Adnexal Mass & Ovarian Carcinoma

Approach to adnexal mass:

• Differential diagnosis:
• Physiologic cyst: simple cyst <2.5cm
• PCOS
• PID
• Fibroid
• Benign mass (e.g. cystadenoma, endometrioma, teratoma)
• Ovarian cancer (e.g. germ cell, epithelial)
• Metastatic disease (endometrial, breast, colon, gastric)
• Risk factors for malignancy: postmenopausal woman, complex/solid appearing, ascites
• Presence of pain suggests ruptured cyst, endometriosis, ovarian torsion, PID
• Diagnosis:
• Exam: normal ovaries in post-menopausal women are not palpable
• Imaging: transvaginal ultrasound better at visualizing pelvic structures
• CA-125: in all comers, non-specific, but after menopause, specificity 90%
• Management:
• Premenopausal:
• Cysts <10cm with benign radiographic appearance can be followed
• Larger or concerning cysts should be removed
• Postmenopausal: given increased risk of malignancy, management is more aggressive
• Cysts >5cm should be removed, as should symptomatic cysts, or those with other concerning features:
• CA-125 >35
• Ascites
• Complex features

 Overview of ovarian carcinoma:

• Risk factors:
• Hereditary: BRCA 1/2, HNPCC (Lynch syndrome)
• Repeated ovulation: nulliparity, early menarche/late menopause
• Environmental factors: talc, asbestos
• Chronic inflammation: endometriosis, PID
• Diagnosis:
• Screening with CA-125 or ultrasound not recommended
• 70% of women have metastatic disease at presentation, given indolent nature of disease
• High risk of peritoneal carcinomatosis (other malignancies predisposed to this are bladder, colon, gastric, breast, pancreatic, lung, and lymphoma)
• Symptoms: change in urinary/bowel patterns, abdominal/pelvic pain, bloating, early satiety
• Management:
• Unlike most other cancers (renal cell carcinoma is the other), surgical cytoreduction (even without complete resection) is associated with increased survival
• Volume of residual disease is inversely related to survival
• Chemotherapy: paclitaxel + platinum + ?bevacizumab

(Christopher Woo MD, 5/10/11)