Imaging in ovarian cancer

Ovarian cancer affects mainly post-menopausal women but is not uncommon in premenopausal women.
.
The presentation of ovarian cancer is usually delayed,
and therefore early detection of disease is important.
.
Imaging has an important role in the detection and
characterisation of adnexal masses with the
primaryimaging modality being transvaginal ultrasound.
.
Cross-sectional imaging is useful to assess the extent of
disease prior to surgery, for monitoring treatment
response and for detecting recurrence.

Ovarian cancer is the fifth most common cancer affecting women in the UK and is associated with a worse prognosis
than other forms of gynaecological malignancy. There are increasing numbers of women presenting with ovarian
cancer over the age of 65 years. The diagnosis of ovarian cancer is often delayed, owing to the lack of symptoms and
the non-specific nature of the disease, particularly in the early stages. The prognosis of advanced ovarian cancer is
poor in the later stages, making early detection of malignancy important. On current classification systems, the
staging of ovarian cancer remains surgical but the role of imaging is contributory throughout the management of
ovarian cancer which defines disease burden. The primary imaging modality for detection of ovarian disease is
transvaginal ultrasound, and CT imaging is predominantly used in the staging of ovarian cancer with MRI being
reserved as a problem-solving technique, especially in younger women where benign disease is more likely. Newer
modalities such as positron emission tomography CT are increasingly being recognised in ovarian cancer where
recurrent disease can be diagnosed more quickly with subsequent treatment. The role of imaging is discussed with
reference to the different imaging modalities available in the assessment of ovarian malignancy.
Ovarian cancer is the second most common gynaecological cancer and is associated with higher mortality rates
compared with other forms of gynaecological malignancy. The incidence of ovarian cancer is approximately 7000
cases per year in the UK [1]. The majority of cases occur in women aged over 60 years, but approximately 10% of
cases occur in younger women. Risk factors for ovarian cancer include nulliparity, early menarche, childbirth after 35
years, late menopause and hereditary cancer syndromes. Ovarian stimulation drugs may slightly increase the risk of
ovarian cancer [2], but the use of the oral contraceptive pill is thought to be protective.
Patients are usually asymptomatic in the early stages and may present in the late stages with abdominal distension,
shortness of breath, fatigue or bony pain. Delayed diagnosis means a poorer prognosis with a survival rate of 520%
in Stage III or IV ovarian cancer compared with approximately 90% at Stage I [3]. The overall survival rate in ovarian
cancer has gradually increased but has not significantly changed in late-stage ovarian cancer, despite developments

in diagnosis and treatment [3]. Early detection requires a multidisciplinary approach, with a thorough clinical
assessment combined with appropriate imaging techniques and tumour markers.

Investigation
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Patients should initially undergo a pelvic bimanual examination, after which serum cancer antigen 125 (CA-125)
levels and a pelvic ultrasound may be performed. CA-125 is a poor marker for screening as only 50% of Stage I
tumours will elevate CA-125 [4]. More than 90% of Stage IV ovarian carcinomas will have raised CA-125 levels, and
levels correlate well with the stage of disease [4]. Certain ovarian tumours (e.g. mucinous and germ cell tumours) do
not elevate CA-125 levels [5], but CA-125 may be raised in many benign conditions including pancreatitis, cirrhosis,
peritoneal irritation and first trimester of pregnancy. Non-ovarian malignancies such as colonic, breast, lung and
pancreatic cancer can also lead to raised CA-125 levels [6, 7]. The specificity of CA-125 is higher when it is combined
with carcinoembryonic antigen (CEA) levels to give a CA-125/CEA ratio [8]. A CA-125/CEA ratio of 25 is more
specific for ovarian malignancy and a ratio of <25 is more likely to indicate a non-ovarian malignancy or benign
disease. CA-125 is a useful marker for predicting tumour recurrence and in post-menopausal women. The trend and
persistence of tumour markers are more useful than a single assay level. The trend and persistence of high values
are more useful than single markers assays.
The initial imaging investigation for suspected ovarian malignancy is pelvic ultrasound, which includes
transabdominal and transvaginal ultrasound (TVUS). TVUS as an initial screening test can lead to a high number of
indeterminate lesions, which have been shown to increase the number of surgical interventions due to high falsepositive rates [9]. This can be reduced by assessing the persistence of abnormal features after a suitable time interval
and information from pelvic examination, CA-125 levels and other tumour markers. Therefore, a multidisciplinary
discussion of the positive findings is essential to ensure that patients are managed appropriately [10].

