What&might&we&be&concerned& about&with&increased&urgency& and& frequency?

1 2 3

Adnexal)masses)represent)a)spectrum)of)conditions)from)gynecologic)
and)non)gynecologic)sources)most)commonly)referring)to)fallopian)tubes)
and)ovaries.
Can)occur)at)all)ages)and)present)w/)non)specific)sx)such)as)inc.)
abdominal)size,)bloating,)urinary)urgency/freq,)early)satiety)and)wt)loss.
These)vague)sx have)been)shown)to)be)present)for)months)in)93% of)pts)
with)ovarian)cancer)and)55%)die)w/in)5)years)of)dx)so,
Goal)of)evaluation:)benign)vs)malignant

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 US&and& CT&have&similar&sensitivity&and&specificity&for&evaluation&of&adnexal&masses,& ROMAG risk& of&ovarian&malignancy&;&uses&ca&and& he4&to&decide& if&woman&is&at&high&risk&
but& ultrasonography& is&generally&more&costGeffective. or&low&risk

Ultrasonography& characteristics&of&simple&cysts&include:&
anechoic& mass;&smooth,& thin&walls;& no& mural&nodules& or&septations;&

Ultrasound& findings&that&should& raise&the&clinicians&level&of&concern& regarding&

malignancy&include&
Gcyst&size&greater&than& 10&cm,&
Gpapillary&or&solid&components,
G presence& of&ascites,&
G High&color& Doppler& flow.

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If&cystic,&mobile,&and&less&than&10&cm,&observation&is&reasonable&in&the&preGmenopausal&
patient&who&is&asymptomatic&(and&with&no&family&history&of&ovarian&cancer).&A&repeat&
ultrasound&in&8G12&weeks&will&assist
in&determining&if&this&is&persistent&or&increasing,&at&which&point&surgical&exploration&would&be&
advisable.&In&this&case,&this&is&most&likely&a&neoplasm.&If&the&cystic&ovary&resolves& or&is&smaller,&
then&this&likely&represents& a&functional&cyst.

Any&postmenopausal&patient&with&a&complex&cystic/solid&mass&requires&surgical&exploration&
and&removal.
If&the&cyst&is&simple&in&nature,&then&observation&is&reasonable&provided&the&patient&is&
asymptomatic,&there&is&no&significant&family&history&of&ovarian&cancer,&and&CA125&is&normal.

If&the&adnexal&cystic&mass&is&solid&or&complex,&fixed,&size&>10&cm,&or&bilateral,&then&surgical&
exploration&is
recommended.

Roma<12.5%&in&premenopausal&woman&=& low&risk
.&Evaluation&of&an&ovarian&mass&depends& on&clinical,&laboratory,&or&radiographic&findings&that&
suggest& malignancy.&Findings&that&suggest&malignancy&include&CA&125&level&greater& than&35&U&
per&mL&(postmenopausal)&or&200&U&per&mL&(premenopausal);& evidence&of&abdominal&or&
distant&metastasis;&family&history&of&firstGdegree& relative&with&ovarian&or&breast& cancer;&
nodular&or&fixed&pelvic&mass&(postmenopausal);&and&concerning&ultrasonography&findings,&
including&a&solid&component,&thick&septations (greater&than&2&to&3&mm),&bilaterality,&Doppler&
flow&to&the&solid&component&of&the&mass,& and&presence& of&ascites.&Women&with&any&of&these&
findings&should&be&referred& to&a&gynecologist&or&gynecologic&oncologist.&

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 Can)present)with)pain)2/2)to)ovarian)enlargement)or)torsion.)Can)also) so&now&i will&be&giving&an&overview&of&all&the&different&adnexal&masses,&inlcuding
contain)functional)thyroid)tissue)and)present)as)hyperthyroidism classifications&and&characteristics&of&each.
malignant&transformation&occurs& in&0.2&to&2&percent& of&mature&cystic&teratomas
Risk&factors&for&malignant&neoplasm&in&a&mature&cystic& teratoma include& age&
over& 45&years&(mean&age&50&years&versus&33&years&for&benign&teratomas),&tumor& adnexal&massses of&ovarian&origin&can&be&grouped& into& 3&different&classes&including:
diameter&greater&than& 10&cm,&rapid&growth,&and&findings&on&imaging&(eg,&low&
resistance&intraGtumor&flow&on& Doppler) In&the&next& slides&we&will&speak&briefly&about& each&of&these&time&of&masses.
TxH prevents complications)as)above.

