|
first-line imaging investigation of
a pelvic mass identified on clinical examination or one suspected based on symptoms. Resolution of imaging within the pelvis is inferior compared with ultrasound when assessing ovarian characteristics. CT( see figures 8, 9 and 10) plays a role when there is a need to assess for potential metastatic disease or in identifying an occult primary when a non-gynaeco-
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Figure 5. Mucinous adenocarcinoma of the ovary arising within a mucinous borderline tumour. |
Table 4. IOTA rules
B-rules
Unilocular cysts
Presence of solid components, where the largest solid component is less than 7mm
M-rules
Irregular solid tumour
Ascites
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logical origin is suspected. However, have a low threshold for ordering CT chest, abdomen and pelvis in patients over 40 with complex masses; CT is required for completion staging of an adnexal mass when an epithelial or stromal malignancy is suspected( see table 6).
MRI has a select role in investigating adnexal masses. It can aid in diagnosis when an alternative diagnosis
|
Presence of acoustic shadowing
Smooth multilocular tumour, with the largest diameter less than 100mm
No blood flow
|
At least four papillary structures
Irregular multilocular solid tumour, with the largest diameter greater than 100mm
Strong blood flow
|
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to an ovarian neoplasm is thought to be more likely. 19 It has value in assessment of pelvic masses in pregnancy |
Source: Timmerman D et al 2005 10 |
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or when malignancy is not suspected |
balance required to manage adnexal |
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but complex masses are present on |
masses appropriately, including mor- |
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ultrasound, which is common in |
bidity by exposing patients to multiple |
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severe endometriosis. MRI should not |
or unnecessary surgical procedures. |
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be part of routine investigations when |
Gynaecology oncology multidis- |
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a complex mass is found but rather be |
ciplinary tumour boards play a cru- |
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used sparingly by non-GP specialists |
cial role in preoperative assessment |
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to answer a specific clinical question. |
of oncological potential. This includes |
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|
MANAGEMENT
MEAN survival time for women with
|
provision of multiple expert opinions from radiologists and gynaecological oncologists on imaging findings in |
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ovarian malignancy is improved when |
combination with serum biochemis- |
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managed by a gynaecological oncolo- |
try and patient history. This process |
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gist; early diagnosis and referral to the |
allows refined operative planning by |
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appropriate specialists are therefore crucial. 20 If malignant disease is a possibility based on the clinical picture |
determining both the most appropriate surgical procedure and surgeon( gynaecological oncologist, advanced |
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and ultrasound findings, it is impor- |
endoscopic surgeon or general |
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tant to promptly refer to a gynaecological oncology team. 2 While general gynaecologists can manage women with a low RMI, women at higher risk |
gynaecologist).
PROGNOSIS
THE prognosis of adnexal masses is
|
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are better managed in a cancer centre |
varied because of the many aetiologies |
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by a gynaecological oncologist, unless |
present. When subdivided into types |
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a multidisciplinary team review deter- |
of lesions, the prognosis becomes |
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mines the woman has a low risk of |
clearer. Benign ovarian lesions have |
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malignancy. 1 |
very favourable prognosis, although |
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The mainstay of management of |
some benign cysts have the poten- |
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concerning ovarian masses is surgi- |
tial for malignant transformation. For |
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cal. This can range from cystectomy |
example, endometriotic lesions can |
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with ovarian conservation through to |
have the potential for malignant trans- |
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pelvic clearance and oncological stag- |
formation into epithelial ovarian can- |
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ing. The most appropriate operation |
cers( clear cell and endometrioid), and |
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is one individualised to each patient, |
dermoid cysts can become rare SCCs. |
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considering the patient’ s age, medical |
Germ cell tumours generally have |
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status, fertility wishes, BMI and the |
a favourable prognosis, even in the |
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level of oncological suspicion. There is often a need for extensive preoperative counselling as the findings at |
Figure 6. Dysgerminoma of the ovary in an adolescent. |
advanced stage, largely because of their chemosensitivity. Germ cell tumours tend to allow for fertility |
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the time of surgery dictate the most |
preservation and successful pregnan- |
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appropriate surgical procedure. This is where the role of the gynaecological oncologist is crucial as they have |
shown equivalent outcomes but with
21, 22 reduced patient morbidity. In recent years, molecular test-
|
Table 3. Risk of Malignancy Index
Findings
Points
|
cies post-treatment. Sex cord – stromal tumours have significantly varied outcomes, which |
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the capacity to assess the oncological status of both the peritoneal and retroperitoneal spaces, perform frozen sections, interpret the results and act immediately on these intraoperative findings. Patients will ideally undergo a single surgical procedure; however, a staged or second procedure may be needed if suboptimal oncological stag- |
ing of tumour types has become the gold standard, opening up maintenance options, such as poly( ADP-ribose) polymerase( PARP) inhibitors after up-front treatment. 23, 24 Tumour samples are ideally collected before starting chemotherapy, thus making the role of the interventional radiologist or laparoscopic biopsy crucial in |
Ultrasound findings( U)- Multilocular cyst- Solid areas- Metastases- Ascites- Bilateral lesions
Menopausal status( M)
|
0 points— No features 1 point— 1 feature 3 points— 2-5 features
1 point – pre-menopausal 3 points – postmenopausal
|
depend on the type and grade of tumour. These tumours rely heavily on optimal primary surgical management with a gynaecological oncologist for ideal outcomes.
The prognosis for epithelial tumours is assessed by allocating these into two categories: borderline and invasive( epithelial carcinoma).
|
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|
ing occurred at the primary operation and a diagnosis of cancer is subsequently made.
Patients with imaging and tumour markers concerning for a metastatic epithelial malignancy often undergo a
|
those not undergoing primary surgical treatment. 24
In general terms, the surgical management of adnexal masses can be divided into fertility sparing( cystectomy or unilateral salpingo-oophorec-
|
Cancer antigen 125( CA125)( U / mL)
Actual level
RMI score = U x M x CA125 Example: A postmenopausal woman with two of the ultrasound features and a CA125 of 100 RMI = 3 x 3 x 100 = 900— Direct referral to a gynaecological oncologist is required
|
Borderline tumours have a good prognosis when managed optimally. However, they do carry a risk of recurrence and malignant transformation, particularly in the setting of ovarian conservation or extra ovarian non-in- |
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biopsy performed by an interventional radiologist. The biopsy aims to sam- |
tomy with uterine conservation) and non-fertility sparing( pelvic clearance) |
Source: Jacobs I et al 1990 9 |
vasive implants at diagnosis. As a general rule, epithelial car- |
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ple a site of suspected metastasis, such |
procedures. Fertility wishes are not |
cinomas have the least favourable |
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as omentum, peritoneum or abnormal |
the only factor that comes into play |
ovaries in the presence of benign dis- |
adnexal masses are reviewed by spe- |
prognosis. They are often initially |
||
lymph nodes that have been identified |
when deciding on the most appropri- |
ease will slightly decrease the risk |
cialists with appropriate knowledge |
responsive to the up-front systemic |
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on imaging. This facilitates neoadju- |
ate surgical approach. Age is crucial |
of ovarian cancer but leads to an |
and skill to manage the wide array of |
chemotherapy, but recurrence is |
||
vant chemotherapy treatment before |
in deciding whether ovarian conser- |
increased risk in overall mortality. 26 |
pathologies that may be present at |
common. Even when chemotherapy |
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surgical intervention, which has |
vation should occur as removal of |
It is crucial that patients with |
the time of surgery. There is a delicate |
is combined with optimal surgical |
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