Learning Objectives Pelvic Pain - IAME · CA 125 0.78 0.78 Agency for Healthcare Research and Quality. ... • EMB lif ti d tiEMB = proliferative endometrium • Failed medical therapy

1

Evaluating the Adnexa with Evaluating the Adnexa with Ultrasound: Improving your Ultrasound: Improving your Preoperative AssessmentPreoperative Assessment

James M. Shwayder, M.D., J.D.James M. Shwayder, M.D., J.D.Professor and ChairProfessor and Chair

Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology University of MississippiUniversity of Mississippi

Jackson, MississippiJackson, Mississippi

DisclosuresDisclosures

James M. Shwayder, M.D., J.D.James M. Shwayder, M.D., J.D.

Disclosures:Disclosures: NoneNone

Learning ObjectivesLearning ObjectivesAt the conclusion of this presentation,

participants should be able to:

•• Discuss the effective use of Discuss the effective use of ultrasound in adnexal evaluation:ultrasound in adnexal evaluation:

•• DiagnosisDiagnosis

•• Patient counselingPatient counseling

•• Procedure planningProcedure planning

•• Discuss case examplesDiscuss case examples

•• Helpful hintsHelpful hints

Pelvic Pain

• 27-year-old woman presents to the ER with pelvic pain x 2 days. No associated nausea or vomiting Hadassociated nausea or vomiting. Had similar pain 3 months ago.

• LMP = 3 weeks prior

• Birth control: None

• hCG = negative

ER = emergency room; LMP = last menstrual period; hCG = human chorionic gonadotropinER = emergency room; LMP = last menstrual period; hCG = human chorionic gonadotropin

Ultrasound

Right adnexal mass – complex in appearance. Cannot rule out

C id t dcancer. Consider computed tomography (CT) or magnetic resonance imaging (MRI) for better characterization and surgical intervention.

Evaluation of Adnexal Masses

Modality Sensitivity Specificity

Transvaginal ultrasound 0.82-0.91 0.68-0.81

Doppler ultrasonography 0.86 0.91opp e u t aso og ap y 0 86 0 9

Computed tomography 0.90 0.75

Magnetic resonance imaging 0.91 0.87

Positron emission tomography 0.67 0.79

CA 125 0.78 0.78

Agency for Healthcare Research and Quality. AHRQ No. 06Agency for Healthcare Research and Quality. AHRQ No. 06--E004. 2006E004. 2006

2

Corpus Luteum

Diagnostic Classification

BenignBenign EquivocalEquivocal MalignantMalignant

BenignBenign EquivocalEquivocal Malignant Malignant

Morphologic EvaluationVARIABLES

VALUE Inner Wall Structure

Wall Thickness Septa Echogenic

1 Smooth < 3 mm None Sonolucent

2Irregular < 3 mm

> 3 mm < 3 mm Low

3Papillation

> 3 mmNA

Mostly solid> 3 mm

Low with echogenic

core

4NA

Mostly solidMixed

5 High

MAX 4 3 3 5

Sassone et al. Obstet Gynecol 1993; 78: 70.Sassone et al. Obstet Gynecol 1993; 78: 70.

Inner Wall Structure Echogenicity

3

Septa MorphologyCorrect Specific Diagnosis

Diagnosis % CI (%)

Endometrioma 80% 72.3-86.7

Dermoid 84% 74.3-91.1

Hydrosalpinx 93% 66.0-99.7

Primary Invasive Cancer

80% 71.3-86.0

Calster et al. J Natl Cancer Inst 2007;99:1706Calster et al. J Natl Cancer Inst 2007;99:1706--14.14.CI = confidence intervalCI = confidence interval

Ultrasound Ultrasound Basic HistoryBasic History

•• Gravida (G), para (P)Gravida (G), para (P)

•• LMPLMP

•• Birth control (BC)Birth control (BC)

•• Prior pelvic surgeryPrior pelvic surgery

www.iotagroup.orgwww.iotagroup.orgApp StoreApp Store

DescriptorsDescriptors

•• Unilocular cystUnilocular cyst

•• UnilocularUnilocular--solid cystsolid cystyy

•• Multilocular cystMultilocular cyst

•• MultilocularMultilocular--solid cystsolid cyst

•• Solid tumorSolid tumor

•• Not classifiableNot classifiable

Timmerman et al. Ultrasound Obstet Gynecol 2000;16:500Timmerman et al. Ultrasound Obstet Gynecol 2000;16:500--505.505.

