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  • 1. ì   Management  of  Adnexal  Mass:   Laparoscopy  versus  Laparotomy   Staging  Requirement   Ha#m  Al-­‐Jifree   MB;ChB(Hon),MMedEd,FRCSC   Assistant  Professor,  Gynecological  Oncologist   KSAU-­‐HS      NGHA  
  • 2. Introduction  
  • 3. Introduction   •  Adnexal  mass  refers  not  only  to  ovarian   abnormali#es.     •  Ovarian  neoplasms  are  one  of  the  most   common  pathologies  among  women  of   all  age  groups.  
  • 4. Introduction   • 5-­‐10%  of  women  in  USA  will   undergo  a  surgical  procedure  due   to  suspicious  adnexal  mass  in  their   life#me.    
  • 5. Introduction   •  13-­‐21%  of  them  will  suffer  from   malignancy.   •  300,000  women  are  hospitalized  each   year  to  evaluate  adnexal  mass.     •  0.17-­‐5.9%  are  asymptoma#c.   •  7.1-­‐12%  are  symptoma#c.  
  • 6. Adnexal  mass   •  Ovary:   •  Func#onal  cyst   •  Endometriosis   •  Neoplasms   •  Fallopian  tube:   •  Tubo-­‐ovarian  abcess   •  Hydrosalpix   •  Paratubal  cyst   •  Ectopic  pregnancy   •  Neoplasms   •  Uterus:   •  Pregnancy   •  Myoma   •  Sarcoma   •  Gastrointes#nal:   •  Appendiceal  abscess   •  Diver#cular  abscess   •  Colonic  tumor  
  • 7. Malignant  lesions  incidents  
  • 8. Adnexal  mass   •  80%  of  adnexal  masses  in  women  under   age  55  are  hormone  dependent.   •  Func#onal  cyst     •  Endometriosis   •  8%  are  benign  neoplasms  and   leiomyomas.   •  0.4%  are  malignant  tumors.  
  • 9. Adnexal  Mass   •  Ovarian  cancer  incidence  is  15.7/100,000   before  the  age  of  40  years  old.   •  Ovarian  cancer  incidence  will  increase  to   54/100,000  a_er  the  age  of  40  years  old.    
  • 10. Adnexal  Mass   •  At  pre-­‐teen  &  teenager:   •  65%  func#onal  cysts   •  28%  benign  ovarian  tumor   •  65%  are  dermoid  cysts     •  8%  are  malignant  ovarian  neoplasms   •  Dysgerminomas   •  Immature  teratomas  
  • 11. Adnexal  mass   •  At  reproduc#ve  age:   •  Majority  are  benign   •  Func#onal  cysts   •  7-­‐13.5%  are  malignant   •  Differen#al  diagnosis  at  this  age  group:   •  Ectopic  pregnancy   •  Pelvic  inflammatory  diseases     •  Hydrosalpinx   •  Leiomyoma  
  • 12. Para-­‐Tubal  Cyst  
  • 13. Crucial  factors  for  diagnosis   •  History   •  Risk  factors  for  ovarian  cancer   •  BRCA  muta#ons.   •  Hereditary  cancer  syndromes.   •  Background  of  infer#lity.   •  Women  with  first  degree  rela#ve  with  ovarian   cancer  have  5%  risk  of  malignancy.   •  With  2  affected  rela#ves  carry  a  30%  risk.   •  Mul#ple  cases  make  the  risk  50%.  
  • 14. Crucial  factors  for  diagnosis   •  Symptoms:   •  Majority  are  asymptoma#c.     •  No  specific  symptoms  indica#ve  of  ovarian   mass.   •  Physical  Examina#on:   •  Bimanual  examina#on  can  detect  most  of   asymptoma#c  adnexal  masses.   •  Rectovaginal  examina#on.  
