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Adnexal Mass In Pregnancy

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Title: Adnexal Mass In Pregnancy


1
Adnexal Mass In Pregnancy
  • Gari
  • Gynecologic Oncology

2
  • Incidence 1200 pregnancies.
  • 11000 F will undergo lap. For pelvic mass.
  • Increased detection (U/S).
  • The commonest are - Teratomas
  • -
    Cysadenomas
  • -
    Functional / C. Luteum
  • 5 of adnexal masses are malignant.
  • Ovarian cancer incidence 170 F.
  • 125000 deliveries (1800 adnexal masses).

3
  • Ovarian Malignancies in Pregnancy
  • Germ cell tumors (45) Dysgerminoma .
  • Epithelial tumors (37.5), especially LMP tumor.
  • Sex cordstromal tumors (10)
  • Miscellaneous pathologies (7.5)
  • Solid Tumors In Pregnancy
  • Luteoma, Fibroma, Mature cystic teratomas and
    Krukenberg tumor.

4
Investigations
  • U/S (30 PPV)
  • /- MRI
  • Size
  • Unilateral/Bilateral
  • Locularity/Septations
  • Simple/Complex
  • Papillary Excrescence / nodules
  • Omental disease/ascites
  • RI

5
  • Tumor markers
  • Ca-125
  • LDH
  • Alk. Phos.
  • HCG
  • AFP
  • Inhibin
  • Others (Ca 15-3, Ca 19-9, CEA).

6
Potential complications
  • Torsion (ante / post partum) occurs in lt 7 , it
    is higher in teratoma (19).
  • Rupture.
  • Hemorrhage.
  • Obstruction during labor.
  • Suspicion of malignancy.

7
Management
  • - Obstetrician / MFM Gyn Onc. Neonatologist
  • - The mother is always first priority (role 1).
  • Factors affects your management
  • GA.
  • U/S / MRI appearance.
  • Size interval change over time.
  • Symptoms.

8
  • A- Adnexal mass Non Reassuring appearance
  • B- Adnexal mass with Reassuring appearance
  • reproductive age group
  • Non pregnant patient / a symptomatic
  • Pregnant patient / a symptomatic
  • if lt 5 cm observe (80-90 may resolve)
  • If gt 5 cm operate when ???
  • (14 16
    weeks)

9
  • Corpus luteum support (8-10 weeks).
  • Risk of SAB is up to 18 (1st trimester).
  • Reduced risk to 4-5 if done after 14 weeks.
  • Consider progesterone supplement (PV/IM).
  • Consider steroids in elective surgery
    (24-34weeks)
  • Emergency Sx. Is associated with worse pregnancy
    out come.
  • Always explain the risk/complications to the
    patient.

10
  • Maternal Fetal risks
  • fetal organogenesis are first trimester events.
  • Newer inhalational anesthetic agents are not
    teratogenic.
  • Regional anesthesia is preferred during
    pregnancy.
  • Preterm labor (up to 9) during the 3ed
    trimester.
  • Erroneous causal associations in the patient's
    mind between surgery/anesthetic agents and common
    first trimester adverse outcomes ( eg,
    miscarriage, vaginal bleeding, structural
    anomalies )

11
  • Relative incompetence of the GE sphincter
    increases the risk for pulmonary aspiration
    (Aspiration Pneumonia).
  • The basal metabolic rate and functional
    residual capacity thus hypoxemia is likely to
    develop rapidly during the period of apnea
    (induction of GA).
  • Minute ventilation by 50.
  • TV
  • Expiratory reserve volume and residual volume
  • RR
  • Forced expiratory volume (FEV1)

12
  • Supine hypotensive syndrome (15 deg. Lateral
    tilt)
  • VTE disease.
  • Other surgical risks (bleeding, infection,
    visceral injuries).
  • Operative Techniques
  • Always document fetal viability before and after
    SX.
  • Cont. FHM/Toco if possible (intra-op) RR.
  • If non reassuring FH consider
  • Check the position.
  • Maintaining maternal normocarbia.
  • Correct hypovolemia.
  • Increase maternal inspired oxygen concentration.

13
  • Be prepared to perform an emrg. C/S if needed.
  • A - Laparoscopy
  • Is an option (not the standard of care).
  • Experienced surgeon, difficult exposure,
    potential for conversion, avoid it if ??
    Malignant.
  • It mandates GA.
  • Avoid pneumo-peritomium gt 15 mmHg.
  • B - Laparotomy
  • Midline / Good exposure (easy to extend).
  • Easy to do full staging (if needed).
  • Always explore other organs.

14
  • Avoid uterine manipulation.
  • Limit your excision/resection
  • Avoid aspiration/drainage only.
  • Adnexal mass discovered during C/S should be
    removed.
  • Biopsy the contralateral ovary if abnormal.
  • Laparotomy is NOT CI to vaginal Delivery.
  • Prophylactic tocolytics ???
  • Post op. Opiates and antiemetics.
  • NSAID should be avoided, especially after 32
    weeks.

