1) Adnexal masses are common gynecological findings that are usually benign. Differential diagnosis includes physiologic cysts, endometriomas, fibroids, and malignancies. 2) Evaluation involves history, physical exam, ultrasound, and tumor markers like CA-125. Ultrasound can identify features suggestive of malignancy such as solid components, blood flow, thick septations, large size, and ascites. 3) For premenopausal women, small unilateral cystic masses may be followed with ultrasound in a few months. Larger or complex masses require surgery. Postmenopausal women with cysts under 10cm may also be followed, but require close monitoring for changes that

1. ―Clinical management of adnexal masses”
PROF. SANTIAGO DEXEUS
Dr. Gustavo Missón

2. Introduction
 Adnexal masses are the fourth most
common gynecological cause for
hospitalization and 90% have benign
characteristics.

3. Adnexal Mases USA
ANNUAL HOSPITALIZATION: 289000 PATIENTS
RISK OF
MALIGNANCY
13% in pre menopause
45% in post menopause
L Van Lie (2000)
48 Meeting of the ACOG

4. ADNEXAL MASSES
N= 4.359
October 1991 – October 1999
average: 37.22 years (14-85)
Rate of malignancy: 2.1%
IUDEXEUS-1999

5. ADNEXAL MASSES
Color Doppler
Absence of pathological flow
3.0% Malignant tumor
Kurjak et al,1993
4.2% Malignant tumor
MªA Pascual y col.,1996

6. PRIORITY
 Differential diagnosis
 Diagnostic studies and interpretation
 Management

7. Anatomy
 ―Adnexa‖
› Area next to the
uterus containing
ligaments, vessels,
tubes, ovaries

8. Background
 Prevalence of adnexal masses is 2
to 8%
› Random TVUS of 335 asymptomatic
premenopausal women, 7.8% with
adnexal masses 2.5 cm or larger (6.6%
were ovarian cysts.
› Transvaginal sonographic ovarian findings in a random sample of women 25-40 years old.
Ultrasound Obstet Gynecol 1999 May;13(5):345-50.

9. Background
 Prevalence of adnexal masses is 2
to 8%
› TVUS in 8794 asymptomatic
postmenopausal women, 2.5% were
found to have adnexal cysts
› Alcazar JL; Jurado M. Natural history of sonographically detected simple unilocular adnexal
cysts in asymptomatic postmenopausal women. Gynecol Oncol 2004 Mar;92(3):965-9.

10. Differential Diagnosis
 Physiologic cysts
› Follicle develops but never ruptures, continues to
grow
› Simple, smooth-walled
 Functional cysts
› Corpus luteum does not involute or continues to
grow
 Most are small (<2.5 cm), but can be larger
 Usually no symptoms, unless rupture or torsion

11. Differential Diagnosis
 Ectopic pregnancy
 PID
 Hydrosalpinx
 Benign neoplasms
› Serous or mucinous cystadenoma
› Endometrioma
› Cy.Dermoid
› Fibroids (exophytic, broad ligament)
 Malignancy
› Primary vs. mts

12. Non-Gyn Etiology
 Abdominal
› Appendicitis
› Diverticulitis
› Inflammatory bowel
disease
 Inclusion cysts
› Peritoneal or omental
 Retroperitoneal
masses
› Pelvic kidney

13. Diagnosis: History
 History
› Pain
 Midcycle physiologic or functional cyst
 Dysmenorrhea/dyspareunia endometriosis
 Sudden onset, severetorsion, rupture, hemorrhage
 Chronic aching, bloatingneoplasm
› Nonspecific GI symptoms
 May suggest ovarian cancer in postmenopausal female
 May suggest appendicitis or GI etiology in younger
women
› FH
 Breast, colon, or ovarian cancer

14. Diagnosis: Physical Exam
 Physical exam—should include bimanual
and rectovaginal exam
› Fever PID, appy, diverticulitis
› Shouldn’t be able to palpate a
postmenopausal ovary
› Cul de sac nodularity, tender ligaments
endometriosis
› Cervical motion tendernessPID
› Fixed, irregular, solid may suggest neoplasia

15. Diagnosis: Physical Exam
 Will probably need more than an H&P
to make a diagnosis
› 84 women underwent pelvic examination
prior to surgery, blinded to surgical
indication
› Attending, resident, student examined
patient
› Padilla L, Radosevich D, Milad M. Limitations of the pelvic examination for evaluation of the
female pelvic organs . Int J of Gyn 2005; 88 (1): 84 – 88.

16. Diagnosis: Physical Exam
› Exam is a ―limited screening tool‖ for
detection of adnexal masses
› Sensitivity at detecting adnexal masses: p
>0.04

17. Diagnosis: Labs
 Labs
› β-HCG to exclude ectopic
› RPC if infection suspected
› Tumor makers
 CA-125 (more to come)
 Others useful in adolescents/premenopaual
women with adnexal masses and high
suspicion
 LDHDysgerminoma
 HCGchoriocarcinoma
 AFPEndodermal sinus tumor

18. Malignancy
 Postmenopausal
› Roughly 50 per 100,000 women, relative risk of ~3.5
› 80% of ovarian cancers occur in women over 50
 Family history
 Symptoms
› Vague, chronic aching, bloating, +/- GI symptoms
 Physical examination
› Remember. . . Not really useful
 Ultrasound findings
 CA-125

19. Family History
 Lifetime risk of ovarian cancer in
general population 1.5%
› In BRCA 1 carrier 45-55%
› In BRCA 2 carrier 15-25%
 Not all mutations have been identified
› Two to three relatives with ovarian cancer
increases lifetime risk to 5% (15% if first
degree relatives)
› Carlson KJ; Skates SJ; Singer DE. Screening for ovarian cancer. Ann Intern Med 1994 Jul 15;121(2):124-32.

