Management of an Adnexal Mass

1. Management of an Adnexal Mass Dr.Alaa Ibrahimi

3. COMMON OVARIAN TUMOURS Infancy -Functional cyst , Germ cell tumor Pre pubertal - Functional cyst , Germ cell tumor Adolescent - Functional cyst , Germ cell tumor Reproductive - Functional cyst - Dermoid Peri menopausal - Epithelial ovarian tumor-- Functional cyst Post Menopausal - Neoplastic ovarian tumor- Functional cyst 3. Epithelial tumor Epithelial tumor Mets

4. CLINICAL PRESENTATION • Asymptomatic – accidentally discovered on USG • Chronic pattern of pain, increasing abdominal girth over months or weeks. • Associated with secondary symptoms of anorexia, nausea, vomiting, urinary frequency. • Could be associated with primary or secondary amenorrhea, menstrual irregularities, virilization, precocious puberty • Become acutely symptomatic if undergoes torsion, rupture or haemorrhage. Benign ovarian neoplasms are indistinguishable clinically from malignant counterparts

5. COMPLICATIONS • Torsion • Intracystic hemorrhage • Infection • Rupture • Pseudomyxoma peritonei • Malignancy

6. PHYSICAL EXAMINATION • Abdominal and vaginal examination and the presence or absence of local lymphadenopathy • Assess – Laterality – Cystic Vs solid – Mobile Vs fixed – Smooth Vs irregular – Ascites – Cul-de-sac nodules – Rapid growth rate

7. the goal of management of the adnexal Mass? Rule out Cancer Alleviate symptoms Prevent cyst accidents

8. Risk Factors for Ovarian Cancer Age (risk increases with age) Nulliparity Ethnic (American, Northern European) Family history(only 10% are familial) Endometrial cancer Breast Cancer

9. ?Fertility Drugs Use of Oral Contraceptives . Tubal Ligation is protective Hysterectomy is protective but BSO does not eliminate the risk

10. Diagnosis of an Adnexal Mass History: risk factors, symptoms Physical exam.: Ultrasound, CT, MRI(not better than US) Tumour markers HCG, CBC, RFT, LFT Laparoscopy/Laparotomy

11. TVS: can achieve sensitivity of 88% to 100% and specificity of 62% to 96%. • Adding doppler does not seem to yield much improvement in the diagnostic precision, but increases the confidence with which a correct diagnosis of benignity or malignancy is made.

12. 1.Solid mass/ or complex mass 2.Cystic Mass(unilocular more likely benign) 3.Size 4.Complex mass can be seen with corpus luteum or hemorrhagic cyst 5.Doppler flow/Pulsitile index Pulsitility index of less than 0.4 is indicative of malignancy (experimental) 6.Associated findings (ascites, omental mass, endometrial abnormalities and metastasis

15. OTHER IMAGING MODALITIES • CT, MRI, PET not recommended in the initial evaluation • CT scan: evaluating – LN involvement, – Omental mets, peritoneal deposits, hepatic mets, – obstructive uropathy – or a probable alternate primary site when cancer is suspected based upon TVS • MRI : differentiating non adnexal pelvic masses (like leiomyomata).

16. TUMOR MARKERS CA- 125 Most useful when non-mucinous epithelial cancers are present Elevated in 80% of patients with epithelial ovarian Ca but only in 50% of patients with stage I disease Increased sensitivity in post menopausal women esp. when associated with relevant clinical and USG findings Cut-off of 30 u/ml, sensitivity of 81% and specificity of 75%

17. Unfortunately can be elevated in endometriosis. menses. Infection. Fibroids. liver or renal failure. Ascites. breast cancer. endometrial and cervical cancers and GI malignancies.

