#174 Evaluation and Management of Adnexal Masses Flashcards
What is the differential diagnosis of an adnexal mass with Benign Gyn Origin?
Functional cyst, endometrioma, TOA, mature teratoma, serous cystadenoma, mucinous cystadenoma, hydrosalpinx, paratubal cyst, leiomyomas, mullerian anomalies
What is the differential diagnosis of an adnexal mass with malignant gyn origin?
Epithelial carcinoma, germ cell tumor, metastatic cancer, sex-cord or stromal tumor
What is the differential diagnosis of an adnexal mass with benign nongynecologic origin?
Diverticular abscess, appendiceal abscess or mucocele, nerve sheath tumor, ureteral diverticulum, pelvic kidney, bladder diverticulum
What is the differential diagnosis of an adnexal mass with malignant nongynecologic origin?
Gastrointestinal cancer, retroperitoneal sarcomas, metastatic cancer
What is the most important independent risk factor for ovarian cancer in the general population?
Age
What is the median age at ovarian cancer diagnosis?
63yo
What percent of patients diagnosed with ovarian cancer are 55+yo?
69.4%
What is the most common diagnosis for an adnexal mass in a postmenopausal woman?
Benign neoplasms such as cystadenomas
What is the most important personal risk factor for ovarian cancer?
Strong family history of breast or ovarian cancer
What is the general population lifetime risk of ovarian cancer?
1.6%
In woman with BRCA1 mutation, what is the lifetime risk of ovarian, fallopian tube, or peritoneal cancer by age 70?
41-46%
In woman with BRCA2 mutation, what is the lifetime risk of ovarian, fallopian tube, or peritoneal cancer by age 70?
10-27%
What is the risk of ovarian cancer through age 70 for women with Lynch syndrome?
5-10%
What factors increase ovarian cancer risk?
Age, family history, nulliparity, early menarche, late menopause, white race, primary infertility, and endometriosis
What physical exam findings for patient with adnexal mass are concerning for malignancy?
Mass that is irregular, firm, fixed, nodular, bilatera, or associated with ascites
What imaging modality is recommended in initial evaluation of adnexal masses?
Ultrasound
What is the use of CT for patients with adnexal masses?
Used to evaluate abdomen for metastasis when cancer is suspected. Can detect ascites, omental metastases, peritoneal implants, pelvic or periaortic lymph node enlargement, hepatic metastases, obstructive uropathy, possible alternate primary cancer site
In patients with adnexal mass, what is MRI used for?
Helpful in differentiating the origin of pelvic masses that are not clearly of ovarian origin. Has lower detection rate for adnexal masses than ultrasound, but may be superior at classifying as malignant
What conditions can cause elevated CA 125?
Epithelial ovarian malignancy, endometriosis, pregnancy, PID, nongynecologic cancer, SLE, IBD, noncommunicating uterine horns, ovarian fibromas, torsed adnexa
In evaluating adnexal masses, when is CA 125 most useful?
In identifying nonmucinous epithelial cancer in postmenopausal women
CA 125 is elevated in what % of women with epithelial ovarian cancer? What % with stage 1 disease?
80% with epithelial ovarian cancer, but only 50% with stage 1 disease
What biomarkers are associated with ovarian histopathology?
CA 124, beta hcg, LDH, AFP, inhibin
Which serum biomarkers are elevated in dysgerminomas?
beta hcg and LDH
Which serum biomarkers are elevated in endodermal sinus tumors?
AFP
Which serum biomarkers are elevated in choriocarcinoma?
beta hcg
Which serum biomarkers are elevated in an immature teratoma?
AFP, LDH, CA 125
Which serum biomarkers are elevated in embryonal carcinoma?
beta hcg, AFP
What two FDA approved serum tumor marker panel tests exist to further assess the risk of ovarian cancer in adult women with pelvic masses?
- Multivariate index assay, a qualitative serum tumor marker panel
- Risk of Ovarian Malignancy Algorithm
What does the multivariate index assay include (tumor marker panel to assess for risk of ovarian malignancy)?
CA 125 II, transferrin, transthyretin [prealbumin], apolipoprotein A-1, and beta 2-microglobulin
What does the Risk of Ovarian Malignancy Algorithm include?
