Download Adnexal mass

Dr Safoura Rouholamin
Isfahan Medical University
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Adnexal mass
 An adnexal is a common gynecologic problem
 5 to 10 % lifetime risk
 Adnexal masses may be found in females of all ages,
fetuses to the elderly
 Wide variety of types of masses
 May be symptomatic or discovered incidentally on
pelvic examination or imaging

National Institutes of Health Consensus Development Conference Statement. Ovarian cancer: screening,
treatment, and follow-up.AU SOGynecol Oncol. 1994;55(3 Pt 2):S4.
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CLINICAL APPROACH
 anatomic location of the mass
 age
 reproductive status of the patient
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CLINICAL APPROACH
 Excluding urgent conditions )ectopic pregnancy,
adnexal torsion)
 Excluding malignancy (ovarian or fallopian tube
cancer)
 few patients who present with an adnexal mass will
ultimately be diagnosed with a malignancy
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Anatomic location
Ovarian masses
 Physiologic cysts (follicular or corpus luteum)
 Benign ovarian neoplasms (endometrioma, mature
teratoma [dermoid cyst])
 Ovarian cancer or metastatic disease from a nonovarian primary cancer
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Anatomic location
Fallopian tube
 Ectopic pregnancy
 Hydrosalpinx
 Fallopian tube cancer
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Anatomic location
Mesosalpinx or mesovarium
 Paratubal or paraovarian cyst
 Tuboovarian abscess
 Broad ligament leiomyoma
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Age
 Children and adolescents
 less frequently in children and adolescents than in reproductive-age
 significant likelihood of adnexal torsion
 ovarian malignancy (approximately 10 to 20 percent (Germ cell tumors are
most common 35 % compared with 20 % in adults)
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Gynecologic malignancies in women aged less than 25 years.AUYou W, Dainty LA, Rose GS, Krivak T, McHale MT, Olsen CH,
Elkas JC SOObstet Gynecol. 2005;105(6):1405.
Can we preoperatively risk stratify ovarian masses for malignancy?AUOltmann SC, Garcia N, Barber R, Huang R, Hicks B,
Fischer A SOJ Pediatr Surg. 2010 Jan;45(1):130-4.
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Age
Premenopausal women
 majority of adnexal masses occur in reproductive-age
 most of these masses are benign 80-85%
 Benign adnexal masses is associated with reproductive function
 Pregnancy-related etiologies
 Many of adnexal masses are associated with the menstrual cycle or
reproductive hormones (eg, follicular cysts, endometriomas) and are
common findings found in this age
 Ovarian or fallopian tube cancer is less likely in premenopausal than
postmenopausal women, but the possibility of malignancy should be
considered in all patients
 Increase ovarian cancer with age (1.8-2.2/100000 age 20-29Y, 9.0-15.2 /100000
age 40-49Y)
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Age
Pregnant women
 Ectopic pregnancy and luteomas
 Corpus luteum cysts
 Theca lutein cysts
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Age
Postmenopausal women
 Excluding malignancy is the main priority in
postmenopausal women with an adnexal mass
 Average age of diagnosis of ovarian cancer in the
United States is 63 years old
 Urgent conditions (eg, adnexal torsion, tuboovarian
abscess) may also occur in postmenopausal women,
but are less common and are more likely to be
associated with malignancy
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seer.cancer.gov/ (Accessed on September 07, 2012)
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GENERAL EVALUATION
 Women with an adnexal mass typically present with
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gynecologic symptoms and a mass is identified on
pelvic imaging. Alternatively, an adnexal mass is
discovered incidentally on pelvic examination or
imaging in many patients.
