Tutorial : 2
نسائيةد. براء لقمان
عدد الاوراق (6)
16/8/2012Approach to the patient with an adnexal mass
IntroductionAnatomically, the adnexa consists of the ovaries, fallopian tubes, broad ligament, and the structures within the broad ligament.
Up to 10% of women will have some form of surgery during their lifetime for the presence of an ovarian mass. In premenopausal women almost all ovarian masses and cysts are benign. The overall incidence of a symptomatic ovarian cyst in a premenopausal female being malignant is approximately 1:1000 increasing to 3:1000 at the age of 50.
Preoperative differentiation between the benign and the malignant ovarian mass in the premenopausal woman can be problematic with no test or algorithm being clearly superior in terms of accuracy. Exceptions are germ cell tumours with elevations of specific tumour markers such as alphafetoprotein (α-FP) and human chorionic gonadotrophin (hCG).
Ten percent of suspected ovarian masses are ultimately found to be non-ovarian in origin
In pregnant women, the most common cause of an adnexal mass is a corpus luteum cyst.
In nonpregnant patients, the most common etiologies are functional cysts and leiomyomata.
The most common benign ovarian neoplasm is the cystic teratoma.
Differential diagnosis of adnexal mass
Gynecologic:
Benign:
functional cyst
endometrioma
tubo-ovarian abscess
hydrosalpinx
ectopic pregnancy
paratubal cyst
leiomyoma
Neoplasm: mature teratoma, mucinous cystadenoma, serous cystadenoma
Malignant:
Epithelial carcinomaGerm cell tumour
Sex cord or stromal tumour
Non gynecologic:
Benign:Diverticular abscess
Appendicular abscess or mucocele
Nerve sheath tumour
Uretral or bladder diverticulum
Pelvic kidney
Malignant:
Gastrointestinal cancer
Retroperitoneal sarcoma
metastases
OrganCysticSolidOvary Functional cyst
Neoplastic cyst
Benign
Malignant
EndometriosisNeoplasm
Benign
MalignantFallopian tubeTubo-ovarian abscess
Hydrosalphinx
Parovarian cystTubo-ovarian abscess
Ectopic pregnancy
Neoplasm Uterus Intrauterine pregnancy in bicornuate uterusPedunculated or intraligamentous
myomaBowel Sigmoid or cecum distended with gas or fecesDiverticulitis
Ileitis
Appendicitis
Colonic cancerMiscellaneous Distended bladder
Pelvic kidney
Urachal cystAbdominal wall hematoma or abscess
Retroperitoneal neoplasm
DiSaia et al, Clinical Gynecologic Oncology, 2007
Differential diagnosis according to age
The differential diagnosis of the adnexal mass varies with the age.
The age is also the most important factor in determining the potential for malignancy.
In premenarchal and postmenopausal women, the presence of an adnexal mass should be considered highly abnormal and must be promptly evaluated.
Premenarchal patient:
In prepubertal girl, most ovarian neoplasm are of germ cell origin and require immediate surgical exploration.
Postmenopausal patient:
Any enlargement of the ovary is abnormal in postmenopausal women and should be considered malignant until proven otherwise. (The postmenopausal ovary atrophies to 1.51.00.5 cm in size and should not be palpable on pelvic examination).
The risk of malignancy in this age group is increased from 13% in premenopausal to 45% in postmenopausal women. (still 55% of postmenopausal women with palpable ovaries do have a benign tumour).
The most common ovarian tumor in this age group include epithelial ovarian tumors followed by stromal tumors and sex cord tumors. However, the most frequent sampling is benign ovarian neoplasm (fibroma, Brenner tumour).
