This document discusses the diagnosis and management of adnexal masses. It provides information on the normal size and variation of ovaries and lifetime risk of ovarian neoplasms. Differential diagnoses of adnexal masses are outlined based on patient age. Diagnostic evaluation includes physical exam, ultrasound, CT or MRI if needed. Common ovarian tumors at different life stages are described. Functional cysts, endometriomas, benign and borderline tumors are discussed. Complications, clinical presentation, imaging and tumor markers are summarized. Guidelines for management of asymptomatic cysts and indications for surgery are provided.

1. DR. SRAVANTHI
DR. CHINMOY
DR. MINAKSHI

2. NORMAL OVARIES
 Normal size 5 x 3 x 3cm
 Variation in dimensions can result from
 Endogenous hormonal production(varies with age and
menstrual cycle)
 Exogenous substances, including OCs, GnRH agonists, or
ovulation-inducing medication, may affect size

4. Lifetime Risk of ovarian neoplasm
 A woman has 5–10% lifetime risk of undergoing surgery
for a suspected ovarian neoplasm and
 13–21% of these will be found to be have an ovarian
malignancy

5. DIFFERENTIAL DIAGNOSIS OF ADNEXAL MASS
ORGAN CYSTIC SOLID
OVARY Functional cyst, Neoplastic cyst, Neoplasm
Benign, Malignant, Endometriosis Benign
Malignant
FALLOPIAN Tubo-ovarian abscess Tubo-ovarian abscess
TUBES Hydrosalpinx Ectopic pregnancy
Paraovarian cyst Neoplasm
UTERUS Intrauterine pregnancy in a bicornuate Pedunculated or
uterus inteligamentous myoma
BOWEL Sigmoid or caecum distended with gas Diverticulitis, Ileitis,
or feces Appendicitis, Colonic cancer
MISCELLANEOUS Distended bladder, Pelvic kidney, Abdominal wall hematoma or
Urachal cyst abscess, retroperitoneal

6.  Differential diagnosis of the adnexal masses varies considerably with
the age of the patients.
 In pre-menarchal girls and post-menopausal women adnexal mass
should be considered highly abnormal – requires immediate
investigation.
 In menstruating patients differential diagnosis is varied.

7. DIAGNOSTIC EVALUATION OF THE PATIENT WITH AN
ADNEXAL MASS
 Complete physical examination
 Pelvic ultrasound examination
 Computed tomography scan with contrast enhancement or
intravenous pyelography
 Colonoscopy or barium enema study, if symptomatic
 Laparoscopy, laparotomy

8. OVARIAN
MASSES
FUNCTIONAL INFLAMMATORY NEOPLASTIC OTHERS
ENDOMETRIOMA
FOLLICULAR CYST TUBO OVARIAN ABSCESS BENIGN
ENLARGED PCO
CORPUS LUTEUM BORDERLINE
PAROVARIAN CYST
CYST MALIGNANT
THECA LUTEIN

9. COMMON OVARIAN TUMOURS
Infancy Pre pubertal Adolescent Reproductive Peri Post
Menopausal Menopausal
1 Functional Functional Functional Functional Epithelial Neoplastic
cyst cyst cyst cyst ovarian ovarian
tumor tumor
2. Germ cell Germ cell Germ cell Dermoid Functional Functional
tumor tumor tumor cyst cyst
3. Epithelial Epithelial Mets
tumor tumor

10. Functional ovarian cysts
 Follicular cysts
 Corpus luteum cysts
 Theca lutein cysts
 Luteomas of pregnancy
 By far the most common clinically detectable enlargements
of the ovary in the reproductive years.
 All are benign and usually asymptomatic.

11. Follicular cysts
 Cystic follicle is defined as Follicular cyst of diameter > 3cm
 Most common functional cysts.
 Rarely larger than 8cm.
 Lined by granulosa cells
 Found incidentally on pelvic examination
 Usually resolve within 4 – 8 weeks with expectant management
 May rupture or torse occasionally causing pain and peritoneal
symptoms.