CA 125, human epididymis protein 4, and menopausal status
Does ultrasound have good positive predictive value for cancer for adnexal masses?
No, especially in premenopausal women
What ultrasound findings suggest malignancy in adnexal mass?
Cyst size >10cm, papillary or solid components, irregularity, presence of ascites, and high color Doppler flow
What ultrasound findings suggest benign disease in adnexal mass?
Simple appearance: thin, smooth walls; absence of solid components, septations, or internal blood flow on color Doppler US imaging.
True or false: simple cysts greater than 10cm will often spontaneously regress when examined with serial ultrasound?
True
What ovarian cyst size is often considered to be an indication for surgery?
10cm
What is the malignancy rate for simple ovarian cysts?
0-1% regardless of menopausal status or cyst size
What are the typical ultrasound findings for endometrioma?
Round homogenous-appearing cyst containing low-level echoes within the ovary
What are the typical ultrasound findings for mature teratomas?
Contain hypoechoic attenuating component with multiple small homogenous interfaces
How do hydrosalpinges appear on ultrasound?
Tubular-shaped sonolucent cysts
At what CA 125 level should a premenopausal paitent with adnexal mass be referred to gyn onc?
Expert opinion is threshold of greater than 200U/mL for referral
What is the overall sensitivity of CA 125 testing in distinguishing benign from malignant adnexal masses?
61-90%
What tumor markers are elevated with granulosa cell tumors?
Estrogen and inhibin
In which patients would you suspect a granulosa cell tumor? (imaging, clinical presentation)
Solid pelvic mass with irregular or postmenopausal bleeding
What biomarker has been found to be more sensitive and specific for evaluation of adnexal masses than CA 125?
Human epididymis protein 4
When is observation recommended for adnexal masses?
When morphology on ultrasound suggests benign disease or when morphology is less certain, but compelling reason to avoid surgical intervention. Asymptomatic woman, normal CA 125.
Are rates of intraoperative ovarian cyst rupture greater for laparoscopic or open cases?
The same
What percentage of women diagnosed with ovarian cancer have advanced disease?
75-80%
What % of adnexal masses in pediatric through adolescent age range that required surgery in specialty care centers, are malignant?
7-25%
Among girls undergoing surgery for adnexal masses, is malignancy more common in pediatric or adolescent population?
Pediatric
What are the most common ovarian malignancies in children and adolescents?
Germ cell tumors
When is aspiration of an adnexal mass appropriate?
TOA (abx is first line) and diagnosis of suspected advanced ovarian cancer for which neoadjuvant therapy is planned (otherwise contraindicated when suspicion for cancer)
Does spillage at the time of surgery affect overall survival of patients with stage I gynecologic cancer compared to patients whose tumors were removed intact?
Yes, decreases overall survival
What percent of patients with ovarian torsion will have ovarian function preserved at 3 months after intervention?
upwards of 90%
When should you operate on a mature teratoma?
If it is large, symptomatic, or growing in size on serial imaging or if malignancy is suspected
Do asymptomatic endometriomas require intervention for infertility?
No
What % of adnexal masses will resolve during pregnancy?
51-92%
What factors predict persistence of an adnexal mass throughout pregnancy?
Size >5cm and “complex” morphology
What is the occurrence rate of acute complications for pregnant women with adnexal masses?
<2%
What is the prevalence of adnexal masses in pregnant women?
0.05-3.2% of live births
What is the most commonly reported pathologic diagnosis for adnexal masses during pregnancy?
Mature teratomas and paraovarian or corpus luteum cysts
What % of pregnant patients with persistent adnexal masses are diagnosed with malignancy?
1.2-6.8%
When should a patient with an adnexal mass be referred to gyn onc?
- postmenopausal with elevated CA 125 and US findings suggestive of malignancy
- premenopausal with very elevated CA 125 and US findings suggestive of malignancy
- Pre or postmenopausal with elevated score on formal risk assessment test or one of the US-based scoring systems from IOTA
How should adnexal torsion in women who want to remain fertile be managed?
Reduction of torsion with concomitant ovarian cystectomy
