Approach to the patient with an adnexal mass Dr Safoura - PowerPoint Presentation

Approach to the patient with an adnexal mass Dr Safoura RouholaminIsfahan Medical University 1

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Adnexal massAn adnexal is a common gynecologic problem 5 to 10 % lifetime risk Adnexal masses may be found in females of all ages, fetuses to the elderly Wide variety of types of massesMay be symptomatic or discovered incidentally on pelvic examination or imaging National Institutes of Health Consensus Development Conference Statement. Ovarian cancer: screening, treatment, and follow-up.AU SOGynecol Oncol. 1994;55(3 Pt 2):S4.   6

CLINICAL APPROACH  anatomic location of the mass age reproductive status of the patient 7

CLINICAL APPROACH Excluding urgent conditions )ectopic pregnancy, adnexal torsion) Excluding malignancy ( ovarian or fallopian tube cancer) few patients who present with an adnexal mass will ultimately be diagnosed with a malignancy 8

Anatomic location Ovarian massesPhysiologic cysts (follicular or corpus luteum)Benign ovarian neoplasms ( endometrioma , mature teratoma [ dermoid cyst]) Ovarian cancer or metastatic disease from a non-ovarian primary cancer 9

 Anatomic location Fallopian tubeEctopic pregnancyHydrosalpinxFallopian tube cancer 10

Anatomic location Mesosalpinx or mesovariumParatubal or paraovarian cyst  Tuboovarian abscess Broad ligament leiomyoma 11

Age  Children and adolescents less frequently in children and adolescents than in reproductive-age significant likelihood of adnexal torsion ovarian malignancy (approximately 10 to 20 percent (Germ cell tumors are most common 35 % compared with 20 % in adults) Gynecologic malignancies in women aged less than 25 years.AUYou W, Dainty LA, Rose GS, Krivak T, McHale MT, Olsen CH, Elkas JC  SOObstet Gynecol. 2005;105(6):1405.  Can we preoperatively risk stratify ovarian masses for malignancy?AUOltmann SC, Garcia N, Barber R, Huang R, Hicks B, Fischer A SOJ Pediatr Surg. 2010 Jan;45(1):130-4. 12

Age  Premenopausal womenmajority of adnexal masses occur in reproductive-age most of these masses are benign 80-85% Benign adnexal masses is associated with reproductive function Pregnancy-related etiologies Many of adnexal masses are associated with the menstrual cycle or reproductive hormones (eg, follicular cysts, endometriomas) and are common findings found in this age  Ovarian or fallopian tube cancer is less likely in premenopausal than postmenopausal women, but the possibility of malignancy should be considered in all patients Increase ovarian cancer with age (1.8-2.2/100000 age 20-29Y, 9.0-15.2 /100000 age 40-49Y) 13

Age Pregnant womenEctopic pregnancy and luteomas Corpus luteum cysts Theca lutein cysts 14

Age  Postmenopausal womenExcluding malignancy is the main priority in postmenopausal women with an adnexal mass Average age of diagnosis of ovarian cancer in the United States is 63 years old Urgent conditions ( eg , adnexal torsion, tuboovarian abscess) may also occur in postmenopausal women, but are less common and are more likely to be associated with malignancyseer.cancer.gov/ (Accessed on September 07, 2012)15

GENERAL EVALUATION Women with an adnexal mass typically present with gynecologic symptoms and a mass is identified on pelvic imaging. Alternatively, an adnexal mass is discovered incidentally on pelvic examination or imaging in many patients.Medical historyPhysical examination  Imaging studies   Laboratory evaluation   16

Medical history  Pelvic pain or pressure is the most common symptom associated with an adnexal mass genital tract bleedingOvarian physiologic cysts or neoplasms: dull, achy pain that is usually localized to the side of the mass or may be asymptomaticendometrioma: dysmenorrhea or dyspareunia history of infertility( endometrioma or hydrosalpinx history of fever or vaginal discharge questions about risk factors and symptoms associated with ovarian or fallopian tube cancer 17

Initial evaluation family history of ovarian, breast, uterine, or colon cancerfamily history suggestive of a hereditary ovarian cancer syndrome (BRCA gene mutation or Lynch syndrome) should be counseled about genetic testingshould undergo surgical evaluation if any suspicious adnexal mass 18

