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Global Endometrial Ablation — 177
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A
B
Figure 8.6.5. The HTATMsystem, showing the console (A, top) and the disposable sheath with a 3-mm hysteroscope attached (A, bottom);
B. shows the new disposable sheath with the cervical stabilizer that reduces the risk of inadvertent withdrawal of sheath from uterus before
cooling.
178 — Philip G. Brooks
https://t.me/med1917
Outcomes
At 36 months, the amenorrhea rate for the patients in the FDA
phase III trial was 53%. Success rate, as measured by patient satisfaction and reduction of bleeding, was reported to be 94%. Of
interest are several reports describing the success of this system
in the presence of submucous myomata, and the success of performing this procedure under local anesthesia.[9,10]
SUMMARY
Asdescribed above,therearefiveglobalablationdevicesapproved
by the FDA for the management of abnormal uterine bleeding. Undoubtedly, more will be forthcoming, in an attempt to
increase efficacy, improve outcomes, reduce the cost, and especially, improve safety. Regarding the latter, it should be obvious that the intent of all the devices is the destruction of the
tissue that allows the excessive and unacceptable bleeding. If the
destructive force is placed inadvertently in the wrong areas, there
will be undesirable damage to tissue or organs not intended to be
injured. There is ongoing development of the next generation of
ablation devices that attempt to solve these problems in a faster,
simpler, more consistent, andsuccessful manner. It remains to be
seen whether this will be accomplished.
Finally, there is a significant amount of effort being made to
provide endometrial ablations as office procedures, using local
instead of general anesthesia, thereby reducing one more area
of increased cost and risk. Several studies have shown that pain
from these procedures comes from high-pressure uterine distention and from movements and manipulations of devices inside
the uterus. NovaSure and HTA are the only devices that do not
distend the uterus under high pressures and are not manipulated
inside the endometrial cavities during the active procedure. For
many, the performanceof the ablationblindly entertains too high
a riskof perforation or partial uterine wall penetration, especially
when performed as an office procedure. Only the HTA system is
performed while viewing the cavity and the sheath placement
hysteroscopically throughout the entire procedure.
Global endometrial ablation devices have been significantly
and successfully added to the surgical armamentarium of practicing physicians for the management of abnormal uterine bleeding, in which hysterectomy for benign conditions can be safely
avoided.
REFERENCES
1. Goldrath MH, Fuller T, Segal S. Laser photo vaporization of
endometrium for the treatment of menorrhagia. Am J Obstet
Gynecol. 1981;140:14–19.
2. Hallez JP, Netter A, Cartier R. Methodical intrauterine resection.
Am J Obstet Gynecol. 1987;156:1080.
3. Neuwirth RS, AminHK. Excision ofsubmucous fibroids with hysteroscopic control. Am J Obstet Gynecol. 1983;131:95.
4. DeCherneyA, PolanML. Hysteroscopicmanagement of intrauterine lesions and intractable uterine bleeding. Obstet Gynecol.
1983;61:392.
5. Lin B-L. The development ofanew hysteroscopicresectoscope and
its clinical applications for trans-cervical resection and endometrial ablation. Jpn J Gynecol Obstet Endosc. 1988;4:4–56.
6. Brooks PG, Loffer FD, Serden SP. Resectoscopic removal of symptomatic lesions. JReprodMed.1989;34:435.
7. U.S. Food and Drug Administration. MAUDE (Manufacturers and User Facility Device Experience) database. Available at:
www.fda.gov/maude.
8. Harris M, Cooper JM. Microwave endometrial ablation:three-year
outcomes of a multi-centered trial. J Am Assoc Gynecol Laparosc.
2005;12:125–128.
9. Glasser MH, Zimmerman JD. The HydroThermAblator system
for management of menorrhagia in women with submucous
myomas: 12- to20-month follow-up. J Am Assoc Gynecol Laparosc.
2003;10:521–527.
10. Brooks PG. Endometrial ablation as an office procedure using
local anesthesia. Presented at: American Association of Gynecologic Laparoscopists Annual Clinical Meeting; November11, 2004;
San Francisco, CA.
9 MANAGEMENT OF ADNEXAL MASSES
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Section 9.1. The Adnexal Mass
Sophia Rothberger, Tanja Pejovic, and Farr Nezhat
The adnexa are in an anatomic region in the pelvis that includes
the ovaries, the fallopian tubes, and the structures within the
broad ligament. The differential diagnosis of an adnexal mass is
complex because of the wide spectrum of disorders that involve
the adnexa. Most frequently, adnexal masses involve the ovary
itself because of its inherent growth properties through ovulation and thus its propensity for neoplasia.[1] During the evaluation of an adnexal mass, the picture may be further complicated
as imaging does not always clearly delineate the adnexa from
other nearby organs. An estimated 5% to 10% of women in the
United States will undergo a surgical procedure for a suspected
ovarian neoplasm during their lifetime.[2] Although the majority of adnexal masses are benign in nature, the primary goal of
the diagnostic evaluation is the exclusion of malignancy.
