Ovarian cancer is among the most common gynaecologic malignancies and a leading cause of cancer-related mortality in women. It accounts for approximately 5% of all cancer-related deaths and remains the deadliest form of gynaecologic cancer [1]. It is the third most common gynaecologic malignancy [2,3], comprising around 23% of all such cancers [4], and is estimated to be the fifth leading cause of cancer deaths in women, following lung, breast, colorectal, and pancreatic cancers [5].

Despite a relatively low incidence, ovarian cancer is notably lethal, largely due to its asymptomatic nature in early stages and its tendency to present

at an advanced stage. The incidence of ovarian cancer increases with age, rising steadily between 30 and 70 years and peaking at approximately 59 years. Even with advancements in chemotherapy, the five-year survival rate for patients with advanced-stage disease and peritoneal metastases remains around 30% [6].

Epithelial ovarian cancer (EOC), the most prevalent and lethal subtype, accounts for the majority of ovarian cancer deaths. Despite significant efforts in early detection and improved treatment response, most women are diagnosed with disseminated disease and experience relapse rates as high as 85%, with a five-year overall survival of just 20–30% [7,8]. Over 70% of ovarian cancer cases are diagnosed at an advanced stage, where the five-year survival rates drop to 37% for stage III and 25% for stage IV disease [9–11].

The nonspecific and subtle symptoms of ovarian cancer contribute to delayed diagnosis. While the overall five-year survival rate is approximately 50%, it can exceed 90% when the disease is confined to the ovary at diagnosis—an occurrence in fewer than 25% of patients [12]. Early and accurate detection is therefore critical for timely and effective treatment. Due to early peritoneal dissemination and the absence of distinct symptoms, around 70% of patients already have extra-pelvic spread at diagnosis.

Initial treatment typically involves surgical cytoreduction combined with chemotherapy, usually platinum and taxane-based regimens, which often achieve complete clinical remission. However, up to 70% of patients experience recurrence within 18 to 28 months [13]. Ovarian carcinoma is notorious for relapsing, often multiple times following initial treatment. While metastases beyond the peritoneal cavity are uncommon at diagnosis, they are increasingly observed during disease progression [14].

Most women treated with primary debulking surgery and adjuvant chemotherapy eventually relapse [15]. The most critical prognostic factor is disease stage at diagnosis; unfortunately, most patients present with peritoneal dissemination and without a well-defined precursor lesion, making the pathogenesis of metastasis poorly understood [6]. Recurrence is frequent despite treatment, with rates of 60–80% in advanced stages and 20–25% even in early-stage (I/II) disease [16,17]. After initial recurrence, disease progression typically accelerates. Among patients who achieve a complete response, more than 70% relapse within two years, and subsequent progression is almost inevitable, with over 70% experiencing progression within one year.

This study aimed to evaluate the various metastatic sites involved in relapsed ovarian carcinoma using MDCT.

Ovarian cancer is among the most common gynaecologic malignancies and a leading cause of cancer-related mortality in women. It accounts for approximately 5% of all cancer-related deaths and remains the deadliest form of gynaecologic cancer [1]. It is the third most common gynaecologic malignancy [2,3], comprising around 23% of all such cancers [4], and is estimated to be the fifth leading cause of cancer deaths in women, following lung, breast, colorectal, and pancreatic cancers [5].

Despite a relatively low incidence, ovarian cancer is notably lethal, largely due to its asymptomatic nature in early stages and its tendency to present

at an advanced stage. The incidence of ovarian cancer increases with age, rising steadily between 30 and 70 years and peaking at approximately 59 years. Even with advancements in chemotherapy, the five-year survival rate for patients with advanced-stage disease and peritoneal metastases remains around 30% [6].

Epithelial ovarian cancer (EOC), the most prevalent and lethal subtype, accounts for the majority of ovarian cancer deaths. Despite significant efforts in early detection and improved treatment response, most women are diagnosed with disseminated disease and experience relapse rates as high as 85%, with a five-year overall survival of just 20–30% [7,8]. Over 70% of ovarian cancer cases are diagnosed at an advanced stage, where the five-year survival rates drop to 37% for stage III and 25% for stage IV disease [9–11].