Medical history
Physical examination
Imaging studies
Laboratory evaluation
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Medical history
 Pelvic pain or pressure is the most common symptom
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associated with an adnexal mass
genital tract bleeding
Ovarian physiologic cysts or neoplasms: dull, achy pain
that is usually localized to the side of the mass or may be
asymptomatic
endometrioma: dysmenorrhea or dyspareunia
history of infertility(endometrioma or hydrosalpinx
history of fever or vaginal discharge
questions about risk factors and symptoms associated with
ovarian or fallopian tube cancer
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Initial evaluation
 family history of ovarian, breast, uterine, or colon
cancer
 family history suggestive of a hereditary ovarian cancer
syndrome (BRCA gene mutation or Lynch syndrome)
should be counseled about genetic testing
 should undergo surgical evaluation if any suspicious
adnexal mass
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Physical examination
 Size, consistency, and mobility of a mass
 solid mass that is irregular or fixed or is associated
with posterior cul-de-sac nodularity
 abdominal distention and ascites and/or an
abdominal mass
 rectal mass, rectal bleeding
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Physical examination
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Determine degree of clinical suspicion of malignancy
symptoms of pelvic or abdominal pain or pressure
bloating, or gastrointestinal or urinary tract symptoms
Asymptomatic present at an advanced stage with an
acute condition and associated symptoms (eg, bowel
obstruction, pleural effusion)
 Infrequently, a malignant mass may rupture or torse
and present with acute pain
 symptoms related to estrogen excess (abnormal
uterine bleeding) or androgen excess (virilization or
hirsutism)
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Imaging studies
Pelvic ultrasound
 sensitivity of pelvic ultrasound for the diagnosis of ovarian
cancer ranged from 86 to 91 percent and the specificity ranged
from 68 to 83 percent
 Laboratory studies
 A baseline level of biomarkers is established for use for further
monitoring during and after treatment
 biomarkers may play a role in predicting whether optimal
cytoreduction is feasible
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Myers ER, Bastian LA, Havrilesky LJ, et al. Management of Adnexal Mass. Evidence Report/Technology
Assessment No.130 (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-02-0025).
AHRQ Publication No. 06-E004, Agency for Healthcare Research and Quality, Rockville, MD February 2006.
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Pelvic examination, tumor marker level, and gray-scale and Doppler sonography in the prediction of pelvic cancer.
AURoman LD, Muderspach LI, Stein SM, Laifer-Narin S, Groshen S, Morrow CP SOObstet Gynecol. 1997;89(4):493.
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Assessing risk
 most important factor: appearance of the mass on
imaging
 transvaginal ultrasound is the preferred study
 sensitivity of pelvic ultrasound for diagnosis of ovarian
cancer ranged from 86 to 91 % and the specificity
ranged from 68 to 83 %
 Myers ER, Bastian LA, Havrilesky LJ, et al. Management of Adnexal Mass. Evidence
Report/Technology Assessment No.130 (Prepared by the Duke Evidence-based Practice Center
under Contract No. 290-02-0025). AHRQ Publication No. 06-E004, Agency for Healthcare
Research and Quality, Rockville, MD February 2006.
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simple cyst
 Anechoic fluid filling the cyst cavity
 Thin walls
 Distal acoustic enhancement – No impairment of
sound transmission through the mass (in other words,
no loss of signal from tissues behind the cyst)
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Transvaginal ultrasound image of the left ovary. A
normal-appearing left ovary containing a simple
anechoic clear cyst, which is consistent with a follicle. A
small amount of ovarian tissue is identified
surrounding the follicle, as indicated by the arrow.
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simple cyst
 normal follicles
 cystadenoma
 paraovarian or paratubal cysts
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Paraovarian cystadenomas and cystadenofibromas: sonographic characteristics in 14 cases.AUKorbin CD, Brown DL,
Welch WR SORadiology. 1998;208(2):459.
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Risk of malignancy in unilocular ovarian cystic tumors less than 10 centimeters in diameter.AUModesitt SC,
Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ, van Nagell JR Jr SOObstet Gynecol. 2003;102(3):594.
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premenopausal women
 simple adnexal cysts that are <3 cm in diameter typically
represent normal follicles and may be considered a normal
finding.
 when up to 5 cm in diameter, these simple cysts are so
commonly due to normal menstrual physiology that the
Society of Radiologists in Ultrasound (SRU) does not
recommend follow-up when asymptomatic
 Asymptomatic simple cysts between 5 and 7 cm should
undergo yearly sonographic evaluation.
 When a simple cysts exceeds 7 cm in size, the SRU suggests
that magnetic resonance imaging be considered if the cyst
was not thoroughly evaluated sonographically due to
potential technical limitations
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postmenopausal women
 any threshold from 1 to 3 cm as a justifiable cut-off for
not following a simple cyst in a postmenopausal
woman
 malignancy in a simple cysts is rare
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Other masses that may appear as
simple cysts
 A cystadenoma is a benign neoplasm that usually
arises from the ovary but sometimes from the fallopian
tube.
 A cystadenoma should be considered as a possible
etiology if there is a relatively large simple cyst (>5 cm
in diameter in premenopausal women or >3 cm in
diameter in postmenopausal women).
 Paraovarian cystadenomas are uncommon but
typically have a small nodule within a cystic
extraovarian mass
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 Simple adnexal cysts are usually ovarian in etiology but
may also be paraovarian or paratubal cysts.
