Epithelial ovarian cancer: Clinical manifestations,

diagnostic evaluation, staging, and histopathology

Authors
Lee-may Chen, MD
Jonathan S Berek, MD Section Editor
Barbara Goff, MD Deputy Editor
Sandy J Falk, MD

Last literature review version 17.1: January 2009 | This topic last updated: November 24,
2008 (More)

INTRODUCTION Ovarian cancer is the second most common gynecologic malignancy:

approximately 21,650 women in the United States are diagnosed with ovarian cancer annually,
and an estimated 15,520 women die of their disease [1] . It is the fifth most common cause of
cancer death in women in the United States, and the most common cause of death among
women with gynecologic malignancies.

The majority (90 percent) of primary ovarian tumors derive from epithelial cells, the remainder
arise from other cell types (germ cell tumors, sex cord-stromal tumors, and mixed cell tumors).
The ovary can also be involved by metastatic disease, especially from breast cancer or
Krukenberg tumors (mucin producing neoplastic signet-ring cells involving the ovarian stroma)
from the gastrointestinal (GI) tract.

The clinical manifestations, diagnostic evaluation, and histopathology of epithelial ovarian cancer
(EOC) will be reviewed here. Risk factors, screening, and treatment of EOC and issues related to
nonepithelial primary ovarian tumors (eg, sex-cord stromal and germ cell tumors) are discussed
separately. (See "Screening for ovarian cancer" and see "Epithelial ovarian cancer: Pathogenesis;
epidemiology; and risk factors", and see "Epithelial ovarian cancer: Initial surgical management"
and see other individual topic reviews).

CLINICAL MANIFESTATIONS Most women with EOCs are diagnosed between the ages of 40 and
65. Nonepithelial histologies (germ cell tumors, sex cord-stromal tumors, and mixed cell tumors)
are more common in girls and younger women. (See "Overview of ovarian germ cell tumors" and
see "Sex cord-stromal tumors of the ovary").

Symptoms of early stage disease are often vague and ill-defined, and may not be severe or
specific enough to prompt a woman to seek medical attention (show table 1). However, in
women who present with recent onset of abdominal or pelvic symptoms (ie, bloating, increased
abdominal size, urinary urgency or frequency, difficulty eating or feeling full, and abdominal or
pelvic pain), ovarian cancer should be considered in differential diagnosis. In particular, ovarian
cancer should be suspected when these symptoms coexist with other symptoms, occur almost
daily, and are more severe than expected. Acute symptoms due to ovarian rupture or torsion are
unusual. (See "Early detection of ovarian cancer: role of symptom recognition").

The majority of cases of EOC are advanced at the time of diagnosis. Advanced disease is
typically associated with abdominal distention, nausea, anorexia, or early satiety due to the
presence of ascites and omental or bowel metastases; dyspnea is occasionally present due to a
pleural effusion [2] .

Although uncommon, reported paraneoplastic phenomena include humoral hypercalcemia of

malignancy (with clear cell EOCs), subacute cerebellar degeneration, and the sign of Leser-Trelat,
characterized by the sudden appearance of multiple seborrheic keratoses. Trousseau's syndrome
(migratory thrombophlebitis) may also occur. (See "Hypercalcemia of malignancy" and see
"Paraneoplastic syndromes affecting brain and cranial nerves" and see "Cutaneous
manifestations of internal malignancy" and see "Hypercoagulable disorders associated with
malignancy").

PHYSICAL EXAMINATION Palpation of an adnexal mass during a pelvic examination is the usual
reason for initiating a diagnostic evaluation for ovarian cancer. However, a number of other
disorders are associated with adnexal pathology (show table 2).

The presence of a solid, irregular, fixed pelvic mass on pelvic examination is highly suggestive of
an ovarian malignancy. On the other hand, endometriomas and tuboovarian abscesses are
benign lesions that may be fixed and irregular, while leiomyomas are common solid benign
masses that may be located in the adnexa. The diagnosis of malignancy is almost certain if a
fixed, irregular pelvic mass is associated with an upper abdominal mass or ascites. The presence
of ascites and findings suspicious for peritoneal carcinomatosis suggests a primary peritoneal
tumor, even in the absence of a pelvic mass. (See "Primary peritoneal carcinoma" below).

Rectovaginal exam and fecal occult blood testing are performed to exclude a rectal mass or
bleeding. Ovaries are easier to palpate on the rectovaginal exam, as they can sit posterior to the
uterus. A breast examination is performed to detect breast masses.

