UP-PGH OBGYN ORAL EXAM REVIEW July 19, 2016

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CASE 1

Benign and Malignant

OVARIAN TUMORS
ANA VICTORIA V. DY ECHO, MD
Clinical Associate Professor
Department of OB-GYN
UP-Manila, Philippine General Hospital

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CASE 1 CASE 1
35 years old G0
CC: intermittent abdominal pain
(-) constitutional signs, symptoms What is the most likely diagnosis?

PE:
Abdomen flat, (-) fluid wave
IE: NEG, nulliparous vagina, cervix 3 x 2 cm,
smooth, corpus small, (+) right adnexal mass, 8
x 8 cm, cystic, movable
RVE: bilateral parametria smooth and pliable

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Benign vs. Malignant CASE 1

BENIGN MALIGNANT
Young Older What is the most likely diagnosis?
Unilateral Bilateral
Cystic Solid OVARIAN NEW GROWTH,
Mobile Fixed
PROBABLY BENIGN
Smooth Irregular
No ascites Ascites
Slow growth Rapid growth

McMeekin DS, et al. The adnexal mass. In: Di Saia, et al (Ed).

Clinical Gynecologic Oncology, 5 th Ed. 2012

OVARIAN TUMORS: DyEcho 1

UP-PGH OBGYN ORAL EXAM REVIEW July 19, 2016

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CASE 1 Benign Tumors of the Ovary

• FUNCTIONAL • BENIGN NEOPLASMS

What are your differentials?
• Follicular • Germ cell tumor
• Corpus luteum Benign cystic teratoma
• Theca lutein (dermoid cyst)
• Endometrioma
• INFLAMMATORY • Fibroma

• Tubo-ovarian abscess or • Epithelial tumors

complex Adenofibroma and
cystadenofibroma
Transitional cell tumors –
Brenner tumors
Katz VL, et al. Comprehensive Gynecology 6 th Ed, 2012

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Other Differentials CASE 1

• UTERUS
• Subserous myoma
• FALLOPIAN TUBE
• Hydrosalpinx
• Paratubal cyst
• NON-GYNECOLOGIC
What diagnostic tests should be requested?
• Diverticular abscess
• Appendiceal abscess or
mucocele
Transvaginal ultrasound
• Nerve sheath tumors
• Ureteral/bladder diverticulum
• Pelvic kidneys CBC
Blood typing

Castro, et al. Signs and Symptoms of Ovarian Masses.

In: POGS CPG on Myoma Uteri and Adnexal Masses, 2010

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CASE 1 Imaging Studies

ULTRASOUND

1. Is the finding a simple (unilocular) or complex

(multicystic/multilocular with solid components)
cyst?
2. Are there papillary projections?
3. Are the cystic walls and/or septa regular and
smooth?
4. What is the echogenicity (tissue characterization)?

Katz VL, et al. Comprehensive Gynecology 6 th Ed, 2012

OVARIAN TUMORS: DyEcho 2

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Imaging Studies CASE 1

ULTRASOUND
B rules M rules
(Benign tumors) (Malignant tumors)
Unilocular Irregular solid tumor
Presence of acoustic Presence of ascites
shadowing At least 4 papillary structures
Smooth multilocular tumor Irregular multilocular solid
No blood flow tumor
Very strong blood flow

Castro, et al. Signs and Symptoms of Ovarian Masses.

In: POGS CPG on Myoma Uteri and Adnexal Masses, 2010

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CASE 1 CASE 1

What is the diagnosis? What is the appropriate management for this

case?
OVARIAN NEW GROWTH,
PROBABLY BENIGN

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Management of Benign Tumors Management of Benign Tumors

• Management depends on diagnosis, patient’s FUNCTIONAL CYSTS
age, patient’s desire for fertility. • Observation

• Cystectomy is the procedure of choice where EPITHELIAL OVARIAN TUMORS

normal ovarian tissue is still appreciated. • Oophorectomy, occasionally cystectomy
• Oophorectomy is indicated when ovarian tissue
cannot be preserved. DERMOID CYSTS, ENDOMETRIOMA
• Cystectomy
• Laparoscopy vs. laparotomy
Gonzales, et al. Management of Adnexal Masses.
In: POGS CPG on Myoma Uteri and Adnexal Masses, 2010 Katz VL, et al. Comprehensive Gynecology 6 th Ed, 2012

OVARIAN TUMORS: DyEcho 3

UP-PGH OBGYN ORAL EXAM REVIEW July 19, 2016

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CASE 1 Benign Tumors of the Ovary

DERMOID CYST ENDOMETRIOMA

What is the appropriate management for this

case?

