adnexal masses donato
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Adnexal Masses:Diagnosis, Types and Treatment
July 9, 2008
Robert A Donato, DO, F.A.C.O.G
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Adnexa consists of fallopian tube, broad
ligament, ovaries, and structures within thebroad ligament derived from embryonicnests.
5-10% of all US women will undergo a
procedure to check for suspected ovarianneoplasm during their lifetime
13-21% of those women will have a malignant
ovarian neoplasm
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Evaluation for surgery
H&P Transvaginal sonography
CA-125 level
Other factors to consider:*age* is the most predictive factor in determiningmalignancy potentialMenopausal statusPositive/negative symptomsCA-125 and other labsUnilaterally vs. bilaterally
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Age
In pre-menarchal and postmenopausal femalesadnexal masses are highly abnormal andrequire immediate investigation
Premenarchal : most derived from germ cellimmediate surgical exploration
Postmenopausal : derived from stromal, germcell, epithelial cells
IN POSTMENOPAUSAL MASSESCONSIDERED MALIGNANT UNTIL PROVENOTHERWISE!
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Differential Diagnosis:
Uterine mass
Ovarian mass
Endometriosis
Tubal mass
Non-GYN origins
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Uterine Masses Most common: myoma
Signs: palpated as 1 or more discrete, rounded, firmmasses
Sx: rapidly enlarging pelvic mass, pain, tendernessRarely (
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Ovarian Masses Functional cyst
most common during reproductive years: non-neoplastic cyststhat form when ovulation does not occur and the matured folliclecollapses on itself
May grow to 10 cm in diameter Usually resolve within 2 weeks
Corpus luteal cysts when ovulation does occur these form in the dead space created
when egg is released from follicle Can delay menses and may present like ectopic pregnancy
Theca-lutein cysts Over-stimulation of ovary by hCG Extensive luteinization of stroma surrounding follicle Seen in hydatidiform moles and choriocarcinoma but not regular
pregnancy
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Endometriotic cysts: encapsulated area of endometriosis
Sizes from 3-4 mm to 10 cm Adhere to surrounding tissue 50% cases involve both ovaries Cyst contents usually dark brown (called chocolate
cysts)
Polycystic/sclerocysticovaries contain multiple
follicle cystswith athickened, fibrotic capsuleand atretic follicles 2-5x normal size
ovaries
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Ovarian Neoplasms
20% are malignant
Cystic vs. solid tumors
Cystic tumors usually
contain mucous orserous material
Most neoplasms areasymptomatic unless
ruptured or twisted
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Benign cystic neoplasms: most common forms arecystadenomasand teratomas
1. cystadenomas: 5-20 cm
thin walled, ovoid, unilocularfilled with mucus or serous fluid that appears yellow-
tinged of variable consistency
2. teratomas:
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Benign Solid Tumors
Usually arise from connective tissue: fibromas, thecomas, Brennertumors
Variable in size
Firm, irregular contour, mobile
Cause palpable post-menopausal ovary (PPMO)
Meigs syndrome uncommon entity of benign ovarian fibroma with
ascites and hydrothorax
Malignant Solid Neoplasms
Most commonly adenocarcinomas (may be found as primary ormetatstatic tumors)
Ovarian carcinoma may be discovered when the patient complainsof abdominal distension caused by ascites 2 widespreadintraperitoneal dissemination
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Endometriosis
A condition in which implants of normal appearingendometrial glands and stroma are found outside theuterine cavity
Most common sites: ovaries, broad and uterosacralligaments, peritoneum of cul-de-sac and bladder
Most common in Caucasian, nulliparous 35-45 y/o
Ovarian involvementchocolate cyst
Bimanual exam may reveal nodularity of uterosacralligaments
Most common symptom: PELVIC PAIN
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Ovarian Endometriosis with chocolate cysts
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Tubal Masses
Rare finding usually represent inflammation 2 tubal
disease or ectopic pregnancy (EP) Palpation cannot differentiate between ovarian and tubal
masses
DDx:acute salpingitis tube distended with pusacute PID look for classic sx and check ESR/WBC
(even these are absent in ~30% cases however)chronic pelvic infection more subtle sx
Paraovarian cysts remnant of Wolffian duct foundbetween fallopian tube and ovary 95% EPs are tubal but
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Adnexal Masses of non-GYN Origin A thorough history is essential! Previous
surgeries/injuries, change in bowel/bladder habits,associated sx
Bowel most common is fecal material in sigmoid colonor cecum; also consider diverticulitis, abscess, ileitis,
GI cancer Bladder should be empty for proper exam Pelvic kidney benign condition when kidneys
fail to ascend during childhood
Retroperitonealdisorders (sarcoma, lymphoma,teratoma in sacrococcygeal area) Also consider lipoma, hernia, AAA, etc.
