Adnexal Masses


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Diagnosis and Management of Adnexal Masses

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Adnexal Masses

  1. 1. Adnexal Masses Todd D. Tillmanns MD Associate Professor Division of Gynecologic Oncology University of Tennessee And West Clinic
  2. 2. Evaluation <ul><li>History and Physical </li></ul><ul><li>Family History </li></ul><ul><li>U/S </li></ul><ul><ul><li>Thickened wall, solid and cystic components, excrescences, ascites </li></ul></ul><ul><li>CT </li></ul><ul><ul><li>Omental cake, ascites, mesenteric disease, liver disease, </li></ul></ul><ul><li>CA-125 </li></ul><ul><ul><li>Premenopausal –vs- postmenopausal </li></ul></ul>
  3. 4. Epithelial Ovarian Carcinoma <ul><li>Serous </li></ul><ul><li>Mucinous </li></ul><ul><li>Endometrioid </li></ul><ul><li>Clear Cell </li></ul><ul><li>Brenner </li></ul><ul><li>Mixed epithelial </li></ul><ul><li>Undifferentiated </li></ul>
  4. 5. Ovarian Serous Cystadenocarcinoma <ul><li>15% of all ovarian malignancies </li></ul><ul><li>Psamoma bodies in 30% </li></ul><ul><li>Bilateral in 1/3 of Stage I cases </li></ul>
  5. 6. Ovarian Papillary Serous Cystadenocarcinoma <ul><li>Ovarian Cancer Low Malignant Potential Tumor </li></ul>
  6. 7. Ovarian Mucinous Cystadenocarcinoma <ul><li>12% of ovarian malignancies </li></ul><ul><li>Bilateral in stage I 5-10% </li></ul><ul><li>Must consider metastatic disease from intestinal primary </li></ul>
  7. 8. Endometrioid Adenocarcinoma <ul><li>15% of ovarian malignancies </li></ul><ul><li>Concommitant endometrial cancer in 15-30% of cases </li></ul><ul><li>Associated with endometriosis in 10%, and in one study 40% of stage I (Sainz de la Cruz 1996) </li></ul><ul><li>15% bilateral in stage I </li></ul>
  8. 9. Sex Cord Stromal Tumors <ul><li>Granulosa stromal cell </li></ul><ul><ul><li>Granulosa cell </li></ul></ul><ul><ul><li>Thecoma Fibroma </li></ul></ul><ul><li>Lipid Cell </li></ul><ul><li>Gynandroblastoma </li></ul><ul><li>Unclassified </li></ul>
  9. 10. Granulosa Cell Tumor <ul><li>This is a granulosa cell tumor of ovary with a variegated cut surface. </li></ul><ul><li>These tumors are derived from the ovarian stroma and often have a component of thecoma. </li></ul><ul><li>They are often hormonally active and can produce large amounts of estrogen </li></ul>
  10. 11. Germ Cell Tumors <ul><li>hCG AFP LDH </li></ul><ul><li>Dysgerminoma + - + </li></ul><ul><li>Endodermal Sinus Tumor - + + </li></ul><ul><li>Embryonal Carcinoma + + + </li></ul><ul><li>Polyembryoma + + - </li></ul><ul><li>Choriocarcinoma + - - </li></ul>
  11. 12. Dysgerminoma
  12. 13. Sertoli Leydig Tumor <ul><li>Differentiate towards testicular structures </li></ul><ul><li><1% of all ovarian cancers </li></ul><ul><li>Many are masculinizing, although estrogen production may predominate </li></ul>
  13. 14. Benign Adnexal Masses <ul><li>Benign ovarian / tubal cysts </li></ul><ul><li>Endometriosis </li></ul><ul><li>Leiomyomas </li></ul><ul><li>Infectious processes </li></ul>
  14. 15. Simple follicular cyst <ul><li>Follicle cysts. Here is a benign cyst in an ovary. This is probably a follicular cyst. Occasionally such cysts may reach several centimeters in size and, if they rupture, can cause abdominal pain. </li></ul>
