Adnexal Masses: Diagnosis, Types and Treatment

July 9, 2008 Robert A Donato, DO, F.A.C.O.G

Adnexa consists of fallopian tube, broad ligament, ovaries, and structures within the broad ligament derived from embryonic nests.
5-10% of all US women will undergo a procedure to check for suspected ovarian neoplasm during their lifetime 13-21% of those women will have a malignant ovarian neoplasm

Evaluation for surgery

H&P Transvaginal sonography CA-125 level
Other factors to consider: *age* is the most predictive factor in determining malignancy potential Menopausal status Positive/negative symptoms CA-125 and other labs Unilaterally vs. bilaterally

Age
In pre-menarchal and postmenopausal females adnexal masses are highly abnormal and require immediate investigation Premenarchal : most derived from germ cell immediate surgical exploration Postmenopausal : derived from stromal, germ cell, epithelial cells IN POSTMENOPAUSAL MASSES CONSIDERED MALIGNANT UNTIL PROVEN OTHERWISE!

Differential Diagnosis:

Uterine mass Ovarian mass Endometriosis Tubal mass Non-GYN origins

Uterine Masses
Most common: myoma Signs: palpated as 1 or more discrete, rounded, firm masses Sx: rapidly enlarging pelvic mass, pain, tenderness Rarely (<0.1%) myomas contain sarcomatous elements (found post-op)

Fibroids: estrogen dependent: enlarge with pregnancy and other estrogen increases NOT affected by exogenous estrogen
Adenomyosis benign invasion endometrium into myometrium Endometrial carcinoma dxed by D&C

Ovarian Masses
Functional cyst most common during reproductive years: non-neoplastic cysts that form when ovulation does not occur and the matured follicle collapses on itself May grow to 10 cm in diameter Usually resolve within 2 weeks Corpus luteal cysts when ovulation does occur these form in the dead space created when egg is released from follicle Can delay menses and may present like ectopic pregnancy Theca-lutein cysts Over-stimulation of ovary by hCG Extensive luteinization of stroma surrounding follicle Seen in hydatidiform moles and choriocarcinoma but not regular pregnancy

Polycystic/sclerocystic ovaries contain multiple follicle cysts with a thickened, fibrotic capsule and atretic follicles 2-5x normal size ovaries

Endometriotic cysts: encapsulated area of endometriosis Sizes from 3-4 mm to 10 cm Adhere to surrounding tissue 50% cases involve both ovaries Cyst contents usually dark brown (called chocolate cysts)

Ovarian Neoplasms
20% are malignant Cystic vs. solid tumors Cystic tumors usually contain mucous or serous material Most neoplasms are asymptomatic unless ruptured or twisted

Benign cystic neoplasms: most common forms are cystadenomas and teratomas 1. cystadenomas: 5-20 cm thin walled, ovoid, unilocular filled with mucus or serous fluid that appears yellowtinged of variable consistency 2. teratomas: <10 cm contain sebaceous material or hair

Malignant cystic neoplasms: usually cystadenocarcinomas Papillary surface outgrowths, necrotic areas, internal papillations suggest malignancy

Benign Solid Tumors Usually arise from connective tissue: fibromas, thecomas, Brenner tumors Variable in size Firm, irregular contour, mobile Cause palpable post-menopausal ovary (PPMO) Meigs syndrome uncommon entity of benign ovarian fibroma with ascites and hydrothorax
Malignant Solid Neoplasms Most commonly adenocarcinomas (may be found as primary or metatstatic tumors) Ovarian carcinoma may be discovered when the patient complains of abdominal distension caused by ascites 2 widespread intraperitoneal dissemination

Endometriosis
A condition in which implants of normal appearing endometrial glands and stroma are found outside the uterine cavity Most common sites: ovaries, broad and uterosacral ligaments, peritoneum of cul-de-sac and bladder Most common in Caucasian, nulliparous 35-45 y/o Ovarian involvement chocolate cyst Bimanual exam may reveal nodularity of uterosacral ligaments Most common symptom: PELVIC PAIN

Ovarian Endometriosis with chocolate cysts

Tubal Masses
Rare finding usually represent inflammation 2 tubal disease or ectopic pregnancy (EP) Palpation cannot differentiate between ovarian and tubal masses DDx: acute salpingitis tube distended with pus acute PID look for classic sx and check ESR/WBC (even these are absent in ~30% cases however) chronic pelvic infection more subtle sx Paraovarian cysts remnant of Wolffian duct found between fallopian tube and ovary 95% EPs are tubal but <50% have a palpable mass on exam Fallopian tube malignancy: <0.5% all genital tract malignancies

Adnexal Masses of non-GYN Origin

A thorough history is essential! Previous surgeries/injuries, change in bowel/bladder habits, associated sx Bowel most common is fecal material in sigmoid colon or cecum; also consider diverticulitis, abscess, ileitis, GI cancer Bladder should be empty for proper exam Pelvic kidney benign condition when kidneys fail to ascend during childhood Retroperitoneal disorders (sarcoma, lymphoma, teratoma in sacrococcygeal area) Also consider lipoma, hernia, AAA, etc.

