management of adnexal masses

Management of Adnexal Masses

Claire Gould, MDMinimally Invasive Gynecology

FellowLegacy Health

Triage

• History and physical• Imaging• Lab Work

History and physical

• History of present illness • Current symptoms• Review of systems

• Full Past Medical History• Menstrual history • Family history• Physical exam – don’t forget the rectal exam!

Risk factorsRelative Risk Lifetime probability

(%)Familial ovarian cancer syndromesBRCA 1BRCA 2

30-5035-4612-23

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

Imaging

• Ultrasound• CT• MRI

Sensitivity/Specificity for diagnostic tools

Sensitivity Specificity

Bimanual pelvic exam 45 90

Ultrasound - Morphology - Presence of vessels - Combined morphology and Doppler

86-918886

68-837891

MRI 91 88

CT 90 75

PET 67 79

CA 125 78 78

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

Kentucky Morphology Index

Ascites

Lab Tests

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

Conditions associated with Elevated CA 125 concentrations

OVA 1

• Immunoassay for 5 biomarkers• Limited usefulness in women with

Rheumatoid factor >250 IU, or triglyceride level greater than 450 mg/dL

Abnormal OVA 1 values

• >4.4 postmenopausal• >5.0 premenopausal

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 physician’s independent clinical and radiological evaluation does not indicate malignancy

• Not intended as a screening or stand-alone diagnostic assay.

When to Operate

• Premenopausal women– Cyst >10cm– Suspicious for malignancy– Family history– pain

• Postmenopausal– >5cm– Suspicious for malignancy

When to Refer to Gyn Oncology• Premenopausal

– Ca 125 >200– Ascites– Evidence of mets– Family history of breast/ovarian ca in 1st degree relative

• Postmenopausal– Ca 125 > 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

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

MIS approaches for removal of masses

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

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.

Case # 2

• 57 year old referred by naturopath due to acute pain in pelvis, bladder pain

• Known right ovarian cyst for >3 years but previously declined treatment.

• Imaging showed 10 cm complex cyst• CA 125 – 162• OVA 1 – 9.1

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• Patient’s CA 125 = 395

Complex mass case