CASE 2: Symptoms suggestive of cancer
Mrs. B is a 47-year-old woman who reports abdominal bloating for the past 3 weeks. She also complains of early satiety and occasional constipation. She has no history of cancer, but her sister was given a diagnosis of breast cancer at 41 years of age, and her maternal aunt had breast cancer at 55 years.
Mrs. B is moderately obese, with a nontender abdomen and no palpable mass. Her pelvic exam also is negative for a mass or nodularity, but the extent of the exam is limited by body habitus. Her physician orders a transvaginal US, which reveals a 6-cm complex mass with thin septation and a 1-cm solid nodule, with no definite blood flow. The patient’s CA 125 level is 80 IU/mL, which we consider to be within the low-risk range for a premenopausal woman.
The patient is counseled about the need to have the mass removed and is scheduled for laparoscopic right salpingooophorectomy. Given the family history of breast cancer, the physician also requests consultation with a gynecologic oncologist, who agrees to assist with surgery and perform a laparotomy and staging in the event that a malignancy is diagnosed.
Is the mass likely to be malignant?
Given the patient’s family history of breast cancer, the recent onset of symptoms associated with ovarian cancer,2 and the characteristics of the mass (complex, with a nodule), malignancy is possible. This patient has an intermediate risk of cancer and requires additional counseling and planning.
However, most women who undergo laparoscopy for removal of an adnexal mass have benign pathologic findings.
What is the real risk of ovarian cancer?
The lifetime risk of developing ovarian cancer in the general population remains stable at approximately 1 in 70 women, with a mean age at diagnosis of 63 years.19 Ninety percent of ovarian cancer cases are sporadic, and less than 10% can be linked to genetic syndromes.
Women who have mutations in the BRCA1 gene carry a lifetime risk of ovarian cancer of up to 50%, and women who have mutations in BRCA2 have a lifetime risk of up to 25%.20,21 Women who have mutations associated with Lynch II syndrome or Hereditary Nonpolyposis Colorectal Cancer syndrome may have a lifetime risk of ovarian cancer of 12%.22,23
Some women who have a strong family history of breast and ovarian cancer do not carry a known mutation, but are likely to be at increased risk.
Additional risk factors known to be associated with ovarian cancer are nulliparity and infertility. However, the single most important risk factor for epithelial ovarian cancer is age.
Risk-reducing strategies include:
In the case of PBSO, it is imperative to ensure that all ovarian surface epithelium is removed. This means excising the infundibulopelvic ligament at least 1.5 cm above the proximal end of the ovary and excising any adjacent tissue to which the ovary is adherent (including pelvic sidewall peritoneum). Both requirements are easily achieved using the techniques outlined here.
Who should perform surgery?
The American College of Obstetricians and Gynecologists (ACOG) and the Society of Gynecologic Oncologists (SGO) have published guidelines for referral to a gynecologic oncologist ( TABLE 3 ). When Im and colleagues reviewed the records of more than 1,000 women who underwent surgery for a pelvic mass at six institutions over 12 months, they found that 70% of premenopausal women and 94% of postmenopausal women who were diagnosed with ovarian cancer were properly referred to a qualified subspecialist.27 “Over”-referral occurred in 30% to 40% of women who had a benign mass, but may be preferable given the importance of proper staging and debulking to survival.
ACOG and the SGO recommend referral for women who have:
- elevated tumor markers
- ascites
- a fixed or nodular mass
- a strong family history of breast or ovarian cancer.
Consider preoperative referral of all high-risk and, probably, intermediate-risk women, depending on the availability of qualified specialists for complete surgical staging.
In addition, women need to be counseled thoroughly about the possibility that a malignancy will be diagnosed by frozen section, necessitating additional surgical procedures.
TABLE 3
Your patient has a newly diagnosed pelvic mass. Should you refer her?
| Is she premenopausal? Then refer her when… | Is she postmenopausal? Then refer her when… |
|---|---|
| CA125 >200 IU/mL Ascites is present Evidence of abdominal or distant metastasis on exam or imaging Family history of breast or ovarian cancer in a first-degree relative | CA125 >35 IU/mL Ascites is present Nodular or fixed pelvic mass Evidence of abdominal or distant metastasis on exam or imaging Family history of breast or ovarian cancer in a first-degree relative |