CYSTECTOMY

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Benign Tumors of the Ovary CASE 1

FIBROMA BENIGN BRENNER TUMOR

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CASE 1 CASE 1

What is the final diagnosis?

MATURE CYSTIC TERATOMA, RIGHT OVARY

OVARIAN TUMORS: DyEcho 4

UP-PGH OBGYN ORAL EXAM REVIEW July 19, 2016

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CASE 2
CASE 2 55 years old G0
CC: 5 months history of enlarging abdominal mass,
associated with intermittent pain
(-) constitutional signs, symptoms

PE:
(+) 22 x 19 cm abdominopelvic mass, cystic with
solid areas, slight mobility, nontender, (-) fluid wave
IE: NEG, nulliparous vagina, cervix 3 x 2 cm,
smooth, corpus small, inferior pole of mass palpated
at cul-de-sac
RVE: bilateral parametria smooth and pliable

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CASE 2 Benign vs. Malignant

BENIGN MALIGNANT
What is the most likely diagnosis? Young Older
Unilateral Bilateral
Cystic Solid
Mobile Fixed
Smooth Irregular
No ascites Ascites
Slow growth Rapid growth

McMeekin DS, et al. The adnexal mass. In: Di Saia, et al (Ed).

Clinical Gynecologic Oncology, 5 th Ed. 2012

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CASE 2 CASE 2

What is the most likely diagnosis? What are your differentials?

OVARIAN NEW GROWTH,

PROBABLY MALIGNANT

OVARIAN TUMORS: DyEcho 5

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Malignant Tumors of the Ovary Nongynecologic Malignant Tumors

• EPITHELIAL • SEX CORD STROMAL • GASTRO-INTESTINAL

• Serous carcinoma • Granulosa cell tumors TUMORS
• Mucinous carcinoma • Sertoli cell tumors
• Endometrioid carcinoma
• RETROPERITONEAL
• Clear cell carcinoma
• Malignant Brenner tumor
• MESENCHYMAL SARCOMAS

• GERM CELL TUMORS • METASTATIC

• Dysgerminoma
• Yolk sac tumors
• Immature teratoma
Castro, et al. Signs and Symptoms of Ovarian Masses.
Katz VL, et al. Comprehensive Gynecology 6 th Ed, 2012 In: POGS CPG on Myoma Uteri and Adnexal Masses, 2010

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CASE 2 Imaging Studies

DOPPLER STUDIES
What diagnostic tests should be requested?
• Allows assessment of tumor vascularity
Transvaginal ultrasound • Malignant tumors display increased vascularity,
Doppler studies decreased peripheral flow resistance, increased blood
CA-125 + HE4 velocity1

CBC
Blood typing • Resistance index – measures resistance to flow
FBS, BUN, creatinine, AST, ALT, Mg, K, Ca, Cl, alb in the vessels; low in neovascularization
Chest x-ray • RI 0.4-0.62
Whole abdomen ultrasound
1Myer ER, et al. Management of adnexal mass. Evidence report/Technology
12-lead ECG assessment No 130, 2006; 2Katz VL, et al. Comprehensive Gynecology 6 th Ed

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Tumor Markers Tumor Markers

CA-125 CA-125
ADVANTAGE DISADVANTAGE
• Elevated in 80% of • Not expressed in 20% of
nonmucinous EOC (i.e. ovarian cancers MENOPAUSE PREMENOPAUSE
endometrioid, serous CA) • Elevated only in 50% of early 35 U/ml 65 U/ml 200 U/ml
• Elevated even before clinical stage ovarian cancers Sensitivity 78% 77% 69%
onset of ovarian cancer • Elevated in benign conditions Specificity 78% 73% 84%
(i.e. endometriosis, myoma,
PID, liver disease, CHF)
• Exhibit fluctuations in
1ACOG Committee Opinion No 477. The role of the obstetrician-gynecologist in the early detection
premenopause (i.e. menstrual of EOC. 2011 2Dearking AC, et al. How relevant are ACOG and SGO guidelines for referral of
cycle, pregnancy) adnexal mass? Obstet Gynecol 2007 3Uelend FR, et al. Effectiveness of a multivariate index
assay in the preoperative assessment of ovarian tumors. Obstet Gynecol 2011 4Myer ER, et al.
Management of adnexal mass. Evidence report/Technology assessment No. 130 2006

OVARIAN TUMORS: DyEcho 6

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Tumor Markers CASE 2

HE4

• Complementary to CA-125
• Decreases the contribution of an erroneously elevated
CA 125 (Less false positive findings)
• Serum HE4 is elevated in > 50% of tumors that do not
express CA 125 (increases sensitivity)
• Less susceptible to peritoneal irritation

Moore RG, et al. Comparison of a novel multiple marker assay vs. the risk of malignancy
index for the prediction of epithelial ovarian cancer in patients with a pelvic mass.
Am J Obstet Gynecol 2010

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CASE 2 CASE 2

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CASE 2 CASE 2

CA-125 1,072 mIU/ml

What is the diagnosis?