  • 15. Crucial  factors  for  diagnosis   •  Laboratory  findings:   •  No  single  marker  with  sufficient  sensi#vity  &   specificity.   •  CA-­‐125  elevated  in  90%  of  advanced  stage   ovarian  cancer.   •  50%  at  stage  I   •  1%  in  normal  popula#on   •  Nega#ve  in  poorly  differen#ated  type   •  High  false-­‐posi#ve  results.  
  • 16. CA-­‐125  elevation  causes   •  Gynecologic:   •  Endometriosis   •  Myoma   •  PID   •  Luteal  phase  menstrua#on   •  Ovarian  hypers#mula#on   •  Pregnancy   •  Ovarian  cystadenoma   •   Non-­‐Gynecologic:   •  Conges#ve  heart  failure   •  Chronic  renal  disease   •  Chronic  liver  disease   •  Coli#s   •  Appendici#s   •  Pneumonia   •  Pancrea##s  
  • 17. Crucial  factors  for  diagnosis   •  Diagnos#c  imaging:   •  Pelvic  ultrasound  most  useful   •  Size   •  Septum  thickness   •  Cyst  wall  thickness   •  Number  of  loculi   •  Papillary  or  solid  excrescences     •  Echo  density   •  Pulsa#lity  &  Resis#vity  indices  (PI  &  RI)  
  • 18. Ultrasonographic  criteria    
  • 19. Crucial  factors  for  diagnosis   •  Diagnos#c  imaging:   •  CT  &  MRI  are  not  indicated  rou#nely.     •  CT  bejer  for  localiza#on  of  metastasis.   •  MRI  more  superior  in  detec#on  of  ovarian   malignancies.   •  MRI  has  the  high  cost  disadvantage.  
  • 20. Considerations  for  surgical  approach     •  Risk  of  malignancy:   •  Age   •  Radiology  findings   •  Tumor  markers   •  Symptoms   •  Size  of  the  mass:   •  Intra-­‐corporal  vs  extra-­‐corporal  drainage  
  • 21. Considerations  for  surgical  approach     •  Prior  surgical  history:   •  Bowel  surgery   •  Prior  history  of  endometriosis,  PID  or   adhesions   •  Co-­‐Morbidity:  COPD,  Heart  disease,  HTN…   •  Surgical  experience   •  Pa#ent’s  expecta#ons  
  • 22. Sensitivities  &  Specificities    
  • 23. Dodge  et  al  2011  
  • 24. Dodge  et  al  2011  
  • 25. Dodge  et  al  2011  
  • 26. Dodge  et  al  2011  
  • 27. Laparoscopy  approach     • Less  de  novo  adhesion  forma#on.   • Decreased  febrile  morbidity.   • Less  post-­‐opera#ve  pain  and  less   analgesic  requirements.  
  • 28. Laparoscopy  approach     • Shorter  hospital  stay  and  faster   recovery.   • Bejer  cosme#c  results.   • Reduced  overall  cost  on  health  care.  
  • 29. Laparoscopy  approach     • Fear  of  encountering  cancer.   • Fear  of  inadequate  staging.   • Upstaging  of  the  disease  by  tumor   seeding.   • But;  careful  pa#ent  selec#on  is  a   cri#cal  issue.  
  • 30. Issues  of  laparoscopy     •  The  role  of  laparoscopy  in  gyne-­‐oncology?   •  The  rate  of  malignancy?   •  The  risk  of  tumor  spillage?   •  The  risk  of  inadequate  resec#on  and  surgical  staging?   •  The  incidence  of  port-­‐site  metastasis?   •  The  risk  of  leading  to  re-­‐explora#on?   •  The  risk  of  delay  in  chemotherapy?   •  Required  training  for  safe  and  efficient  performance?  
  • 31. Laparoscopy  &  suspicious  mass   •  Associa#on  of  Gynecologic   Laparoscopists  Survey:   •  Incidence  of  unsuspected   malignancies  at  laparoscopy  is   0.04%.   •  Maiman  et  al  1991  reported  that   laparoscopic  visualiza#on  might  fail  to   iden#fy  cancer  in  one  3rd  of  the  cases.  
