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Morning Report

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Morning Report

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    1. Morning Report UNC Internal Medicine January 26, 2009 Tyler W. Buckner, MD

    2. The adnexal mass Our patient: Krukenberg tumor Approach to management: Demographics History Physical Diagnostic evaluation and Follow-up

    3. Krukenberg tumor Friedrich Ernst Krukenberg 1871 – 1946

    4. Krukenberg tumor Secondary malignancy of the ovary Often bilateral Primary cancer from GI tract, usually stomach but can be from colon Histology: mucin-secreting signet-ring cells

    5. Adnexal masses Is it benign or malignant?

    6. Adnexal masses - Demographics < 15 years old: high chance of malignancy Pre-menopausal: 6-11% malignant Post-menopausal: 29-35% malignant

    7. Adnexal masses Benign etiologies: Physiologic/functional cysts Follicular cyst Corpus luteum cyst PCOS Pregnancy-related Ectopic pregnancy Theca lutein cyst Corpus luteum of pregnancy Luteoma PID/TOA Benign neoplasm Cystadenoma Endometrioma Mature teratoma

    8. Adnexal masses Malignant etiologies: Epithelial cell tumors Germ cell tumors Sex cord-stromal tumors Mixed cell type tumors Metastases 50-90% are from GI or breast cancer source 4% women with intestinal cancer have Krukenberg tumors Fallopian tube or broad ligament neoplasms

    9. Adnexal masses - History Increased risk of ovarian cancer: FH: breast, ovarian, colon cancer Nulliparity History of infertility History of endometriosis Characterize pain Abnormal uterine bleeding, breast tenderness, hirsutism may be due to hormonally active tumor Non-specific GI symptoms

    10. Adnexal masses – Physical Exam Ovaries are not usually palpable in post-menopausal women Tender adnexa: inflammatory process vs. neoplasm Worrisome mass characteristics: Irregular Solid Immobile Ascites and adnexal mass: highly suggestive of malignancy

    11. Adnexal masses - Evaluation Start with ultrasound (transabdominal +/- transvaginal) Worrisome characteristics: Ovary size >2x contralateral ovary Multilocular cyst Solid mass Cyst/mass with increased blood flow Size > 5-10 cm

    12. Adnexal masses - Evaluation Post-menopausal women: Follow closely*: U/S shows simple unilateral cyst < 5 cm Asymptomatic Pelvic exam not suspicious for malignancy Normal cervical cytology CA-125 normal (< 35) Negative family history Otherwise, go to OR *(U/S every 3 months for a year, then annually until cyst resolves)

    13. Adnexal masses - Evaluation Pre-menopausal women: Beta HCG (r/o pregnancy) U/S shows simple cyst < 10 cm: follow closely OCP x 4-6 weeks Repeat U/S: cyst should be smaller If cyst > 10 cm or any suspicion for malignancy (history, exam, family history) ? to OR

    14. Adnexal masses - Evaluation Remember that benign adnexal masses can also cause other problems: torsion, hemorrhage, spillage of contents into abdomen

    15. Adnexal masses – Summary History and exam are important Risk of malignancy increases with age, especially after menopause Start with U/S (and CA-125 for post-menopausal patients)

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