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Adnexal masses Flashcards

1
Q

What is the differential diagnosis of gyn-related adnexal masses?

A

BENIGN
Functional cyst
Endometrioma
TOA
Mature teratoma
Serous cystadenoma
Mucinous cystadenoma
Hydrosalpinx
Paratubal cyst
Fibroids
Ectopic pregnancy
Mullerian anomalies

MALIGNANT
Epithelial carcinoma
Germ cell tumor
Metastatic cancer
Sex cord or stromal tumor

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2
Q

What is differential diagnosis of non-gyn adnexal masses?

A

Benign: diverticular abscess, appendicel abscess, ureteral diverticulum, pelvic kidney, bladder diverticulum
Malignant: GI cancers, metastatic cancers

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3
Q

What are personal risk factors for malignancy for adnexal masses?

A

Age=most important
Personal RF=strong fam hx or breast or ovarian cancer
Nulliparity, early menarche, late menopause, white race, primary infertility, endometriosis.

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4
Q

What decreases the risk of ovarian cancer?

A

> 5 yr use of OCP
pregnancy <25
lactation
tubal ligation
risk-reducing BSO
removal of fimbrial ends

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5
Q

What is the differential diagnosis of bilateral adnexal masses?

A

germ cell tumors (5-10%)
fibromas (10%)
serous carcinoma (66%)
mucinous carcinoma (20%)
krukenberg (100%)
endometriomas
theca lutein cysts
TOA

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6
Q

How do you assess the risk of ovarian cancer?

A
  1. Multivariate index assay (qualitative serum tumor marker panel)- incorporates 5 serum biomarkers into score (CA-125, transferrin, prealbumin, apolipoprotein a1, b2 macroglobulin)
  2. ROMA: Risk of ovarian malignancy algorithm
    - Ca-125, human epidiymal protein 4, menopausal status). Multimodal tests are algorithms that incorporate serum markers, clinical information and US findings.
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7
Q

At what age do you perform an elective oophorectomy at the time of hysterectomy?

A

Traditionally was age 65. Updated Markov model says age 50 and older. Initiating estrogen in those who needs BSO before age 50, adding estrogen. Hysterectomy and BSO after age 50 confers the same survival to age 80 years as performing hyst alone before age 50.

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8
Q

What are causes of elevated Ca-125?
What values are abnormal for pre and post-menopausal women?

A

Epithelial ovarian cancer
Endometriosis
Pregnancy
PID
Non-gyn cancer (Breast, lung, pancreatic cancers)
Values considered abnormal: post-menopausal>35 and pre-menopausal>200

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9
Q

What are types of ovarian cancer?

A

Type 1 Epithelial cancer: Serous (CA-125), Mucinous adenocarcinoma (CEA), Endometrioid (Ca-125), Clear cell (Ca 125), Brenners

Type 2 epithelial cancer: high-grade serous, undifferentiated carcinoma, carcinoma (most originate in fallopian tube epithelium)

Sex-cord stromal: granulosa cell (Estrogen), fibroma, thecoma, lipid cell, sertoli leydig (testosterone), gynaddroblastoma

Germ cell: mature teratoma, immature teratoma (AFP, CA-125), dysgermimoma (LDH), gonadoblastoma, embryonal carcinoma (AFP, HCG), endodermal sinus (AFP)
Mixed-cell type

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10
Q

US findings suggestive of malignancy?

A
  • Cyst size >10
  • thick separations (>2-3mm) or complex architecture
  • irregular wall or nodularity
  • bilateral cysts
  • high color flow on doppler assessment
  • solid and cystic compomenents
  • presences of ascites on US
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11
Q

Who should you refer to gyn onc?

A

1 or more of following criteria:
- postmenopausal with elevated Ca-125, US findings suggestive of malignancy, ascites, nodular/fixed pelvic mass, evidence of abdominal/distant mets.
- Premenopausal w/ very elevated Ca-125, US findings suggestive of malignancy
Pre or postmenopausal w/ elevated score on formal risk assessment test.

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12
Q

What are considerations for evaluation/management of adnexal masses in adolescents?

What tumor markers should you order?

