## Sites of Metastatic Spread in Ovarian Cancer **Key Point:** Peritoneal surfaces and omentum are the most common sites of metastatic involvement in advanced ovarian cancer, occurring in >80% of Stage III–IV cases. ### Pattern of Spread in Ovarian Cancer | Site of Spread | Frequency in Advanced Disease | Stage Implication | Clinical Significance | |---|---|---|---| | Peritoneal surfaces & omentum | >80% | Stage III–IV | Defines Stage III; determines surgical debulking strategy | | Liver parenchyma | 5–10% | Stage IV | Indicates hematogenous spread | | Lungs | 3–5% | Stage IV | Indicates hematogenous spread | | Retroperitoneal lymph nodes | 60–70% (Stage III) | Stage IIIC | Nodal involvement without peritoneal spread | | Diaphragm | 10–15% | Stage III–IV | Often missed on imaging; found at surgery | **High-Yield:** Stage IIIC is defined by peritoneal metastases >2 cm and/or positive retroperitoneal lymph nodes. Peritoneal spread is the hallmark of advanced ovarian cancer and is the primary target of cytoreductive surgery and intraperitoneal chemotherapy. **Clinical Pearl:** The omentum ("omental cake") is the most frequently involved peritoneal structure and is routinely resected during optimal cytoreductive surgery. Peritoneal carcinomatosis is the reason ovarian cancer is staged surgically and why exploratory laparotomy (or laparoscopy) is essential for accurate staging. ### Mechanism of Peritoneal Spread 1. **Transcoelomic spread:** Direct exfoliation of tumor cells from the ovary into the peritoneal cavity 2. **Gravitational seeding:** Tumor cells settle on dependent peritoneal surfaces (omentum, bowel serosa, pelvic peritoneum) 3. **Lymphatic and vascular involvement:** Secondary to peritoneal disease **Mnemonic: POLD** — Peritoneal (most common), Omental, Lymph nodes, Distant organs (liver, lungs, lungs last).
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