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adnexal_mass

the patient with an adnexal mass

introduction

  • an adnexal mass that is solid, complex, or larger than 8cm in any age group should be treated as possibly malignant (and if larger than 8cm is at risk of complication and should probably be removed anyway).
  • in prepubertal children and in premenopausal women, a small mass less than 5cm that is cystic on US can be watched with repeat US if the patient is asymptomatic.
  • an enlarging or persistent mass should be evaluated
  • any ovarian mass in a post-menopausal woman should be considered potentially malignant and managed surgically
  • don't forget ectopic pregnancy and tubo-ovarian abscess from pelvic inflammatory disease (PID)
  • investigations to consider prior to referral to gynaecology outpatients:
    • repeat USS
    • hCG - to exclude ectopic pregnancy, trophoblastic disease or a hCG-secreting tumour
    • alphafetoprotein (AFP) - secreted by virtually all endodermal sinus tumours
    • CA-125 - elevated in > 70% of ovarian malignancies but can also be elevated in other conditions such as endometriosis or PID.

referrals

  • Gynaecology oncologist:
    • Mr Rome
      • Suite 115, 1st floor Epworth Freemasons Day Centre, 320 Victoria Pde, E. Melbourne
      • ph: 9418 8128 fax 9418 8130
    • patients with suspicious ovarian masses, consider taking blood for FBE, U&E, LFT, CA-125, CA 19.9, HCG as tumour markers

prepubertal years

    • 50% are dermoid cysts (benign cystic teratoma)
    • solid teratomas
    • dysgerminomas
    • gonadoblastomas
      • rare mixed germ cell & sex-cord tumor
      • most patients are karyotypically 46XY or mosaic 45XO-46XY
    • endodermal sinus tumours
      • arise from the yolk sac endoderm
      • mostly seen in children & adolescents
      • highly malignant, metastazing early through lymphatics, secrete AFP, poor prognosis.
    • epithelial ovarian tumours
      • primarily serous & mucinous cystadenomas and have potential to develop into cystadenocarcinoma
      • very uncommon in childhood and early adoloscence but account for 18% of ovarian neoplasms in late adolescence.
    • gonadal stromal tumours
      • granulosa cell tumours are infrequent in children and when present are rarely malignant but occasionally produce precocious puberty.
  • congenital anomalies:
    • bicornuate uterus
    • uterus didelphys - complete utering duplication
    • pelvic kidney - 1 in 600 people
    • functional ovarian cysts:
      • follicular cysts are found even in the ovaries of young children
      • germinal inclusion cysts - seldom large enough to cause concern
      • parovarian cysts - can occur at any age, but most common in reproductive years
  • tumours of fallopian tubes and uterus are very rare in childhood