IOTA ClassificationIOTA Classification

ClassificationClassification SEPTASEPTASOLIDSOLID

componentcomponentPAPILLATIONPAPILLATION

>> 3 mm3 mm

Unilocular cyst No No No

Unilocular-solid cyst NoYes80 %

or > 1U ocu a so d cyst o< 80 %

o

Multilocular cyst > 1 No or > 1

Multilocular-solid cyst

> 1 Yes< 80 %

or > 1

Solid tumor Optional > 80% Optional

Not classifiable ? ? ?

4

DopplerDopplerNeovascularizationNeovascularization

Color Doppler ParametersColor Doppler Parameters

BenignBenign•• PI > 1.0PI > 1.0•• RI > (0.4) 0.5RI > (0.4) 0.5

P i h l flP i h l fl

MalignantMalignant•• PI < 1.0PI < 1.0•• RI < 0.5RI < 0.5•• Central flowCentral flow•• Peripheral flowPeripheral flow

•• Diastolic notchDiastolic notch

•• Central flow, Central flow, unorganizedunorganized

•• “Lakes”“Lakes”•• Changing caliber Changing caliber

of vesselsof vessels•• Absent diastolic Absent diastolic

notchnotch

Resistance Index (RI) with Resistance Index (RI) with Ovarian CancerOvarian Cancer

Epithelial Tumors of OvaryEpithelial Tumors of Ovary# of # of

patientspatientsMean Mean

RIRIpp

Benign ovarian tumor 48 0.695 < 0.001

Wu et al. Cancer 1994;73: 1251Wu et al. Cancer 1994;73: 1251--1256.1256.

Borderline malignancy 6 0.535< 0.001

Early-stage ovarian cancer 10 0.485< 0.001

Advanced-stage ovarian cancer

29 0.395 < 0.05

CFD and Ovarian MalignancyCFD and Ovarian Malignancy

•• 2 European universities2 European universities

•• Italy and SpainItaly and Spain•• Italy and SpainItaly and Spain

•• 1997 women 1997 women

•• 2148 pelvic masses2148 pelvic masses

•• Doppler: Vessel distributionDoppler: Vessel distribution

Guerriero et al. Int J Gynecol Cancer 2010;20:781-786.


Doppler studyDoppler study SensitivitySensitivity SpecificitySpecificity

Doppler vessel distribution

0.95 0.94

Morphology 0.98 0.89

Guerriero et al. Int J Gynecol Cancer 2010;20:781-786.

5


•• Conclusion:Conclusion:

Evaluation of vessel distribution by Evaluation of vessel distribution by

Medeiros et al. Int J Gynecol Cancer 2009;19:1214-1220.

color Doppler sonography color Doppler sonography increases the diagnostic accuracy increases the diagnostic accuracy of grayscale sonography in the of grayscale sonography in the detection of adnexal malignancies detection of adnexal malignancies

Vascularity ScoreVascularity Score

•• Power DopplerPower Doppler

•• PRF = 0 3 kHzPRF = 0 3 kHz•• PRF = 0.3 kHzPRF = 0.3 kHz

•• Velocity scale 3Velocity scale 3--6 cm/sec6 cm/sec

•• Balance 220Balance 220

•• Doppler gain < artifactDoppler gain < artifact

Valentin et al. Ultrasound Obstet Gynecol 2011; 38: 456Valentin et al. Ultrasound Obstet Gynecol 2011; 38: 456--465.465.

