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Management of Adnexal Masses

Management of Adnexal Masses. Claire Gould, MD Minimally Invasive Gynecology Fellow Legacy Health. Triage . History and physical Imaging Lab Work. History and physical. History of present illness Current symptoms Review of systems Full Past Medical History Menstrual history

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Management of Adnexal Masses

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  1. Management of Adnexal Masses Claire Gould, MD Minimally Invasive Gynecology Fellow Legacy Health

  2. Triage • History and physical • Imaging • Lab Work

  3. History and physical • History of present illness • Current symptoms • Review of systems • Full Past Medical History • Menstrual history • Family history • Physical exam – don’t forget the rectal exam!

  4. Risk factors

  5. Imaging • Ultrasound • CT • MRI

  6. Sensitivity/Specificity for diagnostic tools

  7. Ueland, FR et al. Gyn Oncol, 2003 Kentucky Morphology Index Ascites 7

  8. Lab Tests • CA 125 • OVA 1 • HE4 • CEA • CA 19-9 • B-hCG • LDH • AFP

  9. CA 125 • Elevated in over 80% of women with advanced ovarian cancer. • Sensitivity for stage I ovarian cancer – only 50% • Not a specific test for cancer

  10. Conditions associated with Elevated CA 125 concentrations • Epithelial ovarian cancer • Endometrial cancer • Adenocarcinoma of cervix • Adenomyosis • Endometriosis • Leiomyomata • Pregnancy • Pelvic inflammation • Liver disease and cirrhosis • Colitis • Heart failure • Diverticulitis • Lupus • Pericarditis • Postoperative period • Renal disease • TB • Ascites • Pleural effusion • Pancreatic cancer • Colon cancer

  11. OVA 1 • Immunoassay for 5 biomarkers • Limited usefulness in women with Rheumatoid factor >250 IU, or triglyceride level greater than 450 mg/dL

  12. Abnormal OVA 1 values • >4.4 postmenopausal • >5.0 premenopausal

  13. Indications for OVA 1 testing • Over age 18 • Ovarian mass for which surgery is planned (but not yet referred to oncologist) • Aid to further assess the likelihood that malignancy is present when the physician’s independent clinical and radiological evaluation does not indicate malignancy • Not intended as a screening or stand-alone diagnostic assay.

  14. When to Operate • Premenopausal women • Cyst >10cm • Suspicious for malignancy • Family history • pain • Postmenopausal • >5cm • Suspicious for malignancy

  15. When to Refer to Gyn Oncology • Premenopausal • Ca 125 >200 • Ascites • Evidence of mets • Family history of breast/ovarian ca in 1st degree relative • Postmenopausal • Ca 125 > 35 • Ascites • Nodular or fixed pelvic mass • Evidence of mets • Family history of breast/ovarian ca in 1st degree relative ACOGCommitteeOpinion–DEC2002

  16. Special Case - Pregnancy • Most masses are incidental and can be managed expectantly • 50-70% will resolve in pregnancy • Operate if malignancy suspected, acute complication (torsion), size of tumor is likely to cause obstetric difficulty • In non urgent cases, wait until after 1st trimester • Laparoscopy can and should be considered

  17. MIS approaches for removal of masses • Purse string suture and drain • Needle aspiration • Trocar • Endocatch • Hand assist port • Small mini lap • McCartney tube

  18. Case #1 • 19 year old college student with acute onset of right lower quadrant pain that improved with Vicodin. • Pain continued as a dull ache with intermittent sharp stabbing pain, + nausea • Ultrasound showed a 12 cm ovarian mass. No normal ovarian tissue was seen.

  19. Case # 2 • 57 year old referred by naturopath due to acute pain in pelvis, bladder pain • Known right ovarian cyst for >3 years but previously declined treatment. • Imaging showed 10 cm complex cyst • CA 125 – 162 • OVA 1 – 9.1

  20. Case # 3 • 33 year old G0 presented with abdominal pain. • Known fibroid uterus • Ultrasound 2 months ago • Repeat imaging now showed bilateral complex pelvic masses • Mother diagnosed with ovarian cancer • Patient’s CA 125 = 395

  21. Complex mass case

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