High-grade serous carcinoma (HGSC) is the most common ovarian malignancy, accounting for 70% of all epithelial ovarian cancers. Most cases are diagnosed at advanced stage (stage III-IV). Presents as a solid-cystic mass with bilateral involvement and papillary projections. Association with peritoneal carcinomatosis, omental cake, ascites, and extensive pelvic/para-aortic lymphadenopathy is typical. CA-125 is markedly elevated. BRCA1/2 mutation is detected in 20-25% of cases and is associated with response to PARP inhibitors.
Age Range
40-70
Peak Age
60
Gender
Female predominant
Prevalence
Common
High-grade serous carcinoma predominantly originates from the fimbriae of the fallopian tube (STIC — serous tubal intraepithelial carcinoma); the classic 'ovarian surface epithelium' origin concept has been updated. TP53 mutation is present in >96% of cases and leads to genomic instability. BRCA1/2 mutation impairs homologous recombination repair. The aggressive biology of the tumor enables early peritoneal dissemination — implants on omentum, peritoneal surfaces, and diaphragmatic undersurfaces through peritoneal fluid circulation. Imaging findings reflect this pathology: the solid-cystic mass enhances intensely due to rich neovascular network, papillary projections represent epithelial proliferation, peritoneal carcinomatosis and omental cake reflect widespread implants, and ascites results from peritoneal irritation.
Dense mass-like thickening and nodular enhancing implants along the omentum majus. The most characteristic finding of advanced-stage ovarian cancer. Contains tumor tissue replacing normal omental fat. Can also be seen in peritoneal dissemination of gastric and colorectal cancer, but the combination of bilateral ovarian mass + omental cake + ascites is pathognomonic for high-grade serous ovarian carcinoma.
Contrast-enhanced CT shows a solid-cystic mass in ovarian location. The solid component demonstrates intense enhancement. Necrotic/cystic areas show no enhancement. Papillary projections are seen as enhancing solid protrusions within cystic cavities. Bilateral involvement is common.
Report Sentence
Solid-cystic masses are identified in both ovarian locations with intense enhancement of solid components, consistent with high-grade serous carcinoma.
Thickened, nodular/plaque-like enhancing peritoneal implants are seen along the omentum majus — 'omental cake'. This finding is the most characteristic CT finding of advanced-stage ovarian cancer. The omentum may appear as smooth single thickening or multiple nodular implants.
Report Sentence
Extensive thickening and nodular enhancing implants are observed along the omentum majus in an 'omental cake' pattern, consistent with peritoneal carcinomatosis.
T2-weighted MRI shows intermediate signal intensity in solid component (hyperintense to muscle, hypointense to fluid). Cystic component is hyperintense. Papillary projections appear as intermediate signal solid protrusions extending into cystic areas. Necrotic areas show high T2 signal.
Report Sentence
A solid-cystic mass is identified on T2-weighted sequences with intermediate signal intensity in solid component and papillary projections, consistent with malignant epithelial ovarian tumor.
Significant diffusion restriction is seen in the solid component on DWI — bright signal on high b-values and low signal on ADC map. Papillary projections also show diffusion restriction. Necrotic/cystic areas do not show diffusion restriction. ADC values are generally <1.0 x 10-3 mm2/s.
Report Sentence
Significant diffusion restriction is observed in the solid component and papillary projections on DWI with low ADC values, consistent with high cellularity and malignancy.
Complex solid-cystic mass on US. Solid component is echogenic, cystic component is anechoic or hypoechoic. Papillary projections appear as echogenic protrusions extending from the cyst wall into the cavity, disrupting the inner contour. Bilateral masses, ascites, and peritoneal implants may accompany.
Report Sentence
Solid-cystic masses are identified in both ovarian locations with intracystic papillary projections and accompanying ascites; evaluation for ovarian malignancy is recommended.
Doppler US shows markedly increased vascular flows in solid component and papillary projections. Low-resistance arterial flows (RI <0.4) favor malignancy. Central vascularity pattern is more suspicious than peripheral pattern. Neovascularization shows irregular vascular network different from regular vessel architecture.
