1. Ovarian cancer is the deadliest of gynecologic malignancies and often affects perimenopausal and postmenopausal women, with a 5-year survival rate of 38%. 2. Initial evaluation of a pelvic or ovarian mass involves assessing symptoms, examining family history, measuring CA125 levels, performing ultrasound, and calculating a risk of malignancy index score. Masses deemed high risk should be referred to a gynecologic oncologist. 3. Management of ovarian cancer by a gynecologic oncologist results in improved outcomes, including lower recurrence rates and improved survival, compared to management by other specialists.

1. Initial Evaluation and Referral
Guidelines for
Management of
Pelvic/Ovarian
Masses
SOGC/GOC/SCC GUIDELINE, 2009
Aboubakr Elnashar
ABOUBAKR ELNASHAR

2. INTRODUCTION
Ovarian cancer:
relatively uncommon
deadliest of all gynaecologic malignancies
Often affecting perimenopausal and postmenopausal
5 year survival rate: 38%
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3. Factors affecting survival rate:
1. Extent of residual disease after radical surgical
debulking: confirming the importance of
aggressive surgical tumour resection at the time
of initial diagnosis.
2. Intraperitoneal chemotherapy has shown
significant survival benefits over standard IV
chemotherapy
3. Initial surgery is performed by gynaecologic
oncologists: more likely to be appropriately staged
and optimally debulked than those managed initially
by general gynaecologists and general surgeons.
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4. OVARIAN MASS INITIAL ASSESSMENTS
I. Evaluation of symptoms and signs
suggestive of malignancy
 Ovarian cancer
Early: asymptomatic {anatomic location of the
ovaries deep in the pelvis}.
Late: {metastases}: persistent, mild, vague
abdominal symptoms
Ovarian mass:
1. Perimenopausal or postmenopausal: Ovarian
cancer should be considered
2. Reproductive age: Functional origin is the
majority: expectant management
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5. 1. History:
a. Present
 Nature, progression, and duration
 Signs and symptoms suggestive of malignancy:
persistent (present for <1 y and occurred > 12
d/month).
pelvic/abdominal pain
urinary urgency/frequency
increased abdominal size/bloating
difficulty in eating/feeling
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6. b. Family:
Neoplasia:
breast, ovarian, endometrial, colorectal, and
pancreatic
Endometriosis may be of value in differential
diagnosis.
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7. c. Past:
Pelvic mass:
Gynaecologic surgery
operative notes and pathology reports.
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8. 2. Examination
a. General
supraclavicular and inguinal nodal areas
auscultation of the chest
breast examination
b. Abdominal
ascites or abnormal masses.
c. Combined pelvic and rectal
Contour and consistency of the pelvic mass
Pelvic nodularities: suggestive of malignancy.
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9. II. Serum CA125 level measurement
Range of normal is different in each lab
Most reliable serum marker for epithelial ovarian
carcinoma {Raised in over 75% of cases}.
Cut-off of 30 u/ml: sensitivity of 81%
 specificity of 75%.
 Raised in:
1. Only50% of stage I cases.
2.Other malignancies
3. Benign conditions e.g. benign cysts and
endometriosis.
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10. III. Ultrasound examination
TVS/TAS
Sensitivity: 89% and specificity of 73%
TVS: provide more detail and offers greater sensitivity
thanTAS.
Larger cysts may also needTAS
Signs of an increased risk of malignancy.
Complex
Multilocular
Thick septations
Papillary excrescences
Solid components
Increased central vascularity
Ascites
Peritoneal nodularities ABOUBAKR ELNASHAR

11. IV. Risk of malignancy index(RMI)
Objective: assessment of the malignant potential
RMI = ultrasound score Xmenopausal score XCA
125U / mL
RMI II: recommended
Simple
More sensitive than the RMI I
Specificity: 90%
Positive predictive value: 80%.
Cut-off score: 200.
Abnormal: further radiographic evaluations (CT/MRI)
prior to subspecialty referral are unlikely to be
beneficial.
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12. ABOUBAKR ELNASHAR

