Ovarian cancer, which begins in the female's reproductive organ, is notorious for being a "silent killer." It is often discovered late, when the cancer has reached an advanced state and treatment options are limited.
"When ovarian cancer develops, the cancer has a lot of room to grow within the pelvis. The patient does not feel anything, so the tumor can reach a very large size," says Pei Hui, PhD, MD, director of Gynecological Pathology at Yale Medicine. "It's hard to diagnose early ovarian cancer, which is often undetectable clinically."
How is ovarian cancer diagnosed?
There are typically no symptoms of early-stage ovarian cancer (when it is small and confined to the ovary), and effective screening tests are not available for the general population. However, a doctor can physically examine the abdomen for the presence of an ovarian mass and then will usually order imaging tests – such as ultrasound, magnetic resonance imaging (MRI) and computerized tomography (CT) scans – to look for an ovarian tumor. Ultrasound is the most common, Dr. Hui says.
Patients with late-stage ovarian cancer (Stage III or IV) will eventually have symptoms including bloating or swelling in the abdomen, abdominal pain, weight loss and changes in bowel movements. Unfortunately, most ovarian cancer patients seek an initial doctor visit at a late stage.
Most ovarian tumors are benign. However, if ovarian cancer is suspected, based on results of the physical exam and imaging studies, a woman will undergo a blood test to determine the serum level of CA-125, a protein that may be produced by ovarian cancer cells. If levels of CA-125 are elevated, it may be further evidence of ovarian cancer. At this point, a woman may be referred to a gynecologic oncologist for a more focused cancer evaluation.
How does a biopsy work?
If test results indicate potential cancer, the next step is a tissue diagnosis. “It’s the only way to determine with certainty that the ovarian mass is cancer,” Dr. Hui says.
Generally, cancer is diagnosed after an ovarian mass has been examined by a surgical pathologist, a specialist who has medical expertise in diagnosing disease by evaluating tissue samples under the microscope. Ovarian tumors are not diagnosed through small biopsy. That procedure could spread cancer cells within the abdomen, Dr. Hui says. Instead the patient schedules a surgery and a gynecological oncologist removes the ovarian mass in its entirety. At Yale Medicine, diagnostic consultations take place at Smilow Cancer Hospital. “There is a real-time engagement between the pathologist and surgeon, while the patient is on the operating table under general anesthesia,” he notes.
Based on what is seen under the microscope, the surgical pathologist determines whether the tumor is malignant (cancerous) or benign (noncancerous) – usually within 15 minutes of receiving the ovarian specimen. The results are immediately relayed to the surgeon. If the diagnosis is benign, the surgery is over and the patient goes home. If the diagnosis is cancer, the patient will undergo a more thorough surgery designed for ovarian cancer.
"Ultimately, pathologists are the ones who make the determination," Dr. Hui says. "The diagnosis can save the patient time and dollars because a patient will not have to wait weeks to know how the sample turned out, and if it is found to be cancer, they won’t have to come back again for another surgery."
How is ovarian cancer treatment determined?
During surgery, the rest of the gynecologic organs (uterus, cervix, the other ovary and fallopian tubes) will be removed and inspected, as well as the pelvic/abdominal lymph nodes and the omentum (a large intra-abdominal organ),” Dr. Hui says, adding: “Other abdominal organs are inspected by the surgeon for the presence of a metastatic tumor.”
New pathology slides are generated, and the pathologist determines the extent of the cancer spread; based on this, a final ovarian cancer stage will be determined.
Stage I - the cancer is confined to one or both ovaries.
Stage II - the cancer has spread to other parts of the pelvis.
Stage III - the cancer has spread to the abdomen.
Stage IV - the cancer has involved organs outside the abdomen.
What makes Yale Medicine’s approach to diagnosing ovarian cancer unique?
The Gynecologic Oncology Program at Yale Medicine brings together a team of experienced clinicians whose focus is to care for women with gynecologic cancers. This team includes three subspecialized gynecologic pathologists.
“Subspecialization effectively enhances the patient care in the diagnosis and treatment of ovarian cancer,” Dr. Hui says. “Teamed up with gyneco-oncologists and armed with advanced diagnostic tools including precision molecular markers, our gynecologic pathologists not only provide the most accurate diagnosis but also provide the ultimate cancer staging for the prognosis and continued care of patients with ovarian cancer.”