Management of adnexal masses in postmenopausal women

Ovarian endosalpingiosis mimicking hydrosalpinges. Unexpected intraoperative findings and a diagnostic rollercoaster

Over 80 % of ovarian cancer diagnoses are in women aged over 50 years. Post-menopausal women are at significantly increased risk compared with other age groups. Tumour biomarkers and ultrasound assist with diagnostics. A post-menopausal woman was referred with a possible left adnexal cyst on ultrasound. A tertiary gynaecological ultrasound suggested bilateral hydrosalpinges without cysts. Tumour markers were negative. Unexpectedly, while undergoing a laparoscopy, the tubes were normal in appearance; however, multiple cystic deposits suspicious for malignancy were noted on the ovaries. A laparoscopic bilateral salpingo-oophorectomy was performed without spillage and pelvic washings obtained. On histopathology, the ovaries contained multiple, benign epithelial cysts and pelvic washings were negative. This case demonstrates an unanticipated peri-operative diagnostic dilemma. It highlights the surgical management decisions required to balance duty of care and consent compliance within the scope of general gynaecology. It emphasizes the importance of histopathological examination to confirm diagnoses.

The Abnormal Ovary: Evolving Concepts in Diagnosis and Management

Ovarian lesions are common and require a consistent approach to diagnosis and management for best patient outcomes. In the past 20 years, there has been an evolution in the approach to abnormal ovarian lesions, with increasing emphasis on reducing surgery for benign disease, standardizing terminology, assessing risk of malignancy through use of evidence-based scoring systems, and triaging suspicious abnormalities to dedicated oncology centers. This article provides an evidence-based review of how these changes in diagnosis and management of ultrasound-detected abnormal ovarian lesions have occurred. Current recommended practices are summarized. The current literature on transvaginal screening for ovarian cancer also is reviewed and summarized.

Early stage ovarian carcinoma with symptoms mimicking tuberculous peritonitis in a postmenopausal woman: A case report

RATIONALE

Ovarian cancer has the poorest prognosis of the gynecological cancers. Early diagnosis and treatment are important, but early-stage ovarian carcinoma has nonspecific symptoms. Ultrasonography, computed tomography, magnetic resonance imaging, and serum CA-125 levels can be helpful but may not elucidate cases of diffuse peritoneal diseases mimicking carcinomatosis.

PATIENT CONCERNS

The patient had intermittent abdominal discomfort and dysuria. Abdominal-pelvic computed tomography findings were suspicious for peritoneal tuberculosis (TB) and a small cystic mass in the left ovary. The CA-125 values were normal.

DIAGNOSES

She underwent laparoscopy for pathologic confirmation of tuberculous peritonitis and management of the ovary mass. Bilateral adnexectomy was performed. Histopathological examination of the surgical specimen revealed a serous ovarian carcinoma in her left ovary and salpinx.

INTERVENTIONS

Laparoscopic hysterectomy, pelvic lymphadenectomy, para-aortic nodal dissection, and omentectomy were carried out for staging evaluation.

OUTCOMES

We encountered a rare case of ovary cancer stage IA serous ovarian carcinoma incidentally discovered by laparoscopy in a postmenopausal woman. She received adjuvant chemotherapy without relapse.

LESSONS

Peritoneal TB may mimic peritoneal or ovarian carcinoma, but the reverse case is rare. Hence, gynecologists should be careful in assessment of patients before treatment.

The Value of Ultrasound Monitoring of Adnexal Masses for Early Detection of Ovarian Cancer

Although ultrasound has so far been found to be ineffective as a screening tool for ovarian cancer, it is commonly used as a means of evaluating or following ovarian or adnexal masses once they are detected. We review the use of serial ultrasound for the management of adnexal masses and propose an approach to monitoring based on an understanding of the overall risk of cancer among the population in question and an assessment of how the potential benefit of monitoring compares with potential risk. In our approach, masses that are symptomatic, large (>10 cm), associated with an elevated CA 125 level or overt signs of malignancy, or that are determined to have a worrisome appearance by stringent ultrasound criteria should be evaluated surgically. Women with masses that have none of these characteristics should be offered monitoring. Short-term initial ultrasound monitoring carries significant potential benefit in terms of aiding detection of early malignancy and avoidance of unnecessary surgery. However, if a mass remains stable but persistent, the potential benefit of ongoing monitoring wanes with time, whereas the potential harms, in terms of patient anxiety, cost, and the risk of incidental findings and unnecessary surgery increase. Therefore, monitoring of stable lesions should be limited in duration in order to limit potential harms from overtreatment and overdiagnosis.

Adnexal mass in the postmenopausal patient

The adnexal mass in a postmenopausal patient poses an important diagnostic and management dilemma for primary care providers and gynecologists. Postmenopausal women are at a significantly increased risk of gynecologic malignancy; yet even in this population the majority of adnexal masses are benign. Evaluation and management of these lesions centers on the identification of malignancy, especially ovarian cancer, while avoiding unnecessary intervention in patients with benign lesions. Tumor markers and imaging can help in the evaluation of adnexal mass in postmenopausal women. Transvaginal ultrasound has long been considered the imaging modality of choice for the evaluation of adnexal masses. Particularly in the setting of high frequency utilization of transvaginal probes, which project high quality images allowing for detailed descriptions of the macroscopic appearance of the mass, and remains the least expensive of all imaging modalities currently available. For adnexal masses that are highly suspicious for cancer, women should be referred a gynecologic oncologist and facility for optimal care.

