Cancer of the Ovary - Diagnosis

Contents

Work-up for Suspected Ovarian Malignancy or Suspicious Pelvic Mass.

1. Ultrasound or CT scan.
2. Chest X-Ray
3. Full blood count
4. Urea, creatinine and electrolytes
5. Liver function tests
6. CA 125
7. CASA
8. ECG, if age >55, or past history of cardiac abnormalities.

Where clinically indicated:-

1. Intravenous pyelogram (IVP)
2. Colonoscopy

Age <30, or significant solid areas in tumour, or suspicion or germ cell tumour:-

1. Alpha feto protein
2. Beta HCG
3. LDH

Diagnostic paracentesis is discouraged as the above investigations will usually provide sufficient information to recommend definitive surgery. This investigation is often associated with development of tumour implantation at the site of paracentesis.

Pre-operative Preparation

If there is a high index of suspicion for ovarian malignancy, particularly with any evidence of pouch of Douglas nodularity, a bowel prep should be instigated.

A. Standard Bowel Preparation

Day -1: Clear fluids orally + TDS Ensure

0900: Magnesium citrate 1 glass

1000: Coloxyl 50gm x 3 tablets

1200: 2 x Microlax enemas if bowels not open

1200-1500: Colonoscopy prep made up to three litres

Maxolon 10 mg IMI if nausea or vomiting associated with administration of colonoscopy prep

If bowel prep cannot be tolerated orally, consider administration via nasogastric tube 

1900: If bowels return not clear, for further 1 litre colonoscopy prep

20.30: If bowels still not clear, for water enema

B. Modified Bowel Preparation

Day -2: Clear fluids orally 

16.00: 50 mls MgSO4 50%

Day -1: Clear fluids

0600: 50 mls MgSO4 50%

1600: 50 mls MgSO4 50%

1900: 1 litre H20 enema

All Patients

1. Tinidazole 1 gm p.o. 1800 & 2200 hrs if morning case & 2200 and 0600 hrs if afternoon case.
2. Clipper top of pubic hair + umbilicus if hairy
3. Clexane (Low Molecular Weight Heparin) 40mg nocte S/C while inpatient

Screening

The 1994 Consensus Conference on ovarian cancer concluded that there is no effective method for screening and detecting early ovarian cancer (6). Despite this, there is recognition that approximately 5-7% of epithelial ovarian carcinomas have a familial component. First degree relatives of patients with ovarian cancer have a relative risk of ovarian cancer of approximately 3.6 and second degree relative a relative risk of 2.9. There is not a uniform risk across all of these relatives. A small proportion of patients will be a part of a pedigree with a substantially increased risk, as part of a Familial Cancer Syndrome. These have been previously classified as:

1. Lynch Syndrome II
2. Breast-Ovarian Cancer Syndrome 
3. Site-specific Ovarian Cancer Syndrome (probably a variant of Breast-Ovary Syndrome)

With regard to the need for screening, it is of fundamental importance to establish the level of risk by taking a comprehensive family history. Often, uncertainty about malignancy in a deceased individual will require corroborating evidence in the form of archival histological reports.

Screening interventions

Dr James L. Nicklin
M.B., B.S. (Qld), F.R.A.C.O.G., C.G.O
Gynaecologic Oncologist
Queensland Centre for Gynaecological Cancer

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