Management of Suspected Ovarian Masses in Premenopausal Women RCOG, 2011

Management of Suspected
Ovarian Masses
in Premenopausal Women


RCOG, 2011

1. Management of Suspected
Ovarian
Masses
in Premenopausal Women
RCOG, 2011
AboubakrElnashar
BenhaUniversity, Egypt
ABOUBAKR ELNASHAR

2. ABOUBAKR ELNASHAR
CONTENTS
1.Introduction
2.Types of adnexalmasses
3.How to minimisepatient morbidity
4.Assessment
5.Treatment

3. 1. Introduction
Premenopausal ovarian masses
Benign: almost all
Malignant:
<50y: 1:1000
>50y: 3:1000 .
Preoperative differentiation:
Between the benign and the malignant:
problematic.
Exceptions: germ cell tumours
elevations of α-FP and hCG.
10% of suspected ovarian masses:
non-ovarian in origin
ABOUBAKR ELNASHAR

4. 2. Types of adnexalmasses
Benign ovarian
1.Functional cysts
2.Endometriomas
3.Serous cystadenoma
4.Mucinouscystadenoma
5.Mature teratoma
Ovarian cyst:
fluid-containing structure ≥30 mm in diameter
4% of women
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5. Benign non-ovarian
1.Paratubalcyst
2.Hydrosalpinges
3.Tubo-ovarian abscess
4.Peritoneal pseudocysts
5.Appendicealabscess
6.Diverticularabscess
7.Pelvic kidney
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6. Secondary malignant ovarian
Predominantly:
breast and
gastrointestinal carcinoma.
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7. Primary malignant ovarian
Germ cell tumour
Epithelial carcinoma
Sex-cord tumour
Secondary malignant ovarian
Predominantly breast and gastrointestinal
carcinoma.
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8. 3. How to minimisepatient morbidity
I.Conservative management
Functional or simple ovarian cysts:
thin-walled cysts
No internal structures
≤50 mm maximum diameter:
usually resolve over 2–3 menstrual cycles without
the need for intervention.
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9. II. Use of laparoscopic techniques
where appropriate
cost-effective
{earlier discharge from hospital}.
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10. III. Referral to a gynaecologicaloncologist
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 tumoursappear as simple
cysts on US
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11. 4. Preoperative assessment of women
with ovarian masses
I.History
II.Examination
III.Blood tests
IV.Imaging
V.Estimation the risk of malignancy
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12. 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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13. II. Physical examination
Poor sensitivity in the detection of ovarian masses
(15–51%)
Essential
abdominal and vaginal
Evaluation of mass:
tenderness, mobility, nodularityand ascites.
local lymphadenopathy.
Acute pain: complications should be considered
(torsion, rupture, hge).
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14. III. Blood tests
1.Serum CA-125
Marker for epithelial ovarian carcinoma
raised in 50% of early stage disease.
Not indicated: simple ovarian cyst
unreliable in ddbenign from malignant in
premenopausal women
{increased rate of false positives and reduced
specificity}.
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15. Raised in:
1. Fibroids
2. Endometriosis:
in stage III–IV raised to several hundreds or
thousands of units/ml.
3. Adenomyosis
4. Pelvic infection.
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16. ●Raised:
serial monitoring
{rapidly rising levels are more likely to be associated
with malignancy than high levels which remain static}.
<200 units/ml:
Further investigations to exclude/treat the common
differential diagnoses
>200 units/ml
discussion with a gynaecologicaloncologist
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17. 2. Lactate dehydrogenase(LDH), α-FP and hCG
should be measured in all women under age 40 with
a complex ovarian mass
{germ cell tumours}.
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18. IV. Imaging
1. Ultrasound
TVS:
preferable {increased sensitivity over TAS}
TVS+TAS:
larger masses and extra-ovarian disease.
Colourflow Doppler:
Not significantly improve diagnostic accuracy
Colourflow Doppler+3D
Improve sensitivity, particularly in complex cases.
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19. Repeating US in the postmenstrual phase
in cases of doubt
Endometrial pattern:
diagnosis of estrogen-secreting tumof the ovary.
No single US finding differentiates between benign
and malignant ovarian masses.
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20. 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 gynaecologicaloncology
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21. 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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22. 3. Simple models:
CA-125, pulsatilityindex, 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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23. 1. RMI
RMI I
NICE: for women with suspected ovarian
malignancy the RMI I score should be calculated
and used to guide the woman’s 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 tumoursand other
pathologies increasing the level of CA-125 in this
group}
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24. Calculation of the RMI I
RMI = U x M x CA-125.
●The ultrasound:
scored 1 point for each of the following
characteristics:
multilocularcysts,
solid areas,
bilateral lesions.
metastases,
ascitesand
U = 0 (for an ultrasound score of 0),
U = 1 (for an ultrasound score of 1),
U = 3 (for an ultrasound score of 2–5).
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25. ABOUBAKR ELNASHAR

