Kirk J. Matthews and Jori S. Carter
History of present illness
A 48-year-old woman presents to clinic after being seen in a local emergency department for recurrence of a nagging abdominal and pelvic pain that has been bothering her inter- mittently for 3–4 months. Her symptoms have not been severe enough to require pain medications, but she is becom- ing increasingly worried about them. She reports increasing urinary frequency. An abdominal examination revealed no focal pain or peritoneal signs. Laboratory studies from her emergency department visit included a urinalysis, which revealed small leukocytes and blood. A urine culture was obtained and she was treated empirically for a urinary tract infection with trimethoprim/sulfamethoxazole 160 mg/800 mg BID for 3 days. Several days later, when her symptoms persisted and afinal report of her urine culture was negative, she was referred to you.
Today she describes her abdominal pain as a “bloating”
that is rather uncomfortable, but she is still able to go about her day as usual. On the days with worst symptoms, she has troublefitting into most of her pants. Her increasing urinary frequency is not associated with dysuria, hematuria, or urinary incontinence. She usually has regular bowel movements, but occasionally has bouts of constipation that are very uncom- fortable and usually resolve with over-the-counter laxatives and stool softeners.
Her past medical history is positive for mild hypertension, which is controlled with 25 mg of atenolol daily. Her only surgery was a postpartum bilateral tubal ligation after the birth of her second child at the age of 30. Her menstrual periods are noted to be quite regular, every four weeks, and associated with typical cramping and bloating that she has always had. This is usually treated with over-the-counter nonsteoridal anti-inflammatory drugs and hot packs. Her last Pap test was last year, and she has never had an abnormal smear. Her family history is notable only for hypertension.
She denies tobacco use, but does report drinking 2–3 glasses of wine per week.
Physical examination
General appearance:Well-dressed, well-groomed woman with no apparent disease
Vital signs:
Temperature: 36.8°C
Pulse: 85 beats/min
Blood pressure: 132/90 mmHg Respiratory rate: 16 breaths/min Oxygen saturation: 100% on room air BMI: 27.3 kg/m2
HEENT:Moist mucous membranes, no neck lymphadenopathy, normal palpating thyroid
Chest:Clear to auscultation bilaterally, no adventitious breath sounds noted. Heart is noted to have normal rate and rhythm. S1 and S2 noted
Abdomen:Soft, minimally distended, no masses palpated, no rebound or tenderness. The patient appears slightly uncomfortable with the abdominal exam
Lymphatics:No inguinal lymphadenopathy noted. No lower extremity edema
External genitalia/vagina:Normal appearing genitalia for age. No urethral irritation or erythema noted. Normal appearing vaginal mucosa and cervix without masses or lesions
Bimanual examination:Reveals a small uterus, but with limited mobility. Slightly tender fullness noted in the posterior cul-de-sac
Rectovaginal examination:Reveals similar fullness, which is also mildly uncomfortable to the patient. Stool obtained with rectalfinger has no occult blood
How would you manage this patient?
Given the patient’s complaints and examination findings above, a differential diagnosis should include: endometriosis, endometrioma, uterine fibroids, functional ovarian cysts, pelvic inflammatory disease (PID), and ovarian and colon malignancies.
PID is less likely given that the patient has no cervical motion tenderness or mucopurulent discharge from the external cervical os. However, sexually transmitted infections can easily be detected with quick and inexpensive nucleic acid amplification tests (NAATs) obtained from cervix or urine. Information about the other possible diagnoses can be obtained from ultrasonographic imaging.
A colonoscopy and transvaginal ultrasound (TVUS) were both ordered as was a complete blood count (CBC). The CBC showed a hemoglobin level of 10.9 mg/dL with a normal mean corpuscular volume (MCV) of 92 fL. While the uterus
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
appeared to be of normal size and shape, the ultrasound revealed the right ovary to be posterior to the uterus, measur- ing 77 mm × 56 mm with several solid and cystic septations.
There was a small amount of posterior cul-de-sacfluid noted as well. Upon movement of the ultrasound probe, the ovary did not appear to be mobile at all. A colonoscopy revealed no abnormalfindings.
The ultrasonographic findings were concerning for malig- nancy, so a CA-125 was drawn, which returned only slightly elevated at 82 U/mL. The patient was referred to a gynecologic oncologist, who recommended an exploratory laparotomy.
