How Ovarian Cancer Is Diagnosed

A number of tests and procedures may be used to diagnose ovarian cancer, including a pelvic exam; imaging tests, such as transvaginal ultrasound, CT, or MRI; and blood tests, such as CA-125. A biopsy is usually needed to determine whether a mass is malignant (cancerous) and to identify the type and subtype of the disease. When a diagnosis is made, these results and further tests are used to define the stage of the disease, which will help determine the best course of treatment.

ovarian cancer diagnosis
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Self Checks/At-Home Testing

There are no self-checks for ovarian cancer. Furthermore, at-home genetic tests cannot definitely determine your risk of developing the disease. It's important to be familiar with the signs and symptoms and to talk to your doctor if you have any risk factors for the disease.

Ovarian Cancer Doctor Discussion Guide

Get our printable guide for your next doctor's appointment to help you ask the right questions.

Doctor Discussion Guide Woman

Physical Exam

No screening strategy for ovarian cancer has been proven to reduce mortality. A routine pelvic exam performed by your physician (or conducted because of the presence of symptoms) may detect a mass in the region of your ovary, referred to as an adnexal mass.

However, this check has limitations:

  • The exam is performed bimanually with one hand in your vagina and one on your abdomen. Since the doctor is feeling for your ovary beneath fatty tissue, the exam is less accurate in identifying a mass in people who are overweight or obese.
  • Even in thin women, a pelvic exam can miss small ovarian tumors.

It's important to note that a Pap smear alone (without a bimanual exam), is helpful in detecting cervical cancer but not ovarian cancer.

Imaging

Imaging tests can help identify a small ovarian mass and further evaluate a mass that's felt on exam.

Transvaginal Ultrasound

A pelvic ultrasound is a test that uses sound waves to create an image of the pelvic organs. It is usually the first test performed to evaluate an ovarian mass and does not cause radiation exposure.

The procedure can be done either abdominally (the probe is positioned on top of your skin) or transvaginally (the probe is inserted into the vagina to get closer to the ovary). The transvaginal method is better for defining ovarian masses, especially those that are small.

An ultrasound can provide an estimate of the size of a mass, as well as help to determine whether it's a simple cyst, a complex cyst, or solid.

  • Simple cysts are usually benign.
  • A complex cyst may be benign but is more likely to be cancerous if it contains nodules or excrescences (abnormal growths). 

An ultrasound can also detect free fluid in the pelvis, which is often seen with advanced tumors.

Abdominal and/or Pelvic CT Scan

A computerized tomography (CT) scan uses a series of X-rays to create a picture of the abdomen or pelvis. It may be used to aid in the diagnosis, but is more often used in staging cancer. It is a good test to evaluate the lymph nodes, intestines, liver, and lungs (chest CT scan) for evidence of metastasis (spread of cancer).

A CT scan may identify:

  • Ascites (fluid build-up in the abdomen)
  • Metastases
  • Carcinomatosis (widespread areas of tumor)
  • Omental cake (thickening of the omentum, the fatty layer that lies over the abdominal organs)
  • Fat stranding (swelling in abdominal fatty tissues)
  • Effusion (fluid build-up)

Also, lymph nodes may be described as enlarged. Enlarged lymph nodes are usually larger than 2 cm (around 1 inch) in diameter and may have areas of central necrosis (cell death) if cancer is present.

MRI

Magnetic resonance imaging (MRI) may be used in a way similar to a CT scan but does not involve radiation, making it a safer test during pregnancy. MRI tends to be better than CT at defining soft tissue abnormalities and may be used to clarify findings that were detected on other tests.

PET Scan

A PET scan is a functional imaging test that measures tissue activity. This test looks for evidence of metastases (spread) anywhere in the body and is helpful in discriminating between scar tissue and cancer.

With a PET scan, a small amount of radioactive sugar is injected into the bloodstream. The scan is done after the sugar has had time to be absorbed by cells. More actively growing cells, such as cancer cells, will light up on this imaging, which is usually combined with CT. 

Labs and Tests

In addition to imaging studies and a physical exam, blood work can be helpful for assessing some aspects of ovarian cancer.

Blood Work for Tumor Marker Detection

Certain blood tests can detect proteins known as tumor markers. Some of them are produced by both normal and cancerous ovarian cells, and higher than normal amounts may be present with ovarian cancer.

Identifying tumor markers is not an effective way to screen for ovarian cancer, but it can be helpful during the diagnostic phase and for following the treatment response. 