Although routine pelvic examination may identify an ovarian carcinoma before abdominal
dissemination, early stage tumors are rarely found on examination because of the deep anatomic
location of the ovary. Even when an adnexal mass is detected, physical findings are often not
specific for cancer. In premenopausal women, only 5 to 18 percent of such adnexal masses will
prove to be malignant; in contrast, the incidence of malignancy is much higher (30 to 60 percent)
in postmenopausal women. The higher predictive value of physical examination for
discrimination of malignant from benign disease in postmenopausal as compared to
premenopausal women with an adnexal mass (68 versus 36 percent) is due to the higher
prevalence of cancer and lower prevalence of disorders that mimic malignancy in the older
population [3,4] .

INITIAL DIAGNOSTIC EVALUATION

Ultrasound Ultrasound examination is the most useful noninvasive diagnostic test in women
with an adnexal mass. The presence of sonographic features suggestive of malignancy helps in
predicting the likelihood that a pelvic mass is malignant, but is not infallible, even when
combined with other modalities, such as demographic information and biochemical data [5-8] .
Therefore, surgery for definitive histologic diagnosis is usually required.

Sonographic criteria suggestive of ovarian malignancy are listed in the table (show table 3) [9] .
The ability of ultrasound to predict ovarian malignancy reflects, in part, the variation in
prevalence of malignancy in the population studied (eg, proportion of premenopausal and
postmenopausal women). Combining morphological assessment with Doppler evaluation
improves the diagnostic performance of ultrasound examination [10] . (See "Sonographic
differentiation of benign versus malignant adnexal masses").

It is reasonable to pursue a period of observation of ovarian cysts that are not suspicious for
malignancy on ultrasound examination, since some of these will regress. Clinically suspicious or
indeterminate cysts require surgical evaluation. Criteria for prompt surgical intervention versus
expectant management are discussed separately. (See "Overview of the evaluation and
management of adnexal masses" and see "Differential diagnosis of the adnexal mass").

Differential diagnosis When ultrasound examination suggests the presence of ovarian cancer,
malignancies which need to be considered include: Primary epithelial ovarian carcinoma Primary
nonepithelial ovarian carcinoma. Common clinical characteristics of ovarian germ cell tumors
include: they occur in young women and girls, may be benign or malignant, often produce tumor

markers (show table 4), usually present with abdominal pain associated with an adnexal mass,
and, if malignant, are at an early stage of disease. Most ovarian sex cord stromal tumors produce
steroid hormones; therefore, this diagnosis should be suspected in patients who present with
signs of estrogen excess (precocious puberty in a child, abnormal uterine bleeding, endometrial
hyperplasia/carcinoma in an adult), or androgen excess (virilization), especially if an adnexal
mass is present. (See "Sex cord-stromal tumors of the ovary" and see "Overview of ovarian germ
cell tumors"). Metastases to the ovary: metastatic disease accounts for 6 to 9 percent of ovarian
malignancies and is often the first clinical manifestation of a primary GI malignancy [11] . Fifty to
90 percent of metastases to the ovary originate in the GI tract (Krukenberg tumor) or breast and
approximately 4 percent of women with intestinal cancers develop ovarian metastases. The
uterus is also a common primary site for ovarian metastases. Other malignancies, such as acute
leukemia and lymphoma, rarely involve the ovary. Tumors metastatic to the ovary are more likely
to be solid and without ascites than primary ovarian tumors, which tend to have a cystic
component and ascites [12] . CA 125 may be elevated [13] . Fallopian tube cancer may be
mistakenly attributed to the ovary. (See "Fallopian tube cancer").

Nonmalignant conditions should also be considered. Peritoneal tuberculosis can mimic advanced
stage ovarian cancer [14] .

PREOPERATIVE EVALUATION

Laboratory evaluation

CA 125 tumor marker The preoperative evaluation of a woman with suspected ovarian cancer
includes measurement of the serum glycoprotein CA 125 concentration. The serum CA 125
(normal <35 U/mL) is elevated (>65 U/mL) in 80 percent of women with EOC. Such a finding in a
postmenopausal woman with a pelvic or abdominal mass should prompt consultation with a
gynecologic oncologist [15] .

The reported sensitivity of CA 125 for stage I disease is lower (50 percent) than for stage II (90
percent) or higher disease [16] , and also varies according to histology. The prevalence of an
elevated serum CA 125 is highest in women with serous histology (the most common type of
EOC, see "Histopathology" below) and lowest in those with mucinous tumors, many of which are
associated with normal levels of CA 125.

