MANAGEMENT OF ADNEXAL MASSES Objectives Understand which adenexal

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 • • • Unilateral Simple cyst Smooth wall No ascites Resolution over 4 -6 weeks • <10 cm Neoplasm • • • 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 • • 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 Mc. Gowan 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 >5 cm • 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