Association of cul-de-sac seeding with intraperitoneal tumor burden in advanced ovarian cancer (CIEL, KGOG 4003)

Objective: To evaluate the relationship between tumor seeding in the cul-de-sac, assessed by transvaginal or transrectal ultrasound, and intraperitoneal tumor burden in advanced ovarian cancer. Methods: We prospectively enrolled 101 patients scheduled for surgery due to suspected or newly diagnosed ovarian, fallopian tube, or peritoneal cancer at three hospitals in Korea (Feb 2022–Dec 2023). Five were excluded for missing ultrasound or surgery, and eleven for benign or other malignancies. Preoperative ultrasound was used to assess cul-de-sac tumor seeding, categorized as no seeding, reticulonodular, serosal, or mass seeding. Intraperitoneal tumor burden was evaluated using the Peritoneal Cancer Index (PCI) and Fagotti score. Associations with bowel surgery and residual tumors >1 cm were also analyzed. Results: Eighty-five patients were included; 28 received neoadjuvant chemotherapy. Cul-de-sac seeding was classified as no seeding (42 %), reticulonodular (14 %), serosal (18 %), or mass (26 %). Higher PCI and Fagotti scores correlated with more severe seeding. Intraoperative confirmation of seeding was seen in 69 % of cases. Bowel surgery was less frequent in patients without seeding. No significant differences were found in residual tumors >1 cm between groups. Conclusion: Cul-de-sac tumor seeding identified by transvaginal or transrectal ultrasound may reflect intraperitoneal tumor burden and could help predict surgical complexity in advanced ovarian cancer.