General Medical Information

Ovarian Epithelial Cancers - Patterns of Spread

Jonathan S. Berek

Ovarian epithelial cancers spread primarily by exfoliation of cells into the peritoneal cavity, by lymphatic dissemination, and by hematogenous spread.

Transcelomic The most common and earliest mode of dissemination is by exfoliation of cells that implant along the surfaces of the peritoneal cavity. The cells tend to follow the circulatory path of the peritoneal fluid. The fluid tends to move with the forces of respiration from the pelvis, up the paracolic gutters, especially on the right, along the intestinal mesenteries, to the right hemidiaphragm. Therefore, metastases are typically seen on the posterior cul-de-sac, paracolic gutters, right hemidiaphragm, liver capsule, the peritoneal surfaces of the intestines and their mesenteries, and the omentum. The disease seldom invades the intestinal lumen but progressively agglutinates loops of bowel, leading to a functional intestinal obstruction. This condition is known as carcinomatous ileus.

Lymphatic Lymphatic dissemination to the pelvic and paraaortic lymph nodes is common, particularly in advanced-stage disease. Spread through the lymphatic channels of the diaphragm and through the retroperitoneal lymph nodes can lead to dissemination above the diaphragm, especially to the supraclavicular lymph nodes. Burghardt et al. performed systematic pelvic and paraaortic lymphadenectomy on 123 patients and reported that 78% of patients with stage III disease had metastases to the pelvic lymph nodes. In another series, the rate of positive paraaortic lymph nodes was 18% in stage I, 20% in stage II, 42% in stage III, and 67% in stage IV.

Hematogenous Hematogenous dissemination at the time of diagnosis is uncommon, with spread to vital organ parenchyma, such as the lungs and liver, in only approximately 2% to 3% of patients. Most patients with disease above the diaphragm at the time of presentation have a right pleural effusion. Systemic metastases are seen more frequently in patients who have survived for some years. Dauplat et al. reported that distant metastasis consistent with stage IV disease ultimately occurred in 38% of patients whose disease was originally intraperitoneal. Malignt pleural effusion developed in one fourth of the patients, with a subsequent median survival of 6 months. Other sites and their median survivals were as follows: parenchymal lung metastasis in 7.1%, median survival 9 months; subcutaneous nodules in 3.5%, 12 months; malignant pericardial effusion 2.4%, 2.3 months; central nervous system 2%, 1.3 months; and bone metastases in 1.6%, 4 months. Significant risk factors for distant metastases were malignant ascites, peritoneal carcinomatosis, large metastatic disease in the abdomen, and retroperitoneal lymph node involvement at the time of initial surgery.