Attention should be paid to the presence of a history of chronic inflammatory process of the uterine appendages, for which treatment was unsuccessful, multiple uterine nodular fibroids, menstrual dysfunction, infertility, and the presence of cancer in close relatives.
Palpation and percussion of the abdomen and chest allow detecting the presence of free fluid in the abdominal and pleural cavities. With a significant increase in the abdomen, difficulties may arise in the differential diagnosis of a malignant ovarian tumor with ascites and giant ovarian cystoma. With ovarian cancer with ascites, dullness is determined percussively in the flat areas of the abdomen, and tympanitis in the upper sections; with a giant cyst, the inverse ratio.
Two-handed rectovaginal examination
Two-handed rectovaginal examination should be performed with a cleaned intestine and an empty bladder. In the initial stages of the disease in the pelvis, it is possible to identify single or bilateral, dense, tuberous tumors, the body of the uterus. In a common process, the uterine body is not determined separately, and together with tumor-modified ovaries, it represents a single conglomerate. In the presence of dissemination along the pelvic peritoneum, rectovaginal examination reveals finely tuberous formations in the douglas space.
Cytological research method
The cytological research method is used for morphological confirmation of the diagnosis, monitoring the effectiveness of the treatment (mainly chemotherapy), the duration of clinical remission in patients after successful primary treatment and active preclinical diagnosis of the disease. The study material may include effusions from the abdominal and pleural cavities, swabs or effusions from the Douglas space (with puncture of the posterior vaginal fornix), punctate from various suspicious or obviously tumor-like lymph nodes, and aspirate from the uterine cavity. According to indications, an aspiration biopsy and separate diagnostic curettage of the uterus are performed.
Ultrasound tomography with a transvaginal and transabdominal transducer with dopplerometry allows a detailed examination of the pelvic organs and has no contraindications. Sonography is used to clarify the extent of the process (detecting metastases in the liver , retroperitoneal lymph nodes, etc.), as well as for the differential diagnosis of uterine and ovarian tumors, the inflammatory process in the uterus, to identify solid and cystic structures in ovarian tumors.
Overview of the abdominal cavity
A survey picture of the abdominal cavity can be informative in the presence of a tumor that gives a contrast image: calcifications with a long-existing uterine fibroid, dermoid cysts that contain teeth, small bones and other inclusions.
X-ray and chest x-ray
With fluoroscopy and chest x-ray, the presence of free fluid in the pleural cavities (even in small quantities) and lung metastases are determined, which helps to clarify the extent of the process.
X-ray or endoscopic examination of the stomach and colon
X-ray or endoscopic examination of the stomach and colon (fibrogastroscopy, colonoscopy) can exclude the metastatic nature of the ovarian tumor and clarify the relationship of the intestine with the tumor (the presence of tumor invasion into the intestine).
Excretory urography makes it possible to judge the state of the urinary system.
For the purpose of in-depth diagnosis (according to indications), X-ray computed tomography can be performed if the echography does not give a clear idea of the degree of spread of the tumor process.
Magnetic resonance imaging
Magnetic resonance imaging is a more advanced method of radiation diagnostics to assess the degree of spread of the malignant tumor process. Unlike computed tomography, imaging is possible in various projections, which is important for detecting tumor growth in neighboring organs – in the rectum, bladder. Another advantage of this method compared to computed tomography is a lower radiation exposure.
According to indications, cystoscopy and sigmoidoscopy can be performed to clarify the extent of the spread of the tumor process.
Laparoscopy (diagnostic, treatment and diagnostic, control) is one of the leading methods for the diagnosis of ovarian tumors. It allows you to conduct an initial diagnosis of some tumors of the ovaries and uterus; differential diagnosis of pathological processes in the fallopian tubes, ovaries, uterus and adjacent organs; specifying diagnostics, which makes it possible to more clearly determine the location, size, anatomical shape of the tumor and, when taking a biopsy from the tumor and various parts of the peritoneum, its histological structure and degree of distribution (metastatic lesion of the peritoneum). With benign tumors, laparoscopic access provides the ability to perform any amount of surgical intervention. In addition, laparoscopy is performed as a control for the completeness of clinical remission after chemotherapy.
