Adnexal Mass In Pregnancy

1. Adnexal Mass In Pregnancy Gari Gynecologic Oncology

2. Incidence: 1:200 pregnancies. • 1:1000 F will undergo lap. For pelvic mass. • Increased detection (U/S). • The commonest are - Teratomas - Cysadenomas - Functional / C. Luteum • 5% of adnexal masses are malignant. • Ovarian cancer incidence 1:70 F. • 1:25000 deliveries (1:800 adnexal masses).

3. Ovarian Malignancies in Pregnancy: • Germ cell tumors (45%) : Dysgerminoma . • Epithelial tumors (37.5%), especially LMP tumor. • Sex cord–stromal tumors (10%) • Miscellaneous pathologies (7.5%) Solid Tumors In Pregnancy: Luteoma, Fibroma, Mature cystic teratomas and Krukenberg tumor.

4. Investigations: • U/S (30% PPV) • +/- MRI • Size • Unilateral/Bilateral • Locularity/Septations • Simple/Complex • Papillary Excrescence / nodules • Omental disease/ascites • RI

5. Tumor markers: • Ca-125 : • LDH • Alk. Phos. • HCG • AFP • Inhibin • Others (Ca 15-3, Ca 19-9, CEA).

6. Potential complications • Torsion (ante / post partum) occurs in < 7 %, it is higher in teratoma (19%). • Rupture. • Hemorrhage. • Obstruction during labor. • Suspicion of malignancy.

7. Management - Obstetrician / MFM + Gyn Onc. + Neonatologist - The mother is always first priority (role #1). Factors affects your management: • GA. • U/S / MRI appearance. • Size + interval change over time. • Symptoms.

8. A- Adnexal mass Non Reassuring appearance: B- Adnexal mass with Reassuring appearance: * reproductive age group • Non pregnant patient / a symptomatic : • Pregnant patient / a symptomatic : • if < 5 cm observe (80-90% may resolve) • If > 5 cm operate … when ??? • (14 – 16 weeks)

9. Corpus luteum support (8-10 weeks). • Risk of SAB is up to 18% (1st trimester). • Reduced risk to 4-5% if done after 14 weeks. • Consider progesterone supplement (PV/IM). • Consider steroids in elective surgery (24-34weeks) • Emergency Sx. Is associated with worse pregnancy out come. • Always explain the risk/complications to the patient.

10. Maternal & Fetal risks: • fetal organogenesis are first trimester events. • Newer inhalational anesthetic agents are not teratogenic. • Regional anesthesia is preferred during pregnancy. • Preterm labor (up to 9%) during the 3ed trimester. • Erroneous causal associations in the patient's mind between surgery/anesthetic agents and common first trimester adverse outcomes ( eg, miscarriage, vaginal bleeding, structural anomalies )

11. Relative incompetence of the GE sphincter increases the risk for pulmonary aspiration (Aspiration Pneumonia). • The basal metabolic rate and functional residual capacity thus hypoxemia is likely to develop rapidly during the period of apnea (induction of GA). • Minute ventilation by 50%. • TV • Expiratory reserve volume and residual volume • RR • Forced expiratory volume (FEV1)

12. Supine hypotensive syndrome (15 deg. Lateral tilt) • VTE disease. • Other surgical risks (bleeding, infection, visceral injuries). Operative Techniques: • Always document fetal viability before and after SX. • Cont. FHM/Toco if possible (intra-op) & RR. • If non reassuring FH consider : • Check the position. • Maintaining maternal normocarbia. • Correct hypovolemia. • Increase maternal inspired oxygen concentration.

13. Be prepared to perform an emrg. C/S if needed. A - Laparoscopy : • Is an option (not the standard of care). • Experienced surgeon, difficult exposure, potential for conversion, avoid it if ?? Malignant. • It mandates GA. • Avoid pneumo-peritomium > 15 mmHg. B - Laparotomy: • Midline / Good exposure (easy to extend). • Easy to do full staging (if needed). • Always explore other organs.