  15. 16. Corpus Luteum Cyst <ul><li>The corpus luteum secretes progesterone which induces a secretory endometrium. </li></ul><ul><li>It normally regresses in 14 days unless it is rescued by increasing concentrations of human chorionic gonadotropin from a pregnancy </li></ul>
  16. 17. Paratubal Cyst <ul><li>Here is another common incidental finding: a benign paratubal cyst. </li></ul><ul><li>Sometimes such simple cysts are found adjacent to ovary and are called parovarian cysts. </li></ul><ul><li>They are filled with clear serous fluid and lined by flattened cuboidal epithelium. </li></ul>
  17. 18. Mature Cystic Teratomas <ul><li>Here are bilateral mature cystic teratomas of the ovaries. </li></ul><ul><li>These are a form of ovarian germ cell tumor. </li></ul><ul><li>Histologically, a variety of mature tissue elements may be found. </li></ul><ul><li>These tumors are often called &quot;dermoid cysts&quot; because they are mostly cystic. </li></ul>
  18. 19. Ovarian Fibroma <ul><li>This is the cut surface of a fibroma. Such neoplasms slowly enlarge over the years </li></ul>
  19. 20. Endometrioma <ul><li>At laparoscopy the appearance of endometriosis is quite variable. It can take one of the following appearances: </li></ul><ul><li>blue or black powder-burn lesions </li></ul><ul><li>red, blue, white or non-pigmented lesions </li></ul><ul><li>scarring and peritoneal defects </li></ul><ul><li>ovarian cysts </li></ul>
  20. 21. Leiomyomata <ul><li>Leiomyomas may occur in tissues outside of the uterus.  </li></ul><ul><li>Ligaments and connective tissues in the pelvis also contain muscle fibers that may give rise to leiomyomas.     </li></ul>
  21. 22. Tuboovarian Abscess <ul><li>This is an example of a tubo-ovarian abscess from Neisseria gonorrheae. </li></ul><ul><li>Here, there is no clear boundary between tube and ovary and the dilated tube is filled with purulent material. </li></ul>
  22. 23. Appendicitis
  23. 24. Screening Guidelines <ul><li>“Routine screening for ovarian cancer by ultrasound, the measurement of serum tumor markers, or pelvic examination is not recommended. There is insufficient evidence to recommend for or against the screening of asymptomatic women at increased risk of developing ovarian cancer.” </li></ul><ul><li>U.S.Preventive Services Taskforce, Guidelines from Guide to Clinical Preventive Services, 2 nd edition, 1996 </li></ul>
  24. 25. Screening Guidelines <ul><li>NIH Consensus Conference (1994) </li></ul><ul><ul><li>women with presumed hereditary cancer syndrome should undergo annual pelvic exams, CA-125 measurements, and TVUS until childbearing is complete or at age 35, at which time prophylactic bilateral oopherectomy is recommended. </li></ul></ul><ul><li>ACP </li></ul><ul><ul><li>counsel high risk women about potential harms and benefits of screening </li></ul></ul>
  25. 26. Screening Guidelines <ul><li>American Cancer Society, AAFP and ACOG do not recommend screening for ovarian cancer in the general population </li></ul><ul><li>Canadian Task Force on Periodic Health Examination </li></ul><ul><ul><li>“insufficient evidence to recommend for or against screening in high-risk women” </li></ul></ul>
  26. 27. Ovarian Cancer Screening Trials <ul><li>The United Kingdom Collaborative Trial of Ovarian Cancer Screening: will compare TVUS and multimodal screening </li></ul><ul><li>The European Study: RCT to screen women with TVUS at 18-month or 3-year intervals </li></ul><ul><li>The NIH Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial: 10-year study using multimodal strategy </li></ul>
