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Ovarian cancer - Diagnosis

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of ovarian cancer..

Diagnosis:

Up to 95% of women diagnosed with ovarian cancer will survive longer than 5 years if their cancers are treated before they have spread beyond the ovaries. Unfortunately, there are no screening tests for ovarian cancer that are the equivalent to mammography for early detection of breast cancer. Therefore, only about 25% of ovarian cancer cases are diagnosed at such early stages. It is possible to perform genetic screening in high-risk women, but this raises some complex issues.

Annual Gynecologic Checkup

Every woman should have a regular annual examination with her doctor that includes:

Pelvic examination. Routine exams called bimanual pelvic examinations are a reasonable precaution, although they are not perfect screening methods due to their low sensitivity. This exam can be performed two ways. In the more common method, the doctor inserts two fingers into the vagina while palpating the abdomen with the other hand. The other method, called a bimanual rectovaginal exam, involves the insertion of one finger into the vagina and another into the rectum.

Either exam enables the doctor to assess the size of the ovaries as well as the contour and mobility of the uterus and to feel for masses and growths. The rectovaginal exam may reveal rectal lesions that may otherwise go unnoticed and is particularly important for women over 50. A mass felt on pelvic exam often requires further evaluation by ultrasound and sometimes requires surgery to make a definitive diagnosis.

Unfortunately, ovarian cancer rarely produces changes that are detectable during a regular checkup.

Ruling out Benign Conditions

Many women are hospitalized each year in the United States because of ovarian growths or lesions. Many more women find out about some ovarian abnormality during their annual Ob/Gyn check up. The vast majority of conditions are noncancerous. They include:

  • Benign functional ovarian cysts
  • Abscesses and infection
  • Fibroids

Fibroid tumors
Click the icon to see an image of a fibroid tumor.
  • Endometriosis
  • Polycystic ovaries

Overproductive ovaries
Click the icon to see an image of a polycystic ovary.
  • Ectopic pregnancies

Ectopic pregnancy
Click the icon to see an image of an ectopic pregnancy.
  • Meig syndrome (which involves a benign ovarian growth associated with fluid buildup in the abdomen and around the lungs)
  • Ovarian hyperstimulation syndrome following fertility treatments.

Once a growth is detected, additional tests [below] may help the doctor gauge the risk for it being cancerous.

Transvaginal Ultrasound and Other Imaging Tests

Ultrasound. Ultrasound is a noninvasive diagnostic tool that can evaluate tumors and masses discovered during the rectovaginal exam:

  • Typically, a probe is placed in the vagina and emits sound waves (ultrasound). The sound waves bounce off tissues, organs, and masses in the pelvic cavity. These echoes are collected and converted into a picture of the area called a sonogram.

Transvaginal ultrasound
Click the icon to see an image of transvaginal ultrasound.
  • The ultrasound probe may also be placed on abdominal walls above the ovaries (transabdominal ultrasound), but it does not provide as clear a picture of the ovaries. Healthy tissue, fluid-filled cysts, and solid tumors produce different sound waves.

Ultrasound is not helpful for identifying early-stage ovarian cancer in high-risk women. (Researchers hope that blood tests for protein markers may eventually provide a better method for diagnosing early-stage ovarian cancer.) In addition, ultrasound does not provide enough specific information to reliably determine which abnormal masses are cancerous or noncancerous.

Other Imaging Techniques. Other imaging techniques are less common for the diagnosis or evaluation of suspected ovarian cancer but may help determine if cancer has spread to other parts of the body:

  • Computed tomography (CT). Computed tomography records x-ray absorption rates of tissue and bone. These data is converted into clear images on a screen. CT scans help determine if cancer has spread to the lymph nodes, abdominal organs, abdominal fluid, and the liver.

CT scan
Click the icon to see an image of a CT scan.
  • Magnetic resonance imaging (MRI). MRI creates multiple cross-sectional images of the pelvis and abdominal organs, which are assembled into three-dimensional images. An MRI is not usually used to diagnose ovarian cancer, but may help determine if cancer has spread to the brain or spinal cord.

MRI scan
Click the icon to see an image of a MRI scan.
  • Chest x-rays. Find cancer that has spread to the lungs.

X-ray
Click the icon to see an image of an x-ray machine.

CA-125 Blood Test

CA-125 is a protein that is secreted by ovarian cancer cells and is elevated in over 80% of patients with ovarian cancer. The CA-125 blood test is not approved for screening in the general population. Oncologists will usually only obtain a blood test for this protein if ovarian cancer is strongly suspected or has been diagnosed. In general, a CA-125 level is considered to be normal if it is less than 35 U/mL (microns per milliliter). The test may also be useful for evaluating tumor growth and predicting survival in patients with recurrent cancer who have been treated with topotecan or paclitaxel-carboplatin chemotherapy regimens.

The test is not useful for diagnosis or early screening, however. In about half of women with very early ovarian cancer, CA-125 levels are not elevated above the normal standard at all. Furthermore, an elevated level can be caused by a number of other conditions including:

  • Endometriosis (which may be a risk factor for ovarian cancer)
  • Fibroids
  • Noncancerous ovarian cysts
  • Pregnancy
  • Pelvic inflammatory disease
  • Liver diseases
  • Other tumors, such as breast, colon, lung, and pancreatic cancers
  • Age and menstrual status can also affect the levels of CA-125

Exploratory Surgery

An exploratory surgical procedure is required to confirm a diagnosis of ovarian cancer. It is also necessary to properly stage a patient, since the imaging tests may miss small implants of ovarian tumor within the pelvis and the abdominal cavity. Surgery may be laparotomy or a less-invasive laparoscopy. A gynecologic oncologist usually performs these procedures.

