Ultrasound Pictures of Ovarian Cancer

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During the process of diagnosing ovarian cancer, doctors will use several tests to learn more about the tumor. The first test that doctors usually recommend is an ultrasound. This painless imaging test helps doctors see what the inside of the abdomen looks like. Doctors can use ultrasounds to detect various problems with the ovaries and nearby organs.

How Do Ultrasounds Work?

An ultrasound machine uses a small handheld tool called a transducer to send sound waves into the body. These sound waves are painless and are so high-pitched that humans can’t hear them. Echoes of the sound waves bounce back to the transducer, and the machine converts the sound waves into an image. The result is a sonogram — a picture of the tissues and organs within a particular part of the body.

There are a couple of types of ultrasound. When diagnosing potential cases of ovarian cancer, doctors often use a transvaginal ultrasound, in which a probe is placed into the vagina. Doctors may also perform a pelvic ultrasound, in which the transducer is placed on the skin of the lower part of the abdomen. Both of these approaches can capture pictures of the ovaries and uterus.

What Does the Ovary Look Like on an Ultrasound?

Sonograms from an ultrasound test can show several features of the ovary. They allow doctors to see the size and shape of the ovary. A sonogram can also look at the texture of the outer surface of the ovary. Additionally, ultrasound imaging can detect abnormalities or masses on the ovary, which may or may not be cancerous.

The Normal Ovary on an Ultrasound

Ultrasound of the normal right ovary without an ovarian follicle.
This ultrasound image shows a normal right ovary that contains no ovarian follicles. (Medical Images)

In general, the ovaries appear as almond-shaped structures on either side of the uterus. In individuals who have given birth multiple times, the ovaries may have moved slightly from their original position. The ovaries also shrink after menopause, so an ultrasound may not be able to detect them in older people.

For individuals who have not yet gone through menopause and are still getting their period, their ovary will contain follicles. Ovarian follicles are small sacs. Each one contains an egg cell. Follicles develop and grow larger throughout the beginning phase of the menstrual cycle. Then, a single follicle will continue to grow until it releases an egg, called ovulation.

Ultrasound of the left ovary during follicular phase (seventh day) of the menstrual cycle, showing an 11 mm ovarian follicle (pink).
This ultrasound image shows a left ovary during the follicular phase (seventh day) of the menstrual cycle. The ovarian follicle (pink) measures 11 millimeters. (Medical Images)

On an ultrasound, the follicles may appear as small, dark, round shapes around the edge of the ovary. Follicles may be different sizes depending on where a person is within their menstrual cycle.

Cysts on an Ultrasound

Sometimes, an ultrasound may detect other more unusual features within an ovary. Most of these findings are not cancerous, and many are not harmful

An ultrasound showing ovarian cysts.
Ovarian cysts are visible in this ultrasound image. These types of cysts are usually noncancerous and appear round and black on an ultrasound. (Adobe Stock)

A common ultrasound finding is a cyst (a fluid-filled sac). About 8 percent to 18 percent of women have cysts on their ovaries. Occasionally, ovarian cancer may appear as a cyst. However, ovarian cysts are usually benign (noncancerous). Often, cysts develop when a follicle fails to release an egg or fails to disappear after ovulation. These cysts usually go away over time. Occasionally, cysts are caused when blood or tissue from the uterus attaches to the ovary, called endometriomas. Cysts can also be teratomas — masses that form when an egg cell begins growing within the follicle.

Like follicles, cysts usually appear round and black on an ultrasound. They often have thin walls and don’t look like they contain anything inside. However, they are often larger than normal follicles.

Cysts don’t usually need any treatment and are often not a cause for concern. In some cases, doctors may recommend a follow-up ultrasound a few months later to see if the cyst has grown.

Ovarian Cancer on an Ultrasound

In rare cases, ovarian cysts or solid masses may be malignant (cancerous). The ultrasound doesn’t show for sure whether an abnormality is cancer, but it can provide clues. Malignant cysts and masses usually look a little different on an ultrasound. They may:

  • Be very large
  • Have papillary structures (bulges) on their outer or inner surface
  • Be divided into multiple segments called loculations
  • Contain blood or other material inside them, making them not look solid black all the way through
Ultrasound showing a large ovarian cancer mass, 17 cm in diameter.
This ultrasound image shows a large ovarian cancer mass, measuring 17 centimeters in diameter. Images alone don’t necessarily reveal whether these types of abnormalities are cancerous, but they can provide clues. (CAMAL/Medical Images)

Some cases of ovarian cancer begin in the fallopian tubes (the tubes that connect the ovaries to the uterus). Fallopian tubes are usually invisible on an ultrasound. However, if there is a problem with the fallopian tube, it may appear as a long, thin mass. This may happen when the fallopian tube grows larger or fills with fluid due to conditions like a blockage, pelvic inflammatory disease, or cancer.