The nonspecific and subtle symptoms of ovarian cancer contribute to delayed diagnosis. While the overall five-year survival rate is approximately 50%, it can exceed 90% when the disease is confined to the ovary at diagnosis—an occurrence in fewer than 25% of patients [12]. Early and accurate detection is therefore critical for timely and effective treatment. Due to early peritoneal dissemination and the absence of distinct symptoms, around 70% of patients already have extra-pelvic spread at diagnosis.

Initial treatment typically involves surgical cytoreduction combined with chemotherapy, usually platinum and taxane-based regimens, which often achieve complete clinical remission. However, up to 70% of patients experience recurrence within 18 to 28 months [13]. Ovarian carcinoma is notorious for relapsing, often multiple times following initial treatment. While metastases beyond the peritoneal cavity are uncommon at diagnosis, they are increasingly observed during disease progression [14].

Most women treated with primary debulking surgery and adjuvant chemotherapy eventually relapse [15]. The most critical prognostic factor is disease stage at diagnosis; unfortunately, most patients present with peritoneal dissemination and without a well-defined precursor lesion, making the pathogenesis of metastasis poorly understood [6]. Recurrence is frequent despite treatment, with rates of 60–80% in advanced stages and 20–25% even in early-stage (I/II) disease [16,17]. After initial recurrence, disease progression typically accelerates. Among patients who achieve a complete response, more than 70% relapse within two years, and subsequent progression is almost inevitable, with over 70% experiencing progression within one year.

This study aimed to evaluate the various metastatic sites involved in relapsed ovarian carcinoma using MDCT.

Table 1: MDCT findings 50 patients with relapsed ovarian carcinoma: Site distribution

Table 2: MDCT findings 50 patients with relapsed ovarian carcinoma: Usual sites vs unusual sites

Table 3: MDCT findings 50 patients with relapsed ovarian carcinoma: Age distribution

Table 4: MDCT findings 50 patients with relapsed ovarian carcinoma: Histopathological distribution

Table 5: MDCT findings 50 patients with relapsed ovarian carcinoma: Lymph nodal involvement

Table 6: MDCT findings 50 patients with relapsed ovarian carcinoma: Extra peritoneal vs Intraperitoneal involvement

Table 7: MDCT findings 50 patients with relapsed ovarian carcinoma: Recurrent lesions in association with lymph nodes

Table 8: MDCT findings 50 patients with relapsed ovarian carcinoma: Number of sites involved

Table 10: MDCT findings 50 patients with relapsed ovarian carcinoma: Association of surface deposits & ascites.

Table11: MDCT findings 50 patients with relapsed ovarian carcinoma: Type of surgery (primary treatment)

Table 12: MDCT findings: Effect of surgery along with chemotherapy

The pattern of recurrence observed in this cohort provides valuable insight into the behavior and metastatic spread of the underlying malignancy. The recurrence sites were categorized into usual and unusual locations based on their frequency and clinical expectation.

Among the usual sites of recurrence, peritoneal or omental involvement was the most commonly observed, affecting 54% of patients. This finding aligns with the known predilection of many intra-abdominal malignancies, particularly gynecologic cancers such as ovarian carcinoma, to spread across peritoneal surfaces due to transcoelomic dissemination. Similarly, surface deposits over the bowel and other abdominal organs were identified in 50% of cases, further emphasizing the extensive peritoneal seeding that can occur with these cancers.

Abdominal lymph node involvement was noted in 42% of patients, which underscores the role of lymphatic spread in disease progression. Interestingly, both pelvic lymph node involvement and pelvic deposits or local recurrence were each reported in 40% of patients. This suggests a high risk of locoregional recurrence, likely influenced by the proximity of primary tumors to pelvic structures and possible microscopic residual disease after initial treatment. Ascites, a common feature associated with peritoneal carcinomatosis, was also present in 40% of patients, serving as both a clinical sign and a potential route for dissemination. Distant lymph node metastases, although less frequent, were identified in 18% of patients, indicating advanced disease spread beyond the initial regional nodes.

In terms of unusual sites of recurrence, involvement of the liver and bowel loops was each observed in 18% of cases. Liver metastasis, although less common than peritoneal spread, is a serious prognostic indicator and suggests hematogenous dissemination. Involvement of bowel loops may result from direct invasion or seeding and can complicate patient management significantly due to obstruction or perforation.

