HOW TO TREAT 23 debulking, curative treatment can be difficult to achieve as epithelial carcinomas are often diagnosed in the advanced stage.
ausdoc. com. au 12 DECEMBER 2025
HOW TO TREAT 23 debulking, curative treatment can be difficult to achieve as epithelial carcinomas are often diagnosed in the advanced stage.
THE FUTURE
IMPROVEMENT in imaging quality will likely improve preoperative risk profiling of adnexal masses. The development of ultrasound will continue and is likely to lead to higher-quality imaging with dedicated gynaecological clinicians’ interpretation, thus providing far more refined opinions regarding the malignant potential of the adnexa.
It is unlikely further development of CA125 will provide any greater clarity— even within newly developed algorithms. This is because, as previously described, CA125 levels will not always reflect the presence or absence of ovarian malignancy. New tumour markers may be developed in the future, which may provide greater confidence and clarity.
Note that there is currently no screening test available for ovarian cancer, and the largest trial to date has shown that CA125 and ultrasound imaging cannot be used as an effective screening program. 27 Despite the best efforts of researchers, an effective screening paradigm for ovarian cancer remains elusive.
CASE STUDIES
Case study one
MICHELLE, aged 74, presents with abdominal bloating, upper abdominal discomfort and post-prandial fullness. She undergoes a CT abdomen and pelvis that shows complex-appearing solid and cystic masses in the pelvis. Ascites and omental caking are also noted on the CT.
These findings likely represent a disseminated peritoneal malignancy, with an advanced ovarian epithelial malignancy most likely. Michelle will not need any further pelvic imaging as it will not change her management because she has confirmed metastatic disease. She requires a CT chest for completion staging, epithelial tumour markers and referral to a tertiary gynaecology oncology unit. In
Figure 7. Ultrasound of an ovary showing papillary projections.
this unit, Michelle will likely undergo percutaneous biopsy of the omentum with an interventional radiology team to confirm her diagnosis.
Case study two
Ruby, a nulliparous 23-year-old, presents with abdominal bloating,
Table 5. Tumour markers Tumour marker group
Germ cell
Epithelial
Stromal
What markers are included
Alpha-fetoprotein, lactate dehydrogenase, human chorionic gonadotropin
Cancer antigen 125( CA125), carcinoembryonic antigen( CEA), cancer antigen 19.9( CA19.9) with or without human epididymis protein 4( HE4)
Inhibin
Table 6. Summary of appropriate investigations by age if suspicious adnexal mass identified
Age group Tumour markers Imaging
Adolescents |
Germ cell CA125( CEA and CA19.9 can be considered if a gastrointestinal malignancy is suspected) |
Pelvic ultrasound is sufficient MRI or CT may be needed but recommended only after specialist / multidisciplinary team review |
|
|
Age 20-40
Over 40
|
Germ cell Epithelial with or without HE4 Consider inhibin in solid masses
Epithelial Consider inhibin in solid masses
|
Pelvic ultrasound MRI may aid in assessing non-ovarian complex growth CT may be needed if RMI is significantly elevated, IOTA M-rules present or significantly elevated tumour markers
Pelvic ultrasound CT chest, abdomen and pelvis if complex mass or RMI greater than 200 or IOTA M-rules present
|
Figure 8. Coronal CT scan showing a large complex( heterogeneous) pelvic mass extending into the upper abdomen. |