6

Vascularity ScoreVascularity Score

•• 11 No flowNo flow

•• 22 Minimal flowMinimal flow

•• 3 3 Moderate flowModerate flow

•• 44 Strong flow throughoutStrong flow throughout


Logistic regression modelLogistic regression model

•• 3511 patients in the IOTA study3511 patients in the IOTA study

•• 21 centers in 9 countries21 centers in 9 countries

S bj ti tS bj ti t•• Subjective assessmentSubjective assessment

•• RMI (Risk of malignancy index)RMI (Risk of malignancy index)

•• CA 125CA 125

•• > 40 clinical and ultrasound > 40 clinical and ultrasound variablesvariables



CategoryCategory ## %%

TOTAL 3511 100%

Uncertain benign vs malignant

244 6.95%

Invasive malignancy 40 1.14%

Borderline malignancy 33 1.03%

Valentin et al. Ultrasound Obstet Gynecol 2011; 38: 456Valentin et al. Ultrasound Obstet Gynecol 2011; 38: 456--465.465.www.iotagroup.org/adnexmodel/www.iotagroup.org/adnexmodel/


•• The only variable retained to calculate The only variable retained to calculate the risk of malignancy was the largest the risk of malignancy was the largest diameter (mm) of the diameter (mm) of the solid component solid component of the massof the massof the massof the mass

•• Benign:Benign: 24 mm 24 mm

•• Malignant:Malignant: 48 mm 48 mm p<0.001p<0.001

•• Conclusion: Logistic regression models Conclusion: Logistic regression models were NOT superior to subjective were NOT superior to subjective assessmentassessment


Ultrasound Ultrasound Basic HistoryBasic History

•• Gravida (G), para (P)Gravida (G), para (P)

•• LMPLMP

•• Birth control (BC)Birth control (BC)

•• Prior pelvic surgeryPrior pelvic surgery

7

Timing of StudiesTiming of Studies

< 5 mm 10 mm 15-18 mm

G, PLMPBCSurgery

Basic History

G0LMP=9/06/09BC: OBCPGYN SURG: NONE

Infertility Infertility -- MassMass

3232--yearyear--old G0 presents for old G0 presents for baseline ultrasound for ovulation baseline ultrasound for ovulation

induction.induction.

G0LMP=9/29/09BC: NONEGYN SURG: RT OOPHORECTOMY

8

Left Ovary

Ovarian CystsOvarian Cysts

•• 3838--yearyear--old G2P2002 referred for old G2P2002 referred for laparoscopic oophorectomy for laparoscopic oophorectomy for

i t t i ti t t i tpersistent ovarian cystpersistent ovarian cyst

•• Ultrasound (US) reports x 3: Ultrasound (US) reports x 3: persistent ovarian cyst with persistent ovarian cyst with septum, cannot rule out ovarian septum, cannot rule out ovarian cancercancer

Hydrosalpinx

9

Hydrosalpinx – 3D

3D = 3-dimensional

Pelvic Pain Pelvic Pain -- MassMass

•• 2828--yearyear--old G0 presents for evaluation of old G0 presents for evaluation of pelvic pain and pelvic fullness.pelvic pain and pelvic fullness.

•• Exam: Right adnexal mass ~ 5 cmExam: Right adnexal mass ~ 5 cm

RI = 0.51PI = 0.74

EndometriomaEndometrioma

•• Homogenous, lowHomogenous, low--level echoeslevel echoes11

S iti itS iti it 90%90%–– SensitivitySensitivity 90%90%

–– SpecificitySpecificity 97%97%

•• SeptationsSeptations 29%29%

•• Fluid levelsFluid levels 5%5%

•• Color DopplerColor Doppler

11Ubaldi F. Hum Reprod 1998;13:330Ubaldi F. Hum Reprod 1998;13:330--33

10

Pelvic Pain and MassPelvic Pain and Mass

•• 42 yo G2P1011 presents with 42 yo G2P1011 presents with menorrhagiamenorrhagia

EMB lif ti d t iEMB lif ti d t i•• EMB = proliferative endometriumEMB = proliferative endometrium

•• Failed medical therapyFailed medical therapy

•• Referred for ultrasound prior to Referred for ultrasound prior to hysterectomy, “to make sure hysterectomy, “to make sure nothing else is wrong”nothing else is wrong”

Endometrium

Left Ovary Left Ovary

Right Ovary

11

Right Ovary

PI = 1.02

Pelvic Pain and MassPelvic Pain and Mass

•• Diagnosis: Diagnosis:

•• Probable papillary serous cyst Probable papillary serous cyst d i LMPd i LMPadenocarcinoma vs. LMPadenocarcinoma vs. LMP

