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Adnexal Masses:Diagnosis, Types and Treatment

July 9, 2008

Robert A Donato, DO, F.A.C.O.G


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Adnexa consists of fallopian tube, broad

ligament, ovaries, and structures within thebroad ligament derived from embryonicnests.

5-10% of all US women will undergo a

procedure to check for suspected ovarianneoplasm during their lifetime

13-21% of those women will have a malignant

ovarian neoplasm


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Evaluation for surgery

H&P Transvaginal sonography

CA-125 level

Other factors to consider:*age* is the most predictive factor in determiningmalignancy potentialMenopausal statusPositive/negative symptomsCA-125 and other labsUnilaterally vs. bilaterally


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Age

In pre-menarchal and postmenopausal femalesadnexal masses are highly abnormal andrequire immediate investigation

Premenarchal : most derived from germ cellimmediate surgical exploration

Postmenopausal : derived from stromal, germcell, epithelial cells

IN POSTMENOPAUSAL MASSESCONSIDERED MALIGNANT UNTIL PROVENOTHERWISE!


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Differential Diagnosis:

Uterine mass

Ovarian mass

Endometriosis

Tubal mass

Non-GYN origins


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Uterine Masses Most common: myoma

Signs: palpated as 1 or more discrete, rounded, firmmasses

Sx: rapidly enlarging pelvic mass, pain, tendernessRarely (


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Ovarian Masses Functional cyst

most common during reproductive years: non-neoplastic cyststhat form when ovulation does not occur and the matured folliclecollapses on itself

May grow to 10 cm in diameter Usually resolve within 2 weeks

Corpus luteal cysts when ovulation does occur these form in the dead space created

when egg is released from follicle Can delay menses and may present like ectopic pregnancy

Theca-lutein cysts Over-stimulation of ovary by hCG Extensive luteinization of stroma surrounding follicle Seen in hydatidiform moles and choriocarcinoma but not regular

pregnancy


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Endometriotic cysts: encapsulated area of endometriosis

Sizes from 3-4 mm to 10 cm Adhere to surrounding tissue 50% cases involve both ovaries Cyst contents usually dark brown (called chocolate

cysts)

Polycystic/sclerocysticovaries contain multiple

follicle cystswith athickened, fibrotic capsuleand atretic follicles 2-5x normal size

ovaries


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Ovarian Neoplasms

20% are malignant

Cystic vs. solid tumors

Cystic tumors usually

contain mucous orserous material

Most neoplasms areasymptomatic unless

ruptured or twisted


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Benign cystic neoplasms: most common forms arecystadenomasand teratomas

1. cystadenomas: 5-20 cm

thin walled, ovoid, unilocularfilled with mucus or serous fluid that appears yellow-

tinged of variable consistency

2. teratomas:


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Benign Solid Tumors

Usually arise from connective tissue: fibromas, thecomas, Brennertumors

Variable in size

Firm, irregular contour, mobile

Cause palpable post-menopausal ovary (PPMO)

Meigs syndrome uncommon entity of benign ovarian fibroma with

ascites and hydrothorax

Malignant Solid Neoplasms

Most commonly adenocarcinomas (may be found as primary ormetatstatic tumors)

Ovarian carcinoma may be discovered when the patient complainsof abdominal distension caused by ascites 2 widespreadintraperitoneal dissemination


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Endometriosis

A condition in which implants of normal appearingendometrial glands and stroma are found outside theuterine cavity

Most common sites: ovaries, broad and uterosacralligaments, peritoneum of cul-de-sac and bladder

Most common in Caucasian, nulliparous 35-45 y/o

Ovarian involvementchocolate cyst

Bimanual exam may reveal nodularity of uterosacralligaments

Most common symptom: PELVIC PAIN


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Ovarian Endometriosis with chocolate cysts


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Tubal Masses

Rare finding usually represent inflammation 2 tubal

disease or ectopic pregnancy (EP) Palpation cannot differentiate between ovarian and tubal

masses

DDx:acute salpingitis tube distended with pusacute PID look for classic sx and check ESR/WBC

(even these are absent in ~30% cases however)chronic pelvic infection more subtle sx

Paraovarian cysts remnant of Wolffian duct foundbetween fallopian tube and ovary 95% EPs are tubal but


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Adnexal Masses of non-GYN Origin A thorough history is essential! Previous

surgeries/injuries, change in bowel/bladder habits,associated sx

Bowel most common is fecal material in sigmoid colonor cecum; also consider diverticulitis, abscess, ileitis,

GI cancer Bladder should be empty for proper exam Pelvic kidney benign condition when kidneys

fail to ascend during childhood

Retroperitonealdisorders (sarcoma, lymphoma,teratoma in sacrococcygeal area) Also consider lipoma, hernia, AAA, etc.