Physical examination Size, consistency, and mobility of a masssolid mass that is irregular or fixed or is associated with posterior cul-de-sac nodularity abdominal distention and ascites and/or an abdominal mass rectal mass, rectal bleeding  19

Physical examination Determine degree of clinical suspicion of malignancysymptoms of pelvic or abdominal pain or pressurebloating, or gastrointestinal or urinary tract symptomsAsymptomatic present at an advanced stage with an acute condition and associated symptoms (eg , bowel obstruction, pleural effusion) Infrequently, a malignant mass may rupture or torse and present with acute pain symptoms related to estrogen excess (abnormal uterine bleeding) or androgen excess ( virilization or hirsutism ) 20

Imaging studies Pelvic ultrasoundsensitivity of pelvic ultrasound for the diagnosis of ovarian cancer ranged from 86 to 91 percent and the specificity ranged from 68 to 83 percent Laboratory studies   A baseline level of biomarkers is established for use for further monitoring during and after treatment biomarkers may play a role in predicting whether optimal cytoreduction is feasible Myers ER, Bastian LA, Havrilesky LJ, et al. Management of Adnexal Mass. Evidence Report/Technology Assessment No.130 (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-02-0025). AHRQ Publication No. 06-E004, Agency for Healthcare Research and Quality, Rockville, MD February 2006. Pelvic examination, tumor marker level, and gray-scale and Doppler sonography in the prediction of pelvic cancer.AURoman LD, Muderspach LI, Stein SM, Laifer-Narin S, Groshen S, Morrow CP  SOObstet Gynecol. 1997;89(4):493. 21

Assessing risk  most important factor: appearance of the mass on imagingtransvaginal ultrasound is the preferred study sensitivity of pelvic ultrasound for diagnosis of ovarian cancer ranged from 86 to 91 % and the specificity ranged from 68 to 83 % Myers ER, Bastian LA, Havrilesky LJ, et al. Management of Adnexal Mass. Evidence Report/Technology Assessment No.130 (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-02-0025). AHRQ Publication No. 06-E004, Agency for Healthcare Research and Quality, Rockville, MD February 2006.22

simple cyst Anechoic fluid filling the cyst cavityThin wallsDistal acoustic enhancement – No impairment of sound transmission through the mass (in other words, no loss of signal from tissues behind the cyst) 23

Transvaginal ultrasound image of the left ovary. A normal-appearing left ovary containing a simple anechoic clear cyst, which is consistent with a follicle. A small amount of ovarian tissue is identified surrounding the follicle, as indicated by the arrow.24

simple cyst normal follicles cystadenoma  paraovarian or paratubal cysts Paraovarian cystadenomas and cystadenofibromas : sonographic characteristics in 14 cases.AUKorbin CD, Brown DL, Welch WR SORadiology. 1998;208(2):459.  Risk of malignancy in unilocular ovarian cystic tumors less than 10 centimeters in diameter.AUModesitt SC, Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ, van Nagell JR Jr   SOObstet Gynecol. 2003;102(3):594.  25

premenopausal womensimple adnexal cysts that are <3 cm in diameter typically represent normal follicles and may be considered a normal finding. when up to 5 cm in diameter, these simple cysts are so commonly due to normal menstrual physiology that the Society of Radiologists in Ultrasound (SRU) does not recommend follow-up when asymptomatic Asymptomatic simple cysts between 5 and 7 cm should undergo yearly sonographic evaluation.When a simple cysts exceeds 7 cm in size, the SRU suggests that magnetic resonance imaging be considered if the cyst was not thoroughly evaluated sonographically due to potential technical limitations26

postmenopausal womenany threshold from 1 to 3 cm as a justifiable cut-off for not following a simple cyst in a postmenopausal womanmalignancy in a simple cysts is rare 27

Other masses that may appear as simple cystsA cystadenoma is a benign neoplasm that usually arises from the ovary but sometimes from the fallopian tube. A cystadenoma should be considered as a possible etiology if there is a relatively large simple cyst (>5 cm in diameter in premenopausal women or >3 cm in diameter in postmenopausal women). Paraovarian cystadenomas are uncommon but typically have a small nodule within a cystic extraovarian mass 28

