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ADNEXAL MASSES
APPROACH TO MANAGEMENT
Keynote address
MOGS 52ND ANNUAL CONFERENCE 2024
JIO CONVENTION CENTRE, BKC, MUMBAI
DATE- SATURDAY 10TH FEBRUARY, 2024
Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H, Sion Hospital
President, MOGS (2022-2023)
Joint Treasurer, FOGSI (2021-2025)
Organising Secretary, AICOG Mumbai 2025
Treasurer, AFG (2023-2024)
Member Oncology Committee, SAFOG (2021-2023)
Dean AGOG & Chief Content Director, HIGHGRAD & FEMAS Courses
Editor-in-Chief, FEMAS, JGOG & TOA Journal
74 publications in International and National Journals with 184 Citations
National Coordinator, FOGSI Medical Disorders in Pregnancy Committee (2019-
2022)
Chair & Convener, FOGSI Cell Violence Against Doctors (2015-16)
Member, Oncology Committee AOFOG (2013-2015)
Coordinator of 11 batches of MUHS recognized Certificate Course of B.I.M.I.E at
L.T.M.G.H (2010-16)
Member, Managing Committee IAGE (2013-17), (2018-20), (2022-2023)
Editorial Board, European Journal of Gynaec. Oncology (Italy)
Course Coordinator of 3 batches of Advanced Minimal Access Gynaec Surgery
(AMAS) at LTMGH (2018-19)
DR. NIRANJAN CHAVAN
MD, FCPS, DGO, MICOG, DICOG, FICOG, DFP,
DIPLOMA IN ENDOSCOPY (USA)
“IT IS POSSIBLE FOR ORDINARY PEOPLE TO CHOOSE TO BE EXTRAORDINARY.” -
- Elon musk
• An adnexal mass is a lump in tissue of the
adnexa of uterus (structures closely related
structurally and functionally to the uterus
such as the ovaries, fallopian tubes, or any
of the surrounding connective tissue).
• Adnexal masses can be benign or
cancerous, and they can be categorized as
simple or complex .
INTRODUCTION
• The term adnexa is derived from
the Latin word adenectere
meaning "appendage.”
• Adnexa refer to the anatomical
area adjacent to the uterus,
and contains :
• Fallopian tube
• Ovary
• Associated vessels and
ligaments
• Connective tissue
• Adnexal mass lesions are common among women which has a prevalence of 0.17%-5.9%
in asymptomatic women and 7.1%-12% in symptomatic women of all ages.
• Most adnexal masses in reproductive age women are benign cysts.
• Only 10% of masses are malignant.
• The rate of malignancy is low in patients aged under 30.
• About 25% of adnexal growths are endometriomas, 33% are mature cystic teratomas, and
the rest are functional cysts or serous or mucinous cystadenomas.
Webb KE, Sakhel K, Chauhan SP, Abuhamad AZ. Adnexal mass during pregnancy: a review. Am J Perinatol 2015; 32:1010. 2021
INCIDENCE
• Peak incidence typically occurs during
the reproductive years, with a decline
postmenopausally.
• Pediatric cases, while less common, may
involve developmental anomalies or
benign cysts.
Webb KE, Sakhel K, Chauhan SP, Abuhamad AZ. Adnexal mass during pregnancy: a review.
Am J Perinatol 2015; 32:1010. 2021
• Prevalence tends to be higher among
reproductive-age women due to physiological
processes like ovulation and menstruation.
• Menopausal women also experience adnexal
masses, with an increased likelihood of
malignancy.
CLINICAL PRESENTATION
• Pelvic pain and discomfort
• Abdominal bloating and distension
• Changes in menstrual patterns
• Urinary symptoms (frequency, urgency)
• Gastrointestinal symptoms (constipation, diarrhoea)
• Acute complications (rupture, torsion, hemorrhage)
• Asymptomatic presentation
HAEMORRHAGIC
CORPUS LUTEAL CYST
HYDROSALPINX APPENDICITIS
OVARIAN CARCINOMA FALLOPIAN TUBE CARCINOMA GASTROINTESTINAL
CARCINOMA
CASE 1
A14 years old girl, unmarried came with
complaint of
• Large abdominal mass
• Acute pain in abdomen and backache for 2-3 days.
Menstrual history - LMP: 27/12/11.
Menarche attained 5 days back.
Patient had bleeding for 5 days, changing 2 pads per day.
On Examination:
Per Abdomen: 34 – 36 weeks size mass arising from pelvis, Cystic in consistency .
Mobile from side to side. Smooth surface. Lower margin of the mass could not be
made out. Upper border of mass was 1-2 cm below the intercostal margin. Mass was
extending towards both the flanks.
Per Rectal: Lower margin of the mass felt. No involvement of the rectal mucosa.
Mass was free, mobile, non tender. No nodularity or induration felt.
Tumour Markers
• Ca125 - 19.1 u/mL
• AFP - 1.06
• B-HCG - < 1.2
• CEA - 1. 34
USG Abdomen & Pelvis:
Uterus 6 x 3.1 x 2.7 cm. Normal endometrial echoes. ET 5
mm. B/L ovaries not visualized seperately.
A large 16 x 12 x 11 cm complex cystic lesion seen
extending from pelvis to epigastric region with multiple
thick septae & multiple echoes within noted. No
vascularity noted within. The mass displacing the bowels loops
peripherally and uterus inferiorly. No calcification or mass
lesion within.
Impression:
Mucinous Cystadenoma of the ovary of benign aetiology.
.
Investigation:-< 1.2
• CEA- 1. 34
CT Scan Abdomen:
Large 18 x 15 x 11 cm sized, well defined ,
multiloculated , predominantly cystic , with
multiple enhancing septae within noted in the
pelvis, extending into the lower abdomen. No
calcification or solid component
noted within the mass.
