Ovarian masses DR ELIZABETH JACKSON DR ANUSHA LAZZARI DR HELEN GREEN The anatomy and physiology of the ovary DR ELIZABETH JACKSON FRANZCOG MMIS MREPROMED MBBS Overview
Ovarian anatomy
Physiology of ovaries
Basis of physiological ovarian cysts
• TALK AVAILABLE FOR DOWNLOAD: birdsofparadise.clinic/gps
What happens with removal of an ovary? Ovarian cysts and corpus luteal cysts Polycystic ovaries PID and endometriosis causing ectopic pregnancy www.birdsofparadise.clinic Thankyou WWW.DRELIZABETHJACKSON.COM Benign Pelvic Masses
DR ANUSHA LAZZARI – MBBS, BSC, BIRD OF PARADISE Emergencies Ectopic pregnancy and urgent Torted ovary Haemorrhage associated with referrals ruptured ovarian cysts Tubo-ovarian abscess Suspected malignancy Aetiology of pelvic masses
Ovarian Uterine Other adnexal (Tubal, Broad ligament) Infectious Gastrointestinal Retroperitoneal Aetiology of ovarian masses Ovarian masses
Benign Malignant
Functional (physiologic) cyst Epithelial carcinoma
Corpus luteal cyst Epithelial borderline neoplasm
Luteoma of pregnancy Malignant ovarian germ cell tumor
Theca lutein cyst Malignant sex cord-stromal tumor
Polycystic ovaries
Endometrioma
Cystadenoma
Benign ovarian germ cell tumor (eg, mature teratoma) Benign sex cord-stromal tumor WHO classification of ovarian tumours 2014 Tubal Masses
Benign Malignant
Ectopic pregnancy Epithelial carcinoma
Hydrosalpinx Serous tubal intraepithelial neoplasia
Paratubal cyst Metastatic carcinoma
Tubo-ovarian Abscess Uterine masses
Benign Malignant
Leiomyoma Leiomyosarcoma
adenomyoma Endometrial carcinoma
Fetus Non gynaecological pelvic masses
Benign Malignant Constipation Appendiceal neoplasm Appendiceal abscess Bowel neoplasm Diverticular abscess Metastasis (eg, breast, colon, lymphoma) Pelvic abscess Retroperitoneal sarcoma Bladder diverticulum Ureteral diverticulum Pelvic kidney Peritoneal cyst Nerve sheath tumor A few interesting statistics
Up to 10% of women will have some form of surgery during their lifetime for the presence of an ovarian mass.
The overall incidence of a symptomatic ovarian cyst being malignant is approximately 1:1000. Increasing to 3:1000 at the age of 50.
10% of suspected ovarian masses are found to be non-ovarian in origin. What is a simple cyst on ultrasound?
1. Round or oval shape
2. Thin wall
3. No septations or nodules
4. Anechoic fluid
5. Posterior acoustic enhancement
So, everything else is by definition a ‘complex cyst’ Ultrasound features suggestive of malignancy
Solid component that is not hyperechoic and is often nodular or papillary
Septations, that are irregularly thick (>2 to 3 mm) – can be seen with malignancy, but many benign masses, such as hemorrhagic cysts or endometriomas
Color or power Doppler demonstration of flow in the solid component.