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Adnexal Masses Examand Work-up

Pelvic Exam: best identification of ovarianmass

Consider size, shape, contour, general

location. General guidelines Benign tumors smooth & regular walls,

cystic, mobile, unilateral,


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Imaging X-raysmay outline a mass

Teeth: teratoma

Psammoma bodies concentric calcifications foundin adenocarcinoma of the ovary

IVP kidneys, ureters, bladder

Use bladder contourto judge size of mass

See pts anatomy

prior to surgery

CT/MRI helpful but $$ Ultrasound

solid vs.cystic


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Labs

Tumor markers for ovarian cancer arehelpful as an adjunct to H&P

Some germ cell neoplasms produce hCG,LDH, AFP

Early ovarian CA not associated withreliable results

CA-125 in serous cystadenocarcinomas


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Management

Masses >10 cm should be surgically explored

Diagnostic laparoscopy useful if sourceuncertain and can distinguish fibroid vs. tumor

Ovarian Cysts: 95% of those


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Benign Ovarian Tumors

Serous cystadenoma Mucinous cystadenoma Pseudomyxoma peritonei

Brenner tumor Dermoid cyst Fibroma Germinal Inclusion Cyst

Pregnancy Luteoma Endometrioma PPMO


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Serous Cystadenoma more common and smaller than mucinous type Papillary projections on surface with smooth inner wall Low columnar epithelium

Characteristic finding: Psammoma bodies If associated fibrosis may progress to cystadenfibroma 10% are bilateral

Mucinous Cystadenoma

May be come GIGANTIC(>300 lbs!!!)

Round/ovoid mass withsmooth surfaces

Interior septated into loculicontaining clear, viscous fluid

Rarely bilateral


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Pseudomyxoma PeritoneiPeritoneal mesothelium transforms to mucin-

secreting epitheliumGradual accumulation of gelatinous materialUsually reaccumulate after removal

Brenner TumorVery rare, similar to fibromaHyperplastic fibromatous matrix with nests of

epithelioid cells with coffee bean appearance

May arise from various cells of ovaryLargely benignManagement: simple excision, very effective


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Dermoid Cyst (Benign Cystic Teratoma) Small, 15-25% bilat, more common in younger patients Thick, opaque, whitish walled cyst with hair, bone, cartilage,

greasy fluid found at cyst opening Ecto-, meso-, and endoderm at microscopic level 1-3% malignant (usually squamous cell) Management: cystectomy with entire capsule removed (or will

recur) must avoid spillage into pelvis to prevent chemicalperitonitis

Fibroma Range from small nodule on ovarian cortex to filling entire

pelvis Resembles a fibroid (uterine muscle tumor) Meigs syndrome: fibroma, ascites, hydrothorax

Germinal Inclusion Cyst Physiologic cysts seen monthly in menstruating women


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Pregnancy Luteoma With each pregnancy, this corpus luteal cyst forms at site of

ovulation

Creates progesterone to maintain pregnancy cyst of pregnancy

Endometrioma encapsulated endometriosis

PPMO (palpable post-menopausal ovary)

postmenopausally, ovaries gradually atrophy to 1/3 previous sizeare notnormally palpable

If you palpate an ovary worry about malignant neoplasm (earlyovarian CA)

Size matters! Benign < 5cm < Malignant is a good general guideline

Presence of ascites worsens prognosis Diagnostic laparoscopy or laparotomy is indicated (also check CA-

125) 10% PPMOs will be malignant others may be fibroma or Brenner

tumor


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Borderline Malignant EpithelialOvarian Neoplasms

Group of epithelial ovarian tumors with histologicfeatures bordering clearly benign and franklymalignant neoplasms

more common in younger women

95% 10-year survival rate for Stage 1 lesions(least malignant)

Considered low malignant potential Minimally invasive surgery is warranted for

complete extirpation


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Epithelial Ovarian Cancer

Types Serous cystadenocarcinoma (42%) Mucinous cystadenocarcinoma (12%) Endometrioid carcinoma (15%0 Undifferentiated carcinoma (17%)