ETIOLOGY
The differential diagnosis of the adnexal mass varies with age
(Table 9.1.1). Ageis also the most important factor in determining
the potential for malignancy. In fact, the risk that an ovarian
neoplasm is malignant increases 12-fold from ages 12 through
29 and 60 through 69.[3] Although there is emerging evidence
that the presence of anadnexalmassinpostmenopausal women is
more common than once thought, massesfoundin premenarchal
and postmenopausal womenshould be considered abnormal and
must be promptly evaluated.
Premenarchal Patient
Because prepubertal girls are not under the influence of
gonadotropic hormones, physiologic cysts are uncommon.
Adnexal masses, therefore, have a higher rate of malignancy in
girls than in women of reproductive age and require immediate surgical exploration. In the fetus and newborn, however, the
influence ofmaternal hormones may causefollicular cysts. These
regress on their own within 6 months of age.
Histologically, most prepubertal ovarian neoplasms are of
germ cell origin. Abdominal pain is the most common presenting symptom and torsion is present in approximately 20% of
cases. Ehrenet al. [4] reported a series of 63 patients with ovarian
tumors of different histology. The final diagnosis was benign teratoma in 65% of the cases. In 21% of the patients, the removed
tumor was malignant. All patients younger than 12 years had
germ cell tumors, whereas one patient, a 4-year-old girl, had an
epithelial tumor. Appendicitis was themost common misdiagnosis. Rarer symptoms of adnexal mass include precocious puberty,
hirsutism, urinary complaints, and primary or secondary amen-
orrhea. Other nongynecologic diagnoses may include Wilms’
tumor, neuroblastomas, and gastrointestinal abnormalities.
Reproductive-Age Patient
The most common adnexal masses in reproductive-age women
are benign functional cysts of the ovaries. These include follicular cysts, corpus luteum cysts, theca lutein cysts, and polycystic
ovaries. Functional ovarian cysts are usually asymptomatic and
tend to resolve spontaneously in 4 to 6 weeks. Occasionally they
maybeaccompaniedbysome degreeofpelvicdiscomfort,pain,or
dyspareunia. In addition,the rupture of oneof these cystsleads to
peritoneal irritation and possiblyhemoperitoneum. A functional
cyst may also be complicated by torsion, resulting in severe pain.
Other benign conditions include endometriosis (with ovarian
endometriotic cysts), inflammatory enlargement of the fallopian
tubes and ovaries (hydrosalpinges, tubo-ovarian abscess) due to
pelvic infection, ectopic pregnancy, and trophoblastic disease.
Leiomyomata are common benign tumors of smooth muscle
origin. They are found on 80% of surgically excised uteri and
most frequently occur on the uterus and cervix; however, they
may also be found on the broad ligament. Fibroids may resemble
a suspicious ovarian mass on imaging when pedunculating into
the posterior cul-de-sac or degenerated.
True benign ovarian neoplasms could also cause adnexal
enlargement. These include most frequently serous or mucinous
cystadenomas and benign cystic teratomas (Table 9.1.2). Cystic
teratomas make up 70% of benign neoplasms in women younger
than 30 and are made of the three germ cell layers. Mucinous and
serous cystadenomas are usually multiloculated, with thin walls.
It is unclear whether these are precursors of malignant neoplasms,
although some changes may represent true ovarian intraepithelial
neoplasia.
Other neoplastic processes include paraovarian cysts and
ovarian and fallopian tube cancers. In certain instances, the mass
is clinically indeterminate and may be the result of nongynecologic causes, such as full bladder, stool in the colon, distended
cecum, peritoneal cyst, appendiceal abscess, diverticular abscess,
Crohn’s disease, ectopic kidney, urachal cyst, abdominal wall
tumor, lymphoma, retroperitoneal sarcoma, metastatic tumor to
the ovaries, and malignant diseases of the gastrointestinal system
(Table 9.1.1).
Postmenopausal Patient
Any enlargement ofthe ovary is abnormal inthe postmenopausal
women and should be considered malignant until proven otherwise. The postmenopausal ovary atrophies to 1.5 × 1.0. × 0.5 cm
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Table 9.1.1: Differential Diagnosis of Adnexal Mass
Organ Cystic Solid
Ovary Functional cyst
Endometriosis
Cystic neoplasm
Benign
Malignant
Fallopian
tube
Uterus Intrauterine pregnancy Myoma
Bowel Distended colon with gas
Other Distended bladder Abdominal wall hematoma
Tubo-ovarian abscess or
hydrosalpinx
Paratubal cyst
and/or feces
Benign
Malignant
Ectopic pregnancy
Tubo-ovarian abscess
Neoplasm
Appendicitis
Diverticulitis
Diverticular abscess
Colon cancer
or abscess
Pelvic kidney
Retroperitoneal neoplasm
Table 9.1.2: Benign Ovarian Tumors
Non-neoplastic tumors
Inclusion cyst
Follicular cyst
Corpus luteum cyst
Pregnancy luteoma
Thecaluteincyst
Endometrioma
Neoplasm arising from the surface epithelium of the ovary
Serous cystadenoma
Mucinous cystadenoma
Mixed forms
Neoplasms of stromal origin
Fibroma (Meigs’ syndrome
Brenner tumor
Germ cell tumors
Dermoid tumor (mature cystic teratoma)
∗
Meigs’syndrome:presenceofovarian fibroma and right-sided pleural
effusion.
