Surgical Exploration for Ovarian Carcinoma

Introduction to Surgical Exploration

The National Comprehensive Cancer Network recommends surgical exploration with comprehensive staging, utilizing intraoperative frozen section to guide the extent of surgery, when MRI suggests ovarian carcinoma but biopsy/FNAC is not feasible and CA125 is normal 1, 2
Preoperative imaging alone is insufficient for precise staging or definitive diagnosis, and surgical exploration with histopathological examination is necessary for confirmation of diagnosis and staging, except in cases with obvious stage IV disease 2

Fine-needle aspiration should be avoided in presumed early-stage disease to prevent rupturing the cyst and spilling malignant cells into the peritoneal cavity 1
A CT scan of chest/abdomen/pelvis with contrast should be performed to assess for metastases and aid surgical planning, unless contraindicated 1
Additional tumor markers, such as CEA and CA19-9, should be measured if mucinous histology is suspected, as a CA125/CEA ratio ≤25:1 suggests gastrointestinal origin rather than primary ovarian cancer 3, 4
For young women (<35 years), AFP and β-hCG should be measured to exclude germ cell tumors 1, 3
FDG-PET/CT may be useful for indeterminate lesions when standard imaging is inconclusive 1

Intraoperative frozen section can guide the extent of surgery by providing rapid preliminary diagnosis, though interpretation may be difficult for distinguishing well-differentiated adenocarcinomas from borderline tumors 2
Adequate tissue sampling is critical, and peritoneal biopsies alone are insufficient and do not provide proof of ovarian origin or degree of malignancy 2

Delaying surgery for tissue diagnosis is not recommended, as attempting percutaneous biopsy risks tumor spillage and upstaging in early disease 1, 2
CA125 alone should not be relied upon, as normal values occur in 50% of early-stage cancers and can be elevated in benign conditions 3, 4
Ensuring adequate surgical expertise is crucial, and referral to a gynecologic oncologist or specialized cancer center is standard for suspected ovarian malignancy to ensure proper staging 2
For mucinous tumors, it is essential to rule out gastrointestinal primary, and consider gastrointestinal tract evaluation (endoscopy/colonoscopy) if CEA or CA19-9 are elevated 1, 3