•• Probable endometrial polypProbable endometrial polyp•• CA 125 = 67CA 125 = 67

•• CEA = 22CEA = 22

•• Consulted gyn oncology Consulted gyn oncology

ACOGACOG--SGO Referral GuidelinesSGO Referral Guidelines

Premenopausal patients with a pelvic massPremenopausal patients with a pelvic mass

•• CA125 >200 units/mLCA125 >200 units/mLCA125 >200 units/mLCA125 >200 units/mL

•• Evidence of abdominal or distant Evidence of abdominal or distant metastasismetastasis

•• Family history of a 1Family history of a 1stst degree relative with degree relative with ovarian or breast cancerovarian or breast cancer

Dearking et al. Obstet Gynecol 2007;110:841Dearking et al. Obstet Gynecol 2007;110:841––48.48.

ACOGACOG--SGO Referral GuidelinesSGO Referral Guidelines

Postmenopausal patients with a pelvic massPostmenopausal patients with a pelvic mass

•• CA125 >35 units/mLCA125 >35 units/mL

•• AscitesAscitesAscitesAscites

•• Nodular or fixed pelvic massNodular or fixed pelvic mass

•• Evidence of abdominal or distant Evidence of abdominal or distant metastasismetastasis

•• Family history of a 1Family history of a 1stst degree relative with degree relative with ovarian or breast cancerovarian or breast cancer

Dearking et al. Obstet Gynecol 2007;110:841Dearking et al. Obstet Gynecol 2007;110:841––48.48.

12

Menorrhagia and Pelvic MassMenorrhagia and Pelvic Mass42 year old42 year old

•• LaparoscopyLaparoscopy

•• Peritoneal washingsPeritoneal washingsPeritoneal washingsPeritoneal washings

•• Right salpingoophorectomyRight salpingoophorectomy

•• Frozen: Serous cyst adenofibromaFrozen: Serous cyst adenofibroma

•• TLH + BSOTLH + BSO

•• Frozen: Serous cyst adenofibromaFrozen: Serous cyst adenofibroma

Menorrhagia and Pelvic MassMenorrhagia and Pelvic MassFinal PathologyFinal Pathology

•• UterusUterus•• Endometrial polypEndometrial polypp ypp yp

•• Proliferative endometriumProliferative endometrium

•• Right ovaryRight ovary•• Serous tumor of LMPSerous tumor of LMP

•• Left ovaryLeft ovary•• Serous tumor of LMP arising in a background of a Serous tumor of LMP arising in a background of a

serous cyst adenofibromaserous cyst adenofibroma

Menorrhagia and Pelvic MassMenorrhagia and Pelvic MassStaging ProcedureStaging Procedure

•• Peritoneal biopsies (multiple)Peritoneal biopsies (multiple)•• Endosalpingiosis with psammomatous calcificationsEndosalpingiosis with psammomatous calcificationsEndosalpingiosis with psammomatous calcificationsEndosalpingiosis with psammomatous calcifications

•• CulCul--dede--sacsac•• Serous LMP, nonSerous LMP, non--invasive with psammomatous invasive with psammomatous

calcificationcalcification•• Lymph nodesLymph nodes

•• BenignBenign•• OmentumOmentum

•• Endosalpingiosis with psammomatous calcificationsEndosalpingiosis with psammomatous calcifications

Annual Exam Annual Exam –– Adnexal MassAdnexal Mass

•• 58 yo presents for annual 58 yo presents for annual examinationexaminationexaminationexamination

•• Exam: palpable right Exam: palpable right adnexal mass ~ 4adnexal mass ~ 4--5 cm in 5 cm in sizesize

13

Size of Unilocular Cystic TumorsSize of Unilocular Cystic Tumors

Ovarian tumorOvarian tumor

SizeSize nn %%

< 3 cm 2245 68.9

3 – 6 cm 971 29.9

6 – 10 cm 40 1.2

Modesitt et al. Modesitt et al. Obstet GynecolObstet Gynecol 2003: 102 ; 5942003: 102 ; 594--99.99.

