Management on Adnexal Mass

Prof HOSSAM HUSSEIN

Causes of Adnexal Masses

CancerBenign neoplasmsInfection (Abscess)Edematous Ovary secondary to torsionEndometriosisGI conditionsCorpus Luteum

Causes of Adnexal Masses

Follicles and Follicular cystsHydrosalpinxPeduculated LeiomyomasPregnanciesHemorrhageAppendicitis

Symptoms of An Adnexal Mass

NonePain/Abdominal discomfortGI symptomsUrinary symptomsPelvic pressure/BloatingBackache

Symptoms of An Adnexal Mass

EdemaDVT/PEElectrolyte abnormalityAcute abdomenLarge Mass

Discovery of Adnexal Mass

On yearly pelvic examPelvic exam for specific complaintUltrasoundCT (usually a serendipitis finding)MRIOther radiologic test

Discovery of an Adnexal Mass

Serologic abnormalitySeen grosslyDuring surgery for an unrelated complaint

Adnexal MassesThe following aspects of an adnexal mass should be evaluated.

Mobility – the mass should be moved by the vaginal probe or by the hand of the operator that is resting on the abdomen (‘sliding organs’ sign).Pain – its location should be established by watching the on-screen picture when touching different organs with the tip of the transvaginal probe.Wall structure – features of an ovarian mass, such as thickness and outer and inner surface irregularities and papillae, should be described and measured.Septations – the thickness of the septations should be reported.Echogenicity of the mass – the mass can be completely sonolucent and may have low-level echogenic contents, may be with or without an echogenic core, may have mixed echogenicity containing all of these components or may be completely echogenic.

Adnexal MassesThe presence of the following conditions may make it more difficult to detect

ovarian or adnexal masses with ultrasonography.

Fluid-filled loop of bowelFaeces in loop of bowelClosed-loop bowel obstructionArtifact of multipath reflection of sound waves (stratified echo pattern resulting from echoes bouncing back and forth) from fluid-filled structure (e.g. bladder)Mesenteric cystsPeritoneal inclusion cysts (postoperative or after infections)Nabothian cystsHydrosalpinges (acute and chronic)Large fibroids.

What is the goal of management of the adnexal Mass?

Rule out CancerAlleviate symptomsDetermine long term problems (i.e.; fertility, chronic pain, recurrence, and long term treatment)When to not intervene (over test or treat)

Ovarian Cancer

Age

40

75

Incidence

15/100,000

54/100,000

Risk Factors for Ovarian Cancer

Age (risk increases with age)NulliparityAncestry (American, Northern European, and Ashkenazi Jews)Personal history(only 10% are familial)Endometrial cancerBreast Cancer

Risk Factors for Ovarian Cancer

?Fertility DrugsUse of Oral Contraceptives ( the longer the use the more protective it is the relative risk after 10 years use is 0.2)Tubal Ligation is protectiveHysterectomy is protective but BSO does not eliminate the risk

Evaluation of an Adnexal Mass

HistoryPhysical/ PAPUltrasoundCA125 (+/- LDH,AFP,Inhibin)HCG, CBCLaparoscopy/Laparotomy

Ultrasound Exam

Solid mass/ or complex massCystic Mass(unilocular more likely benign)Size (5-6cm in young patient repeat scan 4-6 weeks)Complex mass can be seen with corpus luteum or hemorrhagic cystDoppler flow/Pulsitile index

Ultrasound

Pulsitility index of less than 0.4 is indicative of malignancy (experimental)Associated findings (ascites, fibroids,or endometrial abnormalities)

Labs

CBC-looking for evidence of PID or anemiaSed Rate- non specific but best test for PIDHCG- rule out pregnancy is any reproductive age women (also a tumor marker for germ cell tumors of the ovary and hydatidiform mole)

Labs

CA125- Tumor marker present in 80% of advanced ovarian cancers (less than 50% of stage I cancers)Unfortunately can be elevated in endometriosis, menses, infection, fibroids, liver or renal failure, ascites, breast cancer, endometrial and cervical cancers and GI malignancies

