Adnexal Masses Flashcards
What Ultrasound Findings suggest Malignancy?
- Size > 10 cm
- Papillary or solid components
- Irregularity
- Presence of ascites
- High color doppler flow
What is the most important risk factor that suggests Malignancy?
AGE! Median age for ovarian cancer diagnosis is 63
List risk factors for malignant adnexal mass
AGE!
Family Hx of Br or Ov Ca Nulliparity
Early menarche, late menopause
White race
Primary infertility
Endometriosis
Ultrasound findings that suggest benign disease
Simple appearance
Thin smooth walls
Absence of solid components, septations, or internal blood flow on color doppler
Work up of Adnexal Mass
- 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!
What type of cancer is CA-125 useful in detecting?
- Non-mucinous epithelial cancer
- Elevated in 80% of patients with epithelial ovarian cancer
- Only 50% with Stage I disease
What non-cancerous conditions can cause elevations in Ca-125?
- Endometriosis
- Pregnancy
- PID
- Non-Gyn Cancer
Level of Ca-125 in postmenopausal women suggesting malignancy?
> 35
Level of Ca-125 in premenopausal women suggesting malignancy?
> 70-80 (use to be 200)
List types of epithelial tumors (6)
- Serous
- Mucinous
- Clear cell
- Endometrioid
- Brenner
- Cystadenofibroma
Ca-125 is rarely elevated in which epithelial ovarian tumor? Which tumor marker is usually elevated?
- Mucinous Tumor
- Ca-124 is rarely elevated
- CEA elevated
- Grow very large!
Which epithelial tumor is associated with a history of endometriosis and “hobnail cells” on pathology?
Clear Cell
List the types of sex-cord stromal tumors (4)
- Granulosa
- Cell Fibroma
- Thecoma
- Sertoli-Leydig
Which tumor has elevated Estrogen, and elevated Inhibin?
Granulosa Cell
Which Ov Ca is associated with PMB, endometrial cancer?
Granulosa Cell Tumor
Which Ov Ca is associated with Call-Exner bodies and coffee bean nuclei?
Granulosa Cell
Which sex cord stromal tumor is benign, is not hormonally active?
Fibroma
What is Meigs Syndrome?
- Fibroma
- Ascites
- Pleural Effusions
Most hormonally active sex cord stromal tumors?
Thecomas - androgens (From theca cells)
Which sex cord stromal tumor produces estrogen and testosterone production?
Sertoli-Leydig
List the types of Germ Cell Tumors (7)
Dysgerminoma
Mature Teratoma
Immature Teratoma
Endodermal sinus/Yolk Sac tumor
Choriocarcinoma
Embryonal Carcinoma
Mixed Germ Cell
Elevated AFP, Schiller-duval bodies, rapid growing adnexal mass
Endodermal sinus/Yolk Sac tumor
Elevated bHCG, Syncytio & cytotrophoblasts
Choriocarcinoma
Elevated AFP, LDH, CA125 Immature neural tissue (small round blue cells in rosettes/tubules)
Immature Teratoma
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
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
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
Pt reproductive age
Acute onset pelvic pain
Hemorrhagic cyst
Ectopic pregnancy
If unilateral/intermittent > ovarian torsion
Pt w/ Indolent progressive pelvic pain
Fevers Chills
Vomiting
Abnormal Discharge
Tubo Ovarian Abscess
Pt w/ acute/chronic dysmenorrhea
Dyspareunia
Endometrioma
Pt w/ bloating
Generalizeda abdominal pain
Early satiety
Consider malignancy
Pt w/ pelvic mass
AUB or PMB
Likely due to estrogen produced by sex cord stromal tumors
Elevated B-hCG + LDH
Dysgerminoma
Most common germ cell tumor! Usually women < 30 yo
Elevated AFP
Endodermal sinus tumor
Second most common germ cell tumor
Median age = 18 years
Elevated AFP, LDH, CA125
Immature Teratoma
Elevated BhCG, AFP
Embryonal carcinoma
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)
What is the lifetime ovarian/tubal/peritoneal cancer risk for a patient with BRCA1 mutation?
40% by age 70
What is the lifetime risk of ovarian/tubal/peritoneal cacner in a patient with BRCA2 mutation?
20% by Age 70
What is the lifetime risk of ovarian cancer for women with Lynch Syndrome?
5-10% by Age 70
What percentage of patients with Stage I ovarian epithelial cancer have elevated CA-125?
Only 50%!
When should you refer to Gyn Onc for adnexal mass?
Postmenopausal + elevated CA125
Premenopausal + elevated CA125, US findings concerning for malignancy
Surgical management w/ excision of endometrioma can result in pregancy rates of…
56-65% (compared to 23.4% with just incision and drainage)
What is the recurrence rate of an endometrioma?
25%
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
US Findings: Unilocular, hypoechoic cyst with diffuse low-level echos and ground glass appearance…. what is it?
Endometrioma
Differential diagnosis for solid ovarian mass?
Pedunculated fibroma
Thecoma
Fibroma
Brenner tumor
Granulosa cell tumor
Dysgerminoma
Differentia diagnosis for a cystic tumor?
Function cyst
Serous and mucinous tumors
Dermoid
Endometrioma
Paratubal cyst
False positive elevated CA-125?
Anything that inflames the pelvis
Appendicitis
PID
Endometriosis
Cholecystitis
Diverticulosis
IBD
SLE
Ascites
What is highest on differential for extremely large ovarian tumor?
Likely benign mucinous cystadenoma
Management of postmenopausal woman with simple cyst < 10 cm and normal CA-125?
Observation
When can endometriomas be observed?
If < 3 cm
When can mature cystic teratomas be observed?
If < 4 cm
Young nulliparous patient is found to have a dysgerminoma…. how would you treat?
Unilateral salpingo-oophorectomy, limited staging
Follow w/ serial LDH, HcG
Treatment for granulosa cell tumor?
Surgery alone for most patients. Majority are Stage IA at diagnosis, and confined to one ovary
How accurate is frozen section?
Agreement between frozen section and final pathology is as low as 55%
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
