JI Reyes, R.

& JI Salvadora

ADNEXAL MASSES
CASE
General Data
Name: C.S.
Age: 40
Address: Intramuros, Manila
Religion: Roman Catholic
Occupation: Cashier
Civil Status: Married
Date of Interview: October 26, 2019
Date of admission: October 23, 2019
Chief complaint

Incidental finding of mass on the right ovary

 History of Present Illness

2 months PTC On the day of consult

• Incidental finding of mass on the • Patient sought second opinion at our
right ovary on TVS during an institution, hence consult
annual pap smear
• (+) Constipation
• No palpable abdominal mass,
abdominal pain, abnormal uterine
bleeding, fever, headache

5
 Transvaginal Ultrasound (Sept. 8, 2019)

Length Width AP Diagnosis

The cervix has homogenous stroma and
CERVIX 3.7 cm 3.6 cm 2.9 cm
endocervical canal
The uterus is anteverted with smooth contour and
UTERUS 6.0 cm 6.13 cm 4.10 cm
homogenous echo pattern
ENDOMETRIUM The endometrium is trilaminar measuring 0.71 cm. The subendometrial halo is intact.
The right ovary contains a cystic structure with
RIGHT OVARY hyperechoic nodules measuring 4.84 cm x 4.54
cm x 3.8 cm (vol. 43.68)

LEFT OVARY 2.96 cm 2.09 cm 1.83 cm The left ovary is normal in size and echotexture.

OTHERS There is no free fluid in the cul de sac.

6
Transvaginal Ultrasound (Sept. 8, 2019)

IMPRESSION:

Normal anteverted uterus with no myometrial lesions

Proliferative phase endometrium
To consider dermoid cyst, right ovary
Normal left ovary

7
Past Medical History

(+) Tuberculous cystic mass S/P I and D (-) Hypertension

(OMMC, 2005; completed 6 months of (-) Diabetes mellitus
treatment) (-) Pulmonary tuberculosis
(-) Bronchial asthma
(-) Allergies to food and drugs

8
Family History Personal & Social History

• (+) PTB – paternal side • Smoker (4.2 pack-years)

• (-) Hypertension • Occasional alcoholic beverage drinker
• (-) Cardiovascular disease • Denies illicit drug use
• (-) Diabetes mellitus
• (-) Bronchial asthma
• (-) Thyroid and kidney disease
• (-) Breast cancer
• (-) Ovarian cancer

9
 OB-Gyne History

Menstrual History Sexual History

Menarche: 14 years’ old 1st coitus: 18 years’ old
Regular interval (+) OCP use – Exluton (1999-2003)
3-4 days (-) Dyspareunia
4 pads per day (-) Post-coital bleeding
(+) Dysmenorrhea Denies history of STI

10
 OB-Gyne History

OUTCOM
GRAVIDA YEAR SEX MODE PLACE FMC
E
1 1998 F FT NSD OMMC -
2 2002 ABORTION
3 2004 M FT NSD DMC Lying-in -
4 2009 M FT NSD DMC Lying-in -

11
 Review of Systems

● Constitutional: no fever, no chills, no weight loss, no hot flashes

● HEENT: no blurring of vision, no hearing loss, no tinnitus, no nosebleed
● Respiratory: no dyspnea, no cough, no colds, no apnea
● CVS: no chest pain, no orthopnea, no palpitations
● GIT: no nausea, no vomiting, no diarrhea, (+) constipation
● GUT: no dysuria, no frequency, no urgency, no pelvic pressure/heaviness, no hematuria
● NMS: no arthralgia, no myalgia, no numbness
● Hematology: no easy bruising, no gingival bleeding
● CNS: no headache, no dizziness, no seizures, no loss of consciousness
 • General: Alert, awake, not in cardiorespiratory distress
• Vital signs: 120/80 mmHg, 88 bpm, 18 cpm, 36.6 °C, 99% O2 sat
• HEENT: Anicteric sclerae, pink palpebral conjunctiva, no nasoaural
discharge, no cervical lymphadenopathy
• Chest & Lungs: Symmetric chest expansion, no retraction, clear breath
Physical sounds

Examination • Heart: Adynamic precordium, normal rate and regular rhythm, distinct
heart sounds, no murmur
• Abdomen: Flat, soft, non-tender, normoactive bowel sounds, (-) ascites
• Extremities: no cyanosis, no edema, full equal pulses, capillary refill
time < 2 sec., no bruises
 Pelvic exam

