Ovarian cancer. Diagnosis
Unfortunately, most patients with ovarian cancer are diagnosed after the disease has spread beyond the ovary. In these patients, symptoms may be abdominal pain or a bloated feeling, gastrointestinal or urinary tract disturbances, or in many cases, the onset of clinically detectable ascites. Some patients with advanced disease have menstrual irregularity or postmenopausal bleeding, but these symptoms occur infrequently. Occasionally, a patient may present with a palpable inguinal lymph node, tumor in a hernia sac, or pleural effusion. For patients with advanced disease, diagnosis is established by tissue obtained at exploratory laparotomy. In rare instances when a patient cannot undergo surgery because of medical problems, the histologic or cytologic diagnosis is established by needle biopsy.
Early ovarian cancer is diagnosed by the surgical evaluation of an adnexal mass. The decision to subject a patient to surgical exploration is difficult to make. Ultrasonographic evaluation of the adnexal mass has improved the ability to distinguish patients who should have surgical exploration from those who can be observed, but it has also resulted in an increasing number of patients who are found to have an asymptomatic ovarian cyst. This is of particular concern in the postmenopausal woman. Table 7 outlines the diagnostic criteria for surgical exploration of a patient with an adnexal mass. As with any diagnostic or therapeutic schema, the criteria for exploration cannot be absolute. For example, a patient with known endometriosis may meet the criteria for surgical exploration when it is not the best treatment option, or a postmenopausal patient with a 4-cm simple cyst may have risk factors for surgery that make observation a more reasonable option.
Cancer treatment
The use of tumor markers to assist in the evaluation of a patient with an adnexal mass is not inappropriate, but misinformation may result. Serum CA 125 is used most often and is the only serum marker available with the potential accuracy to be beneficial, but even this marker is less than optimal. Approximately half of early-stage ovarian cancer patients do not have elevated serum CA 125 levels. Also, a variety of nonmalignant and nonovarian malignant conditions can result in elevated serum CA 125 levels. These conditions are listed in Tables 8 and 9, page 43. A serum CA 125 elevation above 35 U may be helpful in deciding whether or not to recommend surgery in a postmenopausal patient with an ovarian mass, but a negative value is not helpful. Likewise, a serum CA 125 elevation in women of reproductive age with both an ovarian mass and leiomyomata or endometriosis may not be helpful.
TABLE 7. Management Schema for a Patient with an Adnexal Mass
Observe and Repeat Examination in 4-6 Weeks Surgical Exploration
Reproductive age Premenarchal or postmenopausal*
Mass <8 cm Mass >8 cm
Simple cysts on ultrasonography Complex cysts on ultrasonography
Decreasing size Increase in size or persistence through 2-3 menstrual cycles
Cystic and smooth Solid and irregular
Mobile Fixed
Unilateral Bilateral
Asymptomatic Pain or other symptoms of acute intraabdominal process
No ascites Ascites
*Simple cysts smaller than 3 cm may be followed closely with ultrasonography.