Simple adnexal cysts are usually ovarian in etiology but may also be paraovarian or paratubal cysts. These are common and generally appear as simple cysts adjacent to the ovary It is usually not important from a management perspective whether the cyst arises from the ovary or is next to the ovary29

not a simple cyst R/O physiologic process corpus luteal involution hemorrhage into a cyst adjoining simple cysts Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement.AULevine D, Brown DL, Andreotti RF, Benacerraf B, Benson CB, Brewster WR, Coleman B, Depriest P, Doubilet PM, Goldstein SR, Hamper UM, Hecht JL, Horrow M, Hur HC, Marnach M, Patel MD, Platt LD, Puscheck E , Smith- Bindman R  SORadiology . 2010 Sep;256(3):943-54. Epub 2010 May 26.  The likelihood ratio of sonographic findings for the diagnosis of hemorrhagic ovarian cysts.AUPatel MD, Feldstein VA, Filly RA SOJ Ultrasound Med. 2005 May;24(5):607-14; quiz 615.  30

Corpus luteum – The corpus luteum has a characteristic appearance to experienced sonographers, with thickened walls, circumferential color Doppler flow, and a small central lucency containing echoes that can be confusing to less experienced imagers.Two simple cysts – Two simple cysts next to each other can simulate a septated single cyst.Hemorrhagic cyst – Hemorrhage into a cyst, which usually indicates a physiologic cyst, can simulate septations and mural nodules. A fine network of thin linear to curvilinear echoes, sometimes called a fishnet or reticular pattern, is strongly suggestive of a hemorrhagic cyst These linear echoes are usually very thin and do not extend completely uninterrupted across the cyst, unlike true septa.31

For patients with the characteristic appearance of a hemorrhagic cyst who are asymptomatic or have symptoms that resolve as expected, follow-up imaging is not needed If follow-up imaging is performed, most hemorrhagic cysts will have resolved or become smaller if the repeat sonographic assessment is performed six to eight weeks after diagnosis. 32

Transvaginal ultrasound image in a 38-year-old female shows a complex ovarian cyst (cursors) that contains a reticular pattern of internal echoes. This appearance is classic for a hemorrhagic ovarian cyst.33

Transvaginal ultrasound image of the left adnexa showing a tubo-ovarian abscess. A complex solid and cystic mass is identified in the left adnexa . The tubo -ovarian abscess is seen as a complex cyst (large arrow) and fluid-filled tube (short arrow). 34

Benign mass   Some benign ovarian masses have characteristic sonographic features follicular or corpus luteal cysts: Surgery is not required endometriomas (depends upon whether the patient is symptomatic) mature teratomas ( dermoid )(exclude malignancy and prevent malignant transformation)35

characteristics of specific entities Endometrioma Homogeneous low- to medium-level echoes in a cystic mass (whether unilocular or multilocular ), in the absence of a solid component small echogenic foci on the inner wall of the cyst varying degrees of echogenicity in the different loculesEndometriomas: diagnostic performance of US.AUPatel MD, Feldstein VA, Chen DC, Lipson SD, Filly RA SORadiology. 1999;210(3):739.  36

Transvaginal ultrasound image of the right adnexa showing an endometrioma of the right ovary. The homogeneous echo pattern of the cyst contents ( ie , "ground-glass" appearance) is characteristic of an endometrioma (short arrow). 37

Transvaginal ultrasound with color Doppler image of the left adnexal showing a benign endometrioma of the left ovary viewed with color Doppler imaging. No flow within the cyst can be demonstrated; however, blood flow is demonstrated within the wall of the cyst in the ovarian tissue itself (long arrow). Also identified within the left ovary is a small follicle (short arrow). 38

Mature teratoma  hyperechoic nodule within the mass with distal acoustic shadowing may also be uniformly hyperechoic or have bright linear to punctate echoes (the latter sometimes referred to as the dermoid mesh Calcification also can be present and may vary in size. Floating globules is an uncommon appearance of teratomas but seems to be predictive Large calcifications in ovaries otherwise normal on ultrasound.AUBrown DL, Laing FC, Welch WR SOUltrasound Obstet Gynecol. 2007;29(4):438.  39

Transvaginal ultrasound image of a benign teratoma that features heterogeneous contents, smooth outer surface. The arrow points to lines that are hair. There are hyperechoic portions and homogeneous echoes ( mucin ). 40