Mass effect on lower ureter with resultant mild proximal b/l hydroureter &
hydronephrosis. The fat plane of this lesion with the surrounding structures
appeared well maintained. Right ovary seen separate from the lesion. Left
ovary not appreciated on the CT .
Impression: Left ovarian cyst adenoma of benign etiology.
Intraoperative finding:
• Patient underwent a successful ovariectomy with partial
salpingectomy on the left side with removal of a multi-lobulated
mucinous cyst adenoma.
• About 300 cc of mucinous fluid was also aspirated from the cyst.
• Post operative course of the patient in the ward was uneventful.
CASE 2
Mrs ABC, a 30-year-old female, married since 5 years came with the c/o
• infertility
• progressive cyclical dysmenorrhea for the last 1 year.
The patient gives no h/o any menstrual irregularities.
• On examination:
• Per Abdomen: Soft, No guarding/rigidity/distention/tenderness
• P/S: Cervix/vagina healthy
• P/V:
• Uterus bulky, Anteverted, firm, restricted mobility
• Right fornix free.
• Evidence of fibrotic band felt in left and posterior fornix.
USG - there is evidence of a left adnexal mass of 6x5 cm with thin septations with no
vascularity.
CA-125 – 105 IU/ml
Rest tumour makers - WNL
• USG - Pelvis:
• Low-level internal echoes.
• „
„
Thick-walled „
„
Homogeneous “ground glass” appearance
• „
„
Multilocular „
Cystic
• „
show varying degrees of echogenicity in locules
• „
„Round Shape „
„Regular Margins
• On Diagnostic & Operative Laparoscopy
• There is evidence of dense adhesions in the pelvic cavity.
• Uterus – restricted mobility.
• POD obliterated.
• Left tubo ovarian chocolate cyst seen with dense adhesions to the bowel.
• Cystectomy
Laparoscopic Cystectomy
Laproscopy is NO LONGER the diagnostic Gold Standard
and is now only recommended in patients with negative
imaging results and/or where empirical treatment was unsuccessful or
inappropriate as per
ESHRE Endometriosis Guidelines 2022.
CASE 3
• A 45yr P2L2 presented with complaints of heaviness in the abdomen, irregular
heavy menses and dysmenorrhea for 2 – 3 months
• On Examination:
P/A – soft, non tender
P/S - cervix, vagina healthy
P/V – uterus bulky firm mobile, AV, soft to cystic mass 10X 8 cm in right and
posterior fornix separate from uterus. Left fornix free and non-tender.
P/R – bogginess felt anteriorly, rectal mucosa and parametrium free.
• Tumor Marker - WNL
• USG Pelvis: solid, hypoechoic, well-circumscribed right adnexal mass size of
11.2 X 9 cm
• Intra-operatively, an abdomino-pelvic mass of
size approximately 11cm × 8 cm × 5cm was seen
with variable consistency and increased
vascularity, arising from the right side of the
uterus pushing the ureter laterally.
• Right fallopian tube, ovarian ligament, and
round ligament stretched over the mass.
• The left ovary was normal.
• DIFFERENCE BETWEEN TRUE AND
FALSE BROAD LIGAMENT
CASE 4
• 30 years old, married since 1 year, came with complaints of amenorrhea since 2
months, acute lower abdominal pain, and P/V spotting since 2 days.
• Urine Pregnancy Test: Positive
• Beta hCG: 5300mIU/ml
• On examination:
General condition fair
Pulse: 78/min
Blood Pressure: 120/80 mmHg
No pallor
• Per abdomen: Soft, no guarding, rigidity,
Minimal tenderness present
• Per Vaginal: Uterusnormal size
Right adnexal fullness present
Right forniceal tenderness
Cervical movement tenderness present
Left fornix non tender
Minimal spotting present
• Transvaginal Ultrasonography:
Uterus normal size
No intrauterine G-sac.
G-sac like structure noted in right adnexa, measuring
5*3cm. Right ovary not seen separately.
Showing ring of fire appearance on color Doppler.
Echogenic pulsating structure noted within G-sac.
No free fluid in pouch of douglas.
• Management:
Emergency Exploratory Laparotomy with sos salphingostomy or salphingectomy.
CASE 5
• 28 year, multiparous, came with complaints of
Dull lower abdominal pain since 6 months, which has increased acutely since 4
day
White foul smelling PV discharge
High grade fever since 4 days
Dyspareunia since 10 days
• Menstrual history – menarche attained at 12 yrs. Past cycles were regular/mod
flow/painless/4/30 days
• History of pelvic inflammatory disease in past
On Examination:
• G/E: GC – average
• Pallor mild
• Febrile 39⁰Celscius
• Pulse 108/min
• BP-90/60mm Hg
• Per Abdomen - Soft, Tenderness in the left iliac fossa
Tender cystic mass of 16 weeks size arising from pelvis
Guarding present,
No rigidity, No Organomegaly
Pelvic examination
Per speculum
Cervix shows signs of cervical erosion circumferentially around the external os
White discharge seen in the vaginal wall
On Bimanual Examination:
Uterus anteverted, normal size
Left Fornix full,
10x8 cm cystic mass palpable
Bilateral fornices tender
Cervical movement tenderness +
Mobility restricted
• Pelvic Inflammatory Disease (PID) comprises a spectrum of inflammatory
disorders of the upper female genital tract, including any combination of
endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.
• Sexually transmitted organisms, especially N. gonorrhoea and C.trachomatis, are
implicated in many cases.
• However, microorganisms that comprise the vaginal flora (e.g.,anaerobes, G.
virginals, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus
agalactiae) also have been associated with PID.
