Management of Suspected Ovarian Masses in Premenopausal Women

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Management of Suspected Ovarian Masses in
Premenopausal Women RCOG, 2011 Aboubakr
Elnashar Benha University, Egypt
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• CONTENTS
• Introduction
• Types of adnexal masses
• How to minimise patient morbidity
• Assessment
• Treatment

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• 1. Introduction
• Premenopausal ovarian masses
• Benign almost all
• Malignant
• lt50y 11000
• gt50y 31000 .
• Preoperative differentiation
• Between the benign and the malignant
• problematic.
• Exceptions germ cell tumours
• elevations of a-FP and hCG.
• 10 of suspected ovarian masses
• non-ovarian in origin

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• 2. Types of adnexal masses
• Benign ovarian
• Functional cysts
• Endometriomas
• Serous cystadenoma
• Mucinous cystadenoma
• Mature teratoma
• Ovarian cyst
• fluid-containing structure 30 mm in diameter
• 4 of women

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• Benign non-ovarian
• Paratubal cyst
• Hydrosalpinges
• Tubo-ovarian abscess
• Peritoneal pseudocysts
• Appendiceal abscess
• Diverticular abscess
• Pelvic kidney

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Secondary malignant ovarian Predominantly
breast and gastrointestinal carcinoma.
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Primary malignant ovarian Germ cell
tumour Epithelial carcinoma Sex-cord
tumour Secondary malignant ovarian Predominantly
breast and gastrointestinal carcinoma.
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• 3. How to minimise patient morbidity
• Conservative management
• Functional or simple ovarian cysts
• thin-walled cysts
• No internal structures
• 50 mm maximum diameter
• usually resolve over 23 menstrual cycles
  without the need for intervention.

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II. Use of laparoscopic techniques where
appropriate cost-effective earlier discharge
from hospital.
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III. Referral to a gynaecological oncologist
where appropriate. Mean survival time for women
is significantly improved early diagnosis and
referral is important. Indications 1.
Histological diagnosis 2. strong suspicion of
Borderline ovarian tumours 20 of borderline
ovarian tumours appear as simple cysts on US
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• 4. Preoperative assessment of women with ovarian
  masses
• History
• Examination
• Blood tests
• Imaging
• Estimation the risk of malignancy

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• I. History
• Risk factors
• Protective factors for ovarian malignancy
• Family history of ovarian or breast cancer.
• Symptoms suggestive of
• endometriosis
• ovarian malignancy
• persistent abdominal distension
• appetite change including increased satiety
• pelvic or abdominal pain
• increased urinary urgency and/or frequency.

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• II. Physical examination
• Poor sensitivity in the detection of ovarian
  masses (1551)
• Essential
• abdominal and vaginal
• Evaluation of mass
• tenderness, mobility, nodularity and ascites.
• local lymphadenopathy.
• Acute pain complications should be considered
  (torsion, rupture, hge).

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• III. Blood tests
• Serum CA-125
• Marker for epithelial ovarian carcinoma
• raised in 50 of early stage disease.
• Not indicated simple ovarian cyst
• unreliable in dd benign from malignant in
  premenopausal women
• increased rate of false positives and reduced
  specificity.

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• Raised in
• 1. Fibroids
• 2. Endometriosis
• in stage IIIIV raised to several hundreds or
  thousands of units/ml.
• 3. Adenomyosis
• 4. Pelvic infection.

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• ?Raised
• serial monitoring
• rapidly rising levels are more likely to be
  associated with malignancy than high levels which
  remain static.
• lt200 units/ml
• Further investigations to exclude/treat the
  common differential diagnoses
• gt200 units/ml
• discussion with a gynaecological oncologist

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2. Lactate dehydrogenase (LDH), a-FP and hCG
should be measured in all women under age 40
with a complex ovarian mass germ cell tumours.
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IV. Imaging 1. Ultrasound TVS preferable
increased sensitivity over TAS TVSTAS larger
masses and extra-ovarian disease. Colour flow
Doppler Not significantly improve diagnostic
accuracy Colour flow Doppler3D Improve
sensitivity, particularly in complex cases.
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• Repeating US in the postmenstrual phase
• in cases of doubt
• Endometrial pattern
• diagnosis of estrogen-secreting tum of the ovary.
  
• No single US finding differentiates between
  benign and malignant ovarian masses.

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• 2. CT and MRI
• Routine use does not improve the sensitivity or
  specificity obtained by TVS
• Indicated
• evaluation of more complex lesions .
• Clinical picture and US
• possibility of malignancy
• referral to a gynaecological oncology

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IV. Estimation the risk of malignancy essential
in the assessment of an ovarian mass. 1. RMI
most widely used model 2. Ultrasound
parameters International Ovarian Tumor Analysis
(IOTA) Group
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3. Simple models CA-125, pulsatility index,
resistance index. 4. Intermediate
models morphology scoring systems and the risk of
malignancy index. 5. Advanced models artificial
neural networks and multiple logistic regression
models 6. CA-125 not useful poor specificity.
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• 1. RMI
• RMI I
• NICE for women with suspected ovarian malignancy
  the RMI I score should be calculated and used to
  guide the womans management.
• 1. most effective
• 2. simple to use and reproducible
• utility is negatively affected in the
  premenopausal woman
• incidence of endometriomas, borderline ovarian
  tumours, non-epithelial ovarian tumours and other
  pathologies increasing the level of CA-125 in
  this group

