Ovarian cancer screening-ultrasound; impact on ovarian cancer mortality

Abstract

Although ovarian cancer (OC) is the most lethal of all female malignancies, debate still exists concerning the benefits and harms of the screening programs and their impact on long-term survival and mortality from the disease. The most widely tested screening strategies have focused on transvaginal ultrasound (TVU) and on algorithms that measure serum levels or interval changes of cancer antigen-125 (CA-125) either individually or in combination. Transvaginal ultrasound can identify size and morphology changes of the ovary that may signal a developing malignancy; yet, it is still accused of having a low specificity. There is preliminary evidence that screening can improve survival, but the impact of screening on mortality from OC is still unclear and warrants further validation. In spite of having many published prospective studies, up to-date, none have been able to demonstrate conclusively a reduction in mortality from OC both in the screened general or high-risk population. Data from the US Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial has not shown survival or mortality benefits in the general population. Most prospective trials have reported a decrease in stage at detection (with the exception of the PLCO trial), thereby allowing treatment to be initiated when the disease is most curable. Research is in progress to develop new diagnostic tests and novel biomarkers, which when used in combination can increase the accuracy and outcomes of screening. In this review article, we will discuss the debate provoked on OC screening programs and the impact of using ultrasound on the reduction of OC-related mortality.

Figure 1.

False-positive high CA-125 level in a 28-year-old female with over simulated ovaries secondary to hormone intake. Ultrasound showed increased ovarian volume, hypertrophied ovarian stoma and multiple large cystic spaces, i.e. follicles. The ovary regained its normal size and morphology on follow-up ultrasound examinations. CA-125, cancerantigen-125.

Figure 2.

(a, b) A patient complaining of dysfunctional uterine bleeding showed benign looking ovarian mass that was surgically excised and proved to be fibrothecoma. The ovarian volume was increased and a solid mass lesion was seen replacing the ovarian stroma evident in the 2D Doppler (a) and the 3D TVU (b). 2D, two-dimensional; 3D, three-dimensional; TVU, trans vaginal ultrasound.

Figure 3.

Ovarian torsion: TVU displayed marked increase of the ovarian volume that showed multiple suspicious irregular vascular that was misdiagnosed as malignant mass. In the follow-up study; CA-125 was normal and the ovary regained normal volume and morphology. CA-125, cancer antigen-125; TVU, trans vaginal ultrasound.

Figure 4.

Cystic ovarian mass. (a) Color Doppler, and (b) grayscale ultrasound images. The mass is complex cystic in (a, b) that showed multilocularity and turbid slightly echogenic mesh like content. The complex cyst evolved over time (after 2 weeks follow-up for one and half month duration). The cyst in (c) showed simple characteristics and become unilocular of clear content and thin unifrom walls.

Figure 5.

A 40-year-old female with a right adnexal small complex malignant mass lesion (a, b). There was an association of extensive ascites and multiple peritoneal implants (c, d).