Ovarian cancer in young women in Sweden, 1989-1991

Adnexal Masses in Pregnancy

Importance

Adnexal masses are identified in approximately 0.05% to 2.4% of pregnancies, and more recent data note a higher incidence due to widespread use of antenatal ultrasound. Whereas most adnexal masses are benign, approximately 1% to 6% are malignant. Proper diagnosis and management of adnexal masses in pregnancy are an important skill for obstetricians.

Objective

The aim of this study was to review imaging modalities for evaluating adnexal masses in pregnancy and imaging characteristics that differentiate benign and malignant masses, examine various types of adnexal masses, and understand complications of and explore management options for adnexal masses in pregnancy.

Evidence Acquisition

This was a literature review using primarily PubMed and Google Scholar.

Results

Ultrasound can distinguish between simple-appearing benign ovarian cysts and masses with more complex features that can be associated with malignancy. Radiologic information can help guide physicians toward recommending conservative management with observation or surgical removal during pregnancy to facilitate diagnosis and treatment. The risks of expectant management of an adnexal mass during pregnancy include rupture, torsion, need for emergent surgery, labor obstruction, and progression of malignancy. Historically, surgical removal was performed more routinely to avoid such complications in pregnancy; however, increasing knowledge has directed management toward conservative measures for benign masses. Surgical removal of adnexal masses is increasingly performed via minimally invasive techniques including laparoscopy and robotic surgery due to a decreased risk of surgical complications compared with laparotomy.

Conclusions and Relevance

Adnexal masses are increasingly identified in pregnancy because of the use of antenatal ultrasound. Clear and specific guidelines exist to help differentiate between benign and malignant masses. This is important for management as benign masses can usually be conservatively managed, whereas malignant masses require excision for diagnosis and treatment. A multidisciplinary approach, including referral to gynecologic oncology, should be used for masses with complex features associated with malignancy. Proper diagnosis and management of adnexal masses in pregnancy are an important skill for obstetricians.

Patient-reported symptoms and survival in ovarian cancer

OBJECTIVE

While the development of an index of clinical symptoms to use for the detection and diagnosis of ovarian cancer is under active investigation, the role of clinical symptoms in survival after the initial diagnosis is poorly understood. The aim of this study was to correlate the type and extent of clinical symptoms with survival outcomes in ovarian cancer.

METHODS

Medical records of 276 cases of primary epithelial ovarian, fallopian tube, and peritoneal cancers were evaluated. Thirty-one symptoms in 5 categories were cataloged. The significance of clinical symptoms in progression-free survival (PFS) and overall survival (OS) was evaluated.

RESULTS

Overall, 93.5% of ovarian cancer patients expressed at least 1 symptom at the time of initial diagnosis. The 3 most common symptoms were abdominal pain (40.6%), increased abdominal size (33.7%), and bloating (21.7%). In survival analysis, weight loss (16.3%), nausea/vomiting (13.4%), and lower extremity edema (6.5%) were significantly associated with both decreased PFS and OS (all, P < 0.05). In multivariate analysis, lower extremity edema remained the strongest significant symptom, associated with increased surgical mortality rate, decreased response rate to adjuvant chemotherapy after primary cytoreductive surgery, and diminished survival outcomes (median PFS, 4.9 vs 15.3 months, P < 0.0001; and median OS, 5.9 vs 49.1 months, P < 0.001). Multiple symptoms were associated with poor survival outcomes (individual number of symptom ≤1 vs 2 vs ≥3; median PFS, 26.8 vs 17.4 vs 11.7 months [P < 0.001]; and median OS, 70 vs 41.6 vs 37.2 months [P < 0.001]).

CONCLUSIONS

Lower extremity edema at initial diagnosis is a strong prognostic indicator of ovarian cancer patient.

Symptoms of ovarian cancer in young patients 2 years before diagnosis, a case-control study

Ovarian cancer is usually diagnosed after it has spread and is difficult to cure. Most of attempts to identify early symptoms have lacked control group or have been based on interviews. We examined early symptoms of ovarian cancer in young women and compared with a matched control group. Symptoms recorded in medical files of 100 women aged 15-35 years with ovarian cancer who were referred to Vali-Asr hospital between 1995 and 2005. Symptoms of cases were compared with 100 matched controls during 2 years before diagnosis. More cases (95%) than controls (28%) complained of at least one symptom up to 2 years before diagnosis, most of these symptoms were abdominal. Others included urinary symptoms, infertility and abnormal vaginal bleeding. The most common symptoms among cases were: unusual abdominal or lower back pain 52%, unusual bloating, fullness and pressure in the abdomen 37%, gastro-intestinal problems 36%. In total, 11%, 3% and 12% of controls reported these symptoms respectively, resulting in odds ratios of 8.7, 18.9 and 4.1 respectively for these symptoms. Unusual abdominal or lower back pain, fullness and pressure, gastrointestinal, urinary problems and infertility should make women and physicians more aware of changes associated with ovarian cancer.

