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HOW TO TREAT 21

Table 2. Types of primary ovarian lesions Source Type Examples
Epithelial
Benign
Cystadenomas
Endometriomas( see figure 3)
Functional cysts( see figure 4)
Sex cord – stromal
Borderline Mucinous( see figure 5) Serous Endometrioid
Malignant
Benign
Malignant
Low-grade serous High-grade serous Mucinous Endometrioid Clear cell
Fibroma Thecoma Fibrothecoma
Adult and juvenile granulosa cell tumour Sertoli – Leydig cell tumour
Germ cell
Benign
Mature teratoma / dermoid
Struma ovarii
Malignant
Endodermal sinus tumour / yolk sac tumour Immature teratoma Dysgerminoma( see figure 6)
Box 1. Symptoms from adnexal masses
• The patient’ s age and menopausal status are the most crucial component of their history:— The risk profile of a lesion changes with age and menopausal status as, aside from genetic factors, advancing age remains the biggest risk factor for epithelial ovarian cancers. 6
• Symptoms from a mass effect can present as dyspareunia, pelvic fullness, urinary changes, bowel changes, weight change, increased abdominal girth and bloating.
• Pain can arise from rupture, torsion or haemorrhage.
• Some rarer tumours are hormonally active, leading to hormonal or functional changes, which can cause secondary amenorrhoea, abnormal bleeding, hirsutism or precocious puberty.
• In addition, exploring possible symptomatology from non-gynaecological organs can help narrow differential diagnoses:— Specific focus on rectal bleeding, change in bowel or bladder function, upper gastrointestinal symptoms or dietary changes can aid in identifying other organs as a source of pathology.
• A targeted history will identify the presence of known endometriosis or symptoms of endometriosis as both benign and malignant complex pelvic masses can arise in patients with this diagnosis:— Certain investigations, such as MRI, may be of benefit in these women.
• Identify a family history of breast, ovarian or colorectal cancers as these are associated with genetic conditions that lead to a significant increase in the risk of ovarian malignancy:— The most common types of known inherited conditions to be aware of include BRCA1 or BRCA2 mutations and Lynch syndrome.— Patients with a confirmed diagnosis of these conditions are often already known to a cancer service, and if they are not, refer them for genetic counselling. 5
markers are divided into three categories based on suspected origin, and not all need to be performed for every adnexal mass. Each category attempts to identify a subtype of ovarian cancer and includes germ cell cancers, epithelial carcinomas and sex cord – stromal tumours( see table 5). Understanding the common malignancies related to age can help direct which tumour markers are the most appropriate to perform.
The most common and widely
Cureus. 2022 Jan 17; 14( 1): e21329 / CC BY: bit. ly / 44jBzng
a Risk of Malignancy Algorithm score( ROMA) that can aid assessment of adnexal masses. 17 It is crucial that HE4 is used in the right context as elevations can occur in non-gynaecological conditions, such as chronic kidney disease, which can often provide a concerning false-positive result. The UK Royal College of Obstetricians and Gynaecologists recommends that HE4 not be used to assess malignant potential in postmenopausal women as it provides limited clini-
used marker is CA125. This is an
cal value in determining the aetiology
epitope found on mucin 16, a glyco-
of the mass and active endometriosis
protein antigen normally expressed in
is unlikely to be a factor. 1
tissues derived from coelomic epithe-
Other epithelial tumour markers
lia, such as the ovary, fallopian tube,
that are often of value are carcinoem-
peritoneum, pleura, pericardium,
bryonic antigen( CEA) and cancer
colon, kidney and stomach. 12
antigen 19.9( CA19.9). Perform these
The role of CA125 is critical, but it
when assessing a suspected epithe-
is crucial that CA125 is interpreted in the context of all individual patient factors. CA125 can be elevated for many reasons, including gynaecological and non-gynaecological conditions— both benign and malignant in
Figure 3. Right ovarian endometrioma( 10cm) and three left ovarian endometriomas, each less than 5cm in size.
lial carcinoma; however, they require interpretation within the greater clinical context. Like CA125, these markers can be elevated in benign conditions, such as smoking( CEA) and dermoid cysts( CA19.9). They can
nature. It is vital to understand that
also provide impetus to search for
an elevated CA125 in combination
occult primary malignancies in the
with a pelvic mass does not always
upper and lower gastrointestinal sys-
indicate malignancy; this is important
tem when significantly elevated.
when counselling patients to avoid
While epithelial tumour markers
undue anxiety.
can be non-specific, some germ cell
Some benign gynaecological con-
markers— such as alpha fetoprotein
ditions— such as fibroids, endo-
for endodermal sinus tumours— are
metriosis, adenomyosis and pelvic
very specific and will often identify
inflammatory disease— can lead to an elevated CA125. 13 Non-gynaecological conditions— such as hepatic,
a likely diagnosis before any histopathological assessment. Consider germ cell tumours and order tumour
renal or cardiac failure, gastrointestinal cancer and breast cancers— can also lead to elevated levels. While an
markers in any patient under 40 with a complex mass. 2 Note that germ cell tumours are rare in women older than
elevated CA125 does not always indi-
30.
cate a malignancy, it is important to
Stromal tumours tend to have
note that a normal CA125 level does
fewer specific tumours markers, with
not always exclude a malignant process. 14 Up to 10 % of advanced and 50 % of early epithelial ovarian cancers will have a normal level. 15 CA125 levels are more likely to be elevated
granulosa cell tumours and inhibin the exception. Assess for stromal tumours in women with solid adnexal masses and in the presence of an abnormal endometrium( suspected
in high-grade serous carcinomas
through either abnormal bleeding or
because of their propensity for perito-
imaging findings).
neal spread. 15 Elevated CA125 levels in postmenopausal women are often more concerning than in pre-menopausal women as the benign pathologies that can falsely elevate the result are
Obstetricians and Gynecologists
Human epididymis protein 4
Figure 4. Simple ovarian cyst on the right ovary at laparoscopy.
and ovarian pathology as a source of
Cascade imaging
Additional imaging modalities have a
role in investigating suspected complex lesions. 18 Again, cascade imaging will often depend on the patient’ s age
less likely to occur in this age group. While pre-menopausal CA125 levels can be elevated for many benign
recommends that pre-menopausal women with a CA125 of greater than 200 are referred directly to a gynae-
( HE4) is a glycoprotein found in the epididymal epithelium. 12, 17 Research suggests that HE4 can aid in differ-
elevated CA125 because HE4 is not increased in endometriosis. 12 HE4 results can be used in a predictive test
and the initial clinical findings. Perform pre-test counselling to reduce anxiety regarding pending results.
reasons, the American College of
cology oncologist. 16
entiating between endometriosis
in combination with CA125 to provide
Do not use CT scanning as the