Diagnostic laparotomy should be resorted to only after exhausting the possibilities of all other examination methods.
Currently, of great importance in the diagnosis of ovarian malignant tumors is the determination of tumor markers specific for these tumors, which include: • oncofetal and oncoplacental antigens (CEA – cancer embryonic antigen, AFP – a-fetoprotein, CG – chorionic gonadotropin); • tumor-associated antigens (CA 125; CA 19.9; CA 72-4); • enzymes (PSAF – placental alkaline phosphatase, NSE – neuron-specific enolase, which is a marker of tumors of the APUD system); • hormones (calcitonin, estradiol, prolactin, TSH – thyroid-stimulating hormone); • products of oncogenes (BRCA 1, 2, p53); in carriers of BRCA genes, by the age of 60 years, the incidence of ovarian cancer reaches 70%; many authors propose to use this fact as a genetic screening; p53 gene is a tumor suppressor; its mutation leads to uncontrolled growth of the neoplasm; • acute phase proteins (ferritin, C-reactive protein, PEA); • biologically active peptides (prostaglandins, glycosamine glycans, MCSF – macrophage colony stimulating factor). The antigen CA 125 is the most well-studied and currently widely used in epithelial tumors. There is a correlation between the level of concentration of this antigen in the blood and the nature of the process in the ovary. CA 125 is found in 78-100% of patients with ovarian cancer, especially with serous tumors. Its level exceeding the norm (35 mU / ml) is observed only in 1% of women without tumor pathology and in 6% of patients with benign tumors. With ovarian cancer, an increase in the concentration of CA 125 is observed in 82% and with epithelial tumors of non-gynecological localization – in 23%. However, for mass screening (in order to identify ovarian tumors) this marker should not be used, as it can be “positive” in normal pregnancy, endometriosis, acute pancreatitis, and liver cirrhosis. In addition, its level may vary depending on the phase of the menstrual cycle. The sensitivity of this diagnostic method is 73% (at stage 1 – 50%, at III-IV – 96%), specificity – 94%. Using this test system, you can fairly objectively monitor the effectiveness of the treatment. To do this, assess the concentration level of CA 125 after each or after 2 courses of treatment. If during the observation the level of the marker is steadily decreasing, then this indicates the effectiveness of the treatment. In the absence of changes or an increase in CA 125, the regimen of drug therapy should be changed. Determination of the concentration of CA 25 in serum during dynamic observation of the patient after treatment is possible provided that the concentration of CA 125 was determined before treatment and its level was increased. An increase in CA 25 concentration is sometimes observed before the clinical signs of relapse appear. Macrophage colony-stimulating factor (M-CSF), determined in 70% of patients with ovarian cancer, may be an addition to CA 125. The discovery of tumor-associated antigens and monoclonal antibodies made it possible to use them in the diagnosis and treatment of cancer. So, in case of serous ovarian cancer, the use of labeled radiopharmaceuticals IMACIS 1 and IMACIS 2 (labeled 131 monoclonal antibodies to CA 25) confirmed a rather high informativeness of the method. The drug was fixed both in the primary tumor and in its metastases, giving an accurate picture of the spread of the process. An identical picture was obtained with relapses of the disease. The sensitivity of the immunolocation method for the pelvis was 87% and for the entire abdominal cavity – 100%, specificity – 50 and 55%, accuracy – 88 and 72%, respectively. Attempts are now being made to use this method for the treatment of tumors. In order to choose the right tactics for treating patients with ovarian cancer, it is necessary to determine the degree of spread of the tumor process. Staging is carried out on the basis of clinical examination data after confirming the diagnosis morphologically. Note. Metastases in the liver capsule are classified as TK / stage III, metastases in the liver parenchyma are classified as Ml / stage IV. Positive cytological findings in pleural fluid – as M1 / stage IV.