Jane Bridges David Oram
Ovarian cancer continues to frustrate. Clinicians are disadvantaged by the characteristics of unreliable, inconsistent symptomatology, which accounts for late presentation and poor associated survival figures. Even when the patient does present early, the preoperative diagnosis of ovarian cancer is frequently a difficult one to make. This is borne out by the fact that 50% of patients with this disease are initially referred to general physicians or general surgeons for investigation of symptomatology or ascites. The development by Jacobs et al (1990) of a scoring system, the risk of malignancy index (RMI), which incorporates the use of the serum CA125 level, pelvic ultrasound features and the menopausal status of the patient, has greatly eased this preoperative difficulty. The details of the calculation are shown in Figure 1 and the RMI has now been validated in clinical practice. Using this calculation to assess the nature of an abdominopelvic mass helps to confirm the diagnosis of malignancy with greater than 95% accuracy. This in turn allows for an appropriate referral to a cancer centre to be made, or at least prevents the initial surgery being inappropriately performed by an inexperienced surgeon. The importance of this has been demonstrated in data from the west of Scotland which confirm improved survival of patients with ovarian cancer if they are managed in a cancer centre using a multidisciplinary team approach. Furthermore, accurate preoperative diagnosis enables appropriate counselling to be given to the patient and her family. Appropriate investigation and management planning can be embarked upon in a proactive manner, and by no means the least important consideration is that the patient's initial surgery and exploration can be performed through the correct surgical incision.
Investigations should include an assessment of the patient herself, including her performance status and her nutritional status; if necessary, parenteral feeding through central lines can be instituted preoperatively. This should not, however, delay the initial surgery. A thorough haematological and biochemical assessment should be undertaken. A chest x-ray is required: if a pleural effusion is present, this should be aspirated and the fluid examined cytologically for malignant cells. Pelvic ultrasonography is usually performed as part of the initial assessment and is complemented by specialist imaging such as computed tomography (CT) and magnetic resonance imaging (MRI) in assessing the extent of the disease spread, including intra- and extraabdominal metastatic deposits (Figure 2). Preoperatively the patient requires a bowel preparatory agent, and in selected cases stoma counselling may be instituted.
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