ABOUBAKR ELNASHAR

Management of Suspected

Ovarian Masses in Premenopausal Women

RCOG, 2011

Aboubakr ElnasharBenha University, Egypt

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CONTENTS1. Introduction2.Types of adnexal masses3.How to minimise patient morbidity4.Assessment5.Treatment

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1. IntroductionPremenopausal ovarian masses Benign: almost allMalignant: <50y: 1:1000>50y: 3:1000 .Preoperative differentiation: Between the benign and the malignant: problematic. Exceptions: germ cell tumourselevations of α-FP and hCG.10% of suspected ovarian masses: non-ovarian in origin

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2. Types of adnexal massesBenign ovarian

1. Functional cysts2. Endometriomas3. Serous cystadenoma4. Mucinous cystadenoma5. Mature teratomaOvarian cyst: fluid-containing structure ≥30 mm in diameter4% of women

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Benign non-ovarian 1. Paratubal cyst2. Hydrosalpinges3. Tubo-ovarian abscess4. Peritoneal pseudocysts5. Appendiceal abscess6. Diverticular abscess7. Pelvic kidney

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Secondary malignant ovarian Predominantly: breast and gastrointestinal carcinoma.

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Primary malignant ovarian Germ cell tumourEpithelial carcinomaSex-cord tumour

Secondary malignant ovarian Predominantly breast and gastrointestinal carcinoma.

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3. How to minimise patient morbidityI. 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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II. Use of laparoscopic techniques where appropriatecost-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.Indications1. Histological diagnosis2. strong suspicion of Borderline ovarian tumours20% of borderline ovarian tumours appear as simple cysts on US

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4. Preoperative assessment of women with ovarian masses

I. HistoryII. ExaminationIII. Blood testsIV. ImagingV. Estimation the risk of malignancy

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I. HistoryRisk factors Protective factors for ovarian malignancyFamily history of ovarian or breast cancer. Symptoms suggestive of endometriosis ovarian malignancy: persistent abdominal distensionappetite change including increased satietypelvic or abdominal painincreased urinary urgency and/or frequency.

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II. Physical examinationPoor sensitivity in the detection of ovarian masses (15–51%) Essentialabdominal and vaginalEvaluation of mass:tenderness, mobility, nodularity and ascites.local lymphadenopathy. Acute pain: complications should be considered (torsion, rupture, hge).

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III. Blood tests1. 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. Fibroids2. Endometriosis: in stage III–IV 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}.<200 units/ml:Further investigations to exclude/treat the common differential diagnoses>200 units/mldiscussion with a gynaecological oncologist

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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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IV. Imaging1. UltrasoundTVS: preferable {increased sensitivity over TAS}TVS+TAS: larger masses and extra-ovarian disease.Colour flow Doppler:Not significantly improve diagnostic accuracyColour flow Doppler+3DImprove sensitivity, particularly in complex cases.

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Repeating US in the postmenstrual phasein cases of doubtEndometrial 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 MRIRoutine use does not improve the sensitivity or specificity obtained by TVSIndicatedevaluation 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 malignancyessential in the assessment of an ovarian mass.1. RMI: most widely used model 2. Ultrasound parametersInternational Ovarian Tumor Analysis (IOTA) Group

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3. Simple models:CA-125, pulsatility index, resistance index.4. Intermediate modelsmorphology scoring systems and the risk of malignancy index.5. Advanced modelsartificial neural networks and multiple logistic regression models6. CA-125not 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 woman’s management.1. most effective2. simple to use and reproducibleutility 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 IRMI = 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 2–5).

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● The menopausal statusscored 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/mlvary 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 ratio:10Negative likelihood ratio: 0.06.

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B-rules1. Unilocular cysts2. Presence of solid

components where the largest solid component <7 mm

3. Presence of acoustic shadowing

4. Smooth multilocular tumour with a largest diameter <100 mm

5. No blood flow

M-rules1. Irregular solid tumour 2. Ascites3. At least four papillary

structures4. Irregular multilocular solid

tumour with 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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Guidelines for managementACOG, SOGCPremenopausal women with a pelvic mass.suspicious for ovarian malignancy: referred to gynaecological oncologist: 1. CA-125 >200 units/ml2. Ascites3. Abdominal or distant Metastasis4. First-degree relative with breast or ovarian

cancer. In the largest study validating these guidelines30% of premenopausal women with ovarian cancer would not have been regarded as high risk.

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5. Management1. 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) orsurgical 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 ovariancysts.(Cochrane review)

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3. Mature cystic teratomas (dermoid cysts) {grow over time, increasing the riskof pain and ovarian accidents}Surgical management preoperative assessment using RMI 1 or ultrasound rules (IOTA Group).

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Lines of managementI. SurgeryThe appropriate route depends on1. Patient:suitability for laparoscopy and her wishes2. Mass: size, complexity, likely nature3. Setting: surgeon’s skills and equipment.

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A. LparotomyIn 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.1. lower postoperative morbidity (fever, pain)2. shorter recovery time: cost-effective

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Spillage of cyst contentsshould 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}: <0.2% of cases.Meticulous peritoneal lavage of the peritonealcavity using large amounts of warmed fluid. Cold irrigation fluid: hypothermiaDifficult retrieval of the contents by solidifying the fat-rich contents.

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Endometrioma >30 mmhistology should be obtained to identify endometriosisexclude 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 pain2. quicker retrieval time than when using lateral ports3. Avoidance of extending accessory portsreducing postoperative painincisional herniaepigastric 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 thewoman’s preference and the specific clinical scenario.

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III. Aspiration of ovarian cystsvaginally or laparoscopicallyless effective high rate of recurrence.RCTs:Resolution rates:Similar to expectant management (46% vs 44.6%).Recurrence rates53%-84%.Done:highly selected casesfollowing discussion between the woman and her clinician

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