  27. 28. GOG-199 <ul><li>Non-randomized trial </li></ul><ul><li>RRSO (1000) </li></ul><ul><li>- CA-125 – quarterly </li></ul><ul><li>- QOL – every 6 months </li></ul><ul><li>Screening (2400) </li></ul><ul><li>- CA-125 – quarterly </li></ul><ul><li>- QOL – every 6 months </li></ul><ul><li>- TVUS - yearly </li></ul>
  28. 29. Screening Recomendations <ul><li>ACOG: Annual gynecologic exam- ination with an annual pelvic examination is recommended for preventative health care. </li></ul>
  29. 30. Who Should be Referred According to ACOG <ul><li>Premenopausal women who have a pelvic mass that is suspicious for a malignant ovarian neoplasm as suggested by one of the following: </li></ul><ul><ul><li>High CA-125 (>200 U/ml) </li></ul></ul><ul><ul><li>Ascites </li></ul></ul><ul><ul><li>Evidence of abdominal or distant metastases </li></ul></ul><ul><ul><li>Family history of one or more first degree relatives with ovarian or breast cancer </li></ul></ul>
  30. 31. OVA1 <ul><li>The U.S. Food and Drug Administration today cleared a test that can help detect ovarian cancer in a pelvic mass that is already known to require surgery. The test, called OVA1, helps patients and health care professionals decide what type of surgery should be done and by whom.OVA1 identifies some women who will benefit from referral to a gynecological oncologist for their surgery, despite negative results from other clinical and radiographic tests for ovarian cancer. The test combines the five separate results into a single numerical score between 0 and 10 to indicate the likelihood that the pelvic mass is benign or malignant.OVA1 is intended only for women, 18 years and older, who are already selected for surgery because of their pelvic mass. It is not intended for ovarian cancer screening or for a definitive diagnosis of ovarian cancer. Interpreting the test result requires knowledge of whether the woman is pre- or post-menopausal. </li></ul><ul><li>OVA1 is developed by Vermillion Inc., headquartered in Fremont, Calif., in conjunction with researchers at The Johns Hopkins University in Baltimore. </li></ul>
  31. 32. Hereditary Risk <ul><li>Hereditary OV- Ca is estimated to represent only 5-10% of all ovarian cancer </li></ul><ul><li>A woman with a germline mutation of BRCA-1 or BRCA-2 has a lifetime risk of 15-45% of developing ovarian cancer </li></ul><ul><li>BRCA-1 or BRCA-2: Should be offered genetic counseling. </li></ul><ul><li>Having one first degree relative with ovarian cancer (mother, sister, daughter) gives a 5% lifetime risk for ovarian cance </li></ul><ul><li>Two first degree relatives increases lifetime risk to 20-30% </li></ul>
  32. 33. Conditions found in association with increased CA-125 <ul><li>Gynecologic </li></ul><ul><ul><li>Endometriosis, fibroids, hemorrhagic ovarian cysts, menstruation, PID, pregnancy (1 st trimester) </li></ul></ul><ul><li>GI and Hepatic </li></ul><ul><ul><li>Pancreatitis, colitis, chronic active hepatitis, cirrhosis, diverticulitis </li></ul></ul><ul><li>Malignancies </li></ul><ul><ul><li>Bladder, breast, uterine, lung, liver, non-hodgkins lymphoma, ovary, pancreas, colon (metastatic) </li></ul></ul><ul><li>Miscellaneous </li></ul><ul><ul><li>Pericarditis, polyarteritis nodosa, renal disease, Sjogrens syndrome, systemic lupus erythematosus </li></ul></ul>