MANAGEMENT OF PID
• AND CASE OF OVARIAN MALIGNANCY
CASE 6
• 18 Yr old presented with abdominal distension and pain in abdomen for 2 month
• Unmarried with regular menstrual cycle
• No family h/o of malignancy
• Regular bowel and bladder habit
O/E -
• normal secondary sexual characters,
• average body built with poor nutritional status. No pallor. Icterus or
lymphadenopathy noted
• P/A- gross ascites, ballotable mass of 18x20cm
P/R lower pole of mass felt
ULTRASONOGRAPHY
• USG ; A large abdomino-pelvic solid
cystic mass of size 16.3x10.7x16 cm
with internal vascularity (neoplastic ?)
with gross ascites and right sided mild
pleural effusion.
• RMI 1- 441X1X3=1323
CECT
• CECT
• A large 16.3x10.7x16 cm heterogenously enhancing mass lesion with internal
areas of necrosis and cystic changes is noted in lower abdomen with increased
perilesional vascularity.
• Right ovary not separately vsualised, lesion is seen to abut and compress the
sigmoid colon
• Gross ascitis
• Mesenteric nodes +
• Rt sided pleural effusion
• Score-4
CECT IMAGING
MANAGEMENT
• Staging Laparotomy
• Mid line vertical incision 4 c.m supraumbillical incision
• Ascitic fluid 500 ml haemorrhagic, collected for fluid cytology.
• Careful inspection performed starting from subdiaphragmatic area, paracolic, pelvic,pelvic
area, omental, mesentry, bowel serosa, retroperitoneal space.
• Right ovarian mass of 20x22 c.m with solid and cystic components, with intact capsule
• Left side tube and ovaries are healthy. Uterus normal looking.
• Omentum shows nodules of size>2x2cm
• Right pelvic lymphnode and para aortic lymphnode dissection done
• Fertility preserving surgery was performed.
• RIGHT SALPINGO OPHORECTOMY+ RTPLND+RTPALND+ OMENTECTOMY+FLUID
CYTOLOGY
• CA-125 (Cancer Antigen 125)
• Primary marker used in the evaluation of adnexal masses.
• Elevated levels may indicate ovarian cancer, but can also be elevated in other conditions
such as endometriosis and pelvic inflammatory disease.
• Serial measurements may help in monitoring treatment response and detecting
recurrence.
• HE4 (Human Epididymis Protein 4)
• Used in conjunction with CA-125 for assessing ovarian masses.
• Can be useful in differentiating between benign and malignant masses.
TUMOR MARKERS
• CEA (Carcinoembryonic Antigen)
• Elevated in some ovarian cancers, particularly mucinous adenocarcinomas.
• May also be elevated in other cancers such as colorectal cancer.
• Not as specific as CA-125 for ovarian cancer.
• AFP (Alpha-Fetoprotein) and β-hCG (Beta-Human Chorionic Gonadotropin)
• AFP and β-hCG are markers for germ cell tumors, which can occur in the ovaries.
• Elevated levels suggest the presence of germ cell tumors, including dysgerminomas
and yolk sac tumors.
IMAGING MODALITIES
• Transvaginal Ultrasound
• Abdo-pelvic Ultrasound
• Magnetic Resonance Imaging
• Computed Tomography Scan
• Preferred initial imaging modality for evaluating adnexal
masses.
• Provides high-resolution images of pelvic structures,
including ovaries, fallopian tubes, and surrounding
tissues.
• Differentiates between cystic and solid masses, assesses
internal vascularity, and characterizes morphological
features.
TRANSVAGINAL SONOGRAPHY
• Distinct ultrasound features help differentiate
between benign and malignant adnexal masses.
• Benign features include simple cysts, thin
septations, smooth walls, and posterior acoustic
enhancement.
• Malignant features encompass irregular
borders, thick septations, solid components,
and increased vascularity.
ULTRASOUND
• Complementary imaging modality to transvaginal
ultrasound, particularly for characterizing complex or
indeterminate masses.
• Offers superior soft tissue contrast and multiplanar
imaging capabilities, facilitating accurate assessment
of mass morphology, tissue characteristics, and
anatomical relationships.
• Evaluate pelvic and abdominal anatomy, detecting
metastases, and planning surgical
interventions.
MAGNETIC RESONANCE
IMAGING
• Reserved for assessing for distant metastases, staging
malignancies, or preoperative planning.
• Limited role in the primary evaluation of adnexal
masses due to radiation exposure and inferior soft
tissue resolution compared to MRI.
• Contrast-enhanced CT may aid in identifying
vascular abnormalities and enhancing lesion
characterization.
CT - SCAN
• Age: Postmenopausal status increases the risk of
malignancy.
• Imaging Features: Certain ultrasound characteristics,
such as solid components, irregular borders, and
septations, raise suspicion for malignancy.
• Tumor Markers: Elevated CA-125 levels and other tumor
markers may indicate the presence of ovarian cancer.
RISK FACTORS FOR
MALIGNANCY
•Family History: Positive family history of
ovarian or breast cancer may suggest
genetic predisposition (e.g., BRCA mutations).
• Prior History: History of previous ovarian or
breast cancer increases the likelihood of
recurrent disease.
• Risk of Malignancy Index (RMI 1,2,3 in 1990,1999): Incorporates patient age, menopausal
status, CA-125 levels, and ultrasound findings to calculate the risk of malignancy.
• ADNEX Model (2014) : Utilizes ultrasound features such as tumor size, vascularity, and
morphology to estimate the risk of malignancy.
• Ovarian-Adnexal Reporting and Data System (O-RADS 2018): A standardized reporting
system
that stratifies adnexal masses based on ultrasound features into low, intermediate, and high-
risk categories.
RISK STRATIFICATION TOOLS
O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee
MANAGEMENT OF
ADNEXAL MASS
• Conservative management
• Surgical intervention
• Fertility sparing surgery
• Adjuvant therapy
Management
Conservative
Management
Surgical Intervention
Fertility Sparing
Surgery
Adjuvant Therapy
• Benign masses
• Asymptomatic masses
(Small, Simple cysts with
reassuring imaging
features and low-risk
clinical profiles)
• Symptomatic masses
• High-risk features
Suspicion of
malignancy.
