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CT of Epithelial Ovarian Tumors¹

¹ From the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, Md. Recipient of a Certificate of Merit award for a scientific exhibit at the 1998 RSNA scientific assembly. Received January 20, 1999; revision requested February 12 and received March 9; accepted March 16. Address reprint requests to E.K.F., Department of Radiology, Johns Hopkins Hospital, 601 N Caroline St, Baltimore, MD 21287.

View larger version (194K): [in a new window]   Figure 1a.   Malignant serous cystadenocarcinoma of the ovary. (a) Low-power photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows papillary projections into a cyst (curved arrow). Note the normal ovary (straight arrow). (b) Higher-power photomicrograph (original magnification, x40; hematoxylin-eosin stain) shows a focus of invasive carcinoma (arrow). (Courtesy of Ralph Hruban, MD, Johns Hopkins Medical Institutions, Baltimore, Md.)

View larger version (211K): [in a new window]   Figure 1b.   Malignant serous cystadenocarcinoma of the ovary. (a) Low-power photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows papillary projections into a cyst (curved arrow). Note the normal ovary (straight arrow). (b) Higher-power photomicrograph (original magnification, x40; hematoxylin-eosin stain) shows a focus of invasive carcinoma (arrow). (Courtesy of Ralph Hruban, MD, Johns Hopkins Medical Institutions, Baltimore, Md.)

View larger version (150K): [in a new window]   Figure 2.   Papillary serous adenocarcinoma (stage IIIb). CT scan shows bilateral complex solid and cystic adnexal tumors (open arrows). The right tumor is closely associated with the pelvic side wall (curved arrow). At surgery, the right ovarian tumor was adherent to the right pelvic side wall and the cul-de-sac. At pathologic analysis, there was extensive tumor involvement of the right and left ovaries, right fallopian tube, and left peritubal soft tissue. B = bladder.

View larger version (134K): [in a new window]   Figures 3-5.   (3) Mucinous cystadenoma with a focus of low malignant potential (borderline malignancy) limited to the right ovary (stage Ia). CT scan shows a multiseptated tumor of low attenuation occupying the central portion of the pelvis. (4) Well-differentiated mucinous cystadenocarcinoma limited to the left ovary (stage Ia). CT scan shows a large, complex, cystic tumor with prominent solid-tissue elements (arrows). (5) Mucinous cystadenoma with a focus of low malignant potential (borderline malignancy) limited to the left ovary (stage Ia). CT scan shows a tumor with relatively high attenuation (20-30 HU), which reflects the high protein content of mucoid material.

View larger version (163K): [in a new window]   Figures 3-5.   (3) Mucinous cystadenoma with a focus of low malignant potential (borderline malignancy) limited to the right ovary (stage Ia). CT scan shows a multiseptated tumor of low attenuation occupying the central portion of the pelvis. (4) Well-differentiated mucinous cystadenocarcinoma limited to the left ovary (stage Ia). CT scan shows a large, complex, cystic tumor with prominent solid-tissue elements (arrows). (5) Mucinous cystadenoma with a focus of low malignant potential (borderline malignancy) limited to the left ovary (stage Ia). CT scan shows a tumor with relatively high attenuation (20-30 HU), which reflects the high protein content of mucoid material.

View larger version (152K): [in a new window]   Figures 3-5.   (3) Mucinous cystadenoma with a focus of low malignant potential (borderline malignancy) limited to the right ovary (stage Ia). CT scan shows a multiseptated tumor of low attenuation occupying the central portion of the pelvis. (4) Well-differentiated mucinous cystadenocarcinoma limited to the left ovary (stage Ia). CT scan shows a large, complex, cystic tumor with prominent solid-tissue elements (arrows). (5) Mucinous cystadenoma with a focus of low malignant potential (borderline malignancy) limited to the left ovary (stage Ia). CT scan shows a tumor with relatively high attenuation (20-30 HU), which reflects the high protein content of mucoid material.