  • 32. Laparoscopic  diagnosis  of   malignant  adnexal  masses  
  • 33. Laparoscopic  mass  evaluation   •  All  peritoneal  surfaces.   •  Pelvis.   •  Pouch  of  Douglas.   •  Diaphragm.   •  Paracolic  gujers.   •  Omentum.   •  Bowel  surfaces.   •  Obtain  peritoneal  washing.   •  Remove  intact  cyst.    
  • 34. Laparoscopic  mass  evaluation  
  • 35. Negative  Predictive  Value   • It  is  defined  as  the  propor#on  of  subjects  with  a   nega#ve  test  result  who  are  correctly   diagnosed.   •  A  high  NPV  for  a  given  test  means  that  when   the  test  yields  a  nega#ve  result,     •  it  is  most  likely  correct  in  its  assessment.  
  • 36. Meta-­‐analysis  by  Nicklin  et  al  1994   •  Aspira#on  ovarian  cysts  cytology  had  a   nega#ve  predic#ve  value  of  58%  to  98%  in   the  diagnosis  of  malignancy.   •  It  also  increase  the  chance  of  slow  malignant   cells  leak.   •  Aspira#on  will  not  achieve  resolu#on  as  11  –   67%  of  cysts  will  recur.      
  • 37. Canis  et  al  1997     •  1600  adnexal  mass  cases  managed  laparoscopically.   •  With  16  years  follow  up.   •  Laparoscopy  sensi#vity  100%.   •  Posi#ve  predic#ve  value  of  laparoscopy  was  34.7%.   •  Nega#ve  predic#ve  value  was  100%.   •  Concluded  that  laparoscopic  treatment  safe,   effec#ve,  nontrauma#c  and  preserve  fer#lity.  
  • 38. Canis  et  al  1997    
  • 39. Canis  et  al  2002   •  Prospec#ve  management  of  247  suspicious   masses  laparoscopically.     •  Without  evidence  of  disseminated  cancer.   •  85%  of  suspicious  masses  proved  benign.   •  Sparing  laparotomy  in  nearly  94%  of  cases  with   benign  mass.   •  The  remaining  37  cases  were  malignant.   •  19%  managed  surgically  by  laparoscopy  alone.  
  • 40. Childers  et  al  1996   •  138  cases  of  suspicious  masses  managed   laparoscopically.   •  Masses  >10cm  required  laparoscopic   drainage.   •  Masses  <10cm  were  removed  with   endoscopic  sacs.   •  86%  (119/138)  were  of  benign  nature.  
  • 41. Childers  et  al  1996   •  19  were  malignant  of  nature.   •  16  were  adnexal  primaries.   •  3  were  non-­‐gynecologic.   •  Cases  managed  laparoscopically  only:   •  95%  (113/119)  of  the  benign  cases.   •  74%  (14/19)  of  malignant  cases.    
  • 42. Low  suspicion  adnexal  mass   •  Younger  than  40  years  of  age.   •  Puncture  followed  by  endocys#c   examina#on  with  the  use  of  strong   aspira#on  system.   •  Peritoneal  lavage  a_erward  to  minimize   spillage.   •  Frozen  sec#on  for  any  suspicious  mass.  
  • 43. High  suspicion  adnexal  mass   •  Adnexectomy  without  puncture.   •  Mass  is  extracted  in  an  endoscopic  bag.   •  Frozen  sec#on.   •  In  case  of  malignancy,  immediate  staging   proceure  should  be  done.   •  Gyne-­‐Oncologist  involvement.  
  • 44. Drake  et  al  1998   •  Masses  at  reproduc#ve  age  group:   •  Func#onal  cyst  is  the  most  likely  diagnosis.   •  Usually  with  benign  ultrasonographic   features.   •  Normal  CA-­‐125  level.   •  50-­‐90%  will  resolve  spontaneously  in  4  to  6   weeks,  with  or  without  oral  contracep#ves.  
