Imaging Pearls ❯ OB GYN ❯ Ovarian Cancer
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- Ovarian cancer remains the sixth most common cause of cancer mortality in women in the United States and is a leading cause of mortality among patients with gynecologic malignancies. Imaging plays an important role in pretreatment staging of epithelial ovarian cancers, the evaluation of posttreatment response, and follow-up. Accurate pretreatment imaging is integral to determine appropriate first-line therapy. By delineating the extent of disease, imaging can assist decision making regarding the likelihood of optimal primary cytoreduction or need for neoadjuvant chemotherapy when optimal cytoreduction is not felt to be achievable. Contrast-enhanced CT serves as a mainstay modality for the pretreatment assessment of ovarian cancer, with MRI, PET/CT, and, in some instances, PET/ MRI used in the pretreatment setting. CT and PET/CT are also integral to assessing response, including in the suspected recurrence setting, with MRI and PET/MRI being used in select cases.
ACR Appropriateness CriteriaŽ Staging and Follow-Up of Ovarian Cancer: 2025 Update
Expert Panel on GYN and OB Imaging: Erica B. Stein,et al.
J Am Coll Radiol 2025;22:S689-S698 
- There are several different histopathologic subtypes of ovarian cancer, with epithelial ovarian cancer being the most common and accounting for approximately 90% of all malignant ovarian neoplasms. Most of the information in this document regarding imaging use for staging and recurrence applies to epithelial ovarian cancers. There are two major subtypes of epithelial ovarian cancers that are distinguished by molecular, genetic, and morphologic characteristics. Type I is the more indolent form that includes low-grade serous, low-grade endometrioid, mucinous tumors, and clear cell carcinomas. Type II includes aggressive neoplasms, such as- high-grade serous or endometrioid, and undifferentiated cancer. The aggressive, or type II ovarian cancers, typically present in advanced stages (stage III-IV), after the disease has spread beyond the pelvis.
ACR Appropriateness CriteriaŽ Staging and Follow-Up of Ovarian Cancer: 2025 Update
Expert Panel on GYN and OB Imaging: Erica B. Stein,et al.
J Am Coll Radiol 2025;22:S689-S698 - Contrast enhanced CT is the most useful procedure in the preoperative evaluation of ovarian cancer. It can provide clinically relevant information, including assessment of locoregional tumor extent and distant sites of disease including peritoneum, omentum, mesentery, liver, and lymph nodes. Contrast-enhanced CT has a reported accuracy for ovarian cancer staging of up to 94%, and accurate abdominopelvic disease assessment can predict successful surgical cytoreduction. The sensitivity of CT staging varies depending on the anatomical location being examined. One of the significant drawbacks of CT in staging ovarian cancer is its limited ability to consistently identify tumor implants on the bowel surface, mesentery, or peritoneum that are smaller than 5 mm, particularly in the absence of ascites .
ACR Appropriateness CriteriaŽ Staging and Follow-Up of Ovarian Cancer: 2025 Update
Expert Panel on GYN and OB Imaging: Erica B. Stein,et al.
J Am Coll Radiol 2025;22:S689-S698 - For initial pretreatment staging of ovarian cancer, CT abdomen and pelvis with IV contrast and CT chest with IV contrast are recommended complementary studies to stage the tumor and evaluate for distant metastases. MRI abdomen and pelvis without and with IV contrast, MRI abdomen and pelvis without IV contrast, CT abdomen and pelvis without IV contrast, CT chest without IV contrast, FDG-PET/MRI, and FDG-PET/CT may be appropriate in staging ovarian cancer before treatment.
ACR Appropriateness CriteriaŽ Staging and Follow-Up of Ovarian Cancer: 2025 Update
Expert Panel on GYN and OB Imaging: Erica B. Stein,et al.
J Am Coll Radiol 2025;22:S689-S698
- “Secondary tumors of the ovary or metastases are most commonly from gastrointestinal malignan- cies (colon, appendix, stomach, pancreas) but can also be from breast, lung, and contralateral ovarian tumors, among others (56,107,108). Hematologic malignancy of the ovary is discussed separately. The differentiation between a primary ovarian borderline or malignant mucinous neoplasm and a metastasis is a common diagnostic challenge to both the radiologist and the pathologist.”
Multimodality Imaging Approach to Ovarian Neoplasms with Patho-logic Correlation
Taylor EC et al.