View larger version (138K): [in a new window]   Figure 6.   Endometrioid carcinoma arising from the left ovary (stage IIc). CT scan shows a complex cystic and solid tumor with enhancement of the solid-tissue elements (arrow) and a thick, irregular wall.

View larger version (135K): [in a new window]   Figure 7.   Clear cell carcinoma arising from the left ovary (stage IV due to parenchymal liver metastases). CT scan shows a complex cystic and solid tumor with an irregular interface between the tumor and the myometrium (arrow). At pathologic analysis, the tumor involved the left ovary, left fallopian tube, and right peritubal soft tissue and extensively infiltrated the myometrium of the fundus and lower uterine segment.

View larger version (131K): [in a new window]   Figure 8.   Poorly differentiated carcinoma of the ovary. CT scan shows a small, plaquelike implant projecting from the parietal peritoneal surface along the undersurface of the right hemidiaphragm (curved arrow). Ascites can help in the detection of small peritoneal implants by outlining them with fluid. Thickening of the falciform ligament (straight arrow) and omentum (arrowheads) also suggests implants.

View larger version (129K): [in a new window]   Figures 9-11.   (9) Serous cystadenocarcinoma of the ovary. (a) CT scan shows ascites in the lesser sac (LS), which displaces the stomach (S) anteriorly. There are diffuse implants (arrows) along the omentum; the parietal peritoneum (right hemidiaphragm); subcapsular regions of the liver; and the gastrosplenic, splenorenal, and hepatogastric and hepatoduodenal ligaments. The surgical clip is from a prior omentectomy. (b) CT scan shows ascites in the greater sac. Nodular masses along the mesentery near the ileocecal junction represent implants (arrows). Also note the subtle implants surrounded by ascites along the parietal peritoneum of the anterior abdominal wall (arrowheads). (10) Serous cystadenocarcinoma of the ovary with psammoma bodies. CT scan shows diffuse, calcified implants along the peritoneum and pleura (arrows). There is a small right pleural effusion. (11) Serous cystadenocarcinoma of the ovary. CT scan shows extensive metastatic involvement of the peritoneum and omentum, which extends through the abdominal wall to the subcutaneous fat (arrow). The tumor also involves the bowel wall, causing encasement and stricture of the small and large intestine, which were confirmed at pathologic analysis. There is a markedly dilated bowel loop (B) in the right abdomen proximal to the obstruction. The fat plane between the anterior abdominal wall and the intestinal wall is obscured.

View larger version (116K): [in a new window]   Figures 9-11.   (9) Serous cystadenocarcinoma of the ovary. (a) CT scan shows ascites in the lesser sac (LS), which displaces the stomach (S) anteriorly. There are diffuse implants (arrows) along the omentum; the parietal peritoneum (right hemidiaphragm); subcapsular regions of the liver; and the gastrosplenic, splenorenal, and hepatogastric and hepatoduodenal ligaments. The surgical clip is from a prior omentectomy. (b) CT scan shows ascites in the greater sac. Nodular masses along the mesentery near the ileocecal junction represent implants (arrows). Also note the subtle implants surrounded by ascites along the parietal peritoneum of the anterior abdominal wall (arrowheads). (10) Serous cystadenocarcinoma of the ovary with psammoma bodies. CT scan shows diffuse, calcified implants along the peritoneum and pleura (arrows). There is a small right pleural effusion. (11) Serous cystadenocarcinoma of the ovary. CT scan shows extensive metastatic involvement of the peritoneum and omentum, which extends through the abdominal wall to the subcutaneous fat (arrow). The tumor also involves the bowel wall, causing encasement and stricture of the small and large intestine, which were confirmed at pathologic analysis. There is a markedly dilated bowel loop (B) in the right abdomen proximal to the obstruction. The fat plane between the anterior abdominal wall and the intestinal wall is obscured.