  • CA-125: CA-125 is commonly measured when there is concern about possible ovarian cancer. The level is elevated in a large percent of epithelial ovarian tumors, but there are false negatives and it could be high without ovarian cancer (false positives). A few conditions that can increase CA-125 include pregnancy, polycystic ovarian syndrome, pelvic inflammatory disease, pancreatitis, cirrhosis, and lupus.
    With ovarian cancer, CA-125 is more likely to be elevated in serous and endometrioid subtypes. A very high result (such as a CA-125 over 1000) increases the likelihood of ovarian cancer diagnosis. The level of CA-125 at the time of diagnosis may also help predict the prognosis.
  • Human epididymis protein 4 (HE4): HE4 may be helpful when combined with CA-125 and is most likely to be elevated with serous and endometrioid epithelial ovarian cancers. This test is less helpful in younger women, due to the type of ovarian cancers that typically affect premenopausal women.
  • CA 72-4: CA 72-4 may be elevated in several other (usually digestive tract) conditions and the level at the time of diagnosis may help predict prognosis for some people.
  • CA-19-9: This tumor marker is more common in mucinous epithelial ovarian tumors.
  • CEA (carcinoembryonic antigen): CEA is a non-specific marker and can be elevated in a number of cancers and gastrointestinal conditions.
  • Alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG): HCG and AFP are commonly tested during pregnancy, and both of these markers can be elevated in germ cell tumors, such as ovarian cancer.
  • Estradiol and inhibin: Both estradiol and inhibin are more likely to be elevated in females who have sex cord-stromal tumors, or germ cell tumors, with inhibin often secreted by granulosa cell tumors in young females (a type of stromal tumor).

Other Blood Tests

Other blood tests you might have include complete blood count (CBC), LDH, alkaline phosphatase, and a sed rate or C-reactive protein test (which looks for inflammation).

Research has found that a combination of red blood cell indices, red blood cell distribution width (RDW), and mean platelet volume (MPV) may be helpful in predicting which ovarian tumors are cancerous and which are not. RDW tends to be high and MPV low with ovarian cancer. 

Ovarian Risk Index

A number of different risk of malignancy indices look at a combination of findings on tests and imaging to predict whether a problem could be ovarian cancer and if a biopsy is needed. While these may be helpful, the objective measures of estimating risk are more accurate when used along with the subjective assessment of an expert, such as a gynecological oncologist. 

Surgical Biopsy

A biopsy (sample) of a suspicious growth is usually done via surgery. At times, a needle biopsy (in which a needle is inserted through the skin) may be considered, but it's thought that if ovarian cancer is present, this could result in what's known as seeding (the spread of the tumor).

A surgical biopsy can be done with laparoscopic surgery, in which a few small incisions are made in the abdomen and a probe with a camera and instruments are inserted. It can also be done with an open laparotomy, during which a traditional incision is made in the abdomen.

The biopsy is taken and sent to a pathologist to determine if it is cancerous, and if so, the type. Your biopsy report should describe the sample as either benign (non-cancerous) or malignant (non-cancerous).

Differential Diagnoses

A mass in the region of the ovary and fallopian tube that's detected with an exam or an imaging test is referred to as an adnexal mass. A few possible causes (there are many) may include the following:

  • Ovarian cysts: Ovarian cysts are very common, and can often be distinguished from solid masses or complex cysts on ultrasound
  • Pelvic inflammatory disease (PID): With PID, an abscess can develop.
  • Endometriosis: Endometriosis is a condition in which uterine tissue grows outside of the uterus.
  • Benign ovarian tumors: In general, premenopausal tumors are more likely to be benign, while postmenopausal tumors are more likely to be malignant.
  • Polycystic ovarian syndrome (PCOS): PCOS is a common condition in which women develop multiple cysts on their ovaries.
  • Corpus luteal cyst: It's not uncommon for women to develop a corpus luteum cyst during pregnancy.
  • Ectopic (tubal) pregnancy: Tubal pregnancies may cause findings similar to ovarian cancer, and when they occur early in pregnancy, women are sometimes unaware they are pregnant.
  • Ovarian torsion: This can lead to inflammation and bleeding and may occur on its own or secondary to an ovarian tumor.
  • Appendiceal abscess: If the appendix ruptures, it may cause an abscess near the region of the right ovary.
  • Pelvic kidney: This condition involves a kidney remaining in the pelvis during fetal development and may first be noticed as a mass in the pelvis.

Tumor Type and Grade

A biopsy is used to determine the type and grade of a tumor.

For advanced ovarian cancers, biopsies are usually taken from the lymph nodes, omentum (a fatty, carpet-like structure overlying the intestine), and often several areas of the peritoneum (the membranes that line the abdominal cavity). A surgeon will also remove or make note of any suspicious-looking nodules or other masses. If the cancer was mucinous, the appendix will be removed.

Washings may also be done, in which the surgeon injects saline into the abdomen and then withdraws the fluid to look for evidence of cancer cells.

After surgery, your surgeon will send any tissue that was removed to a pathologist. This may include your ovaries, fallopian tubes, uterus, and tissue and biopsies taken from other regions of your abdomen.

Type and subtype: Knowing the type and subtype of ovarian cancer can give information on the expected aggressiveness of a tumor and whether it is fast or slow-growing.