Moreover, CA 125 is not specific for EOC. It is also increased in patients with other malignancies,
including endometrial cancer and certain pancreatic cancers; in a variety of benign conditions,
such as endometriosis, uterine leiomyoma, and pelvic inflammatory disease; and in
approximately 1 percent of healthy women (show table 5)(show figure 2) [17] . Serum values

fluctuate during the menstrual cycle, but are rarely greater than 100 to 200 U/mL in patients with
benign conditions. (See "Screening for ovarian cancer", section on CA 125 tumor marker).

CA 125 is not a useful diagnostic test in premenopausal women, especially when detected at low
positive levels, since malignancy is rare relative to benign conditions in this age group. In
mathematical models, discriminating between benign and malignant adnexal masses is not
improved by combining CA 125 results with transvaginal ultrasonography to assess tumor
morphology and color Doppler imaging [18] . It is more useful in postmenopausal women, in
whom the positive predictive value for malignancy is 97 percent [19,20] . Furthermore, and
perhaps more importantly, this baseline measurement is useful in evaluating the success of
subsequent treatment if the patient is found to have a malignancy.

High preoperative CA 125 levels correlate with advanced stage (III or IV) and high grade disease,
serous histology, and the presence of ascites [21] , but they are not a reliable predictor of the
likelihood of optimal cytoreduction [21-23] . (See "Epithelial ovarian cancer: Initial surgical
management").

The American College of Obstetricians and Gynecologists recommends consideration of referral

to or consultation with a gynecologic oncologist in women with a pelvic mass suspicious for
malignancy because of ascites, nodularity/fixation, evidence of metastases, a first degree
relative with ovarian or breast cancer, or an elevated CA 125 level (eg, any level above normal in
a postmenopausal women; a level >200 U/mL in premenopausal women) [20] . These guidelines
perform best in advanced disease and in postmenopausal women [24,25] .

Gene expression profiling Gene expression profiling by cDNA microarray technology to identify
upregulating genes in cancerous cells is a promising method for early identification of cancer
[26] . Osteopontin is one such potential diagnostic marker for ovarian cancer that is under
investigation [27] . Other potentially useful biomarkers under investigation are YKL-40, CA 15-3,
and composite markers [28,29] . Preliminary evidence from a pilot study showed that, compared
to CA-125, YKL-40 was more likely to be negative in women with benign disease and positive in
early stage cancer and mucinous tumors [28] .

Additional imaging: CT or MRI Abdominopelvic computerized tomography (CT) or magnetic

resonance imaging (MRI) may demonstrate sites of metastatic spread, which can be helpful to
the surgeon in planning the optimal surgical procedure. We obtain an abdominopelvic CT to
assess for metastatic disease. In our institution, CTs are less expensive and more comfortable for
the patient than MRI, therefore, we prefer this technique unless the patient has a bad contrast
allergy that would preclude use of CT.

Patients with ascites but no definite pelvic mass should undergo preoperative CT or MRI scan
with particular attention to the possibility of an extraovarian primary tumor.

Liver-spleen scans, bone scans, and brain scans are unnecessary unless symptoms or signs
suggest metastases to these sites.

Excluding an extraovarian primary The preoperative evaluation of the woman with a

suspicious ovarian mass should also exclude the possibility of cancers commonly metastatic to
the ovary (fallopian, primary peritoneal, gastric, colorectal, appendiceal, breast, endometrial).

Gastrointestinal evaluation Primary gastrointestinal tumors (eg, gastric cancer) can mimic
ovarian cancer when metastatic metastatic to the peritoneum or ovaries (Krukenberg tumors). In
addition, ascites without a pelvic mass may indicate primary liver disease. (See "Clinical features
and diagnosis of gastric cancer", section on Signs of tumor extension). Any patient with occult
blood in the stool or evidence of intestinal obstruction should be evaluated for a primary
colorectal tumor; barium enema or colonoscopy are more sensitive than a CT scan. An upper GI
series is indicated if there are signs or symptoms suggestive of an upper GI malignancy.

Mammography Breast cancer can metastasize to the ovaries or be associated with primary or
metastatic ovarian cancer [30] . Bilateral mammography should be performed in the presence of
a breast mass.