View larger version (144K): [in a new window]   Figures 9-11.   (9) Serous cystadenocarcinoma of the ovary. (a) CT scan shows ascites in the lesser sac (LS), which displaces the stomach (S) anteriorly. There are diffuse implants (arrows) along the omentum; the parietal peritoneum (right hemidiaphragm); subcapsular regions of the liver; and the gastrosplenic, splenorenal, and hepatogastric and hepatoduodenal ligaments. The surgical clip is from a prior omentectomy. (b) CT scan shows ascites in the greater sac. Nodular masses along the mesentery near the ileocecal junction represent implants (arrows). Also note the subtle implants surrounded by ascites along the parietal peritoneum of the anterior abdominal wall (arrowheads). (10) Serous cystadenocarcinoma of the ovary with psammoma bodies. CT scan shows diffuse, calcified implants along the peritoneum and pleura (arrows). There is a small right pleural effusion. (11) Serous cystadenocarcinoma of the ovary. CT scan shows extensive metastatic involvement of the peritoneum and omentum, which extends through the abdominal wall to the subcutaneous fat (arrow). The tumor also involves the bowel wall, causing encasement and stricture of the small and large intestine, which were confirmed at pathologic analysis. There is a markedly dilated bowel loop (B) in the right abdomen proximal to the obstruction. The fat plane between the anterior abdominal wall and the intestinal wall is obscured.

View larger version (137K): [in a new window]   Figures 9-11.   (9) Serous cystadenocarcinoma of the ovary. (a) CT scan shows ascites in the lesser sac (LS), which displaces the stomach (S) anteriorly. There are diffuse implants (arrows) along the omentum; the parietal peritoneum (right hemidiaphragm); subcapsular regions of the liver; and the gastrosplenic, splenorenal, and hepatogastric and hepatoduodenal ligaments. The surgical clip is from a prior omentectomy. (b) CT scan shows ascites in the greater sac. Nodular masses along the mesentery near the ileocecal junction represent implants (arrows). Also note the subtle implants surrounded by ascites along the parietal peritoneum of the anterior abdominal wall (arrowheads). (10) Serous cystadenocarcinoma of the ovary with psammoma bodies. CT scan shows diffuse, calcified implants along the peritoneum and pleura (arrows). There is a small right pleural effusion. (11) Serous cystadenocarcinoma of the ovary. CT scan shows extensive metastatic involvement of the peritoneum and omentum, which extends through the abdominal wall to the subcutaneous fat (arrow). The tumor also involves the bowel wall, causing encasement and stricture of the small and large intestine, which were confirmed at pathologic analysis. There is a markedly dilated bowel loop (B) in the right abdomen proximal to the obstruction. The fat plane between the anterior abdominal wall and the intestinal wall is obscured.

View larger version (152K): [in a new window]   Figures 12-14.   (12) Poorly differentiated carcinoma of the ovary. CT scan shows implants as enhancing nodules along the surface of the colon (straight arrows). The thickened, radiating pattern of the mesenteric leaves (curved arrow) also suggests mesenteric tumor implants. There is extensive ascites. (13) Poorly differentiated carcinoma of the ovary. CT scan shows diffuse reticulonodular stranding and enhancement in the omental fat, which represent diffuse omental implants. There is also ascites with enhancement and minimal thickening of the peritoneal surface (arrows), findings indicative of implants. (14) Adenocarcinoma of the ovary. CT scan shows diffuse soft-tissue nodules (arrows) between the anterior abdominal wall and small bowel loops; these nodules represent extensive omental implants.

View larger version (138K): [in a new window]   Figures 12-14.   (12) Poorly differentiated carcinoma of the ovary. CT scan shows implants as enhancing nodules along the surface of the colon (straight arrows). The thickened, radiating pattern of the mesenteric leaves (curved arrow) also suggests mesenteric tumor implants. There is extensive ascites. (13) Poorly differentiated carcinoma of the ovary. CT scan shows diffuse reticulonodular stranding and enhancement in the omental fat, which represent diffuse omental implants. There is also ascites with enhancement and minimal thickening of the peritoneal surface (arrows), findings indicative of implants. (14) Adenocarcinoma of the ovary. CT scan shows diffuse soft-tissue nodules (arrows) between the anterior abdominal wall and small bowel loops; these nodules represent extensive omental implants.

