Complex Adnexal Mass Research Articles

Study of ectopic pregnancy in reference to diagnostic and treatment modalities

Introduction: An ectopic pregnancy occurs when a fertilized ovum implants outside the normal uterine cavity. It is the most important cause of maternal mortality and morbidity in the first trimester. Our aim is to explore the role of various diagnostic aids and treatment modalities in suspected & unusual cases. Materials & methods: Department of Obstetrics & Gynaecology, Sri Aurobindo medical college & post graduate institution, Indore, MP from April 2014 to July 2015. All patients included in the study were diagnosed with ectopic pregnancy, in reproductive age group of 15-49 years. Total 50 patients participated in the study. A pre structured and pre tested questionnaire was used to know age, parity, risk factors & modes of presentation of ectopic pregnancy. Result: Urine pregnancy test was positive in 45 (90%) of the cases. Ultrasonography diagnosed complex adnexal mass in 94% of the patients. Periodic Serum β-hCG done in 10 (20%) cases, The commonest site of ectopic pregnancy was fallopian tube in 48(96%) cases. Salpingectomy was the most commonly performed radical surgery (74%cases).Medical management was successful in 66.6% cases. Laparoscopic management was successful in 84.61% cases. Conventional Laparotomy was successful in 100% cases.74% patients had undergone salpingectomy, among which 20%) cases were successfully managed by laparoscopy, whereas 8% cases were successfully managed by methotrexate. 82% cases required blood transfusion. Significant anaemia (Hemoglobin <8g%) in 30 (60%) patients and Blood transfusions in 41 (82%) cases Conclusion: early diagnosis using various methods and management & treatment plan governs the outcome in case of ectopic pregnancy

Quantifying tumor vascular heterogeneity with DCE-MRI in complex adnexal masses: A preliminary study.

To evaluate the value of quantifying dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) heterogeneity to characterize adnexal masses. Our database was retrospectively queried to identify all surgically proven adnexal masses characterized with a 1.5T DCE-MRI between January 1st 2008 and February 28th 2010 (n = 113 masses, including 52 benign, 11 borderline, and 50 invasive malignant tumors). The solid component of the adnexal mass was segmented. Quantitative analysis with a compartmental model was performed to calculate microvascular parameters, including tissue blood flow (FT ), blood volume fraction (Vb ), lag time (DAT ), interstitial volume fraction (Ve ), permeability-surface area product (PS), and relative area under curve (r AUC), were calculated. Then heterogeneity parameters were evaluated using the analysis of the evolution of the standard deviation (SD) of signal intensities on DCE-MRI series. The area under the receiver operating characteristic (AUROC) curve was calculated to assess the overall discrimination of parameters. Malignant tumors displayed higher FT , Vb , and r AUC and lower DAT than benign tumors (P = 0.01, P < 0.0001, and P < 0.0001, respectively). Invasive malignant tumors displayed lower Vb and r AUC than borderline tumors (P < 0.01). After injection, whenever the heterogeneity parameter was considered, malignant tumors were more heterogeneous than benign tumors, invasive tumors were more heterogeneous than borderline ovarian tumors, and malignant tumors with carcinomatosis were more heterogeneous than tumors without carcinomatosis (P < 0.001). The most discriminant parameter was the SD during the 90 seconds after injection related to arterial input function (ΔSDEARLY/AIF ) with an AUROC between 0.715 and 0.808. This study proposes heterogeneity parameters as a new tool with a potential for clinical application, given that the technique uses routine imaging sequences. 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2017;46:1776-1785.

