Tests
1st tests to order
transvaginal ultrasonography
Test
Order test if there are abnormalities on physical exam or if concerned that exam is nondiagnostic.
Limited by obesity.
Interobserver agreement by skilled ultrasonographers is high.[46]
Results should characterize the size, consistency, location, and nodularity of the abnormality, determine whether it is unilateral or bilateral, and determine presence of free pelvic fluid.
DePriest morphology index based on tumor volume, wall structure, and septal structure yields a negative predictive value of 100% and a positive predictive value of 45% among postmenopausal women.[32]
Reported sensitivities and specificities with regard to malignancy are 88% and 90%; with regard to endometrioma they are 92% and 97%; and with regard to dermoids they are 90% and 98%, respectively.[15][47]
A fixed nodular mass with presence of ascites is very concerning for malignancy.
Result
enlarged ovary or portion of ovarian tissue; may be cystic, solid, or mixed
Tests to consider
serum cancer antigen (CA)-125
Test
Measure in women with cysts suspicious for malignancy and all postmenopausal women.
Levels >35 U/mL in postmenopausal women warrant concern for ovarian cancer. In the premenopausal patient this serum marker yields little because elevated levels are associated with many benign conditions, such as uterine fibroids, pelvic inflammatory disease, endometriosis, adenomyosis, pregnancy, and menstruation. Levels >200 U/mL in premenopausal women warrant a referral to a gynecologic oncologist for further evaluation.[41]
Elevated in about 80% of women with epithelial ovarian cancer.[31]
Most useful in nonmucinous epithelial ovarian cancer.[15]
Not a screening test: only positive in 50% of patients with stage 1 disease.
Overall sensitivity and specificity 78.7% and 77.9%, respectively.[48]
Measure the following in women under the age of 40 years: beta-human chorionic gonadotropin, lactate dehydrogenase, alpha-fetoprotein.[41]
Result
normal or elevated
color power Doppler ultrasonography of abdomen/pelvis
Test
Nonessential test for evaluation of cyst.[30]
Allows assessment of tumor vascularization by localizing vessels and calculating blood flow indices: resistive index, pulsatility index, and maximum systolic velocity.[46]
Most reliable predictive factors are morphologic appearance and blood flow location.[33]
In determining malignancy, sensitivity: 86.0%, specificity: 91.0%, positive predictive value: 93.6%, negative predictive value: 95.5%.[2][33]
One review of 3D ultrasound found it to be the most sensitive and specific modality overall (93.5% and 91.5%), albeit more expensive than 2D ultrasound.[48]
Result
penetrating vessels into solid, papillary, or central areas of malignant tumor
MRI of abdomen/pelvis
Test
The routine use of MRI for assessment of ovarian masses in premenopausal women does not improve the sensitivity or specificity obtained by transvaginal ultrasound in the detection of ovarian malignancy.[41] MRI may improve specificity for malignancy at the expense of sensitivity.[31][34]
May be considered when ultrasound findings are unclear.[49]
Result
enlargement of ovary or ovarian tissue; suspect malignancy if necrosis present in solid tissue
CT imaging of abdomen/pelvis
Test
Best used for detection of metastases if cancer is suspected based on ultrasound findings.
For determining malignancy, sensitivity: 87%, specificity: 84%.[48]
Can evaluate the liver, para-aortic region, omentum, and mesentery better than ultrasound.[34]
Exposure risk due to ionizing radiation.
Result
enlargement of ovary or ovarian tissue; suspect malignancy if ascites, wall/septal thickness >3 cm, or peritoneal, mesenteric, omental disease present
karyotype analysis
Test
Among premenarchal patients with a suspicious ovarian cyst, a karyotype can be obtained to confirm a XX chromosome complement and rule out an undescended testis in a genotypic male (XY) with androgen insensitivity.[43]
Result
karyotype chromosome analysis of peripheral blood lymphocytes or skin fibroblasts should show XX chromosome in a genotypic female
laparoscopy/laparotomy and histopathology
Test
Following laparoscopy, laparotomy, and cystectomy/oophorectomy, histopathology of the ovary is performed to confirm the nature of the cyst.
Adequate sampling of cellular ovarian cysts is required in order to confirm the diagnosis and assign appropriate treatment. Benign, borderline, and malignant ovarian tumors can present as cysts and the histopathology diagnosis, particularly for borderline tumors, may be difficult.[50]
Ultimately, the diagnosis of ovarian cancer is based upon histopathology and usually surgical extirpation of the affected ovary is necessary (as opposed to biopsy).
Benign physiologic cysts such as follicular cysts show benign, flattened, single cells lining the thin fibrous cyst wall, with variable degrees of acute and chronic hemorrhage.
Benign ovarian tumors may be glandular (serous cystadenoma), papillary (serous and mucinous cystadenoma), or solid (serous cystadenofibroma).
Histopathology of malignant ovarian cysts shows cytologic and architectural atypia of cyst lining cells and malignant cells in solid areas.
Result
defines architecture and histology of cyst; distinguishes benign from malignant
Emerging tests
PET imaging of abdomen/pelvis
Test
Patients need to fast and lie still for relatively long periods during the test.
Poor sensitivity and positive predictive value (58% and 28%, respectively).[34]
Mediocre specificity (80%) and negative predictive value (93%), but early-stage disease often missed.[2][34]
Result
malignancy suspected if glucose uptake within tumor equals that of liver
serum biomarkers (ovarian adnexal mass assessment score test system)
Test
Ovarian cancer risk in women with an ovarian mass (for which surgery is planned) can be assessed using an algorithm (ovarian adnexal mass assessment score test system) that incorporates the results of 5 serum biomarkers (transthyretin [prealbumin)], apolipoprotein A-1, beta-2 microglobulin, transferrin, and CA-125) with information regarding menopausal status. Early Detection Research Network, National Cancer Institute: OVA1 Opens in new window The test is not intended as a screening or stand-alone diagnostic assay. In postmenopausal women, measuring the level of the HE4 biomarker in addition to the CA-125 biomarker can more correctly identify benign disease.[37]
Result
elevated
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