RadioGraphics 2021; 41:289–315 - "Ovarian metastases may be the first depicted disease (ie, the primary neoplasm may be occult).The distinction is crucial because of differences in referral (surgical oncology or gynecologic oncology) and subsequently, treatment.”
Multimodality Imaging Approach to Ovarian Neoplasms with Patho-logic Correlation
Taylor EC et al.
RadioGraphics 2021; 41:289–315 
Multimodality Imaging Approach to Ovarian Neoplasms with Patho-logic Correlation
Taylor EC et al.
RadioGraphics 2021; 41:289–315- ”Ovarian metastases are bilateral in the vast ma- jority of cases .The imaging appearance of metastases, specifically whether they are more of- ten solid or cystic, depends on their site of origin. Gastric and breast cancer metastases are usually predominantly solid (and breast cancer metastases are often small and less than 5 cm), while appendiceal, colorectal, and pancreaticobiliary cancer metastases often have more cystic components and can be mistaken for primary epithelial neoplasms by the radiologist.”
Multimodality Imaging Approach to Ovarian Neoplasms with Patho-logic Correlation
Taylor EC et al.
RadioGraphics 2021; 41:289–315 - “The most reliable imaging features that favor a mucinous ovarian metastasis over a primary borderline or malignant mucinous tumor include (a) a smaller size (<13 cm), (b) bilateral- ism, and (c) the presence of peritoneal disease. If a mucinous histology is detected by the pathologist in unilateral, small (<13 cm), or bilateral ovarian tumors of any size, a careful search for a separate primary neoplasm, particularly a gastrointestinal primary neoplasm, should ensue as primary borderline or malignant ovarian tumors are almost always larger than 13 cm and unilateral at initial diagnosis.”
Multimodality Imaging Approach to Ovarian Neoplasms with Patho-logic Correlation
Taylor EC et al.
RadioGraphics 2021; 41:289–315 - "A Krukenberg tumor is a secondary ovarian carcinoma that has a significant component (defined as 10% of the tumor) of mucin-filled signet ring cells, although the term Krukenberg tumor is often more loosely applied to all metastatic ovarian tumors. Immunohistochemical profiles are essential to help determine the site of origin of a metastatic ovarian tumor.”
Multimodality Imaging Approach to Ovarian Neoplasms with Patho-logic Correlation
Taylor EC et al.
RadioGraphics 2021; 41:289–315
- “Not all ovarian metastases are Krukenberg tumors. Krukenberg tumors are the most common subtype of ovarian metastases, and they are histologically characterized by signet ring cell mucinous features. Common primary tumor sites include the stomach or colon. Although often difficult, distinguishing between Krukenberg tumors and primary ovarian malignancy on imaging is important because of management and prognostic implications.”
Krukenberg Tumors: Update on Imaging and Clinical Features
Maria Zulfiqar et al.
AJR 2020; 215:1020–1029 - "Approximately 10% of ovarian tu- mors are metastatic masses, almost 50% of which are Krukenberg tumors. Nearly 80% of Krukenberg tumors are bilateral. The estimated incidence of Krukenberg tumors is approximately 0.16 tumors per 100,000 population per year.”
Krukenberg Tumors: Update on Imaging and Clinical Features
Maria Zulfiqar et al.
AJR 2020; 215:1020–1029 - “ Compared with primary ovarian cancers, Krukenberg tumors more often occur in younger women, possibly because the functioning ovary is prone to metastatic disease as a result of the normal rich ovarian blood supply. Premenopausal women have a higher risk for ovarian metastases, with diagnosis of Krukenberg tumors occurring at a median patient age of 48 years (range, 27–65 years)whereas diagnosis of primary ovarian cancer occurs at a median patient age of 63 years (range, 55–64 years).”
Krukenberg Tumors: Update on Imaging and Clinical Features
Maria Zulfiqar et al.
AJR 2020; 215:1020–1029 - "Signet ring cells tend to arise in tumors that originate in glands, most commonly the gastrointestinal tract, including the stomach, colon, rectum, appendix, small bowel, pancreas, and biliary tract. Other less common sites of primary adenocarcinomas with signet ring cell features that potentially produce Krukenberg tumors include the breast, lung, contralateral ovary, and endometrium. Of note, primary cancers that metastasize to the ovaries without having signet ring cell features, particularly melanoma or lymphoma, therefore are not Krukenberg tumors.”
