Present

1. By: Dr Habtamu G. (OBGYN Resident)
June 19, 2021 GC
TASH, AA
Approach to the Patient
With an Adnexal Mass
1

2. Outline
• Introduction
• Prevalence
• Clinical approach
• General evaluation
• Evaluation for urgent conditions
• Evaluation for malignancy
• Summary and recommendations
• References
2

3. INTRODUCTION
• An adnexal mass (mass of the ovary, fallopian tube or surrounding connective
tissues) is a common gynecologic problem
• In the United States, it is estimated that there is a 5-10% lifetime risk for
women undergoing surgery for a suspected ovarian neoplasm
• Adnexal masses may be found in females of all ages, fetuses to the elderly,
and there is a wide variety of types of masses
• The principal goals of the evaluation:
o To address acute conditions (eg, ectopic pregnancy) and
o To determine whether a mass is malignant
3

4. GROSS ANATOMY
• The uterine adnexa consist of:
o Ovaries
o Fallopian tubes and
o Surround vascular, lymphatic, and
connective tissues
4

5. GROSS ANATOMY …
• The ovaries are suspended lateral and/or posterior to the uterus
The supporting structures of the ovaries include
o The utero-ovarian ligament that attaches the ovary to the uterus
o The infundibulopelvic ligament (also referred to as the suspensory ligament of the
ovary), through which the ovarian vessels travel, that attaches the ovary to the pelvic
sidewall and
o The broad ligament, which condenses to form the mesovarium
It is also attached to the broad ligament through the mesovarium
• The ovary consists of
o An outer cortex, where the ova & follicles are located, and
o A medulla, where the blood vessels & connective tissue compose a
fibromuscular tissue layer
5

6. GROSS ANATOMY …
6

7. GROSS ANATOMY …
• The fallopian tubes
Arise from the uterine corpus posterior and superior to the round ligaments
The broad ligaments support the tubes with a condensation of connective tissue called
the mesosalpinx
7

8. HISTOLOGY
• The ovary includes several different tissue types
• The most common neoplasms are epithelial
These derive from the stem cells that would typically give rise to
o Fallopian tube epithelium (most high-grade serous carcinomas) OR
o Ovarian surface epithelium and inclusions (eg, cystadenomas)
• Ovarian germ cell tumors are derived from primordial germ cells of the ovary
• Ovarian sex cord-stromal tumors derive from stem cells that would normally
give rise to supporting epithelial cells, including ovarian stroma (eg,
fibromas) and follicles (eg, granulosa cell tumors, Sertoli-Leydig cell
tumors)
8

9. HISTOLOGY …
• The fallopian tubes consist of
o An outer muscularis layer of the tube with longitudinal smooth muscle fibers and
o An inner layer with circular fibers
• The fallopian tube mucosa is composed of numerous delicate papillary folds
(plica) consisting of three cell types:
o Ciliated columnar cells
o Non-ciliated, columnar secretory cells and
o Intercalated cells, which may simply represent inactive secretory cells
9

10. DIFFERENTIALS OF ADNEXAL MASS
• An adnexal mass (mass of the ovary, fallopian tube, or surrounding connective
tissues) is a common gynecologic problem
• In the United States, it is estimated that there is a 5-10% lifetime risk for
women undergoing surgery for a suspected ovarian neoplasm
• Adnexal masses may be found in females of all ages, fetuses to the elderly,
and there is a wide variety of types of masses
• The principal goals of the evaluation are
o To address acute conditions (eg, ectopic pregnancy) and
o To determine whether a mass is malignant
10

11. PREVALENCE
• An adnexal mass may be found in females of all ages
Fetuses to the elderly
• The reported prevalence varies widely depending upon
The population studied and
The criteria employed
• In the United States, it is estimated that there is a 5-10% lifetime risk for
women undergoing surgery for a suspected ovarian neoplasm
11

12. CLINICAL APPROACH
• The goal of the evaluation of a patient with an adnexal mass is to determine
the most likely etiology of the mass
This process is often challenging, since there are many types of adnexal masses and a
definitive diagnosis often requires surgical evaluation
• The evaluation is guided in large part by
o The anatomic location of the mass and
o Age & reproductive status of the patient
12

