Adneksiyal Kitlelere Yaklaşım

Adneksiyal kitle sık karşılaşılan jinekolojik bir problemdir. Çoğunluğu over orijinlidir ve benigndir. Ancak adneksiyalkitlelerin preoperatif olarak ovarian bir malignansi açısından yüksek riskli olup olmadığının tespiti, uygulanacakoperatif prosedürün belirlenmesi, hastanın uygun şekilde bilgilendirilmesi gereksiz işlem yapılmasını önlemek için çokönemlidir. Adneksiyal kitlelerin preoperatif değerlendirilmesinde ayrıntılı anamnez, fizik muayene, görüntülemeyöntemleri ve uygun tümör belirteçlerinin kullanımı gerekmektedir. Adneksiyal kitlelerin malign-benign ayrımındakullanılmak üzere son yıllarda ultrasonografi ve doppler bulguları, tümör markırları ve hastanın menopozal durumunadayanan çeşitli malignite risk indeksleri geliştirilmiştir. Ultrasonografi bulguları, adneksiyal kitlenin dopplerincelemesi, menopozal durum, yaş, aile öyküsü, hormonal terapi alınıp alınmadığı ve ağrı durumunun birliktedeğerlendirildiği Uluslararası Over Tümörü Analizi (International Ovarin Tumour Analysis-IOTA) kriterleri, kitledemultilokülasyon olup olmadığı, solid komponentlerin olup olmadığı, bilateralite, asit ve metastaz bulgularının olupolmadığı, hastanın menopozal durumu, serum CA-125 düzeyinin baz alındığı malignite risk indeksi, tümör hacmi, kistduvar yapısı ve septa yapısının değerlendirildiği morfolojik indeks bunlardan bazılarıdır. Skorlama sistemleri arasındayapılan karşılaştırılmalı çalışmalar sonucunda IOTA skorlaması ile daha yüksek sensitivite ve spesifite ile adneksiyalkitleye tanı koyulabileceği görülmüştür. Bu sayede hastaların preoperatif olarak daha doğru bir şekildedeğerlendirilmesiyle optimal cerrahi yöntem planlanabilecektir.

Approach to Adnexal Masses

Adnexal mass is a common gynecologic problem. Most of them are benign and arise from ovary. But, determination of adnexal mass if it has high risk of malignancy preoperatively defining operative procedure and information of patient appropriately is essential for preventing unnecessary procedures. In evaluation of adnexal mass preoperatively it is necessary to use detailed history of patient, physical examination, imaging methods and suitable tumor markers. Recently, in order to discriminate the adnexal mass benign or malign, some malignancy risk indexes based on ultrasound and doppler findings, tumor markers and menopausal status of patient. International Ovarian Tumor Analysis (IOTA) models based on ultrasound findings (septation, papillary projections, presence of acoustic shadows, ascites), doppler imaging of adnexal mass, menopausal status, age, family history, current hormonal therapy, presence of pain; risk of malignancy index (RMI) including multilocularity of adnexal mass, presence of solid component, bilaterality, presence of ascites and evidence of metastasis, menopausal status of patient, serum CA 125 level; and De Priest Morphological Index (MI) based on tumor volume, wall structure of cyst and septa structure are some of these malignancy indexes. As a result of studies that comparing scoring systems it was seen that adnexal masses could be diagnosed with higher sensitivity and specificity by using IOTA scoring system. Thanks to this, with more accurate evaluation of patients preoperatively, optimal surgical method could be planned.