Screening
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Screening for ovarian cancer has been advocated by some authors, both in the general population [4, 11] and in
women at high risk [12]. Women with three or more first-degree relatives are at a substantially higher risk than the
general population, with a lifetime risk of 1660% compared with 1.3% in the general population [13, 14]. BRCA1 is
associated with a higher risk of high-grade serous tumours [15]; BRCA2, hereditary non-polyposis cancer (HNPCC)
and Lynch syndromes (hereditary breast, ovarian, colonic and endometrial cancer) are all associated with a higher
risk of ovarian carcinoma. Unfortunately, no precursor lesion has been identified for serous ovarian cancer and there
is currently no evidence to support screening in women with a genetic predisposition [16]. The American College of
Radiology recommends screening for high-risk women [17] as women with the BRCA gene are more likely to have
longer median survival rates compared with sporadic ovarian cancer [18]. At present, large clinical screening trials
have not shown a reduction in mortality in these patients [2]; however, there are trials currently being undertaken that
are assessing the effectiveness of screening in the general population: the UK Collaborative Trial of Ovarian Cancer
Screening (UKTOCS) and the UK FOCSS (Familial Ovarian Cancer Screening Study), which is assessing screening
of high risk women.

Histopathology
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Ovarian tumours are graded as well (10%), moderately (25%) and poorly differentiated (65%) [14]. The better
differentiated and the lower the grade of tumour, the better the prognosis. Haematoeoxylin and eosin (H&E) staining
is diagnostic in most cases, although further immunohistological stains (e.g. cytokeratins) are useful in differentiating
primary from metastatic tumours, with a CK7+ve/CK20ve profile being typical of a primary ovarian tumour [19]. The
most common type of primary ovarian tumours are epithelial tumours (8590%), which are subtyped as serous
(50%), mucinous (20%), endometriod (20%), clear cell (10%) or undifferentiated (1%) [20]. Another subtype of
epithelial tumour is the Brenner tumour, which is usually benign. Non-epithelial tumours include sex cord stromal
tumours or germ cell tumours.
Benign serous cystadenomas resemble the cells that line the fallopian tubes. They are usually unilocular and thinwalled, and may mimic physiological cysts with homogeneous internal contents, although occasionally they have
inner papillary projections. More than 50% of cases are bilateral and typically occur in women aged 7075 years old.
Serous adenocarcinomas tend to be high grade and are associated with BRCA genes. These tumours are associated
with a disproportionately large volume of ascites, and widespread peritoneal carcinomatosis and omental cake at
diagnosis.
Mucinous tumours are composed of cells similar to those found in the endocervix, gastric pylorus or intestine, and do
not secrete CA-125. They form from epithelial cells containing intracytoplasmic mucin. Malignant mucinous tumours
are more likely to be found in older women, and are characterised by larger, unilateral, multiseptated masses, often
with an enhancing solid component and thick irregular walls and septations. Haemorrhagic, necrotic, solid or papillary
areas are frequently found in malignant tumours [21]. Benign mucinous cystadenomas are unilateral and almost
always composed of simple or septate thin-walled structures with no solid areas. They have a variable composition of
mucin within the cavities of the tumour, leading to differing density on cross-sectionalimaging or varying echogenicity
on ultrasound.
Endometroid tumours resemble the cells that line the endometrium and are associated with endometriosis in 42%
[22] and endometrial carcinoma in 1520% [23] of cases. They present with bilateral mixed solid and cystic tumours.
Approximately 50% of women with endometriosis and ovarian cancer have clear cell tumours, which are always
malignant and behave aggressively. They typically present with a solitary complex mass with a solid mural nodule
and may arise within an existing endometrioma [24]. They are composed of glycogen-containing clear cells, and
common cell types include papillary and tubulocystic tumours with cells staining positively for CA-125 and CEA. Clear
cell carcinoma occurs in a slightly younger age group and is associated with a poorer prognosis compared with other
serous-type tumours.
Another group of tumours called borderline ovarian tumours can be serous or mucinous and are termed tumours of
low malignant potential. They make up 1015% of epithelial ovarian tumours [25] and occur mostly in younger
women. They are slow-growing tumours that present in early stages and may never progress into Stage I tumours. In
most cases, treatment is surgical, except in the presence of invasive peritoneal implants where chemotherapy is
indicated initially. Borderline mucinous tumours presenting with pseudomyxoma peritonei are increasingly being
recognised as metastatic from primary appendiceal tumours rather than originating from the ovary [26]. The most
discriminating feature of borderline tumours on ultrasound are papillary projections [27], although crosssectionalimaging features are non-specific in differentiating borderline tumours from Stage I tumours [28].
Non-epithelial tumours include granulosa cell tumours, dysgerminomas, immature teratomas, endodermal sinus
tumours and metastases. Sex cord tumours derive from ovarian stroma and account for less than 2% of ovarian
malignancy but can occur in perimenopausal women who present with abnormal uterine bleeding. Other diseases
that may resemble ovarian carcinoma radiologically are primary peritoneal or fallopian tube carcinomas, which also
present with ascites and peritoneal tumour implants.

