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Case History

image A 43-year-old woman presents with pelvic pain, urinary frequency and bloating for two months. On pelvic examination she has a normal-sized uterus, deviated posteriorly by a prominent smooth anterior mass. There is no nodularity in the cul-de-sac. A vaginal ultrasound scan reveals a 10 cm mixed solid and cystic right adnexal mass. There is some free fluid. A computed tomography (CT) scan of the abdomen and pelvis confirms the findings. There are no peritoneal implants, omental changes or lymphadenopathy. The serum CA125 level is 150 U/ml. The patient does not have any family history of cancer.

How do you assess the risk of malignancy of an ovarian mass?

What is the optimal surgical management for an apparent early stage ovarian cancer?

What is the role of laparoscopic staging in ovarian cancer?

When can fertility be preserved in ovarian cancer?

What is the optimal management for patients with inadvertent discovery of ovarian cancer ?


How do you assess the risk of malignancy of an ovarian mass?

image When a woman presents with a pelvic mass it is important (a) to distinguish between gynaecological and non-gynaecological pathology, and (b) to determine whether the mass is benign or malignant. The best way to detect an early ovarian cancer is to have a high index of suspicion of the diagnosis in a symptomatic woman. A series of warning signs on clinical assessment, blood tests (serum CA125 level) and imaging points to the diagnosis of a malignancy. Most women with ovarian cancer will report symptoms; however, most of them are usually not gynaecological in nature (Table 47.1). It is very important to take a careful clinical history keeping in mind that the risk of ovarian cancer is related to older age and a family history (positive for breast or ovarian cancer). Physical examination is another cornerstone in the assessment and must not be neglected in favour of blood studies or radiology. If on clinical examination there is the suspicion of a mass, a pelvic ultrasound scan should be able to confirm the diagnosis. Ultrasound features that suggest a malignancy include septations, papillary projections, solid areas and ascites. The presence of ascites has a positive predictive value of 95% for a malignancy. However, less than 20% of early stage ovarian cancers have ascites present. An elevated serum CA125 level can confirm the suspicion of ovarian cancer in a post-menopausal woman. A normal level, however, cannot be taken as a guarantee against malignancy, since about 25% of ovarian carcinomas are marker negative. Furthermore, especially in pre-menopausal women, a large range of gynaecological pathological conditions are known to elevate serum CA125 levels including endometriosis, pelvic inflammatory disease and fibroids.

Table 47.1Ovarian cancer symptoms

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