13. CLINICAL APPROACH:
Excluding urgent conditions or malignancy
• An adnexal mass may represent a serious health issue
A condition that requires urgent intervention (eg, ectopic pregnancy, adnexal torsion) or
An ovarian or fallopian tube cancer (or malignant disease metastatic for a peritoneal cancer
or other primary)
• A general evaluation is performed initially to
Confirm the presence of a mass and
Identify patients who should be further evaluated for an urgent condition or for
malignancy
For other patients, the general evaluation continues as the diagnostic evaluation
• The clinical features of patients with urgent conditions are fairly specific (eg,
severe pain, first trimester bleeding, fever) and these represent a minority of
patients
13

14. CLINICAL APPROACH: Anatomic location
• The anatomic location helps to narrow the differential diagnosis
• Most adnexal masses are ovarian, but some arise from a fallopian tube or the
surrounding tissues or structures
• Ovarian masses include:
o Physiologic cysts (follicular or corpus luteum)
o Benign ovarian neoplasms (eg, endometrioma, mature teratoma [dermoid cyst])
o Ovarian cancer or metastatic disease from a non-ovarian primary cancer
• A mass in the fallopian tube may be:
o Ectopic pregnancy
o Hydrosalpinx
o Fallopian tube cancer
14

15. CLINICAL APPROACH: Anatomic location …
• The ovary & fallopian tube are surrounded by the mesosalpinx or
mesovarium, condensations of connective tissue that are part of the broad
ligament
Some adnexal masses arise from these tissues
• Some adnexal masses are adherent to the adnexa or derive from nearby
structures:
o Paratubal or paraovarian cyst
o Tuboovarian abscess
o Broad ligament leiomyoma
15

16. CLINICAL APPROACH: Age and reproductive
status
Fetuses, children and adolescents
• Follicular ovarian cysts are common in fetuses and increase in frequency with
advancing gestational age and with some maternal complications (eg, diabetes
mellitus, preeclampsia, rhesus isoimmunization)
• A pelvic mass in a newborn is most likely a physiologic cyst that initially arose due
to maternal hormonal stimulation in utero
• The differential diagnosis of an intra-abdominal mass in fetuses or neonates includes
o Genitourinary tract disorders:
Reproductive tract anomalies, urinary tract obstruction, urachal cyst
o GIT disorders:
Mesenteric or omental cyst, volvulus, colonic atresia, intestinal duplication
o Miscellaneous disorders:
Choledochal, splenic or pancreatic cyst, lymphangioma
16

17. CLINICAL APPROACH: Age and reproductive
status …
Fetuses, children and adolescents …
• Between the neonatal period and puberty, physiologic cysts are
uncommon
Because gonadotropin ovarian stimulation decreases in infancy and early childhood
and then increases during puberty
• Nevertheless, most simple ovarian cysts in children are physiologic and
result from enlargement of a cystic follicle
17

18. CLINICAL APPROACH: Age and reproductive
status …
Fetuses, children and adolescents …
• Girls between menarche and 18 years of age constitute an age group in
which the development of both simple and complex cysts is quite common
Adolescent ovaries may contain multiple follicles in different stages of
development
Most simple cysts result from failure of the maturing follicle to ovulate and involute
18

19. CLINICAL APPROACH: Age and reproductive status
…
Fetuses, children and adolescents …
• Adnexal masses occur less frequently in children & adolescents than in
reproductive-age women
• When an adnexal mass is found in this patient population, there is a significant
likelihood of adnexal torsion or an ovarian malignancy (approximately 10-20%)
 Germ cell tumors are the most common type of ovarian cancer in children & adolescents,
comprising 35% compared with 20% in adults
• Ovarian neoplasms (benign & malignant) account for approximately 1% of all
tumors in children & adolescents
Most ovarian masses are physiologic or benign neoplasms
 Fewer than 5% of ovarian cancers occur in this age group
• In girls younger than 9 yrs of age, approximately 80% of ovarian neoplasms are
malignant
• Epithelial neoplasms are rare in the prepubertal age group
19

