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Ovarian cancer

How not to miss

Mr Tim Mould advises on what to look out for – and the signs you should not miss

Worst outcomes if missed

•An early stage potentially curable cancer can develop into a late stage incurable one•Patient undergoes radical surgical and chemotherapy treatments•Death

Epidemiology and incidence

•90 per cent of ovarian cancer is epithelial – it develops from the capsule of the ovary•UK incidence is 20 per 100,000 women; ovarian cancer is the most common gynaecological cancer in the UK and the fourth highest cause of death from cancer in women in the UK•The most common age at diagnosis is over 60•75 per cent of women present with stage three or four disease•Women with stage three or four disease will require radical surgery and chemotherapy and have a five-year survival of 30-40 per cent•Stage one disease can often be treated by surgery alone and has a five-year survival of up to 90 per cent

Symptoms and signsThese are often non-specific. The most common is abdominal pain but only 50 per cent of women with ovarian cancer present with this.

Combinations of the following symptoms and signs may suggest ovarian cancer and should prompt pelvic examination and urgent pelvic ultrasound:

•pain•swollen abdomen•palpable mass•change in bowel or bladder function•back ache•loss of appetite and weight loss•post-menopausal bleeding

The boxes (below, left and right) give key questions to ask and major pitfalls in diagnosis.

Differential diagnosisBenign pelvic masses:

•fibroids•benign ovarian cysts•pyometrium

Other malignant diseases of the pelvis:

•endometrial cancer•fallopian tube cancer•primary peritoneal cancer•large cervical cancers

First-line investigations

•Ultrasound of pelvis +/- abdomen; ultrasound should detect an ovarian cyst and determine if it is suspicious •Ca125 – but not very sensitive or specific (see box on red herrings, right)

Second-line investigations

•BHCG and AFP in women below the age of 30; these tumour markers are raised in non-epithelial ovarian cancers•Full blood count – iron deficiency anaemia may suggest bowel primary•CEA blood test – a bowel tumour marker•CT/MRI scan – to clarify the nature of a mass and to detect intra-abdominal spread •Laparoscopic oophorectomy – in a younger woman if an ovarian cyst causing suspicion of malignancy is found and there is no clear disease outside the ovary•Tap ascites – send to cytology to look for adenocarcinoma cells•Guided biopsy of mass to confirm ovarian cancer if there is evidence of disease spread in the abdomen

The diagnosis is usually confirmed in early stage disease by histopathology of the surgically removed ovary, or in late disease by demonstration of a pelvic mass, high Ca125 and ascites with adenocarcinoma cells.

Five key questions to ask 1 Do you have a family history of breast or ovarian cancer? Only 10 per cent of ovarian cancers are caused by an inherited genetic mutation, but first-degree relatives with ovarian or breast cancer will increase an individual's risk of the disease.2 Are you still having periods? Ultrasound scans and Ca125 blood tests must be interpreted with the knowledge of a woman's menopausal status – see right in red herrings. Bleeding after the menopause will have a malignant cause in about 10 per cent of cases. Exclude endometrial, cervical, vaginal or ovarian malignancy.3 Are you urinating more frequently? An enlarging ovary may press on the bladder. This may happen when the disease is confined to the ovary – stage one. When symptoms such as abdominal swelling occur, it generally represents stage three disease.4 Have you had any change in bowel habit? This may be due to an ovarian mass.5 Are you suffering from nausea, vomiting or weight loss? Once the disease has spread to the abdomen, an omental cake often forms which presses on the stomach.

Five red herrings1 Examination may not help A pelvic mass may be difficult to feel. Request an ultrasound of pelvis.2 In a patient with pain, an initial ultrasound of the pelvis may be normal If the pain persists, request a repeat ultrasound after two to three months. Consider a Ca125 if the patient is post-menopausal.3 An ovarian cyst in a woman before the menopause will most often be ovulatory If an ultrasound report in a younger woman finds 'complex cyst of unknown significance – malignancy cannot be excluded', this is often an ovulation cyst such as a corpus luteum. Referral to a gynaecologist is appropriate, via two-week referral, but the woman can be reassured cancer of the ovary is unlikely.4 Ca125 is a helpful tumour marker for epithelial ovarian cancer, but is not very sensitive or specific Ca125 is normal in 50 per cent of women with stage one ovarian cancer. So, if the ultrasound is suspicious, you cannot rely on the Ca125 to reassure you. Ca125 can be raised in conditions other than ovarian cancer. Moderate rises up to 100 are common in elderly people with cardiac, liver or renal problems. Ca125 from 50 to 1,000 can occur with endometriosis or intra abdominal tuberculosis. 5 CT scanning may not detect small ovarian cysts CT scanning is helpful to examine large masses and to look for abdominal spread of an ovarian cancer, but it is not as accurate as ultrasound for smaller ovarian cysts. MRI may be helpful to determine if a mass is benign or malignant.

Tim Mould is a consultant gynaecological oncologist at the UCLH Gynaecological Cancer Centre and chairs the gynaecological tumour board north London cancer networkCompeting interests None declared

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