12. Follicular cysts

13. Corpus luteal cyst
 Less common than follicular cyst.

 May rupture leading to hemoperitoneum and requiring surgical
management( more in patients taking anti coagulants or with
bleeding diathesis)
 Unruptured cysts may cause pain because of bleeding into
enclosed ovarian cyst cavity.

14. Corpus luteal cyst

15. Theca lutein cysts
 Least common
 Usually bilateral
 Result from overstimulation of the ovary by β- hCG
 Do not commonly occur in normal pregnancy
 Often associated with hydatidiform moles, choriocarcinoma,
multiple gestations, use of clomiphene and GnRH analogues.
 May be quite large (up to 30 cm) , multicystic, and regress
spontaneously.

16. Theca lutein cysts

17. Management of functional cysts
 Expectant
 Watchful waiting for two or three cycles is appropriate.
 Combined oral contraceptives appear to be of no benefit.
 Should cysts persist, surgical management is often
indicated.
Oral contraceptives for functional ovarian cysts (Review)
Cochrane Database of Systematic Reviews 2011

18. Endometriomas
 Most common site of involvement is the ovary.
 Endometriomas are pseudocysts formed by invagination of the ovarian
cortex, sealed off by adhesions.
 They may completely replace normal ovarian tissue. Cyst walls are usually
thick and fibrotic.
 USG: anechoic cysts to cysts with diffuse low-level echoes to solid-
appearing masses.
Fluid–fluid or debris–fluid levels may also be seen.
They may be unilocular or multilocular with thin or thick septations
 Malignant transformation: 0.3% to 0.8%
 Management: medical and/ or surgical

21. Benign ovarian tumors
 Serous cystadenoma
 Mucinous cystadenoma
 Dermoid cyst
 Fibroma
 Thecoma
 Brenner‟s tumor

22. SEROUS CYSTADENOMA
 Generally benign
 Bilateral – 10%
 Risk of malignancy : 5 – 10 % borderline malignant
20 -25% malignant
 GROSS : multilocular with papillary components.
 MICRO : low columnar epithelium with cilia.
 Characteristic psammoma bodies (end products of degeneration
of papillary implants)are found.
 Associated fibrosis may lead to “cystadenofibroma”

24. MUCINOUS CYSTADENOMA
 Have tendency to become huge masses
 Round to ovoid masses with smooth capsules that are
usually translucent or bluish to whitish gray.
 Interior divided by discrete septa into loculi containing
clear , viscid fluid.
 Epithelium – tall, pale staining, secretary with basal nuclei
and goblet cells
 5 – 10% are malignant

26. DERMOID CYST
 Often bilateral (15 -25%)
 GROSS: thick, opaque , whitish wall.
 CONTENTS: hair, bone, cartilage, and a large amount of greasy sebaceous
material.
 MICROSCOPICALLY : all the three germ layers (ectoderm, mesoderm and
endoderm)
 Malignant change occurs in 1-3%. Usually of a squamous type.
 Risk of torsion is 15%
 An ovarian cystectomy is almost always possible, even if it appears that
only a small amount of ovarian tissue remains

29. FIBROMA
 Most common benign, solid neoplasms of the ovary.
 Compose approx 5% of benign ovarian neoplasms and 20% of all solid
tumors of the ovary.
 Frequently seen in middle-aged women.
 Characterized by their firmness and resemblance to myomas
 Misdiagnosed as exophytic fibroids or primary ovarian malignancy
 Not hormonally active
 Fibromas may be associated with ascites or hydrothorax as a result of
increased capillary permeability thought to be a result of VEGF
 Mieg’s syndrome (ovarian fibromas, ascites and hydrothorax) is uncommon
and usually resolves after surgical excision.