Young women
Usually gynecologicOften functional cysts
How do these women present
Initially are asymptomaticLower abdominal discomfort
Pelvic pain
Dyspareunia
Abdominal enlargement
Frequent urination
Constipation
Most frequent presenting symptoms of ovarian cancer
The approach to the patient with a pelvic mass should take into considerationAge
Tumor size
U/S features
Labs
Work up
History
Gynecological history
Family history of ovarian or breast cancer
Examination
AbdominalPelvic
rectovaginal
Lab
CBC
hCG
Markers
Radiology
U/SCT
MRI
Pelvic findings in patients with benign and malignant ovarian tumors
MalignantBenignbilateralunilateralSolid or complexcysticfixedmobileirregularsmoothascitisNo ascitisRapid growthNo growthNodularity of rectovaginal septumsmooth rectovaginal septumLabs
Tumor markers
Epithelial: CA 125, elevated in 80%
35 U/mL is upper limit of normal
Also elevated in many benign conditions
Malignant germ cell tumors: b-hCG, LDH, AFP
Embryonal carcinoma: AFP, BhCG
Endodermal Sinus tumor: AFP
Granulosa cell tumors: inhibin
CA-125 ↑ in:
LeiomyomaEndometriosis/adenomyosis
PID
Pregnancy
Malignancies-lung, breast, colon
Pancreatitis
Cirrhosis
CA 125 level should not be used as a screening tool or when a mass is not identified and should not be routinely used during the diagnostic workup of an adnexal mass in a premenopausal patient.
On the other hand, CA 125 level should be drawn in a postmenopausal patient with an adnexal mass to guide treatment options. A value greater than 35 U per mL should prompt further evaluation.
CA 125 levels are elevated in 80 percent of epithelial ovarian cancers. Only 50 percent of stage I cancers have elevated CA 125 levels.
CA 125 levels are ordered preoperatively. If ovarian cancer is diagnosed, CA 125 level is used to monitor the patient's response postoperatively
Radiology
Pelvic ultrasound is currently the most useful technique for diagnostic evaluation of the adnexal mass.
Trasvaginal ultrasound provides better resolution than abdominal ultrasound.
The parameters of significance for ultrasonographic evaluation of the adnexal mass are the:
Size.
Number of loculi.
Overall echodensity.
Presence of septations with flow within.
Presence of papillary or solid excerscence.
Nodules within the mass.
CT scan:
In general, CT scan is not indicated routinely for the evaluation of the adnexal mass. However, it is indicated in the evaluation of a patient with a:Hard fixed lateralized mass
Ascitis
Abnormal liver function tests
Palpable abdominopelvic mass.
In such cases, malignancy is suspected and CT scan provide significant information about the spread and resectability of the disease.
Findings suggesting malignancy
CA 125 level greater than 35 U per mL (postmenopausal) or 200 U per mL (premenopausal)Evidence of abdominal or distant metastasis
Family history of first-degree relative with ovarian or breast cancer
Nodular or fixed pelvic mass (postmenopausal)
Concerning US findings: solid component, thick septations (greater than 2 to 3 mm), bilaterality, Doppler flow to the solid component of the mass, and presence of ascites
Women with any of these findings should be referred to a gynecologist or gynecologic oncologist.
All prepubescent girls with adnexal masses should be referred.
a follow-up ultrasound examination in 6 to 8 weeks may provide additional information about a mass's etiology.
Repeat sonography is recommended in cases without obvious stigmata of malignancy or a size that would mandate surgery.
Adnexal mass
Indications for Surgery:Ovarian cystic structure >6 cm that has been observed 6-8 weeks without regression
Any cystic structure >10 cm
Any solid ovarian lesions
Any ovarian lesion with papillary vegetation on the cyst wall
Palpable adnexal mass in premenarchal or postmenopausal
ascitis
Torsion or rupture suspected
SHAPE \* MERGEFORMAT
In which one of the following patients is an adnexal mass most likely to be cancerous? (checkone)A.A two-day-old infant girl.
B.A six-year-old girl.
C.A 24-year-old woman.
D.A 28-year-old pregnant woman.
A 42-year-old premenopausal woman presents for a well-woman examination. She has been having urinary incontinence with coughing. You feel a mass in the left adnexa during bimanual examination. A pregnancy test is negative. Transvaginal ultrasonography shows an 8-cm cyst with thin walls, no septae, and no excrescences. Which one of the following steps is most appropriate? (checkone)
A.Order computed tomography of the pelvis.
B.Measure her cancer antigen 125 level.
C.Repeat ultrasonography in four to six weeks.
D.Refer her to a gynecologist.
Mucinous cystadenoma
serous cystadenocarcinoma
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