Michael Frumovitz, MD, MPH, and Pamela Soliman, MD, MPH, practicing gynecologic oncologists at MD Anderson Cancer Center, presented an overview on how general gynecologists should approach an adnexal mass in the Saturday morning clinical seminar “The Pelvic Mass.”
They reviewed screening for ovarian cancer, how to work up an adnexal mass, when to triage a patient and what to do interoperatively if cancer is unexpectedly encountered.
Ovarian cancer is a rare occurrence—approximately 22,000 cases are presented in the US each year—making it difficult to study and screen. Not only is it rare, Dr. Soliman said, but ovaries are not easy to access.
“If you look at the age-specific incidence in patients that are pre-menopausal, the incidence is really one in 10,000, and even in post-menopausal, it’s really one in 2,500. That makes it really challenging to find a test that has enough precision to identify these patients but not have a high false positive rate. … That can make people freak out or get unnecessary testing or procedures,” Dr. Soliman said.
There is no “standard” screening test for asymptomatic, low-risk patients, and Dr. Soliman and Dr. Frumovitz said the only patient populations that should be recommended for ovarian cancer screening are patients with known germline mutations, BRCA for example, and women with family members who have had ovarian cancer or breast cancer.
Two common screening tests for high-risk patients include pelvic ultrasound and checking CA 125 levels. But CA 125 is elevated in only 50 percent of stage I ovarian cancers, and many other conditions can falsely elevate the levels, including endometriosis, liver disease and post abdominal surgery, Dr. Soliman said. Following a positive screening test, a diagnostic test is required.
The Prostate, Lung, Colorectal and Ovarian Cancer (PLCO) study revealed that screening with CA 125 and transvaginal ultrasound did not decrease ovarian cancer mortality, and false positive tests lead to an increase in complications compared to usual follow up. In fact, there are no studies that show screening for ovarian cancer improves survival, Frumovitz said.
Dr. Soliman said oral contraceptive pills, breastfeeding, and tubal ligation can reduce the risk of ovarian cancer.
When a patient comes into the office with an adnexal mass, Dr. Frumovitz said, it’s best to look at history and physical exams first and to avoid ovarian biopsies. One reason ovarian cancer is often found in late stages is because there aren’t any early symptoms.
“Unlike uterine cancer, where a post-menopausal women has some vaginal bleeding and knows that’s abnormal, there’s no good early symptom,” he said.
Dr. Frumovitz reviewed the indications for ovarian surgery for premenarchal girls and women at reproductive age. For premenarchal girls, any mass is abnormal. For women at reproductive age, those indications include simple cysts symptomatic of greater than 10 cm and thick septations. For post-menopausal women, this includes any complex cyst and any cyst with elevated CA 125.
He also reviewed the SGO/ACOG referral to gynecologist oncologist criteria for women with adnexal masses. Those include for pre-menopausal women a CA 125 greater than 200 U/mL, ascites and first-degree family history of breast or ovarian cancer, and for post-menopausal women a CA 125 greater than 35 U/mL, ascites and first-degree family history of breast/ovarian cancer.
“If cancer is found during an operation, call a gynecologic oncologist, if available,” he said. “If it is obviously widespread ovarian cancer, do a biopsy and get out.”