Physical • Genital: Grossly normal looking external genitalia

• Speculum Examination: Clean-looking cervix, no erosions, no cysts, no
Examination bleeding
• Internal Examination: Cervix patulous, admits two fingers with ease,
anterior to the uterus is a cystic, nonmovable mass measuring 5x8 cm,
no cervical motion tenderness
 40 year old
Gravida 4 Para 3 (3-0-1-3) Ovarian cyst, right,
probably dermoid cyst
S/P Bilateral Tubal Ligation (Fabella, 2009)
ASSESSMENT
Plan
DAT, NPO at midnight
IVF: D5LR 1L x 8° while on NPO
Diagnostics: CBC with PC, BTRH, PT/PTT, UA with PT
Medications: Cefazolin 2g TIV as LD 30 mins prior to OR,
Tranexamic acid 2g TIV as LD 15 mins prior to OR,
Metronidazole 500 mg tab 1 tab q8, Bisacodyl oral tab 2 tab at 4
pm and 6 pm, Bisacodyl suppository at 4 pm and 6 pm, Fluid
enema at 8 pm.
Book to anesthesia for exploratory laparotomy, oophorectomy,
right, bilateral salpingectomy
VSQ4
Refer
 WBC 7.7 x 10 ^3 /uL

Lymphocytes 28.4 %
CBC with PC Neutrophils 64.0%

RBC 4.32 x 10 ^6 /uL

October 23, 2019 Hgb 13.3 g/dL

Hct 39.2 %

MCV 90.7 fL

MCH 30.8 pg
 PT 14.7 seconds
Coagulation Tests
% activity 77 %

INR 1.24
October 23, 2019 aPTT 35.4 seconds
BTRH
O POSITIVE

October 23, 2019

 Physical Microscopic
Color Yellow Epithelial Cells Moderate

Transparency Turbid Mucus Threads Many

Amorphous Few
Chemical
Urates/
Urinalysis Blood Negative Phosphates

Bilirubin Negative WBC 0-1

Urobilinogen Negative RBC 1-2

Bacteria Few
October 23, 2019 Ketone Negative
Protein Negative
Nitrite Negative
Glucose Negative
pH 6.0
Specific Gravity 1.030
Leukocytes Negative
Operation Exploratory Laparotomy, Oophorocystectomy, Right, Bilateral
Salpingectomy under Spinal Anesthesia
Performed
 Intraoperative Findings

• There was no ascites or hemoperitoneum.

• The uterus was anteverted.
• Within the right ovary is a unilocular cystic
mass measuring 5 x 3 x 2 cm and on cut
section, contains sebaceous fluid.
• Note of normal ovarian stroma.
• The left ovary was grossly normal.
• Normal bilateral fallopian tubes with note of
previous scar on both tubes.
Post-op Day 1
NPO for now
IVF: PLR 1L x 8°
Diagnostics: None
Medications: Cefazolin 1g TIV q8 x 24°, Tranexamic acid 1 g TIV
q8, Ferrous sulfate 1 tab OD, Multivitamins 1 tab OD,
Mefenamic acid 500 mg tab q6 PRN x pain.
Maintain tight abdominal binder
Maintain IFC for 12 hours
WOF: Severe hypogastric pain, fever, hypotension
Maintain VSQ1, I&O Qshift
Refer
Post-op Day 2
General liquids, soft diet once with flatus
IVF: May remove heplock
Diagnostics: None
Medications: Cefalexin 500 mg tab q12 x 7 days, Ferrous sulfate 1
tab OD, Multivitamins 1 tab OD, Mefenamic acid 500 mg tab
q6 PRN x pain.
Daily body and perineal hygiene.
Maintain tight abdominal binder.
VSQ4
Refer
Post-op Day 3
Soft diet then DAT once with BM
IVF: May remove heplock
Diagnostics: None
Medications: Cefalexin 500 mg tab q12 x 7 days, Ferrous sulfate 1
tab OD, Multivitamins 1 tab OD, Mefenamic acid 500 mg tab
q6 PRN x pain.
Daily body and perineal hygiene.
Maintain tight abdominal binder.
VSQ4
Refer
 40 year old
Gravida 4 Para 3 (3-0-1-3) Dermoid cyst, right S/P
Exploratory Laparotomy, Oophorocystectomy,
Right, Bilateral Salpingectomy (OMMC, 2019)
S/P Bilateral Tubal Ligation (Fabella, 2009)

FINAL DIAGNOSIS
DISCUSSION
Ovarian Teratoma

Arise from a single germ cell

May contain any of the three germ
cell layers – ectoderm,
mesoderm, or endoderm
Haphazard collection of tissues
such as hair, fat, bone, and
teeth
Ovarian Teratoma

Second most common germ cell

malignancy
10-20% of all ovarian tumors in
women <20
50% occur in women between the
ages of 10 and 20 years
Rarely bilateral
Grow rapidly, cause pain early
2/3 confined to ovary
Based on your history and physical
examination, what are the other conditions
that you must rule out in this case? What are
the points that you need to inquire in this
patient that would help you rule out other
conditions?