Pedunculated leiomyoma heterogeneous, hypoechoic, solid masses Hydrosalpinx   tubular in shape and may have septations or nodules in its wall  Interface vessels on color/power Doppler US and MRI: a clue to differentiate subserosal uterine myomas from extrauterine tumors.AUKim SH, Sim JS, Seong CK SOJ Comput Assist Tomogr . 2001;25(1):36. Transvaginal sonographic markers of tubal inflammatory disease.AUTimor-Tritsch IE, Lerner JP, Monteagudo A, Murphy KE, Heller DS  SOUltrasound Obstet Gynecol. 1998;12(1):56.   41

Paratubal or paraovarian cyst A paratubal or paraovarian cyst arises from the broad ligament in the area of the fallopian tube or ovary simple cysts that originate from the remnants of paramesonephric ( Müllerian ) or mesonephric (Wolffian) ducts that are present during urogenital embryologic development.A simple, asymptomatic paratubal or paraovarian cyst can be managed expectantly without further follow-up. Surgical removal is indicated for these lesions if they undergo torsion, cause persistent pain or pressure symptoms, or appear neoplastic .   42

Hydrosalpinx A hydrosalpinx is an edematous fallopian tube, typically caused by an infection A hydrosalpinx may be asymptomatic or may result in chronic pelvic pain or infertility and sometimes be the source of chronic pelvic pain Other etiologies of chronic pelvic pain should be excluded before salpingectomy is performed. An asymptomatic hydrosalpinx does not generally need to be removed or followed with imaging. The exception to this is women undergoing in vitro fertilization. The use of ultrasound-based 'soft markers' for the prediction of pelvic pathology in women with chronic pelvic pain--can we reduce the need for laparoscopy?AUOkaro E, Condous G, Khalid A, Timmerman D, Ameye L, Huffel SV, Bourne T SOBJOG. 2006;113(3):251.  43

Transvaginal ultrasound image of the left adnexa showing a paraovarian cyst. An anechoic structure is noted in the left adnexa separate from the left ovary. The cyst has a thin wall, as indicated by the arrow, with no identifiable ovarian tissue surrounding the cyst. 44

Transvaginal ultrasound image of the adnexa showing a hydrosalpinx. There is a tubular fluid collection with low-level echoes. An incomplete septation is identified by the arrow. 45

Transvaginal ultrasound image of the right adnexa showing a pedunculated fibroid. A solid-appearing mass is noted in the right adnexa (long arrow). No cystic areas are identified. The mass is slightly heterogeneous and has no appreciable posterior enhancement but has some areas of shadowing (short arrow). The mass is separate from the right ovary. The arrowhead demonstrates a thick stalk that connects the fibroid to the uterus. 46

Transvaginal ultrasound image of the adnexa showing ahydrosalpinx with three-dimensional rendering. A cystic structure with a septation (arrow) is identified in the adnexa . The rendered image (on right side of illustration) demonstrates a tubular fluid collection with incomplete septations indicating a serpiginously dilated fallopian tube. 47

Ultrasound morphology associated with malignancy Solid component that is not hyperechoic and is often nodular or papillarySeptations, if present, that are thick (>2 to 3 mm) Color or power Doppler demonstration of flow in solid component Presence of ascites (any peritoneal fluid in postpostmenopausal women and more than a small amount of peritoneal fluid in premenopausal women is abnormal) Peritoneal masses, enlarged nodes, or matted bowel (may be difficult to detect) 48

Malignancy  Septations, if present, that are irregularly thick (>2 to 3 mm)Color or power Doppler demonstration of flow in the solid component. Presence of ascites (any intraperitoneal fluid in postmenopausal women and more than a small amount of intraperitoneal fluid in premenopausal women is usually abnormal). Peritoneal masses, enlarged nodes, or matted bowel (may be difficult to detect by ultrasound ).Evaluating the risk of ovarian cancer before surgery using the ADNEX model to differentiate between benign, borderline, early and advanced stage invasive, and secondary metastatic tumours: prospective multicentre diagnostic study.AUVan Calster B, Van Hoorde K, Valentin L, Testa AC, Fischerova D, Van Holsbeke C, Savelli L, Franchi D, Epstein E, Kaijser J, Van Belle V, Czekierdowski A, Guerriero S, Fruscio R, Lanzani C, Scala F, Bourne T, Timmerman D, International Ovarian Tumour Analysis Group SOBMJ. 2014;349:g5920.  49

ovarian cystadenocarcinoma50

Transvaginal ultrasound image of an ovarian cancer of the left ovary. The ovarian mass is 4.7 cm and primarily solid, as indicated by the long arrow. Color Doppler imaging demonstrates blood flow within the solid portion of the ovarian mass (short arrow). Almost no normal ovary is visible in the image.51