Image-guided biopsy In some cases, if there is diagnostic uncertainty or if neoadjuvant

chemotherapy is being considered rather than initial surgery (eg, because of bulky disease and a
poor performance status), image-guided biopsy of the peritoneum or omental cake may help
exclude a nonovarian malignancy. In a retrospective case series, CT- or ultrasound-guided biopsy
provided a site-specific diagnosis in 93 percent of women with peritoneal carcinomatosis [31] .
(See "Epithelial ovarian cancer: Initial surgical management", section on Predicting optimal
cytoreduction and see "First-line chemotherapy for epithelial ovarian cancer", section on
Neoadjuvant chemotherapy versus initial surgical debulking).

Paracentesis or thoracentesis In patients with ascites, paracentesis or thoracentesis may be

performed in patients who are appropriate candidates for image-guided biopsy (see above).

Excluding a synchronous primary Women with abnormal uterine bleeding should undergo
endocervical curettage and/or biopsy to exclude the presence of endocervical or endometrial
cancer.

Synchronous primary cancers of the ovary and endometrium have been reported in about 10
percent of women with ovarian cancer and 5 percent of women with endometrial cancer [32] .
Risk factors for synchronous cancers include younger age, obesity, premenopausal status, and
nulliparity, which suggests a hormonal field effect [33] . Treatment is based upon the combined
treatment recommendations for each cancer according to stage. (See "Terminology and
evaluation of abnormal uterine bleeding in premenopausal women" and see "The evaluation and
management of uterine bleeding in postmenopausal women").

SURGICAL DIAGNOSIS AND STAGING Surgery is necessary for diagnosis, staging, and
treatment of EOC [34] . A gynecologic oncologist should be consulted to participate in the
surgical procedure if an ovarian malignancy is suspected preoperatively (show table 6) or found
intraoperatively. Multiple studies have shown that treatment by nongynecologic oncologists and
by low volume providers is associated with suboptimal surgical management and shorter median
survival [35-40] .

Staging Ovarian malignancies are surgically staged according to the 2002 revised American
Joint Committee on Cancer (AJCC) and International Federation of Gynecology and Obstetrics
(FIGO) joint staging system (Show table 7), as long as the patient is an appropriate surgical
candidate. The distribution of ovarian cancer worldwide by stage at presentation is: stage I (23 to
33 percent), stage II (9 to 13 percent), stage III (46 to 47 percent), stage IV (12 to 16 percent)
[41,42] .

Thorough surgical staging (show table 8) is critically important because subsequent treatment
and prognosis will be determined by the pathologic or surgical stage of disease. In historical
series in which women did not undergo careful surgical staging, the overall five-year survival for
those with apparent stage I ovarian cancer was reported to be only 60 percent. However, with
proper staging, the five-year survival rate for stage IA disease is actually about 90 percent [43] .

Occult metastases are not uncommon in women with apparent clinical stage I or II EOC [44-49] .
The frequency with which this occurs was illustrated in a study of 100 patients with apparent
stage I or II disease who were referred for additional staging surgery [44] . More advanced
disease was noted in 29 percent of patients initially thought to have stage I disease and 43
percent thought to have stage II disease. Overall, one-quarter of patients were upstaged to stage
III disease, with histologic grade being a significant predictor of occult metastasis: 16 percent of
patients with grade 1 (well differentiated) lesions were upstaged compared to 34 and 46 percent
with grade 2 (moderately differentiated) and grade 3 (poorly differentiated) disease, respectively.

For women diagnosed with EOC who have not been completely staged at the primary surgery,
there are two options: (1) the staging can be completed by a second surgical procedure that is
combined with tumor resection or (2) chemotherapy can be initiated with subsequent surgical
reassessment. A laparoscopic procedure can sometimes be performed to complete surgical
staging.

For patients with advanced disease, optimal cytoreduction (debulking) should be attempted at
the time of initial surgery, as it is an important determinant of the success of systemic
chemotherapy. The majority of women with EOC (except for those with stage I disease) will
require combined therapy with surgery and chemotherapy. (See "First-line chemotherapy for
epithelial ovarian cancer").

The staging procedure is described in detail separately. (See "Epithelial ovarian cancer: Initial
surgical management").

HISTOPATHOLOGY The designation EOC is derived from the origin of these tumors, which arise
from neoplastic transformation of coelomic epithelium and adjacent ovarian stroma. The
histopathological categories of epithelial ovarian carcinomas according to the World Health
Organization and the International Society of Gynecological Pathologists are shown in the table
(show table 9) [50] . The different histologic types may be associated with different risk factors
[51] .

Types of nonepithelial ovarian cancers include sex-cord stromal tumors, which are derived from
nongerm cell components of the gonads (see "Sex cord-stromal tumors of the ovary"); germ cell
tumors, which are derived from germ cells (see "Overview of ovarian germ cell tumors"); and
small cell tumors (origin unclear), which can be associated with hypercalcemia [52] . These
origins are illustrated in the figure (show figure 3).