Depends on
• Histological subtype
• Stage of disease
• Patient factors.
Management options
Conservative
Management
Surgical Intervention
Fertility Sparing
Surgery
Adjuvant Therapy
• Cystectomy
• Unilateral salpingo-
oophorectomy
• Ovarian transposition
• Chemotherapy
• Radiation
therapy
• Laparoscopic
cystectomy
• Oophorectomy
• Salpingo-oophorectomy
• Hysterectomy
• Serial
monitoring
• Reassurane
COMPLICATIONS
A 30-year-old woman, married for 5 years with a history of one live birth and a previous
incomplete abortion, presented with 8 days of dull abdominal pain. Examination revealed a
tender mass in the hypogastrium and right iliac fossa. Ultrasound confirmed torsion of an
8.4x8.1cm left adnexal mass, necessitating emergency laparotomy. Intraoperatively, a
gangrenous 10x10cm hydrosalpinx was found, leading to left total salpingectomy.
Histopathology confirmed necrotic changes in the left fallopian tube.
January 2016 Indian Journal of Obstetrics and Gynecology Research 3(3):289 DOI:10.5958/2394-2754.2016.00064.3
• The differential diagnosis of acute
abdominal pain in all age groups of women
must include adnexal torsion.
• It is best managed by a surgical approach.
• With the advent of the laproscopic era,
conservative methods like detorsion are
gaining popularity.
• Adnexal masses are common among adolescents, they are usually benign and often can be
managed expectantly.
• Among benign lesions, a simple cyst is the most common pathology of adnexal mass.
• Germ-cell tumors are the most common ovarian malignancies in children and adolescents.
• Management of adnexal masses in adolescents should prioritize ovarian conservation to
preserve fertility.
Journal of South Asian Federation of Obstetrics and Gynaecology (2022): 10.5005/jp-journals-10006-
2068
• The maximum number of adnexal masses
belonged to the age-group of 14–16 years
(56.7%).
• In total, 53 masses (88.3%) were non-
neoplastic and 7 (11.7%) masses were
neoplastic.
• Out of 60 patients, 68.3% were managed
conservatively.
• In this study the materials included 45 postmenopausal women who with adnexal mass.
• For 41 (91.11%) out of total 45 cases, the site of adnexal mass were correctly diagnosed by
clinical examination.
• Our study shows a higher incidence of masses in either left than right ovary as compared to
bilateral origin.
• The most common adnexal mass as per USG was Left benign ovarian cyst found in 13
(28.89%) patients.
Distribution according to pathology
USG diagnosis
ADNEXAL MASS IN
PREGNANCY
• The overall estimated incidence of
adnexal masses in pregnancy ranges
from 2% to 10%.
• The mass in adnexa may be
symptomatic or found incidentally.
• Widespread use of ultrasound in early
pregnancy has led to the detection of
incidental adnexal masses more
frequently.
• The overall incidence of malignancy noted
in adnexal masses during pregnancy is
0.04 to 0.4%.
• Prior to the use of routine first trimester
ultrasound, adnexal masses only became
clinically relevant if symptomatic or if they
were large enough to be palpated on
physical examination.
• Adnexal masses in pregnancy can have an array of diagnosis.
• Majority of them are benign and resolve spontaneously.
• Surgical management is required for large, complex, persistent, and suspicious masses
which might undergo torsion, rupture or have high risk of malignancy.
• The study emphasizes that both laparoscopy and laparotomy are safe in pregnancy.
• Removal of corpus luteal cysts early in pregnancy might require progesterone support.
• Patients requiring surgical management must be counselled regarding the risk of
abortion and preterm delivery. ADD YEAR
A 21-year-old female with complaints of acute pain in the abdomen, with vomiting and two
episodes of fever presented on the 7th day of vaginal delivery in surgery dept. She was
diagnosed as having a large mesenteric cyst in the antenatal period, however, on repeat
imaging and exploration, it was an adnexal mass with torsion detorsion.
• Adnexal masses represent a common clinical challenge, requiring a comprehensive
approach to evaluation and management.
• Accurate diagnosis, risk stratification, and treatment decisions are paramount for
optimizing patient outcomes and quality of life.
• Multidisciplinary collaboration and patient-centered care are essential components of
effective management strategies.
TAKE HOME MESSAGE
• American College of Obstetricians and Gynecologists (ACOG). (2019). Practice Bulletin No. 174:
Evaluation and Management of Adnexal Masses. Obstetrics & Gynecology, 133(5), e210-e226.
• Kaijser, J., Bourne, T., Valentin, L., Sayasneh, A., Van Holsbeke, C., Vergote, I., ... & Timmerman, D.
(2014). Improving strategies for diagnosing ovarian cancer: a summary of the International Ovarian
Tumor Analysis (IOTA) studies. Ultrasound in Obstetrics & Gynecology, 44(1), 9-20.
• Prat, J. (2012). Staging classification for cancer of the ovary, fallopian tube, and peritoneum.
International Journal of Gynecology & Obstetrics, 124(1), 1-5.
• Suidan, R. S., Ramirez, P. T., Sarasohn, D. M., Teitcher, J. B., Mironov, S., Iyer, R. B., ... & Brown, C.
L. (2018). A multicenter prospective trial evaluating the ability of preoperative computed tomography
scan and serum CA-125 to predict suboptimal cytoreduction at primary debulking surgery for
advanced ovarian, fallopian tube, and peritoneal cancer. Gynecologic Oncology, 151(1), 39-44.
