Transcript Management of Adnexal Masses

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
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Full Past Medical History
Menstrual history
Family history
Physical exam – don’t forget the rectal exam!
Risk factors
Relative Risk
Familial ovarian cancer syndromes
BRCA 1
BRCA 2
Lifetime probability (%)
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
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
86-91
88
86
68-83
78
91
MRI
91
88
CT
90
75
PET
67
79
CA 125
78
78
Kentucky Morphology Index
14. Ueland, FR et al. Gyn Oncol, 2003
Ascites
7
Lab Tests
• CA 125
• OVA 1
• HE4
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CEA
CA 19-9
B-hCG
LDH
AFP
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
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Epithelial ovarian cancer
Endometrial cancer
Adenocarcinoma of cervix
Adenomyosis
Endometriosis
Leiomyomata
Pregnancy
Pelvic inflammation
Liver disease and cirrhosis
Colitis
Heart failure
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Diverticulitis
Lupus
Pericarditis
Postoperative period
Renal disease
TB
Ascites
Pleural effusion
Pancreatic cancer
Colon cancer
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
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Ca 125 >200
Ascites
Evidence of mets
Family history of breast/ovarian ca in 1st degree relative
• Postmenopausal
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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
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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