Adnexal massExcluding malignancy is a principal goal of the evaluation of an adnexal mass 52

Magnetic resonance imagingultrasound has failed to lead to a confident diagnosis, magnetic resonance imaging (MRI) evaluation can be invaluableMRI can demonstrate findings that lead to a confident diagnosis of a particular entity.adnexal mass may be an exophytic leiomyoma. As another example, if the imager thinks that an adnexal mass is probably a benign cystic teratoma based on sonographic appearance but does not have enough confidence in concluding that malignancy is practically excluded (let us say 1 percent chance or less), MRI would be of tremendous additional value but only if it was used to change who or where the surgical treatment was performed.53

Magnetic resonance imaging the need for further MRI characterization of an adnexal mass evaluated sonographically depends on the experience and diagnostic confidence of the imager as well as the experience and surgical approach of the gynecologic surgeon 54

ultrasound morphology High riskFeatures of malignancy, ie, solid, nodular, thick septations Intermediate risk anechoic  and/or  unilocular , but no features of malignancy ( eg , a mass with thin septations or low level echoes) Low risk . Anechoic unilocular fluid filled cysts with thin walls55

Other characteristics of the mass size bilateralityObservational series have generally found the average size of malignant adnexal masses to be >10 cm Pelvic examination, tumor marker level, and gray-scale and Doppler sonography in the prediction of pelvic cancer.AURoman LD, Muderspach LI, Stein SM, Laifer-Narin S, Groshen S, Morrow CP SOObstet Gynecol. 1997;89(4):493. Management of the adnexal mass.AUCurtin JP  SOGynecol Oncol . 1994;55(3 Pt 2):S42.    56

imaging findings suggestive of metastatic disease Ascites or evidence of metastatic disease (eg, peritoneal masses, enlarged lymph nodes) if are present, even in the absence of malignant features in the mass itself, surgical exploration is required Other factors, such as menopausal status, an elevated tumor marker, symptoms, or risk factors  57

menopausal status The degree of clinical suspicion of ovarian cancer is significantly higher for postmenopausal than for premenopausal womensurgical exploration is required for many postmenopausal women with an ovarian mass.58

serum tumor marker postmenopausal women with a mass with an intermediate or low risk appearance, surgical exploration is required if a serum tumor marker is elevated. CA 125 is the tumor marker used most commonly for the detection of epithelial ovarian cancer59

Serum markers  epithelial ovarian carcinomaCA 125 is the most commonly used laboratory testmeasure CA 125 in all postmenopausal women with an adnexal mass. In premenopausal women, measure a serum CA 125  only  if the ultrasound appearance of a mass raises sufficient suspicion of malignancy to warrant a repeat ultrasound or surgical evaluation 60

serum tumor marker  CA 125 >35 U/mL has a sensitivity of 69 to 97 percent and a specificity of 81 to 93 percent for the diagnosis of ovarian cancer  marker algorithms OVA1 and ROMA may be used to decide whether to refer a patient to a gynecologic oncologist Other serum markers are used to evaluate women for less common histologic types, germ cell and sex cord- stromal tumors Myers ER, Bastian LA, Havrilesky LJ, et al. Management of Adnexal Mass. Evidence Report/Technology Assessment No.130 (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-02-0025). AHRQ Publication No. 06-E004, Agency for Healthcare Research and Quality, Rockville, MD February 2006.61

Serum markers other histologic types (AFP,hCG,LDH,E2,Inhibin,Testost, DHEA,AMH )A child or adolescent who presents with an adnexal mass (germ cell tumor) Patients with an adnexal mass who present with symptoms or signs of estrogen excess (abnormal uterine bleeding) or androgen excess ( virilization or hirsutism ): germ cell or sex cord- stromal tumor. 62

