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1 All authors: Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap-dong, Songpa-gu, Seoul 138-736, South Korea.
Received February 25, 2004;
accepted after revision May 17, 2004.
Address correspondence to K-S Cho
(kscho{at}amc.seoul.kr).
Abstract
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MATERIALS AND METHODS. CT scans of 17 patients with histologically proven serous surface papillary carcinoma of the ovary were retrospectively reviewed. We evaluated the ovary size, omental or mesenteric involvement (none, mild, or severe), ascites (none, small, moderate, or large), and peritoneal thickening (none, smooth, or nodular).We also noted the presence of a cul-de-sac mass, lymphadenopathy, and calcification within the peritoneal mass. The preoperative serum level of cancer antigen (CA)-125 was assessed in all patients.
RESULTS. The diameter of ovaries was 3 cm or smaller in 14 patients (82%). All patients had omental or mesenteric involvement by the tumor (mild, n = 2; severe, n = 15) and ascites (small, n = 1; moderate, n = 3; large, n = 13). Peritoneal thickening (smooth, n = 5; nodular, n = 10) was noted in 15 patients (88%) and a cul-de-sac mass in 10 (59%). Lymphadenopathy was noted in five patients (29%) and calcification within the peritoneal mass in one (6%). Serum CA-125 level was elevated in all patients (168–63,300 U/mL).
CONCLUSION. Serous surface papillary carcinoma of the ovary should be suggested as a diagnosis in patients who have peritoneal carcinomatosis, relatively normal-sized ovaries, and a highly elevated serum CA-125 level.
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Serous surface papillary carcinoma of the ovary has a better response to surgical reduction followed by chemotherapy than peritoneal carcinomatosis from other diseases [3]. Therefore, it is important to differentiate serous surface papillary carcinoma of the ovary from other, unresponsive forms of peritoneal carcinomatosis. The purpose of this study was to describe the CT features of serous surface papillary carcinoma of the ovary.
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Clinical symptoms and signs in these patients included abdominal pain (n = 11), abdominal distention (n = 6), and weight loss (n = 1). The duration of these symptoms and signs ranged from 1 to 24 months (mean ± SD, 3 ± 6 months). All patients underwent hysterectomy with bilateral salpingooophorectomy and omental resection. Serum cancer antigen (CA)-125 level was assessed in all patients within the 2 weeks before surgery.
CT scans were obtained using a single-detector helical CT scanner (Somatom Plus-S, Siemens) from the diaphragm to the symphysis pubis with a beam collimation of 8 or 10 mm, a pitch of 1.5 or 1.7, and image reconstruction increment of 8 mm. Approximately 600–900 mL of a contrast material (E-Z-CAT [barium sulfate suspension concentrate], EZ-EM) was administered orally in all patients 30–40 min before scanning. A second contrast material (100–120 mL of Lopamiro 300 [iopamidol], Bracco Diagnostics or Ultravist 300 [iopromide], Schering) was administered at a rate of 3.0 mL/sec IV in all patients, with injection starting approximately 90–110 sec before scanning.
Two radiologists retrospectively analyzed CT images by consensus. They evaluated the size of the ovaries, degree of omental or mesenteric involvement, amount of ascites, degree of peritoneal involvement, and presence or absence of a posterior cul-de-sac mass, lymphadenopathy, and calcification. The ovarian size was estimated using the greatest diameter of the ovary. The degree of omental or mesenteric involvement was graded as none, mild, or severe. Mild degree was indicated if only infiltration was noted in the omentum and mesentery, whereas severe degree was considered present if there were masses. The amount of ascites was classified as none, small (in either abdomen or pelvis), moderate (in both abdomen and pelvis, but abdomen was not distended), or large (in both abdomen and pelvis, and abdomen was distended). Peritoneal involvement was graded as none, smooth thickening, or nodular thickening. Lymphadenopathy was considered to be present if the short-axis diameter of a lymph node was 1 cm or greater. The location of lymphadenopathy was divided into abdomen and pelvis; the border between abdomen and pelvis was determined by the aortic bifurcation to the common iliac arteries.