Doctors consider other information when deciding how likely it is that a cyst or mass is malignant. Risk factors that help indicate whether an abnormality is malignant include:

  • Your age
  • Whether you have gone through menopause
  • Levels of CA-125 (a protein that can serve as a sign of ovarian cancer)
  • How big the mass is
  • How much solid tissue is inside of the mass, as opposed to fluid
  • How many bulges or projections a mass contains
  • How many masses are present
  • Whether you have ascites (fluid in your abdomen)

If these factors indicate that you may have a malignancy, your doctor may recommend additional diagnostic tests or surgery to get a better look.

What Don’t Ultrasounds Tell You?

Although ultrasounds have several very useful purposes, they also have limitations. Doctors rely on additional diagnostic tests to gather more information about problems with the ovaries.

Whether You Have Cancer

Ultrasounds can detect abnormalities, and they can provide a clue as to whether an ovarian mass or cyst might be cancerous. However, biopsies are the only way to tell for sure whether a mass contains cancer cells.

For people with ovarian cancer, a biopsy is usually taken during surgery. Biopsies of the ovary are not usually performed before surgery because a needle biopsy of the ovary might potentially release cancer cells that were otherwise contained. The surgeon will send pieces of the mass to a laboratory where the cells will be studied under a microscope to determine whether they are cancerous. Biopsies also help determine the type of ovarian cancer.

Whether Ovarian Cancer Has Spread

The later the ovarian cancer stage is, the farther cancer cells have metastasized (spread within the body). Determining cancer’s stage is important for determining the prognosis (outlook) and knowing which treatment plan may be best.

Doctors don’t use ultrasounds to tell how far ovarian cancer cells have spread. Ultrasounds can’t distinguish whether cells are cancerous or not, and they are only used to look at one part of the body at a time. In order to determine cancer stage and locate metastases, doctors use other imaging tests or procedures. These other tests, which are often better at detecting cancer cells and show larger areas of the body, include:

  • Magnetic resonance imaging (MRI)
  • Computed tomography (CT) scan
  • Positron emission tomography (PET) scan
  • Surgery

Ultrasounds and Cancer Screening

Ultrasounds can be used to detect potential ovarian tumors. Does this mean that this test can help screen people for ovarian cancer?

Researchers have studied whether a transvaginal ultrasound helps detect ovarian cancer during its early stages. They have also studied whether adding blood tests to measure CA-125 levels helps improve ultrasound screening. However, the results were not promising. These tests often pick up benign, noncancerous conditions, which means that individuals who use these screening methods often undergo additional and sometimes unnecessary tests and surgeries. Additionally, ultrasound and CA-125 screenings don’t seem to reduce the overall number of people who die from ovarian cancer.

Experts say that individuals who have an average risk of developing ovarian cancer should not be screened using the currently available methods. However, some doctors recommend regular screening for those with a high risk of ovarian cancer. This includes women who have many family members who have had ovarian or breast cancer or women with genetic mutations in high-risk genes such as BRCA1 or BRCA2.

Talk With Others Who Understand

MyOvarianCancerTeam is the social network for people with ovarian cancer. More than 3,000 members come together to ask questions, give advice, and share their stories with others who understand life with ovarian cancer.

Are you living with ovarian cancer? Have you had to get an ultrasound test? Start a conversation by posting on MyOvarianCancerTeam.

The Foundation for Women’s Cancer Educational Series

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The Foundation for Women’s Cancer (FWC) offers a comprehensive set of free educational courses designed to support patients and caregivers that answers the question, “What do I need to know?” for a cancer journey. From the basics of “what is cancer?” to understanding treatments, clinical trials and how genetics play a role, to lifestyle discussions on sexual health and nutrition, these courses meet you where you are to answer the questions you might have. Available in a variety of self-study and live webinar formats, these courses are available for you when you need them. Additional downloadable resources are a part of each course.

