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Adnexal Masses Flashcards

1
Q

What Ultrasound Findings suggest Malignancy?

A
  • Size > 10 cm
  • Papillary or solid components
  • Irregularity
  • Presence of ascites
  • High color doppler flow
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2
Q

What is the most important risk factor that suggests Malignancy?

A

AGE! Median age for ovarian cancer diagnosis is 63

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3
Q

List risk factors for malignant adnexal mass

A

AGE!

Family Hx of Br or Ov Ca Nulliparity

Early menarche, late menopause

White race

Primary infertility

Endometriosis

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4
Q

Ultrasound findings that suggest benign disease

A

Simple appearance

Thin smooth walls

Absence of solid components, septations, or internal blood flow on color doppler

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5
Q

Work up of Adnexal Mass

A
  • UPT
  • CBC, GC/CT if infectious symptoms
  • Consider Serum Marker Testing: CA-125 most useful in post menopausal women. Only get if concerning imaging features!
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6
Q

What type of cancer is CA-125 useful in detecting?

A
  • Non-mucinous epithelial cancer
  • Elevated in 80% of patients with epithelial ovarian cancer
  • Only 50% with Stage I disease
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7
Q

What non-cancerous conditions can cause elevations in Ca-125?

A
  • Endometriosis
  • Pregnancy
  • PID
  • Non-Gyn Cancer
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8
Q

Level of Ca-125 in postmenopausal women suggesting malignancy?

A

> 35

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9
Q

Level of Ca-125 in premenopausal women suggesting malignancy?

A

> 70-80 (use to be 200)

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10
Q

List types of epithelial tumors (6)

A
  • Serous
  • Mucinous
  • Clear cell
  • Endometrioid
  • Brenner
  • Cystadenofibroma
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11
Q

Ca-125 is rarely elevated in which epithelial ovarian tumor? Which tumor marker is usually elevated?

A
  • Mucinous Tumor
  • Ca-124 is rarely elevated
  • CEA elevated
  • Grow very large!
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12
Q

Which epithelial tumor is associated with a history of endometriosis and “hobnail cells” on pathology?

A

Clear Cell

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13
Q

List the types of sex-cord stromal tumors (4)

A
  1. Granulosa
  2. Cell Fibroma
  3. Thecoma
  4. Sertoli-Leydig
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14
Q

Which tumor has elevated Estrogen, and elevated Inhibin?

A

Granulosa Cell

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15
Q

Which Ov Ca is associated with PMB, endometrial cancer?

A

Granulosa Cell Tumor

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16
Q

Which Ov Ca is associated with Call-Exner bodies and coffee bean nuclei?

A

Granulosa Cell

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17
Q

Which sex cord stromal tumor is benign, is not hormonally active?

A

Fibroma

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18
Q

What is Meigs Syndrome?

A
  • Fibroma
  • Ascites
  • Pleural Effusions
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19
Q

Most hormonally active sex cord stromal tumors?

A

Thecomas - androgens (From theca cells)

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20
Q

Which sex cord stromal tumor produces estrogen and testosterone production?

A

Sertoli-Leydig

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21
Q

List the types of Germ Cell Tumors (7)

A

Dysgerminoma

Mature Teratoma

Immature Teratoma

Endodermal sinus/Yolk Sac tumor

Choriocarcinoma

Embryonal Carcinoma

Mixed Germ Cell

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22
Q

Elevated AFP, Schiller-duval bodies, rapid growing adnexal mass

A

Endodermal sinus/Yolk Sac tumor

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23
Q

Elevated bHCG, Syncytio & cytotrophoblasts

A

Choriocarcinoma

24
Q

Elevated AFP, LDH, CA125 Immature neural tissue (small round blue cells in rosettes/tubules)

