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Approach to the patient with an adnexal mass

Approach to the patient with an adnexal mass. Dr Safoura Rouholamin Isfahan Medical University. Adnexal mass. An adnexal is a common gynecologic problem 5 to 10 % lifetime risk Adnexal masses may be found in females of all ages, fetuses to the elderly

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Approach to the patient with an adnexal mass

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  1. Approach to the patient with an adnexal mass DrSafouraRouholamin Isfahan Medical University

  2. Adnexal mass • An adnexal is a common gynecologic problem • 5 to 10 % lifetime risk • Adnexalmasses may be found in females of all ages, fetuses to the elderly • Wide variety of types of masses • May be symptomatic or discovered incidentally on pelvic examination or imaging • National Institutes of Health Consensus Development Conference Statement. Ovarian cancer: screening, treatment, and follow-up.AU SOGynecolOncol. 1994;55(3 Pt 2):S4. 

  3. CLINICAL APPROACH • anatomic location of the mass • age • reproductive status of the patient

  4. CLINICAL APPROACH • Excluding urgent conditions )ectopic pregnancy, adnexal torsion) • Excluding malignancy (ovarian or fallopian tube cancer) • few patients who present with an adnexal mass will ultimately be diagnosed with a malignancy

  5. Anatomic location Ovarian masses • Physiologic cysts (follicular or corpus luteum) • Benign ovarian neoplasms (endometrioma, mature teratoma [dermoid cyst]) • Ovarian cancer or metastatic disease from a non-ovarian primary cancer

  6.  Anatomic location Fallopian tube • Ectopic pregnancy • Hydrosalpinx • Fallopian tube cancer

  7. Anatomic location Mesosalpinx or mesovarium • Paratubal or paraovarian cyst  • Tuboovarian abscess • Broad ligament leiomyoma

  8. Age  • Children and adolescents •  less frequently in children and adolescents than in reproductive-age • significant likelihood of adnexal torsion • ovarian malignancy (approximately 10 to 20 percent (Germ cell tumors are most common 35 % compared with 20 % in adults) • Gynecologic malignancies in women aged less than 25 years.AUYou W, Dainty LA, Rose GS, Krivak T, McHale MT, Olsen CH, Elkas JC SOObstet Gynecol. 2005;105(6):1405.  • Can we preoperatively risk stratify ovarian masses for malignancy?AUOltmann SC, Garcia N, Barber R, Huang R, Hicks B, Fischer A SOJ Pediatr Surg. 2010 Jan;45(1):130-4. 

  9. Age  Premenopausal women • majority of adnexal masses occur in reproductive-age • most of these masses are benign 80-85% • Benign adnexal masses is associated with reproductive function • Pregnancy-related etiologies • Many of adnexal masses are associated with the menstrual cycle or reproductive hormones (eg, follicular cysts, endometriomas) and are common findings found in this age •  Ovarian or fallopian tube cancer is less likely in premenopausal than postmenopausal women, but the possibility of malignancy should be considered in all patients • Increase ovarian cancer with age (1.8-2.2/100000 age 20-29Y, 9.0-15.2 /100000 age 40-49Y)

  10. Age Pregnant women • Ectopic pregnancy and luteomas • Corpus luteumcysts • Theca lutein cysts

  11. Age  Postmenopausal women • Excluding malignancy is the main priority in postmenopausal women with an adnexalmass • Average age of diagnosis of ovarian cancer in the United States is 63 years old • Urgent conditions (eg, adnexal torsion, tuboovarian abscess) may also occur in postmenopausal women, but are less common and are more likely to be associated with malignancy • seer.cancer.gov/ (Accessed on September 07, 2012)

  12. GENERAL EVALUATION • Women with an adnexal mass typically present with gynecologic symptoms and a mass is identified on pelvic imaging. Alternatively, an adnexal mass is discovered incidentally on pelvic examination or imaging in many patients. • Medical history • Physical examination • Imaging studies • Laboratory evaluation

  13. Medical history  • Pelvic pain or pressure is the most common symptom associated with an adnexal mass  • genital tract bleeding • Ovarian physiologic cysts or neoplasms: dull, achy pain that is usually localized to the side of the mass or may be asymptomatic • endometrioma: dysmenorrhea or dyspareunia • history of infertility(endometriomaor hydrosalpinx • history of fever or vaginal discharge • questions about risk factors and symptoms associated with ovarian or fallopian tube cancer 

