Ovarian Cancer

Adnexal mass DDx

Incidence 10 cases per 10 000 women per year
Responsible for 5% of deaths in females (Also makes up 5% of all cancers in women)
Makes up 20% of all gynaecological cancers, also the most lethal of them.
Usually asymptomatic before the development of metastatic spread
Uncommon <40yo
Average age of diagnosis is 50yo (peak incidence 60-65yo)

Abdominal discomfort + anorexia + abdominal bloating/distension
Most common is abdominal swelling (mass or ascites). Abdominal bloating and ‘fullness’
Ache or discomfort in lower abdomen
Constitutional symptoms of fatigue or anorexia, loss of weight
GIT dysfunction (epigastric discomfort, diarrhea, constipation, wind)

Genitourinary symptoms (frequency, urgency, prolapse)

No consensus even if high risk (FHx, Lynch syndrome, BRCA1 or BRCA 2)
For the general population, there are currently no national or international guidelines for screening for ovarian cancer.
No investigation to date has been shown to have adequate sensitivity and specificity as a suitable screening test.
Women with a very strong family history of breast and ovarian cancer should be referred for genetic counselling.
Women who are carriers of the BRCA1 mutation have a lifetime risk of ovarian cancer as high as 60%, and BRCA2 as high as 40%.
Ca-125 – Limited use as a screening tool.
- Elevated in 1% of healthy women.
- Fluctuates during the menstrual cycle so quite useless if premenopausal
- Also increased in other conditions, including endometriosis, fibroids, cirrhosis, PID, cancers (endometrium, breast, lung, pancreas), pleural or peritoneal fluid.
- Average levels also vary with ethnicity and smoking status, increases with age.
- In premenopausal women, Ca125 should be measured only if the ultrasound appearance of a mass raises suspicion of malignancy.
- It is unreliable in differentiating malignant from benign, as Ca125 >35 U/ml has a sensitivity and specificity for ovarian cancer of <80% (potentially as low as 50–60%).
- If Ca125 is elevated, consider repeating 4–6 weeks after the initial test
- Rapidly rising levels are more likely to be associated with malignancy rather than levels that do not change.

Discussion with a gynaecological oncologist is recommended in patients with a Ca125 >250 U/ml

Human epididymis protein 4
1. It has a similar sensitivity as that of Ca125 in comparing ovarian cancer to healthy controls, but is not elevated in as many common benign gynaecological conditions.
2. It is used in conjunction with Ca125 in the Risk of Malignancy Algorithm (ROMA).
3. can be falsely elevated in patients with impaired renal function, and can also be elevated in endometrial, primary liver and non-small cell lung cancer.
4. HE4 is not currently covered by Medicare and costs approximately $45 for the patient.
5. It is not recommended as a screening test for ovarian cancer.
Alpha-feta protein (AFP) = can be elevated in germ cell tumours
human chorionic gonadotropin (hCG) = can be elevated in germ cell tumours
lactate dehydrogenase (LDH) = can be elevated in germ cell tumours
Carcinoembryonic antigen (CEA) and cancer antigen 19.9 (Ca19.9)
1. application to clinical practice is unclear
2. usefulness of these tests is not discussed in the UK and Australian guidelines.
3. non-specific and can be elevated in benign and malignant non-gynaecological conditions.