• U.S. Preventive Services Task Force. (2018). Screening for Ovarian Cancer: US Preventive Services
Task Force Recommendation Statement. JAMA, 319(6), 588-594
REFERENCES
"THE BEST WAY TO FIND YOURSELF
IS TO LOSE YOURSELF IN THE SERVICE OF OTHERS."
- Mahatma Gandhi
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Dr. NN Chavan Keynote address on ADNEXAL MASS- APPROACH TO MANAGEMENT in the 52nd Annual MOGS Conference 10022024.pptx

  • 1. ADNEXAL MASSES APPROACH TO MANAGEMENT Keynote address MOGS 52ND ANNUAL CONFERENCE 2024 JIO CONVENTION CENTRE, BKC, MUMBAI DATE- SATURDAY 10TH FEBRUARY, 2024
  • 2. Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H, Sion Hospital President, MOGS (2022-2023) Joint Treasurer, FOGSI (2021-2025) Organising Secretary, AICOG Mumbai 2025 Treasurer, AFG (2023-2024) Member Oncology Committee, SAFOG (2021-2023) Dean AGOG & Chief Content Director, HIGHGRAD & FEMAS Courses Editor-in-Chief, FEMAS, JGOG & TOA Journal 74 publications in International and National Journals with 184 Citations National Coordinator, FOGSI Medical Disorders in Pregnancy Committee (2019- 2022) Chair & Convener, FOGSI Cell Violence Against Doctors (2015-16) Member, Oncology Committee AOFOG (2013-2015) Coordinator of 11 batches of MUHS recognized Certificate Course of B.I.M.I.E at L.T.M.G.H (2010-16) Member, Managing Committee IAGE (2013-17), (2018-20), (2022-2023) Editorial Board, European Journal of Gynaec. Oncology (Italy) Course Coordinator of 3 batches of Advanced Minimal Access Gynaec Surgery (AMAS) at LTMGH (2018-19) DR. NIRANJAN CHAVAN MD, FCPS, DGO, MICOG, DICOG, FICOG, DFP, DIPLOMA IN ENDOSCOPY (USA)
  • 3. “IT IS POSSIBLE FOR ORDINARY PEOPLE TO CHOOSE TO BE EXTRAORDINARY.” - - Elon musk
  • 4.
  • 5. • An adnexal mass is a lump in tissue of the adnexa of uterus (structures closely related structurally and functionally to the uterus such as the ovaries, fallopian tubes, or any of the surrounding connective tissue). • Adnexal masses can be benign or cancerous, and they can be categorized as simple or complex . INTRODUCTION
  • 6. • The term adnexa is derived from the Latin word adenectere meaning "appendage.” • Adnexa refer to the anatomical area adjacent to the uterus, and contains : • Fallopian tube • Ovary • Associated vessels and ligaments • Connective tissue
  • 7. • Adnexal mass lesions are common among women which has a prevalence of 0.17%-5.9% in asymptomatic women and 7.1%-12% in symptomatic women of all ages. • Most adnexal masses in reproductive age women are benign cysts. • Only 10% of masses are malignant. • The rate of malignancy is low in patients aged under 30. • About 25% of adnexal growths are endometriomas, 33% are mature cystic teratomas, and the rest are functional cysts or serous or mucinous cystadenomas. Webb KE, Sakhel K, Chauhan SP, Abuhamad AZ. Adnexal mass during pregnancy: a review. Am J Perinatol 2015; 32:1010. 2021 INCIDENCE
  • 8. • Peak incidence typically occurs during the reproductive years, with a decline postmenopausally. • Pediatric cases, while less common, may involve developmental anomalies or benign cysts. Webb KE, Sakhel K, Chauhan SP, Abuhamad AZ. Adnexal mass during pregnancy: a review. Am J Perinatol 2015; 32:1010. 2021
  • 9. • Prevalence tends to be higher among reproductive-age women due to physiological processes like ovulation and menstruation. • Menopausal women also experience adnexal masses, with an increased likelihood of malignancy.
  • 10. CLINICAL PRESENTATION • Pelvic pain and discomfort • Abdominal bloating and distension • Changes in menstrual patterns • Urinary symptoms (frequency, urgency) • Gastrointestinal symptoms (constipation, diarrhoea) • Acute complications (rupture, torsion, hemorrhage) • Asymptomatic presentation
  • 11.
  • 12.
  • 14. OVARIAN CARCINOMA FALLOPIAN TUBE CARCINOMA GASTROINTESTINAL CARCINOMA
  • 16. A14 years old girl, unmarried came with complaint of • Large abdominal mass • Acute pain in abdomen and backache for 2-3 days. Menstrual history - LMP: 27/12/11. Menarche attained 5 days back. Patient had bleeding for 5 days, changing 2 pads per day.
  • 17. On Examination: Per Abdomen: 34 – 36 weeks size mass arising from pelvis, Cystic in consistency . Mobile from side to side. Smooth surface. Lower margin of the mass could not be made out. Upper border of mass was 1-2 cm below the intercostal margin. Mass was extending towards both the flanks. Per Rectal: Lower margin of the mass felt. No involvement of the rectal mucosa. Mass was free, mobile, non tender. No nodularity or induration felt.
  • 18. Tumour Markers • Ca125 - 19.1 u/mL • AFP - 1.06 • B-HCG - < 1.2 • CEA - 1. 34
  • 19. USG Abdomen & Pelvis: Uterus 6 x 3.1 x 2.7 cm. Normal endometrial echoes. ET 5 mm. B/L ovaries not visualized seperately. A large 16 x 12 x 11 cm complex cystic lesion seen extending from pelvis to epigastric region with multiple thick septae & multiple echoes within noted. No vascularity noted within. The mass displacing the bowels loops peripherally and uterus inferiorly. No calcification or mass lesion within. Impression: Mucinous Cystadenoma of the ovary of benign aetiology. .
