Approach to Ovarain Masses

2. MilestBackgroundnes 2006 - 2016
Adult Surgery Department
Ovaries according to histology
Epithelial (arising from ovarian or fallopian tube epithelium
• Germ cell (from egg-producing cells)
• Stromal ( from hormone producing cells)
- Serous & mucinous
- most common
- Endometriod
- Brenner
-Dysgermenoma
- Endometrail sinus
- Teratoma
- Choriocarcinoma
-Granulosa theca
-Sertoli lyding cell

3. Milestones 2006 - 2016
Outline
Adult Surgery Department
Concepts On Aetiology
Most premenopausal tumours are benign in origin
 Malignancy can occur at all ages
this risk increases with age
Postmenopausal women require aggressive evaluation

4. NongynaeCauses
Donʼt forget thereʼs other stuff in the pelvis!
Brown G. A gynecologic approach to evaluation of pelvic masses in women JAAPA2012

5. Milestones 2006 - 2016
Adult surgery Department
Clinical Features
Often manifests late
Abdominal or pelvic pain bloating
Abdominal distension
Other nonspecific symptoms

6. Milestones 2006 - 2016
Adult surgery Department
Clinical Features
Inspection
Overall, the patient may
look unwell
The abdomen may be
distended, generally or
asymmetrically
The umbilicus may be
deviated
If acute, the abdomen may not
move with respiration

7. Milestones 2006 - 2016
Adult surgery Department
Clinical Features
Palpation
Is the surface smooth or nodular?
Nodularity is not good
Is the mass fixed or mobile
Consistency - hard, firm or soft

8. Ascites
this is never
a good sign
you must
know how to
evaluate for
shifting
dullness

9. Investigations

10. Ultrasound
TVS image produces greater
resolution

11. Milestones 2006 - 2016
Adult surgery Department
Role of ultrasound
An essential tool for diagnosis - first Ix to be considered
Any mass must initially be scanned Abdominal or transvaginal
Features to look
composition of tumour
 size
 uni- or bilateral and presence of ascites

12. Adult surgery Department

13. • It is the most widely used model
• to predict the probability of malignancy in a formula
• menopausal status,
• ultrasound characteristics
• CA 125 level
• A systematic review showed the
-sensitivity 78% (95% CI 71-85%)
-specificity 87% (95% CI 83-91%)
Risk of Malignancy Index (RMI)
Adult surgery Department

14. Adult surgery Department

15. Adult surgery Department

16. • It is primarily a marker for epithelial ovarian carcinoma .
• sensitivity of 61 to 90 %,
• specificity of 71 to 93%
• It is unreliable in differentiating
• benign from malignant ovarian masses
• in premenopausal women.
• May be used as surveillance when increased
• It is only raised in 50% of early stage disease.
CA 125 antigen
Adult surgery Department

17. Adult surgery Department

18. • in all women under age 40
• complex ovarian mass
• possibility of germ cell tumours.
• Lactate dehydrogenase (LDH)
• α-FP
• hCG should be measured
-Dysgermenoma
- Endometrail sinus
-Choriocarcinoma
Adult surgery Department

19. Adult surgery Department

20. • Routine use of CT and MRI
• in the detection of ovarian malignancy
• not improve the sensitivity or specificity
• obtained by transvaginal ultrasonography
• These imaging modalities
• evaluation of more complex lesions
• Staging of the malignancy
Adult surgery Department

21. • A retrospective study found
• 25% of adnexal masses in were malignant.
•referral to a gynecologist
• An adnexal mass in a premenarchal patient
• presence of symptoms associated with a mass
Adult surgery Department
PREMENARCHAL PATIENTS

22. Milestones 2006 - 2016
Adult surgery Department
The objectives when a growth is discovered
Most importantly, assess the
probability of malignancy
If malignancy is less likely, then
assess the association with fertility
Plan for management, most likely
surgery

25.  Premenopausal females
› If size <10 cm, mobile, cystic,
unilateralfollow, place patient on
monophasic OC, repeat U/S in 2-3 months
 70% of these will resolve8
›
Adult surgery Department

26. • › If size >10 cm, fixed, solid, or other
concerning featurestake it out
• › If mass persists or enlarges at repeat
scantake it out
Adult surgery Department

27. Adult surgery Department

28. Management Algorithm (there are many of these)
Van Nagell, JR, et al. Am J of Obstet & Gynecol 2005:193,30-35
Adult surgery Department

29. ACOG Guidelines:
 Premenopausal (< 50 Years Old)
› CA-125 > 200 U/mL
› Ascites
› Evidence of abdominal or distant metastasis (by exam or imaging
study)
› Family history of breast or ovarian cancer (in a first-degree relative)
 Postmenopausal (>= 50 Years Old)
› CA-125 > 35 U/mL
› Ascites
› Nodular or fixed pelvic mass
› Evidence of abdominal or distant metastasis (by exam or imaging study)
› Family history of breast or ovarian cancer (in a first-degree relative)
ACOG Committee Opinion: number 280, December 2002. The role of the generalist
obstetrician-gynecologist in the early detection of ovarian cancer. Obstet Gynecol 2002;100:1413–6 Adult surgery Department
When should I refer to an
oncologist?

30. Milestones 2006 - 2016
Adult surgery Department
Takehome message
To Formulate A List Of Differentials For A
Patient With A Pelvic Mass
Identify The Risk Factors For
Malignancy
To Establish A System Of Evaluation
For Such Tumours

31. Adult surgery Department

32. • For risk reduction in women with BRCA1 & BRCA2 mutations
• Ideally at the age of 35-40 years
• Completion of childbearing.
• Bilateral salpingo-oophorectomy
Adult surgery Department
Surgical intervention for ovarian cancer prevention