Presence of ascites
Peritoneal masses, enlarged nodes, or matted bowel (may be difficult to detect by ultrasound). How to investigate a complex mass
History and examination may provide useful information TV pelvic ultrasound (Transabdominal only is inadequate) Ovarian tumour markers - All should have CA125, CEA and CA19.9 - If under 40yrs also do HCG, AFP and LDH ( consider germ cell tumours in this age group) MRI is second line imaging modality CT has limited role for initial assessment Use of multimodal scoring systems such as RMI (Risk of Malignancy index) Endometrioma
• Homogeneous low- to medium-level echoes in a cystic mass
• May be multilocular and have echogenic foci
• Goals of treatment
- Relief of symptoms
- Prevention on complications eg tortion
- Exclusion of malignancy ? Enlarging mass
- Treatment of subfertility
- * consider possibility that ovarian reserve may be reduced with resection
- Treatment could be surgical or observation in the asymptomatic woman with cyst <5cm and stable in size. Benign teratoma (Dermoid)
Presence of a markedly hyperechoic nodules within the mass may also be uniformly hyperechoic or have bright linear to punctate echoes Calcification also can be present and may vary in size Benign teratoma (Dermoid)
Malignant transformation occurs in 0.2 to 2 percent
Ovarian cystectomy makes a definitive diagnosis and avoid potential problems such as torsion, rupture, or development of malignant components Benign teratoma (Dermoid)
Mature cystic teratomas contain mature tissue of ectodermal (eg, skin, hair follicles, sebaceous glands), mesodermal (eg, muscle, urinary), and endodermal origin (eg, lung, gastrointestinal) Paratubal and paraovarian cysts
simple cysts that originate from the remnants of paramesonephric (Müllerian) or mesonephric (Wolffian) ducts
Usually incidental finding at ultrasound or during surgery
Paratubal cysts may result in torsion of the adnexa and acute severe pain requiring emergent surgical intervention Functional cysts (Follicular or corpus luteal cysts)
Follicular cysts are usually simple cysts patients with a history of recurrent painful functional cysts are managed with hormonal contraceptives to inhibit ovulation. This prevents the formation of new physiologic ovarian cysts. Corpus luteal cysts
• Scalloped edges • Single peripheral blood vessel • May have evidence haemorrhage within the cyst • Very occasionally functional ovarian cysts can cause life threatening haemorrhage requiring surgical management. Hydrosalpinx
A hydrosalpinx is a post-inflammatory process in which fluid fills the fallopian tube Usually appears tubular in shape and may have septations or nodules in its wall Hydrosalpinx
Septation typically appears to be incomplete and is not a true septation but is just due to the wall of the tube folded in on itself Tubo-ovarian abscess
A complication of PID. An inflammatory mass involving the fallopian tube, ovary, and, occasionally, other adjacent pelvic organs (eg, bowel, bladder)
Medical emergency warranting medical +/- surgical management Leiomyoma (fibroid)
Usually appear as heterogeneous, hypoechoic, solid masses
likely to be confused with an ovarian mass if the ipsilateral ovary is not seen and/or if there is cystic change within the fibroid
Most common pelvic tumour in women
Actual prevalence uncertain as studies only done in symptomatic women Leiomyoma (fibroid)
Symptoms of pain, pressure, abnormal bleeding or subfertility depending on fibroid location and size Leiomyosarcoma is rare and difficult to differentiate from benign disease. Consider if rapidly enlarging fibroid. Conservative, medical, embolization or surgical management depending on symptoms and fertility Serous and mucinous cystadenoma
Serous and mucinous cystadenomas are among the most common benign ovarian neoplasms. They are thin walled, uni- or multilocular, and range in size from 5 to <20 cm Benign-appearing masses that are persistently symptomatic should be removed A repeat ultrasound in six months is reasonable and then yearly thereafter if the mass is stable with benign features and asymptomatic.
Behavior of these masses are uncertain in terms of malignant transformation Peritoneal pseudocyst
Mesothelial lesions that appear as septated, cystic masses that surround the ovary, usually in women with pelvic adhesions Adhesions may be visualized on ultrasound as bands of tissue with surrounding fluid Peritoneal inclusion cyst has angular margins with surrounding structures, insinuating between structures instead of causing mass effect upon them Don’t forget this Common pelvic mass…
Thanks!!! Lady Docs Wellness retreat 2019
28th of September
Sponsored party bus leaves top secret champagne brunch location at 12noon
Retreat held at The Sanctuary, Mission beach (entire venue booked for us)
Dr Pam Rana (Melbourne GP and comedian) will be master of ceremonies
Guest speakers with focus on Doctors' Wellness
Prizes and games
Yoga and optional massage on 29th (Sunday) and party bus return
Husbands and children banned.
Spread the word and lets make this a roaring success so that we can do it again next year with even more sponsorship money !!!!
Visit FNQLDA Facebook site or go to https://www.trybooking.com/BEVAG (Bring a mate and consider sharing a room, = tons more fun! Rooms on site are limited) Lady Docs Wellness retreat 2019 https://www.trybooking.com/BEVAG Ovarian Masses CAIRNS GYNAECOLOGY EDUCATION EVENING 12.9.19
DR HELEN GREEN FRANZCOG CGO Overview
1. Why investigate?
2. How to investigate?
3. When to refer?
4. Differences between pre-menopausal and post-menopausal women Why investigate?
Two groups of patients:
1. Symptomatic patients with abdominal or pelvic pain
Specific attention to RFs and symptoms suggestive of ovarian malignancy and a family history of ovarian, bowel or breast ca.
