Management of ovarian masses
Situations & recommendations
Management of ovarian masses e Clinical
Situations & recommendat...
Review Article
Management of ovarian masses e Clinical
situations & recommendations
Rooma Sinha a,
*, Satyamvada b
, B. Ru...
or gastric cancers. Any postmenopausal woman with an
ovarian mass should have breast and digital rectal examina-
tions, st...
oophorectomy, as there is increased chance of developing
malignant transformation in ovaries in future. She was
advised la...
5.3.1. Learning points
In this procedure the risk of bilaterality is always there and the
woman should be counseled about ...
that a mass can take. The following situations are appropriate
indication to observe with serial ultrasound screening:
 Ul...
6. Modesitt SC, Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ, van
Nagell Jr JR. Risk of malignancy in unilocular ovarian ...
Apollohospitals:http://www.apollohospitals.com/
Twitter:https://twitter.com/HospitalsApollo
Youtube:http://www.youtube.com...
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Management of ovarian masses e Clinical situations & recommendations

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Adenexal mass is a common clinical presentation. This clinical situation is a problem that affects women of all ages. The biggest challenge is that one should not miss out on a diagnosis of malignant ovarian tumor. An ovarian mass or cyst that raises the suspicion of malignancy is a common dilemma in a gynecological practice. In the United States, a woman has a 5-10% lifetime risk of undergoing surgery for a suspected ovarian neoplasm and an estimated 13e21% chance of this turning into a diagnosis of ovarian cancer. Most of the adnexal masses are benign but the first responsibility of the treating gynecologist is to exclude malignancy. Management decisions often are influenced by the age and family history and presentation of the patient.







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Management of ovarian masses e Clinical situations & recommendations

  1. 1. Management of ovarian masses Situations & recommendations Management of ovarian masses e Clinical Situations & recommendations Clinical
  2. 2. Review Article Management of ovarian masses e Clinical situations & recommendations Rooma Sinha a, *, Satyamvada b , B. Rupa b a Senior Gynecologist, Laparoscopic & Robotic Surgeon, Department of Gynecology & Minimally Invasive Surgery, Apollo Health City, Hyderabad, India b Registrar, Department of Gynecology, Apollo Health City, Hyderabad, India a r t i c l e i n f o Article history: Received 25 June 2012 Accepted 3 July 2012 Available online 8 July 2012 Keywords: Ovarian mass Aspiration Ultrasound Tumor markers a b s t r a c t Adenexal mass is a common clinical presentation. This clinical situation is a problem that affects women of all ages. The biggest challenge is that one should not miss out on a diagnosis of malignant ovarian tumor. An ovarian mass or cyst that raises the suspicion of malignancy is a common dilemma in a gynecological practice. In the United States, a woman has a 5e10% lifetime risk of undergoing surgery for a suspected ovarian neoplasm and an estimated 13e21% chance of this turning into a diagnosis of ovarian cancer.1 Most of the adnexal masses are benign but the first responsibility of the treating gynecologist is to exclude malignancy. Management decisions often are influenced by the age and family history and presentation of the patient. We purpose to review the most recent data on imaging modalities, operative assessment of the adnexal mass and preoperative models to predict the probability of ovarian malignancy. A woman’s lifetime risk of developing ovarian cancer is approximately 1 in 70.2 The 5-year survival rate in women in whom stage I ovarian cancer has been diagnosed exceeds 90%; however, only 20% of cancers are detected at this stage.3 Copyright ª 2012, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Disease & management An ovarian mass or also known as adenexal mass can arise from ovaries or fallopian tube. In premenopausal women, most adnexal masses are caused by ectopic pregnancy, ovarian cysts, tumors, polycystic ovaries and abscesses. When a mass is present in women of postmenopausal age group, there is a greater probability that a mass may be malignant. A higher index of suspicion for malignancy is warranted when either the scan shows a complex cyst or the tumor markers are raised. Any elevation of CA 125 levels is highly suspicious for malignancy in women in this age group. Ultrasound find- ings of masses that contain solid areas or excrescences or that are associated with free fluid in the abdomen or pelvis or both. With the exception of simple cysts on a transvaginal ultra- sound finding, most pelvic masses in postmenopausal women will require surgical intervention. Additionally in such women CT scan may give more information. Ovary is a relatively common site for metastases from uterine, breast, colorectal, * Corresponding author. E-mail address: drroomasinha@hotmail.com (R. Sinha). Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/apme a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 7 0 e2 7 5 0976-0016/$ e see front matter Copyright ª 2012, Indraprastha Medical Corporation Ltd. All rights reserved. http://dx.doi.org/10.1016/j.apme.2012.07.010
  3. 3. or gastric cancers. Any postmenopausal woman with an ovarian mass should have breast and digital rectal examina- tions, stool for occult blood, upper and lower gastrointestinal endoscopy as well as mammography. An endometrial biopsy should be performed if transvaginal ultrasound findings show a thickened endometrial lining and abnormal uterine bleeding is present. 2. Preoperative: ultrasound findings Unilocular, thin-walled sonolucent cysts with smooth, regular margins are most often benign. With this kind of ultrasound features malignancy rates in most series of 0e1%.4,5 In a large prospective study 2763 postmenopausal women with uniloc- ular cysts upto 10 cm size were followed up using serial ul- trasonography at 6-month intervals. Spontaneous resolution occurred in more than two thirds of patients, and no cancers were detected after a mean follow-up of 6.3 years, suggesting that the risk of malignancy in such patients was virtually nonexistent.6 Some clinical studies have shown association of such cysts with hypothyroidism. Hence a thyroid profile should be done in women with simple cysts and treated if found to be hypothyroid. Once the thyroid levels reach normal range, the cyst also resolved without any surgical interven- tion. Therefore, simple cysts up to 10 cm in diameter as measured by ultrasonography are almost universally benign and may safely be followed without intervention, even in postmenopausal patients. Some ultrasound characteristics may point toward specific benign diagnoses. Typical findings for endometriomas are a round homogeneous-appearing cyst containing low-level echoes within the ovary, with sensitivity of 83% and specificity of 89%. Mature teratomas contain a hypo echoic attenuating component with multiple small homogeneous interfaces. Hydrosalpinges appear as tubular- shaped sonolucent cysts, with a sensitivity of 93% and speci- ficity of 99.6% for differentiating this diagnosis from other adnexal masses. 3. Tumor markers The most extensively studied serum marker to distinguish benign from malignant pelvic masses is CA 125. It is most useful when nonmucinous epithelial cancers are present. The serum marker CA 125 level is elevated in 80% of patients with epithelial ovarian cancer but only in 50% of patients with stage I disease at the time of diagnosis, hence its lack of utility as a screening test.1 The value of elevated CA 125 levels is in distinguishing between benign and malignant masses in postmenopausal women. Whereas CA 125 level measurement is less valuable in premenopausal than postmenopausal women in predicting cancer risk, extreme values can be helpful. Additionally, b-hCG, L-lactate dehydrogenase (LDH), and alpha-fetoprotein (aFP) levels may be elevated in the presence of certain malignant germ cell tumors, and inhibin A and B sometimes are markers for granulosa cell tumors of the ovary. 4. Aspiration of ovarian cyst Aspiration of nonunilocular ovarian cyst fluid is not recom- mended either for diagnosis or treatment when there is a suspicion for cancer. Aspiration cytology has poor sensitivity to detect malignancy, ranging from 25% to 82%,7 and aspira- tion is never therapeutic and in 25% there is recurrence of the cyst within 1 year of the procedure. This is especially contra- indicated in postmenopausal women. Aspiration of a malig- nant mass may induce spillage and seeding of cancer cells into the peritoneal cavity, thereby changing the stage and prognosis. There have also been reports of aspirated malig- nant masses recurring along the needle tract through which the aspiration was done. Spillage decreases overall survival of stage I cancer patients compared with patients with tumors that were removed intact. Women with clinical and radio- graphic evidence of advanced ovarian cancer and who are medically unfit to undergo surgery, in such situation one can do aspiration to confirm the diagnosis with malignant cytology thereby permitting initiation of neoadjuvant chemotherapy. 