Krukenberg Tumors: Update on Imaging and Clinical Features
Maria Zulfiqar et al.
AJR 2020; 215:1020–1029 
Krukenberg Tumors: Update on Imaging and Clinical Features
Maria Zulfiqar et al.
AJR 2020; 215:1020–1029- "The survival of patients with Krukenberg tumors is very poor (usually less than 2 years) and seems to be associated with the primary tumor site. Frequently, the detection of Krukenberg tumors precedes the diagnosis of the primary tumor, which may be small and asymptomatic and which rarely may even remain undetected for several years after oophorectomy, further complicating the initial diagnosis.”
Krukenberg Tumors: Update on Imaging and Clinical Features
Maria Zulfiqar et al.
AJR 2020; 215:1020–1029 - "On CT, the ovaries are replaced by bilat- eral pelvic masses that may be solid, mixed solid and cystic, or, less commonly, predominantly cystic. A well-demarcated intratumoral cystic component is often identified. The cyst walls show contrast enhancement, which correlates with compacted epithelial cells on histologic analysis. CT is very useful for establishing the extent of extraovarian involvement, including invasion of the bowel, ureter, urinary bladder, and similar organs, and it also helps evaluate for the presence of any extraovarian primary tumor. On the same CT study, the stomach, colon, appendix, pancreas, and biliary tract should be scrutinized for a mass, and when such a mass is identified, a Krukenberg tumor should be strongly suspected.”
Krukenberg Tumors: Update on Imaging and Clinical Features
Maria Zulfiqar et al.
AJR 2020; 215:1020–1029 - "Gastric cancer is the most common primary site for Krukenberg tumors. On imaging, metastatic ovarian masses from gastric carcinoma appear more solid, more frequently have dense enhancement of the solid portion, and generally are smaller compared with metastatic ovarian masses from colon cancer.”
Krukenberg Tumors: Update on Imaging and Clinical Features
Maria Zulfiqar et al.
AJR 2020; 215:1020–1029 - "Pancreatic cancer seems to have more cys- tic Krukenberg metastases than do primary biliary tumors. The metastatic pancreatic Krukenberg tumors often are detected before the primary tumors, and because of their size, they become symptomatic earlier. When such tumors are suspected, dedicated multiphasic CT or MRI may be required for identification of the primary pancreatic neoplasm.”
Krukenberg Tumors: Update on Imaging and Clinical Features
Maria Zulfiqar et al.
AJR 2020; 215:1020–1029 - “Nearly 10% of ovarian cancers are meta- static from other primary malignancies, including cancer of the stomach, colon, breast, or appendix; melanoma; or lymphoma. Not all ovarian metastases are Krukenberg tumors. Krukenberg tumors are poorly differ- entiated adenocarcinomas with signet ring cell features that have metastasized to one or both ovaries. On imaging, Krukenberg tumor should be suspected when bilateral solid, mixed solid and cystic, or predominantly cystic ovarian masses are seen in the presence of a known or suspected gastrointes- tinal primary malignancy such as gastric or colorectal tumors. Krukenberg tumors should also be considered when tumors show well-demarcated intratumoral cystic foci, particularly if their walls appear to strongly enhance. The prognosis of signet ring cell ovarian metastasis is relatively very poor compared with non–signet ring cell ovarian metastasis or primary ovarian malignancy.”
Krukenberg Tumors: Update on Imaging and Clinical Features
Maria Zulfiqar et al.
AJR 2020; 215:1020–1029
- Ovarian Cancer: Key Numbers
- Ovarian Cancer: Key Numbers
- Ovarian Cancer: Key Numbers
- Ovarian Cancer: Key Numbers
- Ovarian Cancer: Key Numbers
- Ovarian Cancer: Key Numbers
Update on Imaging of Ovarian Cancer
Forstner R, Meissnitzer M, Cunha TM.
Curr Radiol Rep. 2016;4:31.- Ovarian Cancer: Facts
- The concept of ovarian cancer as a single disease has been revised. Epithelial ovarian cancer is now understood as a subsumption of diverse cancer entities that vary significantly clinically as well as pathologically and on a molecular level. It comprises the following main cancer subtypes:
- high-grade serous,
- low-grade serous,
- endometrioid,
- clear cell and
- mucinous ovarian cancer - Ovarian Cancer: Staging
- “In MDC, imaging plays a central role for treatment stratification in ovarian cancer. It serves as a roadmap for surgery and is one of the major predictors for successful primary cytoreductive surgery. Currently, CT is the standard of care for staging patients with ovarian cancer. However, MRI using functional techniques is emerging as technique that may be able to overcome limitations of staging CT.”