∗
)
in size and should not be palpable on pelvic examination. Ovaries
that are palpable must alert the physician to possible malignancy.
The risk of malignancy in this age group is increased from 13%
in premenopausal to 45% in postmenopausal women.[2] Still,
55% of postmenopausal women with palpable ovaries do have a
benign tumor.
The most common ovarian tumors in this age group include
epithelial ovarian tumors followed by stromal tumors and sex
cord tumors. These are usually asymptomatic and diagnosed at
late stages. Fallopian tube carcinoma is generally asymptomatic
and may be found incidentally or at late stage of progression.
Patients may experience a clear, watery discharge. Imaging may
show a thickened tubular structure.
Table 9.1.3: Clinical Signs of a Malignant versus Benign
Adnexal Mass
Malignant Benign
Prepubertal or postmenopausal Reproductive age
Personal history of nongynecologic
cancer
Family history of ovarian, breast, or
colon cancer
Rapid growth No growth
Ascites No ascites
Fixed Mobile
Nodularity of rectovaginal septum Smooth rectovaginal septum
Bilateral Unilateral
Solid or complex Cystic
Irregular Smooth
Simple cysts are more common than once thought in this
age group. Although devoid of gonadotropic stimulation,studies
show that simple cystsexistinpostmenopausal women. One Norwegian autopsy study by Dorumet al. [5]examined the adnexaof
234 postmenopausalwomen who diedof nongynecologic causes,
and 15% had ovarian cysts and 5% had paraovarian cysts. One
cyst was aborderlinecystadenomaandtherestwerebenign.Other
studies have shown that the prevalence of asymptomatic simple
cysts on ultrasound in postmenopausal women ranges from 3%
to 15%.[6]
CLINICAL PRESENTATION AND EVALUATION
History and Physical Exam
Surgical exploration is the gold standard for diagnosis; however, much can be discerned about the diagnosis of an adnexal
mass from a careful history, exam, and imaging. The majority
of patients present with symptoms related to compression of the
local pelvic organs due to the adnexal mass. Less commonly, an
ovarian mass is discovered during a routine pelvic examination
in an asymptomatic patient.
Once a mass is identified, onset and quality of pain, demographic considerations, menstrual associations, and bowel and
bladder involvement may help develop an index of suspicion
(Table 9.1.3). Patients with a personal or family history of colon,
ovarian, or breast cancer are at higher risk for malignancy than
others. The BRCA-1 and BRCA-2 genes are two of the known
hereditary links for ovarian cancer, and testing is available.
In several surgical series, the reported incidence of ovarian
malignancy in patients with a preoperative diagnosis of an ovarian mass ranged from 13% to 21%. In patients with a malignant
process, the most common clinical symptom is abdominal discomfort due to ascites. Family and personal historyraise the index
of suspicion for cancer, and as previously mentioned, the most
important predictor ofmalignancy is the age of the patient. However, even in postmenopausal women, the majority of adnexal
masses (55%) are benign.[7]
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The physical examination should include an abdominal,
pelvic, rectovaginal, breast, and lymph node examination (Table
9.1.3). Although physical exam can identify new masses and
help localize and characterize known masses, examination alone
is often inaccurate in determining whether an adnexal mass is
benign or malignant. Associatedfindings ofdisseminated disease
help improvetheaccuracyofdiagnosis.Imagingstudiesincluding
ultrasound and/or computed tomography (CT) scans are usually
required for further evaluation.
The Role of Pelvic Imaging
Pelvic ultrasound is currently the most useful technique for the
diagnostic evaluation of an adnexal mass. Simple physiologic
cysts, teratomas, and endometriomas have characteristic appearancesonultrasoundandsignificantlylowertheconcernfor malignancy when identified. The significant parameters for an ultrasonographic evaluation of the adnexal mass are the size, number
of loculi, overall echo density, presence of septations with flow
within, and presence of papillary or solid excrescences or nodules within the mass. There are no universally accepted criteria
for the sonographic description of ovarian disease. However, the
findings that suggest malignancy include size larger than 6 cm in
postmenopausal women and larger than 8 cm in premenopausal
women, presence of thickseptations, papillary projections within
the lumen of the cyst, complexity (cystic and solid areas) of the
mass, and presence of nodules within the wall.
Various ultrasound techniques are available. Transvaginal
ultrasound provides better resolution of the adnexa than does
abdominal ultrasound.[8] Although most comparison studies
have found gray-scale sonography to be superior to Doppler
sonography, or that Doppler offers no significant improvement
over gray-scale sonography, a minority of studies report Doppler
features to be superior. Most authors prefer pulsatility index (PI)
as a standard and consider a PI of 1.0 or less to be suggestive
of malignancy; however, some authors use resistance index (RI),
with values greater than 0.4 to 0.7 as indicators of malignancy.
A seminal work by Sassone et al.(1991)[9]evaluated an ultrasound scoringsystemtopredictovarianmalignancy. Transvaginal
sonographic pelvic images of 143 patients were correlated with
surgicopathologic findings. The variables in the scoring system
included the inner wall structure of the adnexal cyst, wall thickness, presence and thickness of septa, and echogenicity. The scoring system was useful in distinguishing benign from malignant
masses, with a specificity of 83%, sensitivity of 100%, and positive and negative predictive values of37% and 100%,respectively.
