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Aproach to ovarian masses and managemnt of benign ovarian masses
- 1. APPROACH TO OVARIAN MASSES MANAGEMENT OF BENIGN OVARIAN MASS DR SUNITA SUDHIR PROFESSOR OBG
- 2. OVERVIEW • Introduction • Pelvic masses • Adnexal masess • Steps to evaluate • Ultrasound evaluation, IOTA • Risk assessment • Tumour markers • RMI, ROMA, ROCA, OV1 panel
- 3. PELVIC MASSES NON GYNAECOLOGICAL CAUSES • PREGNANCY • FULL BLADDER • ENCYSTED ASCITIS • DIVERTICULITIS • APPENDICULAR ABCESS • MESENTERIC CYST • CAECUM AND COLON TUMOURS • RETROPERITONEAL TUMOURS GYNAECOLOGICAL CAUSES • OVARIAN TUMOURS • TUBOOVARIAN ABCESS • PARAOVARIAN CYSTS • FIBROIDS • PYOMETRA • PELVIC HAEMATOCELE
- 5. NON NEOPLASTIC FUNCTIONAL CYSTS • Related –temporary hormonal disturbances • Size not more than 5-8cm • Unilocular • Contain clear fluid • Usually asymptomatic • Regress spontaneosly
- 6. FOLLICULAR CYSTS • Most common functional cysts • Usually <5cm • Single or multiple • Usually asymptomatic • Can undergo torsion, haemmorage, rupture& present as acute abdomen • Spontaneous regression
- 7. Theca lutein cysts • Usually bilateral • Increase in hcg( GTD), Clomiphene • Regress after treatment of GTD • May present with pain and tenderness
- 8. Corpus luteal cysts • Due to overactivity of corpus luteum • May have ammenorhea and delayed cycles • Rarely cysts may rupture and cause intra peritoneal haemorrage- mimics ruptured ectopic • May be seen with pregnancy • Spontaneous regression unless complicated
- 9. Steps to evaluate • Is the mass ovarian in origin? • Is it solid or cystic ? • If cystic , is it benign , malignant or intermediate ? • If benign, what most likely it is ? • Whether required follow up , or to go to next modality ? • Do patient have risk factor for malignancy ?
- 10. Diagnosis of adnexal mass • Detailed history taking , family history of malignancies • Risk factors for malignancies • Physical examination –head to toe examination , lymphadenopathy , supraclavicular lymph nodes • Abdomen examination • Speculum and bimanual pelvic examination and when needed per rectal examination • Usg- may detect asymtomatic cysts symptoms if complicated like torsion rupture infected -Benign masses -Malignant masses
- 11. Risk factors for ovarian malignancy • Getting older • Being overweight or obese • Having children later or never having a term pregnancy • Taking hormone therapy after menopause • Family history of ovarian cancer, breast cancer, or colorectal cancer • Using fertility treatment • Having had breast cancer • High fat diet
- 12. Familial • Having a family cancer syndrome Hereditary breast and ovarian cancer syndrome (HBOC) Hereditary nonpolyposis colon cancer (HNPCC) Peutz-Jeghers syndrome MUTYH-associated polyposis Other genes associated with hereditary ovarian cancer- ATM, BRIP1, RAD51C, RAD51D, and PALB2
- 13. Decreased risk • Diet • Late menarche, early menopause • Pregnancy and breastfeeding • multiparity • Birth control • Removal of fallopian tubes • Hysterectomy
- 14. REVIEW HISTORY , EXAMINATION WHEN NEEDED HISTORY • Rapid increase in size • Weightloss, appetite EXAMINATION • Cachexia, anaemia, supraclavicular nodes, breast lump, pleural effusion, leg edema • M features of mass, liver enlarged Bimanual examination • Pod- nodules, mobility of mass absent • Rectovaginal – presence of nodules and deposits
