A 58-year-old postmenopausal woman presents with abdominal distension and loss of appetite for 2 months; ascites with a large solid ovarian mass. How will you investigate, list the steps of staging laparotomy for early ovarian cancer, and define opportunistic salpingectomy
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Ovarian Cancer - Investigation, Staging Laparotomy & Opportunistic Salpingectomy
Clinical Context
This 58-year-old postmenopausal woman with a large solid ovarian mass, ascites, abdominal distension, and anorexia has a presentation that is highly suspicious for ovarian cancer (though Meigs' syndrome - benign ovarian fibroma with ascites and pleural effusion - is a rare differential). Ovarian cancer is the sixth most common malignancy in women; over two-thirds present with advanced disease, which accounts for the overall 5-year survival of under 50%.
Part 1: Investigation
Blood Tests (Tumour Markers)
These should be ordered as a panel and interpreted together:
| Marker | Relevance |
|---|---|
| CA-125 | Primary marker; elevated in 50% of stage I and >90% of advanced epithelial ovarian cancer. Normal cut-off: 35 U/mL. Non-specific - also raised in endometriosis, PID, liver disease, ascites |
| CA 19-9 | Useful supplementary marker |
| CEA | Rules out metastatic bowel primary |
| beta-hCG | Germ cell tumour (especially in younger women); also Gestational trophoblastic disease |
| LDH | Germ cell tumours (particularly dysgerminoma) |
| Alpha-fetoprotein (AFP) | Yolk sac/germ cell tumours |
| Inhibin A & B | Granulosa cell tumours |
LDH, AFP, inhibin, and beta-hCG are especially recommended in women under 40 years.
Risk of Malignancy Index (RMI)
Combines three parameters to stratify risk and guide referral:
RMI = U × M × CA-125
- U = Ultrasound score: 1 point each for multilocularity, solid components, evidence of metastases, ascites, bilateral lesions (score = 0 if no features, 1 if 1 feature, 3 if 2-5 features)
- M = Menopausal status: 1 = premenopausal; 3 = postmenopausal
- CA-125 = absolute value in U/mL
RMI >200 warrants referral to a gynaecological oncologist at a cancer centre.
Imaging
1. Ultrasound (first-line investigation)
- Transabdominal + transvaginal ultrasound (TVUS)
- Features suspicious for malignancy: wall irregularity, thick septations (>3 mm), papillary projections, solid components, size >9 cm, ascites, bilateral lesions
- IOTA (International Ovarian Tumour Analysis) simple rules: B features (benign) vs M features (malignant). If both or neither present, MRI is required.
- Colour Doppler: malignant tumours show neovascularity with thin-walled vessels (low-resistance flow)
2. CT Scan (chest/abdomen/pelvis) - staging
- Modality of choice for evaluating upper abdominal spread and resectability
- Identifies: omental cake, peritoneal/diaphragmatic implants, lymphadenopathy, pleural effusion, liver metastases
- Guides triage for primary surgery vs. neoadjuvant chemotherapy
3. MRI - used when ultrasound findings are indeterminate; superior soft tissue characterisation
4. FDG-PET/CT - used selectively for equivocal CT findings and recurrence detection
Additional Workup
- FBC, renal and liver function tests, coagulation - baseline for surgery
- Chest X-ray - pleural effusion (stage IV if present above diaphragm)
- Colonoscopy - to exclude synchronous colorectal primary
- Genetic counselling - for all patients (BRCA1/BRCA2 mutation incidence; guides adjuvant therapy decisions)
- Paracentesis/ascitic fluid cytology - if surgery is not feasible upfront; needed before neoadjuvant chemotherapy
Part 2: Steps of Staging Laparotomy for Early Ovarian Cancer
Early ovarian cancer (macroscopically confined to pelvis) is treated with a comprehensive staging laparotomy. The purpose is threefold:
- Make a histological diagnosis
- Completely assess the extent of disease
- Achieve cytoreduction
When epithelial ovarian cancer is found on frozen section and disease appears grossly limited to the pelvis, complete staging with nodal dissection upstages nearly one-third of patients - making meticulous staging essential.
