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     1  THE ADNEXAL MASS Dr. Nathalie Gamache Gynecologist Shirley E. Greenberg Women Health Centre Family Medicine December 14th 2007
     2  Classification Ovarian Functional vs non-functional Tubal Ectopic vs tubo-ovarian abscess Uterine Myoma (fibroid) Others
     3  Classification Functional ovarian cysts normal follicular cyst 2-4 cm (< 7 cm) clear fluid resolves within next cycle may persist 2-3 months may be painful if torsion or rupture
     4  Classification The ovarian mass Epithelial serous, mucinous, endometrioid, clear cell, Brenner Germ cell teratoma, dysgerminoma, endodermal sinus, embryonal Sex-cord-stromal granulosa, stromal, Sertoli-Leydig Metastatic Krukenberg (GI), breast…
     5  Ovarian Malignancy Incidence 14/1000 Only 25% are diagnosed as stage I Highest mortality in gyne cancers In the presence of a mass Young girls > 9 80 % Adolescents 50 % Reproductive age 10% Menopausal 10-20 %
     6  The Benign Mass In reproductive age mature teratoma (dermoid) 33% endometrioma 25% serous/mucinous cystadenoma, 42% hemorrhagic, functional cysts
     7  Investigations The pelvic exam Routine pelvic exam in asymptomatic ?, not shown to be justified due to low sensitivity, specificity, prevalence Aust Fam Physician 2006 Nov;35(11):873-7 In presence of malignant mass in post- menopause - sensitivity of bimanual exam was 45% - Evid Rep Technol Assess 2006 Feb;(130):1-145
     8  Investigations The ultrasound in the hands of experienced technician and radiologist/gynecologist… > 90% accuracy in classifying benign vs malignant with pattern recognition accuracy is enhanced by Doppler flow in case of malignancy
     9  Investigations Characteristics of ovarian masses Benign Malignant clear echogenic simple complex fluid/solid mixed unilocular multilocular thin septations thick septations absence of nodularity absence of papillary foci absence of excrescences ? blood flow ? blood flow unilateral bilateral < 8-10cm <50 > 10cm < 50 < 5cm >50 > 5cm > 50
     10  Investigations CA-125 Marker found in epithelial tissue Very low specificity in premenopausal ? Can be elevated if: approaching, or menstruating any ovarian cyst fibroids endometriosis pregnancy any GI inflammatory conditions
     11  Investigations CA-125 As a marker, is ONLY accurate to follow response to treatment in known epithelial ovarian malignancy, BUT….
     12  Investigations CA-125 in presence of an ovarian mass: sensitivity 78% specificity 78% both higher in postmenopausal ? better at negative predictive value cannot be used as single screening test
     13  Investigations In postmenopausal ovarian cyst study 93 ? with cyst and CA-125 < 50ui/ml 75 (80%) had ov cysts < 13cm 77 (81%) with CA-125 < 35ui/ml had benign cysts independent of size and locularity 11/16 with CA-125 35-50ui/ml had borderline pathology - Eur J Gynaecol Oncol 2007;28(1):45-7
     14  Clinical Approach Due to low incidence of ovarian cancer and low sensitivity and specificity of available screening tools it is not recommended to routinely do: screening pelvic exam screening pelvic ultrasound screening CA-125
     15  Clinical Approach In the symptomatic patient: a pelvic ultrasound with vaginal probe should be obtained in a reliable facility in a premenopausal ?, if cyst appears functional (clear, unilocular, <7cm), should observed may repeat ultrasound if still symptomatic in 2-3 months may attempt ovarian suppression with OC
     16  Clinical Approach If symptomatic premenopausal ? with non-resolving or non-functional cyst or mass, consultation to gynecologist should be done If non-symptomatic premenopausal ? with < 8-10cm, benign-looking ovarian mass on ultrasound, may observe, repeat U/S in 3-6 months
     17  Clinical Approach In postmenopausal ? with simple ovarian cyst < 5cm and CA-125 < 35ui/ml, may repeat U/S in 2-3 months In postmenopausal ? with ovarian mass > 5cm, suspicious looking, or CA-125 > 35ui/ml, should refer to gynecologist/oncologist
     18  THANK YOU