Screening Protocol Screening Protocol -- AbnormalAbnormal

•• Repeat TVS in 4Repeat TVS in 4--6 weeks6 weeks

•• AbnormalAbnormal

•• CACA--125125

•• Color Doppler sonographyColor Doppler sonography

•• ComplexComplex

•• Diagnostic surgeryDiagnostic surgery


FollowFollow--up of Unilocular Cystsup of Unilocular Cysts

Finding at followFinding at follow--upup nn %%

Resolution 2261 69.4

Septum 537 16.5

Solid area 189 5.8

Persistent unilocular cyst 220 6.8


Malignancy Risk in Unilocular Malignancy Risk in Unilocular Ovarian Cysts < 10 cmOvarian Cysts < 10 cm

•• 69.4% of simple unilocular cysts 69.4% of simple unilocular cysts << 10 cm in diameter resolve10 cm in diameter resolve< < 10 cm in diameter resolve 10 cm in diameter resolve spontaneouslyspontaneously

•• The risk of malignancy with The risk of malignancy with unilocular cysts < 10 cm = 0.9%unilocular cysts < 10 cm = 0.9%


Management of Simple Management of Simple OvarianOvarian CystsCysts

•• Describe in reportDescribe in report

•• Reproductive age:Reproductive age: > 3 cm> 3 cm

•• Menopause:Menopause: > 1 cm> 1 cm

•• Annual followAnnual follow--upup

•• Reproductive age:Reproductive age: > 5 cm> 5 cm

•• Menopause:Menopause: > 1 cm> 1 cm

Levine et al. Radiology 2010;256:943Levine et al. Radiology 2010;256:943--954.954.

14

82 y.o. G5P302382 y.o. G5P3023•• Recent admission for C. Diff and STEMIRecent admission for C. Diff and STEMI•• Atrial fibrillationAtrial fibrillation•• Diastolic heart failureDiastolic heart failure•• Coronary arterial diseaseCoronary arterial disease•• HypertensionHypertension•• Chronic kidney diseaseChronic kidney disease

•• CTCT•• Multiloculated fluid collection predominantly located in the Multiloculated fluid collection predominantly located in the

right side of the lower pelvis containing small foci of right side of the lower pelvis containing small foci of internal calcification and measuring up to approximately internal calcification and measuring up to approximately 3.0 x 7.5 x 5.4 cm. 3.0 x 7.5 x 5.4 cm. This is favored to represent an This is favored to represent an abscessabscess. . The origin of his abscess could be secondary to The origin of his abscess could be secondary to an infectious process in the an infectious process in the right adnexa or less likely right adnexa or less likely could be secondary to a walled off abscess collection from could be secondary to a walled off abscess collection from a remote episode of diverticulitis. a remote episode of diverticulitis.

Right adnexal mass

15

What’s you diagnosis?What’s you diagnosis?EndometriumEndometrium

1.1. Endometrial carcinomaEndometrial carcinoma

22 Endometrial polypEndometrial polyp2.2. Endometrial polypEndometrial polyp

3.3. Tamoxifen effectTamoxifen effect

4.4. Submucous myomaSubmucous myoma

5.5. OtherOther

What’s you diagnosis?What’s you diagnosis?OvaryOvary

1.1. Papillary serous carcinomaPapillary serous carcinoma

22 CystadenofibromaCystadenofibroma2.2. CystadenofibromaCystadenofibroma

3.3. DermoidDermoid

4.4. EndometriomaEndometrioma

5.5. OtherOther

EvaluationEvaluation

•• TVSTVS•• Uterus: Uterus: Probable endometrial polypProbable endometrial polyp. .

Cannot ruleCannot rule--out cancer based on out cancer based on ultrasound appearance alone. ultrasound appearance alone.

•• Right ovary: Right ovary: Probable serousProbable serouscystadenocarcinoma vs. tumor of lowcystadenocarcinoma vs. tumor of low--malignant potential. malignant potential. ThisThis could also could also represent an unusual appearance for a represent an unusual appearance for a benign ovarian mass, but this is less benign ovarian mass, but this is less likely. likely.