20. CLINICAL APPROACH: Age and reproductive
status …
Premenopausal Women
• The great majority of adnexal masses occur in reproductive-age patients (including post-
menarchal adolescents) and most of these masses are benign
 This is because the pathogenesis of many benign adnexal masses is associated with reproductive
function
• Pregnancy-related etiologies occur exclusively in reproductive-age patients by definition
• Many other types of adnexal masses are associated with the menstrual cycle or reproductive
hormones (eg, follicular cysts, endometriomas) & are common findings found in this patient
population
• Ovarian or fallopian tube cancer is less likely in premenopausal than postmenopausal
women, but the possibility of malignancy should be considered in all patients
 The incidence of ovarian cancer increases with age
 1.8-2.2 per 100,000 women age 20-29
 9.0-15.2 per 100,000 women age 40-49
20

21. CLINICAL APPROACH: Age and reproductive
status …
Premenopausal women …
• Pregnant women
There are several types of adnexal masses that are associated with pregnancy
o Ectopic pregnancy and luteomas
 These occur solely during pregnancy
o Corpus luteum cysts
 These persist longer during pregnancy and thus are likely to reach a larger size and may
become hemorrhagic, rupture, or undergo torsion
o Theca lutein cysts
 These are most likely to occur in women with ovarian hyperstimulation due to
 Ovulation induction for infertility or
 Gestational trophoblastic disease
21

22. CLINICAL APPROACH: Age and reproductive
status …
Postmenopausal Women
• Excluding malignancy is the main priority in postmenopausal women with an
adnexal mass
The average age of diagnosis of ovarian cancer in the United States is 63 years old
• Many of these women will require a surgical evaluation
• Urgent conditions (eg, adnexal torsion, tuboovarian abscess) may also occur
in postmenopausal women, but
Are less common and
Are more likely to be associated with malignancy
22

23. GENERAL EVALUATION
• Women with an adnexal mass typically present with gynecologic symptoms and a
mass is identified on pelvic imaging
Alternatively, an adnexal mass is discovered incidentally on pelvic examination or imaging
in many patients
• Patients with a known or suspected adnexal mass should undergo a general
evaluation to
o Confirm the presence of a mass and
o Determine its characteristics and any associated symptoms or physical findings
• Patients should be assessed for features that indicate immediate intervention or
suggest malignancy, and these patients should undergo a focused evaluation for
these conditions
23

24. GENERAL EVALUATION: Medical history
• Pelvic pain or pressure is the most common symptom associated with an adnexal mass
• Some women present with genital tract bleeding
• Ovarian cancer may be associated with
 Pelvic or abdominal symptoms or
 Symptoms related to hormone production by the tumor, for particular histologic types (eg, sex cord-
stromal tumors)
• Patients who present with symptoms or findings suggestive of an adnexal mass should
undergo pelvic examination and imaging to confirm whether a mass is present
• For patient with a known adnexal mass, the clinician should inquire about associated
symptoms
 Symptom patterns that suggest a particular etiology help to guide further evaluation or
management
24

25. GENERAL EVALUATION: Medical history …
• If pain or pressure is present, the characteristics of the discomfort should be
elicited, including
o The acuity of onset
o Location
o Duration
o Whether it is constant or intermittent and
o Whether it is associated with any other factors (eg, menstrual cycle)
• An adnexal mass that is associated with severe pain, particularly of abrupt
onset, or pelvic pain in a pregnant woman requires immediate evaluation
25

26. GENERAL EVALUATION: Medical history …
• Benign masses that do not require immediate intervention may also present
with pelvic pain
Ovarian physiologic cysts or neoplasms are typically associated with a dull, achy pain
that is usually localized to the side of the mass or may be asymptomatic
An endometrioma may be associated with dysmenorrhea or dyspareunia
• A patient who presents with an adnexal mass and vaginal bleeding and who
may be pregnant should have pregnancy testing
Types of adnexal masses that are particular to pregnancy are;
o An ectopic pregnancy, which requires urgent intervention, or
o A corpus luteum cyst
26