Appropriate tests should be carried out in any post-menopausal woman who has developed symptoms within the last 12/12 that suggest IBS esp >50 years or those with sig family history as this condition rarely presents for the first time in this age group
2. Patients with incidentally detected ovarian masses at the time of imaging for other reasons. Non-genetic risk factors
Lifetime risk 1-1.4% (approximately 1 in 84) Increases with age Age at menopause >52 RR 1.46 Nulliparity (parous women have a HR for ovarian cancer of 0.46) Infertility RR 2.76 Endometriosis: RR 3.05 for clear cell ovarian adenocarcinoma
RR 2.04 for endometrioid ovarian adenocarcinoma RR 2.11 for low grade serous ovarian adenocarcinoma PCOS RR 2.52 Post-menopausal MHT RR 1.14 (1 additional ovarian cancer case per 1000 users and 1 additional ovarian cancer death in 1700 users) Obesity RR 1.1-1.5 Cigarette Smoking RR 2.1 (mucinous cancers) Interesting Stats
Ovarian cysts are diagnosed with increasing frequency in post- menopausal women as more patients are undergoing imaging in connection with medical care.
Prevalence in post-menopausal women 5-17%. Not related to time since menopause or hormonal therapy.
Cystic lesions <1cm are clinically inconsequential in this group and don’t require f/up How to Investigate?
CASE STUDY:
33 year old G0 female
Pelvic examination at the time of her routine CST revealed a L adnexal mass.
On further questioning has had some increased urinary frequency over the past few months
FHx: no family history of ovarian cancer, no family history of breast cancer
How to investigate? L ovary contained a 57x41x46mm cyst with low level echoes
?haemorrhagic cyst ?endometrioma R ovary contained a 44x39x34mm cystic lesion with a 11x13x14mm daughter cyst with no vascularity How to Investigate?
Review of other symptoms: period not painful, no pain with intercourse, no clinical symptoms of endometriosis
2 small intra-mural fibroids <1.5cm
After the USS got her period a day or two later
L ovarian cyst could be functional
R ovarian cyst looks like it could have a solid component on USS- although described as daughter cyst and no blood flow.
Plan: For repeat USS at beginning of next menstrual cycle.
Will need tumour markers if cysts persist. Persistent L ovarian cyst: 54x57x52mm: avascular, low level echoes
Persistent R ovarian cyst: 47x36x61mm with some small, solid, avascular components along the wall
(I measured the solid component myself: 15mm) How to investigate?
Tumour markers:
CA125 = 84 (N = <30); CA19.9 = 11, CEA <0.5.
HE4 = 61, pre-menopausal ROMA score = 12.9% (N= <11.3%).
LDH, AFP and hCG normal.
MDT discussion: morphologically consistent with bilateral endometriomas. For short follow up with USS and tumour markers in 8/52.
CA125 normalized to 19 and ROMA 6.7% with stable appearances of cysts.
Further USS follow up is planned. How to investigate?
First line imaging modality of choice is TV USS. TA USS should not be performed in isolation. Clinical examination provides useful information Blood tests for tumour markers may be helpful CT scan should not be used as the primary investigation tool for the initial assessment of ovarian cysts because of its low specificity, its limited assessment of ovarian internal morphology and its use of ionizing radiation. Use is in the assessment of distant disease for suspicious lesions and all lesions with RMI >200 MRI should be used as the second-line imaging modality for characterisation of indeterminate ovarian cysts where USS is inconclusive. Utility of Clinical Examination
Clinical examination has poor sensitivity in the detection of ovarian masses (15-51%).
Its importance lies in the evaluation of mass tenderness, mobility, nodularity and ascites.
Sensitivity decreased with increasing BMI above 30 Tumour markers CA125 does not need to be undertaken in all pre- menopausal women when an USS dx of a simple cyst has been made
Unreliable in young women due to false positives and reduced specificity due to benign conditions eg fibroids, endometriosis (only Stage III-IV endometriosis is likely to be raised to several hundreds or thousands), adenomyosis and pelvic infection.
CA125 is only raised in 50% of early epithelial ovarian cancers
Serial levels may be helpful as rising levels are more likely to be associated with malignant than high levels that remain static
RCOG recommend discussing cases with CA125 >200 with a gynaeoncologist
LDH, AFP and hCG should be measured in all women under 40 with a complex ovarian mass because of the possibility of germ cell tumours. TV USS
Pattern recognition of specific USS findings can produce sensitivity and specificity equivalent to logistic regression models, especially when performed by more experienced clinicians specialising in women’s imaging.
