Adnexa Tumor

　

INTRODUCTION

　

During the course of her lifetime, every woman develops several adnexal masses. The normal functioning ovary will produce a follicular cyst 6-7 times each year. In most cases, these functional masses are self-limiting and resolve within the length of a normal menstrual cycle. In rare situations, they will persist longer or become greater than 7 cm in diameter. It is at this point that they become a pathological condition.

While most of these masses develop in menstruating women, their presence must be considered in both prepubertal and postmenopausal women, particularly when associated with pain.

History of the Procedure:

A woman presenting with an adnexal mass will most often be unaware of the mass, and as such, she will have no history. Those women who have symptoms will note urinary frequency, pelvic or abdominal pressure, and bowel habit changes due to the mass effect on these organs. Females younger than 10 years frequently present with pain, as will older women who have infected masses or endometriosis. Women with twisted masses will also have acute pain.

When a woman presents with the symptoms of abdominal bloating, gastrointestinal upset, and pelvic pressure, she should be considered a likely candidate for a malignant adnexal mass.

Problem:

In the past, physicians relied on the findings of a pelvic exam to diagnose an adnexal mass. With the introduction of transabdominal or vaginal ultrasound, Doppler color scans, CT scans, MRI scans, and PET scans, the identification and evaluation of adnexal masses becomes entirely different. These radiological tests allow physicians to identify subclinical masses as well as delineate the mass' internal structure such as wall complexity or mass contents.

The following masses pose the greatest concern:

Frequency:

Determining the frequency of adnexal masses is impossible because most develop and resolve without clinical detection. It is important to keep in mind the clinically important masses and their relationship to the age of the woman.

Pathophysiology:

The pathophysiology is not well understood for most adnexal masses; however, the following are some theories:

Clinical:

The clinical presentation can be quite variable, with many presenting symptoms, including the following:

　 INDICATIONS 　

The vast majority of adnexal masses presents as asymptomatic, small, and simple cystic masses. Nearly all of these will resolve spontaneously; therefore, care must be taken to not overreact to such a finding. Surgeons who rush these women into surgery will often create more pathology than they cure. Any surgery performed on adnexal structures can result in impaired fertility.

On the other hand, these same asymptomatic masses can be early ovarian cancers that require immediate attention. As outlined below, the use of radiological testing will often help determine which women require attention.

The use of CA125 values to screen for the presence of cancer should be discouraged. A large Swedish study has shown that around 50% of women with stage I ovarian cancer will have a normal CA125 value. In addition, there is a very high false positive rate that can be caused by pregnancy, endometriosis, cirrhosis, and pelvic or other intra-abdominal infections.

　 RELEVANT ANATOMY AND CONTRAINDICATIONS 　

Relevant Anatomy:

Adnexal masses are located deep in the pelvis, which allows easy assessment with a standard gynecologic examination. However, before surgical intervention is undertaken, several other anatomical structures must be located, including the following:

　 WORKUP 　

Lab Studies:

  • A Pap smear should be obtained on any woman who may undergo a gynecological surgery.
    • This test should be used to rule out any unknown cervical pathology.
    • It will reveal the presence of an adnexal malignancy in extremely rare situations.
  • A CBC will help establish the woman𠏋 general status.
    • An infected mass will result in an increased WBC count with an associated left shift.
    • Adnexal masses rarely cause anemia, but because they often require surgical removal, this information should be known.
  • A U/A will generally be normal in the presence of an adnexal mass.
    • Bladder pathology may present with symptoms of an adnexal mass and may be picked up with a U/A.
    • Appendicitis can present like an adnexal mass but will often be associated with WBCs in the U/A.
  • Testing stool for blood should be negative for adnexal masses but may be positive in those women with colonic pathology.
  • Serum electrolytes should not be altered by an adnexal mass; however, symptoms associated with masses, such as nausea and vomiting, can cause alterations that must be known before anesthesia and surgery are considered.
  • Hormone levels are generally of no value in the evaluation of adnexal masses.
    • Estrogen and progesterone levels may be helpful in women suspected of having functional tumors, such as germ cell tumors, or if a woman younger than 12 years is being evaluated.
    • Beta-HCG values are very important if a gestational trophoblastic tumor is suspected.
  • Obtaining a CA125 is almost never of any value in evaluating a woman with an adnexal mass.
    • It is of near zero value in diagnosing a malignancy (very high false negative rate), while it has a very high false-positive rate.

Imaging Studies:

  • A pelvic x-ray is helpful in identifying the adnexal mass as an adult cystic teratoma (dermoid cyst); otherwise, it is of very limited value.
    • A dermoid cyst will generally contain areas of calcification that can be picked up on a plain x-ray. Less obvious, but also helpful, is the detection of a fat ring in a cyst, which suggests the presence of a dermoid cyst.
  • The most commonly performed test to evaluate an adnexal mass is an ultrasound, either trans abdominal or transvaginal.
    • This test will demonstrate the presence of the mass, its location (ovarian, uterine, bowel). It will also provide the mass size, consistency, and internal architecture. Scoring systems, such as that suggested by DePriest and associates, can then be employed to determine the likelihood of a malignant component.
    • Hystrosonography (ultrasound with the presence of fluid in the uterine cavity) may help distinguish between uterine masses and those arising from other pelvic structures.
    • Color Doppler ultrasounds can be employed to evaluate the resistive index of the mass vessels, which when low, has been indicative of a malignancy.
  • CT scans have become the second most commonly utilized test to evaluate an adnexal mass.
    • As with the ultrasound, they can identify the size, location, and relationship to other organs. The CT scan is less effective in determining the internal architecture of these masses than is ultrasound.
    • CT angiograms have been very useful in evaluating the vascular supply of adnexal masses. This information is particularly useful when dealing with a sarcoma.
  • MRI scans have been used in those individuals who are unable to tolerate the contrast material necessary for CT scanning. MRA (magnetic resonance angiogram) can be used in place of CT angiograms.
  • Both MRI and CT scans are very expensive. Their use should be limited in women whom have masses felt on pelvic examination and that are not well characterized on ultrasound.