Steps of Staging Laparotomy (in sequence):
1. Incision
- Midline (vertical) incision from pubis to above umbilicus - provides access to both the pelvis and upper abdomen
2. Peritoneal washings (first step on entering the abdomen)
- Collect cytological washings from four sites: diaphragm (right), right and left paracolic gutters, and pelvis
- Positive cytology = stage IC3
3. Systematic exploration of the entire peritoneal cavity
- Inspect all peritoneal surfaces: diaphragm, liver surface, bowel, mesentery, omentum, pelvic side walls, uterovesical pouch, Pouch of Douglas
4. Total Abdominal Hysterectomy and Bilateral Salpingo-oophorectomy (TAH + BSO)
- The primary en-bloc procedure
- Careful to keep capsule intact; surgical spill = stage IC1
5. Infracolic Omentectomy
- Removal of the greater omentum below the transverse colon
- Common site of occult metastases even when macroscopically normal
6. Retroperitoneal Lymph Node Sampling
- Pelvic lymph node dissection (external iliac, obturator, common iliac)
- Para-aortic lymph node sampling (up to the level of the renal vessels)
- Nodal metastases alone (without macroscopic peritoneal spread) = stage IIIA1
7. Peritoneal and Diaphragmatic Biopsies (systematic random biopsies)
- Biopsy of normal-appearing peritoneal surfaces even if grossly normal:
- Undersurface of the right hemidiaphragm
- Bladder reflection peritoneum
- Pouch of Douglas (cul-de-sac)
- Right and left paracolic recesses
- Both pelvic side walls
- Biopsy of any suspicious lesion, adhesion, or implant
8. Appendicectomy
- Mandatory for mucinous tumours (appendix is a common primary site for metastatic mucinous ovarian carcinoma)
- Routine appendicectomy may be considered if intraoperative suspicion arises
FIGO Staging (2014, Epithelial Ovarian Cancer)
| Stage | Description |
|---|---|
| I | Tumour confined to ovaries or fallopian tube(s) |
| IA | One ovary, capsule intact, no surface tumour, negative washings |
| IB | Both ovaries, capsules intact, negative washings |
| IC | One/both ovaries, with: IC1 (surgical spill), IC2 (capsule rupture/surface tumour), IC3 (malignant cells in ascites/washings) |
| II | Pelvic extension below pelvic brim |
| IIA | Extension to uterus/tubes/ovaries |
| IIB | Extension to other pelvic tissues |
| III | Peritoneal spread outside pelvis and/or retroperitoneal nodal metastases |
| IIIA1 | Positive retroperitoneal nodes only |
| IIIA2 | Microscopic extrapelvic peritoneal involvement ± nodes |
| IIIB | Macroscopic peritoneal metastases ≤2 cm |
| IIIC | Macroscopic peritoneal metastases >2 cm |
| IV | Distant metastases (pleural effusion with positive cytology, liver/spleen parenchymal mets, inguinal nodes) |
Part 3: Opportunistic Salpingectomy - Definition
Definition
Opportunistic salpingectomy is the removal of both fallopian tubes (bilateral salpingectomy) at the time of another pelvic surgery performed for an unrelated benign indication (such as hysterectomy, tubal ligation, or caesarean section) in women at average risk for ovarian cancer, with the intent of reducing the future risk of ovarian/tubal cancer while preserving ovarian function.
Rationale
The key biological basis is that high-grade serous ovarian carcinoma (HGSOC) - the most common and aggressive subtype - is now understood to frequently originate in the fimbriated end of the fallopian tube (specifically from serous tubal intraepithelial carcinoma, STIC lesions) rather than in the ovary itself. This was confirmed by the SEE-FIM (Sectioning and Extensively Examining the FIMbriated end) protocol, which revealed occult tubal precancers in women with BRCA mutations. Scandinavian population-based cohort studies have demonstrated a significant decrease in epithelial ovarian cancer following salpingectomy.
Key Points
- Recommended at the time of hysterectomy for benign disease as a routine
- Also feasible at tubal ligation (replacing tubal ligation with salpingectomy) or other pelvic surgery
- Differs from risk-reducing salpingo-oophorectomy (RRSO), which also removes the ovaries and is reserved for high-risk women (BRCA1/2 carriers)
- Ovaries are preserved - avoiding premature menopause and its cardiovascular/neurological risks
- In premenopausal women under 50, elective oophorectomy carries increased long-term cardiovascular and neurological morbidity, so ovarian conservation with salpingectomy is preferred
- For confirmed BRCA1/2 carriers: risk-reducing BSO reduces HGSOC lifetime risk to under 3%
- Opportunistic salpingectomy in average-risk women has been associated with decreased ovarian cancer rates in population-based cohort data
Key Sources
- Bailey and Love's Short Practice of Surgery, 28th Ed. - Ovarian cancer chapter (pp. 1613-1616)
- Schwartz's Principles of Surgery, 11th Ed. - Ovarian Cancer (pp. 1843-1845)
- Sabiston Textbook of Surgery - Elective BSO and Opportunistic Salpingectomy
- Berek & Novak's Gynecology - Prophylactic Salpingo-Oophorectomy section
- Grainger & Allison's Diagnostic Radiology - Detection, Diagnosis and Staging of Ovarian Cancer
- Current Surgical Therapy, 14th Ed. - Ovarian Cancer, Preoperative Workup
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