Risk factors  Risk factors (other than a hereditary ovarian cancer syndrome) or symptoms alone are not typically an indication for surgery in a woman with a mass with an intermediate or low risk appearanceThe absence of risk factors and symptoms helps to support a decision to manage the patient with surveillancean adnexal mass in a postmenopausal woman was noted on imaging prior to menopause and is unchanged; this information is reassuring and surveillance is typically appropriate for these patients 63

 Three options for managing an adnexal massSurgery malignancy is suspected Other risks associated with the mass ( eg , torsion, infection ) Mass is symptomatic(oophorectomy or ovarian cystectomy)Continued surveillancesuspicion of malignancy is low, but it has not been completely excluded . Surveillance includes serial pelvic ultrasounds  and/or measurement of serum tumor markers Expectant management etiology of the mass is benign no other indications for surgery or surveillance no further follow-up is needed 64

Premenopausal women  High risksurgery is required for women with a mass with features associated with malignancy or any adnexal mass combined with ascites and/or evidence of metastatic disease consistent with ovarian cancer Intermediate/low   risk Many masses related to reproductive function occur in premenopausal women greater proportion of patients with a mass with an intermediate or low risk appearance . most premenopausal women with a mass with an intermediate or low risk appearance, we suggest surveillance rather than surgeryThe exceptions to this are women with a very elevated serum CA 125 or those in whom a germ cell or sex cord-stromal tumor is suspectedThese neoplasms are uncommon, but often occur in younger women 65

premenopausal women measure a serum CA 125 only if the ultrasound appearance of a mass raises sufficient suspicion of malignancy to warrant a repeat ultrasound or surgical evaluation CA 125 value of >35 U/ mL  has a sensitivity and specificity of less than 80 percent, and possibly as low as 50 to 60 percent, based upon data from a meta-analysis of six studies low specificity in premenopausal women is because an elevated CA 125 is also associated with many conditions other than ovarian cancer, and many of these are found in reproductive age patients Based upon the poor diagnostic performance of CA 125 in premenopausal women, there has been some discussion of using a higher CA 125 level (>200 U/mL), but this has been evaluated in few studiesThe markers OVA1 and ROMA may be used to decide whether to refer a patient to a gynecologic oncologist  Validation of referral guidelines for women with pelvic masses.AUIm SS, Gordon AN, Buttin BM, Leath CA 3rd, Gostout BS, Shah C, Hatch KD, Wang J, Berman ML  SOObstet Gynecol. 2005;105(1):35.  66

Conditions associated with an elevated serum CA 125 concentration Gynecologic malignanciesEpithelial ovarian, fallopian tube, and primary peritoneal cancersEndometrial cancerBenign gynecologic conditionsBenign ovarian neoplasms Functional ovarian cysts Endometriosis Meig syndrome Adenomyosis Uterine leiomyomas Pelvic inflammatory disease Ovarian hyperstimulation PregnancyMenstruation67

Nongynecologic conditionsCirrhosis and other liver disease Ascites Colitis Diverticulitis Appendicular abscess Tuberculosis peritonitis Pancreatitis Pleural effusion Pulmonary embolism Pneumonia Cystic fibrosis Heart failureMyocardiopathyMyocardial infarctionPericardial diseaseRenal insufficiencyUrinary tract infectionRecent surgerySystemic lupus erythematosusSarcoidosisNongynecologic cancersBreastColonLiverGallbladderPancreasLung Hematologic malignancies 68

 manage postmenopausal patients as follows  High riskhigh risk mass require surgical exploration Intermediate risk managed based coexisting tumor marker levels, risk factors, and symptoms Many women may be managed with surveillance, but surgical exploration should be performed if clinically significant risk factors or symptoms are presentLow riskunilocular anechoic ovarian cyst and no other findings suggestive of malignancy, surveillance rather than surgery because the risk of malignancy is less than the risk of complications associated with surgical exploration Risk of malignancy in sonographically confirmed septated cystic ovarian tumors.AUSaunders BA, Podzielinski I, Ware RA, Goodrich S, DeSimone CP, Ueland FR, Seamon L, Ubellacker J, Pavlik EJ, Kryscio RJ, van Nagell JR Jr   SOGynecol Oncol . 2010;118(3):278.  69

