Laparoscopic Surgery of an Adnexal Mass Case File

Laparoscopic Surgery of an Adnexal Mass Case File

Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 10

A 45-year-old G3P3003 woman presents to your office complaining of right lower quadrant pain occurring over the last 6 months which seemed to have increased in intensity during the last 30 days. She is afebrile and her vital signs are stable. She is not in acute distress but presents with tenderness to deep palpation over the right lower abdomen. On pelvic examination, her uterus is non-tender, but has a painful mass of approximately 5 × 6 cm in the right adnexa. Vaginal ultrasound reveals an enlarged right ovary measuring 7 × 7 × 8 cm containing a 5.0 × 5.4 × 1-cm cyst which has diffuse internal echoes with possible calcifications. Cervical cytology is benign and cultures are negative. Cancer antigen (CA) 125 was 41 U/mL. Her past surgical history is significant for three vaginal deliveries and tubal sterilization. She is interested in laparoscopic surgery if possible.

➤ What is the clinical condition?

➤ What is your next step?

ANSWERS TO CASE 10:

Laparoscopic Surgery of an Adnexal Mass

Summary: This is a 45-year-old G3P3003 woman with a painful right adnexal mass desiring laparoscopic surgery if intervention is indicated.

➤ Clinical condition: Multiparous patient with a painful complex adnexal mass.

➤ Next step: Outline the surgical options and explain the risks, benefits, and alternatives of the operation.

ANALYSIS

Objectives

1. Be familiar with the workup of an adnexal mass.
2. Be familiar with different methods of surgical management of adnexal mass, including risks and benefits.
3. Be familiar with the proper patient selection for laparoscopic management of an adnexal mass.

Considerations

This 45-year-old patient has a tender 5-cm complex adnexal mass. The CA-125 tumor marker is somewhat elevated. The differential diagnosis of the adnexal mass in this patient is an endometrioma, or a serous or mucinous cystadenoma, or less likely cystadenocarcinoma. A germ cell tumor is also a possibility, but less likely due to the patient’s age. A functional cyst such as a corpus luteal cyst is possible, but less likely due to the 6-month nature of her symptoms. Due to the patient’s symptoms, as well as importance of assessing whether this adnexal mass is a neoplastic process, surgery should be recommended to the patient. The patient should be informed about the various surgical approaches, and the benefits of laparoscopy—outpatient setting, easier recovery time, and cosmetic ramifactions.

APPROACH TO

Laparoscopic Surgery of an Adnexal Mass

DEFINITIONS

RISK OF MALIGNANCY INDEX (RMI): Use of menopausal status, CA-125, and ultrasound characteristics to determine the likelihood of an adnexal mass being malignant.

GERM CELL TUMOR MARKERS: The serum lactate dehydrogenase (LDH), α-fetoprotein (AFP), and human chorionic gonadotropin (hCG) levels are elevated with germ cell tumors.

EPITHELIAL TUMOR MARKERS: The serum CA-125, serum carcinoembryonic antigen (CEA), and CA-19-9 are the tumor markers which can be elevated with epithelial neoplasms.