27. GENERAL EVALUATION: Medical history …
• Patients should be asked about a history of fever or vaginal discharge
Patients who complain of fever and vaginal discharge and are found to have an adnexal mass
should be evaluated for a tuboovarian abscess
The combination of a tubal mass and a history of PID may also represent a hydrosalpinx
Persistent serosanguineous vaginal discharge without fever has been associated with
fallopian tube cancer
• Women should also be asked about a history of infertility, since an endometrioma or
hydrosalpinx may contribute to infertility
In addition, infertility is associated with an increased risk of ovarian tumors of low malignant
potential
• The medical history should include questions about risk factors and symptoms
associated with ovarian or fallopian tube cancer
In addition to other risk factors, age and reproductive status are important factors
27

28. GENERAL EVALUATION: Physical Examination
• A thorough pelvic examination is performed to
o Assess for an adnexal mass in a symptomatic patient and
o Determine its characteristics
• A finding of an adnexal mass on pelvic examination should be further evaluated with
pelvic imaging
Imaging may reveal
o An adnexal mass
o No mass or
o A mass that derives from another anatomic location in
 The genital (eg, uterine leiomyoma)
 Gastrointestinal tract (eg, mucocele of the appendix)
 Urinary tract (eg, urachal cyst) or
 Other sites (eg, enlarged mesenteric lymph nodes)
28

29. GENERAL EVALUATION: Physical examination …
• The absence of an adnexal mass on examination does not fully exclude the
presence of a pelvic mass
Small adnexal masses are difficult to palpate due to the deep anatomic location of the
ovary
Larger masses can float out of the pelvis and be difficult to feel
Ovaries are not usually palpable in postmenopausal women
A finding of a palpable ovary in this population should prompt pelvic imaging to assess for
an ovarian or tubal neoplasm
29

30. GENERAL EVALUATION: Physical examination …
• The size, consistency and mobility of a mass, if present, should be noted
Features that are suggestive of malignancy include
o A solid mass
o Irregular or fixed or
o Associated with posterior cul-de-sac nodularity
Endometriomas & tuboovarian abscesses are benign lesions that may be fixed &
irregular
Posterior cul-de-sac nodularity is highly suspicious for malignancy in a
postmenopausal woman, but may signify endometriosis in a premenopausal woman
• Patients with an inflammatory process exhibit tenderness with palpation of
the adnexal mass (eg, tuboovarian abscess)
However, some patients with an ovarian neoplasm have tenderness on pelvic
examination
30

31. GENERAL EVALUATION: Physical examination …
• Rectovaginal examination is performed to allow palpation of the ovary
posteriorly
A rectal mass or positive fecal occult blood testing is not usually associated
with an adnexal mass
These findings should be noted, if present, and further evaluated for colorectal cancer
or other conditions, as appropriate
A rectal mass is an uncommon finding in epithelial ovarian cancer (EOC) since
direct transmural extension is rare
Infrequently, rectal bleeding may occur in cases of rectal endometriosis or clear
cell or endometrioid cancers arising in endometriotic implants in the rectal wall
31

32. GENERAL EVALUATION: Physical examination …
• Presacral tumors may also occur
On physical examination, a presacral mass will be posterior to the rectum, while
an ovarian mass will be anterior to the rectum
The location of the mass can then be confirmed with imaging studies
• Abdominal examination includes assessment for abdominal distention &
ascites and/or an abdominal mass
The diagnosis of malignancy is almost certain in patients with both
o A fixed, irregular pelvic mass and
o An abdominal mass or ascites
32

33. GENERAL EVALUATION: Physical examination …
• If malignancy is suspected, the examination should also include sites of
cancer that may metastasize to the ovaries (eg, stomach, colorectal, breast)
• If there is a moderate to high suspicion of ovarian cancer, further
examination should be performed of potential sites of EOC metastases
Rectum, liver, spleen, lungs, inguinal or supraclavicular lymph nodes
33