Clear cell carcinoma (6%)

Some epidemiology 5% all cancers 1/56 will develop EOC 26,500 new cases annually 19,500 deaths annually More common >50 y/o Makes up 85-90% of all malignant ovarian tumors Ovarian cancer (all types) is the most deadly gynecologic cancer


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Risk FactorsFactors that decreaserisk: more pregnanciesMore OCP useIncreasedrisk:Prolonged use of fertility drugs (ex. Clomid)

Family association (discussed later)

Theory of incessant ovulation repeated trauma(follicular rupture) and repair to epithelial ovarian cells byovulation stimulates tumor growth

Gonadotropin Theory persistent stimulation of ovaries bygonadotropins results in increased proliferation ofovarian epithelium


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STAGE DEFINITION

Stage I Growth limited to ovaries

Stage Ia Growth limited to one ovary, no ascites, no tumour on external surface, capsule intact

Stage Ib Growth limited to both ovaries, no ascites, no tumour on external surface, capsule intact

Stage IcTumour either stage Ia or Ib, but with tumour on one or both ovaries, with capsule ruptured, with ascites present containing

malignant cells, or with positive peritoneal washings

Stage II Growth involving one or both ovaries with pelvic extension

Stage IIa Extension and/or metastases to the uterus and/or tubes

Stage IIb Extension to other pelvic tissues

Stage IIcTumour either stage IIa or IIb, with tumour on the surface of one or both ovaries, but with capsule(s) ruptured, with ascites

present containing malignant cells, or with positive peritoneal washings

Stage IIITumour involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal nodes.Superficial liver metastases equal stage III. Tumour limited to the true pelvis but with histologically proven malignant extension to

small bowel or omentum

Stage IIIa Tumour grossly limited to the true pelvis with negative nodes but with histologically confirmed microscopic seeding of abdominalperitoneal surfaces.

Stage IIIbTumour involving one or both ovaries with histologically confirmed implants of abdominal peritoneal surfaces, none exceeding

2cm in diameter. Nodes are negative.

Stage IIIc Abdominal implants >2cm in diameter and/or positive retroperitoneal or inguinal nodes.

Stage IV Growth involving one or both ovaries with distant metastases.


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STAGE No PATIENTS TREATED SURVIVAL3-yr (%) SURVIVAL 5-yr (%)

I 5,559 87.5 82.1

II 3,364 72.1 64.5

III 2,530 47 38.1

IV 492 20.7 14

TOTAL 11,945 71.6 65.4


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Genetics of Ovarian Cancer

Definite increased risk of developing ovarian CA with +family history

Hereditary Syndromes:

1. A site-specific familial ovarian cancer syndrome existsthat places women at high risk for development ofovarian cancer only

2. Breast-Ovarian CA Syndrome: 50% risk of ovarian CAif 1 relative had breast and/or ovarian CA.Association with cancer genes BRCA-1 and 2.

3. Cancer Family Syndrome: risk for men and womento develop colon cancer and to a lesser extentsarcoma, gastric or thyroid cancer


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Symptoms:

Abdominal swelling

Abdominal pain Dyspepsia

Urinary frequency

Weight change

Signs:

You would need to do 10,000 pelvic exams tofind 1 early ovarian cancer!

Unexplained, persistent GI sx in a 40-69 y/osuspect ovarian CA


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Screening?

The US Preventive Task Force does NOTrecommend using CA-125 as a screening toolfor ovarian cancer.

Also no evidence to support transvaginalultrasonography for screening.

These tools should only be utilized for high-riskindividuals or those with a positive H&P.


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Workup

Complete H&P

Pelvic exam and pap smear

CBC

UA CA-125

Comprehensive Metabolic Panel

CXR

IVP/Barium Enema or CT with contrast

Pelvic US


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Surgical Therapy in Ovarian Cancer

TAH/BSO with removal of as much of tumor as possible

Lymph node biopsies

Omentectomy

Based on spread of disease, surgeon will remove anyobvious tumor and biopsy various sites throughabdomen and pelvis (peritoneum, omentum, diaphragm)

Adjunct therapy (radiation/chemo) based on post-oppathologic diagnosis and staging


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Any serous questionomas?

adnexal masses donato

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