Other notable unusual recurrence sites included the lungs and muscle, each in 8% of patients. Pulmonary metastases may occur through hematogenous spread and are often associated with advanced disease. Muscle metastases, though rare, are increasingly recognized due to better imaging modalities, and their presence may suggest aggressive tumor biology.

Pleural effusion was noted in 12% of cases, which might be reactive or malignant in nature, and should prompt further cytologic evaluation. Cutaneous or parietal wall involvement, found in 10% of cases, could be due to surgical implantation or hematogenous spread. Adrenal glands, ureters, and urinary bladder were each involved in 8–10% of patients, highlighting the potential for retroperitoneal and direct extension-based spread.

Less frequently, brain and vaginal vault recurrences were documented in 6% of patients. CNS involvement is relatively rare but represents a serious clinical event, often associated with poor prognosis. Bone, spleen, and pleural thickening were each identified in a small proportion (2–4%) of patients, yet they highlight the importance of whole-body imaging during follow-up in select high-risk cases.

Overall, this distribution pattern reflects the complex and multifocal nature of disease recurrence. The predominance of peritoneal, lymphatic, and visceral involvement emphasizes the need for comprehensive surveillance strategies post-treatment, including imaging modalities that assess both abdominal and distant sites. Awareness of these recurrence patterns can guide clinicians in planning individualized follow-up protocols and potentially facilitate earlier detection and management of recurrences, thereby improving patient outcomes.

According to A Sahdev et al (2005) [18] which was the first study to describe common patterns of recurrence in ovarian cancer, most frequent site is pelvis (48%), followed by peritoneum (45%), serosal surfaces (45%) and nodal disease (33%). Some other studies, 22% of the cases of relapsed ovarian carcinoma have recurred with solitary lesion while in the present study no case of relapse have shown a solitary lesion. A Sahdev et al (2005) did not mention about presence of pleural effusion. However, in the present study of relapsed ovarian carcinoma, 40% cases have shown the presence of ascites and 12% have shown evidence of pleural effusion.

This study evaluated recurrence patterns, histopathological profiles, anatomical distribution, and treatment modalities in 50 patients with relapsed ovarian carcinoma based on multidetector computed tomography (MDCT) findings.

Regarding the site of recurrence, the majority of patients (62%) had involvement of both usual and unusual sites, indicating a widespread disease pattern at relapse. Usual site involvement only was observed in 30%, while unusual site recurrence alone was less common, seen in only 8% of patients. This underlines the importance of comprehensive imaging to detect both common and less typical metastatic locations during follow-up.

Age distribution revealed that most patients were in the 46–60 years age group, with 24% between 46–50 years, 16% between 51–55 years, and 18% between 56–60 years. Very few cases were found at extremes of age, with only 2% under 15 years and another 2% above 80 years, which is consistent with the epidemiological profile of ovarian cancer being more prevalent in middle-aged to older women.

Histopathologically, serous adenocarcinoma was the predominant subtype, accounting for 92% of all relapsed cases. Rare variants included granulosa cell tumors (4%), germ cell tumors (2%), and neuroendocrine tumors (2%), reaffirming that high-grade serous carcinoma remains the most aggressive and recurrent form of epithelial ovarian cancer.

Lymph node involvement was present in a majority, with 34% showing combined pelvic, abdominal, or distant lymphadenopathy. Isolated pelvic, abdominal, or distant lymph node involvement was seen in 8%, 12%, and 10% of patients, respectively. Interestingly, 36% had no lymph node involvement, highlighting the heterogeneity of metastatic patterns in recurrent disease.

However, in Tay SK (2005) [19] study no cases showed relapse with ascites, pleural effusion, muscle involvement, kidneys, cutaneous /parietal wall involvement of abdomen and chest or bowel involvement /fistula which were evaluated in the present study.

In terms of anatomical spread, 54% of patients showed combined intraperitoneal and extraperitoneal involvement, while 46% had extraperitoneal disease only. Notably, none had isolated peritoneal involvement, suggesting that by the time recurrence is clinically or radiologically evident, disease has usually spread beyond the peritoneal cavity.