  • 45. Drake  et  al  1998   •  Indica#ons  for  surgery:   •  Masses  >8cm  in  diameter.   •  Failure  to  resolve  within  2  –  6   months.   •  Persistent  pain.   •  Family  history.  
  • 46. Hulka  et  al  1990   •  American  Associa#on  of  Gynecologic   Laparoscopists  Survey:   •  Majority  of  clinician  consider  laparotomy   the  safest  treatment  for  non-­‐cys#c   masses.  
  • 47. Dottino  et  al  1999   •  Laparoscopy  is  safe  in  88%  of  160  pre-­‐  and   postmenopausal  pa#ents  with  suspicious   masses.   •  9%  of  them  found  to  be  malignant.   •  5%  of  them  found  to  be  low  malignant   poten#al.   •  With  3%  intra-­‐opera#ve  complica#ons.  
  • 48. Mahdavi  et  al  2002   •  Postmenopausal  age  group:   •  Careful  evalua#on  will  be  required.   •  Malignancy  has  to  be  excluded.   •  Standard  approach  is  exploratory   laparotomy.   •  Cystectomy  is  not  recommended.   •  Frozen  sec#on  will  be  appropriate.  
  • 49. Vergote  et  al  2001   Outcomes  of  cyst  rupture  (Before  or  during  surgery)  in  stage  I   ovarian  cancer  of  1545  pa#ents  in  6  countries.  
  • 50. Port-­‐Site  Metastases   •  Also  called  wound-­‐site  metastases.   •  Possible  with  malignant  and  low  malignant   poten#al  masses.   •  Childers  et  al  1994  report  that  this  occur  in  1%   a_er  laparotomy  and  1-­‐2%  a_er  laparoscopy.   •  Kruitwagen  et  al  1996  report  that  this  occur  in   16%  a_er  laparoscopy.    
  • 51. Wound-­‐Site  Metastases    
  • 52. To  reduce  the  risk  of  port-­‐site   metastases     •  Minimize  #ssue  trauma  and  number  of  instrument   transfers.   •  5%  povidone-­‐iodine  to:   •  Rinse  trocars  before  inser#on.   •  Rinse  #p  of  instruments.   •  Irrigate  site.   •  Perform  trocar  fixa#on.   •  Use  protec#ve  endobags.   •  Remove  all  fluid  before  removing  trocar.   •  Deflate  abdomen  with  trocars  in  place.   •  Close  10mm  or  more  peritoneal  trocar  sites.  
  • 53. Systematic  Review     Covens  et  al  2012   •  To  review  the  exis#ng  literature  in  order   to  determine  the  op#mal  protocol  for   surgical  management  of  suspicious   adnexal  mass.   •  All  publica#ons  between  1999  to  2009.   •  31  studies  met  the  inclusion  criteria.  
  • 54. Systematic  Review     Covens  et  al  2012   •  Bivariate  random  effect  analysis  of  15  frozen   sec#on  diagnosis  studies:  overall  sensi#vity  of   89.2%  and  specificity  of  97.9%.   •  Systema#c  lymphadenectomy  and  proper   surgical  staging  improve  survival.   •  Fer#lity  conserving  surgery  acceptable  in  low   malignant  poten#al  tumor.  
  • 55. Systematic  Review     Covens  et  al  2012  
  • 56. Systematic  Review     Covens  et  al  2012   • The  accuracy  and  the  adequacy  of   surgical  staging  by  laparotomy  and   laparoscopy  appear  to  be   comparable.   • Neither  approach  conferring  a   survival  advantage.    
  • 57. Systematic  Review     Covens  et  al  2012   •  Intra-­‐opera#ve  tumor  rupture  reported   more  frequently  in  pa#ents  undergoing   laparoscopy  in  two  retrospec#ve  cohort   studies.    
  • 58. Thank  You