adnexal disorders Flashcards
incidence of ovarian cysts
-aprrox 80% of women will be dx with ovarian cyst if they have US of pelvis
why are adnexal masses important
-They are common
-can rupture, potentially causing hemorrhage
-can lead to ovarian torsion
-cause pain or be silent
-can represent a physiologic, pathologic or malignant process
-often, the issue is for the clinician to decide if the mass is benign or malignant
ultrasound
-initial study with almost all obgyn processes
-Transvaginal US of pelvis is best initial test for adnexal mass
-On U/S:
-Black=fluid
-White=solid structures (bone, etc.)
-Gray=varies; cystic to solid structures
-can also determine if absent, normal, or abnormal blood flow to the adnexa
types of benign adnexal masses
-functional cysts
-corpus luteum cysts
-endometriomas
-tubo-ovarian abscesses
-mature teratomas
nongynecologic diff dx of adenexal masses
-BENGIN:
-diverticular abscess
-appendiceal abscess
-mucocele
-nerve sheath tumors
-ureteral diverticulum
-pelvic kidney
-paratubal cyst
-bladder diverticulum
-MALIGNANT:
-gastrointestinal CA- krukenburg tumor
-retroperitoneal sarcoma
-metastatic ds
A morbidly obese 30 yo G0, LMP 2 weeks ago, presents to the ED with dizziness and intermittent paresthesia of bilateral upper extremities and chest. She also reports a 50# weight gain over the past year.
She attributes the weight gain to having worked as a manager at McDonald’s for last 6 months.
On physical exam, a large abdominal mass measuring 59 cm (from superior to inferior borders) is noted.
CT scan (ordered by ED physician) shows the following, which is noted to arise from the R ovary.
Because of the finding, the ED physician requested a consult from the Gynecology service.
-Mucinous cystadenoma- benign ovarian tumor
-pt underwent laparoscopic drainage of mass and resection of cyst wall and was discharged to home
functional ovarian cysts
-often found incidentally
-resolve within 6wks
-May be symptomatic, especially if rupture -> unilateral lower quadrant pain
-granulosa cells of ovarian follicle occasionally cont to function after ovulation should occur
-Granulosa cells produce estrogen -> abnormal bleeding
-cysts grow to ab 5 cm, and may fill w/ fluid
-abdominal pain, abnormal menstrual cycle
-estrogen can cause abnormal bleeding
-US -> simple cyst with no solid components or septations
-picture- benign
-Tx:
-Manage expectantly
-If ruptures -> usually only pain meds are required
-If persists -> must be re-evaluated and possibly removed
-Hormonal contraceptives often prevent formation of other cysts and may be used if desired (does not affect ones already there)
corpus luteum cysts
-Occur after ovulation
-Progesterone production by the theca cells may delay onset of menses
-May cause unilateral lower quadrant pain
-Often, there is a palpable and tender adnexal mass
-Must r/o ectopic gestation by obtaining UCG
-Pts generally do not have hx of current hormonal contraceptive use
-Ruptured corpus luteum cysts can cause significant hemorrhage
-May require surgery
-Otherwise, manage with analgesics (very painful)
-pic- ring of fire sign on R. due to doppler imaging
endometriomas
-Ovarian endometriosis
-May partially or completely replace normal parenchyma
-Thick-walled structures with brown fluid resembling chocolate syrup (“chocolate cysts”)
-Usually <15 cm in diameter
tubo-ovarian abscess
-complication of PID
-adnexal abscess forms
-Requires surgical or drainage via interventional radiology
mature cystic teratomas (dermoid cysts)
-MC form of ovarian teratoma
-Arise from ectodermal, mesodermal, and endodermal derivatives
-Usually occur in patients of reproductive age, but may be discovered at any age
-Usually benign, but 1-2% undergo malignant transformation
-Complications:
-Ovarian torsion
-Rupture
-Infection
-Autoimmune hemolytic anemia due to contents of teratoma (exceedingly rare)
-Malignant transformation
incidence of ovarian neoplasms and CA
-5-10% of AFAB pts will have surgery for an ovarian mass
-Within this group there is 20% chance of having ovarian CA dx at that time
repeat US in pts with adnexal masses
-Repeat US is probably indicated in pts with:
-Functional cysts
-Endometriomas with normal or elevated but stable CA-125 levels
-Hydrosalpinges
-Simple cysts
-Usually repeat in 2-3 menstrual cycles, but depends on pt -> aim for week after period
A 53 yo G1P0010 LMP 2 years ago with history of Stage 3 breast CA diagnosed 5 years ago presents with incidental finding of complex L adnexal mass 4 months ago that was found to have increased in size by repeat ultrasound 2 weeks ago.
The mass is now 6.6x3.2x4.4 cm in size.
The patient admits to bloating and pelvic pain. She refuses physical examination or phlebotomy for tumor markers.
You refer the patient to a gynecologic oncologist for surgical management of the adnexal mass
risk factors for ovarian CA
-Age: most important RF
-Median age at dx = 63yrs
-Ovarian CA is dx in ~70% of pts after age 55
-Family h/o breast or ovarian CA, or both
-Personal h/o hereditary non-polyposis colorectal carcinoma (HNPCC) or Lynch II syndrome
-+BRCA 1 or 2 carrier status
risk reduction for ovarian CA
-Prophylactic oophorectomy
-May be recommended to pts with very strong family hx of ovarian and/or breast CA, or with +BRCA mutation status
-Does not yield 100% risk reduction, however
-Oral contraceptive use
-One study of >100,000 patients found that OC use at any time in life yielded a 40% risk reduction
-Not as effective but still beneficial in patients with known +BRCA status
screening for ovarian CA
-currently, NO recommended screening method for prevention of ovarian carcinoma in average risk pts
-high risk pts may benefit from B/L oophorectomy, or from routine US
PE: Adnexal masses
-PE not highly accurate in identification of adnexal masses
-problematic in obese pts, or pts who cant relax
-fixed, irregular, solid, b/l mass and/or ascites are more worrisome -> not def dx of malignancy
interpretation of US results
-is it:
-Solid, cystic, or complex (partially solid and cystic)?
-Bilateral or unilateral?
-Are there septations?
-Are there excrescences?
-Is there free fluid in the pelvis?
-Is there ascites?
excrescences or papillary projections seen on US
-suggest malignancy
septations seen on US
-suggest malignancy
color doppler US
-Transvaginal US is best initial study to r/o a suspected adnexal mass
-Permits determination of blood flow to ovaries
-Malignant tissue has a higher oxygen demand due to lack of apoptosis and increased cell growth
-A “chaotic” vascular architecture is worrisome for malignancy
-pic- chaotic vascular architecture seen in US of ovarian sarcoma
other studies
-CT or MRI may be used in cases in which ultrasound is not definitive
-Tumor markers: proteins present in blood that are associated with specific malignancies
-Are not diagnostic of malignancy
-Do not determine virulence of malignancy
-Used in assessment of response to treatment and/or progression of disease for an individual patient
tumor markers
-CA-125 is commonly used in the determination of benign versus malignant ovarian processes
-80% of patients with ovarian CA have an elevated CA-125 level
-However, only 50% of Stage 1 ovarian CA patients have an elevated CA-125
-Also may be elevated in pregnancy, leiomyomata uteri, and endometriosis as well as in liver disease
-Consider CA-125 testing to determine additional evidence that a complex mass is benign or malignant
-May be more beneficial in postmenopausal patients
