management of adnexal masses
DESCRIPTION
Management of Adnexal Masses. Claire Gould, MD Minimally Invasive Gynecology Fellow Legacy 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 - PowerPoint PPT PresentationTRANSCRIPT
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