13. ABOUBAKR ELNASHAR

14. ROLE OF THE GYNAECOLOGIC ONCOLOGIST
IN THE MANAGEMENT OF OVARIAN CANCER
For ovarian cancer, both centralized care and initial
surgery by a gynaecologic oncologist resulted in
improved outcomes.
Early Stage Disease
The management of patients with clinically confined
disease to the ovary centres on comprehensive
surgical staging to rule out occult metastatic disease.
Patients thought to have disease clinically confined to
the ovaries are upstaged approximately 30% of the
time when further comprehensive surgical staging is
performed.
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15. Surgical staging:
1. Bilateral salpingo-oophorectomy and hysterectomy in
postmenopausal women. A more limited surgery may
be acceptable in young women wishing fertility
preservation.
2. Infra-colic omentectomy
3. Peritoneal fluid sampling or pelvic washings
4. Biopsy of any suspicious peritoneal
nodules/adhesions or random peritoneal biopsies from
all intraabdominal serosal surfaces
5. Bilateral diaphragmatic scraping/biopsies
6. Retroperitoneal lymph node evaluations to include
both bilateral pelvic and para-aortic nodal areas
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16. The contributions of the gynaecologic oncologist
to the management of early ovarian cancer
1. Lower recurrence rates
2. Improved overall survival
Patients operated on by gynaecologic oncologists had
a 24% improvement in five-year overall survival when
compared with those patients operated on by
general surgeons and general gynaecologists
When patients with clinically apparent early ovarian
cancer are not staged, consideration is often given to
repeat surgery to assist with the decision regarding
needs for subsequent adjuvant treatment.
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17. The prospect of two surgeries increases the risk for
surgical morbidity and increases cost to the health care
system.
The relative risk of re-operation to be significantly
decreased when gynaecologic oncologists were
present at time of initial surgery.
Patients who are optimally staged according to strict
protocol and who are proven to truly have surgically
stage I disease have a low recurrence rate and high
overall survival even without adjuvant chemotherapy.
Patients who are sub-optimally staged are more likely
to require adjuvant chemotherapy.
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18. Advanced Disease
Inverse relationship between residual tumour volume
and survival in patients with ovarian cancer
An improved rate of optimal debulking and improved
overall survival when patients with ovarian cancer
whose initial surgery is performed by gynaecologic
oncologists.
Six- to nine-month median survival benefit in patients
managed initially by gynaecologic oncologists.
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19. Recommendations
1. Primary care physicians and gynaecologists should
always consider the possibility of an underlying ovarian
cancer in patients in any age group presenting with an
adnexal or ovarian mass. (II-2B)
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20. 2. Appropriate workup of a perimenopausal or post
menopausal woman presenting with an adnexal
mass should include evaluation of symptoms and
signs suggestive of malignancy, such as persistent
pelvic/ abdominal pain, urinary urgency/frequency,
increased abdominal size/bloating, and difficulty
eating.
In addition, CA125 measurement should be
considered. (II-2B).
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21. 3. Transvaginal or transabdominal ultrasound
examination is recommended as part of the initial
workup of a complex adnexal/ovarian mass. (II-2B)
4. Ultrasound reports should be standardized to
include size and unilateral/bilateral location of the
adnexal mass and its possible origin, thickness of
septations, presence of excrescences and internal
solid components, vascular flow distribution pattern,
and presence or absence of ascites.
This information is essential for calculating the risk of
malignancy index II score to identify pelvic mass with
high malignant potential. (IIIC)
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22. 5. Patients deemed to have a high risk of an underlying
malignancy should be reviewed in consultation with a
gynaecologic oncologist for assessment and optimal
surgical management. (II-2B)
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23. ABOUBAKR ELNASHAR