5. Surgery How extensive the surgery should be done in women with ovarian mass depends on the diagnosis, age, and patient wishes for ovarian function or future fertility. In premeno- pausal women, with diagnosis of benign disease cystectomy is the operation of choice, especially in case of teratomas, endometriomas and cystadenomas. When ovarian tissue cannot be preserved, a unilateral oophorectomy or salpingo- oophorectomy is indicated. Below are some cases illustrating these conditions and how one can approach, observe and manage patient care and safety. 5.1. Case 1 A 63-year lady was presented with postmenopausal bleeding. Her USG reported as thickened endometrium of 12 mm with left ovarian cyst of 6 cm. All tumor markers were normal. She underwent hysteroscopy and endometrial biopsy for postmenopausal bleeding. Histopathology was reported as endometrial hyperplasia without atypia. The lady was advised and hence underwent laparoscopic hysterectomy with BSO. Final HPE showed granulosa cell, tumor of left ovary (Fig. 1). 5.1.1. Learning points Whenever there is postmenopausal bleeding one must raise this question e what is the source of hormone in post- menopausal women with endometrial hyperplasia? Should serum estradiol be done as part of evaluation of all such cases? 5.2. Case 2 A 16-year girl with Turner syndrome and primary amenorrhea was referred from endocrinology department for bilateral a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 7 0 e2 7 5 271
  4. 4. oophorectomy, as there is increased chance of developing malignant transformation in ovaries in future. She was advised laparoscopic bilateral oophorectomy but did not report for the procedure due to class 10th board exam. She reported 6 months later with abdominal distension. Her CT scan showed a large solid ovarian tumor 10 Â 12 cm size (Fig. 2). On laparotomy right ovarian mass was removed along with left oophorectomy (Fig. 3). Final histopathology was re- ported as dysgerminoma. 5.3. Case 3 A 21-year lady presented with history of delayed cycles for last 2 years. She was being treated as PCOS. Subsequently she had secondary amenorrhea and hirsuitism and at presentation had frank virilization, alopecia and clitaromegaly (Fig. 4). She was also anxious to conceive. Her TST & DHEAS levels were markedly high. The ultrasound and CT scan showed a 5 cm mass from right ovary with complex features. She was advised laparoscopy with frozen section (Figs. 5 and 6). The frozen section showed steroid cell-producing tumor and a right salpingo-oophorectomy was done. Her final diagnosis was also steroid cell-producing tumor. Her response to tumor was remarkable as depicted by her total testosterone levels. She is 12 weeks pregnant at the time this article is being written (Table 1). Fig. 1 e Operative picture showing granulosa cell tumor of left ovary. Fig. 2 e Showing CT scan showed a large solid ovarian tumor 10 3 12 cm size. Fig. 3 e Showing right ovarian mass final histopathology e dysgerminoma. Fig. 4 e Showing cliteromegaly. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 7 0 e2 7 5272
  5. 5. 5.3.1. Learning points In this procedure the risk of bilaterality is always there and the woman should be counseled about this at the time of the surgery. The risk of bilaterality, is as high as 25% for benign serous tumors, approximately 15% for benign teratomas, and as low as 2e3% for benign mucinous tumors. 5.4. Case 4 A 22-year-old unmarried girl came with complaints of lower abdominal distension. The USG report showed large masses of 5.8 Â 3.2 cm and 13.8 Â 7.4 cm size in right and left ovaries respectively. She had undergone laparoscopic cys- tectomy 6 months ago for similar complaints, which was reported as mucinous cyst adenoma. She had CT scan, which reported large septated low-density tumor measuring 16.1 Â 6.3 Â 10.1 cm, extending from retro umbilical area to pelvis involving both parametria, left more than right (Fig. 7). She underwent laparoscopy with frozen section (Figs. 8 and 9) and once the frozen section report confirmed benign mucinous cyst she underwent bilateral cystectomy. 