What is the recommended workup for ovarian (Ca ovary) cancer?

Workup for Ovarian Cancer

For a patient with suspected ovarian cancer, the essential workup includes: pelvic/abdominal examination, transvaginal and/or transabdominal ultrasound, CT scan of chest/abdomen/pelvis with contrast, serum CA-125, and appropriate additional tumor markers based on clinical suspicion. 1, 2

Initial Clinical Assessment

Key symptoms to evaluate:

• Abdominal/pelvic pain, bloating, early satiety, difficulty eating 2, 3
• Urinary urgency or frequency 2, 3
• Abdominal distention, ascites 1, 2
• Vaginal bleeding, constipation/diarrhea, fatigue 2

Risk factors to document:

• Family history of ovarian or breast cancer (BRCA1/2 mutations) 2, 4
• Lynch syndrome (mismatch repair genes) 2
• Endometriosis, nulliparity, advancing age 3

Imaging Studies

Ultrasound (first-line imaging):

• Transvaginal and/or transabdominal ultrasound by an experienced examiner 1, 2
• Report must document: size, laterality, septation thickness, presence of excrescences/solid components, vascular flow pattern, and ascites 5

CT imaging (essential for staging):

• CT chest/abdomen/pelvis with contrast (unless contraindicated) for complete clinical staging and surgical planning 1, 2
• CT is superior to ultrasound for assessing metastases 1

Additional imaging considerations:

• MRI may be useful if ultrasound is unreliable or for indeterminate lesions 1
• FDG-PET/CT may be useful for indeterminate lesions 1
• Chest imaging should be part of overall evaluation before surgical staging 1

Laboratory Studies

Standard tumor markers:

• CA-125 (elevated in ~85% of advanced disease but only ~50% of early-stage cases) 2, 6
• For women <35 years with pelvic mass: measure AFP to assess for germ cell tumors 1
• Beta-hCG to exclude pregnancy and assess for germ cell tumors 1

For suspected mucinous carcinoma:

• CEA and CA 19-9, especially if CA-125/CEA ratio ≤25:1 2
• Additional gastrointestinal evaluation to distinguish primary ovarian tumors from GI metastases 2

For suspected germ cell tumors:

• AFP, β-hCG, and LDH 2

Pathological Diagnosis

Tissue sampling approach:

• Most ovarian cancers are diagnosed after pathologic analysis of surgical specimens 1
• Avoid fine-needle aspiration (FNA) in presumed early-stage disease to prevent cyst rupture and peritoneal spillage of malignant cells 1
• FNA may be necessary only in patients with bulky disease who are not surgical candidates 1

Critical Pitfalls to Avoid

CA-125 interpretation errors:

• CA-125 is not specific to ovarian cancer and can be elevated in benign conditions (endometriosis, fibroids, pelvic inflammatory disease) and other malignancies 2
• Low sensitivity in early-stage disease limits its utility as a standalone test 2, 6

Inadequate imaging:

• Relying solely on ultrasound without CT for complete staging assessment 2

Mucinous carcinoma misdiagnosis:

• Failing to distinguish primary mucinous ovarian tumors from gastrointestinal metastases (requires CEA, CA 19-9, and GI evaluation) 2

Insufficient tissue sampling:

• Obtaining inadequate tumor samples, especially if neoadjuvant chemotherapy is planned 2

Referral Criteria

Immediate referral to gynecologic oncologist indicated for:

• High risk of malignancy based on imaging findings and elevated CA-125 6, 5
• Complex adnexal masses with features suggestive of malignancy 5
• Confirmed ovarian cancer diagnosis 6

The NCCN guidelines emphasize that gynecologic oncologists should perform primary surgery based on published improved outcomes (category 1 recommendation) 1. Comprehensive surgical staging is essential, as approximately 30% of patients are upstaged after complete staging surgery 1.