Case Conference November 22nd 2017

22-Nov-2017, Divisi Ginekologi Onkologi RSCM

Morphologic features to distinguish between benign and malignant ovarian mass 

Introduction

Adnexal masses may be detected during prenatal ultrasound, and ovarian cancer may be suspected during pregnancy. Even though such masses are rarely malignant (1/10,000 to 1/50,000 pregnancies), the possibility of borderline tumour or cancer must be considered. It is a common assumption by both patients and physicians that if an ovarian cancer is diagnosed during pregnancy, treatment necessitates sacrificing the well-being of the fetus. However, in most cases, it is possible to offer appropriate treatment to the mother without placing the fetus at serious risk.

The care of a pregnant woman with cancer involves evaluation of sometimes competing maternal and fetal risks and benefits. These recommendations attempt to balance these risks and benefits; however, they should be considered advisory and should not replace specific interdisciplinary consultation with specialists in maternal–fetal medicine, gynecologic oncology and pediatrics, as well as imaging and pathology, as needed.

Characterizing ovarian masses enables patients with malignancy to be appropriately triaged for treatment by subspecialist gynecological oncologists, which has been shown to optimize care and improve survival. Furthermore, correctly classifying benign masses facilitates the selection of patients with ovarian pathology that may either not require intervention, or be suitable for minimal access surgery if intervention is required. However, predicting whether a mass is benign or malignant is not the only clinically relevant information that we need to know before deciding on appropriate treatment. Knowing the specific histology of a mass is becoming of increasing importance as management options become more tailored to the individual patient.

 

Case Illutsration

Mrs. 29 years old, G2P1, underwent a laparotomy left salpingo-oophorectomy due to large left mucinous ovarian carcinoma in 16 weeks pregnancy. She suffered from abdominal enlargmenet and distention, larger than the gestational age. She hasn’t feel the fetal movement, but the abdomen was getting larger rapidly in the last 2 month. On ultrasound examination, we revealed uterus wih 16 weeks intrauterine fetus, and we found cystic unilocular mass with solid part sized 188x147x214mm with volume 3500cc. Due to large and rapid growing mass, we did laparotomy left salpingo oophorectomy.

 

Clinical question

P (patients)                   : Women with adnexal mass

I (intervention)             : Cystic mass with solid part in US findings

C (comparison)                        : Morphometric changes (Solid part, papillary growth, ascites and septa) in

US findings

O (objective)                : Malignancy confirmed with histopathology result

 

The clinical questions are

·         How to differenciate benign and malignant ovarian mass from its morphologic findings by ultrasound examination

·         How to do concervative surgical staging in pregnancy for the epithelial and nonepithelial ovarian malignancy?

·         How is the management after delivery?

 

METHODS

Search strategy

We conducted the literature searching on November 19^th 2017 on the Cochrane Library®, Embase ® PubMed® with the combination of keywords of “unilocular solid mass”, and “ovarian cancer in pregnancy”. Reference lists of relevant articles were searched for other possibly relevant trials. Studies about multilocular mass, solid mass and in menopausal women were not included. Surgery was done under 120days after sonography result.

 

Selection

First selection was done by screening the study title and abstract.. Three article were available as full text and included in our analysis.

 

Critical appraisal

Appraisal of three retrospective studies involving women done trasvaginal ultrasound, diagnosed with unilocular cyst with solid part, then underwent surgery (at any types) then the histopathology result came out to be malignant. The quality of study were evaluated using appraisal form developed by Center of Evidence Based Medicine, University of Oxford, available from http://www.cebm.org.

 

 

RESULT

We included three studies in our appraisal. All studies were retrospective studies and included due to suspectec benign mass on ultrasound, but the histopathology result came out to be malignant. From 1 study, the sensitivity of unilocular and solid part findings to be malignancy is 100% due to large variety of samples. Another one also has sensitivity 100% with false positive 34% due to uniloculer

with solid components, but has irregular surface on the solid component. The last study is the larger, including 1148 samples, they show that if only unilocular cyst with solid part, and no other morphometric findings, the risk to be malignant is only 1%.