Laparatomy is an open-surgery procedure that requires general anesthesia. The oncolologist makes an incision from the pubic bone to the navel to explore the abdominal cavity. Laparascopy does not require general anesthesia and the oncologist uses only small incisions to insert a lighted instrument to examine the organs and evaluate the spread of the tumor. With both procedures, tissue samples (biopsies) can be removed for further testing.


Pelvic laparoscopy
Click the icon to see an image of pelvic laparoscopy.

Resources

References

Aletti GD, Gallenberg MM, Cliby WA, Jatoi A, Hartmann LC. Current management strategies for ovarian cancer. Mayo Clin Proc. 2007 Jun;82(6):751-70.

American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Management of adnexal masses. Obstet Gynecol. 2007; 110(1): 201-14.

Beral V; Million Women Study Collaborators; Bull D, Green J, Reeves G. Ovarian cancer and hormone replacement therapy in the Million Women Study. Lancet. 2007 May 19;369(9574):1703-10.

Burger, RA. Experience with bevacizumab in the management of epithelial ovarian cancer. J Clin Oncol. 2007; 25(20): 2902-8.

Chan JK, Tian C, Monk BJ, Herzog T, Kapp DS, Bell J, et al. Prognostic factors for high-risk early-stage epithelial ovarian cancer: a Gynecologic Oncology Group study. Cancer. 2008; 112(10): 2202-10.

Collaborative Group on Epidemiological Studies of Ovarian Cancer, Beral V, Doll R, Hermon C, Peto R and Reeves G. Ovarian cancer and oral contraceptives: collaborative reanalysis of data from 45 epidemiological studies including 23,257 women with ovarian cancer and 87,303 controls. Lancet. 2008; 371(9609): 303-14.

Domchek SM and Rebbeck TR. Prophylactic oophorectomy in women at increased cancer risk. Curr Opin Obstet Gynecol. 2007; 19(1): 27-30.

Elit L, Oliver TK, Covens A, Kwon J, Fung MF, Hirte HW, et al. Intraperitoneal chemotherapy in the first-line treatment of women with stage III epithelial ovarian cancer: a systematic review with metaanalyses. Cancer. 2007; 109(4): 692-702.

Fader AN and Rose PG. Role of surgery in ovarian carcinoma. J Clin Oncol. 2007; 25(20): 2873-83.

Goff BA, Mandel LS, Drescher CW, Urban N, Gough S, Schurman KM, et al. Development of an ovarian cancer symptom index: possibilities for earlier detection. Cancer. 2007 Jan 15;109(2):221-7.

Goff BA, Matthews BJ, Larson EH, Andrilla CH, Wynn M, Lishner DM, et al. Predictors of comprehensive surgical treatment in patients with ovarian cancer. Cancer. 2007 May 15;109(10):2031-42.

Hogdall, E. Cancer antigen 125 and prognosis. Curr Opin Obstet Gynecol. 2008; 20(1): 4-8.

Lacey JV Jr, Brinton LA, Leitzmann MF, Mouw T, Hollenbeck A, Schatzkin A, et al. Menopausal hormone therapy and ovarian cancer risk in the National Institutes of Health-AARP Diet and Health Study Cohort. J Natl Cancer Inst. 2006 Oct 4;98(19):1397-405.

Lacey JV Jr, Greene MH, Buys SS, Reding D, RileyTL, Berg CD, et al. Ovarian cancer screening in women with a family history of breast or ovarian cancer. Obstet Gynecol. 2006; 108(5): 1176-84.

Larkin JM and Kaye SB. Potential clinical applications of epothilones: a review of phase II studies. Ann Oncol. 2007; 18 Suppl 5: v28-34.

Martin L and Schilder R. Novel approaches in advancing the treatment of epithelial ovarian cancer: the role of angiogenesis inhibition. J Clin Oncol. 2007; 25(20): 2894-901.

Morrison J, Swanton A, Collins S and Kehoe S. Chemotherapy versus surgery for initial treatment in advanced ovarian epithelial cancer. Cochrane Database Syst Rev. 2007; (4): CD005343.

National Comprehensive Cancer Network. NCCN Practice Guidelines in Oncology: Ovarian cancer. 2008; v.1.

Prentice RL, Thomson CA, Caan B, Hubbell FA, Anderson GL, Beresford SA, et al. Low-fat dietary pattern and cancer incidence in the Women's Health Initiative Dietary Modification Randomized Controlled Trial. J Natl Cancer Inst. 2007; 99(20): 1534-43.

Rao G, Crispens M and Rothenberg ML. Intraperitoneal chemotherapy for ovarian cancer: overview and perspective. J Clin Oncol. 2007; 25(20): 2867-72.

U.S. Preventive Services Task Force. Genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility: recommendation statement. Ann Intern Med. 2005 Sep 6;143(5):355-61.

Zhou B, Yang L, Wang L, Shi Y, Zhu H, Tang N, et al. The association of tea consumption with ovarian cancer risk: A metaanalysis. Am J Obstet Gynecol. 2007; 197(6): 594 e1-6.

  • Reviewed last on: 9/19/2008
  • Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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