Epithelial carcinomas Papillary serous histology accounts for as many as 75 percent of ovarian
cancers [53] . Mucinous and endometrioid tumors are less common (about 10 percent each),
followed by clear cell tumors, Brenner (transitional cell) tumors, and undifferentiated carcinomas
[54-58] . Some features of each of these types of carcinoma are: The histological pattern of
serous tumors simulates the lining of the fallopian tube. Poorly differentiated forms of serous
carcinomas are grossly indistinguishable from other epithelial tumors. This histologic variant is
often associated with concentric rings of calcification known as psammoma bodies. Mucinous
tumors histologically resemble endocervical epithelium. They tend to remain confined to the
ovaries longer than serous carcinomas and are the largest epithelial ovarian neoplasms, with a
median diameter of 18 to 20 cm [55,59] . CA-125 levels may not be markedly elevated.
Pseudomyxoma peritonei may be present [55] . Primary ovarian mucinous tumors can be difficult
to distinguish from metastatic mucinous tumors from the colon/rectum, appendix, cervix, or
pancreas. In general, primary tumors are usually large ( 10 cm) and unilateral whereas
metastatic tumors tend to be small (<10 cm) and bilateral [60,61] . (See "Cancer of the appendix
and pseudomyxoma peritonei").

At least some data suggest a poorer response to platinum-based first-line chemotherapy for
mucinous as compared to nonmucinous epithelial ovarian cancers, although initial treatment is

typically similar [62,63] . Endometrioid tumors closely resemble the components of endometrial
cancer. They occasionally arise from foci of endometriosis [64,65] . Endometrioid histology
appears to be associated with better survival than when compared to serous adenocarcinoma,
regardless of disease stage or response to platinum-based therapy [66] . Clear cell carcinomas of
the ovary have also been called mesonephroid carcinomas because their histologic features
include "clear cells," similar to those seen in renal cell carcinomas. These tumors can also arise
from endometriosis [57] . Rarely, they may be associated with humorally mediated
hypercalcemia. (See "Hypercalcemia of malignancy").

Patients with ovarian clear cell cancer frequently have a clinical history of endometriosis; most
have stage I disease and there may be a large pelvic mass [67,68] . Recurrences are more
frequent than with other histologies, and the response rate to platinum- and taxane-based
regimens is lower [68-70] . Nevertheless, clear cell cancers are still treated similarly to other
EOCs. Brenner tumors can be benign or malignant. Benign Brenner tumors are small, solid
masses composed of nests of transitional epithelium within the fibrous stroma. Intermediate
Brenner tumors are comprised of proliferating cells of low malignant potential. These are
generally unilateral and multicystic, with a good prognosis. Malignant Brenner tumors are
comprised of frankly malignant cells with atypical features and invasive characteristics.
Undifferentiated carcinoma refers to tumors with no discernible histologic differentiation or only
minor areas of differentiation. Mixed carcinomas are those containing two or more distinct
histologic types of cancer with each subtype involving at least 10 percent of the tumor mass. The
presence of serous carcinoma or sarcoma as one of the components worsens the prognosis [71] .

Sarcoma Malignant mixed mesodermal sarcomas of the ovary (also called ovarian
carcinosarcomas) are rare and aggressive tumors. Most occur in postmenopausal women with
presentation similar to that with EOCs. Optimal treatment has not been established by
prospective trials, but in most patients, consists of cytoreductive surgery and postoperative
chemotherapy using platinum-containing combination therapy [71-78] .

Borderline tumors Tumors of low malignant potential are also called borderline tumors; they
represent approximately 10 percent of malignant ovarian neoplasms [43] . This heterogeneous
group of lesions is defined histologically by atypical epithelial proliferation without stromal
invasion [79] . (See "Ovarian tumors of low malignant potential").

Primary peritoneal carcinoma Primary peritoneal carcinoma (also known as papillary serous
carcinoma of the peritoneum) is another entity closely associated with, but distinct from, EOC
[80-85] . Histologically, this tumor is indistinguishable from papillary serous ovarian carcinoma,
but morphologic distinctions have been described. The criteria established by the Gynecologic
Oncology Group (GOG) to define primary peritoneal carcinoma are: Ovaries normal in size (4.0
cm in largest diameter) or enlarged by a benign process Extraovarian involvement greater than
ovarian involvement A predominantly serous histology Surface involvement of less than 5 mm
depth and width

Using these criteria, between 7 and 20 percent of patients previously identified with primary EOC
may be reclassified as having primary peritoneal carcinoma [82-84,86] . In some cases, they may
be classified as adenocarcinomas of unknown primary site. (See "Adenocarcinoma of unknown
primary site", section on Women with peritoneal carcinomatosis).