View larger version (144K): [in a new window]   Figures 12-14.   (12) Poorly differentiated carcinoma of the ovary. CT scan shows implants as enhancing nodules along the surface of the colon (straight arrows). The thickened, radiating pattern of the mesenteric leaves (curved arrow) also suggests mesenteric tumor implants. There is extensive ascites. (13) Poorly differentiated carcinoma of the ovary. CT scan shows diffuse reticulonodular stranding and enhancement in the omental fat, which represent diffuse omental implants. There is also ascites with enhancement and minimal thickening of the peritoneal surface (arrows), findings indicative of implants. (14) Adenocarcinoma of the ovary. CT scan shows diffuse soft-tissue nodules (arrows) between the anterior abdominal wall and small bowel loops; these nodules represent extensive omental implants.

View larger version (127K): [in a new window]   Figure 15.   Poorly differentiated adenocarcinoma of the ovary. CT scan shows a hypoattenuating mass in the posterior subcapsular region of the right hepatic lobe (straight arrow); the mass is growing into the liver parenchyma. A smaller mass (curved arrow) is seen near the portal vein.

View larger version (112K): [in a new window]   Figure 16.   Serous cystadenocarcinoma of the ovary. CT scan shows multiple subcapsular splenic implants with scalloped margins (straight arrows). Subcapsular liver implants are also seen (curved arrows).

View larger version (162K): [in a new window]   Figure 17.   Poorly differentiated adenocarcinoma of the ovary. The patient developed intractable nausea and vomiting during follow-up. CT scan shows a large cystic mass (m) arising from the posterior wall of the gastric fundus that markedly narrows the lumen. Endoscopic drainage of this mass revealed metastatic ovarian carcinoma.

View larger version (148K): [in a new window]   Figure 18.   Mucinous adenocarcinoma of the ovary. CT scan shows small bowel obstruction due to an ill-defined soft-tissue mass in the right pelvis that involves the distal small intestine (arrows). At pathologic analysis, metastatic adenocarcinoma was found to involve the serosa and smooth muscle of the small intestine.

View larger version (150K): [in a new window]   Figure 19.   Pseudomyxoma peritonei due to mucinous cystadenocarcinoma of the ovary. CT scan shows diffuse intraperitoneal hypoattenuating material in the lesser sac and greater sac with associated scalloping of the liver margin.

View larger version (121K): [in a new window]   Figure 20.   Mesodermal mixed tumor (carcinosarcoma) of the ovary. CT scan shows retroperitoneal adenopathy (arrows) at the level of the renal hilum. The affected nodes have low attenuation due to chemotherapy. A right nephrostomy tube is also evident and was placed to treat ureteral obstruction due to tumor implants in the pelvis.

View larger version (101K): [in a new window]   Figure 21.   Serous cystadenocarcinoma of the ovary. CT scan shows paratracheal and prevascular adenopathy, which is consistent with metastases.

View larger version (135K): [in a new window]   Figures 22-26.   (22) Malignant carcinoid tumor of the ovary. CT scan shows a mass with peripheral enhancement in the right lobe of the liver (arrow), a finding consistent with a liver metastasis. The liver has diffusely decreased attenuation due to fatty infiltration. (23) Endometrioid carcinoma of the ovary. CT scan shows a large metastatic mass (m) in the region of the pancreas that extends to the lesser sac and compresses the stomach (s). The mass also invades the anterior aspect of the left kidney (straight solid arrow). The splenic vein is occluded. There are tumor implants along the undersurface of the right hemidiaphragm (curved arrow), the posterior liver surface, and the fissure for the ligamentum teres (open arrows). Minimal ascites is noted around the liver. (24) Adenocarcinoma of the ovary with psammoma bodies. CT scan shows a large, calcified metastasis that involves the pancreas and displaces the posterior wall of the stomach anteriorly. The splenic vein is occluded. (25) Malignant granulosa cell tumor. The patient developed multiple lytic metastases involving the lumbar spine and pelvis. CT scan shows a lesion in the lumbar spine (arrow) that extends posteriorly through the cortex and effaces the thecal sac. (26) Adenocarcinoma of the ovary. CT scan shows multiple soft-tissue nodules in the subcutaneous tissue and skin of the right gluteal region (open arrows), with an ill-defined mass involving the right gluteus maximus muscle. Adenopathy along the right pelvic side wall is also seen (solid arrow).