Report Sentence
Doppler examination demonstrates markedly increased vascular flows and low-resistance arterial flow pattern in solid component and papillary projections, favoring malignancy.
Free fluid (ascites) in peritoneal cavity and multiple nodular/plaque-like enhancing implants on peritoneal surfaces. Subdiaphragmatic surfaces, paracolic gutters, Douglas cul-de-sac, and small bowel mesentery are commonly involved areas. Pleural effusion may accompany (stage IV).
Report Sentence
Extensive ascites and multiple nodular enhancing implants on peritoneal surfaces are identified in the peritoneal cavity, consistent with peritoneal carcinomatosis.
Criteria
Accounts for >90% of ovarian serous carcinomas. TP53 mutation >96%, high Ki-67 index (>75%). Solid, papillary, and cribriform patterns. Mostly diagnosed at advanced stage.
Distinct Features
Significant solid component, aggressive enhancement, early peritoneal dissemination, bilateral involvement common (50-70%). Marked diffusion restriction on DWI. BRCA1/2 mutation accompanies at 20-25% rate and is associated with PARP inhibitor response.
Criteria
Less than 5% of serous carcinomas. KRAS/BRAF/ERBB2 mutations. Low Ki-67 index. Often develops through progression from serous borderline tumors. TP53 wild-type.
Distinct Features
More indolent course, more prominent cystic component, less aggressive appearance. Calcifications (psammoma bodies) are more common. Limited chemotherapy response but may be sensitive to hormonal therapy.
Criteria
HGSC carrying germline or somatic BRCA1/2 mutation. 20-25% of all HGSCs. Homologous recombination deficiency (HRD) is present.
Distinct Features
Imaging features are similar to sporadic HGSC. Better response to platinum-based chemotherapy and PARP inhibitors (olaparib, niraparib). May be seen in younger age group. Family history is positive for breast/ovarian cancer.
Distinguishing Feature
In ovarian metastasis (Krukenberg), bilateral solid masses are seen but the primary tumor is in another organ (stomach, colon, breast). GI primary should be searched for wall thickening in stomach/colon. In serous carcinoma, the ovary is the primary site and peritoneal dissemination originates from the ovary's own malignancy.
Distinguishing Feature
Mucinous carcinoma is usually unilateral and very large (>10 cm) with multilocular cystic appearance. Serous carcinoma is bilateral, more solid, and shows more aggressive peritoneal dissemination. On MRI, mucinous carcinoma loculations show variable T1/T2 signal while solid component dominates in serous carcinoma.
Distinguishing Feature
Granulosa cell tumor has a 'sponge/Swiss cheese' pattern solid-cystic mass that produces estrogen (endometrial thickening accompanies). Serous carcinoma is more aggressive, shows more peritoneal dissemination, does not produce estrogen, and CA-125 is elevated (not inhibin).
Distinguishing Feature
Tubo-ovarian abscess has a thick wall with wall enhancement but no solid internal component/papillary projections. Clinically accompanied by fever, elevated CRP/WBC, and pelvic inflammatory disease findings. In serous carcinoma, solid tumoral component, papillary projections, and peritoneal dissemination create the difference.
Urgency
urgentManagement
surgicalBiopsy
Not NeededFollow-up
specialist-referralTreatment consists of primary debulking surgery (TAH-BSO + omentectomy + peritoneal staging + lymphadenectomy) and platinum-based chemotherapy (carboplatin + paclitaxel). In advanced stages, neoadjuvant chemotherapy followed by interval debulking may be performed. PARP inhibitors (olaparib, niraparib) are approved as maintenance therapy in BRCA-positive patients. Optimal cytoreduction (<1 cm residual disease) significantly impacts survival. Urgent referral to gynecologic oncology is required. CA-125 is used as follow-up marker.
Ovarian serous carcinoma is usually diagnosed at advanced stage (stage III-IV). CA-125 elevation is used for diagnosis and follow-up. Treatment is debulking surgery + platinum-based chemotherapy. BRCA1/2 mutation is a risk factor. 5-year survival is 40% for stage III and 20% for stage IV.