Management on Adnexal Mass

Prof HOSSAM HUSSEIN

Causes of Adnexal Masses

Cancer Benign neoplasms Infection (Abscess) Edematous Ovary secondary to torsion Endometriosis GI conditions Corpus Luteum

Causes of Adnexal Masses

Follicles and Follicular cysts Hydrosalpinx Peduculated Leiomyomas Pregnancies Hemorrhage Appendicitis

Symptoms of An Adnexal Mass

None Pain/Abdominal discomfort GI symptoms Urinary symptoms Pelvic pressure/Bloating Backache

Symptoms of An Adnexal Mass

Edema DVT/PE Electrolyte abnormality Acute abdomen Large Mass

Discovery of Adnexal Mass

On yearly pelvic exam Pelvic exam for specific complaint Ultrasound CT (usually a serendipitis finding) MRI Other radiologic test

Discovery of an Adnexal Mass

Serologic abnormality Seen grossly During surgery for an unrelated complaint

Adnexal Masses
The following aspects of an adnexal mass should be evaluated. Mobility the mass should be moved by the vaginal probe or by the hand of the operator that is resting on the abdomen (sliding organs sign). Pain its location should be established by watching the on-screen picture when touching different organs with the tip of the transvaginal probe. Wall structure features of an ovarian mass, such as thickness and outer and inner surface irregularities and papillae, should be described and measured. Septations the thickness of the septations should be reported. Echogenicity of the mass the mass can be completely sonolucent and may have low-level echogenic contents, may be with or without an echogenic core, may have mixed echogenicity containing all of these components or may be completely echogenic.

The presence of the following conditions may make it more difficult to detect ovarian or adnexal masses with ultrasonography. Fluid-filled loop of bowel Faeces in loop of bowel Closed-loop bowel obstruction Artifact of multipath reflection of sound waves (stratified echo pattern resulting from echoes bouncing back and forth) from fluid-filled structure (e.g. bladder) Mesenteric cysts Peritoneal inclusion cysts (postoperative or after infections) Nabothian cysts Hydrosalpinges (acute and chronic) Large fibroids.

Adnexal Masses

What is the goal of management of the adnexal Mass?

Rule out Cancer Alleviate symptoms Determine long term problems (i.e.; fertility, chronic pain, recurrence, and long term treatment) When to not intervene (over test or treat)

Ovarian Cancer
Age
40 75

Incidence
15/100,000 54/100,000

Risk Factors for Ovarian Cancer

Age (risk increases with age) Nulliparity Ancestry (American, Northern European, and Ashkenazi Jews) Personal history(only 10% are familial) Endometrial cancer Breast Cancer

Risk Factors for Ovarian Cancer

?Fertility Drugs Use of Oral Contraceptives ( the longer the use the more protective it is the relative risk after 10 years use is 0.2) Tubal Ligation is protective Hysterectomy is protective but BSO does not eliminate the risk

Evaluation of an Adnexal Mass

History Physical/ PAP Ultrasound CA125 (+/- LDH,AFP,Inhibin) HCG, CBC Laparoscopy/Laparotomy

Ultrasound Exam
Solid mass/ or complex mass Cystic Mass(unilocular more likely benign) Size (5-6cm in young patient repeat scan 4-6 weeks) Complex mass can be seen with corpus luteum or hemorrhagic cyst Doppler flow/Pulsitile index

Ultrasound
Pulsitility index of less than 0.4 is indicative of malignancy (experimental) Associated findings (ascites, fibroids,or endometrial abnormalities)

Labs
CBC-looking for evidence of PID or anemia Sed Rate- non specific but best test for PID HCG- rule out pregnancy is any reproductive age women (also a tumor marker for germ cell tumors of the ovary and hydatidiform mole)

Labs
CA125- Tumor marker present in 80% of advanced ovarian cancers (less than 50% of stage I cancers) Unfortunately can be elevated in endometriosis, menses, infection, fibroids, liver or renal failure, ascites, breast cancer, endometrial and cervical cancers and GI malignancies

Management based on:

Age of patient Size of mass Ultrasound description of cystic or complex or solid Other associated finding i.e, ascites, pulmonary effusion, lymphadenopathy, other cancers (cervix, endometrium, breast)

Management under age 30

Cystic or complex Less than 6cm Suppress with birth control pills and/ or repeat ultra sound in 4-6 weeks If persistent laparoscopy with probable ovarian cystecomy Greater than 12cm- surgery

Management under age 30

Cystic 6-10cm can repeat ultrasound or proceed to surgery Solid mass greater than 6cm surgery Grey area complex 6-8cm

Management over 40 to 50
Cystic less than 6cm repeat ultrasound 4-6 weeks +/- suppression Complex greater than 6-8cm- CA125 if elevated proceed to surgery if normal possibly repeat scan 4-6 weeks Solid greater than 6 cm- CA125 and surgery