Size of the mass SuggestionSurgical exploration rather than surveillance for postmenopausal women with a mass that is ≥10 cm in diameter Surgical exploration for women with a 5 to 10 cm mass who also have symptoms suggestive of ovarian cancer some patients without symptoms or other findings suggestive of malignancy may request removal of a mass <10 cm. removal is reasonable if the patient strongly prefers surgical evaluation and removal of the mass and is willing to accept the risks of surgical morbidity and loss of an ovary   70

Surveillance  Women for whom the likelihood of ovarian cancer appears low, but has not been fully excluded, should be managed with continued surveillance with serial pelvic ultrasounds, and, if appropriate, a serum tumor marker. Physiologic cysts typically resolve on follow-up non-physiologic non- neoplastic benign simple cysts usually remain unchanged neoplastic simple cysts enlarge over timeIs expectant management of sonographically benign adnexal cysts an option in selected asymptomatic premenopausal women?AUAlcázar JL, Castillo G, Jurado M, García GL  SOHum Reprod . 2005;20(11):3231.  71

Surveillance If the mass develops features of malignancy, increases in size to ≥10 cm, or the CA 125 increases to >35 U/mL, we proceed with surgeryIf the mass resolves, we discontinue surveillance If the mass remains unchanged or decreases in size and the CA 125 remains <35 U/ mL , surveillance continues until the planned stopping point is reached. 72

Surgery   Surgical exploration for an adnexal mass may be performed laparoscopically (conventional or robotic) or via a laparotomy . The choice of surgical approach depends upon the degree of suspicion of malignancy and surgeon and patient preference . If there is a low or moderate suspicion of malignancy, a laparoscopic approach is typically used. Laparoscopy is associated with a shorter recovery and decreased perioperative morbidity compared with laparotomy. When choosing a surgical approach for a suspected malignancy, it is important to keep in mind that it is unclear if laparoscopy is as sensitive as laparotomy in the detection of small metastatic implants in small bowel mesentery and epigastrium. Laparoscopy is clearly superior to laparotomy for inspection of the diaphragm and for visible peritoneal surfaces. 73

surgical technique must minimize the potential for tumor disruption or dissemination. If malignancy is suspected, oophorectomy is required rather than ovarian cystectomy. Patients with early stage ovarian cancer ( ie , no malignant cells in ascites or peritoneal cytology) benefit from removal of the adnexal mass intact, since opening the mass results in a more advanced stage and adversely affects prognosis If a laparoscopic approach is used, the ovary can be placed in a tissue recovery bag. If the specimen is too large to remove through the existing incisions, cyst fluid may be aspirated (but the collapsed cyst should not be disrupted) or the incision may be enlarged. The practice of morcellating an ovarian mass in a bag is discouraged because it may compromise pathology evaluation.aspiration of cyst contents is not advisable as the sole surgical intervention because no tissue is obtained for histopathology and cytology of cyst fluid is not reliable for exclusion of malignancy, and there is a high rate of recurrence.74

Most ovarian surgeries are for benign disease and can be performed laparoscopically. The major advantages to laparoscopy over laparotomy are reductions in recovery time, hospital stay, cost, and adhesion formation, which is particularly important in women in whom fertility is an issuedata from randomized trials also showed less febrile morbidity and a lower frequency of urinary tract infection, postoperative pain and postoperative complications with laparoscopy

There is increasing sentiment to evaluate some complex cysts laparoscopically because most of them are benign. There are no dogmatic recommendations for this group of patients and clinicians must individualize treatment according to their index of suspicion. The concern associated with the use of laparoscopy in this setting is that the prognosis may be worsened by cyst rupture if malignancy is encountered, although this is unproven.account the patient's age, medical condition, clinical examination (eg, fixed mass or mobile), sonographic appearance of the mass, and tumor markers (eg, CA-125) to gauge the likelihood of malignancy when deciding upon the proper operative approach.

Laparoscopy should be reserved for those cases in which the risk of malignancy is low. Staging and treatment of ovarian cancer via a laparoscopic approach is still under investigation, but it is becoming more commonly used

laparoscopy is the preferred technique for oophorectomy/cystectomy because it is associated with a smaller scar, faster recovery, lower cost, and lower frequency of postoperative adhesion formation than laparotomy.