CLINICAL APPROACH

The management of an adnexal mass provides unique challenges to the treating physician; the decision making is based on the characteristics of the mass, age, and expectations of the patient. The almost universal availability of the Internet provides vast medical information to our patients, including articles about the etiology and also treatment of a particular condition. Laparoscopic treatment is an appealing option due to its shorter hospitalization, less discomfort, faster return to normal activity, and superior cosmetic results.1-4 In addition, laparoscopic management of adnexal mass is a cost-effective surgical option associated with decreased indirect and also direct costs. However, all these benefits should not compromise the clinical outcome in women with ovarian malignancy. Proper patient selection and planning is very important in considering a laparoscopic approach. It is argued that the puncture or spillage of the contents of a malignant mass can compromise the survival of the patient. It definitely worsens the staging and has the potential of diffuse intra-abdominal dissemination with the CO2 gas. However, a multivariate analysis, and a retrospective study, on stage I ovarian epithelial cancers did not show an impact on survival when intraoperative spillage occurred in properly staged patients. It seems that patients with preoperative rupture or positive washings have a worst prognosis than the patients who suffer intraoperative spillage with negative washings. It seems that the delay in definitive surgery carries the worst outcome. It should also be noted that cyst aspiration done percutaneously or during laparoscopy carries a poor correlation between cytology and histology. Thus, a biopsy should accompany a cyst aspiration. In certain types of pathology, such as ovarian endometriomas, the recurrence rate is very high. It should also be noted that as many as 56% of aspirates do not contain diagnostic cells. A patient with a highly suspicious lesion should be treated by laparotomy if the mass cannot be removed intact. Consultation with a gynecologic oncologist should be considered when the patient is suspected of having a strong likelihood of a malignancy, since early and thorough surgical debulking is paramount in the treatment of this condition. In inconclusive cases, the laparoscope can aid the surgeon in identifying the type of pelvic mass, thus allowing for the proper abdominal incision and treatment. The laparoscopic visualization of a mass coupled with frozen section readings carries a sensitivity and specificity of over 92%.5

Although the majority of adnexal masses are benign, the workup should exclude or at least minimize the possibility of a malignant neoplasm. Adnexal masses are a common clinical problem. It is estimated that a woman in the United States has a 5% to 10% lifetime risk of undergoing surgery for a suspected ovarian neoplasm, and within that group 13% to 21% will be diagnosed with a malignant lesion. A woman has a lifetime risk of 1 in 70 of developing ovarian cancer in her lifetime. Unfortunately, of the 22,430 new cases of ovarian cancer diagnosed in the United States, 65% to 70% are diagnosed in an advanced stage, with a survival rate of 30% to 55%. Obviously, early diagnosis of ovarian carcinoma is paramount. It will require more specific ancillary tests, physician suspicion, and patient education. The minimally invasive nature of laparoscopy can also play an important role in early diagnosis of ovarian malignancy.1-2

In the evaluation and subsequent management of an adnexal mass, age of the patient plays an important role. In the reproductive age, the majority of the ovarian lesions are benign, and conservative management with ovarian preservation is very important. In contrast, in the postmenopausal patients, malignant lesions are more frequent and adnexal removal is indicated. The differential diagnosis should include gynecologic and nongynecologic lesions both of the benign and malignant variety. In the gynecologic and benign subtypes, the following entities should be considered: simple ovarian cysts, endometriomas, mature teratomas, leiomyomas, tubo-ovarian abscesses, hydrosalpinx, paratubal cyst, ectopic pregnancy, serous and mucinous cystadenomas, just to mention a few. In the gynecologic malignant subtype, ovarian carcinoma should be considered. In the nongynecological benign subtype, the following entities should be considered: diverticular abscess, appendiceal abscess or mucocele, urological lesions such as pelvic kidney, ureteral diverticulum, and bladder diverticulum. In the nongynecologic malign subtype, the following entities should be considered: gastrointestinal carcinomas, retroperitoneal sarcomas, and metastatic lesions. Metastatic cancers from breast, colon, or stomach may first appear as adnexal masses.

Pelvic examination should be part of the clinical evaluation although it carries a very low sensitivity and specificity in the preoperative diagnosis of an adnexal mass. Pelvic examination coupled with transvaginal ultrasound greatly aids in the correct diagnosis of an adnexal mass. No alternative imaging modality has demonstrated a superior diagnostic sensitivity and specificity to transvaginal ultrasound. Although the only limitation of transvaginal ultrasound lies with its lack of specificity and low positive predictive value for cancer in the premenopausal group of patients; however, a mass that is less than 10 cm in diameter, unilateral, with smooth borders, no excrescences or solid parts, and no free fluid almost excludes the possibility of an ovarian malignancy.6

