Metastatic mucinous cystadenocarcinoma. Axial CT image obtained after administration of intravenous and oral contrast material shows a low-attenuation mass on the serosal surface of the ileum (arrowhead) as well as thickening along the peritoneal surface (arrows). Without adequate bowel opacification, the serosal implant could be easily missed.

View larger version (145K): [in a new window]   Figure 21.  Metastatic serous adenocarcinoma. Unenhanced axial CT image shows calcified serosal (arrows) and mesenteric (arrowhead) implants. These metastases could be potentially obscured if an oral contrast agent had been given.

View larger version (114K): [in a new window]   Figure 22a.  Implant on the liver capsule. (a) Axial CT scan shows a subtle low-attenuation area along the liver capsule (arrow). This finding could not be differentiated from a prominent diaphragmatic slip. (b) Axial T2-weighted, fat-suppressed MR image of the same area shows an obvious high-signal-intensity mass (arrow). (c) Axial gadolinium-enhanced, T1-weighted, fat-suppressed MR image demonstrates enhancement of the mass (arrow). (d) FDG PET images in the axial, sagittal, and coronal planes show uptake within the metastatic implant (arrow).

View larger version (137K): [in a new window]   Figure 22b.  Implant on the liver capsule. (a) Axial CT scan shows a subtle low-attenuation area along the liver capsule (arrow). This finding could not be differentiated from a prominent diaphragmatic slip. (b) Axial T2-weighted, fat-suppressed MR image of the same area shows an obvious high-signal-intensity mass (arrow). (c) Axial gadolinium-enhanced, T1-weighted, fat-suppressed MR image demonstrates enhancement of the mass (arrow). (d) FDG PET images in the axial, sagittal, and coronal planes show uptake within the metastatic implant (arrow).

View larger version (121K): [in a new window]   Figure 22c.  Implant on the liver capsule. (a) Axial CT scan shows a subtle low-attenuation area along the liver capsule (arrow). This finding could not be differentiated from a prominent diaphragmatic slip. (b) Axial T2-weighted, fat-suppressed MR image of the same area shows an obvious high-signal-intensity mass (arrow). (c) Axial gadolinium-enhanced, T1-weighted, fat-suppressed MR image demonstrates enhancement of the mass (arrow). (d) FDG PET images in the axial, sagittal, and coronal planes show uptake within the metastatic implant (arrow).

View larger version (23K): [in a new window]   Figure 22d.  Implant on the liver capsule. (a) Axial CT scan shows a subtle low-attenuation area along the liver capsule (arrow). This finding could not be differentiated from a prominent diaphragmatic slip. (b) Axial T2-weighted, fat-suppressed MR image of the same area shows an obvious high-signal-intensity mass (arrow). (c) Axial gadolinium-enhanced, T1-weighted, fat-suppressed MR image demonstrates enhancement of the mass (arrow). (d) FDG PET images in the axial, sagittal, and coronal planes show uptake within the metastatic implant (arrow).

View larger version (147K): [in a new window]   Figure 23a.  Diffuse peritoneal carcinomatosis from ovarian carcinoma. Axial T1-weighted (a), T2-weighted (b), and breath-hold contrast-enhanced T1-weighted, fat-suppressed (c) images demonstrate that the degree of peritoneal involvement is much better demonstrated on images obtained with fat suppression and after the administration of gadolinium (arrows in c).

View larger version (145K): [in a new window]   Figure 23b.  Diffuse peritoneal carcinomatosis from ovarian carcinoma. Axial T1-weighted (a), T2-weighted (b), and breath-hold contrast-enhanced T1-weighted, fat-suppressed (c) images demonstrate that the degree of peritoneal involvement is much better demonstrated on images obtained with fat suppression and after the administration of gadolinium (arrows in c).

View larger version (165K): [in a new window]   Figure 23c.  Diffuse peritoneal carcinomatosis from ovarian carcinoma. Axial T1-weighted (a), T2-weighted (b), and breath-hold contrast-enhanced T1-weighted, fat-suppressed (c) images demonstrate that the degree of peritoneal involvement is much better demonstrated on images obtained with fat suppression and after the administration of gadolinium (arrows in c).