When evaluating the association of recurrent lesions with lymph node involvement, 54% of patients had recurrent lesions with lymph node metastases, 36% had recurrent lesions without lymphadenopathy, and in 10%, lymph nodes were the only site of recurrence. This supports the role of nodal disease as a critical component of relapse and a potential prognostic factor.

The majority of patients (92%) had multiple sites of recurrence, whereas only 8% showed isolated single-site involvement, reflecting the aggressive and disseminated nature of relapsed ovarian cancer.

An analysis of surface deposits and ascites revealed varied patterns: 16% had ascites without surface deposits, 26% had surface deposits without ascites, and 24% had both. Notably, 34% had neither, indicating that while ascites and surface deposits are common, their presence is not universal and should not be solely relied upon as markers of recurrence.

Regarding the type of primary surgery, the most frequently performed was NACT (neoadjuvant chemotherapy) followed by cytoreduction, accounting for 56% of cases. Cytoreduction alone and TAH + BSO (total abdominal hysterectomy with bilateral salpingo-oophorectomy) were each performed in 20% of patients. Rare surgical approaches included TAH + BSO + omentectomy and laparoscopic salpingo-oophorectomy, both observed in 2% of patients. These variations reflect differences in disease burden, respectability, and institutional practices.

Ettie Piura et al (2011) [20] reviewed literature and concluded brain metastasis from ovarian carcinoma is uncommon with less than 600 cases documented in the literature so far. Whereas in the present study involvement of brain by recurrent disease was seen in 3 patients. One patient was followed up with PET CT and 1

patient was followed up with MRI brain with contrast which showed comparable results.

Finally, the role of chemotherapy in treatment was notable, with 86% of patients receiving surgery along with chemotherapy, while only 14% underwent surgery without adjuvant chemotherapy. This highlights the standard of care involving multimodal treatment and the crucial role of chemotherapy in managing ovarian cancer, even post-surgery.

Overall, this analysis demonstrates the complexity and heterogeneity of recurrent ovarian carcinoma. The findings underscore the importance of MDCT in detecting widespread and varied metastatic patterns, evaluating response to treatment, and planning further therapeutic interventions. The predominance of serous histology, multifocal recurrence, and nodal involvement reaffirms the aggressive nature of this malignancy and the need for vigilant post-treatment surveillance.

Dauplat et al (1987) [21] analyzed 336 patients of distant metastasis from ovarian cancers. Of these, four patients had bone metastasis, two of which belonged to thoracic vertebra; one to the clavicle and one had bone marrow involvement. None of the patients in this series had bone metastasis as first site of presentation. According to the authors bony metastasis is rarest to be presented as first site and median time to development ranged from 13-49 months.

Dimitrios Pectasides et al (2006) [22] reviewed the literature of brain metastases from epithelial ovarian cancer and concluded that no conflicts with it. Present study also showed brain as one of the rare sites to be involved in recurrent disease but if involved, it is readily recognized. Other rare sites of reported recurrences included the skin and subcutaneous tissues, thymus, thyroid, breast, and the urinary tract

The metastatic pattern of relapsed ovarian carcinoma in the present study revealed that the peritoneum was the most commonly involved site, followed by surface deposits and nodal disease. The most commonly affected age group was between 46 and 50 years.

Multidetector computed tomography (MDCT) with contrast provided excellent resolution for evaluating the characteristic features of various sites and appearances of metastatic lesions in relapsed ovarian carcinoma cases. In the present study, recurrent disease at unusual sites was most frequently observed in the liver and bowel.

The study also demonstrated that recurrence involving multiple sites was significantly more common than single-site involvement or solitary lesions. These findings confirm that MDCT is the initial imaging modality of choice, improving diagnostic accuracy in patients with clinical suspicion of relapsed ovarian carcinoma.

MDCT is a less invasive, cost-effective, dynamic, and non-operator-dependent cross-sectional imaging technique, with the added benefit of producing reformatted images in sagittal and coronal planes. It does not require sedation, making the procedure less time-consuming and reducing motion artifacts. As a result, it can be comfortably used in chronically ill and debilitated patients.

Furthermore, patients who had undergone both surgery and chemotherapy at the time of initial diagnosis were found to have a higher tendency for extraperitoneal involvement upon recurrence.

In conclusion, MDCT remains the imaging modality of choice for detecting the metastatic pattern in relapsed ovarian carcinoma.

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