Validación de criterios ecográficos IOTA (International Ovarian Tumor Analysis Group) para caracterizar masas anexiales y determinar riesgo de malignidad en un grupo de mujeres con sospecha de cáncer de ovario

Epithelial carcinoma of the ovary is a gynecological malignancy associated with high mortality&#x0D; rate due to diagnosis in advanced stages, which occurs in more than 75% of the cases.&#x0D; Recent strategies in reducing mortality have been studied, however screening tests have not&#x0D; demonstrated to help in the diagnosis at early stages. Subjective impression of the examiner&#x0D; using transvaginal ultrasound is considered the best method to discriminate between benign&#x0D; and malignant adnexal tumors. The International Ovarian Tumor Analysis Group (IOTA) based&#x0D; on ultrasound features of the adnexal masses, has developed robust rules and prediction&#x0D; models that can be used by different examiners in various clinical settings.In Chile during&#x0D; 2012, national guidelines about epithelial ovarian cancer were published, establishing referral&#x0D; and management criteria. Little mention about ultrasound exam was included: all “solid&#x0D; tumors or complex adnexal masses” are sonographic criteria to refer patients to gynecologic&#x0D; oncology units. Considering that many functional or benign pathologies can be classified as&#x0D; “complex tumors”, it is important to use validated prediction models to improve accuracy of&#x0D; ultrasonography and therefore optimize the referral to gynecological oncologists and avoid&#x0D; surgeries of misclassified adnexal pathologies.

Role of Imaging in Fertility-sparing Treatment of Gynecologic Malignancies.

Treatments for gynecologic cancer usually result in loss of fertility due to surgery or radical radiation therapy in the pelvis. In countries with an established screening program for cervical cancer, the majority of gynecologic malignancies occur in postmenopausal women. However, a substantial number of affected women are of childbearing age and have not completed their families. In these younger women, consideration of fertility preservation may be important. This article describes the fertility-sparing treatment options that are currently available and outlines the role of imaging in the selection of eligible patients on the basis of a review of the literature. In the setting of cervical cancer, magnetic resonance (MR) imaging is used to delineate the size, position, and stage of the tumor for selection of patients who are suitable for radical trachelectomy. In patients with solitary complex adnexal masses, diffusion- and perfusion-weighted MR imaging sequences are used to categorize the likelihood of invasive or borderline malignancy for consideration of unilateral ovarian resection, with fertility preservation when possible. In patients with endometrial cancer, MR imaging is used to rule out signs of invasive disease before hormone therapy is considered. Imaging is also used at patient follow-up to detect recurrent disease; however, evidence to support this application is limited. In conclusion, imaging is an essential tool in the care of patients with gynecologic malignancies who are considering fertility-preserving treatment options. ©RSNA, 2016.

Indeterminate but Likely Unimportant Extracolonic Findings at Screening CT Colonography (C-RADS Category E3): Incidence and Outcomes Data From a Clinical Screening Program.

The purpose of this study was to analyze the incidence and outcomes of unsuspected indeterminate but likely unimportant extracolonic findings (CT Colonography Reporting and Data System [C-RADS] category E3) at screening CT colonography (CTC). Over 99 months (April 2004 through June 2012), 7952 consecutive adults without symptoms of colorectal cancer (4277 women, 3675 men; mean age ± SD, 56.7 ± 7.3 years) underwent first-time screening CTC. Findings prospectively placed into C-RADS category E3 were retrospectively reviewed, including follow-up (range, 2-10 years) and ultimate clinical outcome. Unsuspected C-RADS category E3 extracolonic findings were detected in 9.1% (725/7952) of our patient population. A total of 751 category E3 findings were detected among these 725 patients; 25 patients had multiple findings. Commonly involved organ systems included gynecologic (24.4%, 183/751), genitourinary (20.9%, 157/751), lung (20.6%, 155/751), and gastrointestinal (16.1%, 121/751). Consideration for further imaging, if clinically warranted, was suggested in 83.8% (608/725). Sixty-five patients were lost to follow-up. Conditions requiring treatment or surveillance were ultimately diagnosed in 8.3% (55/660), including eight malignant neoplasms. In the remaining 605 patients, 25 (4.1%) underwent invasive biopsy or surgery to prove benignity (including 18 complex adnexal masses), and 278 (46.0%) received additional imaging follow-up. Indeterminate but likely unimportant extracolonic findings (C-RADS category E3) occurred in less than 10% of adults without symptoms of colorectal cancer who underwent screening CTC. Over 90% of these findings ultimately proved to be clinically insignificant, with fewer than 5% requiring an invasive procedure to prove benign disease, the majority of which (> 70%) were complex adnexal lesions in women.