A

Prioritize ovarian conservation to preserve fertility. Usually benign, often expectant management. Do menstrual history, question sexual activity, transabdominal US. can odo simple cystectomy. Elevation in Ca-125 can occur w/ ovarian malignancies but also w/ non-communicating uterine horns, ovarian fibromas, or torsed adnexa.

physical exam: palpate mass: smooth, nodular, tender, mobile etc.

  • AFP (endodermal sinus)
  • b-hcg (pregnancy)
  • LDH (dysgermimoma) are indicated for evaluation of suspected germ cell tumors.
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13
Q

What to do if malignancy is identified at time of surgery?

A

Remove tumor without spilling contents, sparing fallopian tube if not adherent, harvest ascites for cytology, examine/palpate omentum w/ biopsy or remove suspicious areas, examine iliac vessels.

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14
Q

When is aspiration of adnexal mass appropriate?

A

If TOA (failed antibiotic therapy)
- benign simple cysts (recurrence rate 44% for pre-menopausal, less for post-menopausal)
- suspected advanced cancer for which neoadjuvant therapy is planned. Otherwise contraindicated if suspicion for cancer!

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15
Q

What is the recommended management for mature teratomas and endometriomas?
When would you do surgery?

A

Surgery if large, symptomatic, or growing on imaging. Expectant management an option. Surgical excision of endometriomas can adversely affect ovarian reserve so asymptomatic ones DO NOT require intervention for infertility. If pt requires surgery, conserve as much ovarian tissue as possible.

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16
Q

What are US findings suggestive of torsion?

A
  • unilateral ovarian enlargement
  • ovarian edema (hyperechogenic ovary w/ peripherally displaced follicles
  • free fluid
  • coiled vascular pedicle–WHIRLPOOL SIGN),
17
Q

Diagnosis and Initial Evaluation of Primary Ovarian insufficiency?

A

Menstrual irregularity for at least 3 consecutive months. FSH and estradiol (2 random tests at least 1 month apart, fsh>25), prolactin and TFTs.

If diagnosis confirmed: karyotype, FMR1 premutation (Fragile X), adrenal antibodies (Addison’s disease), pelvic US

18
Q

Causes of POI?

A
  • chromsomal anomalies (gonadal dysgenesis like Turner’s)
  • fragile X
  • chemo/radiation therapy
  • hypoPTH and hypoadrenal
  • infiltrative/infectious
  • pelvic surgery.
19
Q

What is evaluation and management of cystic mass?

A

pelvic exam and rectal exam if indicated
rule out pregnancy!!
- ultrasound characterization:

20
Q

How would you manage a patient with ovarian cyst removal and frozen was borderline?

A

Unilateral salpingo-oophorectomy, peritoneal washings, pelvic exploration and biopsy of abnormal areas.
- If done w/ childbearing: TAH, BSO

  • if cancer on final pathology: refer to gyn-onc to complete proper staging procedure.
21
Q

What is the differential diagnosis for an adnexal mass in pregnancy?

A

Benign mass without complex features: generally functional cysts, can be serous or mucinous cyst adenoma or hydrosalpinx.

  • Benign mass w/ complex features: corpus luteum mature cystic teratoma, multilocular cyst adenoma, hydrosalpinx w/ separations, endometriomas, theca lutein cysts
  • Solid masses: pedunculate leiomyoma, germ cell tumors, stromal tumors
  • Epithelial ovarian tumors
22
Q

What is management of adnexal mass in pregnancy?

A

simple unilateral cyst can be observed - often regresses during pregnancy

complex cyst should be re-evaluated at 17-18 wks

most adnexal masses have low risks of malignancy and can be managed expectantly. operation safest for fetus in mid-second trimester (after 18wks).

**Dysgermimoma accounts for 75% of malignant germ cell tumors diagnosed during pregnancy. bilateral 10-15% of the time. Need intra-op gyn onc. Need USO, pelvic washings, inspect for further spread.

23
Q

What is differential diagnosis of a solid pelvic mass in any age group?

A
  1. Pedunculated/subserosal uterine leiomyoma
  2. cornual/interstitial pregnancy
  3. Fallopian tube mass - carcinoma, ectopic
  4. Bowel masses: appendicitis/abscess, diverticulitis, colon cancer
  5. Other masses: pelvic hematoma, retroperitoneal neoplasm.