Subsequently, Alcazar and Jurado [10] developed alogistic model
to predict malignancy based on menopausal status, ultrasound
morphology, and color Doppler findings in 79 adnexal masses.
The authors derived a mathematical formula to estimate preoperatively the risk of malignancy (or benignity) of a given adnexal
mass in a simple and reproducible way. When this formula was
applied prospectively, 56 of 58 (96.5%) of adnexal masses were
correctly classified. Although following a model would make
management decisions more concrete, most clinicians base their
decisions on the full clinical picture.
In general, CT is not routinely indicated for the evaluation
of the adnexal mass, as it is not sensitive to lesions less than
2 cmin size. Itis, therefore, not a goodtool for the early detection
of ovarian cancer. However, in cases in which malignancy is sus-
Table 9.1.4: Tumor Markers in Ovarian Neoplasms
Neoplasm Marker
Epithelial ovarian cancer
Mucinous epithelial ovarian tumors
Dysgerminoma
Endodermal sinus tumor AFP
Choriocarcinoma, placental site
trophoblastic tumor
Granulosa cell tumor Inhibin A
CA-125
CA-19-9
LDH
hCG, human placental
lactogen
pected, aCT scanmay be used to further evaluate a patient with a
hard fixed lateralized mass, ascites, abnormal liver function tests,
or palpable abdominopelvic mass.
Magnetic resonance imaging (MRI) does not use ionizing
radiation; therefore,itisusefulintheevaluationofadnexalmasses
in pregnancy. It is also useful in further evaluation of adnexal
masses detected by ultrasound and characterized as “intermediate” in nature.Grab et al. [11] investigated the accuracy of sonography versus MRI and positron emission tomography (PET) in
101 patients with asymptomatic adnexal masses detected who
subsequently underwent laparoscopy. Ultrasonography established the correct diagnosis in 11 of the 12 ovarian malignancies (sensitivity, 92%), but the specificity was only 60%. With
MRI and PET, specificity improved to 84% and 89%, but sensitivity declined. When all modalities were combined, specificity
was 85%, sensitivity 92%, and accuracy 86%. However, because
a negative MRI or PET does not rule out early ovarian cancer or
borderline malignancy, ultrasound remains the most important
tool in the evaluation of the adnexal mass.
Laboratory Studies
The most helpful laboratory studies in the evaluation of adnexal
masses are the quantitative beta-human chorionic gonadotropin
(β-hCG), complete blood count (CBC) with differential, and in
selected cases, tumor markers. The quantitative β-hCG is essential in ruling out ectopic pregnancy. A CBC with differential is
necessary when an infectious case is suspected. Serum tumor
markers for malignant germ cell tumors, lactic dehydrogenase
(LDH), β-hCG, and alpha-fetoprotein (AFP) should be obtained
in the young patient with a cystic-solid or solid adnexal mass to
evaluate the risk of a germ cell tumor (Table 9.1.4). A serum
CA-125 level and carcinoembryonic antigen should also be
obtained in patients with suspected gynecologic or gastrointestinal cancers respectively.
Although tempting, using CA-125 outside its clinical indications may cloud rather than clarify the differential diagnosis.
CA-125 is elevated to levels greater than normal (35 IU/mL) in
about 1%of healthy individuals. Also,in premenopausal women,
CA-125 is elevated in a variety of benign conditions, including
myoma, adenomyosis, benign ovarian tumors, pelvic inflammatory disease, liver disease, endometriosis, peritonitis, and pleural
effusions. Normal pregnancy elevates CA-125 above normal, and
hypothyroidism is associated with a slight elevation in CA-125.
Serum CA-125 is elevated in 80% of all patients with serous
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carcinoma of the ovary, but in only half of patients with stage
I disease, making it a poor screening tool for detection of ovarian
cancer.[12] As a diagnostic aid, CA-125 is most useful in postmenopausal women with a suspicious pelvic mass on ultrasound.
In that subgroup of patients, a level greater that 65 IU/mL has
been shown to have a positive predictive value of 97%.[13] The
most reliable use of CA-125 is in the evaluation of patients with
ovarian cancer to monitor treatment response or diseaseprogression.[14]
MANAGEMENT
Indications for Surgery
The crucial decision regarding management of the reproductiveage woman with an adnexal mass is to observe the patient or
proceed with surgical removal of the mass. Surgical removal of
an adnexal mass is indicated when there is suspicion of malignancy,suspicion of torsion, orseverepain.[15] Surgical approach
by laparotomy versus laparoscopy becomes the second question
(Table 9.1.5).