Semiquantitative dynamic contrast-enhanced MRI for accurate classification of complex adnexal masses.

To identify the best dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) descriptive parameters in predicting malignancy of complex ovarian masses, and develop an optimal decision tree for accurate classification of benign and malignant complex ovarian masses. Preoperative DCE-MR images of 55 sonographically indeterminate ovarian masses (27 benign and 28 malignant) were analyzed prospectively. Four descriptive parameters of the dynamic curve, namely, time-to-peak (TTP), wash-in-rate (WIR), relative signal intensity (SIrel ), and the initial area under the curve (IAUC60 ) were calculated on the normalized curves of specified regions-of-interest (ROIs). A two-tailed Student's t-test and two automated classifiers, linear discriminant analysis (LDA) and support vector machines (SVMs), were used to compare the performance of the mentioned parameters individually and in combination with each other. TTP (P = 6.15E-8) and WIR (P = 5.65E-5) parameters induced the highest sensitivity (89% for LDA, and 97% for SVM) and specificity (93% for LDA, and 100% for SVM), respectively. Regarding the high sensitivity of TTP and high specificity of WIR and through their combination, an accurate and simple decision-tree classifier was designed using the line equation obtained by LDA classification model. The proposed classifier achieved an accuracy of 89% and area under the ROC curve of 93%. In this study an accurate decision-tree classifier based on a combination of TTP and WIR parameters was proposed, which provides a clinically flexible framework to aid radiologists/clinicians to reach a conclusive preoperative diagnosis and patient-specific therapy plan for distinguishing malignant from benign complex ovarian masses. 2 J. Magn. Reson. Imaging 2017;45:418-427.

Assessment of General MRI, Morphological and Signal Characteristics of Benign and Malignant Ovarian Tumors

Introduction: Characterization of an ovarian mass is of the utmost importance in the preoperative evaluation of an ovarian neoplasm. In view of this, present study was carried to evaluate the diagnostic accuracy of diffusion weighted MRI in differentiating pathologically confirmed benign and malignant ovarian masses. Material and Methods: This hospital based observational descriptive study comprised of 50 patients diagnosed with ovarian masses clinically or on ultrasonography were evaluated with pelvic MRI. Statistical Analysis was done using IBM SPSS Statistics 21. Surgical pathological findings were used as the reference standard for assessment of ovarian tumors. Non-parametric MRI variables were analyzed using Chi square test or Fischer’s exact test, whichever was applicable. P value of less than 0.05 was considered for statistical significance. Results: There was no difference in maximal diameter between benign (82.5±41.23mm) and malignant (96.3±28.17) adnexal masses. Low signal intensity of solid component on T2W and DW Images was more frequent in benign masses than in malignant masses (p value = 0.002 and 0.001 respectively). Conclusion: The most significant criteria for predicting malignancy were intermediate T2 and high DW signal (PLR = 4.33) followed by papillary projections (PLR = 3.89). Our study demonstrated that diffusion-weighted MR imaging (DWI) combined with classical T2-weighted imaging is an accurate tool to assess the nature of complex adnexal masses depicted by ultrasonography (US).

Ovarian Torsion-A Rare Presentation in Immune Thrombocytopenic Purpura

Idiopathic thrombocytopenic purpura (ITP) is an immune-mediated disorder that is caused by antibody mediated platelet destruction with a normal bone marrow. Bleeding manifestations are mostly muco-cutaneous and mild. Intra-ovarian bleeding leading to enlargement and subsequent torsion is extremely rare and only one case has been reported so far in literature. We describe a case of a 14 year old girl who presented in Medical Emergency with abdominal pain, vomiting and low grade fever. She was clinically observed for gastroenteritis as all her investigations were normal, except for ultrasound which depicted a mildly enlarged polycystic left ovary. On further continuation of symptoms, a repeat scan showed heterogeneous complex left adnexal mass. Color Doppler and MRI confirmed ovarian infarction. She was prepared for laparotomy but had very low platelet counts on pre-anesthetic checkup. With hematology consultation and bone marrow biopsy, a diagnosis of immune thrombocytopenic purpura was made. With initiation of prednisolone her counts improved dramatically and later laparotomy was done after 7 days. Histopathology specimen of ovary confirmed stromal hemorrhage and areas of necrosis. Intra-ovarian bleeding, possibly because of very low platelet count, resulting in an enlarged ovary and subsequent torsion might be the association between these two clinical entities.

