1) Managing an unsuspected ovarian cancer found during surgery requires adequate pre-operative preparation, including a thorough history, exam, imaging and bloodwork to evaluate the risk of malignancy. 2) If an adnexal mass is discovered unexpectedly during surgery, an intra-operative consult with a gynecologic oncologist is recommended to determine if adequate surgery can be performed or if a biopsy and referral is more appropriate. 3) For post-menopausal women with incidental adnexal masses found on imaging, unilocular cysts under 10cm have a very low risk of cancer but should be monitored with serial ultrasounds; complex masses require further evaluation.

1. Managing the Unsuspected
Ovarian Cancer
James Bentley
Professor Department of Obstetrics and
Gynecology
Dalhousie University

2. Disclosure of Potential for
Conflict of Interest
Facilitator’s Name: Dr James Bentley
Grants/research support: Merck, GSK, Guided Therapeutics, Amgen
Speaker’s bureau/honoraria: Merck, GSK
Consulting fees: GSK, Merck

3. Unexpected Intraoperative finding
• 60 year old woman
• Operated on for adnexal mass
• Found to have an unsuspected obvious
malignancy
• How to avoid this?
• How to manage?

4. Unanticipated Ovarian Cancer
• Pelvic mass with inadequate pre-op preparation
• “incidentaloma”
• At the time of other abdominal surgery
• Pregnancy
• Avoiding harm to patient
– Inappropriate surgery
– Inadequate surgery
– Not appropriately referred

5. Inadequate pre-op preparation
• Need to consider what is the diagnosis?
• Hx
– Pain
– Bleeding
– GI symptoms
– ? Pregnancy
– Family history
• Breast / ovarian cancer (BRCA 1,2)
• Colorectal cancer (HNPCC)
• Exam
• Appropriate bloodwork
• Appropriate imaging
• CONSENT

6. Pelvic mass < 40 yrs old
• Clinical assessment: history and examination
• Imaging
– Ultrasound
– CT/ MRI
• Markers
– βHCG
– α Feto protein
– LDH
– CA 125

7. Pelvic mass > 40 years
• Clinical assessment: history and examination
• Imaging
– Ultrasound
– CT (MRI)
• Markers
• CA 125
• CEA
• CA 19-9

8. Importance of history
• Goff et al. JAMA June 2004
– Case-control study, 128 cases 1709 controls
– 94% symptoms, 67% recurring
• Bloating
• Increased abdominal size
• Fatigue
• Urinary tract symptoms
• Pelvic or abdominal pain
– Shorter duration of symptoms than IBS
– More severe
– Greater number of symptoms

9. Risk of Malignancy Index
• Risk of malignancy index is an useful tool for
appropriate patient referral
• Current workup includes clinical exam, ultrasound,
and CA-125 levels
• RMI incorporates information about menopausal
status, US characteristics, and CA-125 to predict risk
of malignancy with greater sensitivity and specificity
than any one factor alone

10. RMI Definition
• RMI = M x CA-125 x US score
– M is menopausal status
– RMI 1: M=1 if premenopausal, M=3 if post-
menopausal
– RMI 2: M=1 if premenopausal, M=4 if post-
menopausal
– CA-125 is entered directly into equation for both
RMI 1 and RMI 2
– Normal CA-125 <35 U/ml
– Cut off for benign vs. malignant is 200

11. RMI Definition
• RMI = M x CA-125 x US score
– US score is based on
• multilocularity
• presence of solid areas
• ascites
• bilaterality
• metastases
– RMI 1: score is 0 if no feature, 1 if 1 feature, 3 if > 2 features
– RMI 2: score is 1 if < 1 if one feature, 4 if > 2 features
Clarke and Bentley JOGC 2007

12. • 60 y/o female with left
adnexal mass
• Complex cystic and solid
mass on US
• RMI = 18
• Mucinous cystadenoma

13. • 25 y/o female
• US demonstrated large 12 x 8 cm irregular mass with cystic and
solid components; ascites
• RMI = 289
• Stage I serous carcinoma of low malignant potential

14. Consent process
• When operating for an adnexal mass need to
consent appropriately
• Pre-menopausal
– Define what reproductive wishes are
– Prepared to get histology and re-operate
• Post-menopausal
– Consent to include full staging with hysterectomy

16. “The incidentiloma”
• Increased imaging with CT or US for other
problems
• Palpable mass, probably more significant but..
– Syndrome of palpable post menopausal ovary
probably not valid.