Feasibility of screening for ovarian cancer using symptoms as selection criteria

OBJECTIVE

Retrospective studies have reported that 95% of women with ovarian cancer have symptoms prior to diagnosis and that women with these symptoms are at an increased risk of ovarian cancer. Failure to recognise these symptoms may result in a delay in referral and diagnosis. We assess the feasibility of screening for ovarian cancer using symptoms as selection criteria.

DESIGN

A randomised controlled trial.

SETTING

General practices in East London.

POPULATION

Three hundred and ninety GPs.

METHODS

GPs were randomised by practice, and those in the study group were given rapid access to ultrasound and CA125 test for women, >45 years, suffering from symptoms that may be caused by ovarian cancer.

MAIN OUTCOME MEASURES

Symptoms leading to referral, ultrasound and CA125 results and ovarian cancer diagnosis.

RESULTS

Seventy nine practices containing 197 GPs were randomised to the study arm. Three hundred and seventeen women were referred, of which 315 were eligible. Women reported the following symptoms: abdominal 87%, gastrointestinal 41% and constitutional 29%. Twenty-three women had abnormal findings on ultrasound: 20 were managed conservatively and 3 surgically. Histology revealed a mucinous cystadenoma, a Brenner tumour and a serous cystadenoma. Incidental findings included endometrial pathology in 13 women and bladder pathology in 2. Ninety five percent of CA125 results were <35 units/ml.

CONCLUSIONS

This pilot study confirms the feasibility of screening for ovarian cancer using symptoms as selection criteria. Specificity was high and patient compliance good. Initial concerns about referral volumes and additional investigations and referrals generated were not confirmed. No ovarian cancers were detected in this pilot study, and this may be due to the size of the cohort.

Ovarian cancer during pregnancy: analysis of 15 cases

GOAL

Our goal was to analyze and describe cases of ovarian cancer in pregnant women treated at our hospital.

METHOD

Retrospective study based on clinical histories from patients diagnosed and treated at our hospital for ovarian cancer and pregnancy from 1987 to 2005.

RESULTS

Fifteen cases of ovarian cancer were diagnosed among pregnant women; the ratio is 0.11/1000 deliveries. Among them, 66.6% of patients were asymptomatic, and 86.6% had been diagnosed via ultrasound. Of the diagnosed tumors, 40% were malignant epithelial tumors, 26.6% of them were of low malignant potential. The 20% were germinal cell tumors. Of these primary ovarian malignancies, the 59.9% were stage I. The remaining 20% were metastatic tumors. Forty percent of the total were treated conservatively (salpingo-oophorectomy) and 60% with hysterectomy and bilateral salpingo-oophorectomy. Chemotherapy was administered to 66.6% of the patients, in two cases during pregnancy. Eighty percent of the newborns were healthy and presented no sequelae or malformations. Global survival at 5 years was 76%.

CONCLUSIONS

Ovarian cancer is rare in pregnant women. Most malignant ovarian neoplasias in pregnant women are at early stages and are associated with good prognosis both for the mother and for the neonate.

Ovarian cancer in younger vs older women: a population-based analysis

To compare the clinico-pathologic prognostic factors and survival of younger vs older women diagnosed with epithelial ovarian cancer. Demographic, clinico-pathologic, treatment, and surgery information were obtained from patients with ovarian cancer from the Surveillance, Epidemiology, and End Results Program from 1988 to 2001 and analysed using Kaplan–Meier estimates. Of 28 165 patients, 400 were <30 years (very young), 11 601 were 30–60 (young), and 16 164 were >60 (older) years of age. Of the very young, young, and older patients, 261 (65.3%), 4664 (40.2%), and 3643 (22.5%) had stage I–II disease, respectively (P<0.001). Across all stages, very young women had a significant survival advantage over the young and older groups with 5-year disease-specific survival estimates at 78.8% vs 58.8 and 35.3%, respectively (P<0.001). This survival difference between the age groups persists even after adjusting for race, stage, grade, and surgical treatment. Reproductive age (16–40 years) women with stage I–II epithelial ovarian cancer who received uterine-sparing procedures had similar survivals compared to those who underwent standard surgery (93.3% vs 91.5%, P=0.26). Younger women with epithelial ovarian cancer have a survival advantage compared to older patients.

Adnexal masses in pregnancy: How often are they malignant?

