I have nothing to disclose. Stefanie M. Ueda, M.D. Assistant - PowerPoint PPT Presentation

UCSF Helen Diller UCSF Helen Diller Approach to the Adnexal Mass Approach to the Adnexal Mass Cancer Center Cancer Center Approach to the Adnexal Mass I have nothing to disclose. Stefanie M. Ueda, M.D. Assistant Clinical Professor Division of Gynecologic Oncology University of California, San Francisco UCSF Helen Diller UCSF Helen Diller Approach to the Adnexal Mass Approach to the Adnexal Mass Cancer Center Cancer Center Management of Adnexal Mass Management of Adnexal Mass Question #1 Question #2 30 y/o G1P0 female found to have adnexal fullness Patient is anxious and strongly desires surgical on routine exam. Pelvic ultrasound shows a 5 cm removal. CA-125 comes back at 67. adnexal mass with septations and trace free fluid. 1. MRI or CT 40% 64% 2. Referral to gynecologic oncologist 1. Repeat ultrasound in 6-8 weeks 30% 3. Laparoscopic cystectomy 25% 2. CA-125 30% 4. Laparoscopic salpingo-oophorectomy 3. OVA-1 5. Laparoscopic salpingo-oophorectomy, 4. MRI or CT 3% 3% washings, possible biopsies 3% 1% 1

UCSF Helen Diller UCSF Helen Diller Approach to the Adnexal Mass Approach to the Adnexal Mass Cancer Center Cancer Center Management of Adnexal Mass Management of Adnexal Mass Question #4 Questions #3 55 y/o postmenopausal female found to have adnexal Patient has mild hypertension and no significant fullness on routine exam. Pelvic ultrasound shows a family history. She is asymptomatic. CA-125 comes 4 cm adnexal mass with thin septation. back at 11. 1. Repeat ultrasound in 6-8 weeks 1. OVA-1 82% 71% 2. CA-125 2. MRI or CT 3. OVA-1 3. Repeat ultrasound and tumor marker in 6-8 weeks 4. MRI or CT 4. Referral to gynecologic oncologist 18% 12% 9% 4% 1% 3% UCSF Helen Diller UCSF Helen Diller Approach to the Adnexal Mass Approach to the Adnexal Mass Cancer Center Cancer Center Prevalence of Adnexal Mass The Adnexal Mass 5-10% lifetime risk of requiring surgery for adnexal mass • • Characteristics of Adnexal Masses – Asymptomatic women age 25-40 1 • 6.6% with ovarian cyst • Diagnostic Tools – Asymptomatic postmenopausal women 2 – Imaging Modalities • 2.5% simple cyst • 84% less than 5 cm and missed on exam – Tumor Markers and Multivariate Assays • Risk of malignancy increases with age • Approach to Management – 6-11% in premenopausal 3 – 29-35% in postmenopausal • Referral to Gynecologic Oncologist 1 Borgfeldt C et al, Ultrasound Obstet Gynecol 1999 2 Castillo G et al, Gynecol Oncol 2004 3 Norris HJ et al, Cancer 1972 2

UCSF Helen Diller UCSF Helen Diller Approach to the Adnexal Mass Approach to the Adnexal Mass Cancer Center Cancer Center Differential Diagnosis Clinical Pearls • Presence of fever, leukocytosis, or pelvic • Physiologic or functional cysts tenderness • Ectopic pregnancy • Past medical history, including personal • Inflammatory Etiologies history of breast cancer • Endometrioma • Gastrointestinal symptoms particularly if • Benign or malignant neoplasms periumbilical or left lower quadrant pain – Serous cystadenomas most common • Hepatic, renal or cardiac disease can – Mucinous cystadenomas more likely to be contribute to ascites or elevated CA-125 multiloculated, unilocular, larger • Metastasis to ovary UCSF Helen Diller UCSF Helen Diller Approach to the Adnexal Mass Approach to the Adnexal Mass Cancer Center Cancer Center Pelvic Ultrasonography Diagnostic Evaluation – Pooled Analysis • Normal ovary Diagnostic Tool Sensitivity Specificity – 3.5 x 2 x 1.5 cm in premenopausal Bimanual exam 45% 90% – 1.5 x 0.7 x 0.5 cm postmenopausal • 173 consecutive cases of women with Ultrasound morphology 86-91% 68-83% pelvic mass 1 MRI 91% 87% – Correct diagnosis 42%, incorrect diagnosis in 7% CT 90% 75% – 92% sensitivity and 97% specificity for PET 67% 79% endometrioma CA-125 78% 78% – 90% sensitivity and 98% specificity for dermoid 1 Valentin L et al, Ultrasound Obstet Gynecol 1999 1 Myers ER et al, Agency Healthcare Res 2006 3

