3. Introduction
• Adnexal
mass
refers
not
only
to
ovarian
abnormali#es.
• Ovarian
neoplasms
are
one
of
the
most
common
pathologies
among
women
of
all
age
groups.
4. Introduction
• 5-‐10%
of
women
in
USA
will
undergo
a
surgical
procedure
due
to
suspicious
adnexal
mass
in
their
life#me.
5. Introduction
• 13-‐21%
of
them
will
suffer
from
malignancy.
• 300,000
women
are
hospitalized
each
year
to
evaluate
adnexal
mass.
• 0.17-‐5.9%
are
asymptoma#c.
• 7.1-‐12%
are
symptoma#c.
8. Adnexal
mass
• 80%
of
adnexal
masses
in
women
under
age
55
are
hormone
dependent.
• Func#onal
cyst
• Endometriosis
• 8%
are
benign
neoplasms
and
leiomyomas.
• 0.4%
are
malignant
tumors.
9. Adnexal
Mass
• Ovarian
cancer
incidence
is
15.7/100,000
before
the
age
of
40
years
old.
• Ovarian
cancer
incidence
will
increase
to
54/100,000
a_er
the
age
of
40
years
old.
10. Adnexal
Mass
• At
pre-‐teen
&
teenager:
• 65%
func#onal
cysts
• 28%
benign
ovarian
tumor
• 65%
are
dermoid
cysts
• 8%
are
malignant
ovarian
neoplasms
• Dysgerminomas
• Immature
teratomas
11. Adnexal
mass
• At
reproduc#ve
age:
• Majority
are
benign
• Func#onal
cysts
• 7-‐13.5%
are
malignant
• Differen#al
diagnosis
at
this
age
group:
• Ectopic
pregnancy
• Pelvic
inflammatory
diseases
• Hydrosalpinx
• Leiomyoma
13. Crucial
factors
for
diagnosis
• History
• Risk
factors
for
ovarian
cancer
• BRCA
muta#ons.
• Hereditary
cancer
syndromes.
• Background
of
infer#lity.
• Women
with
first
degree
rela#ve
with
ovarian
cancer
have
5%
risk
of
malignancy.
• With
2
affected
rela#ves
carry
a
30%
risk.
• Mul#ple
cases
make
the
risk
50%.
14. Crucial
factors
for
diagnosis
• Symptoms:
• Majority
are
asymptoma#c.
• No
specific
symptoms
indica#ve
of
ovarian
mass.
• Physical
Examina#on:
• Bimanual
examina#on
can
detect
most
of
asymptoma#c
adnexal
masses.
• Rectovaginal
examina#on.
15. Crucial
factors
for
diagnosis
• Laboratory
findings:
• No
single
marker
with
sufficient
sensi#vity
&
specificity.
• CA-‐125
elevated
in
90%
of
advanced
stage
ovarian
cancer.
• 50%
at
stage
I
• 1%
in
normal
popula#on
• Nega#ve
in
poorly
differen#ated
type
• High
false-‐posi#ve
results.
19. Crucial
factors
for
diagnosis
• Diagnos#c
imaging:
• CT
&
MRI
are
not
indicated
rou#nely.
• CT
bejer
for
localiza#on
of
metastasis.
• MRI
more
superior
in
detec#on
of
ovarian
malignancies.
• MRI
has
the
high
cost
disadvantage.
20. Considerations
for
surgical
approach
• Risk
of
malignancy:
• Age
• Radiology
findings
• Tumor
markers
• Symptoms
• Size
of
the
mass:
• Intra-‐corporal
vs
extra-‐corporal
drainage
21. Considerations
for
surgical
approach
• Prior
surgical
history:
• Bowel
surgery
• Prior
history
of
endometriosis,
PID
or
adhesions
• Co-‐Morbidity:
COPD,
Heart
disease,
HTN…
• Surgical
experience
• Pa#ent’s
expecta#ons
27. Laparoscopy
approach
• Less
de
novo
adhesion
forma#on.
• Decreased
febrile
morbidity.
