MANAGEMENT OF ADNEXAL MASSES

1. MANAGEMENT OF ADNEXAL MASSES

2. Objectives • Understand which adenexal masses require surgery verses following • Understand how to identify potentially malignant adenexal masses • Decide which patients with adenexal masses should be referred to a gynecologic oncologist

3. Adnexal masses • Management is often driven by concern for malignancy • 289,000 admissions per year for ovarian neoplasms • 22,000 new cases ovarian cancer per year • Risk of malignancy within an ovarian neoplasm varies with age • Peak age is in a women’s 60’s

4. Adnexal Masses in Reproductive Age Women

5. Adnexal masses in reproductive age women • Of non-inflammatory ovarian tumors • 70% functional cysts • 20% benign tumors • 10% endometriomas • ?% tuboovarian complexes/abscesses

6. Unilateral Simple cyst Smooth wall No ascites Resolution over 4-6 weeks <10 cm Bilateral Complex Solid components Internal papillations Ascites Persistence or growth Ultrasound evaluation of adnexal masses Functional Neoplasm

7. Ultrasound: Benign ovarian cyst

8. Ultrasound: Ovarian cancer

9. Presumed functional cysts in reproductive age women • Observe for 3 months • OCPs do not increase likelihood of resolution, but can decrease risk of recurrence

10. Adnexal Masses in Postmenopausal Women

11. Adnexal masses in postmenopausal women • They are not functional cysts and will not go away • Most are benign some are malignant • Concerns about torsion, growth, and missing a malignancy usually lead to removal of adenexal masses

12. Ovarian cancer symptoms • Ovarian cancer is called the “silent killer” (probably not true) • Generally patient and physician ignore the symptoms • One of the best ways to detect early ovarian cancer is for both the patient and the physician to maintain a high index of suspicion of the diagnosis in the symptomatic woman

13. Ovarian cancer symptoms • 95% of patients reported having symptoms prior to diagnosis • Abdominal 77% • Gastrointestinal 70% • Pain 58% • Constitutional 50% • Urinary 34% • Pelvic 26%

14. Evaluation • Physical examination • Including pelvic examination • Transvaginal ultrasonography • CT scan of abdomen and pelvis (optional) • Ca-125 • Should only be done if mass found • Less useful in the premenopausal woman

15. Ca-125 • Antigenic determinant located on large, mucin-like glycoprotein found on cells derived from coelomic epithelium (pericarium, pleura, peritoneum) and Mullerian epithelium (tubal, endometrial, endocervical) • Expressed by 80% nonmucinous epithelial ovarian cancers • Up to 50% of early stage ovarian cancers and 20-25% of advanced stage ovarian cancers are associated with normal Ca-125 values

16. Ca-125 • Normal range in most labs < 35 U/ml • Sensitive marker of response to treatment and disease status in patients with ovarian cancer • Can be used in triage of ovarian masses • Less useful in premenopausal women because many benign conditions can cause “false” elevations • Not useful for screening

17. Screening Ca-125 • 39,114 menopausal women followed 4 years with Ca-125 and ultrasound • 90 cases of ovarian cancer • 60 were found due to the screening • 80% were stage III or IV • 1170 surgeries required to find the 60 cases

18. Benign ovarian cysts Uterine leiomyomata Pelvic inflammatory disease Endometriosis Adenomyosis Pregnancy Menstruation Heart failure Liver failure Renal failure Peritoneal tuberculosis Diverticulitis Pancreatitis Recent abdominal or thoracic surgery Other malignancies Conditions which may cause a “false” elevation of Ca-125

19. Should the patient have surgery by general gynecologist or gyn oncologist?

20. Why consult a gynecologic oncologist? Accurate staging • Complete surgical staging: • 97% gynecologic oncologists • 52% general obstetrician/gynecologists • 35% general surgeons • Better prognosis with complete surgical staging in early disease McGowan L, et al. Misstaging of ovarian cancer. Obstet Gynecol 1985;65:568-72.

21. Optimal cytoreduction results in improved survival in ovarian cancer Slide courtesy of Gynecologic Cancer Foundation

22. Who should be referred to a gynecologic oncologist? • Women who have a pelvic mass that is suspicious for a malignant ovarian neoplasm, as suggested by at least one of the following indicators: • Elevated Ca-125 level • Premenopausal > 200 units/ml • Postmenopausal > 35 units/ml • Ascites • A nodular or fixed pelvic mass • Evidence of abdominal or distant metastasis ACOG Committee Opinion #280, December 2002. The role of the generalist obstetrician-gynecologist in the early detection of ovarian cancer

23. Ovarian Torsion

24. Pathogenesis • Generally associated with ovarian mass but can occur with normal ovaries • Generally both the tube and ovary are envolved but either structure can torse alone • Generally with cysts that are >5cm • Less likely with old PID or malignancies due to the adhesions • Generally in reproductive age women

25. Clinical Presentation • Acute moderate to severe pelvic pain – 90% • Adenexal mass – 90% • Nausea and vomiting – 47 to 70% • Fever – 2 to 20% • Abnormal uterine bleeding – 4%

26. Evaluation • Abdomenal and pelvic exam demonstrating tenderness and generally rebound • Lab • Hcg, CBC • Ultrasound • Adenexal mass with diminished venous blood flow intially, no blood flow later

27. Treatment • Surgery, the sooner the better • If done soon enough, you can save the ovary