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Ovarian Surgery Histology and Evaluation
- 2. MilestBackgroundnes 2006 - 2016 Adult Surgery Department Ovaries according to histology Epithelial (arising from ovarian or fallopian tube epithelium • Germ cell (from egg-producing cells) • Stromal ( from hormone producing cells) - Serous & mucinous - most common - Endometriod - Brenner -Dysgermenoma - Endometrail sinus - Teratoma - Choriocarcinoma -Granulosa theca -Sertoli lyding cell
- 3. Milestones 2006 - 2016 Outline Adult Surgery Department Concepts On Aetiology Most premenopausal tumours are benign in origin Malignancy can occur at all ages this risk increases with age Postmenopausal women require aggressive evaluation
- 4. NongynaeCauses Donʼt forget thereʼs other stuff in the pelvis! Brown G. A gynecologic approach to evaluation of pelvic masses in women JAAPA2012
- 5. Milestones 2006 - 2016 Adult surgery Department Clinical Features Often manifests late Abdominal or pelvic pain bloating Abdominal distension Other nonspecific symptoms
- 6. Milestones 2006 - 2016 Adult surgery Department Clinical Features Inspection Overall, the patient may look unwell The abdomen may be distended, generally or asymmetrically The umbilicus may be deviated If acute, the abdomen may not move with respiration
- 7. Milestones 2006 - 2016 Adult surgery Department Clinical Features Palpation Is the surface smooth or nodular? Nodularity is not good Is the mass fixed or mobile Consistency - hard, firm or soft
- 8. Ascites this is never a good sign you must know how to evaluate for shifting dullness
- 10. Ultrasound TVS image produces greater resolution
- 11. Milestones 2006 - 2016 Adult surgery Department Role of ultrasound An essential tool for diagnosis - first Ix to be considered Any mass must initially be scanned Abdominal or transvaginal Features to look composition of tumour size uni- or bilateral and presence of ascites
- 13. • It is the most widely used model • to predict the probability of malignancy in a formula • menopausal status, • ultrasound characteristics • CA 125 level • A systematic review showed the -sensitivity 78% (95% CI 71-85%) -specificity 87% (95% CI 83-91%) Risk of Malignancy Index (RMI) Adult surgery Department
- 16. • It is primarily a marker for epithelial ovarian carcinoma . • sensitivity of 61 to 90 %, • specificity of 71 to 93% • It is unreliable in differentiating • benign from malignant ovarian masses • in premenopausal women. • May be used as surveillance when increased • It is only raised in 50% of early stage disease. CA 125 antigen Adult surgery Department
- 18. • in all women under age 40 • complex ovarian mass • possibility of germ cell tumours. • Lactate dehydrogenase (LDH) • α-FP • hCG should be measured -Dysgermenoma - Endometrail sinus -Choriocarcinoma Adult surgery Department
- 20. • Routine use of CT and MRI • in the detection of ovarian malignancy • not improve the sensitivity or specificity • obtained by transvaginal ultrasonography • These imaging modalities • evaluation of more complex lesions • Staging of the malignancy Adult surgery Department
- 21. • A retrospective study found • 25% of adnexal masses in were malignant. •referral to a gynecologist • An adnexal mass in a premenarchal patient • presence of symptoms associated with a mass Adult surgery Department PREMENARCHAL PATIENTS
- 22. Milestones 2006 - 2016 Adult surgery Department The objectives when a growth is discovered Most importantly, assess the probability of malignancy If malignancy is less likely, then assess the association with fertility Plan for management, most likely surgery
- 25. Premenopausal females › If size <10 cm, mobile, cystic, unilateralfollow, place patient on monophasic OC, repeat U/S in 2-3 months 70% of these will resolve8 › Adult surgery Department
- 26. • › If size >10 cm, fixed, solid, or other concerning featurestake it out • › If mass persists or enlarges at repeat scantake it out Adult surgery Department
- 28. Management Algorithm (there are many of these) Van Nagell, JR, et al. Am J of Obstet & Gynecol 2005:193,30-35 Adult surgery Department
- 29. 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 Adult surgery Department When should I refer to an oncologist?
- 30. Milestones 2006 - 2016 Adult surgery Department Takehome message To Formulate A List Of Differentials For A Patient With A Pelvic Mass Identify The Risk Factors For Malignancy To Establish A System Of Evaluation For Such Tumours
- 32. • For risk reduction in women with BRCA1 & BRCA2 mutations • Ideally at the age of 35-40 years • Completion of childbearing. • Bilateral salpingo-oophorectomy Adult surgery Department Surgical intervention for ovarian cancer prevention