View larger version (141K): [in a new window]   Figures 22-26.   (22) Malignant carcinoid tumor of the ovary. CT scan shows a mass with peripheral enhancement in the right lobe of the liver (arrow), a finding consistent with a liver metastasis. The liver has diffusely decreased attenuation due to fatty infiltration. (23) Endometrioid carcinoma of the ovary. CT scan shows a large metastatic mass (m) in the region of the pancreas that extends to the lesser sac and compresses the stomach (s). The mass also invades the anterior aspect of the left kidney (straight solid arrow). The splenic vein is occluded. There are tumor implants along the undersurface of the right hemidiaphragm (curved arrow), the posterior liver surface, and the fissure for the ligamentum teres (open arrows). Minimal ascites is noted around the liver. (24) Adenocarcinoma of the ovary with psammoma bodies. CT scan shows a large, calcified metastasis that involves the pancreas and displaces the posterior wall of the stomach anteriorly. The splenic vein is occluded. (25) Malignant granulosa cell tumor. The patient developed multiple lytic metastases involving the lumbar spine and pelvis. CT scan shows a lesion in the lumbar spine (arrow) that extends posteriorly through the cortex and effaces the thecal sac. (26) Adenocarcinoma of the ovary. CT scan shows multiple soft-tissue nodules in the subcutaneous tissue and skin of the right gluteal region (open arrows), with an ill-defined mass involving the right gluteus maximus muscle. Adenopathy along the right pelvic side wall is also seen (solid arrow).

View larger version (133K): [in a new window]   Figures 22-26.   (22) Malignant carcinoid tumor of the ovary. CT scan shows a mass with peripheral enhancement in the right lobe of the liver (arrow), a finding consistent with a liver metastasis. The liver has diffusely decreased attenuation due to fatty infiltration. (23) Endometrioid carcinoma of the ovary. CT scan shows a large metastatic mass (m) in the region of the pancreas that extends to the lesser sac and compresses the stomach (s). The mass also invades the anterior aspect of the left kidney (straight solid arrow). The splenic vein is occluded. There are tumor implants along the undersurface of the right hemidiaphragm (curved arrow), the posterior liver surface, and the fissure for the ligamentum teres (open arrows). Minimal ascites is noted around the liver. (24) Adenocarcinoma of the ovary with psammoma bodies. CT scan shows a large, calcified metastasis that involves the pancreas and displaces the posterior wall of the stomach anteriorly. The splenic vein is occluded. (25) Malignant granulosa cell tumor. The patient developed multiple lytic metastases involving the lumbar spine and pelvis. CT scan shows a lesion in the lumbar spine (arrow) that extends posteriorly through the cortex and effaces the thecal sac. (26) Adenocarcinoma of the ovary. CT scan shows multiple soft-tissue nodules in the subcutaneous tissue and skin of the right gluteal region (open arrows), with an ill-defined mass involving the right gluteus maximus muscle. Adenopathy along the right pelvic side wall is also seen (solid arrow).