Staging
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About 7075% of patients with ovarian cancer have tumour spread beyond the pelvis at the time of diagnosis [29].
Spread in ovarian cancer occurs primarily by intraperitoneal dissemination due to tumour cells shedding into the
peritoneum and being distributed in a clockwise fashion. The commonest sites for spread are the pouch of Douglas,
the right subphrenic space and the omentum [30]. Atypical sites include the ligamentum teres, gastrosplenic,
gastrohepatic ligaments and splenic hilum [31]. Local spread occurs within the pelvis, to the opposite ovary, uterus,
fallopian tubes, bladder, rectum and pelvic side wall. Nodal metastases spread via the lymphatics to the para-aortic
chain, along the ovarian vessels and via the broad ligament to the internal iliac, obturator and external iliac nodes.
Spread to superficial and deep inguinal nodes is via the round ligament. Distant metastases are rare at the time of
diagnosis, but metastatic sites include the liver, spleen, pleura, lung, adrenals and, less commonly, the skeleton and
brain.
Staging remains surgical and is performed in accordance with International Federation of Gynecology and Obstetrics
(FIGO) staging system (Table 1) [32]. Stage I refers to tumour confined to the ovaries, Stage II to ovarian cancer with
peritoneal metastases confined to the true pelvis, Stage III to extrapelvic peritoneal or abdominopelvic metastases
and Stage IV to metastases outside the abdomen and pelvis. The surgical procedure aims to stage regions according
to the spread of cancer and involves aspiration of ascites or washings of the pelvis and paracolic gutters. A total
hysterectomy and bilateral oophorectomy is usually performed. Fertility preservation can only be considered in
patients with Stage IA disease, where dilatation and curettage, unilateral oophorectomy and inspection of
the contralateral ovary are undertaken. All organs and peritoneal surfaces are visualised for disease spread. An
infracolic omentatectomy and biopsies of the pelvic peritoneum, cul-de-sac, bladder reflection, paracolic gutters and
diaphragm are performed [29]. Any suspicious lymph nodes are excised, although some authors advocate systematic
excision of bilateral obturator, left renal vein and retroperitoneal nodes [33]. Appendectomy is recommended in
suspected mucinous tumours [34]. Overall survival is improved in patients who have lymphadenectomy even in early
stage carcinoma [35]. Despite the comprehensive staging of ovarian cancer, 30% of patients with apparent Stage I or
II disease are surgically understaged [36]. Imaging can help pre-operative planning by identifying the extent and
location of disease, and whether specialist input from other surgical teams is required (e.g. with serosal disease,
where bowel resection may be required).

Table 1. International Federation of Gynecology and Obstetrics

staging system for ovarian cancer

Table 1.International Federation of Gynecology and Obstetrics staging system for ovarian cancer

Percenta
5-year
Stag
ge at
Description surviva
e
diagnosis
l
I
25%
Grossly
85%
confined to
one of both
ovaries
IA:
Intracapsula
r and
unilateral
IB:
a

Percenta
5-year
Stag
ge at
Description surviva
e
diagnosis
l
Intracapsula
r and
bilateral
IC: Actual
or potential
microscopic
peritoneal
contaminati
on
IIA:
Involvemen
t of
fallopian
tubes or
uterus
IIB:
Involvemen
t of other
pelvic
II 25%
55%
tissues e.g.
sigmoid
pelvic
implants
IIC: Actual
or potential
microscopic
peritoneal
contaminati
on
IIIA:
Microscopic
abdominal
implants
IIIB: <2 cm
abdominal
III 25%
14%
implants
IIIC: >2 cm
abdominal
implants or
positive
nodes
IV 25%
Distant
4%
a