Intraoperative findings included a frozen section of the right ovary, which showed evidence of an adenocarcinoma (Fig. 91.1). The gynecologic oncologist, after having counseled the patient in the preoperative setting that it may be necessary, proceeded with a full-staging procedure including a total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and pelvic and para-aortic lymph node dissection and pelvic washings to definitively stage the patient. There was no overt evidence of intraperitoneal disease and the pelvic and para- aortic lymph nodes palpated normally.
The final pathology showed a well-differentiated serous cystadenocarcinoma of ovarian origin. The right ovarian capsule was felt to be intact. The only evidence of malignant spread was a focus of tumor involving the right fallopian tube, giving the patient an International Federation of Gyne- cology and Obstetrics (FIGO) stage of 2A. Given that the malignancy in question was found at a relatively early stage, the patient’s prognosis is also proportionately good with an expected 5-year survival rate of approximately 76% [1]. The gynecologic oncologist made plans to start a course of platinum-based chemotherapy with plans for six cycles. This will be followed by CT scans and CA-125 measurements to evaluate response.
Detection of ovarian cancer
Ovarian cancer has, for many years, been the most cata- strophic gynecologic malignancy for women. Ovarian cancer is estimated to cause 14 030 deaths in the United States in 2013, more than cervical and uterine cancer combined [1]. The main reason that this malignancy can be so lethal is due to the usual advanced stages at which it is usually diagnosed. While stage I disease has a 90% 5-year survival rate, stage III or IV has only an 18–34% 5-year survival rate [1]. It has been reported many times that ovarian cancer is a “silent killer.”However, when looking retrospectively, ovarian cancer patients often exhibit signs and symptoms, which may aid in an early diagnosis of this lethal disease.
Currently, there is no good screening test available for ovarian cancer. As the overall prevalence of ovarian cancer diagnoses is very low (only 22 240 estimated new diagnoses in 2013 [1]), any future screening test would be very difficult to implement. As would be true of any disease with a low preva- lence, a theoretical screening examination with 100% sensitiv- ity and 99% specificity would only have a very low positive predictive value, resulting in many false positives. In the case of ovarian cancer screening, such a high false positive rate would result in many unnecessary surgeries. In support of this, several large randomized controlled trials comparing screening with TVUS and CA-125 with usual care have not demon- strated a proven benefit [2,3,4]. At this time, it is not recom- mended that physicians routinely screen for ovarian cancer in asymptomatic, low risk women with either CA-125 or trans- vaginal ultrasound. However, women who exhibit symptoms of possible ovarian malignancy should receive further workup, as this patient did.
While early stage ovarian cancer is a difficult diagnosis to make, ovarian cancer patients oftentimes exhibit a number of signs and symptoms. The majority of ovarian cancer patients (95%) develop symptoms several months prior to seeing a physician. The most common symptoms are increased abdom- inal size, bloating, fatigue, abdominal pain, indigestion, urin- ary frequency, pelvic pain, constipation, back pain, and pain with intercourse (Table 91.1) [5]. The majority of symptoms are not gynecologic. Many of the most common symptoms are abdominal, gastrointestinal, pain, or constitutional in nature, so it is quite common for providers to incorrectly diagnose a patient with irritable bowel syndrome, gastritis, or depression several months before the correct diagnosis can be made [6]. It is incumbent upon both the physician and patient to have a high index of suspicion for ovarian cancer when presented with these nonspecific symptoms.
A thorough physical exam, including a pelvic and rectovaginal examination, is of paramount importance in the evaluation of a patient with these symptoms. Any adnexal masses, posterior cul-de-sac fullness, or nodularity should prompt imaging studies. While slightly invasive, transvaginal ultrasonography is quite sensitive for detecting ovarian abnormalities, oftentimes before symptoms may fully arise.
Fig. 91.1 Intraoperativefindings of ovarian carcinoma arising from right ovary. The normal appearing uterus and contralateral adnexal structures suggest the early stage of disease at time of surgery. (Courtesy of Weldon Chafe, MD.)
Case 91: A 48-year-old woman with a 4-month history of intermittent abdominal pain and urinary frequency
The upper limit of normal for a nonpregnant premenopausal ovary is approximately 20 cm3, and is only 10 cm3 in a postmenopausal ovary. The ultrasound also provides other information, such as cyst wall characteristics, presence or absence of septae, or Doppler blood flow studies, which may be of use in detecting malignant lesions [7].