 These are common and generally appear as simple
cysts adjacent to the ovary
 It is usually not important from a management
perspective whether the cyst arises from the ovary or is
next to the ovary
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not a simple cyst
R/O physiologic process
 corpus luteal involution
 hemorrhage into a cyst
 adjoining simple cysts
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Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound
Consensus Conference Statement.AULevine D, Brown DL, Andreotti RF, Benacerraf B, Benson CB, Brewster WR,
Coleman B, Depriest P, Doubilet PM, Goldstein SR, Hamper UM, Hecht JL, Horrow M, Hur HC, Marnach M, Patel
MD, Platt LD, Puscheck E,
Smith-Bindman R SORadiology. 2010 Sep;256(3):943-54. Epub
2010 May 26.
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The likelihood ratio of sonographic findings for the diagnosis of hemorrhagic ovarian cysts.AUPatel MD, Feldstein VA,
Filly RA SOJ Ultrasound Med. 2005 May;24(5):607-14; quiz 615.
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 Corpus luteum – The corpus luteum has a characteristic
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appearance to experienced sonographers, with thickened walls,
circumferential color Doppler flow, and a small central lucency
containing echoes that can be confusing to less experienced
imagers.
Two simple cysts – Two simple cysts next to each other can
simulate a septated single cyst.
Hemorrhagic cyst – Hemorrhage into a cyst, which usually
indicates a physiologic cyst, can simulate septations and mural
nodules.
A fine network of thin linear to curvilinear echoes, sometimes
called a fishnet or reticular pattern, is strongly suggestive of a
hemorrhagic cyst
These linear echoes are usually very thin and do not extend
completely uninterrupted across the cyst, unlike true septa.
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 For patients with the characteristic appearance of a
hemorrhagic cyst who are asymptomatic or have
symptoms that resolve as expected, follow-up imaging
is not needed
 If follow-up imaging is performed, most hemorrhagic
cysts will have resolved or become smaller if the repeat
sonographic assessment is performed six to eight
weeks after diagnosis.
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Transvaginal ultrasound image in a 38-year-old female
shows a complex ovarian cyst (cursors) that contains a
reticular pattern of internal echoes. This appearance is
classic for a hemorrhagic ovarian cyst.
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Transvaginal ultrasound image of the left adnexa showing a tuboovarian abscess. A complex solid and cystic mass is identified in
the left adnexa. The tubo-ovarian abscess is seen as a complex cyst
(large arrow) and fluid-filled tube (short arrow).
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Benign mass
Some benign ovarian masses have characteristic
sonographic features
 follicular or corpus luteal cysts: Surgery is not required
 endometriomas (depends upon whether the patient is
symptomatic)
 mature teratomas (dermoid)(exclude malignancy and
prevent malignant transformation)
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characteristics of specific entities
 Endometrioma
 Homogeneous low- to medium-level echoes in a cystic
mass (whether unilocular or multilocular), in the
absence of a solid component
 small echogenic foci on the inner wall of the cyst
 varying degrees of echogenicity in the different locules
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Endometriomas: diagnostic performance of US.AUPatel MD, Feldstein VA, Chen DC, Lipson SD, Filly
RA SORadiology. 1999;210(3):739.
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Transvaginal ultrasound image of the right adnexa showing an endometrioma of
the right ovary. The homogeneous echo pattern of the cyst contents (ie, "groundglass" appearance) is characteristic of an endometrioma (short arrow).
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Transvaginal ultrasound with color Doppler image of the left adnexal
showing a benign endometrioma of the left ovary viewed with color
Doppler imaging. No flow within the cyst can be demonstrated; however,
blood flow is demonstrated within the wall of the cyst in the ovarian tissue
itself (long arrow). Also identified within the left ovary is a small follicle
(short arrow).
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Mature teratoma
 hyperechoic nodule within the mass with distal
acoustic shadowing
 may also be uniformly hyperechoic or have bright
linear to punctate echoes (the latter sometimes
referred to as the dermoid mesh
 Calcification also can be present and may vary in size.
 Floating globules is an uncommon appearance of
teratomas but seems to be predictive
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Large calcifications in ovaries otherwise normal on ultrasound.AUBrown DL, Laing FC, Welch
WR SOUltrasound Obstet Gynecol. 2007;29(4):438.
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Transvaginal ultrasound image of a benign teratoma that features
heterogeneous contents, smooth outer surface. The arrow points to
lines that are hair. There are hyperechoic portions and homogeneous
echoes (mucin).