Percenta
5-year
Stag
ge at
Description surviva
e
diagnosis
l
spread
(e.g.maligna
nt pleural
effusion,
intrahepatic
metastases)
a

Source: Kurtz AB, Tsimakas, Tempany CMC, Hamper UM, Arger PH, Bree RL, et al. Diagnosis and staging of
ovarian cancer: comparative values of doppler and conventional US, CT and MRimagingcorrelated with surgery and
histopathologic analysisreportof theRadiology Diagnostic Oncology Group.Radiology1999;212:1927.
a

Treatment
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The standard management of ovarian carcinoma is primary debulking surgery (PDS) followed by chemotherapy.
Stages IIII are primarily treated with surgical cytoreduction and Stage IV is managed with chemotherapy. PDS refers
to initial resection of all tumour sites leaving no macroscopic residual disease. In advanced cases, complete surgical
resection may not be possible and optimal disease reduction with residual sites of less than 12cm is considered
acceptable [37]. PDS should be performed by a trained gynae-oncology surgeon, preferably in a cancer centre [38].
Surgical disease volume reduction facilitates the response to chemotherapeutic agents [39] by reduction in tumour
bulk, which responds more effectively and improves overall survival [40, 41].
It is important for radiologists to differentiate between the different stages of ovarian cancer and to identify sites of
disease that preclude optimal debulking surgery and where neoadjuvant chemotherapy is indicated. Sites of disease
that are important to identify are diaphragmatic disease, mesenteric root disease, retroperitoneal and portal triad
nodes. In these cases, aggressive debulking surgery may be necessary in order to achieve a substantial reduction of
tumour burden and may include radical pelvic surgery, bowel resection, the resection of diaphragmatic disease or
removal of upper abdominal organs. Interval debulking surgery (IDS) may be performed after neoadjuvant
chemotherapy to further reduce the tumour burden or after initial suboptimal PDS, and therefore it is necessary to
have repeat imaging studies to assess tumour residuum. Optimal primary debulking surgery followed by adjuvant
chemotherapy has a better prognosis than IDS [42], but the timing of surgery, especially in patients with advanced
ovarian carcinoma, remains controversial [43], as initial trials suggest that neoadjuvant groups and groups
undergoing PDS have no significant difference in outcome [44]. The primary chemotherapy agents are a combination
of platinum-based drugs and taxanes, commonly carboplatin and paclitaxel. Neoadjuvant chemotherapy includes
carboplatin and combination therapy, depending on the performance status. Second-line chemotherapy depends on
the relapse-free interval, and specifically the platinum-free interval. The majority of patients will relapse following the
initial treatment, and secondary cytoreductive surgery may be beneficial in those patients where there is at least a 12month treatment-free survival and a good performance status following PDS [45, 46]. Imaging plays an important role
in the ongoing staging of patients with ovarian carcinoma who may still have both surgical and chemotherapeutic
interventions.

Imaging
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Ultrasound
The majority of patients with suspected ovarian cancer will undergo a pelvic ultrasound, which includes both
transabdominal and TVUS. Transabdominal scans evaluate larger pelvic masses and focused ultrasound with TVUS
due to the close proximity of the probe allows a more focussed assessment of the ovaries and adnexal masses. The
size and morphology of the ovaries and the relationship of any pelvic masses to the ovaries and uterus can be
assessed. The internal composition of a mass can be determined and whether it is predominantly solid or cystic,
unilocular or multilocular. The vascularity of solid components and the presence of calcification or internal septae can
be demonstrated well on ultrasound. Simple follicular cysts, corpus luteal cysts, endometriomas and benign cystic
teratomas can be identified confidently with ultrasound and will obviate the need for furtherimaging (Figure 1). Simple
cysts <5cm are likely to be benign, especially in premenopausal women [47], and are best followed up on ultrasound,
usually at 6 weeks when the patient is in another period of their menstrual cycle. Persistent cysts (especially in postmenopausal women) will require a gynaecological assessment and tumour markers [48].

Figure 1. A homogeneous hyperechoic left adnexal mass in a young female typical of a benign cystic teratoma. In some
dermoid cysts, the posterior wall of the cyst is ill-defined due to posterior acoustic shadowing; this is termed the tip of
the iceberg sign.