Size may be an indication for removal because size is directly
proportional to risk for malignancy and ovarian torsion. Simple
cystic adnexal masses are rarely larger than 8 cm. During the
reproductive years, simple cystic adnexal masses less than 8 cm
in diameter could be followed expectantly in the asymptomatic
Table 9.1.5: Adnexal Mass: Indications for Surgery
Ovarian cystic structure ≥8 cm without regression for 6–8 weeks
Anycysticstructure≥10 cm
Any solid ovarian lesion
Ovarian lesion with papillary excrescences in the wall
Palpable adnexal mass in premenarchal or postmenopausal patient
Ascites
patient, as 70%of these masses willresolvespontaneously (Figure
9.1.1). Thepatient should undergo a repeat physical examination
and pelvic ultrasound at a specified time interval. A common
practice is to suppressovulation with oral contraceptivepills, but
the value of this strategy remains unproven.
Indications for surgery of a simple cyst include persistence of
the mass, change in ultrasonic characteristics to a more complex
appearance, solid enlargement, and evidence of ascites (Table
9.1.6). However, if the mass remains less than 8 cm, simple on
ultrasound appearance, and asymptomatic, continued follow-up
is a reasonable option. In the reproductive-age woman with an
adnexal mass greater than 8 cm in diameter, solid appearance
on ultrasound, bilaterality, and the presence of ascites, surgical
Risk of malignancy
Risk of torsion
Severe pain
Surgical
exploration
Adnexal Mass
Simple cyst
Reproductive age
Size < 8cm
Size 5-8cm Size < 5cm
Follow-up exam
and U/S
+/- OCP
Regression
Resume previous
health maintenance
Stable or further
growth
Follow-up exam
and U/S
Stable or regression
Resume previous
health maintenance
Growth
Figure 9.1.1. Management of adnexal mass.
Surgical
exploration
Surgical
exploration
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Table 9.1.6: Histologic Classification of Malignant
Ovarian Tumors
Epithelial ovarian cancer
Serous
Mucinous
Endometrioid
Clear cell
Transitional cell carcinoma
Undifferentiated carcinoma
Germ cell tumors
Immature teratoma
Malignant neoplasms arising within mature cystic teratoma
Dysgerminoma
Embryonal carcinoma
Endodermal sinus tumor
Choriocarcinoma
Gonadoblastoma
Sex cord–stromal tumors
Granulosa cell tumor (adult and juvenile types)
Sertoli–Leydig tumor (arrhenoblastoma and Sertoli tumor)
Neoplasms derived from nonspecific mesenchyme
Sarcoma
Lymphoma
Metastatic tumors to the ovary
Gastrointestinal tumor (Krukenberg)
Breast
Uterus
evaluation is indicated.[1] In premenarchal and postmenopausal
patients, presence of an adnexal mass of any size is considered
an indication for surgical removal of the mass. Classification of
malignant ovarian tumors is given in Table 9.1.7.
Use of Laparoscopy
Once surgery is decided on, accuratediagnosis at surgery is essential in the management of adnexal masses. Many surgeons are
now using the laparoscopic approach for the management of
the adnexal mass in reproductive-age women when suspicion of
malignancy is low. In a 1990 survey by the American Association of Gynecologic Laparoscopists, operative laparoscopy was
accomplished in most patients and there were only 53 cases of
unsuspected ovarian cancer in 13,739 cases (0.04%).[16] The
benefits of laparoscopic surgery include shorter length of hospital stay, decreased postoperative pain and recovery time, and
probably reduced cost.[17–20] However, there are understandable persisting concerns about the laparoscopic management of
adnexal masses, including the failure to diagnose ovarian malignancies, tumor spillage, and inability to proceed immediately
with a staging procedure and delay in therapy.
The ability to identify a malignancy during laparoscopy has
been well studied. In the largest series of laparoscopically managed adnexal masses in reproductive-age women, Nezhat et al.
[21] reported that the most reliable indicators of malignancy
were the combination of laparoscopic visualization of the whole
peritoneal cavity and frozen section analysis. Chapron et al. [22]
Table 9.1.7: Indications for Surgery with Functional
Ovarian Cysts
Suspicion of malignancy
Symptoms evolve
Ascites
Change in ultrasound characteristic
Bilaterality
Suspicion of torsion
Size ≥8cm
Severe pain
examined 26 patients with suspicious adnexal masses at the time
of laparoscopy. In all 26 patients, frozen sections showed benign
results, and in each case, definitive histologic diagnosis was confirmatory. Dottino et al. [23] found a discrepancy between the
frozen section and final pathology in 3%of the cases. However, in
a study of 149 patients with macroscopically suspicious ovarian
masses, Canis et al. [24] found the frozen section to be accurate
in 93% of the cases involving tumors smaller than 10 cm and in
74% of larger tumors. Intraoperative pathologic diagnosis was
accurate in 77.8% of low malignant potential tumors.
Overall, the combined accuracy of laparoscopic visualization
and intraoperative frozen section is good for the identification
of malignancies. The two important exceptions are in very large
tumors or tumors with borderline characteristics. The accuracy in
these instances depends on the relative sample bias. The solution
to this problem should be in removing the entire adnexa and
allowing pathologic rather than surgical sampling. If a malignant
ovarian neoplasm is discovered at the time of laparoscopy, the
current standard of care is the performance of a comprehensive
surgical staging procedure.