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 Pedunculated leiomyoma
 heterogeneous, hypoechoic, solid masses
 Hydrosalpinx
 tubular in shape and may have septations or nodules
in its wall
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Interface vessels on color/power Doppler US and MRI: a clue to differentiate subserosal uterine myomas from
extrauterine tumors.AUKim SH, Sim JS, Seong CK SOJ Comput Assist Tomogr. 2001;25(1):36.
Transvaginal sonographic markers of tubal inflammatory disease.AUTimor-Tritsch IE, Lerner JP, Monteagudo A,
Murphy KE, Heller DS SOUltrasound Obstet Gynecol. 1998;12(1):56.
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Paratubal or paraovarian cyst
 A paratubal or paraovarian cyst arises from the broad
ligament in the area of the fallopian tube or ovary
 simple cysts that originate from the remnants of
paramesonephric (Müllerian) or mesonephric (Wolffian)
ducts that are present during urogenital embryologic
development.
 A simple, asymptomatic paratubal or paraovarian cyst can
be managed expectantly without further follow-up.
 Surgical removal is indicated for these lesions if they
undergo torsion, cause persistent pain or pressure
symptoms, or appear neoplastic.
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Hydrosalpinx
 A hydrosalpinx is an edematous fallopian tube, typically caused
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by an infection
A hydrosalpinx may be asymptomatic or may result in chronic
pelvic pain or infertility and sometimes be the source of chronic
pelvic pain
Other etiologies of chronic pelvic pain should be excluded before
salpingectomy is performed.
An asymptomatic hydrosalpinx does not generally need to be
removed or followed with imaging.
The exception to this is women undergoing in vitro fertilization.
The use of ultrasound-based 'soft markers' for the prediction of pelvic pathology in women with
chronic pelvic pain--can we reduce the need for laparoscopy?AUOkaro E, Condous G, Khalid A,
Timmerman D, Ameye L, Huffel SV, Bourne T SOBJOG. 2006;113(3):251.
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Transvaginal ultrasound image of the left adnexa showing a paraovarian cyst. An
anechoic structure is noted in the left adnexa separate from the left ovary. The
cyst has a thin wall, as indicated by the arrow, with no identifiable ovarian tissue
surrounding the cyst.
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Transvaginal ultrasound image of the adnexa showing a
hydrosalpinx. There is a tubular fluid collection with low-level
echoes. An incomplete septation is identified by the arrow.
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Transvaginal ultrasound image of the right adnexa showing a pedunculated
fibroid. A solid-appearing mass is noted in the right adnexa (long arrow).
No cystic areas are identified. The mass is slightly heterogeneous and has
no appreciable posterior enhancement but has some areas of shadowing
(short arrow). The mass is separate from the right ovary. The arrowhead
demonstrates a thick stalk that connects the fibroid to the uterus.
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Transvaginal
ultrasound
image
of
the
adnexa
showing
a
hydrosalpinx
with
three-dimensional
rendering.
A
cystic
structure
with a septation (arrow) is identified in the adnexa. The rendered image (on right side
of illustration) demonstrates a tubular fluid collection with incomplete septations
indicating a serpiginously dilated fallopian tube.
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Ultrasound morphology associated
with malignancy
 Solid component that is not hyperechoic and is often
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nodular or papillary
Septations, if present, that are thick (>2 to 3 mm)
Color or power Doppler demonstration of flow in solid
component
Presence of ascites (any peritoneal fluid in
postpostmenopausal women and more than a small
amount of peritoneal fluid in premenopausal women
is abnormal)
Peritoneal masses, enlarged nodes, or matted bowel
(may be difficult to detect)
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Malignancy
 Septations, if present, that are irregularly thick (>2 to 3 mm)
 Color or power Doppler demonstration of flow in the solid
component.
 Presence of ascites (any intraperitoneal fluid in postmenopausal
women and more than a small amount of intraperitoneal fluid in
premenopausal women is usually abnormal).
 Peritoneal masses, enlarged nodes, or matted bowel (may be
difficult to detect by ultrasound).
 Evaluating the risk of ovarian cancer before surgery using the ADNEX model to
differentiate between benign, borderline, early and advanced stage invasive, and
secondary metastatic tumours: prospective multicentre diagnostic study.AUVan Calster
B, Van Hoorde K, Valentin L, Testa AC, Fischerova D, Van Holsbeke C, Savelli L, Franchi
D, Epstein E, Kaijser J, Van Belle V, Czekierdowski A, Guerriero S, Fruscio R, Lanzani C,
Scala F, Bourne T, Timmerman D, International Ovarian Tumour Analysis Group SOBMJ.
2014;349:g5920.