UCSF Helen Diller UCSF Helen Diller Approach to the Adnexal Mass Approach to the Adnexal Mass Cancer Center Cancer Center Normal premenopausal and postmenopausal ovary Endometrioma Dermoid UCSF Helen Diller UCSF Helen Diller Approach to the Adnexal Mass Approach to the Adnexal Mass Cancer Center Cancer Center Pelvic Ultrasonography Diagnosis of Ovarian Cancer by Sonography • Malignancies rich in neovascularization Sonographic Findings Sensitivity Specificity – Lower resistive and pulsatile indices Ultrasound morphology 86-91% 68-83% • Gray scale with color Doppler flow better than either alone Resistive index 72% 90% • Likelihood of malignancy 1 Pulsatility index 80% 73% – 0.3% of unilocular Presence of vessels 88% 78% – 8% of multilocular Morphology and Doppler 86% 91% – 36% of multilocular, solid – 39% of solid Doppler technology should be combined with morphology assessment 1 Granbery S et al, Gynecol Oncol 1989 4

UCSF Helen Diller UCSF Helen Diller Approach to the Adnexal Mass Approach to the Adnexal Mass Cancer Center Cancer Center Sonographic Characteristics • Low to medium echoes in endometrioma • Fishnet or reticular pattern in hemorrhagic cyst • Hyperechoic nodule with distal acoustic shadowing suggestive of teratoma • Malignant mass • Solid but not hyperechoic • Papillary • Thick septations (>2-3 mm) Color or Doppler flow in solid component • Multiple septations and solid elements with vascular flow UCSF Helen Diller UCSF Helen Diller Approach to the Adnexal Mass Approach to the Adnexal Mass Cancer Center Cancer Center CT Use in Adnexal Masses 4.1% asymptomatic women found to have adnexal mass 1 • • Mean age 56.2 years • 108 unilateral, 10 bilateral • Mean size 4.1 cm – No ovarian cancers among those with incidental mass – 4 cases of ovarian cancer developed after negative CT at 15-44 months follow-up CT should not be used for screening but preferred • technique in the pretreatment evaluation of ovarian cancer to define the extent of disease 2 Mucinous Borderline Tumor 1 Pickhardt PH et al, Radiology 2010 2 Iyer VR et al, AJR 2010 5

UCSF Helen Diller UCSF Helen Diller Approach to the Adnexal Mass Approach to the Adnexal Mass Cancer Center Cancer Center Pelvic MRI in Evaluating Adnexal Mass • Retrospective cohort of 237 with indeterminate adnexal mass by ultrasound at tertiary care center – Sensitivity 95% – Specificity 94.1% – Predicted benign histologic subtype accurately in 56 of 57 women (98.3%) – Predicted malignancy accurately in 23 of 27 women (85.2%) – Offered more detailed patient counseling, surgical referral, and conservative management of benign masses Endometrioma with hypointensity and fluid levels on 1 Haggert AF et al, Int J Gynecol Cancer 2014 T2 (left) and hyperintense blood on T1 UCSF Helen Diller UCSF Helen Diller Approach to the Adnexal Mass Approach to the Adnexal Mass Cancer Center Cancer Center PET/CT Compared to Other Modalities • 99 patients underwent PET, ultrasound technique and T2-weighted MRI – PET depicted 7 of 12 malignant and 66 of 87 benign tumors – False-negative PET obtained in 5 of 7 Stage I cancer and borderline • Sensitivity 58% • Specificity 76% – Sensitivity (83%) and specificity (84%) higher for ultrasound and for MRI (92% & 85%, respectively) – Ultrasound remains method of choice Normal premenopausal ovaries with FDG-avidity 1 Fenchel S et al, Radiol 2002 6

UCSF Helen Diller UCSF Helen Diller Approach to the Adnexal Mass Approach to the Adnexal Mass Cancer Center Cancer Center Multimodal Imaging CA-125 Sonographic Findings Sensitivity Specificity Clinical Scenario Sensitivity Specificity PPV Sonogram with Doppler 92% 60% Stage I 50% MRI 84% Stage II 90% PET 80% Malignancy in 50-87% 26% 73-100% Combination of all 3 92% 85% premenopausal • 101 patients with asymptomatic adnexal masses With complex or solid 85% 92% scheduled for laparoscopy mass on ultrasound – Preoperative ultrasound, MRI, and PET – Correct classification of 11 of 12 ovarian malignancies • Elevated in >80% of advanced ovarian cancers – MRI & PET improved specificities but decreased sensitivities • Higher specificity for malignancy if combined with sonography – Multimodal imaging may improve accuracy 1 Grab D et al, Gynecol Oncol 2000 UCSF Helen Diller UCSF Helen Diller Approach to the Adnexal Mass Approach to the Adnexal Mass Cancer Center Cancer Center Human Epididymis Protein 4 (HE4) • Disulfide family of secreted proteins that is amplified in ovarian cancer – <140-150 pmol/L for postmenopausal – <70 pmol for premenopausal • Increased expression in serous (93%) and endometrioid subtypes (100%) • FDA approval in 2008 to monitor patients with ovarian cancer for disease progression or recurrence HE-4 staining more common in serous and endometrioid • Not elevated in endometriosis ovarian carcinomas, but absent in mucinous 7