34. GENERAL EVALUATION: Imaging studies
• Pelvic ultrasound is the imaging study of choice for the evaluation of an
adnexal mass
Ultrasound is relatively less expensive than other imaging modalities and its diagnostic
performance is similar
Both a transvaginal and transabdominal ultrasound should be obtained in most patients
Transabdominal ultrasound is
Better tolerated and
More helpful in visualizing abdominal processes
Transvaginal ultrasound provides better resolution of pelvic structures with less
artifact and does not require a distended bladder
34

35. GENERAL EVALUATION: Imaging studies …
• A definitive diagnosis of the type of adnexal mass can be made only with
histologic evaluation, not with imaging
Simple ovarian cysts, hemorrhagic cysts, endometriomas and teratomas often have
characteristic ultrasound features that are highly predictive of the histologic
diagnosis
• Magnetic resonance imaging should be used as a second imaging study if
further imaging is needed to decide whether to proceed with surgical
evaluation
Ovarian masses with an indeterminate appearance on ultrasound are typically
o Hemorrhagic masses in which mural clot can appear solid on ultrasound
o Mature teratomas with an atypical appearance or
o Solid ovarian neoplasms
35

36. GENERAL EVALUATION: Laboratory Evaluation
• Laboratory evaluation depends upon the clinical scenario:
o Pregnancy testing with a urine or serum human beta chorionic gonadotropin
should be performed in any reproductive-age woman who presents with an
adnexal mass
o A complete blood count should be drawn
If anemia is suspected due to bleeding in the setting of an ectopic pregnancy,
ruptured or hemorrhagic ovarian cyst, or
To assess for leukocytosis in patients with a tuboovarian abscess
36

37. EVALUATION FOR URGENT CONDITIONS
• Women who present with an abrupt onset of severe pain, first trimester
bleeding, or fever require evaluation in an emergency department or other
urgent care setting
37

38. EVALUATION FOR URGENT CONDITIONS:
First Trimester Bleeding or Pain
• Adnexal masses found in early pregnancy include ectopic pregnancy or corpus
luteum cyst
These two masses are usually easily differentiated on pelvic ultrasound
• A corpus luteum
Is a normal finding and
Is not associated with vaginal bleeding or pain
• Ectopic pregnancy
The finding of an adnexal mass (which is not consistent on ultrasound with a corpus luteum)
in a pregnant patient with no confirmed intrauterine pregnancy, particularly if
accompanied by pelvic pain or vaginal bleeding should be considered an ectopic
pregnancy until proven otherwise
Immediate evaluation & treatment are required for this potentially life-threatening condition
The fallopian tube is the most common site of an ectopic pregnancy, although ovarian
pregnancy may also occur
38

39. EVALUATION FOR URGENT CONDITIONS:
Acute pelvic or abdominal pain
• The abrupt onset of severe pain in a woman with an adnexal mass may be
associated with
o Adnexal torsion
o Rupture of an ovarian cyst or
o A ruptured ectopic pregnancy
39

40. EVALUATION FOR URGENT CONDITIONS:
Acute pelvic or abdominal pain …
• Adnexal torsion
Typically presents with an abrupt onset of severe pelvic pain, and is often accompanied
by nausea and vomiting
Urgent surgical treatment is required to avoid
o Ischemic injury and
o Loss of ovarian and tubal function
40

41. EVALUATION FOR URGENT CONDITIONS:
Acute pelvic or abdominal pain …
• Ruptured or hemorrhagic ovarian cyst
 The classic presentation of a ruptured ovarian cyst is an abrupt onset of severe pain in
the mid-menstrual cycle immediately following sexual intercourse
 In ovulatory patients, a follicular cyst forms mid-cycle, followed by a corpus luteum
 These are typically physiologic cysts
 The cysts are more likely to rupture in the luteal phase and this may be
o Spontaneous or
o Triggered by activity like sexual intercourse
 A cyst may also become hemorrhagic without rupture
 Immediate surgical intervention is required only if there is concern that brisk bleeding
from the cyst may cause
o Anemia or
o Hemodynamic instability
 Other patients may be managed with
o Pain management and
o Follow-up for resolution of the pain and the mass
41