The measurement of CA-125 aids in the diagnosis of nonmucinous epithelial ovarian cancers, but it is of no value in the diagnosis of other type of ovarian malignancies.7 Measurement of β-hCG, L-lactate dehydrogenase (LDH), and AFP can be useful in the diagnosis of certain malignant germ cell tumors, while inhibin A and B can be markers for granulose cell tumors. CEA can be useful with endodermal sinus tumors and immature teratomas. CA-125 has a sensitivity of 61% to 90%, with a specificity of 71% to 93%, a positive predictive value of 35% to 91%, and a negative predictive value of 67% to 90%. Sensitive and specific methods for preoperative diagnosis of ovarian cancer would provide a rational basis for referral and timely treatment. Jacobs et al. proposed a risk of malignancy index (RMI) incorporating levels of CA-125, ultrasound findings, and menopausal status.4 An RMI of 200 or more has a sensitivity of 85% and a specificity of 97%.

The RMI = ultrasound (U) × menopausal status (M) × levels of serum CA-125.

Ultrasound determines the following five characteristics:

• Multiloculated cysts

• Evidence of solid areas

• Evidence of metastasis

• Presence of ascites

• Bilateral lesions

Ultrasound: points for U

0 points = no characteristics

1 point = 1 characteristic

3 points = 2 or more characteristics

M = 1 point for menopausal, 3 points for postmenopausal

Despite our best intentions and workup, an adnexal mass can be ultimately found to be malignant. We should be prepared to offer the patient an adequate and timely surgical staging and treatment. It is also appropriate to consider referring the patient with high probability of ovarian malignancy to a physician with advanced training in gynecologic cancer. The Society of Gynecologic Oncologists and American College of Obstetricians and Gynecologists have developed the following referral guidelines for a newly diagnosed pelvic mass.8

Premenopausal (age < 50 years)

• CA-125 levels greater than 200 U/mL

• Ascites

• Evidence of abdominal or distant metastasis (by results of examination or imaging study)

• Family history of breast or ovarian cancer (in a first-degree relative)

Postmenopausal (age > 50 years)

• Elevated CA-125 levels

• Ascites

• Nodular or fixed pelvic mass

• Evidence of abdominal or distant metastasis (by results of examination or imaging study)

• Family history of breast or ovarian cancer (in a first-degree relative)

Adnexal masses in pregnancy have an incidence of around 4%. This is a recent increase which might be attributable to the more liberal utilization of ultrasonography, and maybe ovulation induction. However, the great majority of adnexal masses in pregnancy will resolve spontaneously by 16 weeks’ of gestation. In approximately 1 in 1300 live births, an adnexal mass will require surgical management during pregnancy. It is estimated that 3% to 13% of persistent adnexal masses in pregnancy are found to be malignant. Indication for surgical management for a persistent adnexal mass in pregnancy includes the presence of a mass 6 cm or greater at 16 to 18 weeks’ of gestation or symptoms due to a mass during any time during pregnancy.9-13

The most frequent pathology is mature cystic teratomas (dermoids), and serous cystadenomas, followed by corpus luteum cysts, mucinous cystadenomas, paraovarian cysts, endometriomas, and malignancies. In the past, surgical management of an adnexal mass in pregnancy consisted solely of a laparotomy. Laparoscopy was considered a contraindication due to the unknown effects of pneumoperitoneum on the fetus and the gravid uterus. However, several studies comparing laparoscopy to laparotomy in pregnancy have shown no difference in fetal outcomes between the two surgical procedures. In animal studies, it seems that an intra-abdominal pressure of 20 mm Hg has no effect on fetal placental perfusion and pH. Human studies are not available. Because of the concern of pneumoperitoneum on the fetus and the gravid uterus, gasless laparoscopy might be a safer alternative. If fetal monitoring is requested, transvaginal fetal monitoring with ultrasound is an option. If fetal distress is detected, the intra-abdominal pressure is decreased and the patient is hyperventilated.9

