Gynecology - Adnexal Mass

Gynecology

[ADNEXAL MASS]

Introduction Much like vaginal bleeding, the most common and most dangerous cause of adnexal masses changes based on the age. In the premenarchal group think cancer  (germ cell). In the post menopausal group think cancer (epithelial). In the reproductive age group, where physiologic (simple) cysts can occur, and where cycles, pregnancy, and infections occur a more expansive differential exists. Regardless, all age groups need a sonogram (ultrasound) if a mass is felt. It’ll help us distinguish a simple (smooth, small, like a balloon) versus a complex (loculated, lobulated, large) cyst. The simple cyst needs watchful management while a complex cyst requires additional workup.

Premenarchal

Ovarian Cancer 11 GERM CELL

Reproductive

Physiologic “Simple Cysts” or

Complex Cyst Once a cyst crosses over the definition from simple cyst, it  becomes complex. Cysts should NOT be aspirated. If additional anatomy is required and imaging is to be considered, MRI is the  best radiographic test, but is often not needed and shouldn’t be the next step. Laparoscopy to remove the cyst is preferred over laparotomy (ex-lap). Oophorectomy and salpingostomy is dependent on the likelihood that it’s cancer, but isn’t routine in the evaluation of a complex cyst.

Complex Cyst Teratoma TOA Ectopic Torsion Endometrioma Cancer

Single, Fluid Filled, Homogenous

Loculated, Lobulated Multiple Spaces

Resolves in 2-3 months 10cm

Ovary Teratoma / Dermoid Cyst The teratoma is a benign (in girls) germ cell tumor of the ovary. Since it’s a germ cell tumor expect the patient to be young (< 20). She’ll complain of weight gain or increased abdominal girth. The ultrasound will show a complex cyst which is enormous. Due to the weight it’s likely to cause the ovary to twist about its vascular supply; it’s a risk factor for torsion. Since it’s complex it must be removed. Cystectomy without oophorectomy is the treatment of choice. Because it’s benign, the patient is young, the chance for recurrence on the contralateral side is high, and we don’t want to put her into menopause early we spare the ovary. If you happen to find one in a woman past child-bearing, Salpingo-oophorectomy is ok.

51 Ovarian Cancer EPITHELIAL

Complex Cyst

Simple Cyst Simple Cyst A simple cyst implies “no big deal,” and something that can be observed. This decision is based on history, imaging, and size. It has to look like clearly not-a-cancer. This will present as an asymptomatic adnexal mass found on exam or imaging for something else. Transvaginal ultrasound is used to evaluate the cyst, which will be simple: smooth, anechoic, unilocular   and small. In the US we use < 10 cm to mean “small” and should expect those cysts to resolve spontaneously. If it’s tiny (< 3 cm) it doesn’t warrant re-evaluation. Between 3 cm-10 cm, it should  be reimaged within 12 weeks. Any growth over time, size > 10 cm, or multiple loculations or multiple echoes suggest this is a complex cyst and need evaluation. OCPs have shown NO BENEFIT in reducing the size; they shouldn’t play a part in our thinking.

Postmenopausal

Ovary

Cyst (can be enormous)

Ectopic Pregnancy A complex cyst may simply be an ectopic pregnancy. In a patient with a history of salpingitis  where inflammation may have created a stricture, fertilized eggs can’t pass. Ectopics most commonly occur in the ampulla. This is a botched pregnancy. The patient will present with amenorrhea  (pregnant), lower abdominal pain (as the cyst grows), and vaginal spotting. The ultrasound will show a complex cyst and

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Gynecology

[ADNEXAL MASS]

absent uterus. An elevation of the B-HCG quant  confirms ectopic. If there isn’t a rupture a salpingostomy is performed. If there is a rupture perform a salpingectomy . In very select patients where the diagnosis is made very early (< 3.5cm and HCG< 8000) and the patient is not on Folate, methotrexate can be used. The risk of ectopic pregnancy is about 1% in the general population. The risk with previous ectopic, previous ectopic with -ostomy, and previous ectopic with -gectomy are all 15%. This is discussed in greater detail in the Obstetrics section. Endometrioma / Endometriosis / Chocolate Cyst Retrograde menses (presumed, unknown true cause) leaves estrogen-sensitive endometrial tissue outside of the uterus. This  produces proliferation and hemorrhage with each cycle, leading to many problems: dysmenorrhea , dyspareunia , and infertility. A sonogram will show a complex cyst. It may be anywhere: on the uterus, ovary, or even distant in the peritoneal cavity. This often takes time to diagnose - as in weeks to months. While a diagnostic scope with laser ablation (i.e. laparoscopic exploratory laparotomy) is both diagnostically superior and curative, it’s invasive. Symptomatic relief with NSAIDs for  pelvic pain is usually first. OCPs are first line, though GnRH analogs (Leuprolide) or danazol (not used because of androgen side effects) often show some benefit. Ultimately, surgical resection (ablation, resection) is needed. In the setting of an adnexal mass an endometrioma as the presenting complaint of endometriosis requires resection.

 Risk of ectopic : 1%  Risk with previous ectopic: 15%  Risk with previous ectopic with salpin gostomy: 15%  Risk with previous ectopic with salpin gectomy: 15%

“Ectopic” Endometrioma

Retrograde

Anterograde  Normal

 Normal endothelial  proliferation

Torsion of the Ovary This won’t be a diagnostic mystery as it’s a surgical emergency. The suspensory ligament acts as a hinge that the ovary spins around, cutting off its own vascular supply. Often, it’s the weight of the cyst that causes torsion. There will be a severe and sudden onset abdominal pain that was not provoked by any inciting event. The sonogram will show a cyst, but can’t tell if the ovary is necrotic or not. Ultrasound Doppler will show limited blood flow to the ovary. The patient must be brought to the OR immediately so the ovary can be untwisted . If the ovary pinks up simply remove the  cyst only and tac it down. If the ovary is necrotic remove the cyst and ovary. Tubo-ovarian Abscess This is discussed in gyn infections. Essentially - repeated acute PID (Gc/Chla) causes inflammation and allows the vaginal flora to access the uterus, tubes, and ovary. One consequence is abscess. The patient will present with a fever, leukocytosis , and an adnexal mass. The sonogram will show said abscess. Treat it with antibiotics x 72 hrs and continue if there’s improvement. If not, the abscess needs to be drained. Other indications to go to emergent surgery for TOA are if the patient is very ill or if it’s very large (>8 cm). TOA is one of the few abscess conditions that doesn’t require emergent drainage.

See Gyn Infections for more details on abx coverage 1.

Inpatient Cefoxitin, Doxycycline, Metronidazole Clindamycin, Gentamycin 2. Outpatient (not for an Abscess) a. Ceftriaxone x 1, Doxycycline, Metronidazole  b. Cefoxitin+Probenecid, Doxycycline, Metronidazole a.  b.

Ovarian Cancer Any complex cyst can be cancer. Please see the Ovarian Cancer section for details.

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