CONFERENCIA 20010

1. ―Clinical management of adnexal masses”
PROF. SANTIAGO DEXEUS
Dr. Gustavo Missón

2. Introduction
 Adnexal masses are the fourth most
common gynecological cause for
hospitalization and 90% have benign
characteristics.

3. Adnexal Mases USA
ANNUAL HOSPITALIZATION: 289000 PATIENTS
RISK OF
MALIGNANCY
13% in pre menopause
45% in post menopause
L Van Lie (2000)
48 Meeting of the ACOG

4. ADNEXAL MASSES
N= 4.359
October 1991 – October 1999
average: 37.22 years (14-85)
Rate of malignancy: 2.1%
IUDEXEUS-1999

5. ADNEXAL MASSES
Color Doppler
Absence of pathological flow
3.0% Malignant tumor
Kurjak et al,1993
4.2% Malignant tumor
MªA Pascual y col.,1996

6. PRIORITY
 Differential diagnosis
 Diagnostic studies and interpretation
 Management

7. Anatomy
 ―Adnexa‖
› Area next to the
uterus containing
ligaments, vessels,
tubes, ovaries

8. Background
 Prevalence of adnexal masses is 2
to 8%
› Random TVUS of 335 asymptomatic
premenopausal women, 7.8% with
adnexal masses 2.5 cm or larger (6.6%
were ovarian cysts.
› Transvaginal sonographic ovarian findings in a random sample of women 25-40 years old.
Ultrasound Obstet Gynecol 1999 May;13(5):345-50.

9. Background
 Prevalence of adnexal masses is 2
to 8%
› TVUS in 8794 asymptomatic
postmenopausal women, 2.5% were
found to have adnexal cysts
› Alcazar JL; Jurado M. Natural history of sonographically detected simple unilocular adnexal
cysts in asymptomatic postmenopausal women. Gynecol Oncol 2004 Mar;92(3):965-9.

10. Differential Diagnosis
 Physiologic cysts
› Follicle develops but never ruptures, continues to
grow
› Simple, smooth-walled
 Functional cysts
› Corpus luteum does not involute or continues to
grow
 Most are small (<2.5 cm), but can be larger
 Usually no symptoms, unless rupture or torsion

11. Differential Diagnosis
 Ectopic pregnancy
 PID
 Hydrosalpinx
 Benign neoplasms
› Serous or mucinous cystadenoma
› Endometrioma
› Cy.Dermoid
› Fibroids (exophytic, broad ligament)
 Malignancy
› Primary vs. mts

12. Non-Gyn Etiology
 Abdominal
› Appendicitis
› Diverticulitis
› Inflammatory bowel
disease
 Inclusion cysts
› Peritoneal or omental
 Retroperitoneal
masses
› Pelvic kidney

13. Diagnosis: History
 History
› Pain
 Midcycle physiologic or functional cyst
 Dysmenorrhea/dyspareunia endometriosis
 Sudden onset, severetorsion, rupture, hemorrhage
 Chronic aching, bloatingneoplasm
› Nonspecific GI symptoms
 May suggest ovarian cancer in postmenopausal female
 May suggest appendicitis or GI etiology in younger
women
› FH
 Breast, colon, or ovarian cancer

14. Diagnosis: Physical Exam
 Physical exam—should include bimanual
and rectovaginal exam
› Fever PID, appy, diverticulitis
› Shouldn’t be able to palpate a
postmenopausal ovary
› Cul de sac nodularity, tender ligaments
endometriosis
› Cervical motion tendernessPID
› Fixed, irregular, solid may suggest neoplasia

15. Diagnosis: Physical Exam
 Will probably need more than an H&P
to make a diagnosis
› 84 women underwent pelvic examination
prior to surgery, blinded to surgical
indication
› Attending, resident, student examined
patient
› Padilla L, Radosevich D, Milad M. Limitations of the pelvic examination for evaluation of the
female pelvic organs . Int J of Gyn 2005; 88 (1): 84 – 88.

16. Diagnosis: Physical Exam
› Exam is a ―limited screening tool‖ for
detection of adnexal masses
› Sensitivity at detecting adnexal masses: p
>0.04

17. Diagnosis: Labs
 Labs
› β-HCG to exclude ectopic
› RPC if infection suspected
› Tumor makers
 CA-125 (more to come)
 Others useful in adolescents/premenopaual
women with adnexal masses and high
suspicion
 LDHDysgerminoma
 HCGchoriocarcinoma
 AFPEndodermal sinus tumor

18. Malignancy
 Postmenopausal
› Roughly 50 per 100,000 women, relative risk of ~3.5
› 80% of ovarian cancers occur in women over 50
 Family history
 Symptoms
› Vague, chronic aching, bloating, +/- GI symptoms
 Physical examination
› Remember. . . Not really useful
 Ultrasound findings
 CA-125

19. Family History
 Lifetime risk of ovarian cancer in
general population 1.5%
› In BRCA 1 carrier 45-55%
› In BRCA 2 carrier 15-25%
 Not all mutations have been identified
› Two to three relatives with ovarian cancer
increases lifetime risk to 5% (15% if first
degree relatives)
› Carlson KJ; Skates SJ; Singer DE. Screening for ovarian cancer. Ann Intern Med 1994 Jul 15;121(2):124-32.