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Adnexal Masses Examand Work-up
Pelvic Exam: best identification of ovarianmass
Consider size, shape, contour, general
location. General guidelines Benign tumors smooth & regular walls,
cystic, mobile, unilateral,
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Imaging X-raysmay outline a mass
Teeth: teratoma
Psammoma bodies concentric calcifications foundin adenocarcinoma of the ovary
IVP kidneys, ureters, bladder
Use bladder contourto judge size of mass
See pts anatomy
prior to surgery
CT/MRI helpful but $$ Ultrasound
solid vs.cystic
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Labs
Tumor markers for ovarian cancer arehelpful as an adjunct to H&P
Some germ cell neoplasms produce hCG,LDH, AFP
Early ovarian CA not associated withreliable results
CA-125 in serous cystadenocarcinomas
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Management
Masses >10 cm should be surgically explored
Diagnostic laparoscopy useful if sourceuncertain and can distinguish fibroid vs. tumor
Ovarian Cysts: 95% of those
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Benign Ovarian Tumors
Serous cystadenoma Mucinous cystadenoma Pseudomyxoma peritonei
Brenner tumor Dermoid cyst Fibroma Germinal Inclusion Cyst
Pregnancy Luteoma Endometrioma PPMO
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Serous Cystadenoma more common and smaller than mucinous type Papillary projections on surface with smooth inner wall Low columnar epithelium
Characteristic finding: Psammoma bodies If associated fibrosis may progress to cystadenfibroma 10% are bilateral
Mucinous Cystadenoma
May be come GIGANTIC(>300 lbs!!!)
Round/ovoid mass withsmooth surfaces
Interior septated into loculicontaining clear, viscous fluid
Rarely bilateral
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Pseudomyxoma PeritoneiPeritoneal mesothelium transforms to mucin-
secreting epitheliumGradual accumulation of gelatinous materialUsually reaccumulate after removal
Brenner TumorVery rare, similar to fibromaHyperplastic fibromatous matrix with nests of
epithelioid cells with coffee bean appearance
May arise from various cells of ovaryLargely benignManagement: simple excision, very effective
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Dermoid Cyst (Benign Cystic Teratoma) Small, 15-25% bilat, more common in younger patients Thick, opaque, whitish walled cyst with hair, bone, cartilage,
greasy fluid found at cyst opening Ecto-, meso-, and endoderm at microscopic level 1-3% malignant (usually squamous cell) Management: cystectomy with entire capsule removed (or will
recur) must avoid spillage into pelvis to prevent chemicalperitonitis
Fibroma Range from small nodule on ovarian cortex to filling entire
pelvis Resembles a fibroid (uterine muscle tumor) Meigs syndrome: fibroma, ascites, hydrothorax
Germinal Inclusion Cyst Physiologic cysts seen monthly in menstruating women
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Pregnancy Luteoma With each pregnancy, this corpus luteal cyst forms at site of
ovulation
Creates progesterone to maintain pregnancy cyst of pregnancy
Endometrioma encapsulated endometriosis
PPMO (palpable post-menopausal ovary)
postmenopausally, ovaries gradually atrophy to 1/3 previous sizeare notnormally palpable
If you palpate an ovary worry about malignant neoplasm (earlyovarian CA)
Size matters! Benign < 5cm < Malignant is a good general guideline
Presence of ascites worsens prognosis Diagnostic laparoscopy or laparotomy is indicated (also check CA-
125) 10% PPMOs will be malignant others may be fibroma or Brenner
tumor
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Borderline Malignant EpithelialOvarian Neoplasms
Group of epithelial ovarian tumors with histologicfeatures bordering clearly benign and franklymalignant neoplasms
more common in younger women
95% 10-year survival rate for Stage 1 lesions(least malignant)
Considered low malignant potential Minimally invasive surgery is warranted for
complete extirpation
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Epithelial Ovarian Cancer
Types Serous cystadenocarcinoma (42%) Mucinous cystadenocarcinoma (12%) Endometrioid carcinoma (15%0 Undifferentiated carcinoma (17%)
Clear cell carcinoma (6%)