Surgical Technique

Laparoscopic management of an adnexal mass requires the same intraoperative concerns as any other procedure, including proper positioning with appropriate stirrups, arms positioned to the side, insertion of a Foley catheter, and sturdy uterine manipulator if the patient is not pregnant. After the insertion of an umbilical port, inspection of the upper abdomen is carried out in order to exclude the possibility of metastatic lesions or any other pathology. The patient is then placed in a steep Trendelenburg position, and two 5-mm trocars are introduced at the level of the anterior and superior iliac spine and lateral to the inferior epigastric vessels. An irrigator is introduced through the ports in the lower abdomen and pelvic washings are obtained. Inspection of the pelvis is carried out.1

In cases of adnexal pathology, such as an ovarian tumor, ectopic pregnancy, and hydrosalpinx, which may be associated with complete or partial adnexal removal, evaluation of the opposite side is recommended. In this case the patient presents with a whitish mass involving the entire right ovary. The

mass is highly suggestive of a mature cystic teratoma (dermoid). No signs of malignancy were observed. Because of the location of uterus, involvement of the ovary, age of the patient, and the history of previous sterilization, it was decided to proceed with a right salpingo-oophorectomy. The course of the right ureter was visualized. The right fallopian tube was retracted with an atraumatic grasper and pulled toward the left side, placing the infundibular pelvic (IP) ligament under tension and away from the ureter. The IP ligament is desiccated with the bipolar forceps in three adjacent areas and transected in the middle. Through a blunt and sharp dissection and proper hemostatic technique, dissection is carried toward the proximal portion of the tube and the utero-ovarian ligament which is transected freeing the right adnexa (Figures 10–1 and 10–2).

The specimen is deposited in the cul-de-sac. There are several options for specimen removal including posterior colpotomy placement in an endoscopic bag with removal from the umbilicus or lower abdominal port and via a minilaparotomy. For the removal of the specimen through the lower ports, it is

Figure 10–1. The tube and ovary are removed by using bipolar cautery and then incising on the utero-ovarian ligament.

Figure 10–2. The infundibular ligament is then cauterized and divided, with care to identify the ureter.

necessary to increase the diameter of the port to 12 mm or greater. To adhere to the principle of minimally invasive surgery, I prefer to remove specimens or perform morcellation of specimens through the umbilical port which can be easily widened. I introduce a 5-mm laparoscope through the left lower port, and under direct visualization an endoscopic bag is introduced through the umbilical port and advanced toward the pelvis. The assistant grasps the specimen and places it inside the bag which is closed and removed through the umbilicus.

The specimen can be decompressed by introducing a Veress needle attached to a syringe and aspirating the contents of the cyst, while the specimen sits inside the endoscopic bag thus preventing any spillage into the abdominal cavity.14-16 Alternatively, the endoscopic bag can be introduced through the posterior colpotomy incision placing the specimen in the bag and removing it through the vagina. A large mass might require decompression prior to removal in order to avoid gross contamination even in benign cases such as endometriomas or dermoid cysts. This can be accomplished by placing the specimen inside the bag and decompressing it with the suction irrigator probe, or by using endoscopic cyst aspirators. Any suspicious masses are sent for frozen section. Frozen section is a highly sensitive and specific test, except with very large masses.17-19

Comprehension Questions

10.1 An adnexal mass is diagnosed in a multiparous patient. Laparoscopic management is contemplated. Which of the following is more likely to indicate benign rather than a malignant process?

A. Septations

B. Size of 10 cm

C. Cystic mass

D. Papillations

10.2 A 28-year-old woman is noted to have a 12-cm adnexal mass. Which of the following tumor markers is most useful in this patient?

A. α-Fetoprotein

B. CEA

C. CA-125

D. CA-19-9

ANSWERS

10.1 C. A cystic mass is more likely associated with a benign process. Septations, complexities, solid component, larger size, ascites, and papillations are more indicative of a malignant process.

10.2 A. In a patient who is premenopausal, particularly less than age 30, germ cell tumors are likely. These tumor markers include AFP, hCG, and LDH.

Clinical Pearls

See Table 1-2 for definition of level of evidence and strength of recommendation

➤ The patient’s age together with the CA-125 and ultrasound characteristics of the adnexal mass can help to determine the likelihood of malignancy (Level B).