Gonadal Imaging in Endocrine Disorders.

Ultrasound (US) is the most widely available method of diagnostic imaging for the evaluation and characterization of gonadal lesions and is usually the method of choice because of its high accuracy, low cost and wide availability. Today's high-resolution images allow for a confident diagnosis of many scrotal and adnexal lesions, with high sensitivity and specificity. Magnetic resonance imaging (MRI) is reliable in the detection of gonadal lesions in males, allowing the differentiation into testicular or nontesticular lesions, and their characterization. It is also an accurate and cost-effective diagnostic adjunct in those patients with solid scrotal lesions for whom the findings of clinical and US evaluations are inconclusive. In females, MRI is recommended as a second-line investigation for the characterization of complex adnexal masses that are indeterminate on US. In this review, gonadal pathologies related with the steroidogenic and gametogenic function of the testes and ovaries will be discussed. The main imaging features of benign and malignant lesions will also be presented.

Abdominal cocoon syndrome caused by Mycobacterium bovis from consumption of unpasteurised cow's milk

A 12-year-old girl presented to the emergency room with severe abdominal pain, non-bilious emesis, and a 3-month history of progressively worsening lower abdominal pain, malaise, night sweats, and 4 kg weight loss. She had emigrated from Iraq 2 years earlier, and had been fed cow’s milk—often taken directly from the udder—after birth because her mother was unable to breastfeed. In the emergency room, her lower abdomen was tender, without peritonitis, and distended. Her white blood cell count, erythrocyte sedimentation rate, and C-reactive protein concentration were raised, whereas tests for hepatitis A, B, and C, HIV, and tuberculosis were negative. MRI of her abdomen and pelvis revealed extensive thickening of the bowel mesentery, peritoneum, and greater omentum, with a complex right-sided adnexal mass (appendix). We did an exploratory laparotomy to assess the mass, and encountered a dense, thick rind of tissue that was studded with tubercles and encased the peritoneal cavity (fi gure). A diagnosis of abdominal cocoon syndrome was made, and the abdomen was closed due to the extreme diffi culty in separating the fi brotic tissue from the abdominal wall. Frozen-section biopsy samples revealed caseating granulomas consistent with tuberculosis. A culture of the peritoneal fl uid grew Mycobacterium bovis subspecies bovis after 4 weeks and was resistant to pyrazinamide. The girl stayed in hospital for 3 months because she had recurrent episodes of partial or complete bowel obstruction that resolved with conservative, non-operative management. She was given isoniazid, rifampicin, and moxifl oxacin for 6 months while in hospital, followed by isoniazid and rifampicin for a further 12 months. On her last follow-up visit, she was no longer receiving antibiotic therapy, and was functioning normally. No further surgical intervention was planned for her, even though a repeat MRI of her abdomen and pelvis continued to show the thickened peritoneum and adnexal mass.

Fertility preservation in gynaecologic malignancy: imaging role in treatment planning

Content organisation A significant number of women with gynaecological cancer are of childbearing age and have not completed their families. In these younger women, consideration of fertility-sparing options is very important. This poster will describe the fertility-sparing treatment options that are currently available and delineate the role of imaging in the selection of suitable patients. A review of the current literature will be presented to provide an evidence base. In cervix cancer, MRI is used to delineate the size, position and stage of the tumour for the selection of patients suitable for radical trachelectomy. In complex adnexal masses, MRI with diffusion and perfusion is used to categorise the likelihood of invasive or borderline malignancy in order to allow potential fertility preservation where possible. In endometrial cancer, MRI is used to rule out imaging signs of invasive disease prior to consideration of hormonal treatment. Imaging is also used in patient follow-up for the detection of recurrent disease. Each of these scenarios will be illustrated.