Guide Question 1
 Salient Features

PERTINENT POSITIVES PERTINENT NEGATIVES

40 y/o Gravida 4 Parity 3 (-) Abdominal/pelvic pain
S/P BTL (Fabella, 2009) (-) Cervical motion tenderness
(+) Constipation (-) Abnormal uterine bleeding
Anterior to the uterus is a cystic, non- (-) Ascites
movable mass 5x8 cm (-) Nausea / vomiting
TVS: The right ovary contains a cystic
structure with hyperechoic nodules
measuring 4.84 cm x 4.54 cm x 3.8
cm (vol. 43.68)
Functional Cysts

Seen in normally menstruating women 40 year old G4P3 (3-0-0-3)

Usually an incidental finding The right ovary contains a cystic structure
Almost always benign with hyperechoic nodules measuring
Characteristics: 4.84 cm x 4.54 cm x 3.8 cm (vol. 43.68)
Simple/once cyst Asymptomatic
No septations
Has thin or thick smooth muscle
Has no solid areas
Fluid-filled (anechoic)
Types:
Follicular cyst (most common)
Corpus luteum cyst
Theca lutein cyst (least common)
Endometrioma

“Chocolate cyst” 40 year old G4P3 (3-0-0-3)

Often associated with endometriosis in the The right ovary contains a cystic structure
other areas of pelvic cavity with hyperechoic nodules measuring
One of the most common causes of ovarian 4.84 cm x 4.54 cm x 3.8 cm (vol. 43.68)
enlargement Asymptomatic
Usually bilateral
Size: From small, superficial blue-black
implants 1-5 mm in size to large
multiloculated hemorrhagic cysts 5-10
cm
Signs and symptoms
Asymptomatic (majority of cases)
If with symptoms: Pelvic pain (most
common), dyspareunia, infertility
Ectopic Pregnancy
Visualization of gestational sac with a yolk
sac or fetal pole
(-) Abdominal pain
(-) Free fluid in the cul de sac
(-) Cervical motion tenderness
40 year old G4P3 (3-0-0-3)
The right ovary contains a cystic structure
with hyperechoic nodules measuring
4.84 cm x 4.54 cm x 3.8 cm (vol. 43.68)
Asymptomatic
S/P Bilateral tubal ligation (Fabella, 2009)
In the ideal set-up, with good financial
support, what are the diagnostic tests you
need to request? What is the contemplated
surgical procedure? Why?

Guide Question 2
 Diagnosis

● Physical examination – limited ability to identify adnexal masses

● Ultrasonography – most widely used imaging modality
○ Advantages: availability, cost-effectiveness, and patient
tolerability
Diagnosis
Diagnosis

Characteristic sonographic features:

• Tip of the iceberg
• Fat-fluid or hair-fluid levels
• Hair
• Rokitansky protuberance
 Management

● Extent of surgical procedure depends on the diagnosis, patient's age, and

the patient's desire for ovarian function or fertility

Premenopausal Cystectomy

Perimenopausal and Cystectomy or unilateral salpingo-oophorectomy;

postmenopausal Hysterectomy or bilateral salpingo-oophorectomy
Management

Exploratory laparotomy,
Oophorocystectomy, Right,
Bilateral Salpingectomy
What are the components of a
comprehensive pre-operative evaluation
plan? For this patient, how will you
implement this?

Guide Question 3
 Comprehensive Pre-operative Plan Evaluation

● Comprehensive history taking

○ To determine risk factors such as strong family history
● Physical Examination
○ Eg. lymphadenopathies, evaluation of mass
● Imaging
○ Transvaginal ultrasound- most superior
● Laboratory tests
○ Eg. pregnancy tests, CBC
● Serum marker testing
○ used in conjunction with imaging to assess the likelihood of
malignancy eg. CA125
 Imaging

● The ultrasound examination should assess the size and composition of

the mass (cystic, solid, or mixed); laterality; and the presence or absence
of septations, mural nodules, papillary excrescences, or free fluid in the
pelvis.

● Ultrasound findings that should raise the clinician’s level of concern

regarding malignancy include cyst size greater than 10 cm, papillary or
solid components, irregularity, presence of ascites, and high color
Doppler flow.
 Comprehensive Pre-operative Plan Evaluation

● Prime the patient with regards to the need of surgical intervention for
dermoid cyst as it could lead to the ff. conditions:
○ Ovarian torsion leading to ovarian infarction
○ Rupture leading to chemical peritonitis
○ Fistulization through pelvic viscera
○ Malignant degeneration
What are the necessary knowledge you need
to know when performing the necessary
gynecologic procedure appropriate for this
patient?

Guide Question 4
Anatomy of the Ovary
How will you proceed with the post-
operative care of this patient based on the
intraoperative course and surgical procedure
done on this patient? What is the evidence-
based enhanced recovery after surgical
protocol?

Guide Question 5
Post-operative care

Require early ambulation

Deep breathing exercises
Daily wound care
 Recovery

● One retrospective multicenter cohort study of ovarian dermoids removed

by laparoscopy compared to exploratory laparotomy found significantly
more ipsilateral recurrences in the laparoscopy group between 2-24
months post-operatively and calculated the probability of recurrence at
two years to be 7.6% by laparoscopy and 0% for laparotomy.
What are the expected post-operative
complications in this patient based on the
risk factors present on this patient?

Guide Question 6
Possible complications

Decreased estrogen levels

Vascular injury and bleeding
Adhesion formation
Incisional hernia
JI Reyes, R. & JI Salvadora

ADNEXAL MASSES