5.4.1. Learning points In such cases wedge biopsy of a normal appearing contralat- eral ovary should not be advised because this can lead to se- vere adhesions as well as loss of normal ovarian tissue and doing so might adversely affect fertility. One can choose cystectomy or unilateral salpingo-oophorectomy even in perimenopausal or postmenopausal patients also. But hys- terectomy or bilateral salpingo-oophorectomy or both are considered appropriate options in this age group. This is rec- ommended to reduce the risk of developing uterine, cervical, or ovarian cancer thus reducing the need of future pelvic surgery. It is unclear whether the potential benefits of ovarian preservation outweigh the risks of leaving them in situ. One decision-analysis model performed in women at average risk demonstrated excess mortality especially due to coronary heart disease and hip fracture if oophorectomy is performed before age 59 years.8 6. Take home message The majority of adnexal masses are benign, but diagnosis of an adnexal mass is difficult because there are many forms Fig. 5 e Laparoscopic picture showing steroid cell producing tumour. Fig. 6 e Showing steroid cell-producing tumor e removal in endo bag to avoid spillage. Fig. 7 e Showing CT scan e large septated low-density tumor measuring 16.1 3 6.3 3 10.1 cm extending from retro umbilical area to pelvis involving both parametria, left more than right. Table 1 e Levels of testosterone pre and post surgery. Total testosterone Preserver 360.40 ng/dl Post surgery e 15 days 0.04 ng/dl Post surgery e 60 days 0.32 ng/dla a 2 months post surgery she reported with a positive pregnancy test. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 7 0 e2 7 5 273
  6. 6. that a mass can take. The following situations are appropriate indication to observe with serial ultrasound screening: Ultrasound finding suggests benign disease. Functional cysts in ovulating women. Suspected endometriomas in asymptomatic women with normal or elevated, but not increasing, CA 125 levels. Simple cysts in any age group. Hydrosalpinges. Women who are at substantial risk for perioperative morbidity and mortality. 7. Recommendations according to ACOG 1. In asymptomatic women with pelvic masses (premen- opausal or postmenopausal), transvaginal ultrasonog- raphy is the imaging modality of choice. No other imaging modality has demonstrated sufficient superi- ority to transvaginal ultrasonography to justify its routine use. 2. Specificity and positive predictive value of CA 125 level measurements are more useful in postmenopausal women compared with premenopausal women. Any CA 125 elevation in a postmenopausal woman with a pelvic mass is highly suspicious for malignancy. 3. Simple cysts up to 10 cm in diameter on ultrasound findings are almost usually benign and may safely be followed without intervention, even in postmenopausal patients. 4. Unilateral salpingo-oophorectomy or ovarian cys- tectomy in patients with germ cell tumors, stage I stromal tumors, tumors of low malignant potential, and stage IA, grade 1e2 invasive cancer who undergo com- plete surgical staging and who wish to preserve fertility does not appear to be associated with compromised prognosis. Conflicts of interest All authors have none to declare. r e f e r e n c e s 1. National Institutes of Health Consensus Development Conference Statement. Ovarian cancer: screening, treatment, and follow-up. Gynecol Oncol. 1994;55:S4e14. 2. Reis LA, Harkins D, Krapcho M, et al. editors. SEER Cancer Statistics Review, 1975e2003. Bethesda, MD: National Cancer Institute. Available at: http://seer.cancer.gov/csr/1975_2003. Retrieved February 16, 2007. 3. Heintz AP, Odicino F, Maisonneuve P, et al. Carcinoma of the ovary. Int J Gynaecol Obstet. 2003;83(Suppl 1): 135e166. 4. Alcazar JL, Castillo G, Jurado M, Garcia GL. Is expectant management of sonographically benign adnexal cysts an option in selected asymptomatic premenopausal women? Hum Reprod. 2005;20:3231e3234. 5. Castillo G, Alcazar JL, Jurado M. Natural history of sonographically detected simple unilocular adnexal cysts in asymptomatic postmenopausal women. Gynecol Oncol. 2004;92:965e969. Fig. 9 e Showing laparoscopic cystectomy in progress bilateral mucinous cyst adenoma. Final histopathology report. Fig. 8 e Showing laparoscopic picture of large mucinous cyst adenoma. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 7 0 e2 7 5274
  7. 7. 6. Modesitt SC, Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ, van Nagell Jr JR. Risk of malignancy in unilocular ovarian cystic tumors less than 10 centimeters in diameter. Obstet Gynecol. 2003;102:594e599. 7. Higgins RV, Matkins JF, Marroum MC. Comparison of fine-needle aspiration cytologic findings of ovarian cysts with ovarian histologic findings. Am J Obstet Gynecol. 1999;180:550e553. 8. Parker WH, Broder MS, Liu Z, Shoupe D, Farquhar C, Berek JS. Ovarian conservation at the time of hysterectomy for benign disease. Obstet Gynecol. 2005;106:219e226. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 7 0 e2 7 5 275
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