Metastases to the ovary

Metastases to the ovary are relatively common with a documented incidence of 5-30% of all malignant ovarian masses.

These may be incorrectly grouped under Krukenberg tumours, which are signet cell containing tumours that form only 30-40% of all ovarian metastases.  

Clinical presentation

There is often a known primary at presentation. Patients may present with abdominal symptoms such as pain or palpable pelvic mass. Hormonal overactivity can also be occasionally seen due to hyperplasia of ovarian stroma.

Pathology

These are large lobulated tumours with areas of haemorrhage and necrosis. The contour of the ovary is usually preserved. Lesions are commonly bilateral. 

They usually spread by haematogenous route, lymphatic route or by the direct spread. There are usually surface deposits of tumours with invasion of the stroma.

Aetiology

Metastases to the ovary commonly arise from the gastrointestinal tract, breast, lungs and contralateral ovaries. Other rare primaries include endometrium, melanoma, pancreas, carcinoid, leukaemia ⁶, renal cell carcinoma ⁷, hepatocellular carcinoma ⁸, gallbladder carcinoma ⁹, bladder transitional cell carcinoma ¹⁰, neuroblastoma ¹¹, and reticuloendothelial tumours ¹².

Radiographic features

Ultrasound

These are mixed echogenicity tumours with vascularity of solid component on Doppler.

CT

Soft tissue density with areas of cystic necrosis. On contrast, solid components demonstrate inhomogeneous enhancement.

MRI

• T1: iso to hypointense with variable enhancement on contrast
• T2: heterogenous signal of the solid component with hyperintensity of the cystic component

Treatment and prognosis

Treatment involves radical tumour-reductive surgery. The prognosis for metastases is very poor with a 1-year rate of survival less than 10%. 

Differential diagnosis

Imaging differential considerations include:

• primary ovarian cancer: see ovarian tumours
  • predominantly multiloculated cystic masses are primary ovarian cancers whereas predominantly solid to mixed tumours are metastases
• ovarian lymphoma: ovarian lymphomas are homogeneously solid masses with extensive lymph nodal involvement