OVARIAN NEW GROWTH,

PROBABLY MALIGNANT

OVARIAN TUMORS: DyEcho 7

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CASE 2 Surgery for Ovarian Cancers

1. Systematic abdominal exploration via midline incision
2. Sampling of peritoneal washings (PFC) on four areas:
diaphragm, right and left hemi-abdomen, pelvis EVEN if
What is the plan of management? there is tumor rupture/present of tumor on capsule
3. Careful inspection and palpation of all peritoneal
EL, PFC, THBSO, surfaces
IO, BLND, PALS, RPB, 4. Removal of primary ovarian/fallopian tube tumor with
intact capsule
+ appendectomy 5. Total abdominal hysterectomy + bilateral salpingo-
oophorectomy (THBSO)
6. Infracolic omentectomy (IO): infragastric omentectomy,
for gross omental involvement
SGOP 2015 Clinical Practice Guideline

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Surgery for Ovarian Cancers CASE 2

7. Random biopsies of normal peritoneal surfaces (RPB),
2 from each: undersurface of right hemidiaphragm,
bladder reflection, cul-de-sac, right and left paracolic
recesses, pelvic sidewalls
8. Systematic lymphadenectomy (pelvic and para-aortic
lymph node) (BLND, PALS)
9. For mucinous tumor, or when appendix is grossly
involved, appendectomy.
Right ovary was converted into a multiloculated,
multiseptated complex mass measuring 20 x 15 x
7 cm., adherent laterally to the pelvic side wall and
anteriorly to the posterior bladder surface. It
inadvertently ruptured during adhesiolysis.
The rest of the abdominopelvic organs were
grossly normal.

SGOP 2015 Clinical Practice Guideline

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CASE 2 CASE 2

OVARIAN TUMORS: DyEcho 8

UP-PGH OBGYN ORAL EXAM REVIEW July 19, 2016

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CASE 2 Benign vs. Malignant Tumors

What is the final diagnosis?

SEROUS TUMORS

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Benign vs. Malignant Tumors Malignant Tumors

MUCINOUS TUMORS ENDOMETRIOID CLEAR CELL

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Malignant Tumors CASE 2

IMMATURE TERATOMA DYSGERMINOMA

OVARIAN TUMORS: DyEcho 9

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CASE 2 Ovarian Cancer Staging

STAGE DESCRIPTION
Tumor confined to ovaries or fallopian
I
tubes
What is the final diagnosis? 1 ovary or fallopian tube, no ascites,
IA
intact capsule
2 ovaries or fallopian tubes, no ascites,
IB
SEROUS CARCINOMA, RIGHT OVARY, intact capsule
1 or 2 ovaries or fallopian tubes, with
IC
STAGE ____ any of the following:
IC1 Surgical spill
Capsule ruptured before surgery,
IC2
tumor on surface
Malignant cells on ascites or
IC3 peritoneal washings

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Ovarian Cancer Staging Ovarian Cancer Staging

STAGE DESCRIPTION STAGE DESCRIPTION

II With pelvic extension (below the pelvic
rim) or primary peritoneal cancer
IIA Uterus / fallopian tubes / ovaries
IIB Other pelvic intraperitoneal tissues
III With spread to the peritoneum outside
pelvis / (+) retroperitoneal LN
IIIA1 Positive retroperitoneal LN
IIIA1i Metastasis up to 10 mm in diameter
IIIA1ii Metastasis > 10 mm in diameter
IIIA2 Microscopic extrapelvic (above the
brim) peritoneal involvement
IIIB Macroscopic peritoneal metastasis
beyond the pelvis up to 2 cm in
diameter
IIIC Macroscopic peritoneal metastasis
beyond the pelvis > 2 cm in diameter

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Ovarian Cancer Staging CASE 2

STAGE DESCRIPTION
IV Distant metastasis
IVA Pleural effusion with positive cytology Will she require additional treatment?
IVB Parenchymal metastasis and
metastasis to extra-abdominal organs