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ovarian cystadenocarcinoma
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Transvaginal ultrasound image of an ovarian cancer of the left ovary. The
ovarian mass is 4.7 cm and primarily solid, as indicated by the long arrow.
Color Doppler imaging demonstrates blood flow within the solid portion of
the ovarian mass (short arrow). Almost no normal ovary is visible in the
image.
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Adnexal mass
 Excluding malignancy is a principal goal of the
evaluation of an adnexal mass
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Magnetic resonance imaging
 ultrasound has failed to lead to a confident diagnosis, magnetic
resonance imaging (MRI) evaluation can be invaluable
 MRI can demonstrate findings that lead to a confident diagnosis
of a particular entity.
 adnexal mass may be an exophytic leiomyoma.
 As another example, if the imager thinks that an adnexal mass is
probably a benign cystic teratoma based on sonographic
appearance but does not have enough confidence in concluding
that malignancy is practically excluded (let us say 1 percent
chance or less), MRI would be of tremendous additional value
but only if it was used to change who or where the surgical
treatment was performed.
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Magnetic resonance imaging
 the need for further MRI characterization of an
adnexal mass evaluated sonographically depends on
the experience and diagnostic confidence of the
imager as well as the experience and surgical approach
of the gynecologic surgeon
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ultrasound morphology
High risk
 Features of malignancy, ie, solid, nodular, thick
septations
Intermediate risk
 anechoic and/or unilocular, but no features of
malignancy (eg, a mass with thin septations or low
level echoes)
Low risk
. Anechoic unilocular fluid filled cysts with thin walls
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Other characteristics of the mass
 size
 bilaterality
 Observational series have generally found the average
size of malignant adnexal masses to be >10 cm
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Pelvic examination, tumor marker level, and gray-scale and Doppler sonography in the prediction of pelvic
cancer.AURoman LD, Muderspach LI, Stein SM, Laifer-Narin S, Groshen S, Morrow CP SOObstet Gynecol.
1997;89(4):493.
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Management of the adnexal mass.AUCurtin JP SOGynecol Oncol. 1994;55(3 Pt 2):S42.
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imaging findings suggestive of
metastatic disease
Ascites or evidence of metastatic disease (eg, peritoneal
masses, enlarged lymph nodes)
 if are present, even in the absence of malignant
features in the mass itself, surgical exploration is
required
 Other factors, such as menopausal status, an elevated
tumor marker, symptoms, or risk factors
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menopausal status
 The degree of clinical suspicion of ovarian cancer is
significantly higher for postmenopausal than for
premenopausal women
 surgical exploration is required for many
postmenopausal women with an ovarian mass.
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serum tumor marker
 postmenopausal women with a mass with an
intermediate or low risk appearance, surgical
exploration is required if a serum tumor marker is
elevated.
 CA 125 is the tumor marker used most commonly for
the detection of epithelial ovarian cancer
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Serum markers
 epithelial ovarian carcinoma
 CA 125 is the most commonly used laboratory test
 measure CA 125 in all postmenopausal women with an
adnexal mass.
 In premenopausal women, measure a serum CA
125 only if the ultrasound appearance of a mass raises
sufficient suspicion of malignancy to warrant a repeat
ultrasound or surgical evaluation
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serum tumor marker
 CA 125 >35 U/mL has a sensitivity of 69 to 97 percent
and a specificity of 81 to 93 percent for the diagnosis of
ovarian cancer
 marker algorithms OVA1 and ROMA may be used to
decide whether to refer a patient to a gynecologic
oncologist
 Other serum markers are used to evaluate women for
less common histologic types, germ cell and sex cordstromal tumors
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Myers ER, Bastian LA, Havrilesky LJ, et al. Management of Adnexal Mass. Evidence Report/Technology
Assessment No.130 (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-02-0025).
AHRQ Publication No. 06-E004, Agency for Healthcare Research and Quality, Rockville, MD February 2006. 61
Serum markers
 other histologic types
(AFP,hCG,LDH,E2,Inhibin,Testost, DHEA,AMH )
 A child or adolescent who presents with an adnexal
mass (germ cell tumor)
 Patients with an adnexal mass who present with
symptoms or signs of estrogen excess (abnormal
uterine bleeding) or androgen excess (virilization or
hirsutism): germ cell or sex cord-stromal tumor.