Enlarging ovaries, or an enlarged ovary that is more than 20cm3 in a pre-menopausal woman or more than 8cm3 in a
post-menopausal woman, should be investigated [49], where the risk of malignancy is high. The features on
ultrasound that are strong predictors of malignancy are solid components, multilocularity, internal papillary or frondlike projections, thick septations (>3mm), wall thickness (>3mm) and central vascularity (Figure 2) [50]. A solid
component within a mass is statistically the most significant predictor of malignancy [51]. Extra-ovarian findings such
as ascites, peritoneal disease and suspicious lymph nodes or parenchymal metastases increase the likelihood of
malignancy. Lesions less than 1cm in thickness, serosal, omental, mesenteric or retroperitoneal disease are less
likely to be identified on ultrasound [52].

Figure 2. Transvaginal ultrasonography shows a multilocular cystic lesion in the right adnexal, which contains thick internal
septations and an internal solid nodule (star). This was confirmed on histopathology as a borderline ovarian tumour.

Doppler findings can increase the specificity for predicting malignancy [53]. Benign tumours tend to have peripheral
vascularity and a regular branching pattern of vessels, whereas high-velocity and low-impedance diastolic flow within
a mass is suggestive of malignancy [54]. This manifests with a low resistive index (RI) of less than 0.41 and a
pulsatility index (PI) of less than 1.0 (Figure 3). In practice, these indices should not be used alone as values overlap
in benign and malignant lesions [55, 56]. Abnormal RI and PI values occur in benign inflammatory lesions and in the
normal corpus luteum, so patients with normal menstrual cycles should ideally be scanned in the first 10 days of
thecycle to avoid confusion with the normal changes in intraovarian blood flow [57].

Figure 3. A solid mass within the left ovary clearly demonstrating central internal blood flow in a complex cystic mass with
abnormal doppler indices (pulsatility index <1, resistive index <0.41).

The sensitivity of ultrasound for detecting malignancy is in the order of 88100% and specificity of 6296% [58].
Ultrasound has a lower detection rate for peritoneal metastases than CT or MRI [59] and certain tumours such as
borderline ovarian tumours may be more difficult to assess accurately, although the presence of papillae or multiple
septae is suggestive (Figure 4) [27]. Various scoring systems have been developed to guide whether a lesion is
benign or malignant. The Risk of Malignancy Index (RMI) is the commonest system, using serum CA-125 levels, an
ultrasound score and the menopausal status [60]. The ultrasound score is made up of one point each for the following
features: a multilocular cyst, solid areas, metastases, presence of ascites and bilateral lesions. The menopausal
score is 3 for a post-menopausal woman and 1 for a pre-menopausal woman. A score of more than 250 is considered
a high risk for malignancy and patients should be managed in a specialist oncology centre. A score between 25 and
250 can be managed in a cancer unit or by a gynae-oncologist [10].

Figure 4. Transabdominal ultrasonography showing a large complex thin-walled cystic pelvic mass containing fine internal
septations (arrow). A CT scan prior to surgery was performed to assess for extrapelvic disease. Thin septations are also
seen on CT and there is altered content within the cavities.

With indeterminate lesions on ultrasound, further investigation with MRI is warranted. Ultrasound is useful for
directing ascitic diagnostic taps, paracentesis and guiding biopsies of omental or peritoneal disease. This is important
in patients with advanced disease, who may not be fit enough to undergo primary debulking surgery but are
candidates for neoadjuvant chemotherapy.

MRI
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Pelvic MRI should be performed with a moderately full bladder and an antiperistaltic agent such as hyoscine
butylbromide (Buscopan; Boehringer Ingelheim, Ingelheim, Germany) or glucagon (Glucagen; Novo Nordisk,
Bagsvrd, Denmark) to reduce bowel motility. Although not used in our centre, a negative contrast agent such as 2%
barium can be used to distend the bowel and improve the detection of serosal deposits [61]. Standard sequences of
the pelvis include axial T1, axial T2 and sagittal T2 images. High-resolution sequences should be performed through
the pelvis and fat-saturated sequences help to distinguish between fat and haemorrhage (Figures 5 and 6) [62]. In
the upper abdomen, images should be obtained from the renal hilum down to the pubic symphysis to assess for
retroperitoneal lymphadenopathy and hydronephrosis in those patients not undergoing staging CT. Post-gadolinium
fat-suppressed T1 weighted images are useful for characterising the internal structure of lesions and to improve the
detection of solid components [63]. Pre- and post-contrast fat-suppressed T1 weighted breath-hold sequences are
important for detecting small peritoneal implants [64, 65].