Intestinal Necrosis due to Giant Ovarian Cyst: A Case Report

Intestinal pathologies due to ovarian cyst are observed rarely. Although a limited number of cases in neonatal and adolescent periods have been observed, no adult case has been reported in the literature. Two mechanisms are involved in intestinal complications due to ovarian cysts: torsion due to adhesion or compression of giant ovarian mass with a diameter of 9-10 cm. We report here a terminal ileum necrosis case due to compression by an ovarian cyst with 11 × 10 × 7 cm size in an 81-year-old woman.

Adnexal masses and malignancies of importance to the colorectal surgeon

In this article, the authors review both benign and malignant ovarian masses, as the colorectal surgeon who encounters an adnexal mass at the time of surgery should be aware of the steps necessary for surgical staging and optimal tumor resection.Ovarian tumors-most of which are benign-are divided into three major categories, in order of frequency: epithelial, germ cell, and sex cord-stromal tumors. Nonneoplastic conditions of the ovary that may present as adnexal masses include the following, according to World Health Organization (WHO) classification: pregnancy luteoma, hyperplasia of ovarian stroma, hyperthecosis, massive edema, solitary follicle cysts and corpus luteal cysts, multiple follicle cysts, and endometriosis.Epithelial ovarian tumors arise from the surface epithelium and can be benign or malignant. Histologic types are serous, mucinous, endometrioid, clear cell, or Brenner. Germ cell tumors are more likely to appear in females under 20 years, accounting for 70% of ovarian tumors in this age group. Approximately 3% are malignant. Teratomas are the most common germ cell tumors. Malignancies, in addition to malignant teratomas, include dysgerminomas, endodermal sinus tumors, and embryonal carcinomas. The more common sex cord-stromal tumors include granulosa stromal cell tumors, Sertoli-Leydig cell tumors, and gynandroblastomas.Surgical staging and optimal tumor resection are also addressed, with a focus on epithelial malignancies, as they are the most relevant to colorectal surgeons.

Imaging of benign adnexal masses: characteristic presentations on ultrasound, computed tomography, and magnetic resonance imaging

Adnexal masses are common in the general population. Although ovarian cancer is a significant cause of mortality, large screening studies demonstrate that the majority of adnexal masses are benign. These benign masses include physiologic cysts, paraovarian masses, and benign ovarian lesions. It is important that gynecologists and radiologists appreciate the appearance of these lesions on multiple imaging modalities, including ultrasound, computed tomography, and magnetic resonance imaging to avoid unnecessary intervention.

Common Gynecologic Problems in Geriatric-aged Women

Gynecologic concerns in postmenopausal women are common. Although various conditions may affect all women in this age group, the prevalence of certain disorders, and also diagnostic approaches and treatment options, may vary significantly when considering very elderly women compared with those early in the sixth decade. The focus of this chapter is to address several commonly encountered gynecologic issues in postmenopausal women, with particular attention given to aspects that must be considered when caring for women in the geriatric age group.

The incidental postmenopausal adnexal mass

The postmenopausal ovary continues to produce cysts; the prevalence in an ovarian cancer screening population approaches 18%. Yet 60% to 70% of unilocular cysts resolve spontaneously. Optimal management of an asymptomatic adnexal mass allows surveillance of women at low malignancy risk while triaging intermediate/high-risk women to surgery. Women with unilocular cysts on transvaginal ultrasound (TVS) and a normal CA-125 are monitored with repeat TVS at 3 to 6 months. Those with a complex mass <5 cm and normal CA-125 should have repeat TVS and CA-125 testing in 4 weeks. Surgery is recommended for any women with increasing morphologic complexity or a rising CA-125.

Laparoscopic management of the adnexal mass

Ovarian neoplasms are common in women of all ages. As many as 10% of women in the United States will undergo surgical removal of an adnexal mass sometime in their lifetime. Gynecologic surgeons have pioneered laparoscopic surgery, developing what was originally a diagnostic tool into a safe and effective approach to management of adnexal masses. Accumulating scientific data support the laparoscopic approach to the adnexal mass as the preferred treatment.

Guidelines for Referral of the Patient With an Adnexal Mass

Gynecologists have to differentiate between benign and malignant adnexal masses. We review the evidence supporting to the specialty care of a gynecologic oncologist on the basis of the physical examination, imaging studies, family history, and CA 125 determination. We recommend adherence to the ACOG/SGO Joint Opinion guidelines. Specifically, referral to a gynecologic oncologist seems warranted for postmenopausal women with elevated CA 125, nodular or fixed pelvic mass, metastatic disease, ascites, or family history of breast or ovarian cancer. Premenopausal women should be referred if the CA 125 is elevated above 200 U/mL, there is an evidence of metastatic disease or ascites, or strong family history of breast or ovarian cancer.