The primary examination of women with pelvic tumors includes:
- Gynecological examination
- Ultrasound, preferably combined vaginal-abdominal
- Chest X-ray in cases where a specimen of pleural fluid is taken for a cytological examination
- Measurement of s-CA125 and s-CEA. In younger women with ovarian tumors, s-AFP and s-HCG should also be measured.
- Calculation of risk of malignancy (RMI score). Scores over 200 are suspicious of ovarian cancer. The value of the risk of malignancy (RMI score) for non-epithelial ovarian cancer is unknown.
- CT of abdomen/pelvis may provide supplementary information about the extent of the disease
- Non-epithelial tumors are often more solid than epithelial ovarian tumors.
- In a predominantly solid tumor in a younger woman, a germ cell tumor is the primary suspect.
- In a predominantly solid tumor in an elderly woman, a non-epithelial ovarian tumor, sarcoma, or metastasis-suspected.
With an RMI-score < 200, the likelihood the tumor represents cancer is relatively modest, and the patient can be operated at a regular gynecological clinic. The RMI score has about 50% sensitivity for predicting ovarian cancer in stage I.
An RMI score ≥ 200 indicates a high likelihood that the tumor is malignant. It is crucial to survey the extent of the tumor adequately preoperatively. The pelvic tumor should also be evaluated to determine whether it represents epithelial ovarian cancer, non-epithelial ovarian cancer, metastasis, or possibly sarcoma.
The size of the tumor is important. If a complex cystic tumor is more than 8 - 10 cm in diameter, the probability for cancer is great, if the patient has not taken chlomiphene or other drugs to induce ovulation. In premenopausal patients, a two month observation period is acceptable, unless the tumor is clinically suspect (should be cystic, mobile, unilateral, and without septa or excrescences). If the tumor increases in size and complexity, one should suspect cancer. In postmenopausal women, with single cysts 8-10 cm or smaller in diameter, without septa or excrescences and with normal CA125 value, observation is acceptable.
When a lesion is clinically suspect (complex cysts with solid areas, thick septa orexcrescences on ultrasound), the patient should undergo surgery with exploratory laparotomy.
Non-epithelial ovarian cancer
Raised s-AFP suggests yolk sac tumor (endodermal sinus tumor), while raised s-HCG suggests an HCG-producing tumor, unless the woman is pregnant. Juvenile granulosa cell tumor is suspect in the case of premature menarche. With spontaneous onset of hirsutism, a Sertoli-Leydig tumor (androblastoma) is suspect.
If it is possible the patient has sarcoma, it is important to uphold the surgical principles for sarcoma surgery.
In metastatic disease, the possibility of metastasis from another cancer type should be considered, primarily gastrointestinal cancer. Measurement of s-CEA may be useful. An ultrasound-guided biopsy for histological investigation may be done.
At The Norwegian Radium Hospital, it is not recommended to do a preoperative biopsy from a single, well-defined tumor since this may lead to spreading of an otherwise localized tumor.
Borderline ovarian cancer
This is the predominant tumor type in younger women with cystic tumors where the differential diagnosis is between a benign cyst, borderline tumor, or invasive epithelial tumor. In a significant number of women with borderline ovarian tumors, the disease is first diagnosed by histological examination of a presumed benign cyst.
Borderline tumors are usually unilocular, cystic, possibly with internal excrescences in the capsule. An RMI score can not be expected to identify a borderline tumor. With multiocular cysts or larger solid areas, one should suspect an invasive epithelial tumor.
Fallopian tube cancer
Early stage fallopian tube cancer may present as hydrosalpinx and will appear as a cystic tumor on ultrasound. In some cases, cancer cells from fallopian tubes can be found in cervical cytology specimens. If adenocarcinoma cells are found in a cervical cell specimen where cancer cannot be found in the cervix or uterus, one should suspect fallopian tube or ovarian cancer. Fallopian tube cancer often metastasizes early to lymph nodes. In some patients, inguinal, mediastinal, or supraclavicular lymph node metastases are the first and only findings.
In metastatic disease, the possibility of metastasis from another cancer type must be considered, primarily gastrointestinal cancer. Measurement of s-CEA may be useful. Raised s-CA125 is not specific for ovarian or fallopian tube cancer. A mild to moderate rise can be seen with benign conditions, as well as in peritoneal metastases from other cancer types. With raised CEA, it is recommended to calculate the relationship between CA125 and CEA. If this is lower than 25, it is recommended to perform upper endoscopy, colonoscopy, and mammography. An ultrasound-guided biopsy for histological examination is clearly recommended.
Oslo University Hospital (The Norwegian Radium Hospital) does not recommend taking a preoperative biopsy from a single, well-defined tumor as this can lead to spreading of an otherwise localized tumor.
Examination of suspect recurrence
If there is clinical suspicion of recurrence or increasing s-CA 125 without a clinically confirmed tumor, the following is recommended:
- CT of the chest, abdomen and pelvis.
- In the case of ascites, a diagnostic puncture for cytological examination.
- Consider verifying recurrence by cytology or histology before new treatment is initiated.
Measurement of s-CA125 is commonly used in the follow-up.
Spontaneous variations of +/- 70% may be accidental and without significance. Gynecologic Cancer Intergroup GCIG has agreed that there must be an increase of at least 100% to define progression. From a normal value, an increase to 70 IU or more must occur before the increase is diagnostic for progression.
It has not been shown that early treatment of recurrence improves prognosis compared to waiting until occurrence of symptoms.