Benign lesions that mimic cancer: Ovarian

As ovarian masses are common in both pre- and in postmenopausal age, a life time risk of up to 5-10% to undergo pelvic surgery has been reported [1]. However, the likelihood of malignancy in these lesions is extremely low. Imaging, particularly, US and MRI, have been integrated as diagnostic tools to better define indications for adequate surgery and to guide referral to specialized centers. Imaging findings are assessed in the context with clinical data, patient history, age, and tumor markers. Furthermore, various risk assessment indices to predict malignancy have been established using clinical and/or imaging parameters. Advances in imaging including the combination of morphologic and functional parameters have further improved the diagnostic performance of MRI. Thus the majority of indeterminate masses on US and CT can be correctly diagnosed with MRI [2,3]. MRI is most beneficial in women with a low likelihood of cancer. Endometriomas, common mimicks of ovarian cancer in CT and US, display specific imaging findings in MRI. This is also true for subserous leiomyomas, which are often difficult to differentiate from solid ovarian masses in US. Meticulous analysis of anatomical landmarks and displacement patterns aid in differentiation of benign extraovarian tumors, particulary of extraperitoneal origin, e.g of neurinomas, from ovarian cancer. Some complex cystic and solid adnexal masses may be challenging to differentiate from ovarian cancer. In these lesions integration of clinical findings will allow in most cases differentiation of benign lesions from cancer. Ovarian torsion, pelvic hematoma, and extrauterine pregnancy are typically associated with pelvic pain. Pain and inflammatory laboratory findings suggest tubo ovarian abscess (TOA). TOA may mimick ovarian cancer even in advanced imaging, including MRI and PET/CT. Aspergillosis, a subtype of TOA mimicks ovarian cancer due to its complex morphology and invasive growth pattern. Differentiation of peritoneal tuberculosis from advanced ovarian cancer is difficult and requires biopsy [4]. Ovarian pseudocysts and cystadenofibroma display typical findings in most cases. However, some of the benign pelvic lesions still present a diagnostic dilemma [5]. These include rare entities, e.g. atypical dermoids, monodermal dermoids, collision tumors, and sometimes also hemorrhage of functional cysts.

Robotic surgery in the management of benign complex adnexal masses with a frozen pelvis in women desiring to preserve fertility

Abstract Background: A “frozen pelvis” is a term often used to describe extensive pelvic adhesions. It is considered as one of the most challenging situations that a gynecologic surgeon can face. It commonly is caused by extensive endometriosis and pelvic inflammatory disease. We present two cases with extensive pelvic adhesive disease with the aim to illustrate the value of robotic assisted laparoscopy in the management of benign complex adnexal masses with severe pelvic adhesive disease in women desiring to preserve the fertility. Case 1: A 27 year old female referred to our clinic for evaluation of a complex left adnexal mass. Trans-vaginal ultrasound scan and an MRI suggested bilateral endometriomas. She was noted to have stage IV endometriosis. Da Vinci robot assisted left salpingo-oophorectomy was performed. Case 2: A 43 year old female presented with recurrent episodes of pelvic inflammatory disease following an unsuccessful in vitro fertilization procedure. A trans-vaginal ultrasound scan showed a complex left adnexal mass. She was noted to have extensive pelvic adhesions secondary to chronic pelvic inflammatory disease. Da Vinci robotic assisted left salpingectomy was performed, while preserving the left ovary. Conclusion: Our experience and review of literature suggest that in hands of an experienced surgeon, the inherent advantages of robotic assisted operative laparoscopy makes it a safe and attractive alternative to conventional operative laparoscopy and laparotomy for managing benign complex adnexal masses with concomitant severe pelvic adhesive disease in women desiring to preserve their fertility.

Indeterminate lesions in cancer (I): pelvic adnexal masses.