  33. 34. Morphology Index for Tumors <ul><li>Ov-Volume (cm 3 )= W x Ht x thickness x 0.523 </li></ul>De Priest et al. Gynecol Oncol 1993;51:7-11 Predom Solid Solid area > 10 mm Thick Septa 3 mm-10 mm Thin septa < 3mm No Septa Septa Structure Predom solid Papillary Projection > 3 mm Papillary Projections < 3 mm Smooth >3 mm thickness Smooth <3 mm thickness Cyst Wall Structure >500 cm 3 >200-500 cm 3 >50-200 cm 3 10-50 cm 3 <10 cm3 Volume 4 3 2 1 0
  34. 35. Morphology Index in Premenopausal Patients <ul><li>62 patients </li></ul><ul><li>4 patients with malignancy, all had scores > 5, 3 were stage I and 1 was stage III </li></ul><ul><li>All tumors < 5 were benign </li></ul><ul><li>No ovarian cancer had a volume < 10 cm 3 </li></ul><ul><li>M/C benign tumors in the pre-menopausal group were endometriosis and corpus luteum cysts </li></ul><ul><li>All Ov-Ca had a papillary projection or solid component protruding from a wall </li></ul>De Priest et al. Gynecol Oncol 1993;51:7-11
  35. 36. U/S Scoring System to Differentiate Benign from Malignant <ul><li>Series of operations after U/S evaluation </li></ul><ul><li>705 adnexal masses (565 benign and 141 malignant) </li></ul><ul><li>Mean age 44.5 years (14-81y/o) </li></ul><ul><li>1995-2001 tertiary care hospital Spain </li></ul><ul><li>441(66%) premenopausal </li></ul><ul><li>Scoring system performance unchanged by menopausal status </li></ul>Alcazar JL et al. Am J Obstet Gynecol 2003;188:685-692
  36. 37. Multivariate Significant Parameters on U/S <ul><li>Parameter Odds ratio p-value </li></ul><ul><li>Thick papillary projection 1.9(1.1-4.0) 0.04 </li></ul><ul><li>High velocity/ low resist 5.3(2.5-11.1) <.0001 </li></ul><ul><li>Solid area 8.6(4.2-17.8) <.0001 </li></ul><ul><li>Central flow 15.5(7.3-32.8) <.0001 </li></ul>Alcazar JL et al. Am J Obstet Gynecol 2003;188:685-692
  37. 38. Prospective U/S Studies with Scoring Systems in use <ul><li>Study Sens Spec PPV NPV Accuracy </li></ul><ul><li>(%) (%) (%) (%) (%) </li></ul><ul><li>Sassone 65 88 74 83 80 </li></ul><ul><li>De Priest 100 81 74 100 88 </li></ul><ul><li>Ferrazzi 84 83 72 91 83 </li></ul><ul><li>Alcazar 100 95 91 100 97 </li></ul>Sassone AM et al. Obstet Gynecol 1991;78:70-6 // De Priest et al. Gynecol Oncol 1993;51:7-11 // Ferazzi E et al. Ultrasound Obstet Gynecol 1997;10:192-7 // Alcazar JL et al. Am J Obstet Gynecol 2003;188:685-692
  38. 39. Ultrasound / CT <ul><li>Which is best at predicting an ovarian malignancy should cost be a factor </li></ul><ul><li>Adnexal masses which is best defining malignancy –vs-benign </li></ul>Ultrasound
  39. 40. CT –vs- U/S to diagnose Premenopausal Adnexal Masses <ul><li>161 premenopausal patients with associated CA-125 levels </li></ul><ul><li>83 persistent masses after 3 month review </li></ul><ul><li>U/S better at diagnosing </li></ul><ul><ul><li>Serous cysts, serous cystadenoma, endometrioma and Ov-Ca </li></ul></ul><ul><li>CT better at diagnosing </li></ul><ul><ul><li>Mature teratomas </li></ul></ul>Mallarini GS.etal. Ultra Obstet Gynecol 1997;9:339
  40. 41. U/S Adnexal Mass > 3 cm <ul><li>1987-1993 referral center in Germany </li></ul><ul><li>1072 ovarian tumors </li></ul><ul><li>Average follicular diameter 15-25 mm </li></ul><ul><li>Unilocular cysts treated with 50 micro grams ethinyl estradiol for at least 2 cycles </li></ul><ul><li>All women examined at 4-6 weeks if unchanged or increased  surgery </li></ul>Osmers RGW et al. Obstet Gynecol 1996;175:428-434
