Clinical Evaluation

The presenting symptoms of women with ovarian cancer are often vague and indistinct. The most common symptoms are abdominal discomfort, abdominal pain, and abdominal distention. Gastrointestinal symptoms are relatively common and may include a change in bowel habits, nausea or dyspepsia, or early satiety. Unfortunately, 75% to 85% of patients have disease that is disseminated throughout the peritoneal cavity at presentation.

 

Because reliable procedures for the early detection of ovarian cancer have yet to be found, early-stage disease is usually diagnosed after detection of an asymptomatic adnexal mass on routine pelvic examination. However, most adnexal masses, particularly in premenopausal women, are not malignant.

 

Abdominal ultrasonography, computed tomography, and magnetic resonance imaging are often used to evaluate early and advanced disease. Although imaging may aid in ruling out the possibility of hepatic metastases, the extent of intraperitoneal disease is best evaluated at surgery.

 

The most useful serum marker for ovarian cancer is CA 125. Between 80% and 85% of patients with epithelial ovarian cancer have elevated CA 125 levels (>35 U/mL). More than 85% of patients with the serous subtype of epithelial ovarian cancer have increased CA 125 levels, but elevations are less common among those with mucinous tumors. For postmenopausal women with asymptomatic pelvic masses, a CA 125 level of greater than 65 U/mL has a sensitivity of 97% and a specificity of 78% in the diagnosis of ovarian cancer. However, in premenopausal women, nonmalignant conditions, including endometriosis, fibroids, and pelvic inflammatory disease, can produce elevations of serum CA 125, lowering the specificity of the test. The finding of an elevated CA 125 level in patients older than 50 years suggests epithelial ovarian cancer and should prompt surgical exploration.

 

Treatment

In the past, treatment for ovarian cancer was selected on the basis of tumor stage and clinical-pathologic features. Postsurgical adjuvant therapy included radiation therapy of the pelvis or whole abdomen, intraperitoneal colloid therapy, chemotherapy, administration of biological response modifiers, or combinations of these treatments. Most patients with ovarian cancer in the United States currently are treated with primary cytoreductive surgery and, when adjuvant therapy is indicated, combination chemotherapy. However, radiation therapy remains useful in the treatment of certain patient subgroups.

 

Surgery

Except in certain subsets of patients with stage I disease, the standard surgical approach to the management of epithelial ovarian cancer is a staging laparotomy with a bilateral salpingo-oophorectomy, a hysterectomy, and surgical cytoreduction of intraperitoneal tumor masses. At many centers, routine para-aortic and pelvic lymph node dissection is performed if this procedure, along with optimal debulking, can render the patient free of residual macroscopic disease.

The volume of tumor remaining at the completion of the surgery and the number of residual masses are significant prognostic factors for outcome. Most surgeons accept that attempts should be made to minimize the tumor residuum at the time of surgery. It is recognized that the amount of residual disease should be treated as a continuum for prognostic purposes, and most investigators define the optimal residuum as the largest diameter of the largest residual lesion being less than 1 cm.