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Calculation of the RMI I RMI U x M x CA-125. ?
The ultrasound scored 1 point for each of the
following characteristics multilocular cysts,
solid areas, bilateral lesions. metastases,
ascites and U 0 (for an ultrasound score of
0), U 1 (for an ultrasound score of 1), U 3
(for an ultrasound score of 25).
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? The menopausal status scored as 1
premenopausal and 3 postmenopausal. ?
Postmenopausal No period for more than one year
or age of 50 who have had a hysterectomy.
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• ? Serum CA-125 IU/ml
• vary between zero to hundreds or even thousands
  of units.
• RMI I score of 200 in the detection of ovarian
  malignancies to be
• Sensitivity 78
• Specificity 87

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2. US alone IOTA Group. high sensitivity,
specificity and likelihood ratios. benign
(B-rules) or malignant (M rules) Sensitivity
95 Specificity 91, Positive likelihood
ratio10 Negative likelihood ratio 0.06.
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• M-rules
• Irregular solid tumour
• Ascites
• At least four papillary structures
• Irregular multilocular solid tumour with largest
  diameter 100 mm
• Very strong blood flow
• Women with an ovarian mass with any of the
  M-rules should be referred to a gynaecological
  oncology

• B-rules
• Unilocular cysts
• Presence of solid components where the largest
  solid component lt7 mm
• Presence of acoustic shadowing
• Smooth multilocular tumour with a largest
  diameter lt100 mm
• No blood flow

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• Guidelines for management
• ACOG, SOGC
• Premenopausal women with a pelvic mass.
• suspicious for ovarian malignancy referred to
  gynaecological oncologist
• CA-125 gt200 units/ml
• Ascites
• Abdominal or distant Metastasis
• First-degree relative with breast or ovarian
  cancer.
• In the largest study validating these guidelines
• 30 of premenopausal women with ovarian cancer
  would not have been regarded as high risk.

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• 5. Management
• Simple ovarian cyst
• lt50 mm
• No follow-up
• very likely to be physiological and almost
  always resolve within 3 menstrual cycles.
• 5070 mm
• yearly ultrasound follow-up
• gt70mm simple cysts
• for either further imaging (MRI) or
• surgical intervention
• difficulties in examining the entire cyst
  adequately by US.

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• 2. Ovarian cysts that persist or increase in size
  unlikely to be functional
• surgical management.
• Combined oral contraceptive pill
• does not promote the resolution of functional
  ovarian
• cysts.
• (Cochrane review)

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3. Mature cystic teratomas (dermoid cysts) grow
over time, increasing the risk of pain and
ovarian accidents Surgical management
preoperative assessment using RMI 1 or
ultrasound rules (IOTA Group).
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Lines of management I. Surgery The appropriate
route depends on 1. Patient suitability for
laparoscopy and her wishes 2. Mass size,
complexity, likely nature 3. Setting surgeons
skills and equipment.
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A. Lparotomy In the presence of large masses
with solid components (for example large dermoid
cysts)
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• B. Laparoscopic approach
• Preferred to laparotomy in suitable patients.
• lower postoperative morbidity (fever, pain)
• shorter recovery time cost-effective

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• Spillage of cyst contents
• should be avoided
• preoperative and intraoperative assessment
  cannot absolutely preclude malignancy.
• use of a tissue bag to avoid peritoneal spill of
  cystic contents bearing in mind the likely
  preoperative diagnosis.
• Any solid content should be removed using an
  appropriate bag.
• The use of tissue retrieval bags is commonplace
  but there is no general consensus for their
  routine use.

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• Chemical peritonitis
• spillage of dermoid cyst contents
• lt0.2 of cases.
• Meticulous peritoneal lavage of the peritoneal
• cavity using large amounts of warmed fluid.
• Cold irrigation fluid
• hypothermia
• Difficult retrieval of the contents by
  solidifying the fat-rich contents.

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• Endometrioma gt30 mm
• histology should be obtained to
• identify endometriosis
• exclude rare cases of malignancy.
• peritoneal spill of cyst contents upstage a
  tumour if the suspected endometrioma is actually
  a malignant tumour.
• This is rare

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• Removal of benign ovarian masses should be via
  the umbilical port.
• 1. less postoperative pain
• 2. quicker retrieval time than when using lateral
  ports
• 3. Avoidance of extending accessory ports
• reducing
• postoperative pain
• incisional hernia
• epigastric vessel injury.
• improved cosmesis.

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• Oophorectomy
• should be discussed with the woman
  preoperatively.
• either an expected or unexpected part of the
  procedure.
• The pros and cons of electively removing an ovary
  should be discussed, taking into consideration
  the
• womans preference and the specific clinical
  scenario.

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• III. Aspiration of ovarian cysts
• vaginally or laparoscopically
• less effective
• high rate of recurrence.
• RCTs
• Resolution rates
• Similar to expectant management (46 vs 44.6).
• Recurrence rates
• 53-84.
• Done
• highly selected cases
• following discussion between the woman and her
  clinician

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