Which was normal, and it included a normal pap smear. What is the SINGLE most appropriate initial investigation?

A 68 year old nulliparous woman presents to her general practitioner with a six month history of poorly-localised abdominal discomfort and a constant feeling of bloatedness. On pelvic examination you find a nontender, 7 cm, solid, irregular, fixed, left adnexal mass. Her last examination was 1 year ago, which was normal, and it included a normal pap smear. What is the SINGLE most appropriate initial investigation?

A. CA-125
B. CA15-3
C. CA19-9
D. CEA
E. AFP

This is a classic presentation of ovarian cancer Concerns should be raised with any pelvic mass that is identified after menopause. Ovaries in the postmenopausal age group should be atrophic, and anytime they are enlarged, the suspicion of ovarian cancer arises. The term “nulliparous” was thrown into the question to help guide you towards the suspicion of ovarian cancer as nulliparity is a risk factor. In a woman of this age with persistent symptoms of abdominal discomfort and bloating it is essential to consider the possibility of ovarian cancer. Due to the nonspecific nature of symptoms of this disease, you should have a low threshold for initiating investigations. Serum CA125 is a tumour marker that is used in the investigation of possible ovarian cancer, though it is not 100% sensitive or specific for this disease. NICE guidelines state that serum CA 125 should be performed if a woman - especially if aged 50 years old or over - has any of the following symptoms on a regular basis: • abdominal distension or ‘bloating’ • early satiety or loss of appetite • pelvic or abdominal pain • increased urinary urgency and/or frequency