How to differentiate ovarian cancer and endometriosis?

Question

Hello doctor,

I am a 45-year-old female. I have been concerned about ovarian cancer or endometriosis.

I have had a 0.9-inch mass on my right ovary for the past year. CA125 was 51 last year, and now it is 109, and CA19-9 was 24 last year, and now it is 130; and I have five cystic lesions on my liver. I also have multiple fibroids (used to have two), and now they say ‘a few fibroids’.

I also have blood in my urine. I also have pain when I pee on my right side. The liver and spleen are sore to the touch. The spleen is mildly enlarged. I always have stitch pain in my right ovary.

I also experience extreme pain with periods. I have an enlarged anteverted uterus with multiple small cysts on the posterior wall. It appears like adenomyosis. I do not trust the radiologist where I live. I work in health care and have seen many mistakes.

Last year, I also had a rupture, which caused a pleural effusion, but I was never properly diagnosed. Only I saw the effusion, but I know the pain and shortness of breath experienced before it was due to a ruptured cyst, perhaps with torsion.

I will add the most recent CT later today when it is available. In the precision one, I was told I had two liver hemangiomas, and they stayed unchanged for ten years. Now I have five. I am not taking any medications. I am very healthy and doing active exercise daily.

I do Pilates and weight lifting, and I am a non-smoker. I have a CEA of 4.4 and a GGT of 77. I am in the perimenopausal stage. I have had heavy periods my entire life. I experienced extreme pain last year, and now it is worse, and my right side is sore all the time.

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I have read your query and can understand your concern.

I can understand why you are deeply concerned, given your symptoms and the changes in your imaging and bloodwork. Your elevated CA-125 (cancer antigen 125) and CA 19-9 (carbohydrate antigen 19-9) levels, ovarian mass, liver lesions, fibroids, and pain need a thorough evaluation by a specialist, ideally a gynecologic oncologist or a multidisciplinary team.

Key concerns to address with your doctors:

Ovarian mass and CA-125 or CA 19-9 increase, CA-125 can be elevated in ovarian cancer but also in endometriosis, adenomyosis, and inflammation. CA 19-9 is less specific but can be associated with gastrointestinal, pancreatic, and ovarian conditions. A repeat pelvic MRI (magnetic resonance imaging) with contrast and possible tumor marker panels (CEA (carcinoembryonic antigen), HE4 (human epididymis protein 4), AFP (alpha-fetoprotein), LDH (lactate dehydrogenase), inhibin) may help differentiate benign vs. malignant causes.
Liver lesions: The increase from two to five lesions and their nature (cystic vs. solid) raises questions. Liver MRI (magnetic resonance imaging) with contrast is more specific for characterizing these lesions (for example., hemangiomas vs. metastases vs. cystic changes). Your elevated GGT (gamma-glutamyl transferase) (77) should be correlated with liver function tests.
Fibroids and adenomyosis: Your worsening symptoms suggest possible rapid growth or degeneration. A pelvic ultrasound with a Doppler or MRI can assess fibroid size and adenomyosis severity.
Blood in urine and right-sided pain: Consider renal ultrasound, cystoscopy, and urine cytology to rule out kidney, bladder, or ureteral involvement. Right-sided pain with hematuria could be related to ureter compression, kidney stones, or even endometriosis affecting the ureters.
Pleural effusion and ruptured cyst history: A previous ruptured cyst with pleural effusion is concerning. If not endometriosis-related, it could suggest a malignant process or peritoneal irritation. CT (computed tomography) scan review will be important to correlate past findings.

Next steps:

Get a second opinion from a high-volume center (preferably a gynecologic oncologist or a hepatobiliary specialist).
A full imaging review with an independent radiologist is required, with comprehensive laboratory work (including liver function, kidney function, and additional tumor markers).
Consider a biopsy of any concerning liver or ovarian lesions if imaging is inconclusive.

Since you are in healthcare, you know how vital it is to advocate for yourself. If you do not trust the radiologists, insist on an external review or referral to a tertiary care center.

I hope this answers the query.

Please let me know if I can assist you further.

Thank you.