Management based on:

Age of patientSize of massUltrasound description of cystic or complex or solidOther associated finding i.e, ascites, pulmonary effusion, lymphadenopathy, other cancers (cervix, endometrium, breast)

Management under age 30

Cystic or complexLess than 6cmSuppress with birth control pills and/ or repeat ultra sound in 4-6 weeksIf persistent laparoscopy with probable ovarian cystecomyGreater than 12cm- surgery

Management under age 30

Cystic 6-10cm can repeat ultrasound or proceed to surgerySolid mass greater than 6cm surgeryGrey area complex 6-8cm

Management over 40 to 50

Cystic less than 6cm repeat ultrasound 4-6 weeks +/- suppressionComplex greater than 6-8cm- CA125 if elevated proceed to surgery if normal possibly repeat scan 4-6 weeksSolid greater than 6 cm- CA125 and surgery

Benign Conditions of the Adnexa

Hydrosalpinx-Rx antibiotics re-assess TOA- IV antibiotics (Cefotetan plus vibramycin or Clindamycin plus Gentamycin) re-assess 4 weeks if no recurrence of Sx no further Rx if recurrent possible TAH BSO after repeat course of antibiotics. It may be necessary to do laparoscopy to establish diagnosis

Benign conditions of the Adnexa

Endometriosis- to establish the diagnosis requires laparoscopy Rx- Lupron(GnRh agonist), Progesterones, Danazol (anti estrogen), Birth control pills either cyclic or continuous, or surgeryOvarian cystectomy if child bearing to be preserved, with excision or ablation of endometriosis

Benign conditions of the Adnexa

Hemorrhagic cyst-usually manage with narcotic analgesics, usually self limiting 2-4 weeks, occasionally surgical intervention needed (again preserve ovary if child bearing wanted)Suppression with OC’s acceptable

Corpus Luteum with or without hemorrhage-Narcotic analgesics +/- BCP’sRare surgeryEctopic pregnancy-Surgery or methotrexatePedunculated fibroids- No Rx if small-surgical removal if large or symptomatic

Benign Conditions of the Adnexa

Benign Conditions of the Adnexa

Diverticular disease- Antibiotics for acute attacks, dietary changes and fiber, surgery if neededAppendicitis- SurgeryOvarian torsion- Oophorectomy occasionally detorsions

Benign Conditions of the Adnexa

Para Tubal cysts- No RxFollicular cyst, Polycystic ovarian disease, and hyperstimulation of the ovary all managed conservatively

Benign Conditions of the Adnexa

Benign cystic Teratoma (Dermoid Cyst)-Most common tumor in reproductive age women 25% of all ovarian neoplasms80% less than 10cm15% bilateral50% asymptomatic1-2% malignant transformation

Cystic Teratoma cont

Complications include rupture, torsion, infection, hemorrhage, and malignant transformation, Thyrotoxicosis, autoimmune hemolytic anemia, and carcinoidTreatment- ovarian cystectomy or Oophorectomy(can wait until after -delivery if pregnant)

Ovarian Cysts

What does this mean?FollicleCorpus luteumSerous cystadenomaMucinous cystadenoma

Case #1

19yo GoPoAcute onset right sided pelvic painAfebrileWBC-8,000Never sexually active

Ultrasound shows a 5cm complex mass R adnexa Pelvic exam acutely tender no discharge

Case #1

Most likely hemorrhagic corpus Treat with narcotic analgesicsConsider suppression with birth control pills

Case # 2

32yo G3P3No symptomsYearly exam feel fullness left adnexa no tenderness HCG neg

Ultrasound exam shows multiple cysts in both ovaries largest 2.3cm R ovary 5cmX4.2cm, L ovary 4.6cmX3.9cm

Case #2

Polycystic ovariesEither induce ovulation is pregnancy desired orSuppress with BCP’sDepending on other factors- labs Insulin, BS TSH, LH, FSH, Testosterone, DHEAS