If a surgeon is prepared to convert to a laparotomy and an
oncologist is available for surgical staging, laparoscopic surgery
can be attempted for selected patients requiring operative treatment of an adnexal mass. Laparoscopy is inappropriate when
there is metastatic disease, when frozen section diagnosis is not
available, and when there is no preparation for staging and possible laparotomy. As with open cases, the patient should follow
up with the physician postoperatively to determine the need for
further therapy based on the results of full pathologic evaluation
of the surgical specimen.
The standard operative approach to adnexal masses in postmenopausal women has been explorative laparotomy to ensure
adequate exposure for the treatment of ovarian cancer. However,
because the observation that evenin this group ofpatients benign
adnexal tumors are more frequent than malignant ones, some
authors justify starting the surgical procedure laparoscopically.
In the only prospective study, Dottino et al. [23] reported that
nearly 90% of cases were managed laparoscopically. The same
principles of carefully visualizing the entire peritoneal cavity and
obtaining pelvic washings and biopsies for the diaphragm, paracolic gutters, and pelvis should be undertaken. Cystectomy is not
recommended in postmenopausal women; removal of the entire
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adnexa with frozen section diagnosis is warranted.[25] Removal
of a normal-appearing contralateral ovary should be performed
according to preoperative consultation and past medical history.
In the premenarchal patient, the same laparoscopic principles for identifying a malignancy should be used. Performance
of a careful inspection of the peritoneal cavity, sampling with
generous biopsies, availability of frozen section, and use of the
principles of cancer surgery are essential in the exclusion of germ
cell malignancies in these young women.
Adnexal Mass in Pregnancy
Adnexal masses are frequently observed in gravid women, complicating as many as one in 190 pregnancies.[26] The risk of
malignancy in the pregnant woman with an adnexal mass is
5%.[27] At least one third of adnexal masses discovered during
pregnancy are found during routine obstetric ultrasonography,
as both benign and malignant ovarian masses tend to be asymptomatic in pregnant women. Careful evaluation is necessary to
differentiate between benign and malignant processes. In this
regard, the sonographic appearance of the mass may be helpful. Simple cystic structures are most consistent with physiologic
cysts. Most of the physiologic cysts resolve spontaneously by the
end of the first trimester. Failure of a simple cyst to resolve by
this time may be an indication for surgery. Other indications for
surgery include tumor size greater than 6 cm, a solid or complex sonographic appearance of the mass, and the presence of
bilateral abnormalities. Doppler ultrasound is potentially useful
in differentiating high- and low-risk ovarian masses. Regardless
of size, adnexal masses with blood flow characterized by a high
resistive index appear to carry little risk, even when these masses
fail to resolve by the second trimester. MRI may be helpful in
situations in which ultrasound is equivocal or the mass cannot
be distinguished from the uterine neoplasm.
Most ovarian cancers complicating pregnancy are either
borderline malignant epithelial ovarian tumors or germ cell
tumors.[1] The latter observation reflects the younger age of
pregnant women when compared with the typical ovarian cancer
patient. Dysgerminomas are the most common ovariangerm cell
tumors complicating pregnancy, followed by endodermal sinus
tumors. Sex cord or stromal tumors may also occur during pregnancy. Great care must be taken to differentiate sex cord–stromal
tumors from a luteoma of pregnancy, ovarian decidualization,
or benign granulosa cell tumor proliferations observed with the
pregnancy. Although elevated levels of tumor markers are helpful in establishing a diagnosis in nonpregnant woman, elevations
of these markers for reasons not related to malignancy reduce
their diagnostic potential. For example, elevations of AFP and
hCG may be effective markers for follow-up of endodermal sinus
tumors and gestational trophoblastic tumors, respectively (Table
9.1.4). However, titers of all these markers as well as CA-125 are
routinely elevated in pregnancy for reasons unrelated to malignancy. Their levels may be misleading, even when normalized as
multiples of the mean for prenatal patients.
Only 3% to 5% of adnexal masses in pregnancy ultimately
prove to be malignant. Thus, most may be managed conservatively, provided the patient’s symptoms and the characteristics of
the mass are consistent with benign etiology. Because adnexal
masses are more likely to undergo torsion during pregnancy,
explorative surgery may be necessary when a patient presents
Table 9.1.8: Indications for Laparoscopy
Availability of intraoperative frozen section
Low suspicion of malignancy
No evidence of metastatic disease
Capability of converting to open
Experienced laparoscopic surgeon
with symptoms and signs of torsion, such as severe or intermittent abdominal pain, nausea, and vomiting.
Surgery in pregnant patients is not without complications.
Abdominal surgery in the first trimester is associated with a 12%
spontaneous abortion rate, a number that is reduced to 0% in
the third trimester. It also causes preterm labor in 30% to 40%
of patients in the third trimester. The optimal time for surgery in
pregnancy, therefore, is during the second trimester.[28] When
first-trimester exploration and ovarian resection have been necessary, supplementary progesterone has been administered to
decrease the likelihood of pregnancy loss. The efficacy of this
treatment, however, remains unproven.