Take Me to Educational Events

Gynecologic Cancer Screening Guidelines

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This resource was originally published by Loyola University Medical Center here.

Screening Guidelines for the Early Detection of Gynecologic Cancers

Screening tests are used to look for disease before you exhibit any symptoms, and are effective when they detect disease early, leading to more effective treatment and positive outcomes. 

American Cancer Society recommends the following screening guidelines for early detection and prevention of gynecologic cancers:

  • Cervical cancer –  Regular testing for cervical cancer should begin at age 21 for cervical cancer prevention. If you are between the ages of 21 and 29, you should have a screening test every three years. Between the ages of 30 and 65, you should have a screening test every five years. If you are over the age of 65 with normal cervical cancer test results, you should no longer be tested. Women over the age of 65 with a history of cervical pre-cancer should continue to be tested for at least 20 years.
     
  • Uterine cancer – The American Cancer Society recommends that at the time of menopause, all women should be told about the risks and symptoms of endometrial cancer, which may include abnormal vaginal bleeding or discharge, or pelvic pain and pressure. Some women, due to their history, may need to consider having a yearly endometrial biopsy.
     
  • Ovarian cancer – There are not currently any screening tests available for ovarian cancer. Doctors often perform a pelvic exam, which includes checking the ovaries, but this exam does not generally detect ovarian cysts unless they are very large. Doctors rely on the common symptoms of bloating, abdominal pain and change in urinary symptoms to guide them in the detection of ovarian cancer. If you believe you are at risk for ovarian cancer, Loyola offers a cancer risk assessment program, which provides detailed risk assessments for patients with a susceptibility to ovarian cancer.
     
  • Vaginal and vulvar cancer – Currently, there are no screening tests available for vaginal and vulvar cancer. The best way for you to know if you might have these cancer types is to get regular check-ups and notify your doctor if you have any signs or symptoms. Your doctor may perform a pelvic exam to look for lumps or changes in your vagina or changes in the skin of your vulva.

Each specific type of gynecologic cancer has its own unique set of risk factors, and there is no way to know who will get gynecologic cancer. Doctors at Loyola are committed to working with you to understand your specific family and medical history and symptoms to develop a screening program specific to your needs. 

What Screening Tests are Available for Gynecologic Cancer?

Cervical cancer is the only gynecologic cancer for which there is a specific screening test, the Pap smear. The Pap test helps prevent cervical cancer by finding precancerous cells that might eventually become cervical cancer. If these cells are detected, doctors at Loyola are able to remove cells and prevent cancer development.

In addition to the Pap test, an HPV test can be performed to look for the HPV virus, a common sexually transmitted virus that, if left untreated, may cause gynecologic cancers. If you are between the ages of 30 and 65, your doctor should perform an HPV test in conjunction with your Pap test. 

Young women can receive an HPV vaccine that will protect against the types of HPV that most commonly cause cervical, vaginal and vulvar cancers. The vaccine is given in a series of three shots, and is recommended for girls ages 11 and 12.

Other gynecologic cancers rely on you to understand your body and work with your doctor if you develop any unusual symptoms or changes in order to detect any cancers early.

If you are concerned about the possibility of gynecologic cancer due to family history, symptoms or screening results, contact your primary care physician who can make additional recommendations for your specific concerns.

Exploring a New Delivery Model for Germline Genetic Testing for Patients With Ovarian Cancer

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This was originally published by The Journal of Clinical Oncology on March 20, 2018 here.

This podcast provides comment on the accompanying JCO article “ENGAGE: Evaluation of a streamlined oncologist-led BRCA mutation testing and counseling model for patients with ovarian cancer” by Nicoletta Colombo, et al and evaluates the need for new delivery models for genetic testing for oncology patients.

Related Article: Evaluation of a Streamlined Oncologist-Led BRCA Mutation Testing and Counseling Model for Patients With Ovarian Cancer

Ovarian Cancer Testing

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This resource was originally published by Lab Tests Online here.

Tests

Currently, there is no specific screening test for ovarian cancer. In 2012, the U.S. Preventive Services Task Force (USPSTF) reaffirmed a 2008 recommendation against screening women for ovarian cancer. This recommendation applies to asymptomatic women but not to women at a high risk of developing ovarian cancer, such as those with a genetic mutation (e.g., BRCA mutation).