17. Simple cysts
• Premenopausal
– < 6 cm normal finding: does not warrant
reimaging
– >6 cm need reimaging to document resolution
• If persist may need surgery to lessen risk of torsion
• Postmenopausal

18. Premenopausal incidental masses
• MRI with contrast useful for lesions on US
suggestive of:
– Endometrioma, dermoid, hydrosalpinx, inclusion
cyst, fibroid
– When US is indeterminate and MRI is used
sensitivity and specificity for OV Ca are 81% and
98% respectively

19. Postmenopausal incidental masses
• University of Kentucky
– 7705 asymptomatic women TV ultrasound
– 256 (3.3%) unilocular cysts; 90% < 5 cm
• 49% resolved spontaneously after 60 days
• 51% persisted, 45 removed, NO CANCERS
– 250 (3.2%) complex cystic masses
• 55% resolved over 60 days
• 115 (45%) persisted, 114 removed 7 ovarian cancers, 1
peritoneal cancer.
– Unilocular cyst < 5 cm risk of malignancy close to
ZERO
Bailey Gynonc 1998

20. Postmenopausal incidental masses
• University of Kentucky:
– 15,106 women over 50 years of age TV US, annual
screening
– If abnormality detected screen repeated in 4-6
weeks, with doppler and CA125
– 2763 (18%) had unilocular masses < 10 cm
• 69 % resolved
• 16.5% developed a septum
• 5.8% developed a solid area
• 220 (6.8%) persisted
Modesitt O and G 2003

21. Postmenopausal incidental masses
– 10 patients with previous unilocular mass
developed Ov Ca, but they also developed a
septum or solid nodule
– Risk of malignancy in a unilocular lesion < 10 cm is
0.1%
Modesitt O and G 2003

22. Postmenopausal incidental masses
• Ovarian cysts continue to be formed after the
menopause
– Incidence 3%-18%
– 50-70% will resolve spontaneously
– May be followed by serial US and CA125
– If it is not unilocular need further evaluation

23. Lee SI et al JACR 2007
Lee SI et al JACR 2007

24. Lee SI et al JACR 2007

25. Lee SI et al JACR 2007

26. Geide et al:
1. Patients with advanced disease operated on by gynecologic
oncologists are more likely to receive optimal cytoreductive
surgery.
2. Patients with advanced disease operated on by gynecologic
oncologists have an improved median and overall 5-year
survival.
3. Patients with advanced disease operated on by general
gynecologists can have survival equal to patients operated on
by gynecologic oncologists if rates of cytoreduction are equal.
4. Patients with early stage disease are more likely to have
comprehensive staging when operated on by gynecologic
oncologists, allowing for better selection of patients requiring
adjuvant chemotherapy.
 We conclude that patients with both advanced and early stage
ovarian epithelial cancer should be operated on by specialists
trained in Gynecological Oncology (level A and level B
recommendations based on good level II-2 evidence)Geide CK, Keiser K, Dodge J and Rosen B Gynecol Oncol 99,2 2005

27. Unexpected Intraoperative finding
• If unanticipated and unable to manage
adequately
• Intra-operative consult
• Gyn Onc
• Experienced colleague
• Frozen section
• Get a biopsy and close
• Omentum
• Ovary
• At time of other surgery
• Appendicectomy
• Colorectal Cancer
• Consider mets to ovary

28. When do you Operate?- is there a role for initial
chemotherapy, with interval debulking?
• Patient with Ascites, pleural fluid, small ovaries, Poor
functional state
– Cytology +/- Histology
– Rule out Breast/ Bowel
– Elevated CA125/ low CEA
• 3-4 cycles of chemotherapy with response
• Interval debulk surgery and 3 further cycles of
chemotherapy
• OV 13 RCT, suggests that the approach is equivalent with
less morbidity, if maximal effort made.
Vergote et al. NEJM 2010, sep 2;363(10) 943-53

29. Adnexal mass at C-Section
• Commonest ovarian
malignancy is
dysgerminoma
• Salpingoophrectomy
and staging is
appropriate, be
prepared to re-operate

30. Conclusions
• Always anticipate that cancer is a possibility
• Plan ahead!
• Use RMI and appropriate imaging
• If unable to adequately debulk
– Biopsy and refer