20. CA-125
 Not specific to ovarian cancer, also elevated
in:
 Other cancers (endometrial, fallopian tube, germ
cell, cervical, pancreatic, breast, colon)
 Benign conditions
(endometriosis, fibroids, PID, adenomyosis, functional
ovarian cysts, pregnancy)
 Other diseases (renal, heart, liver, and many others)
 Also abnormal in 1% of normal females
 Bast R; Klug T; St John E; Jenison E; Niloff J; Lazarus H; Berkowitz R; Leavitt T; Griffiths C; Parker L;
Zurawski V; Knapp R. A radioimmunoassay using a monoclonal antibody to monitor th
 course of epithelial ovarian cancer. N Engl J Med 1983 Oct 13;309(15):883

21. CA-125
 Normal value <35
› Rarely >100-200 in benign conditions

22. CA-125
 Utility as screening tool for ovarian cancer
› CA-125 increased in roughly 80% of ovarian cancers
› About 50% sensitivity for Stage I, 90% for Stage II
 Study of 5550 healthy Swedish women
› Followed women with elevated and normal CA-125
levels
› Serial pelvic exams, U/S, serial CA-125 levels
› Of 175 women with elevated CA-125, 6 with ovarian
cancer
› Of the remaining women with normal CA-125
levels, 3 had ovarian cancer
› Einhorn N; Sjovall K; Knapp RC; Hall P; Scully RE; Bast RC Jr; Zurawski VR Jr. Prospective evaluation of serum CA 125
levels for early detection of ovarian cancer. Obstet Gynecol 1992 Jul;80(1):14-8.

23. CA-125 (follow)

24. BIOMARKERS
› Ca 125
› Ca 19.9
› Ca 15.3
› BCGH
› Alpfa-phetoprotein
› HE-4

25. Ultrasound
Simple cyst
› Less than 2.5 cm
› Unlikely malignant
› Probably a follicle
Homogeneous
appearance may
suggest
endometrioma
www.uptodate.com

26. Ultrasound
 Features suggestive
of malignancy:
› Solid component
› Doppler flow
› Thick septations
› Size
› Presence of ascites or
other peritoneal
masses

27. Ultrasound: The DePriest Score
De Priest PD, Shenson D, Fried A, Hunter JE, Andrew SJ, Gallion HH, et al A morphology index based on sonographic
findings in ovarian cancer. Gynecol Oncol. 1993 Oct;51(1):7-11
 Morphology index
 U/S on 121 patients who
underwent exlap
 Morphology score <5
(80)all benign, 100% NPV
 Morphology score >10 (5)
all malignant, 100% PPV
 Morphology score ≥ 5, 45%
PPV for malignancy
(but, PPV only 14% for
premenopausal women)
 There are other
morphology indices—this is
not the only one

28. So now what?
Management
 Premenopausal females
› If size <10 cm, mobile, cystic,
unilateralfollow, place patient on
monophasic OC, repeat U/S in 2-3 months
 70% of these will resolve8
› If size >10 cm, fixed, solid, or other
concerning featurestake it out
› If mass persists or enlarges at repeat
scantake it out

29. What about the Postmenopausal
Female?
 Modesitt study9
› 15,106 asymptomatic women over 50 who underwent TVUS
› If no abnormalitiesannual screening
› If abnormalrepeat U/S in 4-6 weeks with Doppler and CA-125
› 18% with unilocular ovarian cysts <10 cm in diameter
 69.4% resolved
 5.8% developed solid component
 16.5% developed septum
 6.8% persisted as unilocular
› 10 patients with unilocular lesion who developed ovarian cancer, all
of whom either:
 developed a septum or solid component on U/S,
 underwent complete resolution of the cyst,
 or developed cancer in the contralateral ovary
› Thus. . . The risk of developing ovarian cancer in a woman with a
unilocular, small cyst is VERY low (0.1%)

30. Management
 Postmenopausal
› If asymptomatic, normal exam, simple cyst on U/S, normal
CA-125,unilateral, ≤ 5 cm
 follow with serial U/S and CA-125 q 3-6 months until 12 months,
then annually thereafter
› If above except complex appearance and ≤ 5 cm
 Repeat U/S and CA-125 in 4 weeks
 Resolution
 Persistence or decreasing complexityfollow q 3-6 months with U/S
and CA-125
 Increasing CA-125 or increasing complexitysurgery
› If complex, ≤ 5 cm, and elevated CA-125
 Take it out
› If symptomatic, ≥ 5 cm, clinically apparent, non-simple in
appearance, or elevated CA-125take it out.

31. Management Algorithm (there are many of these)
Van Nagell, JR, et al. Am J of Obstet & Gynecol 2005:193,30-35

32. ADNEXAL MASSES
Anatomical Pathology in surgery
Biopsy of peritoneal implants
Biopsy of growths ovarian / tubal
Cystectomy / oophorectomy
Concordance with definitive biopsy > 95%

33. When should I refer to an
oncologist?
ACOG Guidelines:
 Premenopausal (< 50 Years Old)
› CA-125 > 200 U/mL
› Ascites
› Evidence of abdominal or distant metastasis (by exam or imaging
study)
› Family history of breast or ovarian cancer (in a first-degree relative)
 Postmenopausal (>= 50 Years Old)
› CA-125 > 35 U/mL
› Ascites
› Nodular or fixed pelvic mass
› Evidence of abdominal or distant metastasis (by exam or imaging
study)
› Family history of breast or ovarian cancer (in a first-degree relative)
ACOG Committee Opinion: number 280, December 2002. The role of the generalist
obstetrician-gynecologist in the early detection of ovarian cancer. Obstet Gynecol 2002;100:1413–6

35. Thank you by you attention
www.santiagodexeus.com