Figure 5. (a) Axial T1 weighted fast spin echo MRI showing a well-defined complex pelvic mass containing high-signal
material superiorly. (b) T1 weighted fat-suppressed sequences demonstrate signal drop-out in the superior aspect of this
mass (star), indicating the presence of macroscopic fat, which is consistent with a benign cystic teratoma.

Figure 6. A tubulocystic mass in the pouch of Douglas is demonstrated well on axial and sagittal MRIimages. The
appearances are those of a haematosalpinx. The structure is hyperintense on the axialT1 weighted images and becomes
more conspicuous on fat-suppressed sequences. Not the intermediate signal intensity on the sagittal T2 weighted sequence.

MRI is not widely used in ovarian cancer in some centres and may relate to cost issues, lack of availability and the
variability of study quality. Both CT and MRI are superior to ultrasound in the assessment of the nature of ovarian
masses, with the highest accuracy for MRI [66]. MRI is useful in the assessment of local tumour invasion and for
evaluating local spread to the uterus, bladder, rectum or pelvic sidewall. Similar to CT, it can be used to detect tumour
residuum or recurrence. Due to the lack of ionising radiation, MRI is indicated in patients who are allergic to iodinated
contrast, pregnant patients and younger women. It has a higher specificity than ultrasound [66], and is helpful in
characterising lesions where ultrasound and CT examinations have been inconclusive; it is most useful in those with
a low likelihood of malignancy where surgery can be avoided [67, 68]. Its multiplanar capability and better soft tissue
characterisation relating to tissue signal characteristics make it more useful than CT or ultrasound in helping to
confirm benign disease (Figure 6). However, it is not suitable for all patients, such as those with claustrophobia, a
large body habitus and those with MRI-incompatible metallic implants or difficulties with breath-holding.
The features that increase the suspicion for malignancy on MRI are similar to those found on ultrasound with solid
non-fatty, non-fibrous tissue or cysts with thick walls, septations and papillary projections. Papillary projections are
seen in 92% of malignant tumours [61]. The most predictive features for malignancy are enhancing tissue (Figure 7),
vegetations in a cystic lesion, a diameter of more than 6cm and necrosis [69, 70]. Pelvic organ invasion, implants,
ascites and enlarged lymph nodes increase the likelihood of malignancy. Uterine invasion is identified as distortionof
the uterine contour, an irregular interface between the tumour and the myometrium and increased signal intensityof
the myometrium. Loss of the fat plane between the solid component of the tumour and the adjacent bowel
orbladder can indicate local invasion. Pelvic wall invasion can be diagnosed when tumour reaches the sidewall to
within 3 mm or when iliac vessels are surrounded and distorted [71].

Figure 7. A complex cystic pelvic mass in a 36-year-old woman. The internal septum and the nodule (arrow) demonstrate
enhancement following intravenous gadolinium and is therefore highly suggestive of malignancy.

In a prospective study of adnexal masses, MRI showed a sensitivity of 100% and specificity of 94% in diagnosing
malignancy [61]. The sensitivity for the detection of peritoneal disease greater than 1 cm in diameter is similar to that
of CT [66], although deposits within the mesentery, bowel wall implants or calcified deposits are better detected on
CT. Post-surgical appearances on MRI can be mistaken for disease, especially if there is thickening and
enhancement at the site of the incision. Similar sensitivities for MRI and CT have been reported for abdominopelvic
disease [58] and peritoneal metastases, but MRI is more accurate for lymph node metastases [61], local disease and
liver metastases.

CT
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CT is widely available and allows rapid evaluation of the whole abdomen and pelvis. Oral contrast may be helpful to
opacify the small bowel and colon to facilitate the differentiation of adnexal structures from bowel loops and pelvic
structures [71]. Patients with calcified peritoneal disease may have metastases obscured by positive oral contrast and
therefore require oral water (Figure 8). Patients are required to have a full bladder and are usually given 1l of dilute
(3%) Gastrografin (Bracco, Milan, Italy) at least 1h prior to the scan. The use of intravenous contrast helps to
characterise the internal structure of adnexal masses and to make peritoneal disease more conspicuous. Its mainstay
is in assessing extra-ovarian and distant disease, and disease that may be less amenable to surgery. Particular sites
where surgical resection may be more difficult are supradiaphragmatic (Figure 9), subdiaphragmatic recesses (Figure
10), liver parenchyma, supracolic omentum, suprarenal lymph nodes and small bowel mesentery (Figure 11).

Figure 8. Axial CT section through the lower abdomen showing calcified omental disease in a patient with mucinous
cystadenocarcinoma. This is distinguished from adjacent bowel, which contains a negative oral contrast agent.