20. CA-125
 Not specific to ovarian cancer, also elevated
in:
 Other cancers (endometrial, fallopian tube, germ
cell, cervical, pancreatic, breast, colon)
 Benign conditions
(endometriosis, fibroids, PID, adenomyosis, functional
ovarian cysts, pregnancy)
 Other diseases (renal, heart, liver, and many others)
 Also abnormal in 1% of normal females
 Bast R; Klug T; St John E; Jenison E; Niloff J; Lazarus H; Berkowitz R; Leavitt T; Griffiths C; Parker L;
Zurawski V; Knapp R. A radioimmunoassay using a monoclonal antibody to monitor th
 course of epithelial ovarian cancer. N Engl J Med 1983 Oct 13;309(15):883

21. CA-125
 Normal value <35
› Rarely >100-200 in benign conditions

22. CA-125
 Utility as screening tool for ovarian cancer
› CA-125 increased in roughly 80% of ovarian cancers
› About 50% sensitivity for Stage I, 90% for Stage II
 Study of 5550 healthy Swedish women
› Followed women with elevated and normal CA-125
levels
› Serial pelvic exams, U/S, serial CA-125 levels
› Of 175 women with elevated CA-125, 6 with ovarian
cancer
› Of the remaining women with normal CA-125
levels, 3 had ovarian cancer
› Einhorn N; Sjovall K; Knapp RC; Hall P; Scully RE; Bast RC Jr; Zurawski VR Jr. Prospective evaluation of serum CA 125
levels for early detection of ovarian cancer. Obstet Gynecol 1992 Jul;80(1):14-8.

23. CA-125 (follow)

24. BIOMARKERS
› Ca 125
› Ca 19.9
› Ca 15.3
› BCGH
› Alpfa-phetoprotein
› HE-4

25. Ultrasound
Simple cyst
› Less than 2.5 cm
› Unlikely malignant
› Probably a follicle
Homogeneous
appearance may
suggest
endometrioma
www.uptodate.com

26. Ultrasound
 Features suggestive
of malignancy:
› Solid component
› Doppler flow
› Thick septations
› Size
› Presence of ascites or
other peritoneal
masses

27. Ultrasound: The DePriest Score
De Priest PD, Shenson D, Fried A, Hunter JE, Andrew SJ, Gallion HH, et al A morphology index based on sonographic
findings in ovarian cancer. Gynecol Oncol. 1993 Oct;51(1):7-11
 Morphology index
 U/S on 121 patients who
underwent exlap
 Morphology score <5
(80)all benign, 100% NPV
 Morphology score >10 (5)
all malignant, 100% PPV
 Morphology score ≥ 5, 45%
PPV for malignancy
(but, PPV only 14% for
premenopausal women)
 There are other
morphology indices—this is
not the only one

28. So now what?
Management
 Premenopausal females
› If size <10 cm, mobile, cystic,
unilateralfollow, place patient on
monophasic OC, repeat U/S in 2-3 months
 70% of these will resolve8
› If size >10 cm, fixed, solid, or other
concerning featurestake it out
› If mass persists or enlarges at repeat
scantake it out

29. What about the Postmenopausal
Female?
 Modesitt study9
› 15,106 asymptomatic women over 50 who underwent TVUS
› If no abnormalitiesannual screening
› If abnormalrepeat U/S in 4-6 weeks with Doppler and CA-125
› 18% with unilocular ovarian cysts <10 cm in diameter
 69.4% resolved
 5.8% developed solid component
 16.5% developed septum
 6.8% persisted as unilocular
› 10 patients with unilocular lesion who developed ovarian cancer, all
of whom either:
 developed a septum or solid component on U/S,
 underwent complete resolution of the cyst,
 or developed cancer in the contralateral ovary
› Thus. . . The risk of developing ovarian cancer in a woman with a
unilocular, small cyst is VERY low (0.1%)

30. Management
 Postmenopausal
› If asymptomatic, normal exam, simple cyst on U/S, normal
CA-125,unilateral, ≤ 5 cm
 follow with serial U/S and CA-125 q 3-6 months until 12 months,
then annually thereafter
› If above except complex appearance and ≤ 5 cm
 Repeat U/S and CA-125 in 4 weeks
 Resolution
 Persistence or decreasing complexityfollow q 3-6 months with U/S
and CA-125
 Increasing CA-125 or increasing complexitysurgery
› If complex, ≤ 5 cm, and elevated CA-125
 Take it out
› If symptomatic, ≥ 5 cm, clinically apparent, non-simple in
appearance, or elevated CA-125take it out.

31. Management Algorithm (there are many of these)
Van Nagell, JR, et al. Am J of Obstet & Gynecol 2005:193,30-35

32. ADNEXAL MASSES
Anatomical Pathology in surgery
Biopsy of peritoneal implants
Biopsy of growths ovarian / tubal
Cystectomy / oophorectomy
Concordance with definitive biopsy > 95%

33. When should I refer to an
oncologist?
ACOG Guidelines:
 Premenopausal (< 50 Years Old)
› CA-125 > 200 U/mL
› Ascites
› Evidence of abdominal or distant metastasis (by exam or imaging
study)
› Family history of breast or ovarian cancer (in a first-degree relative)
 Postmenopausal (>= 50 Years Old)
› CA-125 > 35 U/mL
› Ascites
› Nodular or fixed pelvic mass
› Evidence of abdominal or distant metastasis (by exam or imaging
study)
› Family history of breast or ovarian cancer (in a first-degree relative)
ACOG Committee Opinion: number 280, December 2002. The role of the generalist
obstetrician-gynecologist in the early detection of ovarian cancer. Obstet Gynecol 2002;100:1413–6

35. Thank you by you attention
www.santiagodexeus.com