Adnexal masses Flashcards
Features making adnexal mass more likely to be malingant:
- older age
- bilateral
- > 10 cm (ACOG)
- solid components/papillations (ACOG)
- ascites (ACOG)
- increased doppler flow (ACOG)
- complex
- excrescences
- septations
- persistent duration (rather than reduction with menses or on OCPs)
what is most important personal risk factor for ovarian cancer?
family history with ovarian or breast cancer
- if first degree relative, 5%
- BRCA 1: 41-46%
- BRCA 2: 10-27%
- Lynch syndrome: 5-10%
ddx for adenxal mass
cystic:
- functional cysts
- mucinous or serous neoplasms
- mature cystic teratoma
solid:
- fibroid
- fibroma
- thecoma
- brenner cell tumor
- germ cell tumors
- sex cord stromal tumors
- teratoma
how often are the following tumors bilateral?
- germ cell tumors
- fibroma
- serous carcinoma
- mucinous carcinoma
- krukenburg (bonus- order of primary)
- germ cell tumors: 5-10%, except gonadoblastoma (40%)
- fibroma: 10%
- serous carcinoma: 66%
- mucinous carcinoma: 20%
- krukenberg: 100%; breast, GI, endometrium, renal, lymphoma
when to intervene surgically on adnexal mass?
- symptomatic
- concern for malignancy
when to intervene on endometrioma or teratoma?
- increased size
- large size
- symptomatic
- concern for malignancy
management of adolescent/peds mass
- TAUS if possible
- HCG, AFP, inhibin, CA 125
- if surgical - tumor removal, spare fallopian tube if not adherent, harvest ascites, eval omentum for nodules (remove if so), eval PA and pelvic LN for enlarged (remove if so)
how is dysgerminoma managed
in young pt- conservative staging; USO, conserve contralateral ovary and uterus. Serial LDH and HCG tumor markers
what two histologic findings are with granulosa cell tumors?
- call-exner bodies
- coffee bean nuclei (also present in brenner tumors)
when to intervene surgically in pregnancy?
- suspected torsion
- concern for malignancy
- debilitating symptoms due to mass
most common adnexal masses in pregnancy?
- teratoma (#1)
- cystadenoma
- paratubal cyst
- corpus luteum
- hemorrhagic cyst
what is the risk of malignancy for an adnexal mass in pregnancy?
what % of masses resolve in/after pregnancy?
1-6% malignancy
50-90% resolve in/after pregnancy
mass at the time of cesarean section?
- do not perform c-section for this indication only
- if mass at time of c-section, and you need to remove ovary/tube with mass- defer until after unless suspicion for malignancy high
dysgerminoma
hcg/afp/ldh/ca125
hcg +, ldh +
afp -, ca125 -
endodermal sinus tumor
hcg/afp/ldh/ca125
afp +
hcg -, afp -, ca125-
choriocarcinoma
hcg/afp/ldh/ca125
hcg +
afp -, ldh-, ca125-
immature teratoma
hcg/afp/ldh/ca125
afp +, ldh+, ca 125+
hcg -
embryonal carcinoma
hcg/afp/ldh/ca125
afp +, hcg -
ldh -, ca125-
what are histologic features of borderline tumor?
- epithelial stratification
- papillations
- nuclear atypia
but no stromal invasion
frozen borderline/LMP tumor– management?
- pelvic washings, peritoneum and contralateral adnexal inspection (bilateral 50% of time)
- if compelted child bearing: hyst/BSO with staging
- if fertility sparing desired: USO or oopherectomy
- comprehensive staging: unilateral oopherectomy, omentectomy, peritoneal biopsies
- excision of extraovarian implants is most important to improve survival, and reduce recurrence risk
- recurrence rate of borderline tumor if USO: 15%, if cystectomy 30%. Non-invasive peritoneal implants, recurrence rate 40%.
differential for solid adnexal mass
- pedunculated fibroid
- fibroma
- ectopic pregnancy
- GI solid tumor
managment of solid adnexal masses?
- unless confident it is a pedunculated myoma, needs surgical eval/excision
- if suspected benign can do yourself, if suspected malignant get GYN or surg oncologist
- surgical for boards: ex-lap, peritoneal washings, intact specimen, frozen if appropriate, full staging if appropriate
risk of malignant transformation for dermoid?
- 1-2%
- resect if large size (5-10 cm), enlarging over time, suspicion of malingnacy
