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Oncology > Adnexal Masses > Flashcards

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
Q

If Adnexal mass < 8 cm, and pt is premenopausal, what is your next step in management?

A

Repeat pelvic exam and imaging in 1-2 months

26
Q

What is the differential diagnosis for adnexal mass?

A

Epithelial ovarian cancer, germ cell tumor, sex cord stromal tumor, functional cyst, dermoid, endometrioma, TOA, serous or mucinous cystadenoma

27
Q

List the sex cord stromal tumors, and their hormones usually produced

A

Granulosa cell = estrogenic

Theca Cell = estrogenic

Sertoli-Leydig = androgenic

Symptoms > mass, precocious puberty, irregular menses, virilization

28
Q

Pt reproductive age

Acute onset pelvic pain

A

Hemorrhagic cyst

Ectopic pregnancy

If unilateral/intermittent > ovarian torsion

29
Q

Pt w/ Indolent progressive pelvic pain

Fevers Chills

Vomiting

Abnormal Discharge

A

Tubo Ovarian Abscess

30
Q

Pt w/ acute/chronic dysmenorrhea

Dyspareunia

A

Endometrioma

31
Q

Pt w/ bloating

Generalizeda abdominal pain

Early satiety

A

Consider malignancy

32
Q

Pt w/ pelvic mass

AUB or PMB

A

Likely due to estrogen produced by sex cord stromal tumors

33
Q

Elevated B-hCG + LDH

A

Dysgerminoma
Most common germ cell tumor! Usually women < 30 yo

34
Q

Elevated AFP

A

Endodermal sinus tumor
Second most common germ cell tumor
Median age = 18 years

35
Q

Elevated AFP, LDH, CA125

A

Immature Teratoma

36
Q

Elevated BhCG, AFP

A

Embryonal carcinoma

37
Q

10 cm SIMPLE cyst in postmenopausal patient - next step in management?

A

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
Q

What is the lifetime ovarian/tubal/peritoneal cancer risk for a patient with BRCA1 mutation?

A

40% by age 70

39
Q

What is the lifetime risk of ovarian/tubal/peritoneal cacner in a patient with BRCA2 mutation?

A

20% by Age 70

40
Q

What is the lifetime risk of ovarian cancer for women with Lynch Syndrome?

A

5-10% by Age 70

41
Q

What percentage of patients with Stage I ovarian epithelial cancer have elevated CA-125?

A

Only 50%!

42
Q

When should you refer to Gyn Onc for adnexal mass?

A

Postmenopausal + elevated CA125

Premenopausal + elevated CA125, US findings concerning for malignancy

43
Q

Surgical management w/ excision of endometrioma can result in pregancy rates of…

A

56-65% (compared to 23.4% with just incision and drainage)

44
Q

What is the recurrence rate of an endometrioma?

A

25%

45
Q

When should an endometrioma be surgically removed?

A

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
Q

US Findings: Unilocular, hypoechoic cyst with diffuse low-level echos and ground glass appearance…. what is it?

A

Endometrioma

47
Q

Differential diagnosis for solid ovarian mass?

A

Pedunculated fibroma
Thecoma
Fibroma
Brenner tumor
Granulosa cell tumor
Dysgerminoma

48
Q

Differentia diagnosis for a cystic tumor?

A

Function cyst
Serous and mucinous tumors
Dermoid
Endometrioma
Paratubal cyst

49
Q

False positive elevated CA-125?

A

Anything that inflames the pelvis

Appendicitis
PID
Endometriosis
Cholecystitis
Diverticulosis
IBD
SLE
Ascites

50
Q

What is highest on differential for extremely large ovarian tumor?

A

Likely benign mucinous cystadenoma

51
Q

Management of postmenopausal woman with simple cyst < 10 cm and normal CA-125?

A

Observation

52
Q

When can endometriomas be observed?

A

If < 3 cm

53
Q

When can mature cystic teratomas be observed?

A

If < 4 cm

54
Q

Young nulliparous patient is found to have a dysgerminoma…. how would you treat?

A

Unilateral salpingo-oophorectomy, limited staging
Follow w/ serial LDH, HcG

55
Q

Treatment for granulosa cell tumor?

A

Surgery alone for most patients. Majority are Stage IA at diagnosis, and confined to one ovary

56
Q

How accurate is frozen section?

A

Agreement between frozen section and final pathology is as low as 55%

57
Q

How would you manage a borderline tumor?

A

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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