Ovarian serous cystadenocarcinoma
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Increasingly, high-grade serous carcinoma and low-grade serous carcinoma are recognized as distinct tumor types rather than a spectrum of disease grade as implied by the nomenclature (see Pathology for more).
Serous ovarian tumors are traditionally described with a "cyst-" prefix because of their primarily cystic composition, e.g. cystadenoma, cystadenocarcinoma.
Account for the largest proportion of malignant ovarian tumors 1, representing over 50-80% of all malignant epithelial ovarian tumors 4. Serous ovarian cystadenocarcinomas account for ~25% of serous tumors.
The incidence peaks around the 6th to 7th decades of life 2.
- multilocular cystic ovarian tumor with papillary projections
- classified as high-grade versus low-grade carcinoma 9:
- high-grade serous carcinoma (HGSC)
- common (70-80%)
- thought to originate from distal fallopian tube epithelium
- high grade nuclear features (e.g. nuclear pleomorphism, abnormal mitotic figures)
- characterized by intratumoral heterogeneity
- nearly ubiquitous p53 positivity
- low-grade serous carcinoma (LGSC)
- uncommon (~5%) 9
- thought to mostly represent malignant degeneration of serous cystadenoma 9
- high-grade serous carcinoma (HGSC)
- psammomatous bodies may be present in either LGSC or HGSC, but more numerous in LGSC 9
Recognized risk factors include:
- early menarche
- late menopause
- positive family history
- elevated serum CA-125 (>90% of cases 6)
Imaging plays an important role in the diagnosis of ovarian tumors and in the assessment for metastatic disease. However, surgical evaluation is the standard of care for the staging of disease.
Typical imaging features of ovarian cystadenocarcinoma include:
- cystic adnexal mass with a substantial solid component
- calcification uncommon, but can be seen (~12%) 4
- also seen in serous cystadenoma and other tumors
- frequently bilateral
In the setting of suspected ovarian cystadenocarcinoma, features suggestive of extra-ovarian metastasis include:
- ascites - often of disproportionately large volume 3
- peritoneal nodularity with a high propensity to calcification10
- mixed cystic/solid lesion
- more heterogeneous than a serous cystadenoma
- papillary projections, thick septations, and/or solid components
- concerning for peritoneal metastatic spread
- discrete peritoneal deposits may be seen
- color Doppler is useful to confirm vascularity of the solid components
CT may be used for preoperative evaluation to assess for metastatic disease, e.g. peritoneal nodularity, ascites, or intrathoracic lesions.
MRI provides the most detailed imaging evaluation for ovarian malignancies and may be used in either preoperative evaluation or post-treatment follow-up.
- cystic portions are T1 dark unless there has been intralesional hemorrhage (keep in mind mucinous tumors also have a brighter T1 appearance in the cystic component)
- solid portions are T1 intermediate
- cystic portions are T2 bright
- solid portions are T2 intermediate
- solid portions enhance
- time-intensity enhancement curves help in risk stratification11
- solid components restrict diffusion
- metastases may exhibit restricted diffusion. The cystic components are high T2, low T1 signal unless there has been intralesional hemorrhage (where there is typically slightly increased T1 signal of the cystic component).
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- 9. Singh N, McCluggage WG, Gilks CB. High‐grade serous carcinoma of tubo‐ovarian origin: recent developments. (2017) Histopathology. 71 (3): 339. doi:10.1111/his.13248 - Pubmed
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- 11. Sadowski E, Sadowski RA, Sadowski MK, Sadowski RJ, Sadowski TNI, Sadowski. Adnexal lesions: Imaging strategies for ultrasound and MR imaging. (2019) Diagnostic and interventional imaging. doi:10.1016/j.diii.2018.06.003 - Pubmed