Ovaries & Ovarian Carcinoma
Lexicon
ESUR, SAR inter alia have published a Ovarian Ca specific Lexicon and guide to reporting. 1
| Term | Definition | Information |
|---|---|---|
| General Terminology | ||
| Size | Bi-axial at 90 for non-nodal SAD for nodes. |
|
| Adnexa | Ovaries, fallopian tubes and supporting structures including broad ligament, vessels | |
| Lesion | Not normal physiology on imaging criteria | |
| Carcinomatosis | Metastatic disease involving peritoneum | |
| Implant | Lesion on the serosa or surface of an organ. Might invade into the organ | Deposit is also allowed. |
| Parenchymal lesion | SOL within solid organs or replacing soft tissue of the organ via haematogeneous spread; not by direct invasion from an implant. | |
| Adnexal Lesion specific terminology | ||
| Unilateral | One side of body | |
| Bilateral | Affecting both sides | If multiple/bilateral then mention 2 largest masses, preferably the largest on each side. |
| Adnexal Lesion | Abnormality involving the ovaries, fallopian tubes, broad ligament or the vessels of the adnexa. | Can also use mass |
| Cystic | Portion of an adnexal lesion that is not fluid | |
| Solid Component | Part of an adnexal lesion which is not fluid. | |
| i. Solid tissue | A solid component that usually demonstrates enhacement and has the following morphology: - Papillary projection - Mural nodule - Irregular septation. Or, Solid enhancing part of an adnexal lesion. |
But not normal ovarian stroma. |
| ii. Other solid components | Includes smooth septations/walls (thin or thick), debris, fat, calcification or clot. | |
| Peritoneal Carcinomatosis-specific Terminology | ||
| Morphology | ||
| Nodule | Round or irregular tissue, 3cm or less in maximum dimension | Can be poorly defined |
| Mass | Round or irregular tissue, greater than 3cm in maximum dimension | |
| Stranding or Infiltration | Hazy appearance of the peritoneal, omental or mesenteric fat | Can be due to inflammation, prior surgery or ascites. Haziness is not recommended. |
| Peritoneal thickening or nodularity | Smooth or nodular / irregular thickening of the peritoneal lining | |
| Invasion | Growth or direct extension / penetration into surrounding organs or tissues. | Sometimes peritoneal disease may invade an adjacent organ including Liver, spleen, bowel loop or abdominal wall. |
| Tethering | Binding or attachment between the bowel and/or organs | Can be due to tumour, adhesions, infection/inflammation involving the peritoneum |
| Locations | ||
| i. Peritoneal Cavity | Potential space between the parietal and visceral peritoneum that envelopes the abdominal organs. | Includes peritoneal lining, mesentery and omentum. |
| ii. Subdiaphragmatic | Peritoneal cavity along the surface of the diaphragm = RIGHT & LEFT subdiaphragmatic spaces. | Hard-to-resect / Irresectable Site |
| iii Perihepatic | Close approximation to the liver including gastrohepatic ligament, porta hepatis or peri-portal region, RIGHT or part of LEFT subdiaphragmatic space, RIGHT or part of LEFT subhepatic space, lesser sac, falciform ligament, left intersegmental fissure, gallbladder fossa, Morrison's pouch. | Overlaps between subdiaphragmatic, perihepatic and perisplenic terms. NB: always indicate subdiaphragmatic disease if present. |
| iv. Perisplenic | Close approximation to the spleen includes part of LEFT subdiaphragmatic and LEFT subhepatic space, gastrosplenic, splenocolic ligament and splenic hilum. | |
| v. Lesser Sac | Peritoneal space posterior to stomach that extends through the Foramen of Winslow | Hard-to-resect / Unresectable Site |
| vi. Omentum | Fat between a double peritoneal layer that extends from stomach and duodenal bulb to adjacent organs | Greater Omentum = attaches to stomach and hangs like an apron from transverse colon. Lesser Omentum = 2 contiguous components called gastrohepatic and hepatoduodenal ligaments. Attach the stomach and duodenal bulb to the Liver. |