Diagnostic Procedures:

  • In limited cases, a diagnostic laparoscopy may be needed to evaluate an adnexal mass. This allows for direct visualization of the mass.
    • The mass' effect on surrounding structures can be evaluated during this procedure.
    • In limited setting, an aspiration of the mass can be carried out. However, this approach must be reserved for those women in whom an extremely low chance of a malignant mass exists.
　 TREATMENT 　

Medical therapy:

Asymptomatic, small, well-characterized adnexal masses can be observed with regular pelvic examinations and radiological evaluations. A surgical approach should be employed if any growth occurs in these masses.

Masses that are known to be leiomyomas can be approached with GnRH agonists with the expectation that 50% will demonstrate a decrease in size. Radiological ablation of these masses can be employed in certain cases.

It has been suggested that women with adnexal masses be treated with low-dose birth control pills in an effort to reduce tumor size. There seems to be little data to support this approach. Its major value seems to be the additional time it takes, which allows for spontaneous regression of many of the functional adnexal masses.

The information obtained with ultrasound testing should allow the identification of the functional cysts that will require no active treatment. Symptomatic treatment is often all that these women need.

Surgical therapy:

All adnexal masses that are symptomatic or have characteristics of a malignancy must be addressed with surgical removal. It is rare that a functional cyst will have either of these features; therefore, few unnecessary surgeries will result from this approach. The nature of this approach must be discussed prior to the surgery. One must consider all possibilities during this discussion.

  • Obvious benign masses can be treated with resection of the mass alone or removal of the adnexal structure.

  • In those cases in which it is questionable as to whether the mass is malignant, one should limit the resection to the structures involved unless it has been decided preoperatively that a more aggressive approach should be taken.

  • When an obvious malignancy is encountered, a complete staging must be performed. This generally includes a complete exploration of the abdomen, a total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvic and para-aortic lymph node dissections, biopsies of the undersurface of the right and left diaphragms, and biopsies of the colic gutters followed by a maximal resection of the intra-abdominal tumor. In some cases, it may be necessary to resect portions of the small bowel or colon; therefore, preoperative bowel prep is necessary as well as a discussion about possible colostomy or other bowel changes.

Preoperative details:

Preoperative preparation is vital to the proper care of a woman with an adnexal mass. This should include the following:

  • A complete discussion of the possible procedures and the long-term results

  • A complete bowel prep in selected cases

  • A careful evaluation of any associated medical problems or past surgeries

  • An evaluation of the woman𠏋 nutritional status, particularly when ascites is present

Intraoperative details:

During the procedure, several factors must be kept in mind, including the following:

  • The dissection will depend on the preoperative discussion concerning the nature and extent of the procedure.

  • The dissection must be tailored to the woman𠏋 desire regarding future fertility. In most cases, the dissection should not block future reproductive abilities.

  • The presence of extensive disease as seen with cancer or endometriosis will alter normal anatomical relations, which can result in a greater chance for injury to surrounding structures such as the ureters or bowel. Such dissections are best performed with the assistance of a gynecologic oncologist.

Postoperative details:

Most adnexal masses can be removed with relative ease and are associated with little postoperative complexity; however, in those women with significant preexisting medical problems and/or cancer, major postoperative problems can be encountered. They are best addressed with the following:

  • Intense nutritional support

  • ICU care with close monitoring of fluid balance, electrolyte balance, coagulation status, and cardiopulmonary function

  • The placement of right-sided heart monitoring (Swan-Ganz catheter)

Follow-up care:

Most adnexal masses require little more than the normal annual gynecological examination for follow-up as they rarely recur. On the other hand, women found to have a malignancy will require additional therapy, such as chemotherapy or radiation therapy. Their follow-up will include frequent re-examinations to determine the disease status.

　 COMPLICATIONS 　

The major adverse outcomes in the treatment of adnexal masses are related to complications resulting from surgical therapy.

　 OUTCOME AND PROGNOSIS 　

Most adnexal masses are benign; the outcome and prognosis is very good. No impact on the quantity or quality of life is generally noted. In fact, most women treated for adnexal masses have no interruption in their reproductive abilities.

Those women who are found to have malignant adnexal masses fall into 3 groups.

　 FUTURE AND CONTROVERSIES 　

Future:

The future holds 3 very interesting possibilities.

Controversies:

The major controversy surrounding adnexal masses is when and how to treat them.

  • It must be remembered that functional cysts do not become larger than 7 cm. As such, cysts larger than this should be addressed as quickly as is convenient.

  • The corollary to this is where the controversy develops.

    • It is true that all functional cysts are less than 7 cm; however, one must assume that all nonfunctional cysts, particularly the malignant variety, have a portion of their natural history during which they too are less than 7 cm.

    • All nonfunctional cysts require treatment, and this treatment is more successful when administered as early as possible in their natural history. How best to identify those masses that need treatment remains a very difficult and controversial issue.

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