• Less
post-‐opera#ve
pain
and
less
analgesic
requirements.
28. Laparoscopy
approach
• Shorter
hospital
stay
and
faster
recovery.
• Bejer
cosme#c
results.
• Reduced
overall
cost
on
health
care.
29. Laparoscopy
approach
• Fear
of
encountering
cancer.
• Fear
of
inadequate
staging.
• Upstaging
of
the
disease
by
tumor
seeding.
• But;
careful
pa#ent
selec#on
is
a
cri#cal
issue.
30. Issues
of
laparoscopy
• The
role
of
laparoscopy
in
gyne-‐oncology?
• The
rate
of
malignancy?
• The
risk
of
tumor
spillage?
• The
risk
of
inadequate
resec#on
and
surgical
staging?
• The
incidence
of
port-‐site
metastasis?
• The
risk
of
leading
to
re-‐explora#on?
• The
risk
of
delay
in
chemotherapy?
• Required
training
for
safe
and
efficient
performance?
31.
32. Laparoscopy
&
suspicious
mass
• Associa#on
of
Gynecologic
Laparoscopists
Survey:
• Incidence
of
unsuspected
malignancies
at
laparoscopy
is
0.04%.
• Maiman
et
al
1991
reported
that
laparoscopic
visualiza#on
might
fail
to
iden#fy
cancer
in
one
3rd
of
the
cases.
36. Negative
Predictive
Value
• It
is
defined
as
the
propor#on
of
subjects
with
a
nega#ve
test
result
who
are
correctly
diagnosed.
• A
high
NPV
for
a
given
test
means
that
when
the
test
yields
a
nega#ve
result,
• it
is
most
likely
correct
in
its
assessment.
37. Meta-‐analysis
by
Nicklin
et
al
1994
• Aspira#on
ovarian
cysts
cytology
had
a
nega#ve
predic#ve
value
of
58%
to
98%
in
the
diagnosis
of
malignancy.
• It
also
increase
the
chance
of
slow
malignant
cells
leak.
• Aspira#on
will
not
achieve
resolu#on
as
11
–
67%
of
cysts
will
recur.
38. Canis
et
al
1997
• 1600
adnexal
mass
cases
managed
laparoscopically.
• With
16
years
follow
up.
• Laparoscopy
sensi#vity
100%.
• Posi#ve
predic#ve
value
of
laparoscopy
was
34.7%.
• Nega#ve
predic#ve
value
was
100%.
• Concluded
that
laparoscopic
treatment
safe,
effec#ve,
nontrauma#c
and
preserve
fer#lity.
40. Canis
et
al
2002
• Prospec#ve
management
of
247
suspicious
masses
laparoscopically.
• Without
evidence
of
disseminated
cancer.
• 85%
of
suspicious
masses
proved
benign.
• Sparing
laparotomy
in
nearly
94%
of
cases
with
benign
mass.
• The
remaining
37
cases
were
malignant.
• 19%
managed
surgically
by
laparoscopy
alone.
41. Childers
et
al
1996
• 138
cases
of
suspicious
masses
managed
laparoscopically.
• Masses
>10cm
required
laparoscopic
drainage.
• Masses
<10cm
were
removed
with
endoscopic
sacs.
• 86%
(119/138)
were
of
benign
nature.
42. Childers
et
al
1996
• 19
were
malignant
of
nature.
• 16
were
adnexal
primaries.
• 3
were
non-‐gynecologic.
• Cases
managed
laparoscopically
only:
• 95%
(113/119)
of
the
benign
cases.
• 74%
(14/19)
of
malignant
cases.
43.
44. Low
suspicion
adnexal
mass
• Younger
than
40
years
of
age.
• Puncture
followed
by
endocys#c
examina#on
with
the
use
of
strong
aspira#on
system.
• Peritoneal
lavage
a_erward
to
minimize
spillage.
• Frozen
sec#on
for
any
suspicious
mass.
45. High
suspicion
adnexal
mass
• Adnexectomy
without
puncture.
