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Clinical Guidelines

Adnexal Masses

Introduction

• Adnexal masses refer to growths in the ovary, fallopian tube, or surrounding tissues.

• Commonly encountered by OB-GYNs, adnexal masses can be benign or malignant.

• Key challenge: differentiating between benign and malignant masses.

• Goal: to provide evaluation and management guidelines

Differential Diagnosis

• Gynecologic origins:

• Benign: functional cysts, endometriomas, tubo-ovarian abscesses, leiomyomas, etc.

• Malignant: epithelial carcinoma, germ cell tumors, sex-cord stromal tumors, etc.

• Nongynecologic origins:

• Benign: diverticular or appendiceal abscess, ureteral diverticulum, etc.

• Malignant: gastrointestinal cancers, retroperitoneal sarcomas, metastatic cancers.

Risk Factors for Malignancy

• Age:

• Incidence of ovarian cancer increases sharply post-menopause.

• Median age at diagnosis: 63 years.

• Postmenopausal women at higher risk for malignancy.

• Family history:

• BRCA1/BRCA2 mutations increase lifetime risk of ovarian, fallopian tube, or peritoneal cancers.

• Other risk factors include nulliparity, early menarche, late menopause, and endometriosis.

General Evaluation

• Patient history:

• Gynecologic and family history, detailed review of symptoms.

• Pregnancy testing in reproductive-age women to rule out ectopic pregnancy.

• Physical exam:

• Comprehensive examination including pelvic, abdominal, and lymph node evaluation.

• Features concerning for malignancy: irregular, fixed, nodular masses, or ascites.

Imaging

• Transvaginal ultrasonography:

• Primary imaging technique to assess mass size, composition, and features (e.g., septations, solid components).

• Color Doppler ultrasonography: evaluates blood flow, improving specificity for malignancy.

• Other imaging (limited use initially):

• CT and MRI may be employed for further evaluation, especially if metastasis is suspected.

Laboratory Testing

• Serum markers:

• CA-125: elevated in 80% of epithelial ovarian cancers but has limited sensitivity in stage I disease.

• Other markers for specific tumors: beta-hCG, alpha-fetoprotein, LDH.

Question/Answer Section

What is the role of ultrasonography in the evaluation of adnexal masses?

• Transvaginal ultrasonography is the first-line imaging tool.

• Produces high-resolution images of adnexal masses.

• It is widely available, cost-effective, and well-tolerated by patients.

• Color Doppler can assess vascularity to increase specificity for malignancy.

• CT and MRI are reserved for cases with suspicion of metastasis or unclear findings on ultrasound.

What ultrasound findings suggest malignancy?

• Mass size greater than 10 cm.

• Presence of papillary or solid components.

• Irregular borders.

• Ascites or free fluid in the pelvis.

• High vascularity on Doppler flow.

When is serum marker testing indicated for adnexal masses?

• CA-125 is the primary marker used for evaluating malignancy risk, especially in postmenopausal women.

• Elevated CA-125 is concerning in the presence of an adnexal mass but is not specific for ovarian cancer.

• Other markers (e.g., beta-hCG, LDH, alpha-fetoprotein) may be useful for specific tumor types, like germ cell tumors.

• Marker panels, such as the Risk of Ovarian Malignancy Algorithm (ROMA), may improve diagnostic accuracy.

When is surgical intervention indicated for adnexal masses?

• Symptomatic masses causing pain or other complications.

• Ultrasound findings suggestive of malignancy, such as solid components or ascites.

• Masses larger than 10 cm, especially if they are complex.

• Minimally invasive surgery is preferred for benign masses to reduce recovery time and preserve fertility.

Who should be referred to a gynecologic oncologist?

• Postmenopausal women with elevated CA-125, nodular or fixed pelvic masses, or evidence of distant metastasis.

• Premenopausal women with elevated CA-125 and similar suspicious ultrasound findings.

• Patients with abnormal results on multimodal risk assessments, such as the ROMA or IOTA scoring systems.

• Women with complex adnexal masses that are difficult to characterize and require expert evaluation.

When is observation appropriate for adnexal masses?

• Simple cysts smaller than 10 cm with no solid components or septations.

• Asymptomatic women with benign-appearing cysts can be monitored with serial imaging.

• Observation is particularly useful in young women and pregnant women to avoid unnecessary surgeries.

Management Guidelines

1. Observation:

• Simple cysts <10 cm in diameter with benign features can be monitored with serial ultrasounds.

• Larger or complex masses may require further evaluation.

2. Surgical Intervention:

• Minimally invasive surgery is preferred for presumed benign masses.

• Laparoscopy reduces operative time, hospital stay, and postoperative pain compared to laparotomy.

3. Referral to a gynecologic oncologist:

• Referral is indicated for postmenopausal women with elevated CA-125, suspicious ultrasound findings, or metastatic evidence.

• Referral also recommended for premenopausal women with elevated CA-125 and suspicious imaging.

Special Considerations

• Adolescents:

• Prioritize ovarian conservation to preserve fertility.

• Germ cell tumors are the most common ovarian malignancies in adolescents.

• Pregnancy:

• Most adnexal masses resolve spontaneously during pregnancy.

• If intervention is necessary, laparoscopy in the second trimester is generally safe.

Conclusion

• The primary aim in evaluating adnexal masses is to exclude malignancy while considering age, symptoms, and imaging.

• Management is tailored based on individual patient factors, balancing the risks of malignancy against the benefits of conservative versus surgical management.

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