  14. Initial evaluation • family history of ovarian, breast, uterine, or colon cancer • family history suggestive of a hereditary ovarian cancer syndrome (BRCA gene mutation or Lynch syndrome) should be counseled about genetic testing • should undergo surgical evaluation if any suspicious adnexal mass

  15. Physical examination • Size, consistency, and mobility of a mass • solid mass that is irregular or fixed or is associated with posterior cul-de-sac nodularity •  abdominal distention and ascites and/or an abdominal mass • rectal mass, rectal bleeding 

  16. Physical examination • Determine degree of clinical suspicion of malignancy • symptoms of pelvic or abdominal pain or pressure • bloating, or gastrointestinal or urinary tract symptoms • Asymptomatic present at an advanced stage with an acute condition and associated symptoms (eg, bowel obstruction, pleural effusion) • Infrequently, a malignant mass may rupture or torse and present with acute pain • symptoms related to estrogen excess (abnormal uterine bleeding) or androgen excess (virilization or hirsutism)

  17. Imaging studies Pelvic ultrasound • sensitivity of pelvic ultrasound for the diagnosis of ovarian cancer ranged from 86 to 91 percent and the specificity ranged from 68 to 83 percent • Laboratory studies • A baseline level of biomarkers is established for use for further monitoring during and after treatment • biomarkers may play a role in predicting whether optimal cytoreduction is feasible • Myers ER, Bastian LA, Havrilesky LJ, et al. Management of Adnexal Mass. Evidence Report/Technology Assessment No.130 (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-02-0025). AHRQ Publication No. 06-E004, Agency for Healthcare Research and Quality, Rockville, MD February 2006. • Pelvic examination, tumor marker level, and gray-scale and Doppler sonography in the prediction of pelvic cancer. • AURoman LD, Muderspach LI, Stein SM, Laifer-Narin S, Groshen S, Morrow CP SOObstet Gynecol. 1997;89(4):493.

  18. Assessing risk  • most important factor: appearance of the mass on imaging • transvaginalultrasound is the preferred study • sensitivity of pelvic ultrasound for diagnosis of ovarian cancer ranged from 86 to 91 % and the specificity ranged from 68 to 83 % • Myers ER, Bastian LA, Havrilesky LJ, et al. Management of Adnexal Mass. Evidence Report/Technology Assessment No.130 (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-02-0025). AHRQ Publication No. 06-E004, Agency for Healthcare Research and Quality, Rockville, MD February 2006.

  19. simple cyst • Anechoic fluid filling the cyst cavity • Thin walls • Distal acoustic enhancement – No impairment of sound transmission through the mass (in other words, no loss of signal from tissues behind the cyst)

  20. Transvaginal ultrasound image of the left ovary. A normal-appearing left ovary containing a simple anechoic clear cyst, which is consistent with a follicle. A small amount of ovarian tissue is identified surrounding the follicle, as indicated by the arrow.

  21. simple cyst • normal follicles • cystadenoma • paraovarian or paratubalcysts • Paraovariancystadenomas and cystadenofibromas: sonographic characteristics in 14 cases.AUKorbin CD, Brown DL, Welch WR SORadiology. 1998;208(2):459.  • Risk of malignancy in unilocular ovarian cystic tumors less than 10 centimeters in diameter.AUModesitt SC, Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ, van Nagell JR JrSOObstet Gynecol. 2003;102(3):594. 

  22. premenopausal women • simple adnexalcysts that are <3 cm in diameter typically represent normal follicles and may be considered a normal finding. • when up to 5 cm in diameter, these simple cysts are so commonly due to normal menstrual physiology that the Society of Radiologists in Ultrasound (SRU) does not recommend follow-up when asymptomatic • Asymptomatic simple cysts between 5 and 7 cm should undergo yearly sonographic evaluation. • When a simple cysts exceeds 7 cm in size, the SRU suggests that magnetic resonance imaging be considered if the cyst was not thoroughly evaluated sonographically due to potential technical limitations

  23. postmenopausal women • any threshold from 1 to 3 cm as a justifiable cut-off for not following a simple cyst in a postmenopausal woman • malignancy in a simple cysts is rare

  24. Other masses that may appear as simple cysts • A cystadenoma is a benign neoplasm that usually arises from the ovary but sometimes from the fallopian tube. • A cystadenoma should be considered as a possible etiology if there is a relatively large simple cyst (>5 cm in diameter in premenopausal women or >3 cm in diameter in postmenopausal women). • Paraovariancystadenomas are uncommon but typically have a small nodule within a cystic extraovarian mass

  25. Simple adnexal cysts are usually ovarian in etiology but may also be paraovarian or paratubal cysts. • These are common and generally appear as simple cysts adjacent to the ovary • It is usually not important from a management perspective whether the cyst arises from the ovary or is next to the ovary

  26. not a simple cyst R/O physiologic process • corpus lutealinvolution • hemorrhage into a cyst • adjoining simple cysts • Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement.AULevine D, Brown DL, Andreotti RF, Benacerraf B, Benson CB, Brewster WR, Coleman B, Depriest P, Doubilet PM, Goldstein SR, Hamper UM, Hecht JL, Horrow M, Hur HC, Marnach M, Patel MD, Platt LD, Puscheck E, Smith-Bindman R SORadiology. 2010 Sep;256(3):943-54. Epub 2010 May 26.  • The likelihood ratio of sonographic findings for the diagnosis of hemorrhagic ovarian cysts.AUPatel MD, Feldstein VA, Filly RA SOJ Ultrasound Med. 2005 May;24(5):607-14; quiz 615. 

  27. Corpus luteum – The corpus luteum has a characteristic appearance to experienced sonographers, with thickened walls, circumferential color Doppler flow, and a small central lucency containing echoes that can be confusing to less experienced imagers. • Two simple cysts – Two simple cysts next to each other can simulate a septated single cyst. • Hemorrhagic cyst – Hemorrhage into a cyst, which usually indicates a physiologic cyst, can simulate septations and mural nodules. • A fine network of thin linear to curvilinear echoes, sometimes called a fishnet or reticular pattern, is strongly suggestive of a hemorrhagic cyst • These linear echoes are usually very thin and do not extend completely uninterrupted across the cyst, unlike true septa.

  28. For patients with the characteristic appearance of a hemorrhagic cyst who are asymptomatic or have symptoms that resolve as expected, follow-up imaging is not needed • If follow-up imaging is performed, most hemorrhagic cysts will have resolved or become smaller if the repeat sonographic assessment is performed six to eight weeks after diagnosis.

  29. Transvaginal ultrasound image in a 38-year-old female shows a complex ovarian cyst (cursors) that contains a reticular pattern of internal echoes. This appearance is classic for a hemorrhagic ovarian cyst.

  30. Transvaginal ultrasound image of the left adnexa showing a tubo-ovarian abscess. A complex solid and cystic mass is identified in the left adnexa. The tubo-ovarian abscess is seen as a complex cyst (large arrow) and fluid-filled tube (short arrow).

  31. Benign mass   Some benign ovarian masses have characteristic sonographic features • follicular or corpus lutealcysts: Surgery is not required • endometriomas (depends upon whether the patient is symptomatic) • mature teratomas (dermoid)(exclude malignancy and prevent malignant transformation)

  32. characteristics of specific entities • Endometrioma • Homogeneous low- to medium-level echoes in a cystic mass (whether unilocular or multilocular), in the absence of a solid component • small echogenic foci on the inner wall of the cyst • varying degrees of echogenicity in the different locules • Endometriomas: diagnostic performance of US.AUPatel MD, Feldstein VA, Chen DC, Lipson SD, Filly RA SORadiology. 1999;210(3):739. 

  33. Transvaginal ultrasound image of the right adnexa showing an endometrioma of the right ovary. The homogeneous echo pattern of the cyst contents (ie, "ground-glass" appearance) is characteristic of an endometrioma (short arrow).

  34. Transvaginal ultrasound with color Doppler image of the left adnexalshowing a benign endometrioma of the left ovary viewed with color Doppler imaging. No flow within the cyst can be demonstrated; however, blood flow is demonstrated within the wall of the cyst in the ovarian tissue itself (long arrow). Also identified within the left ovary is a small follicle (short arrow).

  35. Mature teratoma • hyperechoic nodule within the mass with distal acoustic shadowing • may also be uniformly hyperechoic or have bright linear to punctate echoes (the latter sometimes referred to as the dermoid mesh • Calcification also can be present and may vary in size. • Floating globules is an uncommon appearance of teratomas but seems to be predictive • Large calcifications in ovaries otherwise normal on ultrasound.AUBrown DL, Laing FC, Welch WR SOUltrasoundObstet Gynecol. 2007;29(4):438. 

  36. Transvaginalultrasound image of a benign teratoma that features heterogeneous contents, smooth outer surface. The arrow points to lines that are hair. There are hyperechoic portions and homogeneous echoes (mucin).

  37. Pedunculatedleiomyoma • heterogeneous, hypoechoic, solid masses • Hydrosalpinx • tubular in shape and may have septations or nodules in its wall  • Interface vessels on color/power Doppler US and MRI: a clue to differentiate subserosal uterine myomas from extrauterinetumors.AUKim SH, Sim JS, Seong CK SOJ Comput Assist Tomogr. 2001;25(1):36. • Transvaginalsonographic markers of tubal inflammatory disease.AUTimor-Tritsch IE, Lerner JP, Monteagudo A, Murphy KE, Heller DS SOUltrasoundObstet Gynecol. 1998;12(1):56.  

  38. Paratubal or paraovarian cyst  • A paratubal or paraovarian cyst arises from the broad ligament in the area of the fallopian tube or ovary • simple cysts that originate from the remnants of paramesonephric (Müllerian) or mesonephric (Wolffian) ducts that are present during urogenital embryologic development. • A simple, asymptomatic paratubal or paraovarian cyst can be managed expectantly without further follow-up. • Surgical removal is indicated for these lesions if they undergo torsion, cause persistent pain or pressure symptoms, or appear neoplastic.  

  39. Hydrosalpinx • A hydrosalpinx is an edematous fallopian tube, typically caused by an infection • A hydrosalpinx may be asymptomatic or may result in chronic pelvic pain or infertility and sometimes be the source of chronic pelvic pain • Other etiologies of chronic pelvic pain should be excluded before salpingectomy is performed. • An asymptomatic hydrosalpinx does not generally need to be removed or followed with imaging. • The exception to this is women undergoing in vitro fertilization. • The use of ultrasound-based 'soft markers' for the prediction of pelvic pathology in women with chronic pelvic pain--can we reduce the need for laparoscopy?AUOkaro E, Condous G, Khalid A, Timmerman D, Ameye L, Huffel SV, Bourne T SOBJOG. 2006;113(3):251. 

  40. Transvaginal ultrasound image of the left adnexa showing a paraovarian cyst. An anechoic structure is noted in the left adnexa separate from the left ovary. The cyst has a thin wall, as indicated by the arrow, with no identifiable ovarian tissue surrounding the cyst.

  41. Transvaginal ultrasound image of the adnexa showing a hydrosalpinx. There is a tubular fluid collection with low-level echoes. An incomplete septation is identified by the arrow.

  42. Transvaginal ultrasound image of the right adnexa showing a pedunculated fibroid. A solid-appearing mass is noted in the right adnexa (long arrow). No cystic areas are identified. The mass is slightly heterogeneous and has no appreciable posterior enhancement but has some areas of shadowing (short arrow). The mass is separate from the right ovary. The arrowhead demonstrates a thick stalk that connects the fibroid to the uterus.

  43. Transvaginal ultrasound image of the adnexa showing ahydrosalpinx with three-dimensional rendering. A cystic structurewith a septation (arrow) is identified in the adnexa. The rendered image (on right side of illustration) demonstrates a tubular fluid collection with incomplete septations indicating a serpiginously dilated fallopian tube.

  44. Ultrasound morphology associated with malignancy • Solid component that is not hyperechoic and is often nodular or papillary • Septations, if present, that are thick (>2 to 3 mm) • Color or power Doppler demonstration of flow in solid component • Presence of ascites (any peritoneal fluid in postpostmenopausal women and more than a small amount of peritoneal fluid in premenopausal women is abnormal) • Peritoneal masses, enlarged nodes, or matted bowel (may be difficult to detect)

  45. Malignancy  • Septations, if present, that are irregularly thick (>2 to 3 mm) • Color or power Doppler demonstration of flow in the solid component. • Presence of ascites (any intraperitoneal fluid in postmenopausal women and more than a small amount of intraperitoneal fluid in premenopausal women is usually abnormal). • Peritoneal masses, enlarged nodes, or matted bowel (may be difficult to detect by ultrasound). • Evaluating the risk of ovarian cancer before surgery using the ADNEX model to differentiate between benign, borderline, early and advanced stage invasive, and secondary metastatic tumours: prospective multicentre diagnostic study.AUVanCalster B, Van Hoorde K, Valentin L, Testa AC, Fischerova D, Van Holsbeke C, Savelli L, Franchi D, Epstein E, Kaijser J, Van Belle V, Czekierdowski A, Guerriero S, Fruscio R, Lanzani C, Scala F, Bourne T, Timmerman D, International Ovarian Tumour Analysis Group SOBMJ. 2014;349:g5920. 

  46. ovarian cystadenocarcinoma

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