Situations in which the traditional open method is safer and more appropriate than the laparoscopic approach are when the surgeon and/or assistants are not experienced in the use of an operative laparoscope, when there are dense adnexal adhesions, when the ovary is very large, or when there is a high suspicion of malignancy

The laparoscopic approach is reasonable for patients whose preoperative evaluation suggests benign disease These patients include those with probable dermoids, endometriomas, or physiological cysts that have not resolved with conservative management or are associated with acute symptoms. A laparoscopy may be converted to a laparotomy if the surgeon encounters a difficult dissection.

Intraoperative findings suspicious for malignancy (ascites, enlarged nodes, matted bowel, excrescences, multiple nodular areas) usually warrant conversion to an open evaluation. However, a smooth appearance on the surface of the cyst does not exclude the possibility of a malignancy

Removing cysts in a specimen bag reduces both operating time and spillage. Controlled intraperitoneal spillage of benign cyst contents (eg, cystic teratoma) does not increase postoperative morbidity as long as the peritoneal cavity is copiously lavaged

Cysts that are complex should be removed, not fenestrated, given the possibility of malignancy and high recurrence rates.A solid adnexal mass that is small enough to be removed intact via colpotomy or via a laparoscopic bag can be managed laparoscopically . Solid masses can also be mobilized laparoscopically and then removed through a mini-laparotomy incision or morcellated inside a specimen bag

After the abdomen is entered, pelvic and abdominal washings are obtained and saved to use for staging if a malignancy is subsequently diagnosed. The entire pelvis, abdomen and retroperitoneum (eg, diaphragm, omentum , viscera, kidneys) are inspected for sites suspicious for carcinoma (excrescences, thick adhesions, nodules, enlarged nodes) should be biopsied and sent for frozen section.If findings are consistent with benign disease, the infundibulopelvic ligament and ureter are identified. The peritoneum is incised parallel to the ovarian vessels and the retroperitoneal space is entered.

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The findings of this study support the practice of serial sonography to evaluate indeterminate adnexal masses, but don’t provide data regarding the frequency of surveillance. The biologic basis of the finding that complex masses resolved more quickly is uncertain, unless the majority of these were hemorrhagic cysts. This warrants further analysis of these data and further study. 86

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Serial follow-up ultrasounds were performed every three to six months. Spontaneous resolution of the simple cysts occurred in 2261 women (69 percent) over a mean follow-up of six years. Ten patients were subsequently diagnosed with ovarian cancer: 7/10 had additional abnormal areas which were identified on an interval ultrasound examination, 2/10 developed ovarian cancer after the cyst in question had resolved on sonographic follow-up, and 1/10developed cancer in the ovary opposite the cyst being followed.88

premenopausal women, 70 percent of adnexal masses will resolve over the course of several menstrual cyclesDuring surveillance, if the mass develops features of malignancy, increases in size to ≥10 cm, or the CA 125 increases to >35 U/mL, we proceed with surgery. If the mass resolves, we discontinue surveillance. If the mass remains unchanged or decreases in size and the CA 125 remains <35 U/ mL , surveillance continues until the planned stopping point is reached. Management of the adnexal mass.AUCurtin JP  SOGynecol Oncol . 1994;55(3 Pt 2):S4289

postmenopausal women Intermediate risk mass repeat a transvaginal ultrasound and CA 125 in six weeks and then again six weeks later . then repeat the ultrasound and CA 125 every three to six months for a year . We do a final ultrasound and CA 125 one year later. low risk masses repeat an ultrasound and CA 125 at three months then six months90

premenopausal women Intermediate risk massesrepeat a transvaginal ultrasound in six weeks. This allows visualization of the mass at a different point of the menstrual cycle. then repeat an ultrasound in three months and then six more months . then do a final ultrasound one year later. Low risk masses repeat an ultrasound in three months and then six more months.91

Peritoneal inclusion cyst multicystic inclusion cysts) are uncommon mesothelial lesions that appear as septated, cystic masses that surround the ovary, usually in women with pelvic adhesions Peritoneal inclusion cysts and their relationship to the ovaries: evaluation with sonography.AUKim JS, Lee HJ, Woo SK, Lee TS  SORadiology . 1997;204(2):481.  92

REFERRAL TO A SPECIALIST  Patients with a complex adnexal mass, findings suggestive of metastatic epithelial ovarian cancer (EOC), fallopian tube or peritoneal carcinoma, or laboratory testing suggestive of ovarian cancer (eg, elevated serum CA 125) should be referred to a gynecologic oncologist for further evaluation 93

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