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Risk factors
 Risk factors (other than a hereditary ovarian cancer
syndrome) or symptoms alone are not typically an
indication for surgery in a woman with a mass with an
intermediate or low risk appearance
 The absence of risk factors and symptoms helps to
support a decision to manage the patient with
surveillance
 an adnexal mass in a postmenopausal woman was
noted on imaging prior to menopause and is
unchanged; this information is reassuring and
surveillance is typically appropriate for these patients
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Three options for managing an
adnexal mass
Surgery
 malignancy is suspected
 Other risks associated with the mass (eg, torsion, infection)
 Mass is symptomatic
 (oophorectomy or ovarian cystectomy)
Continued surveillance
 suspicion of malignancy is low, but it has not been completely
excluded.
 Surveillance includes serial pelvic ultrasounds and/or measurement of
serum tumor markers
Expectant management
 etiology of the mass is benign
 no other indications for surgery or surveillance
 no further follow-up is needed
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Premenopausal women
High risk
surgery is required for women with a mass with features associated with
malignancy or any adnexal mass combined with
ascites and/or evidence of metastatic disease consistent with ovarian
cancer
Intermediate/low risk
Many masses related to reproductive function occur in premenopausal
women
greater proportion of patients with a mass with an intermediate or low
risk appearance.
most premenopausal women with a mass with an intermediate or low risk
appearance, we suggest surveillance rather than surgery
The exceptions to this are women with a very elevated serum CA 125 or
those in whom a germ cell or sex cord-stromal tumor is suspected
These neoplasms are uncommon, but often occur in younger women
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premenopausal women
 measure a serum CA 125 only if
 the ultrasound appearance of a mass raises sufficient suspicion of malignancy
to warrant a repeat ultrasound or surgical evaluation
 CA 125 value of >35 U/mL has a sensitivity and specificity of less than 80
percent, and possibly as low as 50 to 60 percent, based upon data from a meta-
analysis of six studies
 low specificity in premenopausal women is because an elevated CA 125 is also
associated with many conditions other than ovarian cancer, and many of these
are found in reproductive age patients
 Based upon the poor diagnostic performance of CA 125 in premenopausal
women, there has been some discussion of using a higher CA 125 level
(>200 U/mL), but this has been evaluated in few studies
 The markers OVA1 and ROMA may be used to decide whether to refer a patient
to a gynecologic oncologist
 Validation of referral guidelines for women with pelvic masses.AUIm SS, Gordon AN, Buttin BM, Leath CA
3rd, Gostout BS, Shah C, Hatch KD, Wang J, Berman ML SOObstet Gynecol. 2005;105(1):35.
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Conditions associated with an
elevated serum CA 125 concentration
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Gynecologic malignancies
Epithelial ovarian, fallopian tube, and primary peritoneal cancers
Endometrial cancer
Benign gynecologic conditions
Benign ovarian neoplasms
Functional ovarian cysts
Endometriosis
Meig syndrome
Adenomyosis
Uterine leiomyomas
Pelvic inflammatory disease
Ovarian hyperstimulation
Pregnancy
Menstruation
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Nongynecologic conditions
Cirrhosis and other liver disease
Ascites
Colitis
Diverticulitis
Nongynecologic cancers
Appendicular abscess
Breast
Tuberculosis peritonitis
Colon
Liver
Gallbladder
Pancreas
Pancreatitis
Pleural effusion
Pulmonary embolism
Pneumonia
Cystic fibrosis
Heart failure
Lung
Myocardiopathy
Hematologic malignancies
Myocardial infarction
Pericardial disease
Renal insufficiency
Urinary tract infection
Recent surgery
Systemic lupus erythematosus
Sarcoidosis
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manage postmenopausal patients as
follows
High risk
high risk mass require surgical exploration
Intermediate risk
managed based coexisting tumor marker levels, risk factors, and symptoms
Many women may be managed with surveillance, but surgical exploration should
be performed if clinically significant risk factors or symptoms are present
Low risk
unilocular anechoic ovarian cyst and no other findings suggestive of malignancy,
surveillance rather than surgery because the risk of malignancy is less than the
risk of complications associated with surgical exploration
Risk of malignancy in sonographically confirmed septated cystic ovarian tumors.AUSaunders BA, Podzielinski I,
Ware RA, Goodrich S, DeSimone CP, Ueland FR, Seamon L, Ubellacker J, Pavlik EJ, Kryscio RJ, van Nagell JR
Jr SOGynecol Oncol. 2010;118(3):278.