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The results of the analysis of the degree of omental or mesenteric involvement, the amount of ascites, the degree of peritoneal involvement, and the presence or absence of a posterior cul-de-sac mass, lymphadenopathy, and calcification are summarized in Table 1. Ascites and omental or mesenteric involvement were noted in all patients (Figs. 1A, 1B, 1C and 3A, 3B). Thirteen patients (76%) had large amount of ascites, and mass formation in the omentum or mesentery was noted in 15 (88%). Two patients with only infiltration in the omentum and mesentery had serum levels of CA-125 of 168 U/mL and 11,500 U/mL. Peritoneal thickening was found in 15 patients (88%), and 10 patients (59%) had nodular peritoneal thickening (Fig. 1A, 1B, 1C). In 14 (93%) of the 15 patients with peritoneal thickening, the thickening was in both the abdomen and pelvis; in the remaining patient (7%), peritoneal thickening was only in the pelvis. A posterior cul-de-sac mass was identified in 10 patients (59%). Lymphadenopathy was noted in five patients (29%), and the location of lymphadenopathy included the external iliac (n = 1), common iliac (n = 3), paraaortic (n = 5), and retrocaval areas (n = 1) (Fig. 3A, 3B).
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On the basis of the findings of CT, chest radiography, and the physical examination, we determined that no patient had hematogenous metastasis to other organs, and abdominal CT scans showed no foci suspected to represent primary malignancy, such as gastric wall thickening, a mass in the pancreas tail, or a mass in the colon.
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Treatment results and prognosis for patients with serous surface papillary carcinoma of the ovary remains controversial. Although Mills et al. [3] described a significantly worse prognosis for women with serous surface papillary carcinoma of the ovary than for those with stage III–IV serous papillary ovarian carcinoma, a recent report showed that serous surface papillary carcinoma of the ovary responded completely to initial cytoreductive surgery followed by platinol (Cisplatin, Bristol-Myers Squibb)-based chemotherapy [4]. Another report presented evidence of long-term survival of patients with serous surface papillary carcinoma of the ovary [7]. Therefore, a radiologist's suggestion of serous surface papillary carcinoma of the ovary may be important in alerting the treating physician to the unique potential value of cytoreductive surgery in patients with findings characteristic of this disease.
Several reports have described the most characteristic CT features of serous surface papillary carcinoma of the ovary as mesenteric or omental involvement, ascites, peritoneal thickening, and normal-appearing ovaries [8–13]. Stafford-Johnson et al. [9] emphasized three distinct CT features that may distinguish serous surface papillary carcinoma of the ovary from other peritoneal carcinomatosis or peritoneal mesothelioma, including the absence of an ovarian mass and the presence of extensive peritoneal calcification and omental masses with marked omental calcification. However, our results showed minor differences from theirs: No patient in our study had extensive calcification, and one patient had only small calcifications in the pelvic cavity. Furthermore, some patients had relatively large ovarian masses, contrary to findings of previous studies. Zissin et al. [13] also reported that one or both adnexal masses exhibited soft-tissue density in six of 30 patients with pathologically proven serous surface papillary carcinoma of the ovary. In cases with radiologic findings of an enlarged ovary or adnexal mass, serous surface papillary carcinoma of the ovary cannot be differentiated from the other malignant ovarian neoplasms with peritoneal carcinomatosis or from Krukenberg's tumor.
The most important task in assessing cases of serous surface papillary carcinoma of the ovary is distinguishing between it and peritoneal carcinomatosis from another primary malignancy. As found in our study, the major abdominal organs—the stomach, colon, and pancreas—in patients with serous surface papillary carcinoma of the ovary appear to be normal. A previous report described mural thickening of the sigmoid colon and peritoneal carcinomatosis in some patients with serous surface papillary carcinoma of the ovary that was suggestive of primary colon cancer with peritoneal carcinomatosis; however, colonoscopy and barium enema could reveal no mural or luminal disease [13]. On imaging, the small foci of malignancy may not be identified, and some cases of gastrointestinal malignancy could be overlooked. Therefore, the absence of a visible primary tumor cannot always suggest the possibility of serous surface papillary carcinoma of the ovary or exclude the possibility of peritoneal carcinomatosis from another primary malignancy.
In this series, the serum CA-125 level was increased in all patients; moreover, in most patients, the level was above 200 U/mL. We believe that a highly elevated serum CA-125 level is a critical indicator that suggests the possibility of serous surface papillary carcinoma of the ovary. The CA-125 level is not as high in peritoneal carcinomatosis from a primary malignancy as that resulting from an ovarian malignancy. Furthermore, the serum CA-125 level can be used for estimating the effect of cytoreductive surgery or chemotherapy and monitoring the tumor recurrence [14].
In conclusion, serous surface papillary carcinoma of the ovary should be suggested as a diagnosis in patients with extensive peritoneal carcinomatosis, relatively normalsized ovaries, and a highly elevated serum CA-125 level.
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