42. Evaluation For Urgent Conditions: Fever
• Patients with an adnexal mass & fever should be evaluated for:
o Tuboovarian abscess
o Periappendiceal abscess
o Diverticular abscess
o Adnexal torsion (infrequently)
42

43. Evaluation For Urgent Conditions: Fever …
• Tuboovarian abscess
The classic presentation of a tuboovarian abscess includes:
o Acute lower abdominal pain
o Fever, chills
o Vaginal discharge and
o An adnexal mass
Pelvic imaging typically shows a complex multilocular mass that obliterates normal
adnexal architecture
Timely diagnosis and management are required to
o Diagnose or avoid sepsis and
o Prevent further damage to the ovaries and fallopian tubes
Many women with tuboovarian abscess, particularly the elderly, are asymptomatic
43

44. EVALUATION FOR MALIGNANCY
• One of the principal goals of the evaluation of an adnexal mass is to determine
whether it is benign or malignant
• The types of malignant adnexal masses include:
o Ovarian cancer
 The most common histologic type is epithelial ovarian carcinoma (EOC)
o Fallopian tube or peritoneal carcinoma
 Women with peritoneal carcinoma may present with or without an adnexal mass
 High grade serous EOC, fallopian tube and peritoneal carcinomas are considered a single
clinical entity to their shared clinical behavior & treatment and there is accumulating evidence
of a common pathogenesis
o Metastatic disease from another primary cancer
 Gastric and breast cancer are the most common malignancies that metastasize to the ovaries
44

45. Evaluation For Malignancy …
• Excluding malignancy is typically a two-phase process
An initial evaluation is performed to establish the degree of clinical suspicion that a mass
is malignant
If malignancy is suspected, surgical exploration is performed to make a definitive diagnosis
• The likelihood that an adnexal mass is malignant depends mainly upon one or more
of the following factors:
o Imaging study findings that are consistent with malignancy
o Age or menopausal status
o Risk factors
o Laboratory results
• If malignancy is suspected based upon these factors, surgical exploration is
required to obtain a specimen for histologic diagnosis
45

46. Evaluation For Malignancy …
• There is no minimally invasive biopsy technique for ovarian cancer
This is because patients with early stage disease (i.e., no malignant cells in
ascites or peritoneal cytology) benefit from removal of the adnexal mass
intact, since opening the mass results in a more advanced stage and adversely
affects prognosis
Image-guided ovarian biopsy is not performed and, unfortunately, many women
undergo surgical procedures to identify the few who have a malignancy
• If the mass can be successfully removed without disruption via a minimally
invasive technique, this is preferred
46

47. Evaluation For Malignancy: Initial Evaluation
• The goal of the initial evaluation is to determine the degree of clinical
suspicion of malignancy
47

48. EVALUATION FOR MALIGNANCY: Initial Evaluation …
Medical History
• The age and menopausal status of the patient help to guide the process of evaluation
 The highest proportion of malignancy found in an adnexal mass in
o a postmenopausal woman or
o a child or adolescent
• Patients with an adnexal mass should be asked about symptoms associated with ovarian cancer
 Pelvic or abdominal pain or pressure, bloating, or gastrointestinal or urinary tract symptoms
 These symptoms are typically mild to moderate and develop over a period of weeks or months
• It is common for ovarian cancer to be asymptomatic or to present at an advanced stage with an
acute condition and associated symptoms (eg, bowel obstruction, pleural effusion)
• Infrequently, a malignant mass may rupture or torse and present with acute pain
• Ovarian tumors that secrete hormones may present with symptoms related to
 Estrogen excess (abnormal uterine bleeding) or
 Androgen excess (virilization or hirsutism)
48

