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Adnexal Mass - Case presentation-

Adnexal Mass - Case presentation-. By: Joël Cadrin Claudine Davidson. History. ID : ♀,18 y.o . G0 Reason for consultation : presents to your office for routine gynecologic examination. OBGYN history:

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Adnexal Mass - Case presentation-

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  1. Adnexal Mass- Case presentation- By: Joël Cadrin Claudine Davidson

  2. History ID: ♀,18 y.o. G0 Reason for consultation: presents to your office for routine gynecologic examination. OBGYN history: Last menstrual period began about 23 days ago. It was light in flow, and lasted 4 days in length. Minimal dysmenorrhea. Denies any history of sexually transmitted infections Sexually active with two male partners in the last 2 weeks. Given prescription for OCP 3 months ago; however, she has not started taking these. Ø complaints or medical/surgical history.

  3. Physical Exam Pelvic examination: PAP and bimanual examination. Discover a 6 cm nontender left adnexal mass that is mobile. Ø rebound tenderness Ø guarding

  4. Classification of Pelvic Masses

  5. According to Williams’ Gynecology: Most benign and malignant ovarian masses are predominantly cystic, especially in the younger population. Incidence of ovarian cysts: 5 - 15% Histologically, they are often divided into: Created by disruption of normal ovulation (functional ovarian cysts) Derived from ovarian cystic neoplasms Derived from neoplastic growth Differentiation of these is not always clinically apparent using either imaging tools or tumor markers. Origin of AdnexalMasses

  6. Functional: mass that is often self-limiting and resolves during the duration of the menstrual cycle. It can be caused by a hormonal dysfunction related to ovulation. If it persists longer or becomes enlarged it becomes pathological. Non-functional: a mass not associated to the normal menstrual or hormonal cycle. Functional vs Non-Functional

  7. FunctionalOvarianCysts

  8. Originate from follicles Created by hormonal dysfunction related to ovulation. They are not neoplasms Derive mass from accumulation of intrafollicular fluids rather than cellular proliferation. Subdivisions -similar symptoms and management, but differ in the potential hormones produced as well as histologic appearance. FunctionalOvarianCysts • Follicular cyst: • Hormonal dysfunction prior to ovulation • Results in expansion of the follicular antrum with serous fluid and formation of a follicular cyst • Luteal cyst (usually hemorrhagic) • Retention cyst from premature sealing of CL after egg release, up to 10cm • Disappear after a few weeks • Following ovulation excessive hemorrhage may fill the corpus luteum, creating corpus luteumcysts

  9. NeoplasticOvarianCysts • Benign • Malignant Epithelial Germ Stromal

  10. NeoplasticOvarianCysts • Benign • Malignant • Epithelial: serous (70%)>mucinous>endometrioid • Most are benign • Management: surgical removal due to malignancy potential, via: • Cystectomy (to conserve fertility) • Oophorectomy • Bilateral oophorectomy (postmenopausal) Serouscyst

  11. NeoplasticOvarianCysts • Benign • Malignant • Germ cell: named “benign cystic teratoma”, “dermoid cyst” or “dermoid” • Filled with mixed tissue types (mostly ectodermic origin), can include: sebabeous glands, teeth, hair, etc. • Presentation : • Frequently asymptomatic, mobile, non-tender mass • High torsion rate (due to high fat content), risk of rupture and peritonitis • Management: surgical removal

  12. NeoplasticOvarianCysts • Benign • Malignant • Stromal cell: granulosa theca cell tumours, Sertoli-Leydig cell tumours, ovarian fibroma • Granulosa: feminizing effects due to oestrogen production • Sertoli:hirsutism and verilizingeffects due to testosterone production • Fibroma: is non-functional, high concentration of collagen production and paired with ascites, pleural effusion (Meigs Syndrome) • Management: surgical removal

  13. NeoplasticOvarianCysts • Benign • Malignant • Symptoms: often missed. Most common are: • Abdominal fullness or distension • Abdominal or back pain • Decreased energy, lethragy • Urinary frequency • 8-13% associated with BRCA1 or 2 Epithelial Germ Stromal

  14. NeoplasticOvarianCysts • Benign • Malignant • Stromal • Granulosa cell tumours • Fibroma • Thecoma • Sertoli-Leydig • Epithelial origin • Malignant epithlial serous tumour • Malignant mucinous epithelial tumour • Breast/ovarian familial cancer syndrome • HNPCC (combination of colon, endometrial, ovarian and breast with family history) • Germ cell origin • Germ cell tumours: can be functional (excreting bhCG, AFP) • Dysgerminomos • Immature teratomas

  15. Ethnicity Age of menarche Previousperiods (length of cycle, dysmenorrhea, volume, regularity) Previouspaps? Normal? Sexual practices: protection? dyspareunia? Anyotherpartners? Hursutism and verilization? (Weight gain, hairgrowth,acne etc.) GI? Dyschezia? GU? Dysuria? Constitutionalsymptoms? (Weight changes, fever, night sweats, fatigue, loss of appetite) Family OBGYN history? BRCA 1 or BRCA2 (+) ? OtherUseful Information

  16. Blood work: β-HCG: R/O pregnancy, ectopic pregnancy, gestational trophoblastic neoplasm Tumor markers: CA125, AFP, lactate dehydrogenase (dysgerminoma), CA 19-9 (mucinous epithelial ovarian carcinoma), BRCA 1 and 2 (according to family history)  R/O neoplastic origin STI and viral pannel: R/O PID (pyosalpinx) To R/O PCOS (hyperandrogenism): prolactin, 17-hydroxyprogesterone, free testosterone, DHEA-S, TSH, free T4, androstenedione, sex binding globulin (SHBG). LH:FSH ratio Physical Pap test: R/O gonorrhea, chlamydia Imaging Transvaginal + transabdoU/S (R/O: cyst (tubo-ovarian, dermoid, follicular, luteal), ectopic pregnancy, PCOS) If U/S abnormal or inconclusive: Consider abdoMRI or CT (if pregnancy R/O) Investigations

  17. Observation Asymptomatic Simple cyst No signs of malignancy < 8 cm in premenopausal ♀ Suppression OCP (↑E2 e.g., Brevicon 35/0.5) GnRH Analogue (e.g., Lupron) Excision Procedure to be chosen according to age, risk factors for malignancy, desire for fertility Cystotomy, cystectomy or rarely Oopherectomy Drainage, Salpingo-oopherectomy or TAH ∓ BSO (Pelvic abscess or extensive endometriosis) Follow-up • A F/U transvaginal US can be performed to confirm disappearance or changes, usually the liquid is resorbed and functional cysts resolve within 2 menstrual cycles (Medscape)

  18. Follow-up: Postmenopausal Williams’ Gynecology 2008, table 9-4

  19. Sources UpToDate Medscape Toronto Notes, 2012 Williams’ Gynecology, 2008 Obstretrics and Gynecology, 6th edition, Beckmann

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