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Follicular GAn&abnormal&release&of&gonadotropinGreleasing& hormone& (GnRH)&causes

Present)in)5H15%)of)reproductive)age)women,)originate) from)unruptured a&persistently&elevated&LH.&The&LH:FSH& ratio&is&often&>&3:1.& There&are&
graafian follicles.) levels&of&androgens&produced& from&the&adrenal&gland&and&the&ovary.
Many)are)clinically) insignificant) and)discovered)accidentally.) They)are)usually) These&women&also&have&higher&levels&of&estradiol&that&is&not& bound& to&sex
small)and)only)rarely)exceed)5cm.)The)contents)vary)from)serous)through)
hormonebinding& globulin&(SHBG),&although& the&total&estradiol&level&is
serosanguinous)to)clotted)blood)
not& elevated.&There&is&&estrone due&to&adipose& conversion& of&androgens
Lutein)Cysts
Corpus)Luteum)Cysts
These)are)cystic)dilatations) of)corpora)lutea and)result)from)delayed)
resolution)of)the)central)cavity)of)the)corpus)luteum.
Most)commonly)occur)early)in)pregnancy)and)release)progesterone
Theca)Lutein) Cysts
Caused)by)elevated) hCG
These)are)cystic)dilatations) of)corpora)lutea and)result)from)delayed)
resolution)of)the)central)cavity)of)the)corpus)luteum
Dx and&Tx for&functional&cysts:
DIAGNOSIS&w/&US&confirms&the&diagnosis&and&is&also&helpful&to&see& whether&the&cyst&is
ruptured.&May&show&an&ovarian&cyst&or&fluid&in&the&culGdeGsac,&which&is&consistent&with&a&
ruptured&cyst.
No&tx necessary& most&resolve&w/in&2months;&if&pt is&symptomatic&OCPS&may&help&sx.&If&cyst&is&
unresolved&after&2&months&laparotomy/&laparoscopy&indicated&to&rule&out&malignancy
G Surgical&resection&can&be&considered&in&symptomatic&cysts&>&5cm
G G cysts&>&5cm&inc risk&of&torsion.

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Clinical&diagnosis&can&be& made&in&women&with&a&history&of&endometriosis, TOA&is&a&polymicrobial process.& Treat&with&broadspectrum antibiotics&(includes& Serous(30%;60%&benign)G Most&common& ovarian& neoplasm.&Lined&with&fallopian&
pelvic&pain,& and&an&ovarian&cyst coverage&for&gram&positive,& gramnegative,&and&anaerobic&organisms). tubelike& epithelium.&Often&bilateral.

Definitive&diagnosis&is&made&by&laparoscopy& and&a&biopsy&showing&hemosiderin Again&this&mass&is&confirmed&via&US Mucinous(15%;& 80%&benign)G Multiloculated,& large.&Lined&by& mucusGsecreting&

laden&macrophages. epithelium.&Tend& to&be&unilateral&and& larger&then& serousl
Pt&should& be&treated&inpatient& w/&IV&abs&cefoxitin+&doxycycline& or&clinda/gent
TX:$only$ surgical;$medical$ tx not$ effective. ThecomaG Like&granulosa&cell&tumors,&may&produce& estrogen&common&in&post&
Surgical$treatment$ typically$consist$ of$Cystectomy$or$oophorectomy,$ if$completed$ menopausal&may&cause&endometrial&hyperplasia.& Usually&presents& as&abnormal&
childbearing uterine& bleeding

FibromaG Benign.&Most&common& sex&cordGstromal&tumor;& 4%&ovarian& neoplasms.&4

8%&bilateral.&Postmenopausal&women.& Whorled&bundles& of&spindleGshaped& fibroblasts&
&&collagen.&A/w Meigs syn &&basal&nevus& syn.

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Ovarian&cancer& is&the Just)want)to)touch)briefly on)the)different)type)of)epithelial)

deadliest&gynecologic
cancer& because&it&is&diffi cult
ovarian)neoplasms
to&detect& before Hepithelial OC)most)common)accounting)for)90%)of)ca
dissemination.& H Serous)is)most)common)accounts)for)40H50%,)and)is)
70%&of&ovarian&cancer& that&is&found& is&either& stage&3&or& 4 most)common)in)brca and)lynch)patients.)Most)
common)BL
H Mucinous)10%)of)eoa,)most)commonly)BL
H EndometrioidH 10%)of)all)cancersU)42%)w.)
endometriosis)15H20%)associated)with)endometrial)
carcinoma
H BrennerH transitional)cell)carcinoma.)Poorly)
differentiated
H Clear)cellH 10%)of)all)ovarian)cancers.)Associated)with)
endometriosis)and)hypercalcemia.