Benign Conditions of the Adnexa

Hydrosalpinx-Rx antibiotics re-assess TOA- IV antibiotics (Cefotetan plus vibramycin or Clindamycin plus Gentamycin) re-assess 4 weeks if no recurrence of Sx no further Rx if recurrent possible TAH BSO after repeat course of antibiotics. It may be necessary to do laparoscopy to establish diagnosis

Benign conditions of the Adnexa

Endometriosis- to establish the diagnosis requires laparoscopy Rx- Lupron(GnRh agonist), Progesterones, Danazol (anti estrogen), Birth control pills either cyclic or continuous, or surgery Ovarian cystectomy if child bearing to be preserved, with excision or ablation of endometriosis

Benign conditions of the Adnexa

Hemorrhagic cyst-usually manage with narcotic analgesics, usually self limiting 2-4 weeks, occasionally surgical intervention needed (again preserve ovary if child bearing wanted) Suppression with OCs acceptable

Benign Conditions of the Adnexa

Corpus Luteum with or without hemorrhageNarcotic analgesics +/- BCPs Rare surgery Ectopic pregnancy-Surgery or methotrexate Pedunculated fibroids- No Rx if small-surgical removal if large or symptomatic

Benign Conditions of the Adnexa

Diverticular disease- Antibiotics for acute attacks, dietary changes and fiber, surgery if needed Appendicitis- Surgery Ovarian torsion- Oophorectomy occasionally detorsions

Benign Conditions of the Adnexa

Para Tubal cysts- No Rx Follicular cyst, Polycystic ovarian disease, and hyperstimulation of the ovary all managed conservatively

Benign Conditions of the Adnexa

Benign cystic Teratoma (Dermoid Cyst)-Most common tumor in reproductive age women 25% of all ovarian neoplasms 80% less than 10cm 15% bilateral 50% asymptomatic 1-2% malignant transformation

Cystic Teratoma cont

Complications include rupture, torsion, infection, hemorrhage, and malignant transformation, Thyrotoxicosis, autoimmune hemolytic anemia, and carcinoid Treatment- ovarian cystectomy or Oophorectomy(can wait until after -delivery if pregnant)

Ovarian Cysts
What does this mean? Follicle Corpus luteum Serous cystadenoma Mucinous cystadenoma

Case #1
19yo GoPo Acute onset right sided pelvic pain Afebrile WBC-8,000 Never sexually active Ultrasound shows a 5cm complex mass R adnexa Pelvic exam acutely tender no discharge

Case #1
Most likely hemorrhagic corpus Treat with narcotic analgesics Consider suppression with birth control pills

Case # 2
32yo G3P3 No symptoms Yearly exam feel fullness left adnexa no tenderness HCG neg Ultrasound exam shows multiple cysts in both ovaries largest 2.3cm R ovary 5cmX4.2cm, L ovary 4.6cmX3.9cm

Case #2
Polycystic ovaries Either induce ovulation is pregnancy desired or Suppress with BCPs Depending on other factors- labs Insulin, BS TSH, LH, FSH, Testosterone, DHEAS

Case # 3
30yo G2P1ab1 Mass left adnexa at yearly exam No Sx HCG neg Ultrasound shows 6cm complex mass with internal echoes (possible teratoma)

Case # 3
These are fairly obvious on U/S Surgical removal by cystectomy in younger patients. Older patient oophorectomy These are not emergency cases

Case #4
26yo GoPo Pt noticed weight gain and protuberant abdomen HCG neg Mass on exam to xyphoid , non tender Ultrasound exam shows 26cm cystic mass with multiple septations CA125- 5

Case # 4
Usually one would suspect a mucinous cystadenoma This patient had a huge hydrosalpinx Surgical removal

Case #5
55yo G5P4 C/O clothes not fitting well, fullness in lower pelvis, early satiety Pelvic exam normal but limited do to pt mild obesityUltrasound shows solid mass in R ovary 5cm L ovary not seen CA125-95 CT normal

Case # 5
Ovarian cancer

Case #6
45yo G3P3 Mild menorrhagia Yearly exam 10week size uterus with solid mass in L adnexa HCG neg Ultrasound shows enlarged uterus with multiple fibroids CA125- 40

Case # 6
Pedunculated uterine fibroid TAH No treatment

Case #7
55yo G4P4 PMB Endometrial biopsy atrophic endometrium Ultrasound exam shows 4mm endometrium with 3cm unilocular cyst R adnexa

Case #7
Benign cyst Repeat U/S 4- 6 weeks if no change possibly recheck one more time If it changes laparoscopy possible laparotomy

Case #8
23yo G3P1 Severe pelvic pain onset 2 days prior to admission WBC- 22,000 Temp101 HCG neg Ultrasound exam shows 8cm complex mass L adnexa CA125-50 + rebound

Case # 8
PID with tubo-ovarian abscess IV Clindamyacin and Gentamyacin Repeat U/S 4-6 weeks

Case #9
42yo G2P2 Acute onset R lower pelvic pain Pelvic exam severe pain making exam poor WBC- 15,000 Temp 101 Ultrasound exam shows 8cm mass in the R adnexa + rebound

Case # 9
Ovarian torsion Oophorectomy

Review
Ovarian cysts in reproductive age women are usually follicles Less than 5cm in young patients can be reassessed in about 6 weeks Small unilocular cysts can be managed conservatively in most patients CTs are usually less accurate than ultrasound

Review
CA125 is not a screening test If the clinical picture does not match the finding on laboratory exams reassess

Congenital Uterine Anomalies

3D Ultrasound is more accurate than 2D Ultrasound for diagnosing arcuate, subseptated, septated and bicornuate uteri, but not for didelphys. It is very useful to determine the dimensions of uterine septum, which may provide very useful information to surgeons during hysteroscopy.

