Ovarian Cancer Surgical Practice Guidelines

Scope and Format of Guidelines

The Society of Surgical Oncology surgical practice guidelines focus on the signs and symptoms of primary cancer, timely evaluation of the symptomatic patient, appropriate preoperative evaluation for extent of disease, and role of the surgeon in diagnosis and treatment. Separate sections on adjuvant therapy, follow-up programs, or management of recurrent cancer have been intentionally omitted. Where appropriate, perioperative adjuvant combined-modality therapy is discussed under surgical management. Each guideline is presented in minimal outline form as a delineation of therapeutic options.

Since the development of treatment protocols was not the specific aim of the Society, the extensive development cycle necessary to produce evidence-based practice guidelines did not apply. We used the broad clinical experience residing in the membership of the Society, under the direction of Alfred M. Cohen, md, Chief, Colorectal Service, Memorial Sloan-Kettering Cancer Center, to produce guidelines that were not likely to result in significant controversy.

Following each guideline is a brief narrative highlighting and expanding on selected sections of the guideline document, with a few relevant references. The current staging system for the site and approximate 5-year survival data are also included.

The Society does not suggest that these guidelines replace good medical judgment. That always comes first. We do believe that the family physician, as well as the health maintenance organization director, will appreciate the provision of these guidelines as a reference for better patient care.

Society of Surgical Oncology Practice Guidelines: Ovarian Cancer

Symptoms and Signs

Early-stage disease

• Symptoms:
1. Abdominal swelling (self-palpation of mass)
2. Abdominal pain
3. Urinary symptoms
4. Abnormal vaginal bleeding
5. Fatigue
• Signs:
1. Palpation of a mass on pelvic examination (Risk of malignancy increases if mass is solid, irregular, fixed, or bilateral.)
2. Identification of an ovarian mass on ultrasound, CT scan, or MRI (Risk of cancer increases with increasing size of mass, with a complex mass, and with increasing age of patient.)
3. Elevation of CA-125 above 35 units (CA-125 may be less than 35 units in up to 50% of stage I cancers.)

Advanced-stage disease

• Symptoms:
1. Abdominal swelling (secondary to masses or ascites)
2. Abdominal pain
3. Urinary symptoms
4. Gastrointestinal symptoms
5. Abnormal vaginal bleeding
6. Fatigue
7. Respiratory distress
• Signs:
1. Abdominal distension
2. Palpation of masses on pelvic or abdominal eamination
3. Ultrasound, CT scan, or MRI evidence of ascites and/or complex pelvic and/or abdominal masses
4. X-ray evidence of pleural effusion

Evaluation of the Symptomatic Patient

Early-stage disease

• Complete history and physical examination
• Serum CA-125 level
• Serum beta hCG, AFP, and LDH in women less than 30 years old
• Chest x-ray
• Pelvic ultrasound (Morphology index and color flow Doppler may be helpful but are of unproven benefit.)
• CT scan and MRI usually add little to the evaluation of early disease and should not be considered routine.
• Uterine curettage or biopsy if patient has abnormal vaginal bleeding
• In women over age 45, stool guaiac should be performed. Consider colon evaluation (barium enema and sigmoidoscopy or colonoscopy) if symptoms warrant. Consider upper gastrointestinal x-ray studies or endoscopy if symptoms warrant.
• Mammography screening as appropriate for age

Advanced-stage disease

• Complete history and physical examination
• Serum CA-125 level
• Serum beta hCG, AFP, and LDH in women less than 30 years old
• Chest x-ray
• CT scan (or MRI) of the abdomen and pelvis
• Uterine curettage or biopsy if patient has abnormal vaginal bleeding
• Stool guaiac for women over age 45. Consider colon evaluation (barium enema and sigmoidoscopy or colonoscopy) if symptoms warrant. Consider upper gastrointestinal x-rays or endoscopy if symptoms warrant.
• Mammography screening as appropriate for age

Appropriate timeliness of surgical referral

• Evaluation with due diligence for the above symptoms or signs