- 16. • CA 125- Epithelial ovarian cancer • CEA- Mucinous ovarian cancer • Hcg – Embryonal ca, choriocarcinoma • Inhibin a , Inhibin B- granulosa cell tumour • LDH- Dysgerminoma • α Feto protein- yolk sac tumour • CA 125- Released in normal ovarian and endometrial cells also, but high values in malignancy • He4 is released in malignant ovarian cells • He4 and ca125 to gether increase sensitivity and specificity TUMOUR MARKERS
- 17. Role of Imaging
- 18. Asymptomatic Ovarian cysts Size < 5cm in premenopausal women Size 5-8cm Benign morphology Normal ca 125 Size > 8cm Suspicious of malignancy Size > 5cm in post menopausal
- 19. Size < 5cm Premenopausal women Functional cysts Resolve within 3 months Conservative mx
- 20. Size 5-8cm Benign morphology Normal ca 125 COC 3-6 mths Follow up with usg • Lifestyle changes regress • May require surgery If increase in size
- 21. Benign masses Depending on • The type of tumor, size • Age, parity, future fertility desire, MANAGEMENT • Conservative(if cyst<7cm,unilocular thin walled,ca125-n - close follow up • Cystectomy • Oophorectomy or salpingo oophorectomy • TAH-BSO
- 22. Size > 8cm Suspicious of malignancy Size > 5cm in post menopausal Further imaging and surgical intervention
- 23. RISK OF MALIGNANCY INDEX (RMI) RMI ≥ 250 SUSPICIOUS OF MALIGNANCY
- 24. International ovarian tumour analysis IOTA defined as a standardized technique for preoperative classification of adnexal masses
- 27. • It is a glycoprotein associated with mullerian epithelial tissues and elevated in 80% of epithelial cancers • Normal value is < 35u/ml • Levels of > 200 favors malignancy • Post menopausal women with adnexal mass and high CA125 levels has 96% of positive predictive value CA-125
- 28. ROMA Risk Of Malignancy Algorithm • Numerical score - based on HE4(human epididymis protein 4), - Ca125 - Menopausal status interpreted in conjunction with clinical and imaging methods ROCA Risk Of Ovarian Cancer Algorithem Prepared on the slope of serial ca125 measurement drawn at regular intervals
- 29. Ova1 panel • Measurements of 5 biomarkers in serum Transthyretin Apo lipoprotein A-1 Transferrin β2 Microglobulin CA125 OVA 1 PANEL SCORE OF > 5 IN PREMENOPAUSAL SCORE OF >4.4 IN POSTMENOPAUSAL PROBABLITY OF MALIGNANCY
- 30. BORDERLINE OVARIAN TUMOUR • Intermediate between benign cystic & frank invasive carcinoma • 5-10% of epithelial OV CA • Lot of dilemma of diagnosis & Mx • Histological criteria: nuclear atypia,epithelial stratification, cellular pleomorphism, mitotic activity or microscopic papillary projections(atleast 2) • No stromal invasion like invasive cancer, microinvasion may be less 3mm • Mx: young age fertility sparing uso or TAH BSO
- 31. SURFACE EPITHELIAL TUMOURS 1.SEROUS CYST ADENOMA • Arises from surface epithelium • Constitutes 40% of ovarian tumours • Bilateral in 40% ofcases • Risk of malignancy in 40% of cases • Wall is smooth, shiny and greyish white • Usually uniloculated , may be multiloculated • Content fluid is clear & rich in serum protiens
- 32. Mucinous cystadenoma • Arises from surface epithelium • Accounts for 20 -25% of all tumours • 10% of cases it is bilateral • Risk of malignancy is 10% • May enlarge to huge size • The cyst is multiloculated and cut section shows honey comb pattern • Contents are thick viscid and mucinous • Rupture can result in
- 33. Germ cell tumours Dermoid cyst • Arise from germ cells of ovary • Most common 95% of germ cell tumours& bilateral in 15-20% of cases • Risk of malignancy 1-2%(SCC) • Most common ovarian tumour in pregnancy • It consists structures of all germ layers, predominantly sebaceous • Torsion is most likely complication
- 34. CHANGE IS THE ONLY CONSTANT THING ,KEEP UPDATING YOURSELF Thank you