This document summarizes guidelines for managing adnexal masses from the SOGC in 2020. It discusses examining patients with adnexal masses through history, physical exam, investigations including ultrasound, lab tests, cancer antigen 125 levels, and the risk of malignancy index. Ultrasound is emphasized for distinguishing benign from malignant features, with IOTA criteria outperforming RMI. Referral to a gynecologic oncologist is recommended for suspected malignancy based on sonographic features, family history, clinical findings or indeterminate ultrasound results.

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MANAGEMENT OF ADNEXAL
MASSES
SOGC, 2020
Prof. Aboubakr Elnashar
Benha University Hospital, Egypt
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CONTENTS
 INTRODUCTION
I. HISTORY
II. EXAMINATION
III. INVESTIGATIONS.
1. ULTRSONOGRAPHY
2. LAB TESTING
3. CANCER AG
4. THE RISK MALIGNANCY INDEX
 CONCLUSION
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INTRODUCTION
 Adnexal masses
 lumps that appear near the uterus or in or around the
ovaries, fallopian tubes, or surrounding connecting tissues
 common
 Although the majority of these masses are benign, the
primary goal of assessment is to rule out ovarian cancer.
 Ovarian cancer outcomes
 improved when initial surgery is performed by a
gynaecologic oncologist as opposed to a general
gynaecologist or general surgeon
 {appropriate surgical staging & optimal cytoreduction}.
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 Ultrasound criteria
 Distinguishing benign vs malignant features of an adnexal
mass is emphasized
 IOTA criteria
 Outperform the RMI
 Demand further exploration & discussion in
contemporary guidelines.
 Tumour markers
 unreliable in early stage malignancy
 histology dependent
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I. HISTORY
 Take a detailed history
 Personal &family can guide decisions on further testing &
evaluation
 For a woman with a personal history of infertility, endometriosis,
or cancer or a family history of cancer, refer the patient to a
gynaecologic oncologist for further evaluation if possible (strong)
 The majority of women with ovarian cancer have symptoms in
the year prior to their diagnosis, although these symptoms can
be vague (low).
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II. PHYSICAL EXAMINATION
 General:
 Lymph node survey, respiratory examination to rule out
pleural effusion or consolidation,
 Breast & axillary examination to rule out breast malignancy
 Abdominal for ascites, omental caking, and organomegaly
 Pelvic including a bimanual
 Rectovaginal, to assess for mass size, contour, mobility, and
parametrial, bladder, and rectal abnormality (strong, low)
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III. INVESTIGATIONS
1. ULTRASONOGRAPHY
 Using either
 Subjective pattern recognition (best in the hands of an
expert sonographer) or
 The risk prediction model developed by IOTA group (strong,
moderate).
 allows sonographers with varying degrees of expertise to
use uniform terminology & accurately classify these
masses as
 “likely malignant,”
 “benign,” or
 “indeterminate” (moderate).
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Malignant (M) Rules
 M1: Irregular solid tumour
 M2: Presence of ascites
 M3: Presence of at least 4
papillary structures
 M4: Irregular multilocular-
solid tumour, with largest
diameter ≥100 mm
 M5: Very strong blood flow
(colour score 4)
Benign (B) Rules
 B1: Unilocular cyst
 B2: Presence of solid
components, with largest
diameter <7 mm
 B3: Presence of acoustic
shadows
 B4: Smooth multilocular tumour,
with largest diameter <100 mm
 B5: No blood flow (colour score
1)
International Ovarian Tumor Analysis group simple rules for
tumour identification: malignant and benign sonographic features
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 Refer to a gynaecologic oncologist any of the following
sonographic features, suggestive of malignancy:
1. Solid component with strong or central colour flow
2. ≥4 papillary projections (defined as >3 mm in height)
3. Thick multiple irregular septations
4. Ascites & peritoneal nodularity.
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 While awaiting a gynaecologic oncologist consult, where
resources permit, pursue further investigations
1. Tumour marker levels
2. CT scan of the chest, abdomen, and pelvis, as appropriate
(strong, moderate).
 Women with adnexal masses with indeterminate features
should be evaluated by
 US conducted by an expert sonographer (if available) or
 MRI or
 Referred to a gynaecologic oncologist (strong, low).
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2. LABORATORY TESTING
 Can aid in DD of an adnexal mass.
 Testing for sexually transmitted infection with
results showing leukocytosis can help identify tubo-
ovarian abscesses
 Pregnancy test can lead to diagnosis of possible
ectopic pregnancies (low).
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3. CANCER ANTIGEN 125
 Non-specific glycoprotein that can be elevated in
 benign & malignant gynaecologic conditions
 non-gynaecologic conditions (moderate).
 Only half of all early stage ovarian cancers & 80% of advanced
stage ovarian cancers show elevated cancer antigen 125 levels
(moderate).
 The sensitivity & specificity are higher in women who are
postmenopausal
{many of the benign clinical conditions that can increase the level of cancer
antigen 125 occur in the premenopausal population, while most cases of
epithelial ovarian, fallopian tube, and peritoneal cancer occur in the
postmenopausal population (moderate)}.
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 Asymptomatic women without a pelvic or adnexal mass: Do not
use CA 125 testing as a screening tool(strong, moderate).
 <40 years of age with an adnexal mass, rare forms of ovarian
cancer must be considered:
 HCG,
 lactate dehydrogenase
 alpha-fetoprotein, should be obtained (strong,low).
 Bilateral masses with features of malignancy:
 carcinoembryonic antigen and
 cancer antigen, along with
 referral to a gynaecologic oncologist are recommended
(strong, moderate).
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4. THE RISK OF MALIGNANCY INDEX: RMI2
 Items
 CA 125
 Sonographic features
 Menopausal status
 Outperformed by IOATA group’s logistic regression model 2 &
simple rules.
 Sensitivity: 57%
 Specificity: 87% (moderate).
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CONCLUSION
 An important first step during the initial assessment of a
patient with an adnexal mass is the ability to appropriately
triage her care by either referring the patient to a gynaecologic
oncologist for suspected malignancy or continuing to provide care
 The optimal prediction method of triage is
 US by an expert sonographer or in conjunction with
 medical& family history and clinical findings.
 Additional imaging and tumour marker tests may be indicated.
 Referral to gynaecologic oncologist for any indeterminate
cases, or suspected malignancy.
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