Tumor grade: This is a measure of the tumor's aggressiveness. With endometrioid ovarian cancers, cancers are given a tumor grade between 1 and 3:

  • Grade 1: Cells are more normal looking (differentiated) and tend to be less aggressive. 
  • Grade 2: Cells fall between the above and below classifications.
  • Grade 3: Cells look very abnormal (undifferentiated) and tend to be more aggressive. 

Serous tumors are given one of two ratings instead: low grade or high grade.

Stages

If a diagnosis of ovarian cancer is made, staging the tumor is critical in choosing the best treatment options.

Some of the information needed for staging may be gathered from imaging tests and a biopsy, and sometimes surgery (to remove the ovaries and often additional tissue) is needed to accurately stage cancer. Imaging tests and surgery can help determine if cancer has spread to lymph nodes or other regions of the body.

Ovarian cancer is staged using either simplified or full FIGO staging methods. Findings may also be defined as borderline ovarian cancer. Though the below mostly concerns your physician, it may be helpful as you work to understand what treatment options may be appropriate for you.

Borderline Ovarian Cancer

Borderline ovarian cancers are those that have low malignant potential. These are usually early stage tumors and usually do not grow back after surgery. These tumors may be given a stage if your surgeon is uncertain during surgery whether higher grade cancer is present, or if it appears there was spread of the tumor.

Simplified Staging

To get a broad picture of the differences between stages, these can be broken down into:

  • Stage 1: The cancer is confined to the ovary.
  • Stage 2: The tumor has spread to pelvic organs (such as the uterus and fallopian tubes), but not to abdominal organs.
  • Stage 3: The tumor has spread to abdominal organs (for example, the surface of the liver or bowel) or lymph nodes (pelvic or abdominal nodes).
  • Stage 4: The tumor has spread to distant regions, such as the lungs, liver (inside not just the surface), brain, or distant lymph nodes.
  • Recurrent: Recurrent ovarian cancer refers to cancers that come back during or after treatment. If cancer comes back in the first three months, it is usually considered a progression rather than a recurrence.
ovarian cancer stage at diagnosis chart
Illustration by Verywell

Full FIGO Staging

The full FIGO, named for the International Federation of Gynecology and Obstetrics, is a surgical staging system that uses Roman numerals for stages (to estimate the prognosis) and letters for substages (which help guide treatment options).

  • Stage IA: The cancer is limited to one ovary and the outer ovarian capsule is not ruptured. There is no tumor on the external surface of the ovary and there is no ascites and/or the washings are negative.
  • Stage IB: The cancer is present in both ovaries, but the outer capsule is intact and there is no tumor on the external surface. There are no ascites and the washings are negative.
  • Stage IC: The cancer is either Stage IA or IB level, but the capsule is ruptured, there is a tumor on the ovarian surface, or malignant cells are present in ascites or washings.
  • Stage IIA: The cancer involves one or both ovaries and has extended on to the uterus and/or fallopian tube. The washings are negative washings and there are no ascites.
  • Stage IIB: The cancer involves one or both ovaries and has extended onto other pelvic tissues beyond the uterus and fallopian tube. The washings are negative and there are no ascites.​
  • Stage IIC: The cancer involves one or both ovaries and has extended to pelvic tissues like Stage IIA or IIB, but with positive pelvic washings.
  • Stage IIIA: Cancer has spread to the lymph nodes. The tumor is grossly (to the naked eye) confined to the pelvis but with microscopic peritoneal metastases (spread seen only under the microscope) beyond the pelvis to abdominal peritoneal surfaces or the omentum. The omentum is the fatty structure that drapes over the intestines and other abdominal organs.
  • Stage IIIB: Cancer has spread to the lymph nodes. This stage is similar to stage IIIA, but with macroscopic spread (spread that can be seen visually) to the peritoneum or omentum. At this stage, the areas of cancer that have spread are less than 2 cm (a little less than an inch) in size.
  • Stage IIIC: Cancer has spread to the lymph nodes. This stage is also similar to stage IIIA, but with peritoneal or omental metastases (spread) beyond the pelvis with areas that are larger than 2 cm (an inch) diameter in size, or with spread to lymph nodes in the groin (inguinal nodes), pelvis (pelvic nodes), or para-aortic (para-aortic nodes).
  • Stage IV: The cancer has spread to the body of the liver or to areas outside of the lower abdomen (the peritoneal cavity) to areas such as the chest or brain.

Frequently Asked Questions

  • What are the symptoms of ovarian cancer?

    Ovarian cancer often has vague symptoms in the early stages, or none at all. When they do appear, the most common symptoms are bloating, pelvic and abdominal pain, difficulty with eating and feeling full, and feeling like you need to urinate frequently. Other less common symptoms include fatigue, back pain, pain during sex, and changes in the menstrual cycle.

  • What is the survival rate of ovarian cancer?

    The five-year relative survival rate for localized ovarian cancer that has not spread outside the ovaries is 93%. The rate for regional ovarian cancer that has spread to nearby lymph nodes or structures is 75%, and the rate for distantly metastasized ovarian cancer that has spread to other areas, such as the lungs or liver, is 31%.

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Article Sources
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