Diagnostic Ultrasound - Abdomen and Pelvis

Mucinous Ovarian Cystadenoma/Carcinoma
Diagnoses: Female Pelvis
– Liver and lung most common sites
Staging, Grading, & Classification
• FIGO staging system of ovarian carcinoma
○ Stage I: Tumor limited to ovaries
– IA: Unilateral, no malignant ascites
– IB: Bilateral, no malignant ascites
– IC: Tumor limited to 1 or both ovaries with any of the
following
□ IC1: Surgical spill intraoperatively
□ IC2: Capsule rupture before surgery, or tumor on
ovarian/fallopian tube surface
□ IC3: Malignant cells present in ascites or peritoneal
washings
○ Stage II: Tumor involves 1 or both ovaries with pelvic
extension
– IIA: Extension to uterus or fallopian tubes, no
malignant ascites
– IIB: Extension to other pelvic tissues, no malignant
ascites
○ Stage III: Peritoneal implants outside pelvis &/or
retroperitoneal nodal metastases
– IIIA1: Positive retroperitoneal lymph nodes only
– IIIA2: Microscopic metastasis outside pelvis &/or
positive retroperitoneal lymph nodes
– IIIB: Macroscopic extrapelvic implants ≤ 2 cm ± positive
nodes
– IIIC: Macroscopic extrapelvic implants > 2 cm or ±
positive nodes
○ Stage IV: Distant metastases (excluding peritoneal
implants)
– IVA: Pleural effusion with positive cytology
– IVB: Hepatic &/or splenic parenchymal metastasis, or
metastasis to extra-abdominal organs (including
inguinal nodes and nodes outside of abdomen)
Microscopic Features
• Ovarian origin of pseudomyxoma peritonei called into
question
○ Most cases now thought to be appendiceal with
metastases to ovary
○ Appendix should be thoroughly examined with special
tissue staining in every case
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Incidental mass discovered on exam
○ Pelvic discomfort/pain from large tumors
– Massive tumors can actually cause weight gain and
distended abdomen
○ Symptoms from metastatic disease
• CA-125 not useful for mucinous tumors: False-negative in
30%
Demographics
• Age
○ Mucinous cystadenoma 3rd-5th decade
○ Mucinous cystadenocarcinoma in peri- and
postmenopausal age group
• Epidemiology
○ Mucinous tumors 2nd most common epithelial
neoplasm (serous most common)
○ Malignant: 10%; borderline: (Low malignant potential)
10%; benign 80%
○ Bilateral in 5% of benign tumors, 10% of borderline
tumors and 20% of malignant tumors
Natural History & Prognosis
• 95% 5-year survival for low malignant potential tumors
○ If metastatic, prognosis is similar to those with frankly
malignant histology
• 5-year survival for malignant epithelial tumors
○ Stage I: 90%
○ Stage II: 70%
○ Stage III: 39%
○ Stage IV: 17%
Treatment
• Primary treatment is surgery
○ Complete staging laparotomy and tumor debulking
(cytoreduction)
– Staging laparotomy includes hysterectomy with
bilateral salpingo-oophorectomy, pelvic and
paraaortic node biopsies, omentectomy, peritoneal
biopsies and washings
– More conservative surgery may be done for women
with stage I disease in reproductive age group
– Care taken to avoid intraoperative rupture
□ May increase potential for recurrence
○ Gelatinous, insinuating nature of pseudomyxoma
peritonei makes complete resection difficult
– Recurrence common and multiple laparotomies
required
○ Chemotherapy after cytoreductive surgery
○ Neoadjuvant chemotherapy before cytoreductive
surgery in patients with unresectable disease
– Includes bulky disease in difficult to reach areas (porta
hepatis, lesser sac, root of mesentery), extensive
surrounding organ or sidewall invasion, or stage IV
disease
DIAGNOSTIC CHECKLIST
Image Interpretation Pearls
• Mucinous tumors are less commonly malignant than serous
tumors
SELECTED REFERENCES
1. Sayasneh A et al: The characteristic ultrasound features of specific types of
ovarian pathology (Review). Int J Oncol. 46(2):445-58, 2015
2. Ledermann JA et al: Gynecologic Cancer InterGroup (GCIG) consensus review
for mucinous ovarian carcinoma. Int J Gynecol Cancer. 24(9 Suppl 3):S14-9,
2014
3. Alcázar JL et al: Clinical and ultrasound features of type I and type II epithelial
ovarian cancer. Int J Gynecol Cancer. 23(4):680-4, 2013
4. Lalwani N et al: Histologic, molecular, and cytogenetic features of ovarian
cancers: implications for diagnosis and treatment. Radiographics. 31(3):625-
46, 2011
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