adnexal mass in pregnancy a.gari gynecologic oncology

42
Adnexal Mass In Pregnancy A. Gari Gynecologic Oncology

Upload: ezra-tyler

Post on 25-Dec-2015

235 views

Category:

Documents


2 download

TRANSCRIPT

Adnexal Mass In Pregnancy

A. Gari

Gynecologic Oncology

• Incidence: 1:200 pregnancies.

• 1:1000 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 1:70 F.

• 1:25000 deliveries (1:800 adnexal masses).

Ovarian Malignancies in Pregnancy:

• Germ cell tumors (45%) : Dysgerminoma .

• Epithelial tumors (37.5%), especially LMP tumor.

• Sex cord–stromal tumors (10%)

• Miscellaneous pathologies (7.5%)

Solid Tumors In Pregnancy:

Luteoma, Fibroma, Mature cystic teratomas and Krukenberg tumor.

Investigations:

• U/S (30% PPV)• +/- MRI

• Size• Unilateral/Bilateral• Locularity/Septations• Simple/Complex• Papillary Excrescence / nodules• Omental disease/ascites• RI

Tumor markers:

• Ca-125 :

• LDH

• Alk. Phos.

• HCG

• AFP

• Inhibin

• Others (Ca 15-3, Ca 19-9, CEA).

Potential complications

• Torsion (ante / post partum) occurs in < 7 %, it is higher in teratoma (19%).

• Rupture.

• Hemorrhage.

• Obstruction during labor.

• Suspicion of malignancy.

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.

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 < 5 cm observe (80-90% may resolve)

• If > 5 cm operate … when ???

(14 – 16 weeks)

• 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.

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 )

• 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)

• 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.

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 > 15 mmHg.

B - Laparotomy:• Midline / Good exposure (easy to extend).• Easy to do full staging (if needed).• Always explore other organs.

• 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.

• Post operative management:

• 1 - Germ cell tumors: BEP / ?? Rad therapy • 2 - Epithelial tumors: Carbo / Taxol 2&3ed

T

• 3 - Tumor of LMP : depend on the implants.

• Most of the chemotherapeutic agents are class -D

Radiation During Pregnancy

• 1 Gy = 100 rad

• 1 cGy = 1 rad

• Threshold below which no effects are seen.

if it is < 5 rads

• No increased risk of any adverse effects other than slight risk of leukemia at <5 rads.

• Gross congenital malformations will not be increased at doses <20 rads.

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

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

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

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

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

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

Cervical Cancer in Pregnancy

Staging • Clinical staging.

• Permitted exam. / inv. :

Inspection. IVP.

Palpation. CXR.

Colposcopy. Proctoscopy (+/- Bx).

ECC. Cystoscopy (+/- Bx).

Conization (Coin). Hysteroscopy.

Staging (cont’d) 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.

Optional investigations , Pathological findings and report :

Should not change your clinical staging

• RT is an option for non Sx candidates.

• Similar out come but with morbidity: Bowel Bladder Atrophy. Vaginal Fibrosis.

Stenosis.

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) ?

Small Field Pelvic RT

Standard field vs. Small field RT

Teletherapy (External beam) - Small Field RT.

- Standard Field RT.

- Extended Field RT.

Brachytherapy - Intracavitary.

- Interstitial.

Brachytherapy:

• HDR : > 1200 cGy

• MDR : 200 – 1200 cGy

• LDR : 40 – 200 cGy

• PDR : pulses over 30 hrs.

• 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.

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

Commonly used points in Rad. Onc.

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%).

Causes of elevated Ca-125