Repeat USS in the post-menstrual phase can be helpful. MRI
While assessment with MRI can improve overall sensitivity and specificity of ovarian cyst characterisation, there are inherent limitations to the more widespread use of MRI which preclude its routine use over TV USS.
Institutional: high cost, more restricted availability
Patient factors: contra-indication with pacemaker, cochlear implants, claustrophobia
MRI identification of enhancing vegetation in cystic masses or the presence of ascites are the best indicators of malignancy. When to refer? Conservative Mx
Many ovarian masses in pre-menopausal women can be managed conservatively. Functional or simple ovarian cysts (thin-walled without internal structures) which are <50mm usually resolve over 2-3 menstrual cycles without the need for intervention and don’t require further imaging follow up (Society of Radiologists in USS Guidance). Women with simple ovarian cysts of 50-70mm should have yearly USS follow up and those with larger simple cysts should be considered for either further imaging with MRI or surgical intervention (due to difficulties examining the entire cyst adequately at time of USS). Persistent cysts
Ovarian cysts that persist or increase in size are unlikely to be functional and may warrant surgical mx
No evidenced based consensus on the size above which surgical mx should be considered
COCP does not promote resolution of functional ovarian cysts.
Up to 20% of borderline ovarian tumours appear as simple cysts on USS Conservative Mx Post-menopausal women
Asymptomatic, simple, unilateral ovarian cysts <5cm have a low risk of malignancy (<1%). In the presence of normal CA125 levels, these cysts can be managed conservatively with repeat evaluation in 4- 6/12. Reasonable to d/ch women from follow up after 1 year if the cyst remains unchanged or reduces in size with normal CA125.
In a 2 year follow up study of asymptomatic post-menopausal women with simple cysts smaller than 5cm, these cysts were shown to disappear (53%), remain static (28%), enlarge (11%), decrease (3%), or fluctuate in size (6%).
If a woman is symptomatic surgical evaluation is necessary
A post-menopausal woman with a suspicious or persistent complex adnexal mass needs surgical evaluation Estimation of risk of malignancy
RMI is most widely used model
First described by Jacobs in 1990 and has since evolved intro RMI II, RMI III and RMI IV.
Only RMI I and RMI II have been sufficiently validated.
Utility is confounded in premenopausal women due to endometriomas, borderline tumours, non-epithelial tumours and other pathologist which increase CA125
Currently recommended by NICE guidelines
ROMA
IOTA USS rules RMI
For a RMI of 200: Sensitivity 78% and specificity 87% If increase score to 250, sensitivity of 70%, but higher specificity 90% A simple cyst has 5 features: round or oval shape, thin or imperceptible wall, posterior acoustic enhancement, anechoic fluid, absence of septations or nodules A cyst meeting these 5 features has 95-99% chance of being benign in a post- menopausal woman Increased risk of malignancy 8% for multilocular and 36-39% for lesions with solid elements. if RMI <25 risk of cancer is <3%, if 25-250: 20%, >250: 75. IOTA:
The(International use of specific OvarianUSS morphological Tumour findingsAnalysis) without CA125
Using the B and M rules, the reported sensitivity was 95% and specificity 73.2% for a risk of 10% and sensitivity of 98% and specificity of 61% for risk of 5%.
Women with any M rules should be referred to a gynaecological oncologist HE4 and ROMA
Currently not enough data to be recommended for routine clinical use as the data are not substantial enough to enable recommendation routinely or instead of CA125 Increased HE4 levels occurs in ovarian cancer as well as lung, pancreas, breast, bladder/ureteral transitional cell and endometrial cancers. Also with benign disease: increasing age, HTN, renal disease, benign lung disease. NOT increased in endometriosis and therefore has fewer false positive results with benign dx cf CA125 In a retrospective r/v HE4 had a higher sensitivity (73%) cf CA125 (43.3%) for 95% specificity in distinguishing benign vs malignant masses. HE4 + CA125 yielded a sensitivity of 76.4%. Ie. HE4 instead of CA125 would ID and additional 7 patients with cancer with 81 fewer false-positives for every 1000 women referred. ROMA combines CA125, HE4 and menopausal status to calculate a risk of ovarian cancer. Needs to be interpreted in conjunction with clinical and radiological assessments. Overall it has a sensitivity of 89% and specificity of 75%. ‘ROMA utilisation requires further evaluation’ (Compared with RMI that has a Sensitivity of 78% and specificity of 87%) ROMA case study
75 year old woman with persistent R adnexal mass.
R ovarian cyst measuring 26x27x23mm simple appearing cyst with single septation.