  • 20. Investigation:-< 1.2 • CEA- 1. 34 CT Scan Abdomen: Large 18 x 15 x 11 cm sized, well defined , multiloculated , predominantly cystic , with multiple enhancing septae within noted in the pelvis, extending into the lower abdomen. No calcification or solid component noted within the mass. Mass effect on lower ureter with resultant mild proximal b/l hydroureter & hydronephrosis. The fat plane of this lesion with the surrounding structures appeared well maintained. Right ovary seen separate from the lesion. Left ovary not appreciated on the CT . Impression: Left ovarian cyst adenoma of benign etiology.
  • 21.
  • 22. Intraoperative finding: • Patient underwent a successful ovariectomy with partial salpingectomy on the left side with removal of a multi-lobulated mucinous cyst adenoma. • About 300 cc of mucinous fluid was also aspirated from the cyst. • Post operative course of the patient in the ward was uneventful.
  • 23.
  • 25. Mrs ABC, a 30-year-old female, married since 5 years came with the c/o • infertility • progressive cyclical dysmenorrhea for the last 1 year. The patient gives no h/o any menstrual irregularities. • On examination: • Per Abdomen: Soft, No guarding/rigidity/distention/tenderness • P/S: Cervix/vagina healthy • P/V: • Uterus bulky, Anteverted, firm, restricted mobility • Right fornix free. • Evidence of fibrotic band felt in left and posterior fornix.
  • 26. USG - there is evidence of a left adnexal mass of 6x5 cm with thin septations with no vascularity. CA-125 – 105 IU/ml Rest tumour makers - WNL
  • 27. • USG - Pelvis: • Low-level internal echoes. • „ „ Thick-walled „ „ Homogeneous “ground glass” appearance • „ „ Multilocular „ Cystic • „ show varying degrees of echogenicity in locules • „ „Round Shape „ „Regular Margins
  • 28. • On Diagnostic & Operative Laparoscopy • There is evidence of dense adhesions in the pelvic cavity. • Uterus – restricted mobility. • POD obliterated. • Left tubo ovarian chocolate cyst seen with dense adhesions to the bowel. • Cystectomy
  • 30. Laproscopy is NO LONGER the diagnostic Gold Standard and is now only recommended in patients with negative imaging results and/or where empirical treatment was unsuccessful or inappropriate as per ESHRE Endometriosis Guidelines 2022.
  • 32. • A 45yr P2L2 presented with complaints of heaviness in the abdomen, irregular heavy menses and dysmenorrhea for 2 – 3 months • On Examination: P/A – soft, non tender P/S - cervix, vagina healthy P/V – uterus bulky firm mobile, AV, soft to cystic mass 10X 8 cm in right and posterior fornix separate from uterus. Left fornix free and non-tender. P/R – bogginess felt anteriorly, rectal mucosa and parametrium free. • Tumor Marker - WNL
  • 33. • USG Pelvis: solid, hypoechoic, well-circumscribed right adnexal mass size of 11.2 X 9 cm
  • 34. • Intra-operatively, an abdomino-pelvic mass of size approximately 11cm × 8 cm × 5cm was seen with variable consistency and increased vascularity, arising from the right side of the uterus pushing the ureter laterally. • Right fallopian tube, ovarian ligament, and round ligament stretched over the mass. • The left ovary was normal. • DIFFERENCE BETWEEN TRUE AND FALSE BROAD LIGAMENT
  • 35.
  • 37. • 30 years old, married since 1 year, came with complaints of amenorrhea since 2 months, acute lower abdominal pain, and P/V spotting since 2 days. • Urine Pregnancy Test: Positive • Beta hCG: 5300mIU/ml • On examination: General condition fair Pulse: 78/min Blood Pressure: 120/80 mmHg No pallor
  • 38. • Per abdomen: Soft, no guarding, rigidity, Minimal tenderness present • Per Vaginal: Uterusnormal size Right adnexal fullness present Right forniceal tenderness Cervical movement tenderness present Left fornix non tender Minimal spotting present
  • 39. • Transvaginal Ultrasonography: Uterus normal size No intrauterine G-sac. G-sac like structure noted in right adnexa, measuring 5*3cm. Right ovary not seen separately. Showing ring of fire appearance on color Doppler. Echogenic pulsating structure noted within G-sac. No free fluid in pouch of douglas.
  • 40. • Management: Emergency Exploratory Laparotomy with sos salphingostomy or salphingectomy.
  • 41.
  • 43. • 28 year, multiparous, came with complaints of Dull lower abdominal pain since 6 months, which has increased acutely since 4 day White foul smelling PV discharge High grade fever since 4 days Dyspareunia since 10 days • Menstrual history – menarche attained at 12 yrs. Past cycles were regular/mod flow/painless/4/30 days • History of pelvic inflammatory disease in past
  • 44. On Examination: • G/E: GC – average • Pallor mild • Febrile 39⁰Celscius • Pulse 108/min • BP-90/60mm Hg • Per Abdomen - Soft, Tenderness in the left iliac fossa Tender cystic mass of 16 weeks size arising from pelvis Guarding present, No rigidity, No Organomegaly
  • 45. Pelvic examination Per speculum Cervix shows signs of cervical erosion circumferentially around the external os White discharge seen in the vaginal wall On Bimanual Examination: Uterus anteverted, normal size Left Fornix full, 10x8 cm cystic mass palpable Bilateral fornices tender Cervical movement tenderness + Mobility restricted
  • 46. • Pelvic Inflammatory Disease (PID) comprises a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. • Sexually transmitted organisms, especially N. gonorrhoea and C.trachomatis, are implicated in many cases. • However, microorganisms that comprise the vaginal flora (e.g.,anaerobes, G. virginals, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae) also have been associated with PID.