PDF

___

1. Ayhan A, Durukan T, Günalp S. Temel Kadın Hastalıkları ve Doğum Bilgisi. 2. Baskı. Ankara: Güneş Tıp Kitabevi; 2008. s. 943-4.
2. Yüce K, Dursun P. Adneksiyal Kitle ve Erken Ovaryan Kanser. Ayhan A, çeviri editör. Klinik Jinekolojik Onkoloji. 6. Baskı. Ankara: Güneş Kitabevi; 2003. s. 259-88.
3. Hillard PA. Kadın Genital Traktus Malign Hastalıkları: Semptom ve Bulgular. Berek JS, Adashi EY, Hillard PA, editörler. Novak Jinekoloji. Erk A, çeviri editör. 13. Baskı. İstanbul: Nobel Tıp Kitabevi; 2007. s. 443-541.
4. Scully RE. Tumors of the ovary, maldeveloped gonads, fallopian tube and broad ligament. In: Young RH, Clement PB. Atlas of tumor pathology. Washington, DC: Armed Forces Institute of Pathology; 1998. p. 51-79.
5. Penson RT, Wenzel LB, Vergote I, Cella D. Quality of life considerations in gynecologic cancer. FIGO 6th Annual Report on the Results of Treatment in Gynecological Cancer. Int J Gynaecol Obstet. 2006; 95(Suppl 1): S247-57.
6. Webb PM, Purdie DM, Grover S, Jordan S, Dick ML, Green AC. Symptoms and diagnosis of borderline, early and advanced epithelial ovarian cancer. Gynecol Oncol. 2004; 92(1): 232-9.
7. Ayhan A, Yapar E. Overin Malign Hastalıkları. Atasü T, Aydınlı K, editörler. Jinekolojik Onkoloji. İstanbul: Logos Tıp Yayıncılık; 1997. s. 198-243.
8. Le T, Krepart GV, Lotocki RJ, Heywood MS. Does debulking surgery improve survival in biologically aggressive ovarian carcinoma? Gynecol Oncol. 1997; 67(2): 208-14.
9. Tingulstad S, Hagen B, Skjeldestad FE, Onsrud M, Kiserud T. Evaluation of a risk of malignancy index based on serum CA125, ultrasound findings and menopausal status in the pre-operative diagnosis of pelvic masses. Br J Obstet Gynaecol. 1996; 103(8): 826-31.
10. Manjunath AP, Pratapkumar, Sujatha K, Vani R. Comparison of three risk of malignancy indices in evaluation of pelvic masses. Gynecol Oncol .2001; 81(2): 225-9.
11.Jacobs IJ, Oram D, Fairbanks J, Turner J, Frost C, Grudzinskas JG. A risk of malignancy index incorporating CA125, ultrasound and menopausal status for the accurate preoperative diagnosis of ovarian cancer. Br J Obstet Gynaecol. 1990; 97(10): 922-9.
12. Yavuzcan A, Çağlar M, Özgü E. Should cut-off values of the risk of malignancy index be changed for evaluation of adnexal masses in Asian and Pacific Populations? Asian Pac J Cancer. 2013; 14(9): 5455- 9.
13. Yavuzcan A, Çağlar M, Özgü E. Addition of parity to the risk of malignancy index score in evaluating adnexal mass. TJOG. 2014; 53(4): 518-22.
14. Lerner JP, Timor-Tritsch IE, Federman A, Abramovich G. Transvaginal ultrasonographic characterization of ovarian masses with an improved, weighted scoring system. Am J Obstet Gynecol. 1994; 170(1): 81-5.
15. DePriest PD, Varner E, Powell J, Fried A, Puls L, Higgins R. The efficacy of a sonographic morphology index in identifying ovarian cancer: A multiinstitutional investigation. Gynecol Oncol. 1994; 55(2): 174-8.
16. Ueland FR, DePriest PD, Pavlik EJ, Kryscio RJ, van Nagell JR. Preoperative differentiation of malignant from benign ovarian tumors: The efficacy of morphology indexing and Doppler flow sonography. Gynecol Oncol. 2003; 91(1): 46-50.
17. Sassone AM, Timor-Tritsch IE, Artner A, Westhoff C, Warren WB. Transvaginal sonographic characterization of ovarian disease: Evaluation of a new scoring system to predict ovarian malignancy. Obstet Gynecol. 1991; 78(1): 70-6.
18. Geomini P, Kruitwagen R, Bremer GL, Cnossen J, Mol BW. The accuracy of risk scores in predicting ovarian malignancy: A systematic review. Obstet Gynecol. 2009; 113(2): 384-94.
19. Ries LA, Miller BA, Hankey BF, Kosary CL, Edwards BK. SEER Cancer Statistics Review, 1973- 1995. Bethesda, Maryland: National Cancer Institute; 1998.
20. Timmerman D, Testa AC, Bourne T, Ferrazzi E, Ameye L. Logistic regression model to distinguish between the benign and malignant adnexal mass before surgery: A multicenter study by the International Ovarian Tumor Analysis Group. J Clin Oncol. 2005; 23(34): 8794-801.
21. Van Holsbeke C, Van Calster B, Testa AC. Ovarian cancer screening. Clin Cancer Res. 2009; 15(2): 684- 91.
22. Timmerman D. Lack of standardization in gynecological ultrasonography. Ultrasound Obstet Gynecol. 2000; 16(5): 395-8.
23. Granberg S, Wikland M, Jansson I. Macroscopic characterization of ovarian tumors and the relation to the histological diagnosis: Criteria to be used for ultrasound evaluation. Gynecol Oncol. 1989; 35(2): 139-44.
24. Timmerman D, Schwarzler P, Collins WP. Subjective assessment of adnexal masses with the use of ultrasonography: An analysis of interobserver variability and experience. Ultrasound Obstet Gynecol. 1999; 13(1): 11-6.
25. Twickler DM, Forte TB, Santos-Ramos R, McIntire D, Harris P, Miller DS. The ovarian tumor index predicts risk for malignancy. Cancer. 1999; 86(11): 2280-90.
26. Menon U, Gentry-Maharaj A, Hallett R. Sensitivity and specificity of multimodal and ultrasound screening for ovarian cancer, and stage distribution of detected cancers: Results of the prevalence screen of the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). Lancet Oncol. 2009; 10(4): 327-40.
27. Twickler M, Moschos E. Ultrasound and assessment of ovarian cancer risk. AJR Women’s Imaging. 2010; 194(2): 322-9.
28. Lu C, Van Gestel T, Suykens JAK, Van Huffel S, Vergote I, Timmerman D. Preoperative prediction of malignancy of ovarian tumor using least squares support vector machines. Artif Intell Med. 2003; 28(3): 281-306.
29. Van Holsbeke C, Van Calster B, Bourne T, Ajossa S. External validation of diagnostic models to estimate the risk of malignancy in adnexal masses. Clin Cancer Res. 2012; 18(3): 815-25.
30. Van Calster B, Timmerman D, Valentin L. Triaging women with ovarian masses for surgery: observational diagnostic study to compare RCOG guidelines with an International Ovarian Tumour Analysis (IOTA) group protocol. BJOG. 2012; 119(6): 662-71.