•• CA125CA125 118118

SurgerySurgery•• Exploratory laparotomyExploratory laparotomy

•• Staging and debulkingStaging and debulking•• Rectosigmoid and small bowel resection Rectosigmoid and small bowel resection

and reanastamosisand reanastamosis•• PathologyPathology•• PathologyPathology

•• One endometrial polyp One endometrial polyp with two adjacent with two adjacent foci of foci of serousserous carcinoma carcinoma measuring 3 mm measuring 3 mm and 1.3 mmand 1.3 mm

•• Right Ovary: Right Ovary: Serous papillary carcinoma Serous papillary carcinoma with foci of necrosis with foci of necrosis

•• Rectosigmoid: Rectosigmoid: Metastatic adenocarcinoma Metastatic adenocarcinoma in the mesenteryin the mesentery

•• Stage 3C serous ovarian carcinomaStage 3C serous ovarian carcinoma

16

66 y.o. G1P100166 y.o. G1P1001

•• MenopausalMenopausal

B t C HER2 P itiB t C HER2 P iti•• Breast Cancer: HER2 PositiveBreast Cancer: HER2 Positive

•• Finished chemotherapy 2 weeks Finished chemotherapy 2 weeks agoago

•• Prior gyn surgery: D&CPrior gyn surgery: D&C

17

What’s you diagnosis?What’s you diagnosis?OvaryOvary

1.1. Papillary serous carcinomaPapillary serous carcinoma

22 CystadenofibromaCystadenofibroma2.2. CystadenofibromaCystadenofibroma

3.3. DermoidDermoid

4.4. EndometriomaEndometrioma

5.5. OtherOther

Surgical FindingsSurgical Findings

•• Slightly enlarged left ovarySlightly enlarged left ovary

R d d l d iR d d l d i•• Removed and placed in an Removed and placed in an endoscopic bagendoscopic bag

•• Pathology:Pathology:

•• Serous cystadenofibromaSerous cystadenofibroma

36 y.o. G2P200236 y.o. G2P2002

HistoryHistory

•• Mass on outside ultrasoundMass on outside ultrasound

18

Vascularity 2

36 y.o. G2P200236 y.o. G2P2002

•• Mucinous cystadenomaMucinous cystadenoma

19

45 y.o. G4P400445 y.o. G4P4004

•• MenopausalMenopausal•• MenopausalMenopausal

•• c/o Abdominal discomfortc/o Abdominal discomfort

•• Abdominal/pelvic massAbdominal/pelvic mass

45 yo G4P400445 yo G4P4004

45 yo G4P400445 yo G4P4004 45 yo G4P400445 yo G4P4004

45 yo G4P400445 yo G4P4004PI = 0.45RI = 0.38

45 y.o. G4P400445 y.o. G4P4004

•• CA 125 = 22.5CA 125 = 22.5

•• Differential diagnosisDifferential diagnosis

•• Mucinous cystadenomaMucinous cystadenoma

•• LMP vs. MalignantLMP vs. Malignant

•• DermoidDermoid

•• EndometriomaEndometrioma

20

45 y.o. G4P400445 y.o. G4P4004

•• GynGyn--OncologyOncology

•• LaparotomyLaparotomy

•• TAH + BSOTAH + BSO

•• StagingStaging

45 y.o. G4P400445 y.o. G4P4004

•• Mucinous borderline tumor, intestinal Mucinous borderline tumor, intestinal type, with intraepithelial carcinomatype, with intraepithelial carcinoma

•• Tumor involves (R) ovarian parenchyma Tumor involves (R) ovarian parenchyma ( ) p y( ) p yand the ovarian capsule is intactand the ovarian capsule is intact

•• Fallopian tube free of tumorFallopian tube free of tumor

•• Appendix: NegativeAppendix: Negative

•• Nodes: NegativeNodes: Negative

•• Peritoneal washings: negativePeritoneal washings: negative

•• Stage: pT1aStage: pT1a

63 y.o. G3P300363 y.o. G3P3003

•• Postmenopausal woman Postmenopausal woman with vaginal bleedingwith vaginal bleeding

21

Ultrasound InterpretationUltrasound Interpretation

•• EndometriumEndometrium

•• IndistinctIndistinct

P b bl d t i l lP b bl d t i l l•• Probable endometrial polypProbable endometrial polyp

•• Must have concern for Must have concern for endometrial cancerendometrial cancer