A

Immature Teratoma

25
If Adnexal mass \< 8 cm, and pt is premenopausal, what is your next step in management?
Repeat pelvic exam and imaging in 1-2 months
26
What is the differential diagnosis for adnexal mass?
Epithelial ovarian cancer, germ cell tumor, sex cord stromal tumor, functional cyst, dermoid, endometrioma, TOA, serous or mucinous cystadenoma
27
List the sex cord stromal tumors, and their hormones usually produced
Granulosa cell = estrogenic Theca Cell = estrogenic Sertoli-Leydig = androgenic Symptoms \> mass, precocious puberty, irregular menses, virilization
28
Pt reproductive age Acute onset pelvic pain
Hemorrhagic cyst Ectopic pregnancy If unilateral/intermittent \> ovarian torsion
29
Pt w/ Indolent progressive pelvic pain Fevers Chills Vomiting Abnormal Discharge
Tubo Ovarian Abscess
30
Pt w/ acute/chronic dysmenorrhea Dyspareunia
Endometrioma
31
Pt w/ bloating Generalizeda abdominal pain Early satiety
Consider malignancy
32
Pt w/ pelvic mass AUB or PMB
Likely due to estrogen produced by sex cord stromal tumors
33
Elevated B-hCG + LDH
Dysgerminoma **Most common germ cell tumor! Usually women < 30 yo**
34
Elevated AFP
Endodermal sinus tumor **Second most common germ cell tumor** Median age = 18 years
35
Elevated AFP, LDH, CA125
Immature Teratoma
36
Elevated BhCG, AFP
Embryonal carcinoma
37
10 cm SIMPLE cyst in postmenopausal patient - next step in management?
Observation and repeat ultrasound in 6 months In large prospective study of (2,763 women) with unilocular cysts up to 10 cm were evaluated at 6 month intervals. Spontaneous resolution occurred in 69% of women, and no cases of cancer were detected after a mean follow-up of 6.3 years ***If imaging shows septations, papillary projections, thick walled borders, or cystic and solid components, these should be further assessed and worked up as the chance of malignancy is higher. (Get tumor markers)
38
What is the lifetime ovarian/tubal/peritoneal cancer risk for a patient with BRCA1 mutation?
40% by age 70
39
What is the lifetime risk of ovarian/tubal/peritoneal cacner in a patient with BRCA2 mutation?
20% by Age 70
40
What is the lifetime risk of ovarian cancer for women with Lynch Syndrome?
5-10% by Age 70
41
What percentage of patients with Stage I ovarian epithelial cancer have elevated CA-125?
Only 50%!
42
When should you refer to Gyn Onc for adnexal mass?
Postmenopausal + elevated CA125 Premenopausal + elevated CA125, US findings concerning for malignancy
43
Surgical management w/ excision of endometrioma can result in pregancy rates of...
56-65% (compared to 23.4% with just incision and drainage)
44
What is the recurrence rate of an endometrioma?
25%
45
When should an endometrioma be surgically removed?
Large (>/= 4 cm) Symptomatic = having pain Is looking to increase fertility (excision has better pregnancy rates than incision/drainage/ablation) **Drainage has a recurrence rate of 80-100% at 6 month follow up
46
US Findings: Unilocular, hypoechoic cyst with diffuse low-level echos and ground glass appearance.... what is it?
Endometrioma
47
Differential diagnosis for solid ovarian mass?
Pedunculated fibroma Thecoma Fibroma Brenner tumor Granulosa cell tumor Dysgerminoma
48
Differentia diagnosis for a cystic tumor?
Function cyst Serous and mucinous tumors Dermoid Endometrioma Paratubal cyst
49
False positive elevated CA-125?
Anything that inflames the pelvis Appendicitis PID Endometriosis Cholecystitis Diverticulosis IBD SLE Ascites
50
What is highest on differential for extremely large ovarian tumor?
Likely benign mucinous cystadenoma
51
Management of postmenopausal woman with simple cyst < 10 cm and normal CA-125?
Observation
52
When can endometriomas be observed?
If < 3 cm
53
When can mature cystic teratomas be observed?
If < 4 cm
54
Young nulliparous patient is found to have a dysgerminoma.... how would you treat?
Unilateral salpingo-oophorectomy, limited staging Follow w/ serial LDH, HcG
55
Treatment for granulosa cell tumor?
Surgery alone for most patients. Majority are Stage IA at diagnosis, and confined to one ovary
56
How accurate is frozen section?
Agreement between frozen section and final pathology is as low as 55%
57
How would you manage a borderline tumor?
Consult gyn oncologist If unavailable, I would perform a cystectomy or unilateral salpingo-oophorectomy Inspect the rest of the abdomen! This is usually adequate treatment in someone with a low malignant potential and desire to preserve fertility Chemo/radiation unlikey to improve the outcome Yearly pelvic exams and U/S If recurrs, highly curable by re-operation/resection If she has completed childbearing I would discuss removal of the other ovary tube and uterus weighing the issue of recurrence with menopausal issues

Oncology (9 decks)

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