OBJECTIVE

The primary objective was to investigate the occurrence rates of benign and malignant ovarian tumors associated with pregnancy among women identified in three large California databases between 1991 and 1999. The secondary objective was to determine maternal and perinatal outcomes among these pregnancies.

METHODS

This is a population-based study of 4,846,505 obstetrical patients using California hospital discharge records from 1991-1999. The California vital statistics birth/patient discharge database was linked to the California Cancer Registry (CCR). Cases of maternal ovarian cancers and low malignant potential (LMP) tumors were separated into three periods based on the timing of diagnosis and pregnancy: prenatal, at delivery, and postpartum. International Classification of Diseases, Revision 9 (ICD-9) codes were used to identify both diagnostic and procedural factors occurring during hospitalizations. The CCR database was used to identify cancer outcomes such as stage, histology, treatments, and vital status.

RESULTS

9375 women had a hospital diagnosis of an ovarian mass associated with pregnancy. CCR database identified 87 ovarian cancers and 115 LMP tumors in the same cohort. The occurrence rates were 0.93% (87/9375) ovarian cancers per total number of ovarian masses diagnosed during pregnancy, and 0.0179 ovarian cancers per 1000 deliveries. The summary stages of the ovarian cancers and LMP tumors were (respectively): localized 65.5% and 81.7%, regional 6.9% and 7.8%, remote 23.0% and 4.4%, and unknown 4.6% and 6.1%. 34 of the 87 ovarian cancers were germ cell tumors (GCT). Malignant ovarian tumors increased the likelihood of maternal outcomes such as cesarean delivery, hysterectomy, blood transfusions, and prolonged hospitalization compared to noncancer pregnant controls, but did not adversely affect neonatal outcomes. Cause-specific maternal mortality of patients with follow-up was 4.7% (9/191) at a mean of 2.43 years after diagnosis.

CONCLUSIONS

Ovarian malignancies are rare during pregnancy. Most maternal malignant ovarian neoplasms are early stage and associated with favorable maternal and neonatal outcomes. The low maternal mortality rate is likely due to the predominance of GCTs among the ovarian cancers.

Rapidly growing bilateral ovarian cystadenoma in a 6-year-old girl: case report and literature review

BACKGROUND

Benign ovarian neoplasms originating from epithelial tissue are common tumors in adult women. However, they are rarely seen in the pediatric population, especially in the first decade of life.

CASE

We report a case of a 6-year-old, premenarchal girl, previously healthy, with frequent micturition lasting 3 days prior to the first examination, without discomfort or pain. Laboratory analyses of blood and urine showed no abnormalities. Repeated ultrasonographic examinations revealed bilateral, cystic, rapidly growing ovarian masses. Cysts were surgically removed, with preservation of normal ovarian tissue, and histopathologic findings showed a serous cystadenoma of both ovaries.

Symptoms and referral of women with epithelial ovarian tumors

OBJECTIVE

To study referral to hospital units and the clinical characteristics of women with epithelial ovarian tumors in a prospective, population-based study.

METHODS

Clinical information on all women diagnosed with epithelial invasive (n=486) and borderline ovarian tumors (n=137) in Norway during 2002 was derived from notifications to the Cancer Registry of Norway and medical, surgical and histopathological records.

RESULTS

Sixty-one percent of women with invasive ovarian tumors were initially referred to gynecology units. The 38% of women referred to surgical and medical units were more likely to have symptoms as 'bowel irregularity', 'pain outside the abdominal cavity', 'persisting fatigue' and 'respiratory difficulties'. These women were older, had lower performance status and had a delay in treatment of 20 and 24 days respectively compared to 11 at gynecology units.

CONCLUSION

Greater awareness of the symptoms of ovarian cancer might lead to earlier diagnosis and treatment and thus possibly improve survival.

Ovarian cancer: the neglected diagnosis

OBJECTIVE

To investigate presenting signs and symptoms of ovarian cancer and stage of tumor in a community cohort of women with the diagnosis of ovarian cancer.

PATIENTS AND METHODS

We reviewed retrospectively the medical records of all women who sought primary and specialty care in Olmsted County, Minnesota, between January 1, 1985, and December 31, 1997, to evaluate presenting symptoms, time from first symptom to diagnosis of ovarian cancer, and stage of tumor at diagnosis.

RESULTS

Of 107 women with a diagnosis of ovarian cancer, the most commonly documented presenting symptom was crampy abdominal pain. Urinary symptoms and abdominal pain were the most commonly documented presenting symptom in patients with stage I and II ovarian cancers, whereas abdominal pain and increased abdominal girth were the most commonly documented symptoms in patients with stage III and IV cancer. Approximately 15% of tumors (n = 15) were found during routine evaluations or during a procedure for another problem. Less than 25% of presenting symptoms (n = 24 women) related directly to the pelvis or were more traditional gynecologic symptoms. Delays in women seeking medical care, health care system issues, competing medical conditions, physicians' failure to follow up, and women not returning for follow-up were associated with longer time to diagnosis.