Some epidemiology 5% all cancers 1/56 will develop EOC 26,500 new cases annually 19,500 deaths annually More common >50 y/o Makes up 85-90% of all malignant ovarian tumors Ovarian cancer (all types) is the most deadly gynecologic cancer
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Risk FactorsFactors that decreaserisk: more pregnanciesMore OCP useIncreasedrisk:Prolonged use of fertility drugs (ex. Clomid)
Family association (discussed later)
Theory of incessant ovulation repeated trauma(follicular rupture) and repair to epithelial ovarian cells byovulation stimulates tumor growth
Gonadotropin Theory persistent stimulation of ovaries bygonadotropins results in increased proliferation ofovarian epithelium
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STAGE DEFINITION
Stage I Growth limited to ovaries
Stage Ia Growth limited to one ovary, no ascites, no tumour on external surface, capsule intact
Stage Ib Growth limited to both ovaries, no ascites, no tumour on external surface, capsule intact
Stage IcTumour either stage Ia or Ib, but with tumour on one or both ovaries, with capsule ruptured, with ascites present containing
malignant cells, or with positive peritoneal washings
Stage II Growth involving one or both ovaries with pelvic extension
Stage IIa Extension and/or metastases to the uterus and/or tubes
Stage IIb Extension to other pelvic tissues
Stage IIcTumour either stage IIa or IIb, with tumour on the surface of one or both ovaries, but with capsule(s) ruptured, with ascites
present containing malignant cells, or with positive peritoneal washings
Stage IIITumour involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal nodes.Superficial liver metastases equal stage III. Tumour limited to the true pelvis but with histologically proven malignant extension to
small bowel or omentum
Stage IIIa Tumour grossly limited to the true pelvis with negative nodes but with histologically confirmed microscopic seeding of abdominalperitoneal surfaces.
Stage IIIbTumour involving one or both ovaries with histologically confirmed implants of abdominal peritoneal surfaces, none exceeding
2cm in diameter. Nodes are negative.
Stage IIIc Abdominal implants >2cm in diameter and/or positive retroperitoneal or inguinal nodes.
Stage IV Growth involving one or both ovaries with distant metastases.
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STAGE No PATIENTS TREATED SURVIVAL3-yr (%) SURVIVAL 5-yr (%)
I 5,559 87.5 82.1
II 3,364 72.1 64.5
III 2,530 47 38.1
IV 492 20.7 14
TOTAL 11,945 71.6 65.4
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Genetics of Ovarian Cancer
Definite increased risk of developing ovarian CA with +family history
Hereditary Syndromes:
1. A site-specific familial ovarian cancer syndrome existsthat places women at high risk for development ofovarian cancer only
2. Breast-Ovarian CA Syndrome: 50% risk of ovarian CAif 1 relative had breast and/or ovarian CA.Association with cancer genes BRCA-1 and 2.
3. Cancer Family Syndrome: risk for men and womento develop colon cancer and to a lesser extentsarcoma, gastric or thyroid cancer
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Symptoms:
Abdominal swelling
Abdominal pain Dyspepsia
Urinary frequency
Weight change
Signs:
You would need to do 10,000 pelvic exams tofind 1 early ovarian cancer!
Unexplained, persistent GI sx in a 40-69 y/osuspect ovarian CA
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Screening?
The US Preventive Task Force does NOTrecommend using CA-125 as a screening toolfor ovarian cancer.
Also no evidence to support transvaginalultrasonography for screening.
These tools should only be utilized for high-riskindividuals or those with a positive H&P.
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Workup
Complete H&P
Pelvic exam and pap smear
CBC
UA CA-125
Comprehensive Metabolic Panel
CXR
IVP/Barium Enema or CT with contrast
Pelvic US
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Surgical Therapy in Ovarian Cancer
TAH/BSO with removal of as much of tumor as possible
Lymph node biopsies
Omentectomy
Based on spread of disease, surgeon will remove anyobvious tumor and biopsy various sites throughabdomen and pelvis (peritoneum, omentum, diaphragm)
Adjunct therapy (radiation/chemo) based on post-oppathologic diagnosis and staging
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Any serous questionomas?