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Size of the mass
Suggestion
 Surgical exploration rather than surveillance for
postmenopausal women with a mass that is ≥10 cm in
diameter
 Surgical exploration for women with a 5 to 10 cm mass who
also have symptoms suggestive of ovarian cancer
 some patients without symptoms or other findings
suggestive of malignancy may request removal of a mass
<10 cm.
 removal is reasonable if the patient strongly prefers
surgical evaluation and removal of the mass and is willing
to accept the risks of surgical morbidity and loss of an
ovary
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Surveillance
 Women for whom the likelihood of ovarian cancer appears
low, but has not been fully excluded, should be managed
with continued surveillance with serial pelvic ultrasounds,
and, if appropriate, a serum tumor marker.
 Physiologic cysts typically resolve on follow-up
 non-physiologic non-neoplastic benign simple cysts
usually remain unchanged
 neoplastic simple cysts enlarge over time

Is expectant management of sonographically benign adnexal cysts an option in selected asymptomatic
premenopausal women?AUAlcázar JL, Castillo G, Jurado M, García GL SOHum Reprod. 2005;20(11):3231.
71
Surveillance
 If the mass develops features of malignancy, increases
in size to ≥10 cm, or the CA 125 increases to
>35 U/mL, we proceed with surgery
 If the mass resolves, we discontinue surveillance
 If the mass remains unchanged or decreases in size
and the CA 125 remains <35 U/mL, surveillance
continues until the planned stopping point is reached.
72
Surgery
 Surgical exploration for an adnexal mass may be performed





laparoscopically (conventional or robotic) or via a laparotomy.
The choice of surgical approach depends upon the degree of
suspicion of malignancy and surgeon and patient preference.
If there is a low or moderate suspicion of malignancy, a
laparoscopic approach is typically used.
Laparoscopy is associated with a shorter recovery and decreased
perioperative morbidity compared with laparotomy.
When choosing a surgical approach for a suspected malignancy,
it is important to keep in mind that it is unclear if laparoscopy is
as sensitive as laparotomy in the detection of small metastatic
implants in small bowel mesentery and epigastrium.
Laparoscopy is clearly superior to laparotomy for inspection of
the diaphragm and for visible peritoneal surfaces.
73
surgical technique
 must minimize the potential for tumor disruption or dissemination. If
malignancy is suspected, oophorectomy is required rather than ovarian
cystectomy. Patients with early stage ovarian cancer (ie, no malignant
cells in ascites or peritoneal cytology) benefit from removal of the
adnexal mass intact, since opening the mass results in a more advanced
stage and adversely affects prognosis
 If a laparoscopic approach is used, the ovary can be placed in a tissue
recovery bag. If the specimen is too large to remove through the
existing incisions, cyst fluid may be aspirated (but the collapsed cyst
should not be disrupted) or the incision may be enlarged. The practice
of morcellating an ovarian mass in a bag is discouraged because it may
compromise pathology evaluation.
 aspiration of cyst contents is not advisable as the sole surgical
intervention because no tissue is obtained for histopathology and
cytology of cyst fluid is not reliable for exclusion of malignancy, and
there is a high rate of recurrence.
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 Most ovarian surgeries are for benign disease and can
be performed laparoscopically.
 The major advantages to laparoscopy over laparotomy
are reductions in recovery time, hospital stay, cost, and
adhesion formation, which is particularly important in
women in whom fertility is an issue
 data from randomized trials also showed less febrile
morbidity and a lower frequency of urinary tract
infection, postoperative pain and postoperative
complications with laparoscopy
 There is increasing sentiment to evaluate some complex cysts
laparoscopically because most of them are benign.
 There are no dogmatic recommendations for this group of
patients and clinicians must individualize treatment according
to their index of suspicion.
 The concern associated with the use of laparoscopy in this
setting is that the prognosis may be worsened by cyst rupture if
malignancy is encountered, although this is unproven.
 account the patient's age, medical condition, clinical
examination (eg, fixed mass or mobile), sonographic appearance
of the mass, and tumor markers (eg, CA-125) to gauge the
likelihood of malignancy when deciding upon the proper
operative approach.
 Laparoscopy should be reserved for those cases in
which the risk of malignancy is low.
 Staging and treatment of ovarian cancer via a
laparoscopic approach is still under investigation, but
it is becoming more commonly used
 laparoscopy is the preferred technique for
oophorectomy/cystectomy because it is associated
with a smaller scar, faster recovery, lower cost, and
lower frequency of postoperative adhesion formation
than laparotomy.

 Situations in which the traditional open method is
safer and more appropriate than the laparoscopic
approach are when the surgeon and/or assistants are
not experienced in the use of an operative laparoscope,
when there are dense adnexal adhesions, when the
ovary is very large, or when there is a high suspicion of
malignancy
 The laparoscopic approach is reasonable for patients
whose preoperative evaluation suggests benign disease
 These patients include those with probable dermoids,
endometriomas, or physiological cysts that have not
resolved with conservative management or are
associated with acute symptoms.