View larger version (129K): [in a new window]   Figures 22-26.   (22) Malignant carcinoid tumor of the ovary. CT scan shows a mass with peripheral enhancement in the right lobe of the liver (arrow), a finding consistent with a liver metastasis. The liver has diffusely decreased attenuation due to fatty infiltration. (23) Endometrioid carcinoma of the ovary. CT scan shows a large metastatic mass (m) in the region of the pancreas that extends to the lesser sac and compresses the stomach (s). The mass also invades the anterior aspect of the left kidney (straight solid arrow). The splenic vein is occluded. There are tumor implants along the undersurface of the right hemidiaphragm (curved arrow), the posterior liver surface, and the fissure for the ligamentum teres (open arrows). Minimal ascites is noted around the liver. (24) Adenocarcinoma of the ovary with psammoma bodies. CT scan shows a large, calcified metastasis that involves the pancreas and displaces the posterior wall of the stomach anteriorly. The splenic vein is occluded. (25) Malignant granulosa cell tumor. The patient developed multiple lytic metastases involving the lumbar spine and pelvis. CT scan shows a lesion in the lumbar spine (arrow) that extends posteriorly through the cortex and effaces the thecal sac. (26) Adenocarcinoma of the ovary. CT scan shows multiple soft-tissue nodules in the subcutaneous tissue and skin of the right gluteal region (open arrows), with an ill-defined mass involving the right gluteus maximus muscle. Adenopathy along the right pelvic side wall is also seen (solid arrow).

View larger version (106K): [in a new window]   Figures 22-26.   (22) Malignant carcinoid tumor of the ovary. CT scan shows a mass with peripheral enhancement in the right lobe of the liver (arrow), a finding consistent with a liver metastasis. The liver has diffusely decreased attenuation due to fatty infiltration. (23) Endometrioid carcinoma of the ovary. CT scan shows a large metastatic mass (m) in the region of the pancreas that extends to the lesser sac and compresses the stomach (s). The mass also invades the anterior aspect of the left kidney (straight solid arrow). The splenic vein is occluded. There are tumor implants along the undersurface of the right hemidiaphragm (curved arrow), the posterior liver surface, and the fissure for the ligamentum teres (open arrows). Minimal ascites is noted around the liver. (24) Adenocarcinoma of the ovary with psammoma bodies. CT scan shows a large, calcified metastasis that involves the pancreas and displaces the posterior wall of the stomach anteriorly. The splenic vein is occluded. (25) Malignant granulosa cell tumor. The patient developed multiple lytic metastases involving the lumbar spine and pelvis. CT scan shows a lesion in the lumbar spine (arrow) that extends posteriorly through the cortex and effaces the thecal sac. (26) Adenocarcinoma of the ovary. CT scan shows multiple soft-tissue nodules in the subcutaneous tissue and skin of the right gluteal region (open arrows), with an ill-defined mass involving the right gluteus maximus muscle. Adenopathy along the right pelvic side wall is also seen (solid arrow).

View larger version (162K): [in a new window]   Figure 27.   Poorly differentiated carcinoma of the ovary. CT scan shows a ring-enhancing mass in the right parietal lobe (arrow) with associated diffuse white matter edema, findings consistent with a metastasis.

View larger version (151K): [in a new window]   Figure 28.   Serous cystadenocarcinoma of the ovary. CT scan shows a heterogeneous mass in the enlarged left psoas muscle (solid arrow), which represents a metastasis. The left kidney is displaced anteriorly. There are also enhancing masses in the anterior right aspect of the abdomen (open arrows), which represent omental implants.

View larger version (113K): [in a new window]   Figures 29, 30.   (29) Serous cystadenocarcinoma of the ovary with psammoma bodies. CT scan shows calcified right pleural implants (arrow) with an associated pleural effusion. (30) Poorly differentiated ovarian cancer. The patient presented with cardiac tamponade. CT scan shows a large pericardial effusion (arrows), which was positive for ovarian cancer. There are also malignant pleural effusions with consolidation of the right lung base.

View larger version (143K): [in a new window]   Figures 29, 30.   (29) Serous cystadenocarcinoma of the ovary with psammoma bodies. CT scan shows calcified right pleural implants (arrow) with an associated pleural effusion. (30) Poorly differentiated ovarian cancer. The patient presented with cardiac tamponade. CT scan shows a large pericardial effusion (arrows), which was positive for ovarian cancer. There are also malignant pleural effusions with consolidation of the right lung base.