Clinical History
Asthenia and unspecified abdominal pain in patient with late history of ovarian neoplasm treated with surgery and chemotherapy.
Imaging Findings
Asthenia and unspecified abdominal pain.
18 months earlier the patient was submitted to total hysterectomy, bilateral adnexectomy and omentectomy due to bilateral serous cystoadenocarcinoma of the ovary (incidentally associated with synchronous onset of carcinoma of the right kidney). She also received intense chemotherapy.
During US and CT follow-ups we have been witnessing the progressive development of multiple calcified implants upon peritoneal surfaces (preminently perihepatic, perisplenic and in the lesser sac).
Ascites was never present. Liver parenchyma was unaltered.
Discussion
Serous cystoadenocarcinoma, the most common ovarian malignancy, frequently and extensively metastasizes to the peritoneum, primarily affecting the right subphrenic region (perihepatic calcification sign), the greater omentum and the pouch of Douglas, but it may sprout anywhere in the abdomen, following the pathways of ascitic fluid convective flows, gaining the lesser sac, the paracolic gutters, the mesentery, the abdominal wall, lymph nodes etc..
Such sort of "seeding" may involve both parietal and visceral layers of the serosa and sink into contiguous parenchymas (liver, diaphragm, spleen).
Unlike other localizations the left subphrenic/ perisplenic region involvement is fairly uncommon because of interposition of phrenicocolic ligament (substentaculum lienis), which acts as an obstacle to the flows going up the left paracolic gutter.
Findings of diffuse abdominal calcifications in patients with known ovarian or gastrointestinal neoplasms (or other mucin-producing carcinomas) is usually a sign of metastasization. These tumors and their repetitions, in fact, may contain psammoma bodies (granular/ amorphous deposits of calcium carbonate in the fibrous stroma, believed to be of a degenerative nature) which represent the histological counterpart of macroscopical calcifications.
Ascites, also reported in literature as one of the most recurring manifestations of peritoneal widening of ovarian neoplasms, was not present at any stage of disease anyway (and we must not forget its concrete help in detecting small peritoneal implants, especially when calcium is absent). This is a distinctive condition, if we think of peritoneal fluid as the main responsible for diffuse seeding. The absence of liquid excess is due to regular outflow through intact transdiaphragmatic lymphatic channels, free from neoplastic obstruction, as a fortuitous event or as a consequence of therapy (which our patient began shortly after surgery). Another possibility could be a hematogen dissemination, but it is exceptional in peritoneal carcinosis from ovarian cancer and metastases would affect other organs as well. Furthermore studies on oncofetal fibronectin explain how molecules like that participate in tumor-associated peritoneal adhesive interactions, apart from the amount of fluid carrier. So, our case proves that considerable peritoneal repetitions may actually grow without significant ascites, but the factors involved and their role remain to be evaluated yet.
We should be aware of the possibility, which CT offers, of an early detection of these calcified nodules, sometimes evidence of an aggressive chemotherapy but most likely pointing tumor spreading.
Differential Diagnosis List
Calcified intraperitoneal metastases from ovarian carcinoma.
Final Diagnosis
Calcified intraperitoneal metastases from ovarian carcinoma.