The pattern of spread is similar to that in women with EOC [87,88] . Women with papillary serous
carcinoma of the peritoneum are treated similarly to those with EOC. Optimal surgical
cytoreduction may be more difficult to achieve in the setting of widespread peritoneal disease
without a predominant ovarian or pelvic mass. Chemotherapy regimens and response rates are
similar to EOC [89] .

PATTERNS OF SPREAD Epithelial ovarian cancers can spread intraperitoneally, via lymphatic
channels, or by hematogenous dissemination. The most common and earliest mode of spread is
by exfoliation of cells that implant along the surfaces of the peritoneal cavity. The cells tend to
follow the circulatory path of peritoneal fluid, often moving with the forces of respiration from the
pelvis, up the paracolic gutters (especially on the right), along the intestinal mesentery, to the
right hemidiaphragm. These implanted cells give rise to metastatic foci in the cul-de-sac, the
paracolic gutters, on the diaphragmatic surface, the liver capsule, the surface of the intestines,
and the omentum. The disease seldom invades the intestinal lumen, but progressively
agglutinates loops of bowel leading to functional intestinal obstruction, or carcinomatous ileus.

Lymphatic dissemination to the pelvic and paraaortic lymph nodes is common, particularly in
clinically advanced disease [90,91] . Spread through the lymphatic channels of the
retroperitoneal lymph nodes and the diaphragm can lead to dissemination of disease into the
supraclavicular lymph nodes and pleural space.

Hematogenous dissemination at the time of diagnosis is uncommon, with only 2 to 3 percent of

patients found to have parenchymal involvement of the lungs or liver. Brain metastases are rare.

Pleural effusion is the most common finding constituting stage IV disease, followed by
parenchymal liver metastasis [92] . Most patients with disease above the diaphragm have a right
pleural effusion [93] .

INFORMATION FOR PATIENTS Educational materials on this topic are available for patients.
(See "Patient information: Ovarian cancer diagnosis and staging" and see "Patient information:
Ovarian cancer treatment"). We encourage you to print or e-mail these topic reviews, or to refer
patients to our public web site, www.uptodate.com/patients, which includes these and other
topics.

SUMMARY AND RECOMMENDATIONS Symptoms of early stage ovarian cancer are often illdefined, and may not be severe or specific enough to prompt a woman to seek medical
attention. Acute symptoms due to ovarian rupture or torsion are unusual. As a result, the
majority of cases are advanced at the time of diagnosis. (See "Clinical manifestations" above).
The diagnosis of ovarian malignancy is almost certain if a fixed, irregular pelvic mass is
associated with an upper abdominal mass or ascites. (See "Physical examination" above).
Ultrasound examination is the most useful noninvasive diagnostic test in women with an adnexal
mass. The presence of sonographic features suggestive of malignancy (show table 3) helps in
predicting the likelihood that a pelvic mass is malignant, but is not infallible, even when
combined with other modalities, such as demographic information and biochemical data.
Therefore, surgery for definitive histologic diagnosis is usually required. (See "Initial diagnostic
evaluation" above). The serum CA 125 (normal <35 U/mL) is elevated (>65 U/mL) in 80 percent
of women with epithelial ovarian cancer, as well as in some women with benign and other
malignant lesions (show table 5). It is more predictive of ovarian cancer in postmenopausal than
premenopausal women since malignancy is rare relative to benign conditions in the
premenopausal group. Nevertheless, the preoperative evaluation of a woman with suspected
ovarian cancer should include a baseline measurement of the serum glycoprotein CA 125
concentration because it is useful in evaluating the success of subsequent treatment if the
patient is found to have a malignancy. (). Surgery is necessary for diagnosis, staging, and
treatment of epithelial ovarian cancer. A gynecologic oncologist should be consulted to
participate in the surgical procedure if an ovarian malignancy is suspected preoperatively or
found intraoperatively. (See "Surgical diagnosis and staging" above). Ovarian malignancies are
surgically staged according to the American Joint Committee on Cancer and International
Federation of Gynecologic Oncologists joint staging system (Show table 7). The procedure is
summarized in the table (show table 8). (See "Staging" above).

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