Update on Imaging of Ovarian Cancer
Forstner R, Meissnitzer M, Cunha TM.
Curr Radiol Rep. 2016;4:31.
- “ Incidental indeterminate adnexal lesions were relatively common at unenhanced CT (4.1%) but subsequent work-up revealed no ovarian cancers. Furthermore, a normal finding at CT was not protective against short term development of ovarian cancer. More sophisticated risk factor assessment is needed to identify woman at higher risk.”
Incidental Adnexal masses Detected at Low-Dose Unenhanced CT in Asymptomatic Woman Age 50 and Older: Implications for Clinical Management and Ovarian Cancer Screening
Pickhardt PJ, Hanson ME
Radiology 2010:257:144-150
"Moderate to large pleural effusion on preoperative CT images in patients with stage III or IV epithelial ovarian cancer was independently associated with poorer overall survival after controlling for age, preoperative CA-125 level, surgical stage, ascites, and cytoreductive status."
Pleural Effusion Detected at CT prior to Primary Cytoreduction for Stage III or IV Ovarian Carcinoma: Effect on Survival
Mironov O et al.
Radiology 2011; 258:776-784- Summary of International Federation of Obstetric Gynecology (FIGO) Staging
OB/GYN
Summary of International Federation of Obstetric Gynecology (FIGO) Staging
FIGO StageDefinitionI Tumor confined to ovaryII Peritoneal implants within the pelvisIII Peritoneal implants beyond the pelvis,positive lymph nodes, or bothIV Liver parenchymal involvement or tumor beyond the peritoneal cavity "Incidental adnexal masses are common in both pre-and postmenopausal woman with the vast majority being benign."
MRI, CT and PET/CT for Ovarian Cancer Detection and Adnexal Lesion Characterization
Iyer VR, Lee SI
AJR 2010; 194:311-321"If diagnosed at stage I (ovary confined)there is a greater than 90% survival at 5 years. At the time of diagnosis, the majority of patients (65-70% of cases) are found to have stage III (upper abdominal or regional lymph node metastases) or stage IV disease (extraabdominal or hematogenous metastases) disease with a 5 year survival rate of 30-73%."
MRI, CT and PET/CT for Ovarian Cancer Detection and Adnexal Lesion Characterization
Iyer VR, Lee SI
AJR 2010; 194:311-321"Ovarian cancer is the leading cause of death from gynecologic cancers, with 21,550 estimated new cases and 14,600 estimated deaths in the United States in 2009. The lifetime risk of dying from invasive ovarian cancer is about one in 95."
MRI, CT and PET/CT for Ovarian Cancer Detection and Adnexal Lesion Characterization
Iyer VR, Lee SI
AJR 2010; 194:311-321"For lesions indeteminate on ultrasound, MRI increases the specificity of imaging evaluation, thus decreasing benign resections. CT is useful in diagnosis and treatment planning of advanced cancer. Although 18F-FDG avid ovarian lesions in postmenopausal woman are considered suspicious for malignancy, PET/CT is not recommended for primary cancer detection because of high false positive rates."
MRI, CT and PET/CT for Ovarian Cancer Detection and Adnexal Lesion Characterization
Iyer VR, Lee SI
AJR 2010; 194:311-321“ Spiral CT is accurate in the depiction of peritoneal metastases from ovarian cancer, although sensitivity is reduced in patients with tumor implants 1 cm. or smaller.”
Peritoneal Metastases: Detection with Spiral CT in Patients with Ovarian Cancer Coakley FV et al. Radiology 2002;223:495-499
“ The results of this study demonstrate a sensitivity of 85%-93% for the detection of peritoneal metastases with spiral CT, in contrast to previously reported values of 63-79% with conventional CT.”
Peritoneal Metastases: Detection with Spiral CT in Patients with Ovarian Cancer Coakley FV et al. Radiology 2002;223:495-499
“ In patients with recurrent ovarian carcinoma considered for secondary cytoreductive surgery, preoperative CT can be helpful in identifying the extent of the disease and can be used as an adjunct to treatment planning and management decisions.”
Role of CT in the Management of Recurrent Ovarian Cancer Funt SA et al. AJR 2004; 182:393-398