  41. 42. 1072 Consecutive Ovarian tumors in Premenopausal Women <ul><li>Adnexal Mass Number % </li></ul><ul><li>Functional Ovarian Tumors 570 53 </li></ul><ul><li>Endometriosis or Non-epi cysts 264 25 </li></ul><ul><li>Benign Neoplasms 192 18 </li></ul><ul><li>Low Malignant Potential Tumors 9 1 </li></ul><ul><li>Ovarian Malignancy 37 3 </li></ul>
  42. 43. Functional Tumors <ul><li>Functional Tumors  90% regressed </li></ul><ul><li>Frequency of functional cysts with age </li></ul><ul><ul><li>Age # (%) of functional cysts </li></ul></ul><ul><ul><li><20 59 (70%) </li></ul></ul><ul><ul><li>21-30 181 (66%) </li></ul></ul><ul><ul><li>31-40 182 (50%) </li></ul></ul><ul><ul><li>41-50 125 (43%) </li></ul></ul><ul><ul><li>>51 20 (36%) </li></ul></ul>Osmers RGW et al. Obstet Gynecol 1996;175:428-434
  43. 44. Ovarian Cancer and Pregnancy <ul><li>California Cancer Registry </li></ul><ul><li>Years 1991-1999 </li></ul><ul><li>4,846,505 deliveries </li></ul><ul><li>Prenatal diagnosis  115 (0.024 per 1000) </li></ul><ul><li>Delivery diagnosis  56 (0.012 per 1000) </li></ul><ul><li>Post Partum diagn  82 (0.017 per 1000) </li></ul><ul><li>Total  253 (0.052 per 1000) </li></ul>Smith LH et al. Obstet Gynecol 2003;189:1128-1135
  44. 45. Adnexal Masses in Pregnancy <ul><li>Regional Center East Carolina </li></ul><ul><li>12 year experience </li></ul><ul><li>60 adnexal masses of 37,929 deliveries </li></ul><ul><li>Incidence of 1/632 or 0.15% </li></ul><ul><li>Mean gestattional age at diagnosis 12 weeks with mean age at surgery of 20 weeks </li></ul><ul><li>54 operations by laparotomy, 2 laparoscopic </li></ul><ul><li>55/56 elective, 1 non-elective for torsion </li></ul><ul><li>Term delivery in 69% </li></ul>Sherard GB et al. Obstet Gynecol 2003;189:358-362
  45. 46. Adnexal Masses in Pregnancy <ul><li>Histologic Diagnosis n % </li></ul><ul><li>Mature teratoma 30 50 </li></ul><ul><li>Cystadenoma 12 20 </li></ul><ul><li>Functional cyst 8 13 </li></ul><ul><li>Fibroma 1 2 </li></ul><ul><li>Paratubal cyst 1 2 </li></ul><ul><li>Low Malig Potential Tumor 5 8 </li></ul><ul><li>Cancer (2 imm tera, 1 dysgerm) 3 5 </li></ul>Sherard GB et al. Obstet Gynecol 2003;189:358-362
  46. 47. Ovarian Conservation -vs- Oophorectomy <ul><li>Nurses Health Study </li></ul><ul><li>Prospective Observational Study </li></ul><ul><li>Increased mortality in women prophylactic oophorectomy if not given ERT </li></ul><ul><ul><li>Primarily as a result of CHD and Lung Cancer </li></ul></ul><ul><ul><li>Did not improve survival at any age (<45, 45-54, >55 y/o) </li></ul></ul><ul><ul><li>Less frequent for all cases of cancer </li></ul></ul>Parker, WH et al. Ovarian Conservation at the time of hysterectomy and long term Health Outcomes in the Nurses’ Health Study. Obstet Gynecol 2009;113:1027-1037
  47. 48. Specific Guide Line Work Up History & Physical CXR, abd/pelvic CT scan or U/S Obtain family cancer history CA 125, CBC, Chem Profile, BE/colonoscopy if symptomatic Adnexal Mass Surgical Candidate? Counsel Patient on Risks of Pregnancy Loss, Preterm Delivery, Fetal Morbidity, Torsion, Possibility of benign disease –vs- LMPT –vs- Malignancy
  48. 49. Questions / Comments Even my family has stopped listening to me! Love is unconditional with Nora