Ask The Expert - Answers

The Johns Hopkins Ovarian Cancer Center of Excellence acknowledges and thanks Aventis, Genzyme, GlaxoSmithKline, Oncotech, Ortho Biotech, and The Pam McDonald Fund for their support of this website through provision of unrestricted educational grants.

The Johns Hopkins Ovarian Cancer Center of Excellence

Below are answers to previously submitted questions in the Ask the Expert Forum. Please note that the information is not indended to be used as medical advice -- please consult your physician with any medical concerns.

Category: Ovarian Cancer Detection and Diagnosis

Q: How may CA125 levels reveal ovarian cancer recurrence?

A: Typical CA125 levels in women are less than 35U/ml. For ovarian cancer patients, we consider an adequate response to therapy as achieving a baseline CA125 level of 20U/ml or less. Once the CA125 levels have normalized in ovarian cancer patients, we cannot necessarily rely on standard laboratory values to determine what is “normal.” We interpret laboratory results from each patient on an individual basis, relying on the history of their specific disease and prior CA125 levels. For example, a patient whose CA125 value normally is at 8U/ml could be lulled into thinking she has plenty of leeway before her value reaches the standard limit of 35. If her CA125 level doubles to 16U/ml, we believe this may be evidence for a recurrence of cancer. At this point, radiologic exams would be warranted to try and locate the recurrence. Still, a combined PET/CT evaluation can detect cancer as small as 8 – 10 millimeters.

If no cancer can be located, CA125 levels and radiologic tests will be used monitor whether a recurrent cancer appears. Since there are many reasons other than cancer to explain why CA125 levels may slightly increase, beginning a chemotherapy regimen without radiologic evidence of disease would be a risky option. Another option is to perform a diagnostic surgery, using laparoscopy as a minimally invasive way to look inside the body cavity for recurrent cancer. It is controversial whether early detection of recurrent ovarian cancer has a significant impact on long-term survival. Our feeling is that, at least in theory, a proactive approach to early detection facilitates identifying recurrent disease while it is hopefully still small and more amenable to surgical intervention followed by chemotherapy.

Q: Is there a role for laparoscopy in the diagnosis of an ovarian mass?

A: The benefits of laparoscopy are:
--it is a minimally invasive approach with a shorter recovery time.

The risk of laparoscopy, if ovarian cancer is present, is:
--the ovarian cyst may rupture during removal. This can result in a higher stage of disease being assigned and the possible need for chemotherapy (whereas chemotherapy might have been avoided had the cyst not been ruptured during surgery).

If ovarian cancer is discovered at the time of laparoscopy:
--you should have a complete and informed discussion with your surgeon about the possible options in this situation. In general, most surgeons recommend proceeding directly to a complete ovarian cancer staging operation, with possible removal of the other ovary and the uterus. It is important to determine beforehand whether this procedure will be done at the same time as removal of the ovarian mass and whether it can be accomplished laparoscopically or via the standard open laparotomy approach. Most surgeons will recommend the laparotomy approach if ovarian cancer is discovered, as this is the community standard of care and presents the best opportunity for tumor debulking should there be any tumor spread outside of the ovary.

Q: I have symptoms common to ovarian cancer (ie. bloating, constipation), cysts on my ovaries and low CA125 -- is watchful waiting okay or are there other proactive steps I should take?

A: Unfortunately, the symptoms of early-stage ovarian cancer are very non-specific. This means that there are many non-ovarian cancer conditions that can produce similar symptoms and be confused with ovarian cancer. This is one of the main reasons why ovarian cancer is so difficult to detect at an early stage. The CA125 is not necessarily a reliable means of excluding the presence of an ovarian cancer. In fact, we know that of women with Stage I and II ovarian cancer, about 50% will have a normal CA125 level at the time of diagnosis. The decision to continue with close observation (serial pelvic sonograms) or proceed with surgical intervention (for diagnosis and treatment if necessary) should be primarily based on the appearance of the ovarian cysts over time and the associated symptoms. If the cysts are increasing in size or complexity (that is, there are ‘septations’ or solid areas) or symptoms are worsening, then surgery should be considered. If the cysts decrease in size or remain stable and symptoms resolve, then continued observation is usually the preferred management.

Q: Though I had my ovaries and uterus removed many years ago, my doctors now tell me I have a fluid-filled ovarian cyst, but they don't know if it's cancerous until it is removed and biopsied. How can ovarian cancer appear even if my ovaries were removed?

A: The most likely scenario is that you have what is called a ‘peritoneal inclusion cyst’, which form as a result of benign fluid becoming trapped beneath adhesions or scar tissue created from previous surgery. Often times, these can be observed over time, without surgery, as long as they remain stable and do not cause symptoms. Although less likely, it is also possible that a very small portion of one of the ovaries was inadvertently not removed at the time of hysterectomy; this is called ovarian remnant symdrome. In this case, it is possible that the ovarian remnant is forming cysts. Even more uncommon is a condition called primary peritoneal carcinoma. This disease looks and acts like ovarian cancer but in fact arises from the peritoneal cells lining the abdominal cavity (incidentally, these are the same cells from the surface of the ovary that give rise to most cases of ovarian cancer). Unfortunately, it is very difficult to tell the difference between these conditions based on imaging studies alone, and definitive diagnosis does usually require some type of surgery to find out what it is. The decision about conservative observation or surgical intervention should only be made after a thorough discussion with your treating clinician.