Figure 9. Numerous paracardiac or cardio-phrenic lymph nodes (arrow) in a patient with Stage III ovarian cancer.

Figure 10. Nodular thickening of the right hemidiaphragm due to subdiaphragmatic disease. Note the peritoneal disease
medial to the spleen (arrow).

Figure 11. Ill-defined streaky soft tissue opacity in the root of the small bowel mesentery due to peritoneal disease (arrow).
There is also ascites in the right paracolic gutter.

The specific features of ovarian malignancy on CT are pelvic masses greater than 4 cm, cystic masses of variable
density, wall irregularity, thick septa (>3mm), vegetations and solid enhancing components within adnexal masses.
Peritoneal disease is highly suggestive of malignancy and is demonstrated as thickening, nodularity and abnormal
enhancement of the peritoneum. Calcified deposits within the peritoneum may be seen in serous cyst
adenocarcinomas [72]. Peritoneal disease is commonly seen in the paracolic gutter, omentum, bowel serosa (Figure
12), liver surface, subphrenic spaces and mesentery. It is important to review deposits close to the diaphragm on
coronal reformats (Figure 13) as deposits adjacent to the liver can be difficult to discriminate from subcapsular
deposits, which are Stage III disease, and liver parenchymal involvement, which is Stage IV disease (Figures
14 and15). Omental disease can be seen as generalised thickening or diffuse increased attenuation within the fat of
theanterior abdominal wall. Advanced disease may be characterised by suprarenal adenopathy, tumour extending
into abdominal or pelvic organs, hydroureter or pelvic sidewall invasion [73].

Figure 12. Extensive thickening and serosal disease of the sigmoid colon (arrow) with further peritoneal disease seen along
the right pelvic side wall.

Figure 13. Coronal reformats can help to identify subdiaphragmatic and subcapsular disease more easily. Note the
subdiaphragmatic disease inferior to the right hemidiaphragm (arrow).

Figure 14. There is an invasive subcapsular deposit in the posterior part of the right lobe of liver (arrow), which should not
be mistaken for a parenchymal metastasis. Significantly enlarged peri-portal lymphadenopathy (star) is also seen in this
patient with Stage III ovarian cancer.

Figure 15. A parenchymal metastasis in a patient with Stage IV ovarian cancer. Note the periportal lymphadenopathy and
left adrenal metastasis.

Pelvic ascites, although suggestive of malignancy, is not specific for malignancy, and may be present in ovarian
torsion, pelvic inflammatory disease and benign ovarian fibromas [74]. Abdominal ascites alone or the finding of
ascites anterior to the uterus is highly suggestive of peritoneal disease [75]. It is important to visualise pelvic
extension, assess for liver metastases, parenchymal disease and pleural effusions, as these are features of more
advanced disease and would usually be treated with neoadjuvant chemotherapy rather than surgery.
Although features on CT may appear typical for ovarian cancer, ascites, peritoneal disease, parenchymal metastases
and lymphadenopathy are also recognised features of other primary tumours such as colonic, gastric, pancreatic
carcinoma, primary peritoneal and fallopian tube carcinoma. CT may identify occult tumours other than ovarian
carcinoma or metastatic disease to the ovaries and it is important to differentiate these as the primary treatment for
these tumours will be chemotherapy rather than primary debulking surgery. In those unable to undergo radical
surgery, CT scanning can guide sites for biopsy of peritoneal or omental disease to obtain a histological diagnosis.
CT accuracy is inferior to surgical staging but has a reported accuracy of 7090% in staging pre-operative disease
[76], and a sensitivity of 92% and a specificity of 89% [77]. Modern CT scanners provide thinner slices, with better
resolution and better accuracy, allowing peritoneal deposits of 5mm or less to be identified [51]. CT is useful in
defining the extent of disease prior to staging laparotomy, for identifying acute complications such as bowel
obstruction in advanced disease and evaluating the response to chemotherapy. CT is used for detecting recurrence,

and can be used along with other forms of cross-sectional imaging such as MRI and newer modalities such as
positron emission tomography (PET)/CT.