➤ Pregnancy is not a contraindication to laparoscopic ovarian surgery (Level B).

➤ A variety of techniques may be used to remove an adnexal mass laparoscopically such as through a colpotomy incision, with a specimen bag through the umbilical incision, or a lateral port incision (Level C).

REFERENCES

1. Papasakelariou C, Saunders D, De La Rosa A. Comparative study of laparoscopic oophorectomy. J Am Assoc Gynecol Laparosc. 1995;2(4):407-410. 

2. Dembo AJ, Davy M, Stenwig AE, et al. Prognostic factors with stage I epithelial cancer. Obstet Gynecol. 1990;75:263-273. 

3. Sevelda P, Dittrich C, Salzar H. Prognostic value of the rupture of the capsule in stage I epithelial ovarian carcinoma. Gynecol Oncol. 1989;35:321-322. 

4. Jacobs I, Oram D, Fairbanks J, et al. A risk of malignancy index incorporating Ca 125, ultrasound and menopausal status for the accurate preoperative diagnosis of ovarian cancer. Br J Obstet Gynaecol. 1990;97:922-929. 

5. National Institutes of Health Consensus Development Conference Statement. Ovarian cancer: screening, treatment, and follow up. Gynecol Oncol. 1994;55: S4-S14. 

6. Schutter EM, Kenemans P, Sohn C, et al. Diagnostic value of pelvic examination, ultrasound, and serum CA 125 in postmenopausal women with pelvic mass. An international multicenter study. Cancer. 1994;74:1398-1406. 

7. Maggino T, Gadducci A, D’Addario V, et al. Prospective multicenter study on CA 125 in postmenopausal pelvic masses. Gynecol Oncol. 1994;54:117-123. 

8. Manjunath AP, Pratapkumar, Sujatha K, et al. Comparison of three risks of malignancy indices in evaluation of pelvic masses. Gynecol Oncol. 2001;81:225-229. 

9. Yuen PM, Chang AMZ. Laparoscopic management of adnexal mass during pregnancy. Acta Obstet Gynecol Scand. 1997;76:173-176. 

10. Whitecar MC, Turner S, Higby K. Adnexal masses in pregnancy: a review of 130 cases undergoing surgical management. Am J Obstet Gynecol. 1999;181:19-24. 

11. Platek DN, Henderson CE, Goldberg GL. The management of a persistent adnexal mass in pregnancy. Am J Obstet Gynecol. 1995;173:1236-1240. 

12. Buttery BW, Beisner NA, Fortune DW, et al. Ovarian tumors in pregnancy. Med J Aust. 1973;1:345-349. 

13. Curet MJ, Voght DA, Schob O, et al. Effects of CO2 pneumoperitoneum in pregnant ewes. J Surg Res. 1996;63:339-344. 

14. Higgens RV, Matkins JF, Marroum MC. Comparison of fine needle aspiration cytologic findings of ovarian cysts with ovarian histologic findings. Am J Obstet Gynecol. 1999;180:550-553. 

15. Mulvany NJ. Aspiration cytology of ovarian cysts and cystic neoplasms. A study of 235 aspirates. Acta Cytol. 1996;40:911-920. 

16. Vercellini P, Oldani S, Felicette I, et al. The value of cyst puncture in the differential diagnosis of benign ovarian tumors. Hum Reprod. 1995;10:1465-1469. 

17. Smorgick N, Barel O, Halperin R, Schneider D, Pansky M. Laparoscopic removal of adnexal cysts: is it possible to decrease inadvertent intraoperative rupture rate? Am J Obstet Gynecol. 2009 Mar;200(3):237.e1-3. 

18. Whiteside JL, Keup HL. Laparoscopic management of the ovarian mass: a practical approach. Clin Obstet Gynecol. 2009 Sep;52(3):327-334. 

19. Tinelli R, Malzoni M, Cosentino F, et al. Feasibility, safety, and efficacy of conservative laparoscopic treatment of borderline ovarian tumors. Fertil Steril. 2009 Aug;92(2):736-741 [Epub 2008].

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