| vii. Gastrocolic ligament | Space between anterior stomach and the transverse colon | Hard-to-resect / Irresectable Site |
| viii. Gastrosplenic ligament | Ligament connecting superior 1/3 of greater curvature to the splenic hilum | |
| ix. Mesenteric | Double fold of peritoneum attaching the bowel to the posterior abdominal wall. Contains soft tissue and vessels. | Hard-to-resect / Irresectable Site Mesenteric involvement indicates tumour deposits in the mesentery. Mesenteric involvement is suspected with mesenteric retraction, nodules or small bowel loop tethering. |
| x. Serosal | Visceral peritoneum surrounding bowel or solid organ. | |
| xi. Paracolic gutters/posterior peritoneal lining | Space lateral to the peritoneal reflections to the left and right side of the colon. | RIGHT paracolic gutter communicates freely with RIGHT subdiaphragmatic space whilst the LEFT is partly limited by the splenocolic ligament. BUT, both gutters communicate freely with pelvic spaces and serve as routes of peritoneal disease spread. |
| xii. Paravesical | Spaces around the bladder inc: Anterior paravesical, supravesical, vesicouterine spaces, and medial and lateral inguinal fossae. | |
| xiii. Pelvic sidewall | Includes muscular sidewall ( = obturator internus, pyriformis or levator muscles) and the iliac vessels and nerves. | Hard-to-resect / Irresectable Site Invasion suspected if disease is <3mm from the muscular sidewall or ureteric involvement / hydronephrosis or encasement of the iliac vessels. |
| xiv. Pouch of Douglas / cul-de-sac | Retrouterine space between rectum and posterior wall of the uterus. | Is most dependent part of the peritoneum. |
| 4. Lymph node-specific terminology | ||
| Morphology | ||
| Oval | Length > Width | Both benign & malignant. |
| Round | Length ~ Width | Ratio of short to long axis >0.8 means likely to be metastatic for nodes between 8 and 10mm SAD. |
| Irregular / Spiculated | Jagged or saw-tooth-like contour | Mostly metastatic |
| Fatty hilum | Preservation of central fat and thin rim of nodal tissue | Benign feature |
| Heterogeneous | Variable attenuation or signal or enhancement | Metastatic feature |
| Necrotic | Non-enhancing variable CT attenuation or MRI signal parts | Non-specific feature in malignancy & benign like abscess, TB & fungi. "Necrosis" is a path term and uncertain at imaging = can be necrosis, fibrosis or cystic. |
| Calcification | Calcium deposits in tissue | Relates to tumour sub-type (low-grade or borderline) Also other cancers such as colorectal or bladder cancer as well as granulomatous disease or treated cancer. |
| Location | ||
| Thoracic Lymph Nodes | Hard-to-resect / Irresectable | |
| i. Supraclavicular | Lower margin of cricoid to the clavicles & in midline to the upper border of the manubrium | >= 0.5cm SAD or suspicious features. |
| ii Mediastinal | Centrally from the level of the apex of both lungs to the diaphragm. Including R/L upper and lower paratracheal, prevascular, retrotracheal, aortopulmonary windows, subcarinal, paraoesophageal and pulmonary ligament. RIGHT/LEFT hilar and segmental nodes. |
>=1cm SAD or suspicious features. |
| iii. Hilar | Immediately adjacent to mainstem bronchus & hilar vessels, inc. proximal portions of the pulmonary veins and the main pulmonary artery. | >= 1cm SAD or suspicious features. |
| iv. Axillary | Anteriorly bounded by pec.major muscle, medially by serratus anterior & posteriorly by subscapularis & lat.dorsi. | >= 1cm SAD or suspicious. |
| v. Internal Mammary | Adjacent to junction of ribs + sternum along IMAs | >0.5cm SAD or suspicious |
| vi. Supradiaphragmatic or Epiphrenic | Just above diaphragm including pre and paracardiac or cardiophrenic lymph nodes | >= 0.5cm SAD or suspicious features |