Ultrasound (US) is the primary imaging study of most women with pelvic symptoms and signs that suggest a gynaecological cause, and for the majority it defines the site and nature of any pelvic mass. The key clinical questions are (a) is there a mass and is it uterine or ovarian; (b) is it likely to account for the clinical presentation; (c) does it need removing and (d) if so, by simple resection or as part of cancer surgery? The principal concern is for ovarian cancer, which typically presents with advanced stage (FIGO III and IV) disease. For these women US confirms the presence of a complex adnexal mass, ascites and/or metastatic deposits in the peritoneum or viscera. When there are no features of peritoneal dissemination, assessment of the pelvic mass relies upon detailed morphological assessment using US, which is more reliable than Doppler US measurements in defining their nature. The early promise of Doppler US has not been realised[1]. A variety of morphological scoring systems are described[2,3]. Another scoring system combines US and CA-125 data to produce the risk of malignancy index (RMI). There is overlap in the scores of benign lesions such as dermoid tumours, inflammatory masses and endometriomas, which may be managed non-operatively, and malignancy. For these indeterminate masses MR imaging is superior to US in characterisation[4,5]. With MR imaging dermoid tumours or endometriomas can be confidently characterised using fat suppression sequences and by recognition of the appearances of haemorrhage. The importance of MR imaging is in averting unnecessary intervention for complex benign lesions. At other end of the spectrum, with overt and disseminated malignancy there is little doubt about the nature of the mass, and most women proceed to radical cytoreductive surgery. For women unfit for or beyond the scope of surgery, or with a history of a cancer whose metastases may mimic ovarian cancer (e.g. breast and GI tract), CT-guided biopsy provides a simple alternative to limited surgery or laparoscopy for obtaining a confident histological diagnosis[6]. Biopsy of omental cake, peritoneal or adnexal mass is possible. After surgery for ovarian cancer CT is widely used for monitoring chemotherapy, but this stems more from its use in clinical trials as a reproducible modality than from any evidence base. Another situation in which indeterminate lesions cause clinical concern is when the baseline post-surgical pre-chemotherapy examination reveals a pelvic mass but the surgeon reports complete resection. Here, resolution of uncertainty should be in the forum of a specialist multidisciplinary team meeting. Imaging has a role when management options would be altered by clarifying the nature of the mass. The distinction to be made is between residual cancer and a treatment complication[7]. The main imaging options for further assessment are MR imaging to distinguish haematoma from solid tumour and transvaginal US, which allows aspiration if infection is a clinical concern.

Recommendation Patterns Among Obstetrician–Gynecologists and Radiologists for Complex Adnexal Masses on Ultrasonography [370

Recommendation Patterns Among Obstetrician–Gynecologists and Radiologists for Complex Adnexal Masses on Ultrasonography [370

Vaginal Agenesis and Atresia of the Uterine Cervix Associated to Vestibular Fistula: Successful Staged Combined Laparoscopic and Perineal Approach Preserving the Uterus

Abstract Uterovaginal anomalies are a spectrum of anomalies, sometimes associated with anorectal malformations (ARM). Among them, atresia of the cervix uteri is a rare condition that represents a therapeutic dilemma. Aim: Show a successful staged laparoscopic treatment of a patient previously operated for an ARM with a nondiagnosed associated vaginal agenesis and atresia of the uterine cervix. Case: A 13-year-old female presented with severe acute pelvic pain. She had undergone an anorectoplasty through a posterior sagittal approach at the age of 2 with the diagnosis of a vestibular fistula. Although presenting normal puberal parameters, she had never had menses. No vaginal opening was found at a perineal examination. Ultrasonography showed a hematometra and a left complex adnexal mass. An initial laparoscopic approach showed a single uterus with a normal external appearance but distended with blood and left ovarian endometrioma and hematosalpinx that were removed and drained, respectively. As there was n...

Emergency Management of Heavy Uterine Bleeding in a Jehovas Witness

A 40 yr. old Jehovah’s Witness presented with acute blood loss secondary to heavy uterine bleeding. At admission hemoglobin was 5.0 mg/dl. She was treated with IV estrogen and crystalloid solutions. With unsuccessful medical management, refusal of transfusion of blood and consultation with anesthesia team, the decision was made to do endometrial curettage and thermal ablation under conscious sedation. The patient bleeding was controlled and her post-operative hemoglobin was 4.8 mg/dl. She was treated with human erythropoietin, oral iron, folic acid and vitamin B12. Later she underwent exploratory laparotomy for evaluation of her large complex adnexal mass. At the laparotomy lysis of adhesions, total abdominal hysterectomy, bilateral salphingooophorectomy and umbilical hernia repair was performed. The pathology of the mass was identified as tubo-ovarian abscess. Although endometrial ablation is usually done to avoid major surgery, it can be lifesaving in cases of hemodynamically unstable patients and special circumstances such as Jehovah as witnesses. Endometrial ablation usually provides long term treatment, however its use as a short term solution can be lifesaving.