 

 

 

 

 

 

	Population	Design	Intervention	Outcome
Fagotti, et al (2011)	Women aged ≤ 50 years with unilocular-solid adnexal masses with a maximum diameter ≤ 10 cm, undergoing surgery within 3 months from TVS, n = 51	Retrospective study	TVS, compared with histological result	Ovarian malignancy: Sensitivity 100%, specificity 74%, accuracy 77% distinguishing benign and BOT lesions from invasive carcinoma 95% CI = 0.046 to 1.575)
Alcazar , et al (2015)	Women with preoperative diagnosis of unilocular-solid cyst that underwent surgical removal, n = 91	Retrospective study	TVS compared with histopathological result	Ovarian malignancy Irregular surface of the solid component  identified 100% of malignant lesions with a false-positive  rate of 34%
Valentin, et al (2010)	Patients with an adnexal mass underwent transvaginal ultrasound examination between 1999 and 2007 and operated on within 120 days after the ultrasound examination, n =1148	Retrospective study	TVS compared with histopathological result	Ovarian Malignancy rate: 1%

 

 

 

 

DISCUSSION

We found the risk of malignancy in surgically removed adnexal lesions judged to be unilocular cysts at transvaginal scan to be 0.96%; it was 0.54% in premenopausal women and 2.76% in postmenopausal women and the difference in malignancy rate between pre and postmenopausal women was statistically significant.  Hemorrhagic cyst contents on ultrasound increased the risk of malignancy, as did a personal history of ovarian or breast cancer. However, seven of the 11 malignant cysts described as unilocular on ultrasound proved to contain papillary projections or other solid components at macroscopic inspection of the corresponding surgical specimen by the pathologist.

 

In this study, we found morphometric changes that is recorded in ultrasound tend to be benign, but the pathology result unexpectedly came out malignant. So we try to find out whether only solid part found in unilocular mass can predict the malignancy. The result came out that it only has 1& changes even less to be malignant if we only found unilocular solid mass.

 

Although the occurrence of ovarian masses in pregnancy is relatively common, the majority of them is functional and resolve spontaneously; nevertheless, ovarian cancer is the fifth most common malignancy diagnosed in pregnancy. If malignancy is suspected, treatment should be decided on the basis of gestational age, stage of the disease and patient preferences. The management also depends on the type of malignancy.

            In pregnancy we can do conservative staging and in this case we can wait until delivery and continue to work up for reccurency  after delivery. On many literature also stated that we will do the restaging or chemotherapy after the delivery.

 

Conclusion

We shound chenk for complete morphologic changes on sonography, because solid part only cannot predict the risk of malignancy. We shout do the doppletr, find whether any septa, papillary growth and also the ascites. The complete morphometric index give better outcomes for predicting malignant ovarian mass

 

 

 

 Morphologic features to distinguish between benign and malignant ovarian mass

Finna Hardjono, Kartiwa Hadi Nuryanto

 

Introduction

Adnexal masses may be detected during prenatal ultrasound, and ovarian cancer may be suspected during pregnancy. Even though such masses are rarely malignant (1/10,000 to 1/50,000 pregnancies), the possibility of borderline tumour or cancer must be considered. It is a common assumption by both patients and physicians that if an ovarian cancer is diagnosed during pregnancy, treatment necessitates sacrificing the well-being of the fetus. However, in most cases, it is possible to offer appropriate treatment to the mother without placing the fetus at serious risk.

The care of a pregnant woman with cancer involves evaluation of sometimes competing maternal and fetal risks and benefits. These recommendations attempt to balance these risks and benefits; however, they should be considered advisory and should not replace specific interdisciplinary consultation with specialists in maternal–fetal medicine, gynecologic oncology and pediatrics, as well as imaging and pathology, as needed.

Characterizing ovarian masses enables patients with malignancy to be appropriately triaged for treatment by subspecialist gynecological oncologists, which has been shown to optimize care and improve survival. Furthermore, correctly classifying benign masses facilitates the selection of patients with ovarian pathology that may either not require intervention, or be suitable for minimal access surgery if intervention is required. However, predicting whether a mass is benign or malignant is not the only clinically relevant information that we need to know before deciding on appropriate treatment. Knowing the specific histology of a mass is becoming of increasing importance as management options become more tailored to the individual patient.

 

Case Illutsration

Mrs. 29 years old, G2P1, underwent a laparotomy left salpingo-oophorectomy due to large left mucinous ovarian carcinoma in 16 weeks pregnancy. She suffered from abdominal enlargmenet and distention, larger than the gestational age. She hasn’t feel the fetal movement, but the abdomen was getting larger rapidly in the last 2 month. On ultrasound examination, we revealed uterus wih 16 weeks intrauterine fetus, and we found cystic unilocular mass with solid part sized 188x147x214mm with volume 3500cc. Due to large and rapid growing mass, we did laparotomy left salpingo oophorectomy.