Laparoscopic surgery in pregnancy has been slow to gain
popularity because of the potential risks of injury to the uterus
and fetus. In fact, pregnancy formerly was a contraindication to
laparoscopy. However, recent surgical studies of appendectomies
and cholecystectomies have shown success with laparoscopy and
similar outcomes with laparotomy, with decreased hospitalization and narcotic use.[28] Several reports have suggested the
safe use of laparoscopy in the management of adnexal masses in
the first and second trimesters. Laparoscopic management by an
experienced team is asafe and effective procedure that allows for a
reducedrateofpostoperativecomplications and decreasedmaternal and fetal morbidity.[29,30] When performing laparoscopy
in pregnant patients, special steps should be taken to protect the uterus while placing the trocars. Low-pressure pneumoperitoneum should be used, maternal end-tidal CO
2
gases
should be monitored, the fetus should be monitored transvaginally, and the patient should be mobilized soon after surgery
(Table 9.1.8).[28]
In the rare case of ovarian cancer, complete surgical staging should be performed in a manner similar to that in the
nonpregnant woman. Although the gravid uterus makes the
assessment of the retroperitoneum more difficult, every effort
should be made to remove the tumor intact. The remaining
ovary should be carefully inspected and biopsied if suspicious.
Because germ cell tumors are almost invariably unilateral, it is
not necessary to remove both ovaries. The exception is a dysgerminoma, which may be bilateral in 20% of cases and may be
present in a grossly normal contralateral ovary. Even in this situation, it is not absolutely necessary to remove the entire ovary.
However, if both ovaries are involved with malignancy and the
gestation has reached the second trimester,bothovaries should be
removed as the pregnancy no longer requires the hormonal support from the corpus luteum. Because dysgerminomas spread to
para-aortic lymph nodes, every effort should be made to sample
these nodes.An omentectomy andperitoneal biopsies along with
The Adnexal Mass — 185
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cytologic assessment of the peritoneal cavity should routinely be
performed.
Pregnant patients with stage IA or IB ovarian cancer may be
managed conservatively with surgery and allowed to continue to
term. Need for further chemotherapy is dictated by the histologic type of the tumor and the tumor’s invasiveness. Cytotoxic
chemotherapy should be avoided in the first trimester; however,
it may be distributed in the second and thirdtrimesters with little
if any harm to the fetus. For this reason, women with stage IC
or high-grade tumors should be given the opportunity to receive
chemotherapy without terminating the pregnancy.
KEY POINTS
1. Five percent to 10% of women in the United States will
undergo surgery for suspected ovarian neoplasm. Of these,
13% to 21% will be found to have ovarian cancer.
2. Age is the most important factor in determining the risk of
malignancy.
3. In reproductive-age women, functional cysts are the most
frequent finding. These may be managed conservatively as
most disappear within 4 to 6 weeks.
4. Any cystic ovarian enlargement greater than 8 cm with
a solid mass component is an indication for surgery in
reproductive-age women.
5. Solid mass of any size is an indication for surgery in prepubertal girls. Abdominal pain and an abdominal mass are the
two mostfrequent presenting symptoms in children.Malignant neoplasms are found in 8% of children undergoing
surgery for an adnexal mass. Germ cell tumors are the most
frequent malignant tumor in children.
6. Ovaries should not be palpable in postmenopausal women.
Any ovarian enlargement in this age group is suggestive of
malignancy until proven otherwise. Up to 40% to 45% of
these patients who undergo surgery will have a malignant
tumor.However, the most frequent finding isa benign ovarian neoplasm (fibroma or Brenner tumor).
7. Fibromas are benign and associated sometimes with a rightsided pleural effusion (Meigs’ syndrome).
8. A combination of history, physical examination, tumor
marker analysis, and pelvic ultrasound isused in the evaluation of an adnexal mass. Although pelvic ultrasound remains
the best imaging tool for evaluation of ovarian pathology,
MRI is useful in the diagnosis of endometriotic and hemorrhagic cysts. CT is useful in evaluating the extent of ovarian
cancer.
9. The surgical approach to the adnexal mass has traditionally
been via laparotomy. Withtheadvancementsinlaparoscopy,
more surgeons initially approach adnexal masses laparoscopically. Laparoscopy offers better visualization, shorter
hospital stay,and lower rate of complications in comparison
with laparotomy. The availability of frozen section diagnosis and ability to obtain immediate gynecologic oncology
assistance in cases of malignant disease found are essential.
10. An adnexal mass is found in one in 190 pregnancies. The
most frequentadnexaltumorsinpregnancyaredysgerminomas and borderline ovarian tumors. The adnexal mass may
be surgically removed safely during the second trimester of
pregnancy.Surgeons with extensive laparoscopic experience
can safely approach these masses laparoscopically.
REFERENCES
1. Disaia PJ, Creasman WT. The adnexal massand earlyovarian cancer. In: Clinical Gynecologic Oncology. 6th ed. St. Louis: Mosby;
2002:253–281.
2. Curtin JP. Management of the adnexal mass. Gynecol Oncol .
1994;55:S42–S46.
3. Koonings PP, Campbell DR, Mishell JR, Grimes DA. Relative frequency of primary ovarian neoplasms: a 10-year review. Obstet
Gynecol. 1989;74:921–926.
4. Ehren IM, Mahour GH, Isaacs H. Benign and malignant ovarian
tumors in children and adolescents. Cancer. 1984;147:339–343.
