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Adnexal Mass (Reproductive group)From: Geffrey H. Klein, MD (gklein@bcm.tmc.edu)Sun Jul 13 23:43:43 1997
This post is a summary of my attempt to outline a protocol for management of adnexal masses in reproductive age patients. I think we will agree that these are all patients under 45 years of age. Starting with ACOG's criteria for cystectomy for asymptomatic benign cyst in nonpregnant women of reproductive age a.Pelvic examination or ultrasound demonstrating a cystic mass that is 8 cm or larger b.Persistence of a cystic mass of 6 cm or larger for two cycles c.Presence of cystic mass that is multilocular or has solid components, as confirmed by ultrasound examination The above findings are an indication for operation rather than observation. Although it is stated in the criteria set that this is an indication for cystectomy, there should be some room for ovariectomy in some cases for the same indication. Due to many of these patient's desire to maintain reproductive capacity cystectomy is preferable, especially if there are bilateral masses. Cyst aspiration probably has no role and should be avoided. I propose that this group be called Reproductive, surgical. Pelvic examination in the operating room or within 24 hours prior to the procedure is required to confirm persistence or presence of mass. The surgical procedure can be chosen at the discretion of the surgeon, however, laparoscopic approach is encouraged due to decrease in hospital stay and length of disability. Surgeons not comfortable with this technique may be encouraged to enlist the help of a colleague, refer to another physician, or opt for laparotomy. Choice of incision for primary laparotomy? Any suggetions? Perhaps utilization of Lerner's weighted scoring system (1) 0 1 2 3 Wall Smooth or - solid or papillarities structure small irreg N/A > or = 3 mm < 3mm Shadowing yes no Septa none or Thick thin (> or (<3mm) 3mm) Echogenic sonolucent, Mixed or low-level, or high echogenic core The patients with scores 3 or greater might be considered for primary vertical skin incisions when primary laparotomy is chosen. Preoperative CA125 is not indicated to determine need for surgery due to the high false positive rate in the reproductive age group. (2) It is unclear to me if it is cost effective to get CA125 preop after determination of the need for surgery on another basis. Solid masses in this group should get tumor markers specific for germ cell tumors (AFP and HCG) (3) Preoperative doppler studies are still considered investigational due to variation in equipment and training. Historical factors like family or personal history of breast, colon, uterine, or ovarian cancers should be noted. Risk factors for the patient such as nulliparity, infertility, and delayed childbearing should be noted. Factors requiring conversion to laparotomy from laparoscopy include the usual complications of laparoscopy that require laparotomy and signs of malignancy. Signs of malignancy include excrescences on the surface of the ovary, ascites, dense ovarian adhesions, or diaphragm nodules. (4) In the absence of the above criteria, observation for 2 cycles is in order. The addition of oral contraceptives for patients without contraindications to their use should be strongly encouraged. I propose this group be called Reproductive, observation.
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