31. THECOMA
 Solid fibromatous lesions that show varying degrees of yellow or
orange discoloration
 Almost always confined to one ovary
 Usually >40 years, 65% after menopause
 May be hormonally active and hence associated with estrogenic or
occasionally androgenic effects.
 Luetinised thecoma – younger, sclerosing peritonitis and ascites
 Leydeig cell thecoma – ass. with Reinke crystals
 Rarely malignant

32. BRENNER TUMOR
 Uncommon tumor grossly identical to fibroma
 Arise from Walthard cell rests ,also from surface epithelium, rete
ovarii and ovarian stroma
 On microscopy – markedly hyperplastic fibromatous matrix
interspersed with nests of epitheloid cells showing coffee bean
pattern
 Considered uniformly benign. But scattered reports of malignant
Brenner‟s available
 Endocrinologically inert, but could be ass. with virilization and
endometrial hyperplasia

34. GONADOBLASTOMAS
 Gonadoblastoma is a rare benign tumor that has the potential for malignant
transformation and affects a subset of patients with an intersex disorder or
disorder of sex development (DSD).
 Contain both germ cells and sex cord stromal cells.
 Arise in patients with dysgenetic gonads - 46 XY f/b 45XO/ 46 XY mosaic.
 Presents usually as phenotypic female <30 years with primary amenorrhea
and virilization.
 Treatment – laparoscopy or laparotomy with removal of b/l dysgenetic
gonads.
 Further treatment depends on malignant germ cell component

35. CLINICAL PRESENTATION
 Asymptomatic – accidentally discovered on USG
 Chronic pattern of pain, increasing abdominal girth over months or weeks.
 Associated with secondary symptoms of anorexia, nausea, vomiting, urinary
frequency.
 Could be associated with primary or secondary amenorrhea, menstrual
irregularities, virilization, precocious puberty
 Become acutely symptomatic if undergoes torsion, rupture or haemorrhage.
Benign ovarian neoplasms are indistinguishable clinically from malignant
counterparts

36. COMPLICATIONS
 Torsion
 Intracystic hemorrhage
 Infection
 Rupture
 Pseudomyxoma peritonei
 Malignancy

38. PHYSICAL EXAMINATION
 Abdominal and vaginal examination and the presence or
absence of local lymphadenopathy
 Assess
 Laterality
 Cystic Vs solid
 Mobile Vs fixed
 Smooth Vs irregular
 Ascites
 Cul-de-sac nodules
 Rapid growth rate

39. TVS
 Pattern recognition is superior to all other scores.
 Subjective evaluation of ovarian masses based on pattern
recognition can achieve sensitivity of 88% to 100% and
specificity of 62% to 96%.
 Adding doppler does not seem to yield much improvement in
the diagnostic precision, but increases the confidence with
which a correct diagnosis of benignity or malignancy is made.

40. Simple ultrasound-based rules for the
diagnosis of ovarian cancer.
Ultrasound Obstet Gynecol2008
RCOG 2011

42. DOPPLER EVALUATION
 Hypoxic tissue in tumors recruit low-resistance, high-flow blood
vessels
 Role in evaluating ovarian mass is controversial – as the ranges of
values of RI,PI,MSV between benign and malignant masses overlap.
PI<1, RI<0.4
 To overcome this, vascular sampling of suspicious areas (papillary
projections, solid areas, thick septations) using both 3D USG and
power doppler both has been evaluated and found effective.
 “Chaotic” vascular pattern in malignancy

43. OTHER IMAGING MODALITIES
 CT, MRI, PET not recommended in the initial evaluation
 CT scan: evaluating
 LN involvement,
 Omental mets, peritoneal deposits, hepatic mets,
 obstructive uropathy
 or a probable alternate primary site when cancer is suspected based upon
TVS
 MRI : differentiating non adnexal pelvic masses (like leiomyomata),
expensive and inconvenient.
 ACOG GUIDELINES 2007

45. CA125
SENSITIVITY SPECIFICITY PPV NPV
61-90% 71-93% 35-91% 67-90%
Most useful when non-mucinous epithelial cancers are present
Elevated in 80% of patients with epithelial ovarian Ca but only in 50% of patients
with stage I disease
Increased sensitivity in post menopausal women esp. when associated with
relevant clinical and USG findings
Cut-off of 30 u/ml, sensitivity of 81% and specificity of 75%