Positron emission tomography CT

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PET/CT can detect extrapelvic disease and distant metastases, and is an alternative to CT imaging for the evaluation
of hypermetabolic implants, especially on the subdiaphragmatic, subhepatic, serosal and subcapsular surfaces
(Figure 16). Fluorodeoxyglucose (FDG) PET/CT combines metabolic information with the anatomical information
obtained from CT to increase the accuracy of imaging [78]. Although PET/CT can serve as both a primary staging tool
and for evaluating recurrence, its strength lies in detecting recurrence, where it is particularly useful in distinguishing
later stages of ovarian cancer, with an accuracy of 95% [79, 80]. Studies have reported low sensitivities and
specificities for detecting primary ovarian cancer [81, 82].

Figure 16. A subcapsular liver deposit is shown as a highly metabolic lesion on coronal positron emission
tomography/CT images (arrow). There is also left hydronephrosis.

The usefulness of PET/CT may be limited in pre-menopausal women, where high rates of false-positive results can
occur with benign disease and high false-negative results with borderline tumours, low-grade and early
adenocarcinomas [83]. Physiological uptake in the pelvis due to superimposed bladder and bowel activity can make
assessment of the pelvis challenging. Benign conditions such as endometriosis, hydrosalpinges, pedunculated
fibroids and benign ovarian tumours are associated with high uptake (Figure 17) [84]. Normal physiological uptake in
the ovaries occurs in the late follicular to early luteal phases and can mimic metastases (Figure 18) [85]. Ovarian
tracer uptake should therefore be correlated carefully with menstrual status and phase. A study by Castellucci
suggests that a standard uptake value (SUV) of 3 or more is positive for malignancy and a SUV of up to 2.7 is
considered benign [80]. Incidental avid ovarian uptake in a post-menopausal woman should be investigated further
with TVUS and correlated with CA-125 as uptake is unlikely to be physiological. Abnormal lymph nodes are better
detected on PET/CT as conventional imaging relies on size criteria to distinguish pathological nodes, but PET/CT
adds functional information (Figure 19). CT is traditionally very sensitive for detecting peritoneal implants but small
peritoneal implants less than 7mm may be difficult to identify on PET/CT. Studies report high a sensitivity of 87% and
specificity of 100% [86], although it is not the preferred technique of staging it is comparable in accuracy to CT. In
addition to CT, it can evaluate extrapelvic disease and distant metastases more easily demonstrated compared with
CT alone (Figure 20) [87]. It has been shown to more significantly influence the management of patients with
suspected disease recurrence where other studies have been negative or inconclusive [88].

Figure 17. A fused axial positron emission tomography/CT image showing no uptake in a benign cystic teratoma. Normal
bowel uptake is noted around the teratoma.

Figure 18. (a) Benign physiological uptake in both ovaries indicated by bilateral faint uptake. (b) Marked bilateral uptake
within the ovaries in a patient with ovarian metastases secondary to melanoma.

Figure 19. (a) There is a single enlarged aorto-caval node shown on CT (arrows) in a patient with known ovarian cancer. (b)
This node shows avid uptake on positron emission tomography/CT, indicating metastatic involvement. It was resected and
confirmed to represent recurrent disease.

Figure 20. (a) A metastatic lesion in the spleen in a patient with Stage IV ovarian cancer. (b) This lesion shows marked
uptake on the corresponding positron emission tomography/CT image.

Early diagnosis of disease relapse is important as up to 75% of patients with ovarian cancer will relapse [89], and
although CA-125 is a sensitive marker for relapse, relevant sites of recurrence need to be identified early (Figure 20).
PET/CT performs better than CT or MRI in the detection of recurrence [90], with high sensitivity for disease
recurrence (sensitivity 91%, specificity 88%) [91]. False-positives can occur in assessing patients following surgery,
with inflammatory change or fibrosis and in tumours less than 3 weeks post chemotherapy [92]. PET/CT can modify
treatment planning and is an important tool for patients with suspected recurrent disease where CT and MR have
been negative or inconclusive [93].

Conclusion
Section:
Choose

There are multiple imaging modalities available for the radiologist in assessing ovarian cancer. Ultrasound is useful
as a first-line investigation for suspected malignancy and identifying the need for further imaging. MRI can
characterise adnexal masses with more accuracy and may prevent surgery in those with benign pathology especially
in younger women. CT and MRI have a similar accuracy in the assessment of extrapelvic disease, but the wider
availability and reproducibility of CT makes it more useful in the pre-operative setting. Both CT and PET/CT are
utilised in assessing response to treatment, and detecting disease progression and relapse. PET/CT is less readily
available and is currently being implemented in specific settings such as detection of recurrence or for clarification of
disease in patients being considered for secondary debulking surgery.

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