Diagnosis Ovarian epithelial cancers must be differentiated from benign neoplasms and functional cysts of the ovaries. A variety of benign conditions of the reproductive tract, such as pelvic inﬂammatory disease, endometriosis, and pedunculated uterine leiomyomas, can simulate ovarian cancer. Nongynecologic causes of a pelvic tumor, such as an inﬂammatory (e.g., diverticular) disease or neoplastic colonic mass, must be excluded (3). A pelvic kidney can simulate ovarian cancer.
Serum CA125 levels are useful in distinguishing malignant from benign pelvic masses (92). For a postmenopausal patient with an adnexal mass and a very high serum CA125 level (>200 U/mL), there is a 96% positive predictive value for malignancy. For premenopausal patients, the specificity of the test is low because the CA125 level tends to be elevated in common benign conditions.
For the premenopausal patient, a period of observation is reasonable provided the adnexal mass does not have characteristics that suggest malignancy (i.e., it is mobile, mostly cystic, unilateral, and of regular contour). An interval of no more than 2 months is allowed, during which hormonal suppression with an oral contraceptive may be used. If the lesion is not neoplastic, it should regress, as measured by pelvic examination and pelvic ultrasonography. If the mass does not regress or if it increases in size, it must be presumed to be neoplastic and must be removed surgically.
The size of the lesion is important. If a cystic mass is greater than 8 cm in diameter, the probability is high that the lesion is neoplastic, unless the patient is taking clomiphene citrate or other agents to induce ovulation (37–40). Premenopausal patients whose lesions are clinically suspicious (i.e., large, predominantly solid, relatively fixed, or irregularly shaped) should undergo laparotomy, as should postmenopausal patients with complex adnexal masses of any size.
Ultrasonographic signs of malignancy include an adnexal pelvic mass with areas of complexity, such as irregular borders, multiple echogenic patterns within the mass, and dense multiple irregular septae. Bilateral tumors are more likely to be malignant, although the individual characteristics of the lesions are of greater significance. Transvaginal ultrasonography may have a somewhat better resolution than transabdominal ultrasonography for adnexal neoplasms (93–96). Doppler color ﬂow imaging may enhance the specificity of ultrasonography for demonstrating findings consistent with malignancy (97–99).
In postmenopausal women with unilocular cysts measuring 8 to 10 cm or less and normal serial CA125 levels, expectant management is acceptable, and this approach may decrease the number of surgical interventions (100–102).
The diagnosis of an ovarian cancer requires an exploratory laparotomy. The preoperative evaluation of the patient with an adnexal mass is outlined in Figure 14.19 (see Chapter 14).
Before the planned exploration, the patient should undergo routine hematologic and biochemical assessments. A preoperative evaluation in a patient undergoing laparotomy should include a radiograph of the chest. Abdominal and pelvic computed tomography (CT) or MRI are of limited value for a patient with a definite pelvic mass (103–105). A CT or MRI should be performed for patients with ascites and no pelvic mass to look for liver or pancreatic tumors. The findings only rarely preclude laparotomy (103). The value of PET scanning is still being evaluated (105–107). If the hepatic enzyme values are normal, the likelihood of liver disease is low. Liver-spleen scans, bone scans, and brain scans are unnecessary unless symptoms or signs suggest metastases to these sites.
The preoperative evaluation should exclude other primary cancers metastatic to the ovary.