• Mass
is
extracted
in
an
endoscopic
bag.
• Frozen
sec#on.
• In
case
of
malignancy,
immediate
staging
proceure
should
be
done.
• Gyne-‐Oncologist
involvement.
46. Drake
et
al
1998
• Masses
at
reproduc#ve
age
group:
• Func#onal
cyst
is
the
most
likely
diagnosis.
• Usually
with
benign
ultrasonographic
features.
• Normal
CA-‐125
level.
• 50-‐90%
will
resolve
spontaneously
in
4
to
6
weeks,
with
or
without
oral
contracep#ves.
47. Drake
et
al
1998
• Indica#ons
for
surgery:
• Masses
>8cm
in
diameter.
• Failure
to
resolve
within
2
–
6
months.
• Persistent
pain.
• Family
history.
48. Hulka
et
al
1990
• American
Associa#on
of
Gynecologic
Laparoscopists
Survey:
• Majority
of
clinician
consider
laparotomy
the
safest
treatment
for
non-‐cys#c
masses.
49. Dottino
et
al
1999
• Laparoscopy
is
safe
in
88%
of
160
pre-‐
and
postmenopausal
pa#ents
with
suspicious
masses.
• 9%
of
them
found
to
be
malignant.
• 5%
of
them
found
to
be
low
malignant
poten#al.
• With
3%
intra-‐opera#ve
complica#ons.
50. Mahdavi
et
al
2002
• Postmenopausal
age
group:
• Careful
evalua#on
will
be
required.
• Malignancy
has
to
be
excluded.
• Standard
approach
is
exploratory
laparotomy.
• Cystectomy
is
not
recommended.
• Frozen
sec#on
will
be
appropriate.
51. Vergote
et
al
2001
Outcomes
of
cyst
rupture
(Before
or
during
surgery)
in
stage
I
ovarian
cancer
of
1545
pa#ents
in
6
countries.
52. Port-‐Site
Metastases
• Also
called
wound-‐site
metastases.
• Possible
with
malignant
and
low
malignant
poten#al
masses.
• Childers
et
al
1994
report
that
this
occur
in
1%
a_er
laparotomy
and
1-‐2%
a_er
laparoscopy.
• Kruitwagen
et
al
1996
report
that
this
occur
in
16%
a_er
laparoscopy.
54. To
reduce
the
risk
of
port-‐site
metastases
• Minimize
#ssue
trauma
and
number
of
instrument
transfers.
• 5%
povidone-‐iodine
to:
• Rinse
trocars
before
inser#on.
• Rinse
#p
of
instruments.
• Irrigate
site.
• Perform
trocar
fixa#on.
• Use
protec#ve
endobags.
• Remove
all
fluid
before
removing
trocar.
• Deflate
abdomen
with
trocars
in
place.
• Close
10mm
or
more
peritoneal
trocar
sites.
55.
56. Systematic
Review
Covens
et
al
2012
• To
review
the
exis#ng
literature
in
order
to
determine
the
op#mal
protocol
for
surgical
management
of
suspicious
adnexal
mass.
• All
publica#ons
between
1999
to
2009.
• 31
studies
met
the
inclusion
criteria.
57. Systematic
Review
Covens
et
al
2012
• Bivariate
random
effect
analysis
of
15
frozen
sec#on
diagnosis
studies:
overall
sensi#vity
of
89.2%
and
specificity
of
97.9%.
• Systema#c
lymphadenectomy
and
proper
surgical
staging
improve
survival.
• Fer#lity
conserving
surgery
acceptable
in
low
malignant
poten#al
tumor.
59. Systematic
Review
Covens
et
al
2012
• The
accuracy
and
the
adequacy
of
surgical
staging
by
laparotomy
and
laparoscopy
appear
to
be
comparable.
• Neither
approach
conferring
a
survival
advantage.
60. Systematic
Review
Covens
et
al
2012
• Intra-‐opera#ve
tumor
rupture
reported
more
frequently
in
pa#ents
undergoing
laparoscopy
in
two
retrospec#ve
cohort
studies.