Need: pelvic exam, TVUS, CA-125.
REMOVE MASS INTACT.

exam findings worrisome: irregular contour, limited mobility/fixed, ascites or free fluid on US.

24
Q

What are age-specific considerations for solid mass?

A

Age 20-30: exclude pregnancy. Possibly germ cell, benign teratoma or fibroma/thecoma/benner. low chance malignancy.

Age 40-50: exclude pregnancy. teratoma less likely. chance of malignancy 1%. tumor markers: Ca-125, CEA, Ca 19-9, inhibin A/B (granulose cell)

Age 50+: suspect malignancy.

Adolescents: exclude pregnancy/ectopic, infection (TOA), torsion. Persistent complex masses: mature teratoma, immature teratoma, endometrioma. Solid masses malignant until proven otherwise. Get HCG, AFP, LDH.
- germ cell tumor (dysgermimoma), sex-cord stromal tumor (granulosa cell, sertoli-leydig cell).

25
Q

Walk through 16 y/o w/ sharp RLQ pain and N/V. Differential and management?

A

Differential: torsion, appendicitis, ECTOPIC PREGNANCY, PID, muscle strain/pull, GI pathology, pregnancy w/ corpus lutes cyst.

eval: H&P, CBC, HCG, pelvic US.
torsion usually w/ teratoma or benign functional cyst. intermittent pain, non-radiating, N/V. surgical diagnosis.
surgery: minimally invasive, detorsion and preservation of adnexal structures regardless of appearance of ovary. DO NOT remove tossed ovary unless oophorectomy is unavoidable (necrotic).

26
Q

How do you counsel for pt desiring elective BSO?

A

if need hyst for benign condition, in absence of ovarian pathology or familial cancer syndrome, ovarian conservation with elective salpingectomy recommended.
- oophorectomy reasonable for pts >51 who place higher priority on ovarian/breast cancer prevention than risk of mortality and CVD. If oophorectomy, need estrogen therapy until age 51-52 to prevent adverse effects.

  • Risks: oophorectomy before age 55 incr cardiovascular disease risk: MI, CVA, cognitive impairment, dementia, CKD, osteoporosis, all-cause mortality, sexual dysfunction. Need for estrogen therapy and risks associated w/ longterm use.
  • benefit: reduce lifetime risk ovarian and breast cancer, reduce problems related to ovaries (pain, ovarian masses)
27
Q

How do you counsel pt w/ 6cm pelvic mass and BRCA positive?

A

incr risk ovarian cancer.
BRCA1 40-45%
BRCA2 10-25%
prophylactic BSO by age 40
- if mass is benign, benefit from BSO is reduction in lifetime risk of ovarian, fallopian tube and peritoneal cancer of 85%.

28
Q

s/p cystectomy, path w/ low-malignant potential tumor.
How would you counsel the patient? What is her prognosis?

A

Good prognosis. Stage 1 99% 5-year survival.
Unilateral salpingo-oophorectomy. Risk of recurrence 7-30%. Recurrence usually borderline.

29
Q

What staging procedure is recommended with a borderline tumor?

What tumor markers and adjuvant therapy are endorsed?

A

Complete staging: TAH, BSO, peritoneal washings, omentectomy, tumor debulking.
If desired fertility: more conservative. Unilateral SO, omental biopsy, peritoneal lesion biopsy.
If borderline mucinous: appendectomy.

No need for tumor marker. Q6mo surveillance w/ TVUS.
Chemo rarely indicated.

30
Q

What ultrasound findings are suggestive of benign disease?

A

Unilocular
Thin-walled
Sonolucent
Smooth, regular borders
<10cm
Homogeneous
No solid component, excrescences, papillations

31
Q

What is lifetime risk of ovarian cancer with Lynch syndrome?

A

5-10% by age 70

32
Q

What are ultrasound findings for dermoid (mature cystic teratoma)?

A

contain least two of the three germ cell layers (i.e. ectoderm, mesoderm, and endoderm

  • echogenic mass
  • hyperechoic Rokitansky nodule (dermoid plug) - solid protuberance projecting from an ovarian cyst in the context of mature cystic teratoma. It often contains calcific, dental, adipose, hair

mermaids can be bilateral 10% of the time

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