| vii. Retrocrural | Small triangular area within the most inferior posterior mediastinum and is bordered by diaphragmatic crura | |
| Upper Abdominal Nodes | Above renal arteries. Include gastrohepatic, peripancreatic, celiac axis, portocaval and periportal stations. | Hard-to-resect / Irresectable >=1cm SAD or suspicious features. Except Portocaval >= 1.5cm SAD. |
| Abdominal Retroperitoneal | Deep to the peritoneal lining, surrounding the aorta + below the diaphragm. | >= 0.8cm (!) SAD or suspicious. Nodes below level of aortic bifurcation should be described separately as Pelvic lymph nodes |
| Mesenteric | At mesenteric root & throughout mesentery | >=0.8cm or suspicious |
| Pelvic retroperitoneal | Deep to the peritoneal lining below the bifurcation of the aorta. Includes Common Iliac, External Iliac, Internal Iliac nodes. | >=0.8cm SAD or suspicious |
| Inguinal | Distal to Inguinal ligament Superficial: Within femoral triangle (Inguinal ligmament, Sartorius & Adductor Longus) Deep: Medial to Femoral vasculature. |
Hard-to-resect / Irresectable >=1.5cm SAD or suspicious. |
| 5. Metastatic disease other than peritoneal carcinomatosis | ||
| Hepatic parenchyma | Space-occupying met disease involving the hepatic parenchyma | Hard-to-resect / Irresectable This means haematogeneous disease and NOT direct invasive spread by peritoneal implants |
| Splenic parenchymal | Space-occupying metastatic disease involving splenic parenchyma | Hard-to-resect / Irresectable As above, this is haematogeneous spread. |
| Bowel/Stomach | Tumour spread to wall of GIT | Hard-to-resect / Irresectable Specify which segments |
| Pulmonary | Spread to lungs as nodules, masses or lymphangitis. | Hard-to-resect / Irresectable |
| Pleural | Metastatic disease within the pleural space | Hard-to-resect / Irresectable |
| Other Visceral | Space-occupying disease of other sites inc pancreas, adrenals, kidneys, bones, and brain | Hard-to-resect / Irresectable Disease here is rare. |
| 6. Fluid-specific Terminology | ||
| Pleural Effusion | Non-physiologic fluid in pleural space | Malignancy determined by pleural nodularity OR cytological proof. |
| Pleural Effusion volume | Small/Large or small/medium/large | Subjective assessment |
| Ascites | Non-physiological fluid in peritoneal cavity | Malignancy is determined by peritoneal nodularity, omental cake or nodular peritoneal thickening. OR cytological confirmation. |
| Ascites Volume | Small/large or small/medium/large | Subjective assessment |
Points made in Lexion
Peritoneal Implantation
If peritoneal implant has smooth contour with liver => suggests no invasion.
But, if ill-defined, irregular or interface obliteration => suggests invasion.
Perihepatic implants along bare area == always look for & mention.
Lesser Sac implants or Gastrocolic implants => Not easily seen on laparoscopy and may need more aggressive approach, thus often have neo-adj chemo.
Extensive bowel involvement Stage IV ( rather than serosal implants Stage III) should be called as may need pre-op assessment by serum albumin to determine resectability.
Disease involvement in root of small-bowel mesentery or upper abdominal or suprarenal retroperitoneal lymph node involvement is associated with higher rates of suboptimal cytoreduction.
Mesenteric involved nodes vs mesenteric implants can be difficult to separate. Involved nodes often round, enlarged, heterogeneous and irregular / spiculated. Whilst implants can look similar they are usually accompanied with other peritoneal involvement findings such as ill-defined peritoneal involvement elsewhere, nodulariy, mesenteric root retraction or fluid between mesenteric folds.
Pelvic sidewall invasion call in detail.
No agreement to include any various peritoneal carcinomatosis.
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Shinagare A, Sadowski, E. European Radiolojgy (2022) 32:3220–3235 https://doi.org/10.1007/s00330-021-08390-y ↩