This patient's age and clinical presentation make ovarian cancer the most likely diagnosis. Pre-operative work-up in suspected ovarian cancer should include baseline serum CA-125 level, CT abdomen/pelvis for staging, chest radiograph, mammogram, pap smear, and colonoscopy, particularly when a patient is experiencing gastrointestinal symptoms.
Ovarian cancer is the most deadly gynecologic cancer in the United States and is the second most common gynecologic cancer behind endometrial cancer. Risk factors include a family history of ovarian cancer and an increased number of ovulatory cycles (infertility, nulliparity, older than 50 years of age). Oral contraceptive use is believed to be protective. There are numerous different types of ovarian cancer. However, all are deadly due to the typical late development of symptoms until late in the course of the disease, when treatment options are limited.
Roett et al. review the presentation, work-up, and management of ovarian cancer. Ovarian cancer is more common in patients over 50 years of age, with pelvic masses in patients under 50 years of age more likely to benign. Initial presentation is typically characterized by nonspecific pelvic and abdominal symptoms. Although relatively nonspecific, transvaginal ultrasound and CA-125 level are useful in the initial work-up. Management typically entails surgical debulking of the tumor followed by chemotherapy. Epithelial ovarian cancer is the most common type, with 70% of cases first diagnosed at stage III or IV; in turn, this leads to a poor prognosis for these patients.
Ding et al. conducted a systematic review of the efficacy of bevacizumab for the treatment of recurrent ovarian cancer. They found that bevacizumab, in combination with other chemotherapy agents, prolonged progression-free survival without affecting overall survival. Adverse events included increased risk of hypertension and bleeding.
Illustration A shows the staging classification for ovarian cancer; note that most ovarian cancers are diagnosed at stage III. Illustration B, in turn, shows the time of diagnosis and survival by staging of ovarian cancer; note that the majority of cancers in the US are diagnosed at stage III or IV, which carries the worst prognosis in terms of lowest 5-year survival.
Answer 1: CEA is a tumor marker for colorectal and breast cancer; this patient's presentation is most suggestive of ovarian cancer and therefore this would not be included in the initial work-up.
Answer 2: CA 19-9 is a tumor marker for pancreatic, gallbladder, bile duct, and gastric cancers; this patient's presentation is most suggestive of ovarian cancer and therefore this would not be included in the initial work-up.
Answer 3: Fine needle aspiration is not recommended for patients with an ovarian mass; if the clinical presentation suggests ovarian cancer, then a laparotomy for diagnosis and staging should be performed.
Answer 5: CT chest is not recommended as part of the initial work-up. If an abnormality is seen on a chest radiograph, then advanced imaging with CT may be recommended.
Roett MA, Evans P. Ovarian cancer: an overview. Am Fam Physician. 2009 Sep 15;80(6):609-16.
PMID:19817326 (Link to Abstract)
Ding S, Li L, Yu C. Systematic evaluation of bevacizumab in recurrent ovarian cancer treatment. J BUON. 2014 Oct-Dec;19(4):965-972.
PMID:25536603 (Link to Abstract)