26. ●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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27. ●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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28. 2. US alone:
IOTA Group.
high sensitivity, specificity and likelihood ratios.
benign (B-rules) or malignant (M rules)
Sensitivity: 95%
Specificity: 91%,
Positive likelihood ratio:10
Negative likelihood ratio: 0.06.
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29. B-rules
1.Unilocularcysts
2.Presence of solid
components where
the largest solid
component <7 mm
3.Presence of
acoustic
shadowing
4.Smooth
multiloculartumour
with a largest
diameter <100 mm
5.No blood flow
M-rules
1.Irregular solid tumour
2.Ascites
3.At least four papillary
structures
4.Irregular multilocularsolid
tumourwith largest
diameter ≥100 mm
5.Very strong blood flow
Women with an ovarian mass with
any of the M-rules should be
referred to a gynaecological
oncology
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30. Guidelines for management
ACOG, SOGC
Premenopausal women with a pelvic mass.
suspicious for ovarian malignancy: referred to
gynaecologicaloncologist:
1.CA-125 >200 units/ml
2.Ascites
3.Abdominal or distant Metastasis
4.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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31. 5. Management
1.Simple ovarian cyst
<50 mm
No follow-up
{very likely to be physiological and almost always
resolve within 3 menstrual cycles}.
50–70 mm
yearly ultrasound follow-up
>70mm simple cysts
for either further imaging (MRI) or
surgical intervention
{difficulties in examining the entire cyst adequately
by US}.
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32. 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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33. 3. Mature cystic teratomas(dermoidcysts)
{grow over time, increasing the risk
of pain and ovarian accidents}
Surgical management
preoperative assessment using RMI 1 or ultrasound
rules (IOTA Group).
ABOUBAKR ELNASHAR

34. 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:
surgeon’s skills and equipment.
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35. A. Lparotomy
In the presence of large masses with solid
components (for example large dermoidcysts)
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36. B. Laparoscopic approach
Preferred to laparotomyin suitable patients.
1.lower postoperative morbidity (fever, pain)
2.shorter recovery time: cost-effective
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37. Spillage of cyst contents
should be avoided
{preoperative and intraoperativeassessment 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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38. Chemical peritonitis
{spillage of dermoidcyst contents}:
<0.2% of cases.
Meticulous peritoneal lavageof 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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39. Endometrioma>30 mm
histology should be obtained to
identify endometriosis
exclude rare cases of malignancy.
: peritoneal spill of cyst contents: upstage a tumourif
the suspected endometriomais actually a malignant
tumour.
This is rare:
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40. 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
incisionalhernia
epigastricvessel injury.
improved cosmesis.
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41. 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
woman’s preference and the specific clinical
scenario.
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42. III. Aspiration of ovarian cysts
vaginally or laparoscopically
less effective
high rate of recurrence.
RCTs:
Resolution rates:
Similar to expectant management (46% vs44.6%).
Recurrence rates
53%-84%.
Done:
highly selected cases
following discussion between the woman and her
clinician
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43. ABOUBAKR ELNASHAR