18. HE4 is a precursor to the epididymal secretory protein E4 and in normal ovarian tissue, there is minimal gene expression and production of HE4. • As a single tumor marker, HE4 had the highest sensitivity for detecting ovarian cancer, especially Stage I disease.  HE4 levels(>70 pM) were found to be elevated in over half of the patients with ovarian cancer with normal serum CA125 levels (>35 U/ml) 

19. Management based on: Age of patient Size of mass Ultrasound description of cystic or complex or solid Other associated finding i.e, ascites, pulmonary effusion, lymphadenopathy, other cancers (cervix, endometrium, breast)

20. Ovarian mass in childhood: -Simple cyst - Observe and reassess -Solid or solid cystic MRI and tumor markers High suspicion of malignancy -Laparotomy laparoscopy Frozen section Malignant – oophorectomy and staging Benign - cystectomy

21. Ovarian mass in reproductive age group Asymptomatic simple cysts <5cms : Likely physiological (do not require follow up) USG cystic -observation every 3-6 months Complex, solid, suspicious Persistence or progression then –surgery. 5-7 cms : Yearly USG >7cm Require further imaging/surgical intervention.

22. • The value of ovarian suppression with OCP not prevent Ovarian cyst but remains common practice. • Repeat evaluation: physical examination and TVS • Indications for surgery: change in sonographic characteristics to a more complex mass and rise in CA 125 indications for surgical management: • Remember—‘THIN RIM’ • T—Torsion • H—Haemorrhage • I—Infection • N—Necrosis • R—Rupture • I—Infarction • M—Malignant change

23. Ovarian cysts in postmenopausal women: • Post menopausal gonad atrophies to a size of 1.5 X 1 X 0.5cm on average • Shouldn’t be palpable on pelvic examination. • Presence of palpable ovary must alert the possibility of an underlying malignancy. • Causes -10% functional 90% neoplastic (either benign or malignant) ASSESSMENT using CA125 and transvaginal grey scale sonography. 

24. Simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a low risk of malignancy. It is recommended that, in the presence of a normal serum CA125 levels, they be managed conservatively. • Aspiration is not recommended for the management of ovarian cysts in postmenopausal women. • It is recommended that a ‘risk of malignancy index’ should be used to select women for laparoscopic surgery. • It is recommended that laparoscopic management of ovarian cysts in postmenopausal women should involve oophorectomy (usually bilateral) rather than cystectomy.

25. Laparoscopy or laparotomy? The advantages of laparoscopic surgery are less post-operative pain, shorter hospital stay, quicker return to normal activities and possibly less adhesion formation than after an open procedure. However, the consequences of spillage of cyst contents, incomplete excision of the cyst wall and an unexpected histological diagnosis of malignancy are considerable disadvantages.

26. Functional ovarian cysts • Follicular cysts • Corpus luteum cysts • Theca lutein cysts • Luteomas of pregnancy  By far the most common clinically detectable enlargements of the ovary in the reproductive years.  All are benign and usually asymptomatic.

27. Common Epithelial Tumors: • Serous tumors • Mucinous tumors • Endometrioid tumors • Clear cell tumors • Brenner tumors • Mixed epithelial tumors • Undifferentiated ca. • Unclassified epithelial tumors

28. Sex cord tumors: • Granulosa-stromal cell tumors, theca cell tumors • Androblastomas • Gynandroblastomas

29. Germ cell tumors: • Dysgerminoma • Endodermal sinus tumor • Embryonal ca. • Polyembryoma • Choriocarcinoma • Teratoma • Mixed

30. endometrioma Small cysts < 5 cm can be monitored by serial scans, before making a decision as to what the definitive treatment should be. As regards treatment choices, the options include medical therapy or surgery.

31. Medical therapy consists of medicines such as danazol or GnRH analogs to suppress the endometriosis; and while this is very effective in providing temporary symptom relief , it is not very effective in treating the cyst, which tends to remain in spite of the treatment. The definitive solution is surgical; this usually consists of operative laparoscopy .

32. The major problem with chocolate cysts is that they tend to recur. This is why doctors will often combine medical suppression with surgical treatment.

35. Benign cystic Teratoma (Dermoid Cyst)- Most common tumor in reproductive age women 25% of all ovarian neoplasms 80% less than 10cm 15% bilateral 50% asymptomatic 1-2% malignant transformation

36. Complications : rupture, torsion, infection, hemorrhage, and malignant transformation, Thyrotoxicosis, autoimmune hemolytic anemia, and carcinoid Treatment: ovarian cystectomy or Oophorectomy(can wait until after -delivery if pregnant)