Adnexal  Masses
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Adnexal Masses

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CONFERENCIA 20010

CONFERENCIA 20010

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Adnexal  Masses Adnexal Masses Presentation Transcript

  • ―Clinical management of adnexal masses” PROF. SANTIAGO DEXEUS Dr. Gustavo Missón
  • Introduction  Adnexal masses are the fourth most common gynecological cause for hospitalization and 90% have benign characteristics.
  • Adnexal Mases USA ANNUAL HOSPITALIZATION: 289000 PATIENTS RISK OF MALIGNANCY 13% in pre menopause 45% in post menopause L Van Lie (2000) 48 Meeting of the ACOG
  • ADNEXAL MASSES N= 4.359 October 1991 – October 1999 average: 37.22 years (14-85) Rate of malignancy: 2.1% IUDEXEUS-1999
  • ADNEXAL MASSES Color Doppler Absence of pathological flow 3.0% Malignant tumor Kurjak et al,1993 4.2% Malignant tumor MªA Pascual y col.,1996
  • PRIORITY  Differential diagnosis  Diagnostic studies and interpretation  Management
  • Anatomy  ―Adnexa‖ › Area next to the uterus containing ligaments, vessels, tubes, ovaries
  • Background  Prevalence of adnexal masses is 2 to 8% › Random TVUS of 335 asymptomatic premenopausal women, 7.8% with adnexal masses 2.5 cm or larger (6.6% were ovarian cysts. › Transvaginal sonographic ovarian findings in a random sample of women 25-40 years old. Ultrasound Obstet Gynecol 1999 May;13(5):345-50.
  • Background  Prevalence of adnexal masses is 2 to 8% › TVUS in 8794 asymptomatic postmenopausal women, 2.5% were found to have adnexal cysts › Alcazar JL; Jurado M. Natural history of sonographically detected simple unilocular adnexal cysts in asymptomatic postmenopausal women. Gynecol Oncol 2004 Mar;92(3):965-9.
  • Differential Diagnosis  Physiologic cysts › Follicle develops but never ruptures, continues to grow › Simple, smooth-walled  Functional cysts › Corpus luteum does not involute or continues to grow  Most are small (<2.5 cm), but can be larger  Usually no symptoms, unless rupture or torsion
  • Differential Diagnosis  Ectopic pregnancy  PID  Hydrosalpinx  Benign neoplasms › Serous or mucinous cystadenoma › Endometrioma › Cy.Dermoid › Fibroids (exophytic, broad ligament)  Malignancy › Primary vs. mts
  • Non-Gyn Etiology  Abdominal › Appendicitis › Diverticulitis › Inflammatory bowel disease  Inclusion cysts › Peritoneal or omental  Retroperitoneal masses › Pelvic kidney
  • Diagnosis: History  History › Pain  Midcycle physiologic or functional cyst  Dysmenorrhea/dyspareunia endometriosis  Sudden onset, severetorsion, rupture, hemorrhage  Chronic aching, bloatingneoplasm › Nonspecific GI symptoms  May suggest ovarian cancer in postmenopausal female  May suggest appendicitis or GI etiology in younger women › FH  Breast, colon, or ovarian cancer
  • Diagnosis: Physical Exam  Physical exam—should include bimanual and rectovaginal exam › Fever PID, appy, diverticulitis › Shouldn’t be able to palpate a postmenopausal ovary › Cul de sac nodularity, tender ligaments endometriosis › Cervical motion tendernessPID › Fixed, irregular, solid may suggest neoplasia
  • Diagnosis: Physical Exam  Will probably need more than an H&P to make a diagnosis › 84 women underwent pelvic examination prior to surgery, blinded to surgical indication › Attending, resident, student examined patient › Padilla L, Radosevich D, Milad M. Limitations of the pelvic examination for evaluation of the female pelvic organs . Int J of Gyn 2005; 88 (1): 84 – 88.
  • Diagnosis: Physical Exam › Exam is a ―limited screening tool‖ for detection of adnexal masses › Sensitivity at detecting adnexal masses: p >0.04
  • Diagnosis: Labs  Labs › β-HCG to exclude ectopic › RPC if infection suspected › Tumor makers  CA-125 (more to come)  Others useful in adolescents/premenopaual women with adnexal masses and high suspicion  LDHDysgerminoma  HCGchoriocarcinoma  AFPEndodermal sinus tumor
  • Malignancy  Postmenopausal › Roughly 50 per 100,000 women, relative risk of ~3.5 › 80% of ovarian cancers occur in women over 50  Family history  Symptoms › Vague, chronic aching, bloating, +/- GI symptoms  Physical examination › Remember. . . Not really useful  Ultrasound findings  CA-125
  • Family History  Lifetime risk of ovarian cancer in general population 1.5% › In BRCA 1 carrier 45-55% › In BRCA 2 carrier 15-25%  Not all mutations have been identified › Two to three relatives with ovarian cancer increases lifetime risk to 5% (15% if first degree relatives) › Carlson KJ; Skates SJ; Singer DE. Screening for ovarian cancer. Ann Intern Med 1994 Jul 15;121(2):124-32.
