The role of ultrasound and tumour markers in the early detection of ovarian cancer

Differential diagnosis of peri- and postmenopausal ovarian cysts

OBJECTIVES

To test the value of preoperative and intracystic parameters in the differential diagnosis of ovarian cysts.

METHODS

Criteria for admission of 58 patients were age > 47 years, complete history, detection of CA 125 serum level, and ultrasound findings. Tumor markers (CA 125, cancer-associated serum antigen (CASA), CA 72-4), hormones (estradiol (E2), follicle-stimulating hormone (FSH), luteinizing hormone (LH)), epidermal growth factor (EGF) receptor and c-erb B-2 amplification rate were detected in cyst fluid.

RESULTS

Of the 58 subjects, 9 (15.4%) had functional cysts, 37 (63.8%) had benign tumors and 12 (20.8%) had malignant tumors. No functional ovarian cyst presented as echoic or multilocular cyst sonographically. The serum CA 125 values demonstrated significant differences between the non-malignant and malignant patient groups (P < 0.0005). The majority (63.8%, n = 37) of ovarian cysts were obtained at laparotomy, whereas only 36.2% (n = 21) were laparoscopically operated. The cyst fluid levels of FSH (P < 0.005) and LH (P < 0.05) were significantly lower in the functional group than in the benign or malignant group. Malignant cysts were significantly different from non-malignant cysts regarding low E2 (P < 0.01), high FSH (P < 0.05) and CASA (P < 0.02) values. There were no significant correlations between EGF receptor (P = 0.14) and c-erb B-2 (P = 0.06) gene amplification rates and malignant histology.

CONCLUSIONS

Simple ovarian cysts combined with normal serum CA 125 levels are candidates for conservative follow-up or laparoscopy. The serum CA 125 is a powerful marker for prediction of histology in postmenopausal ovarian cyst. Laparoscopic surgery may be considered in patients with multilocular sonographic findings and normal CA 125 serum level. Combining serum CA 125 levels with cyst fluid parameters (E2, FSH, CASA) improves the sensitivity and specificity in predicting malignancy.

Ureteral carcinoma presenting as a complex pelvic mass in a post menopausal patient

This is a report of a low-grade ureteral carcinoma presenting as a pelvic mass in a postmenopausal woman with a prolonged history of lower back pain. A right complex adnexal mass and right hydroureter and hydronephrosis in an atrophic nonfunctioning right kidney was found during evaluation for the back pain. Operative evaluation revealed a normal uterus and ovaries; however, a 2 x 3-cm mass in the right ureter was found at the level of the uterine arteries. A total abdominal hysterectomy, bilateral salpingo-oophorectomy, and right nephroureterectomy were performed with pathology returning grade I papillary transitional cell carcinoma of the ureter.

Concentration of vascular endothelial growth factor (VEGF) in the serum of patients with suspected ovarian cancer

As a promoter of angiogenesis, vascular endothelial growth factor (VEGF) is believed to play a pivotal role in tumour growth and metastasis. The aim of this study was to determine the value of preoperative serum VEGF levels in the early diagnosis of ovarian cancer and in the differential diagnosis of adnexal masses. We examined preoperative serum VEGF levels in healthy women (n = 131), patients with benign ovarian cysts (n = 81) and in ovarian cancer patients (n = 44) by using an ELISA (R&D Systems, Minneapolis, MN, USA). A logistic regression model was carried out to determine the influence of VEGF and CA 125 on the probability of malignancy. VEGF revealed a significant influence on the odds of presenting with malignancy vs healthy women (P = 0.001). At 363.7 pg ml(-1), VEGF achieved a sensitivity of 54% and a specificity of 77%. With respect to the differentiation between benign cysts and ovarian cancer, CA 125 (P < 0.0001) but not VEGF (P = 0.229) predicts the presence of malignancy in a multivariate model. In conclusion, VEGF does not appear to be a useful tool in the early diagnosis of ovarian cancer or for indicating the absence or presence of malignancy in patients with an adnexal mass.

Transvaginal color Doppler and CA125 as tools in the differential diagnosis of postmenopausal ovarian masses

OBJECTIVE

To evaluate whether transvaginal color Doppler and CA125 are valid in differentiating malignant from benign postmenopausal ovarian masses.

METHODS

Sixty-two women with ovarian masses were studied with transvaginal color Doppler ultrasound before surgery. Serum CA125 levels were also measured. Resistance index (RI) and pulsatility index (PI) were calculated from the waveforms generated from blood flow within the ovary.

RESULTS

Benign tumors had a significantly higher pulsatility index (mean 1.23 +/- 1.02; range 0.65-2.99) and resistive index (mean 0.78 +/- 0.22; range 0.5-1.1) than did malignant tumors. However some overlap in individual values for benign and malignant lesions was found. RI and PI sensitivity were significantly higher than those with CA125 (P < 0.05). Blood flow was detectable by color Doppler imaging in 95% of cases with malignant masses.

CONCLUSION

Doppler sonographic evaluation of resistance and pulsatility indexes in the vessels of ovarian masses together with CA125 increased the sensitivity of prediction of malignancy for pelvic masses, but further work is needed before the validity of these factors is proved.

Ovarian surface epithelium, ovulation and carcinogenesis

It appears that ovarian surface epithelial cells activated by contact with gonadotropin-stimulated preovulatory follicles can release bioactive substances that weaken the tunica albuginea and apical follicular wall (e.g. collagenolytic enzymes) and induce cell death (e.g. apoptotic agents). However, a definitive obligatory role of the ovarian surface epithelium in ovulation remains equivocal. Epithelium exfoliated from the dome of ovulatory follicles is replenished by generative stem cell replication and migration from the wound edges. Mutagenesis has been related to successive bouts of ovulation and mitosis. Common epithelial ovarian cancer is a deadly insidious disease, mainly because it is asymptomatic until the malignancy has reached beyond the ovaries. The most important susceptibility factors are nulliparity and association to an affected first-degree relative. It will be critical to resolve whether parity and oral contraceptive use confer significant protection to women with a family history of ovarian carcinoma. Clearly, innovative approaches to non-invasive screening and treatment are needed. Early detection is the key to saving lives (90% cure by salpingo-ovariectomy alone if diagnosis is at Stage I). Active immunization with defined tumor epitopes or (passive) intraperitoneal administration of effector-functional humanized antibodies may be of special value in the regional management of common epithelial ovarian cancer.