5. Dorum A, Blom GP, Ekerhovd E, et al. Prevalence and histologic
diagnosis of adnexal cysts in postmenopausal women: an autopsy
study. Am J Obstet Gynecol. 2005;192:48–54.
6. Oyelese Y, Kueck KS, Barter JF, et al. Asymptomatic
postmenopausal simple ovarian cyst. Obstet Gynecol Surv.
2002;57:803–809.
7. Shalev E, Eliyahu S, Peleg D, Tsabari A. Laparoscopic management of adnexal cystic masses in postmenopausal women. Obstet
Gynecol. 1994;83:594–596.
8. Kurjak A, Predanic M, Kupresic-Urek S, Jukic S. Transvaginal
color and pulsed Dopplerassessmentofadnexal tumor vascularity.
Gynecol Oncol. 1993;50:3–8.
9. Sassone A, Timor-Tritch I, Artner A, et al. Transvaginal sonographic characterization of ovarian disease: evaluation of a new
scoring system to predict ovarian malignancy. Obstet Gynecol.
1991;78:7–11.
10. Alcazar JL, Jurado M. Prospective evaluation of a logistic model
based on sonographic morphologic and color Doppler findings
developed topredict adnexal malignancy. J Ultrasound Med. 1999;
18:837–843.
11. Grab D, Flock F, Stohr I. Classification of asymptomatic adnexal
masses by ultrasound, magnetic resonance imaging, and positron
emission tomography. Gynecol Oncol. 2000;77:454–459.
12. Jacobs I, Davies AP,BridgesJ,etal. Prevalencescreening forovarian
cancer in postmenopausal women by CA125 measurement and
ultrasonography. BMJ. 1993;306:1030–1032.
13. Brooks SE. Preoperative evaluation of patients with suspicious
ovarian cancer. Gynecol Oncol. 1994;55:80–90.
14. Meyer T, Rustin GSJ. Role of tumor markers in monitoringepithelial ovarian cancer. Br J Cancer. 2000;82:1535–1538.
15. Berek JS. Benign diseases of the female reproductive tract. In:
Novak’s Gynecology. 13th ed. Philadelphia: Lippincott Williams
& Wilkins; 2002:396–399.
16. Hulka JF, Parker WH, Surrey MW, Phillips JM. Management of
ovarian masses. AAGL 1990 survey. JReprodMed. 1992;37:599–
602.
17. Mais V, Ajossa S, Piras B, et al. Treatment of nonendometriotic
benign adnexal cyst. A randomized trial to evaluate benefits in
early outcome. Am J Obstet Gynecol. 1996;174:654–658.
18. Davison J, Park W, Penney L. Comparative study of operative
laparoscopy vs. laparotomy: analysis of financial impact. Reprod
Med. 1993;38:357–360.
19. Lundorff PJ,Thorburn J, Hahlin M, et al.Adhesion formation after
laparoscopic surgery in tubalpregnancy: a randomized trial versus
laparotomy. Fertil Steril. 1991;55:911–915.
20. Maruiri F, Azziz A. Laparoscopic surgery for ectopic pregnancies: technology assessment and public health implications. Te c h-
nol Steril. 1993;59:487–498.
186 — Sophia Rothberger, Tanja Pejovic, and Farr Nezhat
https://t.me/med1917
21. Nezhat FR, NezhatCH,Welander CE, BenignoB.Fourovarian cancers diagnosed during laparoscopic management of 1011 women
with adnexal masses. Am J Obstet Gynecol. 1992;167:790–796.
22. Chapron C, DubuissonJB, Kadoch O,et al. Laparoscopicmanagement of organic ovarian cysts: is there a place for frozen section in
the diagnosis? Hum Reprod. 1998;13:324–329.
23. Dottino PR, Levine DA, Ripley DL, Cohen CJ. Laparoscopic management of adnexal masses in premenopausal and postmenopausal
women. Obstet Gynecol. 1999;93:223–228.
24. Canis M, Mashiach R, Wattiez A, et al. Frozen section in laparoscopic management ofmacroscopicallysuspiciousovarian masses.
J Am Assoc Gynecol Laparosc. 2004;11:365–369.
25. Pejovic T, Nezhat F. Laparoscopic management of adnexal masses.
The opportunities and the risks. AnnNYAcadSci. 2003;943:255–
268.
26. Whitecar MP, Turner S, Higby MK. Adnexal masses in pregnancy:
a review of 130 cases undergoing surgical management. AmJObstet
Gynecol. 1999;181:19–24.
27. Schnee DM. The adnexal mass in pregnancy. Mo Med. 2004;101:
42–45.
28. Curet MJ, Allen D, Joskoff RK, Pitcher DE, Curet LB, Miscell BG,
Zucker KA. Laparoscopy during pregnancy. Arch Surg. 1996;131:
5:546–550.
29. Mathevet P, Nessah K, Dargent D, Mellier G. Laparoscopic management ofadnexal masses inpregnancy. Acase series. EurJ Obstet
Gynecol Reprod Biol. 2003;108:217–222.
30. Yen PM, Ng PS, Leung PL, Rogers MS. Outcome in laparoscopic management of persistent adnexal mass during the
second trimester of pregnancy. Surg Endosc. 2004;18:1354–
1357.
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