reproductive years

  • most commonly are physiologic or functional disorders but infectious causes should be high on the DDx
    • functional ovarian cysts:
      • follicular cysts account for 20-50% of ovarian masses in post-menarchal women during the reproductive years
        • ruptured cysts may present as acute severe pelvic pain worse on movement +/- rebound tenderness. The pain usually decreases over 1-2 days.
        • torsion of the cyst is more likely in larger cysts and will cause prolonged pain unless it spontaneously untwists. Torsion may also cause bleeding or infarction of the ovary.
        • those smaller than 6-8cm will usually disappear after 1-2 menstrual cycles, and if still a problem, may shrink or disappear with combined oral contraceptive pill (OCP) Rx.
        • those larger than 6-8cm should be referred to O&G as suspicion of neoplasm is increased.
      • corpus luteum cysts:
        • occur after ovulation (and thus in early pregnancy) and can reach 6-8cm diameter.
        • usually disappear over 1-2 menstrual cycles or with combined oral contraceptive pill (OCP) Rx, or by the end of the 1st trimester of pregnancy.
      • luteoma of pregnancy:
        • occurs in 10-40% of pregnancies and is a benign solid tumour usually 5-10cm and occasionally produces testosterone causing mild maternal masculinisation during pregnancy and has been reported to cause masculinisation in the female fetus.
        • these regress post-partum leaving no residua.
        • NB. a solid ovarian tumour discovered during pregnancy should be surgically evaluated because of the possibility of ovarian cancer.
    • germinal inclusion cysts may occur
    • theca lutein cysts:
      • sometimes present in normal pregnancy, but more often accompany trophoblastic disease (30% of these patients have enlarged ovaries)
      • multiple cysts ranging from 1-15cm causing ovaries to enlarge rapidly and may continue growing for a short time after delivery of the molar pregnancy then return to normal size within 3-4 months.
  • parovarian cysts:
    • remnants of wolffian ducts & account for 10% of adnexal masses in reproductive years.
    • benign cysts are most commonly found in 30-40yr olds but may occur in any age.
    • have no pedicle and thus not at risk of torsion.
    • hydatid of Morgagni is a pedunculated cyst of mullerian origin, usually 1-2cm and usually of no concern, however, may reach 10-15cm and cause torsion of the adnexa.
    • result from elevated levels of LH & cysts become more apparent with each postmenarchal year
    • generally numerous 2-3cm subcapsular cysts
  • endometrioma:
    • acute salpingitis may cause a pyosalpinx or hydrosalpinx and may progress to a tuboovarian abscess (DDx includes appendiceal rupture and subsequent sequestration or diverticular abscess).
    • germ cell tumours account for 80% of ovarian neoplasms requiring surgery in adolescents
      • dermoid cysts - 99% are benign. 10-20% are bilateral.
      • solid teratomas:
        • usually malignant; 50% occur before age 20yrs, 98% are unilateral.
        • rarely hormonally active, although occasional one does produce hCG.
      • dysgerminomas:
        • arise from undifferentiated germ cells and are always malignant.
        • usually occur before 20yrs age & may be bilateral, and may secrete hCG.
      • choriocarcinoma:
        • very rare to arise without a pregnancy; highly malignant; secretes hCG.
      • gonadoblastomas and endodermal sinus tumours
    • epithelial ovarian tumours:
      • serous cystadenomas are most frequent in 20-40yr olds
      • mucinous cystadenomas
        • most frequent in 30-50yr olds and usually > 15cm at diagnosis and may form tumours weighing more than 45kg. prone to torsion and adhesion formation.
      • endometrioid tumors:
        • less common than cystadenomas; most frequent in 30-50yr olds and are usually malignant although with reasonable prognosis. May be cystic and up to 25cm.
    • gonadal stromal tumours (sex cord mesenchymal tumors)
      • often hormonally active
      • granulosa cell tumours
        • usually 5-10cm and generally solid but may undergo cystic degeneration if large.
        • may produce dub as they can produce excess oestrogen (25% do), and thus can cause endometrial hyperplasia or carcinoma, particularly in woman aged > 40yrs.
        • if malignant (25% are), late recurrence beyond 5yrs often occurs.
      • thecoma fibromas
        • almost never malignant but almost always hormonally active
        • rarely occur before age 30yrs, and less common after menopause than granulosa cell tumours
        • luteoma - may produce oestrogen, androgen or be inert, and more likely to become malignant than thecoma fibromas
      • Sertoli-Leydig cell tumours (formerly called arrhenoblastomas or androblastomas)
        • very rare; 25% are hormonally active; 3-20% are malignant.

menopausal women

  • functional cysts should not occur after the menopause
  • diverticular abscess (left side more common than right side)
  • ovarian tumours are common in older women
    • although benign dermoid and epithelial cysts do occur, any ovarian mass in a post-menopausal woman should be considered potentially malignant and managed surgically
    • cysts < 5cm may be observed with repeat US in 2-3months and if unchanged may be oberved with interval examinations as more than 90% of these are benign.
adnexal_mass.txt · Last modified: 2009/10/30 09:43 (external edit)