Primary Fallopian Tube Clear Cell Adenocarcinoma in Pregnancy: Case Presentation and Review of the Literature

Primary fallopian tube cancer in pregnancy is rare and is even more so for the clear cell variant. Our case is the third case of primary fallopian tube cancer in pregnancy and the first case of clear cell adenocarcinoma of the fallopian tube in pregnancy. The patient presented with increasing pelvic pain starting in the second trimester. Serial ultrasound evaluations were performed and revealed a rapidly growing complex adnexal mass adjacent to the uterus. Her pregnancy was further complicated by spontaneous preterm labor and she delivered prematurely per vaginam at 31 weeks. She underwent an urgent laparotomy in the immediate postpartum period for acute aggravation of her right pelvic pain and fever. The diagnosis of tubal clear cell adenocarcinoma was subsequently made on histopathology examination.

Outcomes From Ultrasound Follow-up of Small Complex Adnexal Masses in Women Over 50

Objective The discovery of a complex adnexal mass in an older woman often raises concern for cancer. We evaluate outcomes for a large population-based cohort of women older than age 50 years with a small complex adnexal mass reported on ultrasound, without elevated CA125 or other evidence of malignancy, including time to detection of malignancy and stage at diagnosis for those initially observed. Study Design Women older than age 50 years who had an ultrasound during 2007-2011 reporting a complex adnexal mass 1-6 cm in size were identified. Previous or subsequent pelvic ultrasounds were reviewed to determine when the mass was first identified and whether there was change over time. Women with concurrent elevated CA125, evidence of metastatic disease, or less than 24 months of clinical follow-up were excluded. Surgical pathology from removal and diagnoses of ovarian cancer within 24 months of follow-up were identified. Results Among 1363 complex masses identified, 18 cancers or borderline tumors (1.3%; 95% confidence interval, 0.8–2.1%) were found. Six cases were diagnosed among 204 women who had immediate surgery after initial ultrasound (15%), and 12 additional cases were found among 994 women with at least 1 repeat ultrasound (73%). Growth was apparent on ultrasound by 7 months for all borderline and epithelial ovarian cancers. Of the 12 cases diagnosed during follow-up, 10 were found to be stage 1 at surgery. Conclusion Among isolated adnexal masses reported as complex and 1-6 cm on pelvic ultrasound in women older than 50 years, the overall risk of malignancy is low. All cases of epithelial cancer and borderline tumor demonstrated growth by 7 months of observation.

Robotic resection of bulky aorto-caval lymphadenopathy in a patient with serous fallopian tube carcinoma

Objective:Inpatientswithovarian/fallopiantube/primary peritoneal cancer, maximum surgical effort is aimed at complete cytoreduction as it results in longer overall survival [1]. In selected patients, achieving this goal with robotic-assisted surgery provides the patient with the benefits of minimally invasive surgery [2,3]. The authors present resection of bulky aorto-caval lymph nodes in a patient with serous fallopian tube cancer. Methods: A 51-year-old underwent robotic hysterectomy and bilateral salpingo-oopherectomy by her gynecologist for bilateral complex adnexal masses and leiomyomatous uterus. The findings were consistent with a high-grade serous carcinomaarising from the right fallopian tube. The tumor size was 7 × 1.7 cm and was metastatic to bilateral ovaries. Pelvic washings and lymphovascular invasion were negative. After the patient was referred to gynecologic oncology with these findings, enhanced computed tomography demonstrated 4.5 × 2 cm lymphadenopathy at the level of aortic bifurcation and 2.5 × 2 cm