Subseptate Uterus

Complete Septate

The two uterine bodies and the two endometrial cavities with similar dimensions and morphology are clearly distinguishable. E: endometrium.

Fibroids

Benign Ovarian

Simple cyst
clear fluid Smooth wall

echogenic contents nodule in cyst wall

Dermoid cyst

Haemorrahgic cyst

Haemorrhagic cyst
Resolves spontaneously

Echogenic contents

Endometrioma

thick wall

Endometrioma

Endometrioma in POD

Endometrioma

hyperstimulation

The appearance of an ovary demonstrating multiple follicular development characteristic of ovarian hyperstimulation syndrome

Hypo/anechoic cysts containing one or more hyperechoic nodules (dermoid plug), Cysts containing hyperechoic thin stripes and spots on a hypo/anechoic background (starry sky appearance

dermoids

Bening mucinious cystadenoma

Ovarian fibroma

A haemorrhage inside an ovarian cyst in a patient represented by acute abdomen

Ultrasound in detecting early ovarian carcinoma

Among high-risk women (women with a family history of ovarian cancer or a personal history of breast cancer) the sensitivity for detection of Stage I disease was 25% while the sensitivity for low-risk women was 67 %. This less-than-ideal sensitivity is not unexpected, because in many Stage I ovarian cancers, the ovaries are neither enlarged nor morphologically abnormal.

Ultrasound in detecting early ovarian carcinoma

The use of color or Power Doppler imaging has not been shown to add significantly to the diagnosis of early-stage disease. 3-D volume acquisition and 3-D Power Doppler may help in the early identification of abnormal vascularity and architectural changes within the ovary. Excrescences not seen by 2-D technology may be observed. While 3-D Power Doppler provides a new tool for measuring the quality of ovarian vascularity, its clinical value for the early detection of ovarian carcinoma has yet to be determined. The efficiency of 3-D Power Doppler imaging in identifying Stage I ovarian cancer has yet to be determined.

The low annual prevalence of ovarian cancer within the general population, the large number of women who must therefore be screened to identify a single ovarian cancer, and the poor sensitivity of the test for Stage I disease make routine use of ultrasound for detection of ovarian cancer

impractical.

Vascular projection in a cyst

Surface rendering of a papillary in a cyst

Cont.

cont

A 10 years old girl US shows a predominantly a solid tumor (Dysgerminoma)

A granulosa cell tumor in 6 years old girl

An immature teratoma with a apartially solid and cystic mass seen in 11 years girl

Ovarian carcinoma note the solid and cystic nature

Tubal

A hydrosalpinx containing anechoic fluid and incomplete septation (s)

The beads-on-a-string sign (arrows) considered as additional evidence of the presence of hydrosalpinx.

A hydrosalpinx showing a low level echoes within the distended fetal tube together with incomplete septations.

The typical colour Doppler energy findings of hydrosalpinx

Hydroalpinx

Ectopic pregnancy
The introduction of beta hCG testing and transvaginal ultrasound has changed our approach to the patient suspected of an ectopic pregnancy. Important advantage of the most currently used trans-vaginal transducers is the ability to perform simultaneous color and spectral Doppler studies, allowing easy identification of the ectopic peritrophoblastic flow. Therefore, color Doppler may be applied whenever a finding is suggestive of ectopic pregnancy.

Ectopic pregnancy in Lt. tube

Ectopic gestational sac in the left adnexal region surrounded by a ring of fine near by vessels.

(TAS) Lt EP

Left EP

Hetrotopic pregnancy

Rt. interstitial ectopic pregnancy by 3-D trasnvaginal sonography

Rt inflammatory mass

Appendicular mass

Acutely inflamed appendix in deep pelvic position. The appendix could only be visualized with the help of a transvaginal probe

Cecal carcinoma. US reveals asymmetric, hypoechoic, circumferential wall thickening of the cecum (arrowheads) with narrowing of the lumen. There is one pathologically enlarged lymph node.

Thanks

HOW TO ASSESS AN ADNEXEAL MASS USING US

PROF ABOUSHADY

The appearance of an ovary demonstrating multiple follicular development characteristic of ovarian hyperstimulation syndrome

Tubal

A hydrosalpinx containing anechoic fluid and incomplete septation (s)

Ectopic pregnancy in Lt. tube

Ectopic gestational sac in the left adnexal region surrounded by a ring of fine near by vessels.

Rt. interstitial ectopic pregnancy by 3-D trasnvaginal sonography

Thanks