46. HE4
 HE4 is a precursor to the epididymal secretory protein E4 and in normal
ovarian tissue, there is minimal gene expression and production of HE4.
 As a single tumor marker, HE4 had the highest sensitivity for detecting
ovarian cancer, especially Stage I disease.
 Combined CA125 and HE4 is a more accurate predictor of malignancy
than either alone or to any other dual combination of markers
 HE4 levels(>70 pM) were found to be elevated in over half of the patients
with ovarian cancer with normal serum CA125 levels (>35 U/ml)
 HE4 when studied in the premenopausal group of patients was able to
discriminate benign tumors from malignancies
Moore et al. / Gynecologic Oncology, 2008

47. NEW SCORES
 ROMA: Risk of Ovarian Malignancy Algorithm
The dual marker algorithm utilizing HE4 and CA125 to calculate a ROMA value
In patients with stage I and II disease, ROMA achieved a sensitivity of 85.3%
compared with 64.7% for RMI
MOORE ET AL, AJOG 2010
 OVA 1:
FDA approved. Combination of 5 immunoassays
CA 125, transthyrettin, apo lipoprotein A1, transferrin, B2 microglobulin
Sensitivity : 93%, specificity: 43% PPV 42% NPV 93%
COMMUN ONCOL, 2010

49. INDICATIONS FOR SURGERY
 Any solid ovarian lesion
 Any ovarian lesion with papillary vegetation on the cyst
wall
 Any adnexal mass >10cm in diameter
 Palpable adnexal mass in a premenarchal or
postmenopausal women
 Torsion or rupture suspected

50. Ovarian mass in reproductive age group
<5 cms. >/= 5 cms
USG USG
cystic
Complex,
observation solid,
suspiciou
s
Persistence or progression
surgery

51. Asymptomatic simple cysts
<5cms Likely physiological
(do not require follow up)
5-7 cms Yearly USG
>7cm Require further
imaging/surgical
intervention.
RCOG 2011

52. CYST ASPIRATION
 Diagnostic cytology has poor sensitivity to detect
malignancy, ranging from 25% to 82%
 Not therapeutic, even when a benign mass is aspirated
 Approx. 25% of cysts will recur within 1 year
 Aspiration of a malignant mass may induce spillage and
seeding of cancer cells into the peritoneal cavity

53. INDICATIONS OF FNAC
 Predominantly benign masses based on clinical, USG findings and
CA125 levels, but a few findings are causing diagnostic dilemma –
then FNAC helps to confirm the nature and aid in pre-op planning
and counseling.
 Patients who have clinical and radiographic evidence of advanced
ovarian cancer and who are medically unfit to undergo surgery-
Malignant cytology will establish a cancer diagnosis, thereby
permitting initiation of neo-adjuvant chemotherapy
ACOG, 2007

54. OPERATIVE MODALITIES
 Laparoscopy vs laparotomy – decision based on suspicion of
malignancy and technical expertise
 No RCTs comparing recurrence rates following laparoscopy or
laparotomy.
 The objective is to try cystectomy if possible.
 Laparoscopic surgery for benign ovarian tumours is associated with
less pain, shorter hospital stay, and fewer adverse events than with
laparotomy.
Cochrane Database of Systematic Reviews 2009

55. The standards for laparoscopy in benign tumours
1. careful examination of the external surface of the tumour and
sampling of the peritoneal cavity
2. avoidance of any tumoral rupture
3. protection of the ovarian tumour with an endoscopic bag
before removal

56. ROLE OF FROZEN SECTION
 The diagnostic accuracy of frozen section analysis is
high for malignant and benign ovarian tumours, but
accuracy is poor in the case of borderline ovarian
tumors.
Medeiros 2005