49. EVALUATION FOR MALIGNANCY: Initial Evaluation …
49

50. EVALUATION FOR MALIGNANCY: Initial Evaluation …
• The presence of risk factors for EOC or other histologic types of ovarian cancer is a
key determinant of clinical suspicion of the disease
• Patients with an adnexal mass should be asked about a family history of ovarian,
breast, uterine, or colon cancer
 Those with a family history suggestive of a hereditary ovarian cancer syndrome (BRCA gene
mutation or Lynch syndrome) should be counseled about genetic testing
 Women with a hereditary ovarian cancer syndrome are at a greatly increased risk of ovarian
cancer and should undergo surgical evaluation if any suspicious adnexal mass is found
 Ovarian Ca risk in BRCA1/2 carriers to age 70 years (from multiple studies)
o BRCA1: Approximately 40%
o BRCA2: Approximately 15%
 The incidence of ovarian cancer diagnosed younger than 50 yrs of age is higher in BRCA1
carriers, and overall rare in all carriers younger than 40 yrs old; risk of fallopian tube cancer is
also substantially elevated
 General population risk to age 70 years is <1%
50

51. EVALUATION FOR MALIGNANCY: Initial Evaluation …
51

52. EVALUATION FOR MALIGNANCY: Initial Evaluation …
Physical Examination
• Look in the general evaluation part (above)
52

53. EVALUATION FOR MALIGNANCY: Initial Evaluation …
Imaging Studies
• Pelvic ultrasound
is the first line imaging study for the evaluation of an adnexal mass
The sensitivity of pelvic ultrasound for the diagnosis of ovarian cancer ranged from
86-91% and the specificity ranged from 68-83% in a large meta-analysis
Use of a second imaging study after ultrasound is reasonable if a clinician can’t
determine whether surgical evaluation is warranted based upon the results of
ultrasound and the other components of the initial evaluation
Additional imaging studies may be necessary to evaluate the abdomen or
other sites in patients with suspected metastatic ovarian cancer
53

54. EVALUATION FOR MALIGNANCY: Initial Evaluation …
54

55. EVALUATION FOR MALIGNANCY: Initial Evaluation …
Laboratory Studies
• Serum biomarkers contribute to the evaluation of an adnexal mass for
malignancy
Their utility is limited
• Preoperative measurement of biomarkers in women with possible ovarian
cancer has several additional functions
A baseline level is established for use for further monitoring during and after treatment
Biomarkers may play a role in predicting whether optimal cytoreduction is feasible
55

56. EVALUATION FOR MALIGNANCY: Initial Evaluation …
Laboratory Studies …
Serum markers for epithelial ovarian carcinoma
• Serum CA 125
Is the most commonly used laboratory test for the evaluation of adnexal masses for
EOC
Measured in all postmenopausal women with an adnexal mass
In premenopausal women, serum CA 125 is measured only if the ultrasound
appearance of a mass raises sufficient suspicion of malignancy to warrant a
repeat ultrasound or surgical evaluation
• Biomarkers that are used to decide whether to refer a patient with suspected
EOC to a gynecologic oncologist are OVA1 and the Risk of Malignancy
Algorithm
56

57. EVALUATION FOR MALIGNANCY: Initial Evaluation …
Laboratory Studies …
Serum markers for other histologic types
• Germ cell & sex cord-stromal tumors may secrete hormones or other
substances that can be detected preoperatively to contribute to the diagnostic
evaluation
In many cases, however, the diagnosis of these histologic types is made only upon
postoperative pathology evaluation of the ovary
• Clinical scenarios in which markers for these tumors should be drawn include:
o A child or adolescent who presents with an adnexal mass
 Since the most likely histology of an ovarian neoplasm is a germ cell tumor in this population
o Patients with an adnexal mass who present with symptoms or signs of estrogen excess
(AUB) or androgen excess (virilization or hirsutism)
 May have a germ cell or sex cord-stromal tumor
57

58. EVALUATION FOR MALIGNANCY: Initial Evaluation …
Laboratory Studies …
Serum markers for other histologic types
• Germ cell and sex cord-stromal tumors may secrete hormones or other
substances that can be detected preoperatively to contribute to the diagnostic
evaluation
In many cases, however, the diagnosis of these histologic types is made only upon
postoperative pathology evaluation of the ovary
• Clinical scenarios in which markers for these tumors should be drawn include:
o A child or adolescent who presents with an adnexal mass, since the most likely histology
of an ovarian neoplasm is a germ cell tumor in this population.
o Patients with an adnexal mass who present with symptoms or signs of estrogen excess
(abnormal uterine bleeding) or androgen excess (virilization or hirsutism) may have a germ
cell or sex cord-stromal tumor
58

