Early-Stage Ovarian Cancer

GENERAL PRINCIPLES

Differential Diagnosis

The diagnosis of early ovarian cancer often begins with the evaluation of an adnexal mass.
Benign neoplasms such as functional cysts, uterine fibroids, endometriomas, and benign epithelial tumors are the most common tumors to be considered when evaluating for early ovarian cancer (EOC).
For premenopausal patients, a simple cyst of regular shape should have repeat ultrasound (US) in 2 months. If it is a functional cyst, it should be gone. An endometrioma will have typical cloudy echos and a CA-125 may be 200 or less. If the mass has papillary growths and cystic-solid components, the risk of malignancy is higher. A CA-125 over 200 is another high-risk factor.
For postmenopausal women, the size, shape, and consistency of the mass are important. A simple cyst with thin capsule or septum (less than 3 mm) under 10 cm is rarely malignant. Even so, a cyst this size will rarely regress and should be removed to prevent torsion or rupture. Masses that are irregular with solid elements and an elevated CA-125 of over 35 are at high risk of EOC and should be advised to have it removed by a gynecologic oncologist. Excess free fluid on US (more than 50 cc) is another indicator of possible malignancy.
Metastatic cancer to the ovary is another rarer cause of adnexal mass. Cancer of the bowel, stomach, gall bladder, pancreas, and breast are all possibilities.

Anatomic Considerations

The International Federation of Gynecology and Obstetrics (FIGO) staging for early ovarian cancer is shown in the table (Table 28.1).

IMAGING AND OTHER DIAGNOSTICS

US findings in an adnexal mass that suggest malignancy are papillary projections, solid elements, ovarian capsule or septations over 3 mm in thickness, increased vascular flow on Doppler, or free fluid.
If the US reveals ascites, a CT scan may be necessary to evaluate for upper abdominal disease or lymph node metastasis.
If the patient is a candidate for fertility-sparing surgery (FSS), a CT or MRI should be obtained. In the absence of lymph node enlargement, extrapelvic masses, or ascites, the patient may be a candidate.

PREOPERATIVE PLANNING

Women who want fertility should be counseled about the possibility of FSS.
FSS can be offered to women with stage IA, or grade 1 or 2 histology. Grade 3 histology does not preclude the woman from FSS, but she will need chemotherapy and her risk of recurrence will be higher.
Comprehensive staging with pelvic and paraaortic node dissections, omentectomy, peritoneal biopsies and cytologic evaluation of fluid or washings are necessary.
Since the grade of tumor and the status of lymph nodes are not known before surgery, the patient needs to have the discussion preoperative.
If FSS is desired, the staging can be performed and then results waited upon before determining if the contralateral ovary and the uterus are to be removed.
See the Outcomes section of this chapter for information to give to the women considering FSS.

SURGICAL MANAGEMENT

Women with adnexal masses that are simple cystic and low suspicion for cancer will be able to undergo laparoscopic surgery. The ovary can be put into a bag and the fluid suctioned out before removing through a 10-mm port or through the vagina. Larger cysts will require a 15-cm bag which can be placed by enlarging the suprapubic port and inserting the bag tubing directly into the abdomen (Figs. 28.1 and 28.2).

Table 28.1 FIGO 2014 Staging of Ovarian Cancer

Tumor Confined to Ovaries or Fallopian Tube(s)		TI
IA	Tumor limited to one ovary (capsule intact) or fallopian tube No tumor on ovarian or fallopian tube surface No malignant cells in the ascites or peritoneal washings	TIA
IB	Tumor limited to both ovaries (capsules intact) or fallopian tubes No tumor on ovarian or fallopian tube surface No malignant cells in the ascites or peritoneal washings	TIB
IC	Tumor limited to one or both ovaries or fallopian tubes, with any of the following: surgical spill intraoperatively capsule ruptured before surgery or tumor on ovarian or fallopian tube surface malignant cells present in the ascites or peritoneal washings	TIC
II	Tumor involves one or both ovaries or fallopian tubes with pelvic extension (below pelvic brim) or peritoneal cancer (Tp)	TII
IIA	Extension and/or implants on the uterus and/or fallopian tubes and/or ovaries	TIIA
IIB	Extension to other pelvic intraperitoneal tissues	TIIB
From Mutch DG, Prat J. 2014 FIGO staging for ovarian, fallopian tube and peritoneal cancer. Gynecol Oncol. 2014;133(3):401-404.

Women with masses suspicious for cancer but smaller than 8 cm will have their masses fit into a bag which can be removed through the vagina without spilling tumor. The rest of the staging can be performed with the laparoscope (Figs. 28.3, 28.4, 28.5 and 28.6).
Women with suspicious masses larger than 8 cm may be first evaluated with a laparoscope, but if malignant characteristics are seen, the mass should be removed unruptured through an abdominal incision.

Figure 28.1. The 15-cm bag has been inserted and the ovary placed into it. The bag is pulled up and “fluted” so the cyst wall can be punctured and the fluid aspirated.