The need for a reliable method for early detection of ovarian cancer among asymptomatic women continues to drive ongoing research. Molecular (gene) tests and multimarker approaches are being explored to improve early detection of ovarian cancers. For example, the OVA-1 blood test, which measures levels of five proteins, is used to categorize tumors in ovarian cancer patients as low or high risk. In the meantime, regular physicals, pelvic exams, and an awareness of family history and symptoms are important.

Laboratory Tests

  • CA-125 (Cancer antigen 125) – this is the main laboratory test used to detect and monitor this condition in symptomatic women, even though this tumor marker is not recommended for screening.
  • HE4 (Human epididymis protein 4) – a relatively new tumor marker that shows promise is; it is used to monitor epithelial ovarian cancer in treated patients.
  • BRCA-1 and BRCA-2 – genetic tests that can determine if a woman is at high risk of developing ovarian cancer, but these tests are not used for diagnosis or monitoring.

Other tests that may be ordered to help detect and monitor different types of ovarian tumors include:

Non-laboratory Tests

Non-laboratory tests that are used to evaluate abnormalities include:

  • Ultrasound (pelvic and/or transvaginal) – uses sound waves to create a picture of the uterus and ovaries; it can help determine whether an ovarian growth is likely to be a cancer or a fluid-filled cyst.
  • CT scan (computerized tomography)
  • X-ray of the gastrointestinal tract
  • MRI (magnetic resonance imaging)

It is important to have regular checkups and to consult with a healthcare practitioner if symptoms develop. Symptoms associated with ovarian cancer are subtle and non-specific, and there are many non-cancerous conditions that can cause similar symptoms.

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Identifying Biomarkers Gives Doctors Known Targets to Treat Many Cancers

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This blog was originally published by Cancer Treatments Centers of America on August 21, 2019, here.

Biomarkers
Doctors are increasingly relying on biomarkers, which help determine a patient’s overall health and/or the presence of disease. Learn what biomarkers are and why they are increasingly important in cancer care.

When faced with opposition, it’s beneficial to learn as much as possible about the opponent. A pitcher reads a scouting report before facing a lineup. An army consults intelligence before engaging the enemy in battle.

The same principles apply to the treatment of some cancers. When treating a tumor, it’s important for a doctor to know as much as possible about that cancer—specifically, what is driving the tumor’s growth.

To get the inside information on a tumor, doctors are increasingly relying on biomarkers, short for biological markers, measurable signs or substances in the body that may indicate a patient’s overall health and/or the presence or progression of disease.

The discovery of biomarkers in cancer drastically changed the course of cancer treatment. For decades, many cancers were treated similarly, with surgery, radiation therapy or chemotherapy. Identifying biomarkers in cancer cells has led to the development of new precision medicine drugs, such as targeted therapy and immunotherapy, designed to target specific features in cancer cells, potentially reducing the damage to healthy cells. “The routine use of a variety of biomarkers has substantially changed the way in which cancer medicine is practiced,” says Maurie Markman, MD, President of Medicine & Science at Cancer Treatment Centers of America® (CTCA), “from providing more accurate prognostic information to assisting in the prediction of specific therapeutic strategies that are more likely to result in a favorable outcome for an individual patient.”

What are biomarkers?

A biomarker is any measurable indicator of a person’s health. Blood pressure is a biomarker, as are body temperature, blood sugar and cholesterol measurements. In cancer, biomarkers also include proteins, hormones, gene aberrations, such as mutations or rearranged genes, and other molecules found in or on cancer cells. Cancer biomarkers may be found in routine blood, urine or stool tests. Others may require a biopsy and/or advanced genomic testing to uncover. “Genomics has made it so much easier to find gene mutations,” says Arturo Loaiza-Bonilla, MD, MSEd, FACP, Vice Chair for the CTCA® Department of Medical Oncology. “Now we may be able to target a mutation and potentially get the cancer to stop growing.”

Biomarkers play multiple roles in the treatment of diseases, such as cancer, including:

Diagnostic: Helping confirm the presence of disease, sometimes before symptoms develop

Prognostic: Helping forecast the progression and aggressiveness of the disease and the risk of recurrence

Predictive: Helping doctors identify how patients may respond to certain drugs

Biomarkers may play any or all these roles and more. Some biomarkers may be used to assess a patient’s risk of developing disease, the effectiveness of a treatment or whether a treatment is safe or toxic.

