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Ovarian Cancer (cont.)

Exams and Tests

Many exams and tests are used to determine if a woman has ovarian cancer.

Physical exam: Every woman should have an annual pelvic exam in which the health care provider feels (palpates) the ovaries and obtains a Pap smear (Papanicolaou test).

Although the Pap smear is designed to check for cervical cancer, there have been some rare cases in which abnormal ovarian cells were identified with this test.
Ovaries are normally small, especially in women who have been through menopause, and are deep within the pelvis. Normal-sized ovaries are difficult to feel. Because of this, the pelvic exam is not very effective in detecting early ovarian cancer.
Masses large enough to be felt may represent advanced disease. More often, they are harmless growths or other noncancerous conditions.

Imaging

Ultrasound: If a mass is present, the health care provider may recommend an ultrasound examination to find out what kind of mass it is.

Ultrasound imaging can detect small masses and can distinguish whether a mass is solid or fluid filled (cystic).
A solid mass or complex mass (having both cystic and solid components) may be cancerous.

Incorporating Doppler technology to identify certain patterns associated with tumors seems to improve the usefulness of ultrasound screenings.

If the ultrasound shows a solid or complex mass, the next step is to obtain a sample of the mass to see whether it is a cancerous tumor.

Many studies have reviewed the value of ultrasound screenings for ovarian cancer of women who have no symptoms. Although ultrasound identified many masses, very few of these masses (about 1 in 1000) were cancerous. Furthermore, many women underwent unnecessary surgeries only to discover benign masses.

CT (computed tomography) scanning: If ultrasound reveals a solid or complex mass, a CT scan of the pelvis may be done.

A CT scan is a type of x-ray that shows much greater detail in 3 dimensions.
A CT scan provides more information about the size and extent of the tumor. It can also show whether the tumor has spread to other organs in the pelvis.

Lab tests

The health care provider also conducts lab tests to gather information about the woman's medical condition and to detect substances released into the blood by ovarian cancers (tumor markers).

The health care provider may request a pregnancy test if there is any chance the woman could be pregnant. Pregnancy can be detected by checking the blood level of beta-HCG, a hormone that increases dramatically during pregnancy.

Ovarian masses during pregnancy may be associated with ectopic pregnancies (pregnancy outside the womb) or may be normal structures that produce other hormones important in gestation.

The woman's blood will probably also be checked for tumor markers. Health care providers suspicious that ovarian cancer is present usually conduct the CA-125 test.

The level of the most widely studied tumor marker, CA-125, is elevated in more than 80% of women with advanced ovarian cancer and in about 50% of women with early ovarian cancer.
The level of this marker value can be affected by a number of factors, including age, menstrual status, and conditions such as endometriosis, pregnancy, liver disease, and congestive heart failure.
Cancers of the breast, pancreas, colon, and lung also secrete the CA-125 marker.
Because this marker can be influenced by so many factors that have nothing to do with ovarian cancer, this marker is not generally used for routine screening of women who have no symptoms.

Health care providers do not recommend genetic screening for women with no first-degree relative, or only one relative, with ovarian cancer.

Women with 2 or more relatives with breast or ovarian cancer should be referred to a specialist to discuss genetic testing.
Members of families with hereditary nonpolyposis colon cancer (HNPCC or Lynch syndrome II) should also be referred to a specialist.

Biopsy and staging

Ovarian cancer is diagnosed by taking a sample of the tumor (biopsy). The tumor material is examined by a pathologist, a physician who specializes in diagnosing diseases by looking at the cells under a microscope. There are several ways to collect a biopsy of an ovarian mass.

Laparoscopy is the usual first step in confirming the presence of a mass and obtaining a tissue sample for biopsy. Laparoscopic surgery uses small incisions and specially designed instruments to enter the abdomen or pelvis. (This type of operation is widely used to remove the gallbladder.)
If the mass is small, it may be possible to remove the entire mass during laparoscopy. Usually, the surgeon removes the entire ovary.
If the mass is larger that 2.75 inches (complex mass) or 3.5 inches (solid mass) on ultrasound, removal will probably be through conventional surgery. This procedure, called exploratory laparotomy, involves making a larger incision in the skin and abdominal muscles to gain access to the pelvic region.

If the biopsy finding is positive for cancer, further staging procedures will be performed.

Staging is a system of classifying tumors by size, location, and extent of spread, local and remote.
Staging is an important part of treatment planning, because tumors respond best to different treatments at different stages.
Staging is also a good indicator of prognosis.
Staging usually requires imaging studies, lab tests, and exploratory laparotomy.

Exploratory laparotomy is a careful and thorough attempt to find the exact extent of cancer spread.

During the surgery, removal of the ovarian mass usually includes the entire affected ovary.
To identify possible invasion by the cancer, samples are taken of other structures in the pelvis and abdomen including the diaphragm (the muscle that separates the organs of the chest from the organs of the abdomen), the peritoneum (the membrane that lines the abdomen), the omentum (a fatty membrane that covers the organs of the abdomen), lymph nodes, bladder, and bowel.
The goal is to remove as much cancerous tissue as possible (debulking). This may involve removing one or both ovaries (oophorectomy), the uterus (hysterectomy), fallopian tubes (salpingectomy), and other organs.
Typically, the surgeon does not know ahead of time exactly which organs and structures will require removal. If a woman plans to undergo exploratory laparoscopy or laparotomy, she should discuss the possible full extent of the operation with her surgeon before consenting to the procedure. Gynecologic oncologists are specialist trained to operate on ovarian cancer. If a high suspicion of a gynecologic cancer exists, a gynecologic oncology consult may provide input into the surgery.

Ovarian cancers are classified in stages I through IV. Stages I, II, and III are further described by the letters A, B, or C depending on the location of the tumor, the presence of metastasis, and other factors. Stage IV cancer is not subdivided.

Stage I: The cancer is confined to one (IA) or both (IB) ovaries. The tumor may be on the surface of the ovaries, or ascites may be present (IC).
Stage II: Cancer is found outside the ovary (pelvic extension) and has spread to the uterus or fallopian tubes (IIA) or other areas in the pelvis (IIB). The tumor may involve the capsule of the ovary, or fluid in the abdomen may contain malignant cells (IIC).
Stage III: Cancer has spread to pelvic organs and possibly to lymph nodes. Microscopic "seeds" of cancer are on abdominal peritoneal surfaces (IIIA), or small implants of tumor on abdominal peritoneal surfaces (IIIB). Abdominal implants may be larger or lymph nodes may be involved (IIIC).
Stage IV: Cancer has spread to the abdominal organs (liver, spleen), or malignant cells are in the fluid surrounding the lungs.