What have we done differently?
At Desert Women’s Care we have developed a treatment algorithm to assure appropriate referral of women with adnexal masses likely to represent ovarian cancer to Gynecologic Oncologists and treatment of adnexal masses felt to be benign using Minimally Invasive Surgical techniques while carefully observing standard principals of oncologic surgery.
The prevalence of adnexal masses is relatively high in the general population while ovarian cancer has a relatively low prevalence. Ovarian cancer has non-specific symptoms and is usually silent in its early stages. Presently we have no reliable screening test for ovarian cancer and we have a limited ability to detect it using current diagnostic strategies.
Various studies have addressed the likelihood of malignancy within an ovarian mass.
Table 1. Likelihood of Malignancy in Adnexal Masses
Mage et al, 1990 |
433 |
9 |
2.08% |
Mecke et al, 1992 |
773 |
11 |
1.42% |
Nezhat et al, 1992 |
1011 |
4 |
0.40% |
Hulka et al, 1992 |
13793 |
411 |
2.98% |
Canis et al, 1994 |
757 |
19 |
2.51% |
Marzana et al, 1994 |
527 |
2 |
0.38% |
Wenzl et al, 1996 |
16601 |
108 |
0.65% |
Childers et al, 1996 |
138 |
19 |
13.77% |
Canis et al, 1997 |
230 |
15 |
6.52% |
Hidlebaugh et al, 1997 |
405 |
8 |
1.98% |
Malik et al, 1998 |
292 |
11 |
3.77% |
Mettler et al, 2001 |
493 |
8 |
1.62% |
Valentin et al, 2006 |
1066 |
199 |
18.67% |
Demir & Marchand 2011 |
257 |
15 |
5.84% |
Total |
36776 |
839 |
2.28% |
In 2002 the American College of Obstetricians & Gynecologists evaluated the various predictors of ovarian malignancy and published ACOG Committee Opinion 280 setting forth criteria to refer both premenopausal and postmenopausal women for care by Gynecologic Oncologists.
Table 2. ACOG Committee Opinion 280 Referral Criteria [44]
Premanopausal Women
CA 125 > 200 U/ml
Ascites
Evidence of abdominal or distant metastases
Family history 1st degree relative(s) with breast or ovarian cancer
Postmenopausal Women
Elevated CA 125
Ascites
Nodular or fixed pelvic mass
Evidence of abdominal or distant metastases
Family history 1st degree relative(s) with breast or ovarian cancer
What Is The Chance a Patient Has Cancer If The Pre-Operative Testing Suggests The Mass Is Benign?
Im, et al, in 2005, showed that strict adherence to ACOG Committee Opinion 280 in a referral population yields a negative predictive value (NPV) of 92.0 % % for all cases of ovarian cancer in premenopausal women and an NPV of 91.1% in post menopausal women.
Dearking, et al, in 2007, demonstrated that with strict adherence to ACOG Committee Opinion 280 in a non-referred population arising from their primary catchment area yields an NPV of 97.7% for all cases of ovarian cancer in premenopausal women and an NPV of 95.0% in post menopausal women. In their referral population NPV was 91.0% in premenopausal and 90.5% in postmenopausal women, or essentially identical to the Im, et al, data.
Our study has similar results with a NPV of 95.57% for premenopausal women and a NPV of 90.91% for postmenopausal women.
Table 3. Negative Predictive Value of ACOG Committee Opinion 280
Premenopausal Postmenopausal
Im et al, 2005 |
92.00 |
|
91.10 |
Dearking et al, 2007 |
|
|
|
--overall |
93.10 |
|
91.70 |
--referral population |
91.00 |
|
90.50 |
--general population |
97.70 |
|
95.00 |
Demir & Marchand, 2011 |
95.57 |
|
90.91 |
What Happens If My Mass is Later Found To Be Malignant?
In this case a second surgery will be required.
Definitive staging of ovarian cancer includes: 1.) cytologic washings, total hysterectomy, bilateral salpingo-oophorectomy, peritoneal surface biopsies, total omentectomy and retroperitoneal lymphadenectomy from the pelvis and paraaortic regions to the left renal vessel. Laparoscopy and laparotomy have equal efficacy in both early and advanced stage ovarian cancer. If the mass is found to be malignant, the patient will be referred to a GYN Oncologist who will perform definitive surgery, usually using minimally invasive techniques. Various studies show that when disease preoperatively was felt to be benign, upstaging on definitive surgery happens between 10 and 45% of the time. It is essential to perform definitive surgery then to use chemotherapy and other adjuvant therapies based on the actual Stage of disease to assure the greatest long-term survival for the patient with ovarian malignancy.
Table 4. Frequency of Upstaging at Definitive Procedure
Pomel et al [79] 1995 |
10 |
1 |
10.00% |
Childers et al [80] 1995 |
14 |
5 |
35.70% |
Stier et al [81] 1996 |
45 |
7 |
15.56% |
Tozzi et al [83] 2004 |
24 |
5 |
20.80% |
Leblanc et al [84] 2004 |
44 |
8 |
18.20% |
Spirtos et l [85] 2005 |
58 |
6 |
11.00% |
Chi et al [86] 2005 |
20 |
2 |
10.00% |
Ghezzi et al [87] 2007 |
15 |
4 |
26.70% |
Colomer et al [72] 2008 |
20 |
4 |
20.00% |
Nezhat et al [73] 2009 |
36 |
7 |
19.44% |
Demir & Marchand 2011 |
9 |
4 |
44.44% |
Total |
295 |
53 |
17.96% |
What This Means
Minimally Invasive Surgery is a safe, achievable treatment expectation for women with adnexal masses. Laparoscopic adnexectomy, bagging and colpotomy is a desirable goal for patients with adnexal masses meeting selection criteria for suspected benign lesions outlined in ACOG Committee Opinion 280 affording a minimally invasive approach with attendant benefits including out-patient treatment, decreased incidence of capsular rupture, few complications and low necessity for re-operation after final pathology is evaluated.
We believe our treatment algorithm leads to fewer laparotomies, fewer women unnecessarily upstaged as a consequence of inadvertent capsular rupture and heightened ability to offer out-patient treatment for women with presumed benign adnexal masses.
We know you have a choice in referral practices so we take thie request seriously. Give us a chance with your next complicated patient requiring surgery, then evaluate us based on the results provided to your patient. We are confident we will not disappoint.
Remember, the single most important factor in determining whether your patient will avoid laparotomy is the choice of surgeon you make!
To view the full Paper Dr. Demir published in the Journal of the Society of Laparoendoscopic Surgeons (JSLS) in 2012, click on the icon below:
To view the Abstract we submitted to AAGL for presentation at their 2011 Annual Meeting, click the AAGL Meeting 2011 icon below:
Desert Women's Care
9377 East Bell Road, Suite 131, Scottsdale, Arizona 85260
80 North McClintock Drive, Suite 104, Chandler, Arizona 85226
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