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Metastatic Involvement of Lesser Sac in Advanced Epithelial Ovarian Cancer
  1. Asima Mukhopadhyay, MD, MRCOG, PhD, MSc*,,
  2. Nicolò Bizzarri, MD,
  3. Melissa Bradbury, MD,
  4. Subir Sinha, MS§,
  5. Jaydip Bhaumik, MS, FRCOG, MPH* and
  6. C. William Helm, MBBChir, FRCS
  1. *Department of Gynaecological Oncology, Tata Medical Center, Kolkata, India;
  2. Newcastle University, Newcastle upon Tyne;
  3. Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead, UK;
  4. §Department of Biostatistics, Tata Medical Center, Kolkata, India; and
  5. Princess Alexandra Wing, Royal Cornwall Hospitals Trust, Truro, Cornwall, UK.
  1. Address correspondence and reprint requests to C William Helm, MBBChir, FRCS, Princess Alexandra Wing, Royal Cornwall Hospitals Trust, Truro, Cornwall, TR13LJ United Kingdom. E-mail:


Objectives In advanced epithelial ovarian cancer (AOC), lesser sac (LS) metastasis particularly to the supragastric LS (SGLS) may be overlooked, resulting in unrecognized residual disease. We aimed to identify the frequency, distribution, and predictors of LS metastasis using laparoscopic evaluation at laparotomy and perioperative surgical complications associated with evaluation and resection/ablation.

Methods Prospective observational study in consecutive patients with AOC undergoing laparotomy for primary or interval cytoreductive surgery in 2 centers between November 2013 and December 2016.

Results Of 182 AOC patients undergoing laparotomy, 150 were eligible for metastasis distribution analysis; 96/150 (64%) had LS metastasis with 90/150 (60%) involving the SGLS, including lesser omentum (47.3%), floor (42%), upper recess (24.6%), and caudate lobe (22.6%), with 62/90 (68.8%) being less than 1 cm in dimension. Of 144 undergoing cytoreductive surgery, 92 (64%) had LS metastasis, which was completely resected/ablated in 77/92 (83.6%).

The strongest multivariate predictors of LS metastasis were involvement of Morison pouch (P < 0.001) and peritoneal cancer index of 17 or greater (P < 0.001). The LS metastasis was significantly associated with diaphragmatic surgery (84% vs 54%), cholecystectomy (33% vs 2%), splenectomy (50% vs 14%), retroperitoneal nodal metastasis (75% vs 49%), and surgical complexity score of 8 or higher (75% vs 35%). Morbidity related to treatment of LS metastasis was minimal.

Conclusions Lesser sac metastasis and SGLS metastasis are present in almost two thirds of cases of AOC and often small in size. Systematic exploration is necessary to detect and treat metastases to LS to prevent unrecognized incomplete cytoreduction.

  • Epithelial ovarian cancer
  • Lesser sac
  • Supragastric lesser sac
  • Omental bursa
  • Cytoreductive surgery

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  • Meeting presentation: Initial results from this study were presented at the International Gynecological Cancer Society (IGCS) Biennial Meeting on October 29 to 31, 2016, in Lisbon, Portugal.

  • A.M and N.B contributed equally to this work.

  • The authors declare no conflicts of interest.

  • Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (