DIAGNOSIS OF OVARIAN NEOPLASMS
Ovarian neoplasms may be found at any age. The majority occur during the reproductive years, though about 4% are present in children less than 10 years old. Of these, about half are malignant (dysgerminoma, solid teratoma, carcinoma, granulosa cell tumor) and the remainder benign (dermoid and epithelial cysts). Malignancy may be expected in about 15% of all ovarian tumors. The highest incidence of ovarian malignancy occurs between 40 and 60 years of age.
The most important objective of the management of an ovarian mass is the timely diagnosis of its type and origin. Subsequent therapy and assessment of risk are based on the correct diagnosis. For acutely symptomatic cysts, rapid evaluation and intervention may be necessary.
Benign ovarian tumors are most frequently diagnosed at the time of routine examination and are asymptomatic. An insidious growth to large proportions may occur, with an increase in girth as the only subjective symptom. When symptoms do occur, they generally are either catastrophic (as when bleeding, rupture, or torsion occur) or indolent and nonspeciﬁc (such as a vague sense of pressure or fullness). The symptomatology presented by an ovarian tumor is dependent upon its size, location, and type as well as on the presence of such complications as torsion, hemorrhage, infection, or rupture. Pain, if present, may be mild, intermittent, and localized in the hypogastrium or either lower quadrant. It may radiate to the anterior or lateral thigh. Severe pain usually attends an acute accident. Generally, the menses are not affected. On occasion, dysmenorrhea, menorrhagia, or hypomenorrhea may be prevalent symptoms. The biologically active tumors manifest distinctive endocrinologic features. Solid, ﬁxed, and inﬁltrating neoplasms may give rise to pressure symptoms related to impingement upon the bladder, rectosigmoid, or ureter.
History and physical examination are generally suf-ﬁcient to establish the presence of the mass. There are no laboratory tests that are of speciﬁc help in the global diagnosis of ovarian masses. Laboratory investigations may support speciﬁc diagnoses. Ultrasonography, computed tomography, and magnetic resonance imaging are of limited value in evaluating small asymptomatic masses in young patients. Exceptions to this are patients in whom clinical assessment is impractical or inadequate (e.g., massive obesity) or those in whom malignancy is suspected. Serum testing for tumor markers, such as CA-125, lipid-associated sialic acid, carcinoembryonic antigen, α-fetoprotein, lactate dehydrogenase, and others should be reserved for following the progress of patients with known malignancies and not for prognostic evaluation.
Some authors favor giving young patients with small, presumably benign, cystic masses ovulation suppression therapy, such as oral contraceptives, to hasten the process of regression. Regression rates of 65% to 75% are often cited for this approach, but this strategy is largely a matter of personal choice because deﬁnitive studies are lacking and most evidence suggests that oral contraceptives are more likely to prevent the growth of new or existing cysts than to hasten regression. Physiologic ovarian enlargements, including follicular or corpus luteum cysts, should not be present if a patient is using oral contraceptives. For this reason, patients who are already using oral contraceptives and develop adnexal masses are more likely to have pathologic conditions that will not regress, increasing the possibility that eventual surgical exploration may be required. Perimenopausal and postmenopausal patients may still have benign processes as a cause of an adnexal mass, but the likelihood of a malignant process is much increased (up to one-third of cases), altering management. In these patients, masses larger than 6 cm generally prompt surgical exploration and excision. The avail- ability of transvaginal ultrasonography to measure and track masses has allowed smaller masses that once would have required exploration to be followed conser-vatively. As in younger patients, the size, shape, mobility, and consistency of the mass should be estimated. Irregular, immobile, or mixed character masses (solid and cystic) are more likely to be malignant and deserve immediate consultation with a surgeon for exploration. The ﬁnal diagnosis of ovarian cancer must be made surgically.