Case # 3

30yo G2P1ab1Mass left adnexa at yearly examNo SxHCG neg

Ultrasound shows 6cm complex mass with internal echoes (possible teratoma)

Case # 3

These are fairly obvious on U/SSurgical removal by cystectomy in younger patients. Older patient oophorectomyThese are not emergency cases

Case #4

26yo GoPoPt noticed weight gain and protuberant abdomenHCG negMass on exam to xyphoid , non tender

Ultrasound exam shows 26cm cystic mass with multiple septationsCA125- 5

Case # 4

Usually one would suspect a mucinous cystadenomaThis patient had a huge hydrosalpinx Surgical removal

Case #5

55yo G5P4C/O clothes not fitting well, fullness in lower pelvis, early satietyPelvic exam normal but limited do to pt mild obesity-

Ultrasound shows solid mass in R ovary 5cm L ovary not seenCA125-95CT normal

Case # 5

Ovarian cancer

Case #6

45yo G3P3Mild menorrhagiaYearly exam 10week size uterus with solid mass in L adnexaHCG neg

Ultrasound shows enlarged uterus with multiple fibroidsCA125- 40

Case # 6

Pedunculated uterine fibroidTAHNo treatment

Case #7

55yo G4P4PMBEndometrial biopsy atrophic endometrium

Ultrasound exam shows 4mm endometrium with 3cm unilocular cyst R adnexa

Case #7

Benign cystRepeat U/S 4- 6 weeks if no change possibly recheck one more timeIf it changes laparoscopy possible laparotomy

Case #8

23yo G3P1Severe pelvic pain onset 2 days prior to admissionWBC- 22,000Temp101HCG neg

Ultrasound exam shows 8cm complex mass L adnexaCA125-50+ rebound

Case # 8

PID with tubo-ovarian abscessIV Clindamyacin and GentamyacinRepeat U/S 4-6 weeks

Case #9

42yo G2P2Acute onset R lower pelvic painPelvic exam severe pain making exam poorWBC- 15,000Temp 101

Ultrasound exam shows 8cm mass in the R adnexa+ rebound

Case # 9

Ovarian torsionOophorectomy

Review

Ovarian “cysts” in reproductive age women are usually folliclesLess than 5cm in young patients can be reassessed in about 6 weeks Small unilocular cysts can be managed conservatively in most patientsCT’s are usually less accurate than ultrasound

Review

CA125 is not a screening testIf the clinical picture does not match the finding on laboratory exams reassess

Congenital Uterine Congenital Uterine AnomaliesAnomalies

3D Ultrasound is more accurate than 2D Ultrasound for diagnosing arcuate, subseptated,

septated and bicornuate uteri, but not for didelphys. It is very useful to determine the

dimensions of uterine septum, which may provide very useful information to surgeons

during hysteroscopy.

Subseptate Uterus Complete Septate

The two uterine bodies and the two endometrial cavities with similar dimensions and morphology are clearly distinguishable. E: endometrium.

Fibroids

Benign Ovarian

Simple cyst Dermoid cyst clear fluid echogenic contentsSmooth wall nodule in cyst wall

Haemorrahgic cyst

Haemorrhagic cyst EndometriomaEchogenic contents thick wallResolves spontaneously

Endometrioma

Endometrioma in POD

Endometrioma

hyperstimulation

The appearance of an ovary demonstrating multiple follicular development characteristic of ovarian hyperstimulation

syndrome

Hypo/anechoic cysts containing one or more hyperechoic nodules (“dermoid plug”), Cysts containing hyperechoic thin stripes and spots on a hypo/anechoic background (“starry sky” appearance

dermoids

Bening mucinious cystadenoma

Ovarian fibroma

A haemorrhage inside an ovarian cyst in a patient represented by acute abdomen

Ultrasound in detecting early Ultrasound in detecting early ovarian carcinomaovarian carcinoma

Among ‘high-risk’ women (women with a family history of ovarian cancer or a personal history of

breast cancer) the sensitivity for detection of Stage I disease was 25% while the sensitivity for low-risk

women was 67 %.