Stable in appearance on USS for last 4 years.
Tumour markers:
CA125: 10, CA19.9: <1, CEA = 0.7
HE4 = 243 giving ROMA of 44%
(previously 74 in 2015 giving ROMA of 9.9%) ROMA case study -2-
PMSHx: Chron’s disease for 35 years, nephritis, HTN
Serial CT Abdo/Pelvis shows nil evidence of metastatic disease. Also show multiple stable, small liver cysts.
HE4 increases with age, renal failure and smoking, effusions, HTN, DMII, liver or lung disease
Opinion of MDT is that R ovarian cyst is very unconcerning and it is appropriate to cease surveillance.
Society Guidelines
ACOG and the Society of Obstetricians and Gynaecologists of Canada have guidelines for mx of pre-menopausal women with pelvic mass
Consider following suspicious: CA125 >200, evidence of abdominal of distant mets, first degree relative with breast or ovarian cancer.
However, in the largest study validating these guidelines 30% of pre-menopausal women with ovarian cancer would not have been regarded as high risk. NICE Guidelines Awareness of symptoms and signs Refer the woman urgently if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids) Carry out tests in primary care if a woman (especially if 50 or over) reports having any of the following symptoms on a persistent or frequent basis – particularly more than 12 times per month persistent abdominal distension (women often refer to this as 'bloating') feeling full (early satiety) and/or loss of appetite pelvic or abdominal pain increased urinary urgency and/or frequency. Consider carrying out tests in primary care if a woman reports unexplained weight loss, fatigue or changes in bowel habit. Advise any woman who is not suspected of having ovarian cancer to return to her GP if her symptoms become more frequent and/or persistent. Carry out appropriate tests for ovarian cancer in any woman of 50 or over who has experienced symptoms within the last 12 months that suggest irritable bowel syndrome (IBS), because IBS rarely presents for the first time in women of this age. NICE Guidelines -2-
Asking the right question – first tests
Measure serum CA125 in primary care in women with symptoms that suggest ovarian cancer.
If serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis.
If the ultrasound suggests ovarian cancer, refer the woman urgently for further investigation
For any woman who has normal serum CA125 (less than 35 IU/ml), or CA125 of 35 IU/ml or greater but a normal ultrasound:
assess her carefully for other clinical causes of her symptoms and investigate if appropriate
if no other clinical cause is apparent, advise her to return to her GP if her symptoms become more frequent and/or persistent. Case Study – Mrs KB
65 year old with bloating, abdominal pain, constipation and reduced appetite
8/12 history of feeling unwell
PMSHX: menopause age 54, no HRT, P3, one maternal aunt ovarian cancer, one maternal aunt breast cancer
Initially put her symptoms down to IBS
Daughter passed away 6/12 prior to presentation– put her symptoms down to grief
4/12 prior noticed weight loss in arms and legs and weight gain in abdomen Case Study – Mrs KB
2/12 prior to presentation went to her LMO and had a TV USS that was normal.
PET CT 1/52 prior to presentation: peritoneal nodularity, ascites and omental cake
CA125 = 925
Pelvic examination: fixed mass in pouch of Douglas
Cytology (ascites): high grade serous adenocarcinoma of tubo-ovarian origin. Case Study – Mrs KB Case Study – Mrs JO
64 year old presented to LMO with cough and inability to lie flat at night. Mild digestive complaints. Abdominal distention noted on clinical examination. Mrs JO had been SOB for 2-3/12 on further questioning. ED presentation with CT CAP showing gross ascites, pleural effusion and omental caking, nil obvious pelvic mass reported on CT or pelvic USS. CA 125 = 1070 6-7 litres of ascitic fluid drained Cytology of ascites: high grade serous adenocarcinoma of tubo- ovarian origin. Review of CT in Gynaeoncology MDT: R ovary is slightly enlarged and is likely to be the primary, fallopian tubes thickened bilaterally. Family History: paternal aunt: breast cancer (age 70), paternal aunt: bowel cancer, maternal aunt: bowel cancer Case Study – Mrs JO
Mrs JO was started on neoadjuvant chemotherapy
Questions:
What are the indications for repeat ascites drain?
What are the other considerations for women with malignant ascites?
Social issues for this patient: carer for husband with heart failure. Adult daughter has stopped work to look after her parents.
Genetic testing for patient with ovarian cancer Overview
1. Why investigate?
2. How to investigate?
3. When to refer?
4. Differences between pre-menopausal and post-menopausal women www.birdsofparadise.clinic