Adnexal Masses Exam and Work-up

Pelvic Exam: best identification of ovarian mass Consider size, shape, contour, general location. General guidelines
Benign tumors smooth & regular walls, cystic, mobile, unilateral, <8 cm Malignant tumors firm & irregular walls, bilateral, fixed, assoc. with nodules in cul-desac and/or ascites Bilateral findings = 2.6x risk of malignancy

Imaging
X-rays may outline a mass Teeth: teratoma Psammoma bodies concentric calcifications found in adenocarcinoma of the ovary IVP kidneys, ureters, bladder Use bladder contour to judge size of mass See pts anatomy prior to surgery CT/MRI helpful but $$ Ultrasound solid vs.cystic

Labs
Tumor markers for ovarian cancer are helpful as an adjunct to H&P Some germ cell neoplasms produce hCG, LDH, AFP Early ovarian CA not associated with reliable results CA-125 in serous cystadenocarcinomas

Management
Masses >10 cm should be surgically explored Diagnostic laparoscopy useful if source uncertain and can distinguish fibroid vs. tumor Ovarian Cysts: 95% of those <5 cm are benign
Suspected functional cysts (<7 cm, unilat, mobile, resolve < 2 wks) recheck in 3-6 wks. May prescribe OCP to hasten involution based on theory that they are gonadotropin-dependent. If still present at recheck/after OCP trial OR!

Benign Ovarian Tumors

Serous cystadenoma Mucinous cystadenoma Pseudomyxoma peritonei Brenner tumor Dermoid cyst Fibroma Germinal Inclusion Cyst Pregnancy Luteoma Endometrioma PPMO

Serous Cystadenoma more common and smaller than mucinous type Papillary projections on surface with smooth inner wall Low columnar epithelium Characteristic finding: Psammoma bodies If associated fibrosis may progress to cystadenfibroma 10% are bilateral Mucinous Cystadenoma May be come GIGANTIC (>300 lbs!!!) Round/ovoid mass with smooth surfaces Interior septated into loculi containing clear, viscous fluid Rarely bilateral

Pseudomyxoma Peritonei Peritoneal mesothelium transforms to mucinsecreting epithelium Gradual accumulation of gelatinous material Usually reaccumulate after removal
Brenner Tumor Very rare, similar to fibroma Hyperplastic fibromatous matrix with nests of epithelioid cells with coffee bean appearance May arise from various cells of ovary Largely benign Management: simple excision, very effective

Dermoid Cyst (Benign Cystic Teratoma) Small, 15-25% bilat, more common in younger patients Thick, opaque, whitish walled cyst with hair, bone, cartilage, greasy fluid found at cyst opening Ecto-, meso-, and endoderm at microscopic level 1-3% malignant (usually squamous cell) Management: cystectomy with entire capsule removed (or will recur) must avoid spillage into pelvis to prevent chemical peritonitis Fibroma Range from small nodule on ovarian cortex to filling entire pelvis Resembles a fibroid (uterine muscle tumor) Meigs syndrome: fibroma, ascites, hydrothorax
Germinal Inclusion Cyst Physiologic cysts seen monthly in menstruating women

Pregnancy Luteoma With each pregnancy, this corpus luteal cyst forms at site of ovulation Creates progesterone to maintain pregnancy cyst of pregnancy
Endometrioma encapsulated endometriosis PPMO (palpable post-menopausal ovary) postmenopausally, ovaries gradually atrophy to 1/3 previous size are not normally palpable If you palpate an ovary worry about malignant neoplasm (early ovarian CA) Size matters! Benign < 5cm < Malignant is a good general guideline Presence of ascites worsens prognosis Diagnostic laparoscopy or laparotomy is indicated (also check CA125) 10% PPMOs will be malignant others may be fibroma or Brenner tumor

