Imaging showing omental thickening and adnexal masses in an older woman is most suggestive of which diagnosis?

• A. Tubo-ovarian abscess
• B. Endometriosis
• C. Ovarian carcinoma with peritoneal spread
• D. Mesothelioma

Answer: (C)

Ovarian carcinoma with peritoneal spread is most likely when imaging shows omental thickening (often described as omental caking) together with adnexal masses in an older woman. Ovarian cancers commonly disseminate transcoelomically to the peritoneum, so the omentum becomes thickened with diffuse nodularity as implants seed the peritoneal surfaces. The presence of adnexal masses supports an ovarian primary rather than a purely inflammatory or endometriotic process, and the age fits the typical presentation of ovarian cancer. In contrast, a tubo-ovarian abscess would usually accompany fever and leukocytosis with a pelvic infectious process rather than prominent omental involvement. Endometriosis involves pelvic implants and endometriomas and typically affects younger patients, not presenting with widespread omental thickening. Mesothelioma can cause diffuse peritoneal thickening but does not explain the adnexal masses as the primary source; ovarian cancer with peritoneal spread remains the most consistent explanation.