Download Functional Neoplasm

MANAGEMENT OF
ADNEXAL MASSES
Objectives
• Understand which adenexal masses
require surgery verses following
• Understand how to identify potentially
malignant adenexal masses
• Decide which patients with adenexal
masses should be referred to a
gynecologic oncologist
Adnexal masses
• Management is often driven by concern for
malignancy
– 289,000 admissions per year for ovarian
neoplasms
– 22,000 new cases ovarian cancer per year
• Risk of malignancy within an ovarian
neoplasm varies with age
– Peak age is in a women’s 60’s
Adnexal Masses in Reproductive
Age Women
Adnexal masses in reproductive
age women
• Of non-inflammatory ovarian tumors
– 70% functional cysts
– 20% benign tumors
– 10% endometriomas
– ?% tuboovarian complexes/abscesses
Ultrasound evaluation of adnexal
masses
Functional
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Unilateral
Simple cyst
Smooth wall
No ascites
Resolution over 4-6
weeks
• <10 cm
Neoplasm
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Bilateral
Complex
Solid components
Internal papillations
Ascites
Persistence or growth
Ultrasound: Benign ovarian cyst
Ultrasound: Ovarian cancer
Presumed functional cysts in
reproductive age women
• Observe for 3 months
• OCPs do not increase likelihood of
resolution, but can decrease risk of
recurrence
Adnexal Masses in
Postmenopausal Women
Adnexal masses in
postmenopausal women
• They are not functional cysts and will not
go away
• Most are benign some are malignant
• Concerns about torsion, growth, and
missing a malignancy usually lead to
removal of adenexal masses
Ovarian cancer symptoms
• Ovarian cancer is called the “silent killer”
(probably not true)
• Generally patient and physician ignore the
symptoms
• One of the best ways to detect early ovarian
cancer is for both the patient and the physician
to maintain a high index of suspicion of the
diagnosis in the symptomatic woman
Ovarian cancer symptoms
• 95% of patients reported having symptoms
prior to diagnosis
– Abdominal 77%
– Gastrointestinal 70%
– Pain 58%
– Constitutional 50%
– Urinary 34%
– Pelvic 26%
Evaluation
• Physical examination
– Including pelvic examination
• Transvaginal ultrasonography
• CT scan of abdomen and pelvis (optional)
• Ca-125
– Should only be done if mass found
– Less useful in the premenopausal woman
Ca-125
• Antigenic determinant located on large, mucinlike glycoprotein found on cells derived from
coelomic epithelium (pericarium, pleura,
peritoneum) and Mullerian epithelium (tubal,
endometrial, endocervical)
• Expressed by 80% nonmucinous epithelial
ovarian cancers
• Up to 50% of early stage ovarian cancers and
20-25% of advanced stage ovarian cancers are
associated with normal Ca-125 values
Ca-125
• Normal range in most labs < 35 U/ml
• Sensitive marker of response to treatment
and disease status in patients with ovarian
cancer
• Can be used in triage of ovarian masses
– Less useful in premenopausal women
because many benign conditions can cause
“false” elevations
• Not useful for screening
Screening Ca-125
• 39,114 menopausal women followed 4
years with Ca-125 and ultrasound
• 90 cases of ovarian cancer
• 60 were found due to the screening
• 80% were stage III or IV
• 1170 surgeries required to find the 60
cases
Conditions which may cause a
“false” elevation of Ca-125
• Benign ovarian cysts
• Uterine leiomyomata
• Pelvic inflammatory
disease
• Endometriosis
• Adenomyosis
• Pregnancy
• Menstruation
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Heart failure
Liver failure
Renal failure
Peritoneal
tuberculosis
Diverticulitis
Pancreatitis
Recent abdominal or
thoracic surgery
Other malignancies
Should the patient have
surgery by general
gynecologist or gyn
oncologist?
Why consult a gynecologic
oncologist?
Accurate staging
• Complete surgical staging:
– 97% gynecologic oncologists
– 52% general obstetrician/gynecologists
– 35% general surgeons
• Better prognosis with complete surgical
staging in early disease
McGowan L, et al. Misstaging of ovarian cancer. Obstet Gynecol 1985;65:568-72.
Optimal cytoreduction results in
improved survival in ovarian cancer
Slide courtesy of Gynecologic Cancer Foundation
Who should be referred to a
gynecologic oncologist?
• Women who have a pelvic mass that is
suspicious for a malignant ovarian
neoplasm, as suggested by at least one of
the following indicators:
– Elevated Ca-125 level
• Premenopausal > 200 units/ml
• Postmenopausal > 35 units/ml
– Ascites
– A nodular or fixed pelvic mass
– Evidence of abdominal or distant metastasis
Ovarian Torsion
Pathogenesis
• Generally associated with ovarian mass
but can occur with normal ovaries
• Generally both the tube and ovary are
envolved but either structure can torse
alone
• Generally with cysts that are >5cm
• Less likely with old PID or malignancies
due to the adhesions
• Generally in reproductive age women
Clinical Presentation
• Acute moderate to severe pelvic pain –
90%
• Adenexal mass – 90%
• Nausea and vomiting – 47 to 70%
• Fever – 2 to 20%
• Abnormal uterine bleeding – 4%
Evaluation
• Abdomenal and pelvic exam
demonstrating tenderness and generally
rebound
• Lab
– Hcg, CBC
• Ultrasound
– Adenexal mass with diminished venous blood
flow intially, no blood flow later
Treatment
• Surgery, the sooner the better
• If done soon enough, you can save the
ovary