Common cancer biomarkers include:

  • BRCA1 and BRCA2 genes: Mutations in these genes may increase a woman’s risk of breast and ovarian cancer. In men, it may increase the risk of prostate cancer.
  • PSA: Prostate specific antigen may indicate prostate cancer. This biomarker may be used not just to diagnose the disease, but to measure its progression and how the treatment is performing.
  • HER2: Human epidermal growth factor receptor 2 is found in many cancers, especially breast cancer. The targeted therapy drug trastuzumab and other similar monoclonal antibodies may be a treatment option for patients with HER2-positive cancers.
  • BCR-ABL: This gene, known as the Philadelphia chromosome, is found in patients with chronic myelogenous leukemia. Presence of the gene may indicate the patient may respond well to treatment with a tyrosine kinase inhibitor drug such as imatinib.
  • PD-L1: Programmed death ligand 1 is the companion receptor to PD-1. It may indicate a cancer’s ability to evade the immune system. Immunotherapy drugs called checkpoint inhibitors may be an option to treat cancers high in PD-L1.
  • CA-125: High levels of cancer antigen-125 are found in many cancers as well as other diseases. Treatment options for cancers with CA-125 vary depending on where the cancer originated.
  • MSI-H: Microsatellite instability-high is a mutation in the DNA of cells found in many cancers, especially colorectal cancer. Checkpoint inhibitor drugs have been approved for cancers with MSI-H.

Difficult targets

Biomarkers don’t always tell the full story. Discovery of a biomarker that might indicate an increased cancer risk doesn’t mean a patient will get cancer. Not all cancers have identifiable biomarkers. And identifying a driving biomarker in a cancer does not necessarily lead to a treatment option. Some biomarkers for cancer have no corresponding targeted therapy or immunotherapy drug. For example:

  • TP53: Tumor protein 53 is a tumor suppressor gene designed to help stop cancer cells from growing. TP53 mutations are the most common found in cancer cells and may be found in most types of cancer.
  • RAS: About 30 percent of all cancers, including 95 percent of all pancreatic cancers, have known mutations in the RAS family of genes that control cell death and growth.

No targeted therapy drugs have been approved specifically to treat cancers with these mutations. “A number of recognized critical signaling pathways in cancer development, progression and resistance remain very difficult to ‘target’ to influence clinical outcomes,” Dr. Markman says. “The ability to successfully and safely target either or both of these pathways has the potential to be an important advancement in cancer management.”

Many cancers, especially solid tumors, have multiple biomarkers, any one of which may be able to drive a cancer’s growth. Target one biomarker, and another may take over as the driving mutation. And not all the same biomarkers are found in every cancer cell. “As cancer cells grow, they start to develop new abnormalities, mistakes made while the cells are multiplying,” Dr. Bonilla says. These new mutations may make the cancer more resistant to treatment.

Also, doctors need to take steps to prevent the patient from being harmed by the process of targeting a specific biomarker. For instance, patients on a checkpoint inhibitor that targets cancers high in PD-L1 may develop symptoms of autoimmune diseases, such as colitis. “The goal is to find the specific biomarker that every single cell expresses without compromising the normal cells,” Dr. Bonilla says, “because once you tell the immune system to kill a population of cells, it is going to kill all those cells, whether they are good or bad. But if you are able to find the specific biomarker that is the hallmark of this disease and needs to be eliminated, then it’s much easier to find a therapy.”

The discovery of biomarkers has led to game-changing developments in the cancer treatment. Women who learn they have BRCA mutations are now empowered to make potentially life-saving decisions to prevent breast and ovarian cancer. Men with slow-developing prostate cancer can now actively monitor their disease, in part, because their PSA levels can be measured. And research is ongoing to find new biomarkers to help in the treatment of other cancers and diseases, such as diabetes, Parkinson’s disease and heart disease.

“Biomarkers offer an opportunity to apply genomics to population health and see what diseases or conditions people may be predisposed to,” says Pamela Crilley, DO, Chair of the CTCA Department of Medical Oncology. “Am I going to get diabetes? Am I going to get elevated cholesterol? Is there anything I can do about it? Look at hereditary breast and ovarian cancers. The science has led to being able to prevent disease in patients with BRCA1 and BRCA2 mutations. Now we may be able to significantly reduce your risk of disease.”