CONCLUSION

Both stage I and II cancer are associated with symptoms, but few symptoms are directly related to the reproductive pelvic organs or unique to ovarian cancer. A longer interval from first sign or symptom to diagnosis of ovarian cancer is associated with both patient and health care system factors.

Characterization of prediagnostic symptoms among primary epithelial ovarian cancer cases and controls

OBJECTIVE

The goal of this study was to characterize types, frequency, combinations, and relative onset of symptoms among ovarian cancer cases and controls.

METHODS

Participants were from an ongoing, population-based, case-control study of primary epithelial ovarian cancer in a 48-country region of North Carolina. Incident cases (N = 267), aged 20-74, were identified by area hospitals on a rapid case ascertainment basis between April 1999 and March 2001. Population-based controls, with at least one intact ovary, frequency matched on age and race, were identified using random-digit dialing (N = 287) and Health Care Financing Administration (HCFA) phone lists (N = 30). Trained nurse-interviewers, using a standardized questionnaire, asked participants about specific symptoms experienced for at least 2 weeks in the year prior to diagnosis (cases)/interview (controls).

RESULTS

More than 90% of cases reported at least one symptom and symptoms were most often the reason for the doctor visit leading to diagnosis (74%), followed by routine examination (12%). Among invasive cases, symptoms with onsets longer before diagnosis (median 5-7 months) included gas/nausea/indigestion; urinary frequency/urgency; bowel irregularity; abnormal menstrual/vaginal bleeding or discharge; pain during intercourse; and ongoing fatigue. Symptoms with onsets closer to diagnosis (median of 2-4 months) included distended/hard abdomen; bloating/feeling of fullness; unexplained weight gain/loss; pelvic/abdominal discomfort; chest pain/respiratory difficulties; and "other" symptoms. Controls reported fewer symptoms than cases (median 1 vs 5 or 6). Control symptoms were of longer duration and much less likely to occur in combination.

CONCLUSION

Earlier diagnosis of ovarian cancer may be possible if women and physicians recognize the importance of combinations of seemingly unrelated symptoms, especially those identified as occurring longer before diagnosis.

Types and duration of symptoms prior to diagnosis of invasive or borderline ovarian tumor

OBJECTIVE

The objective was to describe and compare types and duration of symptoms among women with invasive versus borderline ovarian tumors.

METHODS

Cases were women, ages 20-69 years, diagnosed with invasive (616) and borderline (151) epithelial ovarian tumors from 1994 to 1998. Symptoms were obtained using a standardized in-person interview. Differences in types and duration of symptoms, time to diagnosis after consulting a physician, and primary reason for diagnosis by invasive/borderline status and histologic type were determined using bivariate and regression analyses controlling for age.

RESULTS

Borderline and invasive cases reported similar types of symptoms. However, borderline cases were twice as likely to report not having had symptoms as invasive cases (16 vs 8%, P = 0.005). Prediagnostic symptom duration was longer among borderline versus invasive cases (median: 6 vs 4 months, P < 0.001). The median time from first consultation with a physician to diagnosis (1 month) did not differ by invasive/borderline status. Borderline cases were twice as likely to be diagnosed through routine examination as invasive cases (28 vs 16%, P = 0.001). Invasive cases were more likely to be diagnosed because of symptoms (62 vs 48%, P = 0.002).

CONCLUSIONS

Because most (90%) women with ovarian tumors have symptoms and median symptom duration is 4 months, greater awareness of symptoms by women and physicians is needed for the earlier detection of ovarian tumors. The lesser likelihood of being detected by routine examination and the shorter symptom duration for invasive versus borderline cases underscores the need for effective screening and preventive strategies.

Low-grade ovarian cancer in an adolescent patient

BACKGROUND

Ovarian tumors in the pediatric population are most likely to be of germ cell origin. However, serous tumors have also been reported in adolescent patients.

CASE

A 14-year-old girl was diagnosed with stage IIIc low-grade ovarian cancer. Her serum CA-125 was elevated preoperatively and was a marker for recurrence of disease. Five months after completing standard chemotherapy, she developed recurrent disease, which progressed despite hormonal therapy. She then developed toxicity on liposomal doxorubicin (Doxil) and is now receiving hospice care.

CONCLUSION

Low-grade serous adenocarcinoma of the ovary can present as advanced disease and should be considered in the differential diagnosis of an ovarian mass in an adolescent patient.