•• Right ovarian massRight ovarian mass

•• Granulosa cell tumor Granulosa cell tumor

Granulosa Cell TumorGranulosa Cell TumorUltrasound AppearanceUltrasound Appearance

•• MultilocularMultilocular 52%52%

•• SolidSolid 39%39%

•• UnilocularUnilocular––solidsolid 4%4%

•• MultilocularMultilocular 4%4%

Granulosa cell tumorGranulosa cell tumor

•• Accounts for ~ 3% of all ovarian Accounts for ~ 3% of all ovarian malignanciesmalignancies

Th t (70%)Th t (70%)•• The most common (70%) sex The most common (70%) sex cord stromal tumor cord stromal tumor

•• The most common (80%) The most common (80%) hormonehormone--producing ovarian producing ovarian tumortumor

Granulosa cell tumorGranulosa cell tumor

•• Incidence = 0.5Incidence = 0.5––1.5 per 100,000 1.5 per 100,000 women per yearwomen per year

M th 50% iM th 50% i•• More than 50% in More than 50% in postmenopausal women postmenopausal women

•• OneOne--third of GCTs occur in third of GCTs occur in premenopausal womenpremenopausal women

•• 5% in the prepubertal period5% in the prepubertal period

22

Granulosa cell tumorGranulosa cell tumorMacroscopic AppearanceMacroscopic Appearance

•• Large, commonly Large, commonly encapsulated tumorsencapsulated tumors

S th l b l t dS th l b l t d•• Smooth or lobulated Smooth or lobulated surface. surface.

•• Gray or yellow cut Gray or yellow cut surfacesurface

•• Solid and cystic areas Solid and cystic areas

Hormonal ActivityHormonal Activity

•• Estrogen productionEstrogen production

•• Breast growthBreast growth

•• Abnormal bleedingAbnormal bleeding

•• 2424--80% of patients have endometrial 80% of patients have endometrial pathologypathology

•• Endometrial hyperplasiaEndometrial hyperplasia 2020--65%65%

•• Endometrial cancer Endometrial cancer up to 10%up to 10%

Tumor MarkersTumor Markers

•• EstradiolEstradiol

•• Minimal value in Minimal value in premenopausal womenpremenopausal women

•• Inhibin AInhibin A

•• Inhibin BInhibin B

•• CA125 of little valueCA125 of little value

Ultrasound DiagnosisUltrasound Diagnosis

•• Granulosa cell tumorGranulosa cell tumor

•• Probable LMPProbable LMP

•• Endometrial hyperplasia or Endometrial hyperplasia or cancercancer

Pathology DiagnosisPathology Diagnosis

G l ll t f LMPG l ll t f LMP•• Granulosa cell tumor of LMPGranulosa cell tumor of LMP

•• Complex endometrial Complex endometrial hyperplasia with atypiahyperplasia with atypia

Infertility Infertility -- MassMass

3333--yearyear--old G0 presents for baseline old G0 presents for baseline ultrasound (day 3) for ovulation induction ultrasound (day 3) for ovulation induction

on Sundayon Sunday

23

35 y.o. G4P004035 y.o. G4P0040

•• Right ovarian cystic massRight ovarian cystic mass

•• Medical conditionsMedical conditions

•• HIVHIV

•• H/O stroke (cocaine)H/O stroke (cocaine)

•• AsthmaAsthma

•• HypothyroidismHypothyroidism

•• Hearing lossHearing loss

•• CA125 = 20.4CA125 = 20.4

24

25

First ExaminationFirst Examination

•• 2323--yearyear--old G0 presents for old G0 presents for first examinationfirst examination

•• Complains of pelvic pressureComplains of pelvic pressure

•• LMP = 3 weeks priorLMP = 3 weeks prior

•• Menses regularMenses regular

•• Birth control: noneBirth control: none

Annual ExaminationAnnual Examination

•• Uterus enlarged ~ 12 weeks, NTUterus enlarged ~ 12 weeks, NT

•• UCG: negativeUCG: negative

•• Plan: pelvic ultrasoundPlan: pelvic ultrasound

NT = nontenderNT = nontender

Ovarian MassesOvarian MassesBilateral TumorsBilateral Tumors

•• Serous cystadenomasSerous cystadenomas 25%25%Se ous cystade o asSe ous cystade o as 5%5%