15
  • Post operative management
  • 1 - Germ cell tumors BEP / ?? Rad therapy
  • 2 - Epithelial tumors Carbo / Taxol
    23ed T
  • 3 - Tumor of LMP depend on the implants.
  • Most of the chemotherapeutic agents are class -D

16
Radiation During Pregnancy
17
  • 1 Gy 100 rad
  • 1 cGy 1 rad
  • Threshold below which no effects are seen.
  • if it is lt 5 rads
  • No increased risk of any adverse effects other
    than slight risk of leukemia at lt5 rads.
  • Gross congenital malformations will not be
    increased at doses lt20 rads.

18
8 -25 weeks
  • Greatest Risk
  • Organogenesis
  • Affected cells once destroyed
  • can not be replaced---microcephaly
  • Threshold 12 rad 8-15 weeks
  • Threshold 21 rad at 16-25 weeks

19
Adverse Effects
  • Threshold phenomena in order of frequency
  • Growth Retardation
  • Microcephaly
  • Mental Retardation
  • Microphthalmia
  • Pigment changes in the retina
  • Genital and skeletal abnormalities
  • Catarct
  • Abortion
  • Non-threshold phenomena
  • Carcinogenesis
  • Dental Radiography may be associated with LBW

20
Examination type Plain Films Estimated fetal dose per examination (rad) Number of exams required for a cumulative 5-rad
Skull 0.004 1250
IVP 1.398 3
Cervical Spine 0.002 2500
Upper or Lower Extremity 0.001 5000
Chest (AP Lat) 0.00007 71429
21
Examination type Plain Films Estimated fetal dose per examination (rad) Number of exams required for a cumulative 5-rad
Mammogram 0.020 250
Abdominal series 0.245 20
Hip (single view) 0.213 23
Lumbosacral Spine 0.359 13
Pelvis 0.040 125
22
Examination type CT 10 mm slices Estimated fetal dose per examination (rad) Number of exams required for a cumulative 5-rad
Head 10 slices 0.050 100
Chest (10 slices) 0.1 50
Lumbar spine (5 slices) 3.5 1
Abdomen (10 slices) 2.6 1
Pelvis 2.5 2
23
Examination type Misc. Estimated fetal dose per examination (rad) Number of exams required for a cumulative 5-rad
Barium Enema 3.986 1
VQ Scan 0.215 23
Iodine 131 590 Contraindicated
TC99M 0.500 10
HIDA 0.150 33

24
Cervical Cancer in Pregnancy
25
Staging
  • Clinical staging.
  • Permitted exam. / inv.
  • Inspection. IVP.
  • Palpation. CXR.
  • Colposcopy. Proctoscopy (/-
    Bx).
  • ECC. Cystoscopy (/-
    Bx).
  • Conization (Coin). Hysteroscopy.

26
Staging (contd)
  • Optional investigations ( for treatment plan )
  • Lymphangiography.
  • Art./Venography.
  • Laparoscopy. Non
    pregnant F.
  • LN-FNA.
  • CT , US.
  • MRI (in pregnancy)
  • Spread
    beyond the CX.
  • Determine
    tumor size.
  • LN
    involvement.

27
Optional investigations , Pathological findings
and report
  • Should not change your clinical staging

28
  • RT is an option for non Sx candidates.
  • Similar out come but with morbidity
  • Bowel
  • Bladder Atrophy.
  • Vaginal Fibrosis.
  • Stenosis.

29
High risk or Low risk cervical ca is it
important to know ???
  • Post op. treatment plan
  • No adjuvant treatment ?
  • Radiation therapy ?
  • Chemo-Radiation (Cisplatin /- 5FU) ?

30
Small Field Pelvic RT
31
Standard field vs. Small field RT
32
  • Teletherapy (External beam) - Small Field RT.

  • - Standard Field RT.

  • - Extended Field RT.
  • Brachytherapy -
    Intracavitary.

  • - Interstitial.

33
  • Brachytherapy
  • HDR gt 1200 cGy
  • MDR 200 1200 cGy
  • LDR 40 200 cGy
  • PDR pulses over 30 hrs.

34
  • Commonly used points in Rad. Onc
  • Point A
  • originally defined by Manchester system as a
    point 2 cm above the lateral fornix and 2 cm
    lateral to the cervical canal representing the
    crossing of the ureter and uterine artery
    (parametriem)
  • more currently defined as 2 cm lateral and 2 cm
    superior to the cervical os.

35
  • Point B
  • Defined by Manchester system as a point at the
    same level as point A and extending 5 cm lateral
    to midline representing the obturator nodes.
  • Point P
  • Defined by Fletcher system as a point 2 cm
    superior to the lateral fornix and 6 cm lateral
    to midline representing the pelvic sidewall

36
Commonly used points in Rad. Onc.
37
Extended Field RT.
  • Para aortic LN mets is 30 in stage III compared
    with 7 in stage IB.
  • superior border is T12 L1 interspace, and width
    is 10 cm.
  • RTOG reported a significant improvement in 5y
    survival for pts who had EFRT compared with had
    standard field RT (66 vs. 55).

38
Thank you
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Causes of elevated Ca-125
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