Ovarian masses encompass a broad differential diagnosis ranging from benign to malignant. Ovarian malignancies have a similarly broad differential diagnosis including:
- Epithelial: high-grade or low-grade serous, mucinous, clear cell, endometrioid or mixed histologies
- Germ cell tumours
- Sex cord stromal tumours
- Sarcomas
- Small cell carcinomas
- Metastases from other primary sites
Differentiating between these vast diagnoses that often carry vastly different treatment and prognoses is a daunting task.
Initial evaluation
If a patient presents with pelvic symptoms or if there are concerns on physical examination, a pelvic ultrasound is the first step in assessment.
There is no effective screening test for ovarian cancer so routine ultrasounds in the absence of symptoms or physical examination findings should be avoided.
CA-125 is not a screening test and should only be ordered if a pelvic mass or free fluid is found on imaging. CA-125 is extremely non-specific and can be elevated in a large number of benign conditions including, and not limited to: fibroids, endometriosis, diverticulitis, pregnancy, pneumonia, arthritis.
Additionally, CA-125 is not sensitive - 50% of early ovarian cancers will have a normal CA-125.
Red flags that warrant expedited direct referral to a gynaecologic oncologist
Rapid onset of symptoms – often over the course of a few months. Symptoms include:
- Progressive abdominal distension
- Pelvic discomfort
- Urinary frequency/decreased bladder capacity
- Constipation
Concerning descriptors on ultrasound:
- Complex
- Heterogeneous
- Increase vascularity
- Solid
- Free fluid
Elevated tumour markers (in the presence of an ovarian mass and/or free fluid).
Family history of associated cancers:
- Ovarian cancer
- Breast cancer, particularly if premenopausal or male breast cancer
- Pancreatic cancer
- Bowel cancer
- Endometrial cancer
Treatment
Treatment varies dramatically depending on the particular type of ovarian cancer so initial assessment by a gynaecologic oncologist is imperative in decision making.
Generally, when a patient is referred for a suspicious mass or free fluid on imaging (regardless of the CA-125 result), the first step is additional imaging with a CT scan or PET scan to assess the chest, abdomen and pelvis for any evidence of extraovarian sites of disease.
Additional tumour markers (for example, CA19-9, CEA, AFP, inhibin B, etc) may be ordered. These markers may guide us in narrowing down our differential diagnosis prior to surgery, but mainly serve as markers of treatment efficacy and for monitoring in the surveillance phase of patient care.
If there is free fluid and sites of extraovarian disease, we may recommend neoadjuvant chemotherapy prior to surgery so we may organise an image-guided biopsy to confirm the histology prior to referring to a medical oncologist.
These decisions are often complex and all patients with proven or suspected ovarian cancer should be discussed in the multidisciplinary setting of a gynaecologic oncology tumour board at a tertiary centre both before and after definitive surgery.
Epithelial ovarian cancers typically receive adjuvant chemotherapy following surgery.
All patients diagnosed with high-grade non-mucinous ovarian cancers are recommended for genetic blood testing which is fully covered by Medicare. Genetic assessment is important for several reasons - it may provide access to some newer very successful targeted therapies, it would impact on the patient’s surveillance for other associated cancers and it would allow for genetic testing to be offered to family members so they can potentially undergo risk-reducing surgery.
Non-epithelial ovarian cancers typically occur in younger women and are often able to be treated with fertility-sparing surgery, but do sometimes require adjuvant chemotherapy. Expedited fertility consults are obtained in these settings to try to maximise options for future fertility when appropriate.
Following an ovarian cancer diagnosis, patients are followed by a gynaecologic oncologist (often in conjunction with a medical oncologist) for at least 5 years with clinic visits with examinations, tumour markers and sometimes imaging.
If you feel that you are ticking boxes for direct referral to a gynaecologic oncologist as outlined above, please don’t hesitate to contact me through my rooms and I am happy to discuss your case with you and/or your doctor.
Dr Robyn Sayer
BA (Hons) MD FACOG FRANZCOG CGO
Consultant Gynaecologic Oncologist
Specialising in:
- Ovarian cancer
- Endometrial cancer and endometrial hyperplasia
- Cervical cancer
- Vulvar/vaginal cancer
- Dysplasia of the genital tract
- Risk-reducing surgery for hereditary cancer predispositions
- Benign gynaecologic surgery in surgically complex patients
To arrange an appointment with Dr Robyn Sayer, please contact:
P 02 9519 6376
F 02 8079 0650
E info@drrobynsayer.com
Visit website
Northern Beaches Hospital
105 Frenchs Forest Rd W
Frenchs Forest NSW 2086