  • 48. • AND CASE OF OVARIAN MALIGNANCY
  • 50. • 18 Yr old presented with abdominal distension and pain in abdomen for 2 month • Unmarried with regular menstrual cycle • No family h/o of malignancy • Regular bowel and bladder habit O/E - • normal secondary sexual characters, • average body built with poor nutritional status. No pallor. Icterus or lymphadenopathy noted • P/A- gross ascites, ballotable mass of 18x20cm P/R lower pole of mass felt
  • 51. ULTRASONOGRAPHY • USG ; A large abdomino-pelvic solid cystic mass of size 16.3x10.7x16 cm with internal vascularity (neoplastic ?) with gross ascites and right sided mild pleural effusion. • RMI 1- 441X1X3=1323
  • 52. CECT • CECT • A large 16.3x10.7x16 cm heterogenously enhancing mass lesion with internal areas of necrosis and cystic changes is noted in lower abdomen with increased perilesional vascularity. • Right ovary not separately vsualised, lesion is seen to abut and compress the sigmoid colon • Gross ascitis • Mesenteric nodes + • Rt sided pleural effusion • Score-4
  • 54. MANAGEMENT • Staging Laparotomy • Mid line vertical incision 4 c.m supraumbillical incision • Ascitic fluid 500 ml haemorrhagic, collected for fluid cytology. • Careful inspection performed starting from subdiaphragmatic area, paracolic, pelvic,pelvic area, omental, mesentry, bowel serosa, retroperitoneal space. • Right ovarian mass of 20x22 c.m with solid and cystic components, with intact capsule • Left side tube and ovaries are healthy. Uterus normal looking. • Omentum shows nodules of size>2x2cm • Right pelvic lymphnode and para aortic lymphnode dissection done • Fertility preserving surgery was performed. • RIGHT SALPINGO OPHORECTOMY+ RTPLND+RTPALND+ OMENTECTOMY+FLUID CYTOLOGY
  • 55.
  • 56. • CA-125 (Cancer Antigen 125) • Primary marker used in the evaluation of adnexal masses. • Elevated levels may indicate ovarian cancer, but can also be elevated in other conditions such as endometriosis and pelvic inflammatory disease. • Serial measurements may help in monitoring treatment response and detecting recurrence. • HE4 (Human Epididymis Protein 4) • Used in conjunction with CA-125 for assessing ovarian masses. • Can be useful in differentiating between benign and malignant masses. TUMOR MARKERS
  • 57. • CEA (Carcinoembryonic Antigen) • Elevated in some ovarian cancers, particularly mucinous adenocarcinomas. • May also be elevated in other cancers such as colorectal cancer. • Not as specific as CA-125 for ovarian cancer. • AFP (Alpha-Fetoprotein) and β-hCG (Beta-Human Chorionic Gonadotropin) • AFP and β-hCG are markers for germ cell tumors, which can occur in the ovaries. • Elevated levels suggest the presence of germ cell tumors, including dysgerminomas and yolk sac tumors.
  • 58. IMAGING MODALITIES • Transvaginal Ultrasound • Abdo-pelvic Ultrasound • Magnetic Resonance Imaging • Computed Tomography Scan
  • 59. • Preferred initial imaging modality for evaluating adnexal masses. • Provides high-resolution images of pelvic structures, including ovaries, fallopian tubes, and surrounding tissues. • Differentiates between cystic and solid masses, assesses internal vascularity, and characterizes morphological features. TRANSVAGINAL SONOGRAPHY
  • 60. • Distinct ultrasound features help differentiate between benign and malignant adnexal masses. • Benign features include simple cysts, thin septations, smooth walls, and posterior acoustic enhancement. • Malignant features encompass irregular borders, thick septations, solid components, and increased vascularity. ULTRASOUND
  • 61. • Complementary imaging modality to transvaginal ultrasound, particularly for characterizing complex or indeterminate masses. • Offers superior soft tissue contrast and multiplanar imaging capabilities, facilitating accurate assessment of mass morphology, tissue characteristics, and anatomical relationships. • Evaluate pelvic and abdominal anatomy, detecting metastases, and planning surgical interventions. MAGNETIC RESONANCE IMAGING
  • 62. • Reserved for assessing for distant metastases, staging malignancies, or preoperative planning. • Limited role in the primary evaluation of adnexal masses due to radiation exposure and inferior soft tissue resolution compared to MRI. • Contrast-enhanced CT may aid in identifying vascular abnormalities and enhancing lesion characterization. CT - SCAN
  • 63. • Age: Postmenopausal status increases the risk of malignancy. • Imaging Features: Certain ultrasound characteristics, such as solid components, irregular borders, and septations, raise suspicion for malignancy. • Tumor Markers: Elevated CA-125 levels and other tumor markers may indicate the presence of ovarian cancer. RISK FACTORS FOR MALIGNANCY
  • 64. •Family History: Positive family history of ovarian or breast cancer may suggest genetic predisposition (e.g., BRCA mutations). • Prior History: History of previous ovarian or breast cancer increases the likelihood of recurrent disease.
  • 65. • Risk of Malignancy Index (RMI 1,2,3 in 1990,1999): Incorporates patient age, menopausal status, CA-125 levels, and ultrasound findings to calculate the risk of malignancy. • ADNEX Model (2014) : Utilizes ultrasound features such as tumor size, vascularity, and morphology to estimate the risk of malignancy. • Ovarian-Adnexal Reporting and Data System (O-RADS 2018): A standardized reporting system that stratifies adnexal masses based on ultrasound features into low, intermediate, and high- risk categories. RISK STRATIFICATION TOOLS
  • 66. O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee
  • 67. MANAGEMENT OF ADNEXAL MASS • Conservative management • Surgical intervention • Fertility sparing surgery • Adjuvant therapy
  • 68. Management Conservative Management Surgical Intervention Fertility Sparing Surgery Adjuvant Therapy • Benign masses • Asymptomatic masses (Small, Simple cysts with reassuring imaging features and low-risk clinical profiles) • Symptomatic masses • High-risk features Suspicion of malignancy. Depends on • Histological subtype • Stage of disease • Patient factors.