 A laparoscopy may be converted to a laparotomy if the
surgeon encounters a difficult dissection.
 Intraoperative findings suspicious for malignancy
(ascites, enlarged nodes, matted bowel, excrescences,
multiple nodular areas) usually warrant conversion to
an open evaluation.
 However, a smooth appearance on the surface of the
cyst does not exclude the possibility of a malignancy
 Removing cysts in a specimen bag reduces both
operating time and spillage.
 Controlled intraperitoneal spillage of benign cyst
contents (eg, cystic teratoma) does not increase
postoperative morbidity as long as the peritoneal
cavity is copiously lavaged
 Cysts that are complex should be removed, not
fenestrated, given the possibility of malignancy and
high recurrence rates.
A solid adnexal mass that is small enough to be removed
intact via colpotomy or via a laparoscopic bag can be
managed laparoscopically.
Solid masses can also be mobilized laparoscopically and
then removed through a mini-laparotomy incision or
morcellated inside a specimen bag
 After the abdomen is entered, pelvic and abdominal
washings are obtained and saved to use for staging if a
malignancy is subsequently diagnosed.
 The entire pelvis, abdomen and retroperitoneum (eg,
diaphragm, omentum, viscera, kidneys) are inspected for
sites suspicious for carcinoma (excrescences, thick
adhesions, nodules, enlarged nodes) should be biopsied
and sent for frozen section.
 If findings are consistent with benign disease, the
infundibulopelvic ligament and ureter are identified.
 The peritoneum is incised parallel to the ovarian vessels
and the retroperitoneal space is entered.
85
 The findings of this study support the practice of serial
sonography to evaluate indeterminate adnexal masses,
but don’t provide data regarding the frequency of
surveillance.
 The biologic basis of the finding that complex masses
resolved more quickly is uncertain, unless the majority
of these were hemorrhagic cysts. This warrants further
analysis of these data and further study.
86
87
 Serial follow-up ultrasounds were performed every three to
six months.
 Spontaneous resolution of the simple cysts occurred in
2261 women (69 percent) over a mean follow-up of six
years.
 Ten patients were subsequently diagnosed with ovarian
cancer: 7/10 had additional abnormal areas which were
identified on an interval ultrasound
examination, 2/10 developed ovarian cancer after the cyst
in question had resolved on sonographic follow-up,
and 1/10developed cancer in the ovary opposite the cyst
being followed.
88
 premenopausal women, 70 percent of adnexal masses
will resolve over the course of several menstrual cycles
 During surveillance, if the mass develops features of
malignancy, increases in size to ≥10 cm, or the CA 125
increases to >35 U/mL, we proceed with surgery.
 If the mass resolves, we discontinue surveillance.
 If the mass remains unchanged or decreases in size
and the CA 125 remains <35 U/mL, surveillance
continues until the planned stopping point is reached.

Management of the adnexal mass.AUCurtin JP SOGynecol Oncol. 1994;55(3 Pt 2):S42
89
postmenopausal women
Intermediate risk mass
repeat a transvaginal ultrasound and CA 125 in six weeks
and then again six weeks later.
then repeat the ultrasound and CA 125 every three to six
months for a year.
We do a final ultrasound and CA 125 one year later.
low risk masses
repeat an ultrasound and CA 125 at three months then
six months
90
premenopausal women
Intermediate risk masses
repeat a transvaginal ultrasound in six weeks. This
allows visualization of the mass at a different point of
the menstrual cycle.
then repeat an ultrasound in three months and then six
more months.
then do a final ultrasound one year later.
Low risk masses
repeat an ultrasound in three months and then six more
months.
91
 Peritoneal inclusion cyst
 multicystic inclusion cysts) are uncommon
mesothelial lesions that appear as septated, cystic
masses that surround the ovary, usually in women with
pelvic adhesions

Peritoneal inclusion cysts and their relationship to the ovaries: evaluation with sonography.AUKim JS, Lee HJ, Woo SK,
Lee TS SORadiology. 1997;204(2):481.
92
REFERRAL TO A SPECIALIST
 Patients with a complex adnexal mass, findings
suggestive of metastatic epithelial ovarian cancer
(EOC), fallopian tube or peritoneal carcinoma, or
laboratory testing suggestive of ovarian cancer (eg,
elevated serum CA 125) should be referred to a
gynecologic oncologist for further evaluation
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94