14. Avoid uterine manipulation. • Limit your excision/resection • Avoid aspiration/drainage only. • Adnexal mass discovered during C/S should be removed. • Biopsy the contralateral ovary if abnormal. • Laparotomy is NOT CI to vaginal Delivery. • Prophylactic tocolytics : ??? • Post op. : Opiates and antiemetics. • NSAID : should be avoided, especially after 32 weeks.

15. Post operative management: • 1 - Germ cell tumors: BEP / ?? Rad therapy • 2 - Epithelial tumors: Carbo / Taxol 2&3ed T • 3 - Tumor of LMP : depend on the implants. • Most of the chemotherapeutic agents are class -D

16. Radiation During Pregnancy

17. 1 Gy = 100 rad • 1 cGy = 1 rad • Threshold below which no effects are seen. if it is < 5 rads • No increased risk of any adverse effects other than slight risk of leukemia at <5 rads. • Gross congenital malformations will not be increased at doses <20 rads.

18. 8 -25 weeks • Greatest Risk • Organogenesis • Affected cells once destroyed can not be replaced---microcephaly • Threshold 12 rad 8-15 weeks • Threshold 21 rad at 16-25 weeks

19. Adverse Effects • Threshold phenomena in order of frequency: • Growth Retardation • Microcephaly • Mental Retardation • Microphthalmia • Pigment changes in the retina • Genital and skeletal abnormalities • Catarct • Abortion • Non-threshold phenomena: • Carcinogenesis • Dental Radiography may be associated with LBW

24. Cervical Cancer in Pregnancy

25. Staging • Clinical staging. • Permitted exam. / inv. : Inspection. IVP. Palpation. CXR. Colposcopy. Proctoscopy (+/- Bx). ECC. Cystoscopy (+/- Bx). Conization (Coin). Hysteroscopy.

26. Staging (cont’d) Optional investigations ( for treatment plan ): • Lymphangiography. • Art./Venography. • Laparoscopy. Non pregnant F. • LN-FNA. • CT , US. • MRI (in pregnancy) Spread beyond the CX. Determine tumor size. LN involvement.

27. Optional investigations , Pathological findings and report : Should not change your clinical staging

28. RT is an option for non Sx candidates. • Similar out come but with morbidity: • Bowel • Bladder Atrophy. • Vaginal Fibrosis. Stenosis.

29. High risk or Low risk cervical ca is it important to know ??? Post op. treatment plan: • No adjuvant treatment ? • Radiation therapy ? • Chemo-Radiation (Cisplatin +/- 5FU) ?

30. Small Field Pelvic RT

31. Standard field vs. Small field RT

32. Teletherapy (External beam) - Small Field RT. - Standard Field RT. - Extended Field RT. • Brachytherapy- Intracavitary. - Interstitial.

33. Brachytherapy: • HDR : > 1200 cGy • MDR : 200 – 1200 cGy • LDR : 40 – 200 cGy • PDR : pulses over 30 hrs.

34. Commonly used points in Rad. Onc: Point A: • originally defined by Manchester system as a point 2 cm above the lateral fornix and 2 cm lateral to the cervical canal representing the crossing of the ureter and uterine artery (parametriem) • more currently defined as 2 cm lateral and 2 cm superior to the cervical os.

35. Point B • Defined by Manchester system as a point at the same level as point A and extending 5 cm lateral to midline representing the obturator nodes. Point P: • Defined by Fletcher system as a point 2 cm superior to the lateral fornix and 6 cm lateral to midline representing the pelvic sidewall

36. Commonly used points in Rad. Onc.

37. Extended Field RT. • Para aortic LN mets is 30% in stage III compared with 7% in stage IB. • superior border is T12 – L1 interspace, and width is 10 cm. • RTOG reported a significant improvement in 5y survival for pts who had EFRT compared with had standard field RT (66% vs. 55%).

38. Thank you

42. Causes of elevated Ca-125