 

Clinical question

P (patients)                   : Women with adnexal mass

I (intervention)             : Cystic mass with solid part in US findings

C (comparison)                        : Morphometric changes (Solid part, papillary growth, ascites and septa) in

US findings

O (objective)                : Malignancy confirmed with histopathology result

 

The clinical questions are

·         How to differenciate benign and malignant ovarian mass from its morphologic findings by ultrasound examination

·         How to do concervative surgical staging in pregnancy for the epithelial and nonepithelial ovarian malignancy?

·         How is the management after delivery?

 

METHODS

Search strategy

We conducted the literature searching on November 19^th 2017 on the Cochrane Library®, Embase ® PubMed® with the combination of keywords of “unilocular solid mass”, and “ovarian cancer in pregnancy”. Reference lists of relevant articles were searched for other possibly relevant trials. Studies about multilocular mass, solid mass and in menopausal women were not included. Surgery was done under 120days after sonography result.

 

Selection

First selection was done by screening the study title and abstract.. Three article were available as full text and included in our analysis.

 

Critical appraisal

Appraisal of three retrospective studies involving women done trasvaginal ultrasound, diagnosed with unilocular cyst with solid part, then underwent surgery (at any types) then the histopathology result came out to be malignant. The quality of study were evaluated using appraisal form developed by Center of Evidence Based Medicine, University of Oxford, available from http://www.cebm.org.

 

 

RESULT

We included three studies in our appraisal. All studies were retrospective studies and included due to suspectec benign mass on ultrasound, but the histopathology result came out to be malignant. From 1 study, the sensitivity of unilocular and solid part findings to be malignancy is 100% due to large variety of samples. Another one also has sensitivity 100% with false positive 34% due to uniloculer

with solid components, but has irregular surface on the solid component. The last study is the larger, including 1148 samples, they show that if only unilocular cyst with solid part, and no other morphometric findings, the risk to be malignant is only 1%.

 

 

 

 

 

 

	Population	Design	Intervention	Outcome
Fagotti, et al (2011)	Women aged ≤ 50 years with unilocular-solid adnexal masses with a maximum diameter ≤ 10 cm, undergoing surgery within 3 months from TVS, n = 51	Retrospective study	TVS, compared with histological result	Ovarian malignancy: Sensitivity 100%, specificity 74%, accuracy 77% distinguishing benign and BOT lesions from invasive carcinoma 95% CI = 0.046 to 1.575)
Alcazar , et al (2015)	Women with preoperative diagnosis of unilocular-solid cyst that underwent surgical removal, n = 91	Retrospective study	TVS compared with histopathological result	Ovarian malignancy Irregular surface of the solid component  identified 100% of malignant lesions with a false-positive  rate of 34%
Valentin, et al (2010)	Patients with an adnexal mass underwent transvaginal ultrasound examination between 1999 and 2007 and operated on within 120 days after the ultrasound examination, n =1148	Retrospective study	TVS compared with histopathological result	Ovarian Malignancy rate: 1%

 

 

 

 

DISCUSSION

We found the risk of malignancy in surgically removed adnexal lesions judged to be unilocular cysts at transvaginal scan to be 0.96%; it was 0.54% in premenopausal women and 2.76% in postmenopausal women and the difference in malignancy rate between pre and postmenopausal women was statistically significant.  Hemorrhagic cyst contents on ultrasound increased the risk of malignancy, as did a personal history of ovarian or breast cancer. However, seven of the 11 malignant cysts described as unilocular on ultrasound proved to contain papillary projections or other solid components at macroscopic inspection of the corresponding surgical specimen by the pathologist.

 

In this study, we found morphometric changes that is recorded in ultrasound tend to be benign, but the pathology result unexpectedly came out malignant. So we try to find out whether only solid part found in unilocular mass can predict the malignancy. The result came out that it only has 1& changes even less to be malignant if we only found unilocular solid mass.

 

Although the occurrence of ovarian masses in pregnancy is relatively common, the majority of them is functional and resolve spontaneously; nevertheless, ovarian cancer is the fifth most common malignancy diagnosed in pregnancy. If malignancy is suspected, treatment should be decided on the basis of gestational age, stage of the disease and patient preferences. The management also depends on the type of malignancy.

            In pregnancy we can do conservative staging and in this case we can wait until delivery and continue to work up for reccurency  after delivery. On many literature also stated that we will do the restaging or chemotherapy after the delivery.

 

Conclusion

We shound chenk for complete morphologic changes on sonography, because solid part only cannot predict the risk of malignancy. We shout do the doppletr, find whether any septa, papillary growth and also the ascites. The complete morphometric index give better outcomes for predicting malignant ovarian mass

 

 

 

 

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