59. EVALUATION FOR MALIGNANCY:
Surgical Exploration
• Surgical exploration is performed if the initial evaluation results in sufficient
suspicion of a malignant adnexal mass
• Surgical evaluation allows a definitive histologic diagnosis
• If a malignancy is present, the surgeon may proceed with staging and
cytoreduction
59

60. REFERRAL TO A SPECIALIST
• The following patients should be referred to a gynecologic oncologist for further
evaluation:
o Patients with a complex adnexal mass
o Findings suggestive of metastatic epithelial ovarian cancer (EOC), fallopian tube or
peritoneal carcinoma, or
o Laboratory testing suggestive of ovarian cancer (eg, elevated serum CA 125)
• Patients in whom there is a high suspicion of EOC should be referred to a
gynecologic oncologist
There is evidence that prognosis is improved when EOC staging and cytoreduction is
performed by a gynecologic oncologist
• Criteria for referral to a gynecologic oncologist:
60

61. REFERRAL TO A SPECIALIST …
• Patients with a complex adnexal mass, findings suggestive of metastatic
epithelial ovarian cancer (EOC), fallopian tube or peritoneal carcinoma, or
laboratory testing suggestive of ovarian cancer (eg, elevated serum CA 125)
should be referred to a gynecologic oncologist for further evaluation
• Patients in whom there is a high suspicion of EOC should be referred to a
gynecologic oncologist
There is evidence that prognosis is improved when EOC staging and
cytoreduction is performed by a gynecologic oncologist
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62. SUMMARY AND RECOMMENDATIONS
• An adnexal mass (mass of the ovary, fallopian tube, or surrounding connective
tissue) is a common gynecologic problem
An adnexal mass may be found in females of all ages, fetuses to the elderly, and there is a
wide variety of etiologies
• Some patients with an adnexal mass present with symptoms or physical
examination findings
Pelvic pain or pressure is the most common symptom of an adnexal mass
Other potential symptoms or signs include abnormal genital tract bleeding, abdominal
distension, ascites, or hirsutism
Many adnexal masses are asymptomatic and the mass is discovered as an incidental
finding on pelvic imaging
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63. SUMMARY AND RECOMMENDATIONS …
• The goal of the evaluation of a patient with an adnexal mass is to determine the
most likely etiology of the mass
• The process of evaluation includes:
o A general evaluation to
 Confirm the presence and anatomic location of the mass and
 Identify any associated symptoms or physical findings
o A focused evaluation for conditions that require immediate treatment for patients who
present with first trimester bleeding, acute pain, or fever
o A focused evaluation to exclude malignancy if the results of the general evaluation raise the
suspicion that the adnexal mass is malignant
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64. SUMMARY AND RECOMMENDATIONS …
• The medical history includes questions regarding symptoms associated with an
adnexal mass and risk factors for ovarian or fallopian tube cancer
A thorough pelvic examination is performed to assess for an adnexal mass and determine its
characteristics
Features that are suggestive of malignancy include a solid mass that is irregular or fixed or
is associated with posterior cul-de-sac nodularity
On the other hand, some benign lesions may have these features
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65. SUMMARY AND RECOMMENDATIONS …
• Pelvic ultrasound is the first line imaging study for the evaluation of an adnexal
mass
Ultrasound is relatively less expensive than other imaging modalities and its diagnostic
performance is similar
Use of a second imaging study after ultrasound is reasonable if a clinician cannot determine
whether surgical evaluation is warranted based upon the results of ultrasound and the other
components of the initial evaluation
• Laboratory evaluation includes a pregnancy test in patients of reproductive-age
and tests to evaluate for malignancy or other conditions
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66. REFFERENCES
• Uptodate 2018
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