Management of Adnexal Masses

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Management of Adnexal Masses

• Claire Gould, MD
• Minimally Invasive Gynecology Fellow
• Legacy Health

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Triage

• History and physical
• Imaging
• Lab Work

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History and physical

• History of present illness
• Current symptoms
• Review of systems
• Full Past Medical History
• Menstrual history
• Family history
• Physical exam dont forget the rectal exam!

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Risk factors
Relative Risk Lifetime probability ()
Familial ovarian cancer syndromes BRCA 1 BRCA 2 30-50 35-46 12-23
2-3 relatives with ovarian ca 4.6 5.5 (15 if 1st degree)
One relative with ovarian ca 3.1 3.7 (5 if 1st degree)
No risk factors 1.0 1.8
Past OCP use 0.65 0.8
Past pregnancy 0.5 0.6
Infertility 2.8
Nulligravity 1.6
Breast feeding 0.81
Tubal ligation 0.59

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Imaging

• Ultrasound
• CT
• MRI

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Sensitivity/Specificity for diagnostic tools
Sensitivity Specificity
Bimanual pelvic exam 45 90
Ultrasound - Morphology - Presence of vessels - Combined morphology and Doppler 86-91 88 86 68-83 78 91
MRI 91 88
CT 90 75
PET 67 79
CA 125 78 78
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Kentucky Morphology Index
Ascites

1. Ueland, FR et al. Gyn Oncol, 2003

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Lab Tests

• CA 125
• OVA 1
• HE4
• CEA
• CA 19-9
• B-hCG
• LDH
• AFP

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CA 125

• Elevated in over 80 of women with advanced
  ovarian cancer.
• Sensitivity for stage I ovarian cancer only 50
• Not a specific test for cancer

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Conditions associated with Elevated CA 125
concentrations

• Epithelial ovarian cancer
• Endometrial cancer
• Adenocarcinoma of cervix
• Adenomyosis
• Endometriosis
• Leiomyomata
• Pregnancy
• Pelvic inflammation
• Liver disease and cirrhosis
• Colitis
• Heart failure
• Diverticulitis
• Lupus
• Pericarditis
• Postoperative period
• Renal disease
• TB
• Ascites
• Pleural effusion

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OVA 1

• Immunoassay for 5 biomarkers
• Limited usefulness in women with Rheumatoid
  factor gt250 IU, or triglyceride level greater
  than 450 mg/dL

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Abnormal OVA 1 values

• gt4.4 postmenopausal
• gt5.0 premenopausal

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Indications for OVA 1 testing

• Over age 18
• Ovarian mass for which surgery is planned (but
  not yet referred to oncologist)
• Aid to further assess the likelihood that
  malignancy is present when the physicians
  independent clinical and radiological evaluation
  does not indicate malignancy
• Not intended as a screening or stand-alone
  diagnostic assay.

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When to Operate

• Premenopausal women
• Cyst gt10cm
• Suspicious for malignancy
• Family history
• pain
• Postmenopausal
• gt5cm
• Suspicious for malignancy

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When to Refer to Gyn Oncology

• Premenopausal
• Ca 125 gt200
• Ascites
• Evidence of mets
• Family history of breast/ovarian ca in 1st degree
  relative
• Postmenopausal
• Ca 125 gt 35
• Ascites
• Nodular or fixed pelvic mass
• Evidence of mets
• Family history of breast/ovarian ca in 1st degree
  relative
• ACOG Committee Opinion DEC 2002

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Special Case - Pregnancy

• Most masses are incidental and can be managed
  expectantly
• 50-70 will resolve in pregnancy
• Operate if malignancy suspected, acute
  complication (torsion), size of tumor is likely
  to cause obstetric difficulty
• In non urgent cases, wait until after 1st
  trimester
• Laparoscopy can and should be considered

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MIS approaches for removal of masses

• Purse string suture and drain
• Needle aspiration
• Trocar
• Endocatch
• Hand assist port
• Small mini lap
• McCartney tube

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Case 1

• 19 year old college student with acute onset of
  right lower quadrant pain that improved with
  Vicodin.
• Pain continued as a dull ache with intermittent
  sharp stabbing pain, nausea
• Ultrasound showed a 12 cm ovarian mass. No
  normal ovarian tissue was seen.

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Case 2

• 57 year old referred by naturopath due to acute
  pain in pelvis, bladder pain
• Known right ovarian cyst for gt3 years but
  previously declined treatment.
• Imaging showed 10 cm complex cyst
• CA 125 162
• OVA 1 9.1

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Case 3

• 33 year old G0 presented with abdominal pain.
• Known fibroid uterus
• Ultrasound 2 months ago
• Repeat imaging now showed bilateral complex
  pelvic masses
• Mother diagnosed with ovarian cancer
• Patients CA 125 395

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Complex mass case