According to the American College of Obstetricians and Gynecologists (ACOG), a CA-125 may be helpful in the fur- ther evaluation of suspicious ovarian lesions. In the premeno- pausal woman, a mildly elevated CA-125 has low specificity for an ovarian malignancy, however severely elevated levels may be useful. In contrast, for the postmenopausal women with a pelvic mass, a CA-125 is helpful in predicting the likelihood of a malignancy [7]. However, a normal CA-125 may be found in up to 50% of early stage ovarian cancer and 25% of advanced stage cancers. For this reason, it may be better to order an ultrasound study prior to a CA-125, as was done in this patient.
If ovarian cancer is likely, a gynecologic oncologist should perform the surgery in a facility that has a pathology depart- ment prepared to perform intraoperative surgical frozen sections. According to ACOG, patients who receive a compre- hensive staging procedure have better outcomes than those who do not [7]. Patients with ovarian cancer who have surgery done by gynecologic oncologists have improved overall sur- vival [8].
Full staging includes peritoneal cytology and complete inspection of the abdominal and pelvic organs. Any adnexal masses should be removed intact where possible and complete staging should include a hysterectomy, bilateral salpingo- oophorectomy, omentectomy, bilateral pelvic and paraaortic lymphadenectomy, and peritoneal biopsies. It may be appro- priate to preserve the uterus and contralateral ovary and fallo- pian tube in a younger woman with limited disease who wishes to retain her fertility.
For many years, ovarian cancer has been seen as “the silent killer.” However, patients diagnosed with ovarian cancer often exhibit symptoms prior to seeking medical evaluation, and often receive an initial incorrect diagnosis.
While a difficult diagnosis to make, early stage ovarian cancer has much betterfive-year survival rates than advanced stage cancers. Currently, the best detection strategy for ovarian malignancies is for the treating provider to have a high index of suspicion. A complete evaluation of the symptomatic patient always includes a thorough physical examination and may include transvaginal ultrasonography and CA-125 measurement.
Key teaching points
At this time, there is no effective screening test for ovarian cancer and screening for ovarian cancer in women of average risk is not recommended.
Most women with ovarian cancer exhibit symptoms prior to their diagnosis and this malignancy should no longer be considered a“silent killer.”The best detection tool currently available is physician and patient awareness, and suspicion of ovarian malignancy in women with symptoms.
The most common symptoms of ovarian cancer include abdominal or pelvic pain, gastrointestinal issues, early satiety, or urinary issues.
Further workup for an ovarian malignancy should include transvaginal ultrasonography. Consideration may also be given to a CA-125 measurement.
References
1. American Cancer Society.Cancer Facts and Figures 2013. Atlanta, American Cancer Society, 2013.
2. Buys SS, Partridge E, Greene M, et al.
Ovarian cancer screening in the prostate, lung, colorectal and ovarian (PLCO) cancer screening trial: Findings from the initial screen of a randomized
trial.Am J Obstet Gynecol2005;193(5):
1630–9.
3. Kobayashi H, Yamada Y, Sado T, et al.
A randomized study of screening for ovarian cancer: A multicenter study in Table 91.1 Frequency of symptoms in ovarian cancer
Symptom Frequency (%)
Increased abdominal size 61
Bloating 57
Fatigue 47
Abdominal pain 36
Indigestion 31
Urinary frequency 27
Pelvic pain 26
Constipation 25
Back pain 23
Pain with intercourse 17
Unable to eat normally 16
Palpable mass 14
Vaginal bleeding 13
Weight loss 11
Nausea 9
Bleeding with intercourse 3
Diarrhea 1
Deep venous thrombosis 1
None 5
Japan.Int J Gynecol Cancer2008;
18(3):414–20.
4. Menon U, Gentry-Maharaj A, Hallett R, et al. Sensitivity and specificity of multimodal and ultrasound screening for ovarian cancer, and stage
distribution of detected cancers: Results of the prevalence screen of the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS).Lancet Oncol 2009;10(4):327–40.
5. Goff, BA. Ovarian cancer: Screening and early detection.Obstet Gynecol Clin North Am2012;39(2):
183–94.
6. GoffBA, Mandel L, Muntz HG, et al.
Ovarian carcinoma diagnosis.Cancer 2000;89:2068–75.
7. American College of Obstetricians and Gynecologists. The role of the obstetrician/gynecologist in early
detection of epithelial ovarian cancer. Committee Opinion Number 477.Obstet Gynecol2011;117(3):
742–6.
8. Chan J, Sherman AE, Kapp DS, et al. Influence of gynecologic oncologists on the survival of patients with endometrial cancer.
Obstet Gynecol2007;109(6):
1342–50.
Case 91: A 48-year-old woman with a 4-month history of intermittent abdominal pain and urinary frequency