  • CA-125  Not specific to ovarian cancer, also elevated in:  Other cancers (endometrial, fallopian tube, germ cell, cervical, pancreatic, breast, colon)  Benign conditions (endometriosis, fibroids, PID, adenomyosis, functional ovarian cysts, pregnancy)  Other diseases (renal, heart, liver, and many others)  Also abnormal in 1% of normal females  Bast R; Klug T; St John E; Jenison E; Niloff J; Lazarus H; Berkowitz R; Leavitt T; Griffiths C; Parker L; Zurawski V; Knapp R. A radioimmunoassay using a monoclonal antibody to monitor th  course of epithelial ovarian cancer. N Engl J Med 1983 Oct 13;309(15):883
  • CA-125  Normal value <35 › Rarely >100-200 in benign conditions
  • CA-125  Utility as screening tool for ovarian cancer › CA-125 increased in roughly 80% of ovarian cancers › About 50% sensitivity for Stage I, 90% for Stage II  Study of 5550 healthy Swedish women › Followed women with elevated and normal CA-125 levels › Serial pelvic exams, U/S, serial CA-125 levels › Of 175 women with elevated CA-125, 6 with ovarian cancer › Of the remaining women with normal CA-125 levels, 3 had ovarian cancer › Einhorn N; Sjovall K; Knapp RC; Hall P; Scully RE; Bast RC Jr; Zurawski VR Jr. Prospective evaluation of serum CA 125 levels for early detection of ovarian cancer. Obstet Gynecol 1992 Jul;80(1):14-8.
  • CA-125 (follow)
  • BIOMARKERS › Ca 125 › Ca 19.9 › Ca 15.3 › BCGH › Alpfa-phetoprotein › HE-4
  • Ultrasound Simple cyst › Less than 2.5 cm › Unlikely malignant › Probably a follicle Homogeneous appearance may suggest endometrioma www.uptodate.com
  • Ultrasound  Features suggestive of malignancy: › Solid component › Doppler flow › Thick septations › Size › Presence of ascites or other peritoneal masses
  • Ultrasound: The DePriest Score De Priest PD, Shenson D, Fried A, Hunter JE, Andrew SJ, Gallion HH, et al A morphology index based on sonographic findings in ovarian cancer. Gynecol Oncol. 1993 Oct;51(1):7-11  Morphology index  U/S on 121 patients who underwent exlap  Morphology score <5 (80)all benign, 100% NPV  Morphology score >10 (5) all malignant, 100% PPV  Morphology score ≥ 5, 45% PPV for malignancy (but, PPV only 14% for premenopausal women)  There are other morphology indices—this is not the only one
  • So now what? Management  Premenopausal females › If size <10 cm, mobile, cystic, unilateralfollow, place patient on monophasic OC, repeat U/S in 2-3 months  70% of these will resolve8 › If size >10 cm, fixed, solid, or other concerning featurestake it out › If mass persists or enlarges at repeat scantake it out
  • What about the Postmenopausal Female?  Modesitt study9 › 15,106 asymptomatic women over 50 who underwent TVUS › If no abnormalitiesannual screening › If abnormalrepeat U/S in 4-6 weeks with Doppler and CA-125 › 18% with unilocular ovarian cysts <10 cm in diameter  69.4% resolved  5.8% developed solid component  16.5% developed septum  6.8% persisted as unilocular › 10 patients with unilocular lesion who developed ovarian cancer, all of whom either:  developed a septum or solid component on U/S,  underwent complete resolution of the cyst,  or developed cancer in the contralateral ovary › Thus. . . The risk of developing ovarian cancer in a woman with a unilocular, small cyst is VERY low (0.1%)
  • Management  Postmenopausal › If asymptomatic, normal exam, simple cyst on U/S, normal CA-125,unilateral, ≤ 5 cm  follow with serial U/S and CA-125 q 3-6 months until 12 months, then annually thereafter › If above except complex appearance and ≤ 5 cm  Repeat U/S and CA-125 in 4 weeks  Resolution  Persistence or decreasing complexityfollow q 3-6 months with U/S and CA-125  Increasing CA-125 or increasing complexitysurgery › If complex, ≤ 5 cm, and elevated CA-125  Take it out › If symptomatic, ≥ 5 cm, clinically apparent, non-simple in appearance, or elevated CA-125take it out.
  • Management Algorithm (there are many of these) Van Nagell, JR, et al. Am J of Obstet & Gynecol 2005:193,30-35
  • ADNEXAL MASSES Anatomical Pathology in surgery Biopsy of peritoneal implants Biopsy of growths ovarian / tubal Cystectomy / oophorectomy Concordance with definitive biopsy > 95%
  • When should I refer to an oncologist? ACOG Guidelines:  Premenopausal (< 50 Years Old) › CA-125 > 200 U/mL › Ascites › Evidence of abdominal or distant metastasis (by exam or imaging study) › Family history of breast or ovarian cancer (in a first-degree relative)  Postmenopausal (>= 50 Years Old) › CA-125 > 35 U/mL › Ascites › Nodular or fixed pelvic mass › Evidence of abdominal or distant metastasis (by exam or imaging study) › Family history of breast or ovarian cancer (in a first-degree relative) ACOG Committee Opinion: number 280, December 2002. The role of the generalist obstetrician-gynecologist in the early detection of ovarian cancer. Obstet Gynecol 2002;100:1413–6
  • Thank you by you attention www.santiagodexeus.com