  • 69. Management options Conservative Management Surgical Intervention Fertility Sparing Surgery Adjuvant Therapy • Cystectomy • Unilateral salpingo- oophorectomy • Ovarian transposition • Chemotherapy • Radiation therapy • Laparoscopic cystectomy • Oophorectomy • Salpingo-oophorectomy • Hysterectomy • Serial monitoring • Reassurane
  • 71. A 30-year-old woman, married for 5 years with a history of one live birth and a previous incomplete abortion, presented with 8 days of dull abdominal pain. Examination revealed a tender mass in the hypogastrium and right iliac fossa. Ultrasound confirmed torsion of an 8.4x8.1cm left adnexal mass, necessitating emergency laparotomy. Intraoperatively, a gangrenous 10x10cm hydrosalpinx was found, leading to left total salpingectomy. Histopathology confirmed necrotic changes in the left fallopian tube. January 2016 Indian Journal of Obstetrics and Gynecology Research 3(3):289 DOI:10.5958/2394-2754.2016.00064.3
  • 72. • The differential diagnosis of acute abdominal pain in all age groups of women must include adnexal torsion. • It is best managed by a surgical approach. • With the advent of the laproscopic era, conservative methods like detorsion are gaining popularity.
  • 73. • Adnexal masses are common among adolescents, they are usually benign and often can be managed expectantly. • Among benign lesions, a simple cyst is the most common pathology of adnexal mass. • Germ-cell tumors are the most common ovarian malignancies in children and adolescents. • Management of adnexal masses in adolescents should prioritize ovarian conservation to preserve fertility. Journal of South Asian Federation of Obstetrics and Gynaecology (2022): 10.5005/jp-journals-10006- 2068
  • 74. • The maximum number of adnexal masses belonged to the age-group of 14–16 years (56.7%). • In total, 53 masses (88.3%) were non- neoplastic and 7 (11.7%) masses were neoplastic. • Out of 60 patients, 68.3% were managed conservatively.
  • 75.
  • 76. • In this study the materials included 45 postmenopausal women who with adnexal mass. • For 41 (91.11%) out of total 45 cases, the site of adnexal mass were correctly diagnosed by clinical examination. • Our study shows a higher incidence of masses in either left than right ovary as compared to bilateral origin. • The most common adnexal mass as per USG was Left benign ovarian cyst found in 13 (28.89%) patients.
  • 77. Distribution according to pathology USG diagnosis
  • 79. • The overall estimated incidence of adnexal masses in pregnancy ranges from 2% to 10%. • The mass in adnexa may be symptomatic or found incidentally. • Widespread use of ultrasound in early pregnancy has led to the detection of incidental adnexal masses more frequently.
  • 80. • The overall incidence of malignancy noted in adnexal masses during pregnancy is 0.04 to 0.4%. • Prior to the use of routine first trimester ultrasound, adnexal masses only became clinically relevant if symptomatic or if they were large enough to be palpated on physical examination.
  • 81. • Adnexal masses in pregnancy can have an array of diagnosis. • Majority of them are benign and resolve spontaneously. • Surgical management is required for large, complex, persistent, and suspicious masses which might undergo torsion, rupture or have high risk of malignancy. • The study emphasizes that both laparoscopy and laparotomy are safe in pregnancy. • Removal of corpus luteal cysts early in pregnancy might require progesterone support. • Patients requiring surgical management must be counselled regarding the risk of abortion and preterm delivery. ADD YEAR
  • 82.
  • 83.
  • 84. A 21-year-old female with complaints of acute pain in the abdomen, with vomiting and two episodes of fever presented on the 7th day of vaginal delivery in surgery dept. She was diagnosed as having a large mesenteric cyst in the antenatal period, however, on repeat imaging and exploration, it was an adnexal mass with torsion detorsion.
  • 85.
  • 86. • Adnexal masses represent a common clinical challenge, requiring a comprehensive approach to evaluation and management. • Accurate diagnosis, risk stratification, and treatment decisions are paramount for optimizing patient outcomes and quality of life. • Multidisciplinary collaboration and patient-centered care are essential components of effective management strategies. TAKE HOME MESSAGE
  • 87. • American College of Obstetricians and Gynecologists (ACOG). (2019). Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses. Obstetrics & Gynecology, 133(5), e210-e226. • Kaijser, J., Bourne, T., Valentin, L., Sayasneh, A., Van Holsbeke, C., Vergote, I., ... & Timmerman, D. (2014). Improving strategies for diagnosing ovarian cancer: a summary of the International Ovarian Tumor Analysis (IOTA) studies. Ultrasound in Obstetrics & Gynecology, 44(1), 9-20. • Prat, J. (2012). Staging classification for cancer of the ovary, fallopian tube, and peritoneum. International Journal of Gynecology & Obstetrics, 124(1), 1-5. • Suidan, R. S., Ramirez, P. T., Sarasohn, D. M., Teitcher, J. B., Mironov, S., Iyer, R. B., ... & Brown, C. L. (2018). A multicenter prospective trial evaluating the ability of preoperative computed tomography scan and serum CA-125 to predict suboptimal cytoreduction at primary debulking surgery for advanced ovarian, fallopian tube, and peritoneal cancer. Gynecologic Oncology, 151(1), 39-44. • U.S. Preventive Services Task Force. (2018). Screening for Ovarian Cancer: US Preventive Services Task Force Recommendation Statement. JAMA, 319(6), 588-594 REFERENCES
  • 88. "THE BEST WAY TO FIND YOURSELF IS TO LOSE YOURSELF IN THE SERVICE OF OTHERS." - Mahatma Gandhi