OVARIAN TUMORS: DyEcho 10

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Management of EOC CASE 2.1

STAGE STATUS PRIMARY TREATMENT
ADJUVANT
TREATMENT
27 years old G0
Young/desirous of USO/BSO, complete surgical
IA-IB pregnancy staging
(G1,G2) Reproductive THSBO, complete surgical
None 5 months enlarging abdominopelvic mass
function complete staging ONG, malignant
Young/desirous of USO/BSO, complete surgical
IC (G1/2, pregnancy staging Mucinous cystadenocarcinoma
good Chemotherapy
Reproductive THBSO, complete surgical
histology)
function complete staging
Intraop stage IC2
IA-IC (G3,
CCC, THBSO, complete surgical
Chemotherapy
HGSC), staging
II-III
IV THBSO, tumor debulking Chemotherapy
SGOP 2015 Clinical Practice Guideline

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CASE 2.1 Management of EOC

ADJUVANT
STAGE STATUS PRIMARY TREATMENT
TREATMENT
Young/desirous of USO/BSO, complete surgical
Will there be a difference in the management of IA-IB pregnancy staging
None
(G1,G2) Reproductive THSBO, complete surgical
this patient? function complete staging
Young/desirous of USO/BSO, complete surgical
IC (G1/2, pregnancy staging
good Chemotherapy
histology) Reproductive THBSO, complete surgical
function complete staging
IA-IC (G3,
CCC, THBSO, complete surgical
Chemotherapy
HGSC), staging
II-III
IV THBSO, tumor debulking Chemotherapy
SGOP 2015 Clinical Practice Guideline

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CASE 2.1
CASE 3

Will there be a difference in the management of

this patient?

YES, may perform

EL, USO, IO, BLND, PALS, RPB, appendectomy
followed by chemotherapy

OVARIAN TUMORS: DyEcho 11

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CASE 3 CASE 3
18 years old G0
CC: 3 months history of abdominal enlargement

PE:
(+) 15 x 10 cm abdominopelvic mass, predominantly
solid mass, nontender, (-) fluid wave
DRE: intact rectal vault, (-) intraluminal masses, cervix
small, smooth, corpus difficult to assess due to
abdominopelvic mass which is seems to be anterior to
the uterus

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CASE 3 CASE 3

What diagnostic tests should be requested?

What is the diagnosis?
Transvaginal ultrasound
Doppler studies
OVARIAN NEW GROWTH, CA-125, AFP, LDH, HCG
PROBABLY MALIGNANT
CBC
Blood typing
FBS, BUN, creatinine, AST, ALT, Mg, K, Ca, Cl, alb
Chest x-ray
Whole abdomen ultrasound
12-lead ECG

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CASE 3 CASE 3

What is the plan of management?

EL, PFC, USO + FS, IO, BLND, PALS, RPB

OVARIAN TUMORS: DyEcho 12

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CASE 3 CASE 3

There is a 3 x 5 cm solid necrotic mass at the right

pelvic sidewall.

There is another 3 x 3 cm solid necrotic mass on

the omentum.

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CASE 3 Management of GCT

ADJUVANT
STAGE STATUS PRIMARY TREATMENT
TREATMENT
Young/desirous of USO/BSO, complete surgical Chemotherapy
How should this patient be managed pregnancy staging (except pure
IA (G1) dysgeminoma and
intraoperatively? Reproductive THSBO, complete surgical G1 immature
function complete staging teratoma)
Young/desirous of USO/BSO, complete surgical
pregnancy staging Chemotherapy
IA (G2,
EBRT for
G3), II-III Reproductive THBSO, complete surgical dysgerminoma
function complete staging OR tumor debulking
Young/desirous of
USO/BSO, tumor debulking
pregnancy
IV Chemotherapy
Reproductive
THBSO, tumor debulking
function complete

SGOP 2015 Clinical Practice Guideline

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CASE 3 SUMMARY
BENIGN MALIGNANT, MALIGNANT,
YOUNG/DESIROUS, COMPLETED FAMILY,
GERM CELL TUMORS ADVANCED STAGE,
AGGRESSIVE
How should this patient be managed TUMORS
Ultrasound Ultrasound Ultrasound
intraoperatively? CA-125 + HE4 CA-125 + HE4
+ AFP, LDH, HCG + AFP, LDH, HCG
Metastatic work-up Metastatic work-up
EL, PFC, USO, tumor debulking, infragastric USO EL, USO, FS EL, THBSO
omentectomy Cystectomy IO, BLND, PALS, RPB IO, BLND, PALS, PRB
+ appendectomy + appendectomy
For IC above, For IC above,
Carboplatin + Paclitaxel Carboplatin + Paclitaxel
Bleomycin + Etoposide + Bleomycin + Etoposide +
Cisplatin Cisplatin

OVARIAN TUMORS: DyEcho 13

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Benign and Malignant

OVARIAN TUMORS
ANA VICTORIA V. DY ECHO, MD
Clinical Associate Professor
Department of OB-GYN
UP-Manila, Philippine General Hospital

OVARIAN TUMORS: DyEcho 14