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More)than)5)yrs of)OCP)use 10G15%of&cases&occur& in&association&with&genetically&predisposed Because)of)the)low)prevalence)of epithelial)ovarian)
syndromes& called&hereditary& ovarian& cancer&(HOC)&syndromes.& In
)risk)of)ovarian)cancer)by these&patients,&ovarian& cancer&is&diagnosed& at&a&median&age&of&50&yr.&
cancer,)reported)to)be)approximately 1)case)per)2,500)
2550%.)This)protection women)per)year,)it)has been)estimated that)a)test)with)
lasts)15)yrs after even)100%)sensitivity)and)99%)specificity would)have)a)
discontinuation. PPV)of)only)4.8%,)which)means)20)of)21)women)
undergoing)surgery)would)not)have)ovarian)cancer.

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I)just)wanted) to speak)briefly)on)CA125) and)it)use) POSTOP&&MANAGEMENT so&that&wraps&up& the&discussion& on&epithelial&ovarian&cancer.& now&id&like&to&discuss&the&

in)dx)ovarian) cancer.)It)is)thougth that)it)should)not) In&selected&patients,&chemotherapy& can&improve&survival&and& diseasefree other& two&types&including& germ&cell&and&stromal&cell.
be)used)as)a)screening) tool)for)multile reasons) intervals.
FirstGline&chemotherapy:& Paclitaxel&and&cisplatin&or&paclitaxel&and& carboplatin: GArise&from&the&sex&cords& and&specialized&stroma&of&the&embryonic& gonads
including) its)non) specificity)in)premenopausal) (before&they&differentiate&into&ovaries& or&testes).
woman.) There) are)many)other)conditions) that)may)
casue elevated) CA)125) see)tbale.) GThey&behave& as&lowGgrade&malignancies&and&usually& affect&older&women
CA)125) level)should) not)be) used)as)a)screening)
tool)or)when) a)mass)is)not)identified Because&of&its&low$sensitivity$ TX:Surgical:
(5062%$for$early$stage$epithelial$ ovarian$ cancer) and&limited& specificity$(9498.5%) TAHGBSO&in&women&who& have&completed&childbearing.
The& CA&125&level&is&elevated& in&80%&of&patients&with&epithelial& ovarian& cancer&but&in&only&50%&of&patients&with&
stage& I&disease& (25). Unilateral&salpingoGoophorectomy& in&young& women&with&lowGstage/
GCA&125&measurement& is&most&useful&in&postmenopausal&women&and&in&identifying grade&neoplasia.
nonmucinous epithelial&cancer
G it&is&also&useful&in&monitoring&response&to&chemo.&It& is&hoped&that&a&patients&CA125&decrease&by&&50%&reduction&
of&a&pretreatment& sample& of&70&kU/L&or&greater.& T

Risk&of&Malignancy&Index,& which&includes&
GCA125,
G transvaginal& ultrasound,&and&
G Gmenopausal&status,&
G is&recommended& for&the& differential& diagnosis&of&a&pelvic&mass.&Because& human&epididymis&protein& 4&has&been&
reported& to&have& superior&specificity&to&CA125,&especially&in&premenopausal& women,& it&may& be&considered&
either& alone& or&as&part&of&the&risk&of&ovarian& malignancy& algorithm,& in&the&differential& diagnosis&of&pelvic&
masses,&especially& in&such&women.&

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Prognosis&is&generally&good&because& most&are&discovered& early.& FiveGyear&survivalis
85%&for&dysgerminomas,&75%&for&immature&teratomas,&and&65%&for
endodermal& sinus&tumors.

TX:)USO)and)adjuvant chemo

Adjuvant& chemotherapy:& Recommended&for&all&malignant&GCTs&except

stage&IA,&grade&I&immature&teratomas.&Stage&IA,&grade&1&immature&teratomas
have&a&high&cure&rate&with&surgery& alone.&The&BEP&regimen&is
the&standard&of&care:

BEP&chemo:& bleomycin,&etoposide& and& cisplatin

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