1. Approach to the Patient with a Pelvic Mass Karen Carlson, MD Assistant Professor Department of Obstetrics and Gynecology

2. How do these women present? Pressure/fullness Increasing girth Pain Annual exam Obstetrical exam Bleeding

3. The approach to the discovery of a pelvic mass should take into consideration 4 things: Age Tumor size U/S features Labs

4. Work-up Examination Radiology –U/S –CT –MRI Lab –CBC –hCG –Markers

5. Work-up Examination –Always include rectal exam –EUA

6. Work-up U/S –Relatively inexpensive –Delineates cystic vs solid structures –Assesses for ascites CT –Assesses other organs –Excellent for retroperitoneum (1-5 mm) MRI –Allows for ID of soft tissue lesions –Safe in pregnancy –Can differentiate normal from malignancy –Safe in women with IUD or surgical clips –Does not use radiopaque contrast agent

7. Lab - Tumor Markers CA-125 –Epithelial tumors –Antibody for antigen produced by coelomic epithelium –Normal <35 U/mL –NOT an effective screening tool for cancer

8. Lab - Tumor Markers CA-125 ↑ in: –Leiomyoma –Endometriosis/adenomyosis –PID –Pregnancy –Malignancies-lung, breast, colon –Pancreatitis –Cirrhosis

9. Lab - Tumor Markers CA-125 –Epithelial tumors AFP –Endodermal sinus tumor hCG –Choriocarcinoma LDH –Dysgerminoma

10. Ovarian cancer is the 2 nd most common malignancy of the female genital tract. Most frequent cause of death from GYN cancers. Annually, 23,000 new cases with 14,000 deaths.

11. Median age of ovarian cancer is 52. Life-time risk is 1.4%. 5% risk if 1° relative has ovarian cancer.

12. Ovarian enlargement in the pre-menarchal female is usually the result of a benign teratoma (dermoid).

13. 60-85% of ovarian neoplasms in the pediatric and younger adolescent age groups are of germ cell origin. In adults, germ cell tumors account for only 20% of ovarian neoplasms. Van Winter, JT. Am J Obstet Gynecol 1994;170:1780

14. The frequency of ovarian malignancies correlates inversely with patient age. 14% of all masses and 33% of neoplastic masses were malignant in patients < 16 years of age. Van Winter, JT. Am J Obstet Gynecol 1994;170:1780

15. In patients 16–20 years of age, 7% of all masses and 20% of neoplastic masses are malignant. Van Winter, JT. Am J Obstet Gynecol 1994;170:1780

16. A compilation of studies conducted from 1940-1975 reported that 35% of all ovarian neoplasms in childhood were malignant. Van Winter, JT. Am J Obstet Gynecol 1994;170:1780

17. In girls aged <9 years, approximately 80% of ovarian neoplasms were malignant. Van Winter, JT. Am J Obstet Gynecol 1994;170:1780

18. The vast majority (97%) of mature teratomas (dermoids) are benign.

19. Etiology of Pelvic Mass Uterine

20. Etiology - Uterine Leiomyoma Endometrioma Pregnancy

22. Fundus Tube Ovary Fimbria Round ligament Fibroid

23. Etiology of Pelvic Mass Uterine Ovarian

24. Etiology - Ovarian Neoplastic –Epithelial –Germ cell –Sex cord-Stromal Functional cysts Torsion Tubo-ovarian abscess (TOA)

25. The most common benign tumor in reproductive aged women is a serous cystadenoma followed by mature teratoma.

26. 6,300 grams, 30 cm X 30 cm Benign serous cystadenoma

27. 6,810 grams, 20 cm X 40 cm Benign serous cystadenoma

28. Dermoid cyst 5-10% are bilateral < 1% are malignant When malignancy is encountered, the malignant cell line is of ectodermal origin

30. Epithelial ovarian cancer, stage 1C ovarian capsule

33. Theca-lutein cysts

34. Etiology of Pelvic Mass Uterine Ovarian GI

35. Etiology - GI Diverticular abscess Appendiceal abscess Primary malignancy

36. Etiology of Pelvic Mass Uterine Ovarian GI Adnexal

37. Etiology - Adnexal Ectopic pregnancy Abscess Peritubular cyst Endometrioma Round ligament fibroid Torsion Hydrosalpinx Müllerian defect

39. R hematosalpinx R uterine horn with hematocolpos L uterine horn L tube and ovary

40. Etiology of Pelvic Mass Uterine Ovarian GI Adnexal Infectious

41. Etiology - Infectious TOA Appendiceal abscess Diverticular abscess

42. Etiology of Pelvic Mass Uterine Ovarian GI Adnexal Infectious Retroperitoneal

43. Clinical Conundrums : Adnexal mass in pregnancy Persistent unilocular ovarian cysts Whom to refer to a gynecologic oncologist

44. Adnexal Mass in Pregnancy 1/1,300 patients 6% CA or LMP (8/130) Dermoid most common (30%) No ↑ incidence of adverse outcome Remove for 3 reasons –Prevent dystocia –Danger of rupture, torsion, or hemorrhage –Malignancy Whitecar, P. Am J Obstet Gynecol 1999;181:19

45. Persistent Unilocular Ovarian Cysts Common: 3 to 17% Expectant management is acceptable in post-menopausal women provided: –Diameter < 5 cm –No increase in size –Normal CA-125 Nardo, LG, et al. Obstet Gynecol 2003;102:589

46. Persistent Unilocular Ovarian Cysts 15,106 women over 50 screened 18% found to have unilocular cyst 69% resolved spontaneously None of the women with isolated unilocular ovarian cysts developed ovarian CA Modesitt SC, et al. Obstet Gynecol 2003;102:594

47. Persistent Unilocular Ovarian Cysts 27 of 15,106 developed ovarian cancer. 10 had previously documented simple cyst. All 10 developed other morphologic abnormalities. Conservative follow-up with serial TVU is acceptable with unilocular cyst <10 cm Modesitt SC, et al. Obstet Gynecol 2003;102:594

48. Whom to refer to a gynecologist oncologist? In a retrospective chart review of 1,035 patients with a pelvic mass, this question was thoroughly evaluated. The newly developed guidelines correctly identify 70% of premenopausal and 94% of postmenopausal women with ovarian cancer. Im SS, et al., Obstet Gynecol 2005;105:35-41

49. Referral Criteria for Women with a Pelvic Mass Premenopausal (<50 years old) –CA-125 > 50 U/ml Ascities Evidence of abdominal or distant metastasis Postmenopausal (>50 years old) –CA-125 > 35 U/ml Ascites Evidence of abdominal or distant metastasis Im SS, et al., Obstet Gynecol 2005;105:35-41

50. Conclusions Ovarian enlargement in pre-menarchal female is dermoid 60-85% of ovarian neoplasm in women < 20 is germ cell. In adults, only 20% Frequency of ovarian cancer is inversely related to age. 14% in women < 16 and 7% age 16-20

51. Conclusions Dermoid is the most common mass in pregnancy Unilocular cysts can be followed if < 10 cm and stable with normal CA-125

52. Conclusions Refer premenopausal patients with a CA-125 > 50 U/ml and ascites and evidence of abdominal or distant metastasis to a gynecologic oncologist. Refer postmenopausal patients with a CA-125 > 35 U/ml with ascites and evidence of abdominal or distant metastasis to a gynecologic oncologist.