Borderline Malignant Epithelial Ovarian Neoplasms

Group of epithelial ovarian tumors with histologic features bordering clearly benign and frankly malignant neoplasms more common in younger women 95% 10-year survival rate for Stage 1 lesions (least malignant) Considered low malignant potential Minimally invasive surgery is warranted for complete extirpation

Epithelial Ovarian Cancer

Types Serous cystadenocarcinoma (42%) Mucinous cystadenocarcinoma (12%) Endometrioid carcinoma (15%0 Undifferentiated carcinoma (17%) Clear cell carcinoma (6%) Some epidemiology
5% all cancers 1/56 will develop EOC 26,500 new cases annually 19,500 deaths annually More common >50 y/o Makes up 85-90% of all malignant ovarian tumors Ovarian cancer (all types) is the most deadly gynecologic cancer

Risk Factors
Factors that decrease risk: more pregnancies More OCP use Increased risk: Prolonged use of fertility drugs (ex. Clomid) Family association (discussed later) Theory of incessant ovulation repeated trauma (follicular rupture) and repair to epithelial ovarian cells by ovulation stimulates tumor growth Gonadotropin Theory persistent stimulation of ovaries by gonadotropins results in increased proliferation of ovarian epithelium

STAGE Stage I Stage Ia Stage Ib

DEFINITION Growth limited to ovaries Growth limited to one ovary, no ascites, no tumour on external surface, capsule intact Growth limited to both ovaries, no ascites, no tumour on external surface, capsule intact Tumour either stage Ia or Ib, but with tumour on one or both ovaries, with capsule ruptured, with ascites present containing malignant cells, or with positive peritoneal washings Growth involving one or both ovaries with pelvic extension Extension and/or metastases to the uterus and/or tubes Extension to other pelvic tissues Tumour either stage IIa or IIb, with tumour on the surface of one or both ovaries, but with capsule(s) ruptured, with ascites present containing malignant cells, or with positive peritoneal washings Tumour involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal nodes. Superficial liver metastases equal stage III. Tumour limited to the true pelvis but with histologically proven malignant extension to small bowel or omentum Tumour grossly limited to the true pelvis with negative nodes but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces. Tumour involving one or both ovaries with histologically confirmed implants of abdominal peritoneal surfaces, none exceeding 2cm in diameter. Nodes are negative. Abdominal implants >2cm in diameter and/or positive retroperitoneal or inguinal nodes. Growth involving one or both ovaries with distant metastases.

Stage Ic Stage II Stage IIa Stage IIb

Stage IIc

Stage III

Stage IIIa

Stage IIIb

Stage IIIc Stage IV

STAGE No

PATIENTS TREATED

SURVIVAL3-yr (%)

SURVIVAL 5-yr (%)

5,559

87.5

82.1

II

3,364

72.1

64.5

III

2,530

47

38.1

IV

492

20.7

14

TOTAL

11,945

71.6

65.4

Genetics of Ovarian Cancer

Definite increased risk of developing ovarian CA with + family history Hereditary Syndromes: 1. A site-specific familial ovarian cancer syndrome exists that places women at high risk for development of ovarian cancer only 2. Breast-Ovarian CA Syndrome: 50% risk of ovarian CA if 1 relative had breast and/or ovarian CA. Association with cancer genes BRCA-1 and 2. 3. Cancer Family Syndrome: risk for men and women to develop colon cancer and to a lesser extent sarcoma, gastric or thyroid cancer

Symptoms: Abdominal swelling Abdominal pain Dyspepsia Urinary frequency Weight change
Signs: You would need to do 10,000 pelvic exams to find 1 early ovarian cancer! Unexplained, persistent GI sx in a 40-69 y/o suspect ovarian CA

Screening?
The US Preventive Task Force does NOT recommend using CA-125 as a screening tool for ovarian cancer.

Also no evidence to support transvaginal ultrasonography for screening. These tools should only be utilized for high-risk individuals or those with a positive H&P.

Workup
Complete H&P Pelvic exam and pap smear CBC UA CA-125 Comprehensive Metabolic Panel CXR IVP/Barium Enema or CT with contrast Pelvic US

Surgical Therapy in Ovarian Cancer

TAH/BSO with removal of as much of tumor as possible Lymph node biopsies Omentectomy Based on spread of disease, surgeon will remove any obvious tumor and biopsy various sites through abdomen and pelvis (peritoneum, omentum, diaphragm) Adjunct therapy (radiation/chemo) based on post-op pathologic diagnosis and staging

Any serous questionomas?