•• TeratomasTeratomas 15%15%

•• Mucinous cystadenomasMucinous cystadenomas 22--3%3%

ACOG Practice Bulletin. Management of Adnexal Masses. ACOG Practice Bulletin. Management of Adnexal Masses. Number 83, July 2007Number 83, July 2007

26

RI = 0.80PI = 1.58

RI = 0 36RI = 0.36PI = 0.58

AgeAge--Related Risk of Malignancy of Related Risk of Malignancy of an Ovarian Tumor (959 Patients)an Ovarian Tumor (959 Patients)

MalignantMalignant BenignBenignAge, years Age, years NN %% NN %% RM (%)RM (%) RRRR<< 2020 1414 55 446446 24.124.1 2.92.921 21 -- 3030 1212 44 132132 1919 8.38.3 1.01.031 31 -- 4040 2121 88 138138 2020 13.213.2 1.61.641 41 -- 5050 4242 1616 180180 1515 43.343.3 2.32.351 51 -- 6060 8181 3030 106106 1515 43.343.3 5.25.261 61 -- 7070 6868 2525 5656 88 54.854.8 6.66.6>> 7171 3333 1212 3232 55 50.850.8 6.16.1

Rate of malignancy (RM)Rate of malignancy (RM) Relative risk of malignancy (RR)Relative risk of malignancy (RR)

Minaretzis et al. Minaretzis et al. Gynecol Obstet InvestGynecol Obstet Invest 1994; 38, 1401994; 38, 140--144144

27

Pelvic Mass Pelvic Mass –– 2323--yearyear--old G0old G0

•• Additional testingAdditional testing

•• CA 125 = 25.1CA 125 = 25.1

P b bl di iP b bl di i•• Probable diagnosisProbable diagnosis

•• Bilateral papillary serous Bilateral papillary serous cystadenomas of low malignant cystadenomas of low malignant potential potential

•• Preoperative counselingPreoperative counselingRIGHT OVARYRIGHT OVARY

LEFT OVARYLEFT OVARY

Pelvic Masses Pelvic Masses –– 2323--yearyear--old G0old G0

LaparoscopyLaparoscopy•• Peritoneal washingsPeritoneal washings•• Right salpingoRight salpingo--oophorectomyoophorectomy

•• PathologyPathology--frozenfrozen•• Papillary serous cystadenomaPapillary serous cystadenoma lowlow•• Papillary serous cystadenoma Papillary serous cystadenoma –– low low

malignant potentialmalignant potential•• Left ovaryLeft ovary

•• Ovarian cystectomyOvarian cystectomy•• PathologyPathology--frozenfrozen

•• Papillary serous cystadenoma Papillary serous cystadenoma –– low low malignant potentialmalignant potential

28

Pelvic Masses Pelvic Masses –– 2323--yearyear--old G0old G0

Final pathologyFinal pathology

•• Peritoneal washingsPeritoneal washings

•• NegativeNegative

•• Right salpingoophorectomyRight salpingoophorectomy•• Right salpingoophorectomyRight salpingoophorectomy


•• Left Ovarian cystectomyLeft Ovarian cystectomy


Preoperative UltrasoundPreoperative UltrasoundSummarySummary

•• More accurate diagnosis More accurate diagnosis

•• If surgery is required:If surgery is required:

•• Preoperative counselingPreoperative counseling•• Preoperative counselingPreoperative counseling

•• Select the procedureSelect the procedure

•• Select the approachSelect the approach

•• Select equipmentSelect equipment

•• Selecting personnelSelecting personnel

•• Surgical correlationSurgical correlation

Thank YouThank YouThank YouThank You

James M. Shwayder, M.D., J.DJames M. Shwayder, M.D., J.D..Professor and ChairProfessor and ChairDepartment of Obstetrics and Gynecology Department of Obstetrics and Gynecology University of MississippiUniversity of MississippiJackson, MSJackson, MS

Documents

Learning Objectives Pelvic Pain - IAME · CA 125 0.78 0.78 Agency for Healthcare Research and Quality. ... • EMB lif ti d tiEMB = proliferative endometrium • Failed medical therapy