Ovarian Cancer: Diagnosis and Treatment
A careful history may reveal frequent, multiple symptoms with a relatively acute onset and severity, but is unlikely to distinguish between benign and malignant disease.
Physical examination may reveal no pertinent findings, as an early tumor is often not palpable. However, as the tumor enlarges, physical examination may reveal a lower abdominal mass. Pelvic examination may reveal an asymptomatic, irregular, and fixed adnexal mass. Although not pathognomonic for ovarian cancer, especially in premenopausal women, a pelvic or abdominal mass should prompt further evaluation through imaging and/or laboratory analysis.
Ultrasound helps to distinguish benign from malignant masses. In general, most women should have surgery to determine a histologic diagnosis. In cases where ultrasonography reveals an apparently benign mass, continued observation may be prudent. Ultrasound may also serve as an annual screening tool in women with the BRCA gene mutation.
CT scan and MRI are not helpful for the diagnosis of a known pelvic mass, but they may reveal extra–ovarian primary tumors or serve to quantify the extent of metastases in presumed ovarian cancer prior to surgery.
Tumor markers, such as CA–125, are not helpful for screening or diagnosis because they can be elevated in benign conditions (eg, endometriosis), particularly in premenopausal women, and also for nonovarian malignancies. CA–125 is also not always positive in early stages of ovarian cancer. However, in postmenopausal women, the test has a positive predictive value of 97%.2 The CA–125 marker is used to monitor treatment of ovarian cancer, comparing presurgery and posttreatment levels.
The preferred treatment depends on histology and surgical tumor staging:
Stage I is limited to the ovary or ovaries.
Stage II includes pelvic extension.
Stage III includes extra–pelvic peritoneal spread and/or inguinal or retroperitoneal lymph node involvement.
Stage IV involves distant metastases.
In early stages, treatment involves surgical resection, along with abdominal hysterectomy, bilateral salpingo–oophorectomy, omentectomy, and selective lymphadenectomy. With more advanced disease, surgical removal and postoperative chemotherapy are indicated.
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