This less-than-ideal sensitivity is not unexpected, because in many Stage I ovarian cancers, the

ovaries are neither enlarged nor morphologically abnormal.

Ultrasound in detecting early Ultrasound in detecting early ovarian carcinomaovarian carcinoma

The use of color or Power Doppler imaging has not been shown to add significantly to the diagnosis of early-stage disease.

3-D volume acquisition and 3-D Power Doppler may help in the early identification of abnormal vascularity and architectural changes within

the ovary. Excrescences not seen by 2-D technology may be observed. While 3-D Power Doppler provides a new tool for measuring the quality of ovarian vascularity, its clinical value for the early detection of ovarian

carcinoma has yet to be determined. The efficiency of 3-D Power Doppler imaging in identifying Stage I ovarian cancer has yet to be

determined.

The low annual prevalence of ovarian cancer within the general population, the large number of

women who must therefore be screened to identify a single ovarian cancer, and the poor sensitivity of

the test for Stage I disease make routine use of ultrasound for detection of ovarian cancer

impractical.

Vascular projection in a cyst

Surface rendering of a papillary in a cyst

Cont.

cont

A 10 years old girl US shows a predominantly a solid tumor (Dysgerminoma)

A granulosa cell tumor in 6 years old girl

An immature teratoma with a apartially solid and cystic mass seen in 11 years girl

Ovarian carcinoma note the solid and cystic nature

Tubal

A hydrosalpinx containing anechoic fluid and incomplete septation (s)

The ‘beads-on-a-string’ sign (arrows) considered as additional evidence of the presence of hydrosalpinx.

A hydrosalpinx showing a low level echoes within the distended fetal tube together with incomplete septations.

The typical colour Doppler energy findings of hydrosalpinx

Hydroalpinx

Ectopic pregnancyEctopic pregnancyThe introduction of beta hCG testing and

transvaginal ultrasound has changed our approach to the patient suspected of an ectopic pregnancy.

Important advantage of the most currently used trans-vaginal transducers is the ability to perform simultaneous color and spectral Doppler studies,

allowing easy identification of the ectopic peritrophoblastic flow. Therefore, color Doppler may

be applied whenever a finding is suggestive of ectopic pregnancy.

Ectopic pregnancy in Lt. tube Ectopic pregnancy in Lt. tube

Ectopic gestational sac in the left adnexal region Ectopic gestational sac in the left adnexal region surrounded by a ring of fine near by vessels.surrounded by a ring of fine near by vessels.

(TAS) Lt EP

Left EP

Hetrotopic pregnancy

Rt. interstitial ectopic pregnancy by 3-D trasnvaginal Rt. interstitial ectopic pregnancy by 3-D trasnvaginal sonographysonography

Rt inflammatory mass

Appendicular mass

Acutely inflamed appendix in deep pelvic position. The appendix could only be visualized with the help of a transvaginal probe

Cecal carcinoma. US reveals asymmetric, hypoechoic, circumferential wall thickening of the cecum (arrowheads) with narrowing of the lumen. There is one pathologically enlarged lymph node.

Thanks

HOW TO ASSESS AN ADNEXEAL MASS USING US

PROF ABOUSHADY

The appearance of an ovary demonstrating multiple follicular development characteristic of ovarian hyperstimulation

syndrome

Tubal

A hydrosalpinx containing anechoic fluid and incomplete septation (s)

Ectopic pregnancy in Lt. tube Ectopic pregnancy in Lt. tube

Ectopic gestational sac in the left adnexal region Ectopic gestational sac in the left adnexal region surrounded by a ring of fine near by vessels.surrounded by a ring of fine near by vessels.

Rt. interstitial ectopic pregnancy by 3-D trasnvaginal Rt. interstitial ectopic pregnancy by 3-D trasnvaginal sonographysonography

Thanks