57. Ovarian mass in childhood:
History and physical examination
Appr. Imaging studies
Simple cyst
Solid or solid cystic
- Observe and reassess
MRI and tumor markers
High suspicion Low suspicion
of malignancy of malignancy
Laparotomy laparoscopy
Frozen section
Malignant –
oophorectomy Benign - cystectomy
and staging

58. Post op surveillance in children
• No specific lit. regarding recurrence rate esp.
• Hence recommendations are at best empirical.
• Should be followed up with annual USG.
• In adults follow up with biannual USG is sufficient
• Tumor markers are not regularly used

60.  Post menopausal gonad atrophies to a size of
1.5 X 1 X 0.5cm on average
 Shouldn‟t be palpable on pelvic examination.
 Presence of palpable ovary must alert the
physician to the possibility of an underlying
malignancy.

61.  Incidence in asymptomatic post menopausal women –
1.5% by pelvic examination
3.3% to 14.5% by USG.
obstet gynecol survey, 2002
 Causes -10% functional
90% neoplastic (either benign or malignant)

62. ASSESSMENT
 It is recommended that ovarian cysts in postmenopausal women should
be assessed using CA125 and transvaginal grey scale sonography.
 There is no routine role yet for Doppler, MRI, CT or PET.
SENSITIVITY SPECIFICITY
TVS 89% 73%
CA 125 81% 75%
RCOG 2010

63. Calculation of RMI (Risk malignancy
index):
 It is an effective way of triaging patients into low ,
moderate, high risk for malignancy, according to which
the referral to a higher centre and management protocol
will differ.
RCOG 2010

65.  It is recommended that a ‘risk of malignancy index’ should
be used to select those women who require primary
surgery in a cancer centre by a gynecological oncologist.
RCOG Guideline No. 34 October 2003
 Using a cut off point of 250, a sensitivity of 70% and
specificity of 90% can be achieved.

67. RCOG
 Simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a
low risk of malignancy. It is recommended that, in the presence of a normal
serum CA125 levels, they be managed conservatively.
 Aspiration is not recommended for the management of ovarian cysts in
postmenopausal women.
 It is recommended that a „risk of malignancy index‟ should be used to select
women for laparoscopic surgery, to be undertaken by a suitably qualified
surgeon.

68.  It is recommended that laparoscopic management of
ovarian cysts in postmenopausal women should involve
oophorectomy (usually bilateral) rather than cystectomy.

70. They were not separately classified by the FIGO and the WHO
until the early 1970s.
 Borderline tumors make up approximately 15% of all
epithelial ovarian tumors.
 The mean age of occurrence is approximately 10 years
younger than that of women with frankly malignant ovarian
cancer.

71. Tumour subtypes
 2 major histological tumor subtypes
 Serous(50%)
 (bilateral in 30%)
 Could be associated with extraovarian lesion : implants(35%)
 Mucinous (46%)
 Mucinous tumors do not have a clearly defined origin.
 Substantial information indicates that many tumors may actually
originate from the appendix; thus, this organ should be removed at
the time of surgery.

73. Histology and Cytology
 According to Dietel and Hauptmann, the histology of borderline
tumors is characterized by the following features:
 Epithelial multi-layering of more than 4 cell layers
 Not more than 4 mitoses per 10 high-power field (HPF)
 Mild nuclear atypia
 Increase in nuclear/cytoplasmic ratio
 Slight to complex branching of epithelial papillae and pseudopapillae
 Epithelial budding and cell detachment into the lumen
 No destructive stromal invasion - A major component in differentiating
malignant from borderline tumors

74. TUMOR STAGING
 Comprehensive staging : of significant prognostic value
and is performed surgically
 Borderline ovarian tumors are staged according to the
FIGO classification of ovarian cancer.

76. INACCURATE STAGING
 Pathologic diagnosis is difficult to confirm by frozen
section.
 The diagnosis of borderline ovarian cancer is based on
surgical staging.
 There is no accurate way to predict the final pathology of
ovarian tumors from laboratory or imaging studies alone.

77. PROGNOSIS
 Excellent overall prognosis
 60% chance of having stage I disease when diagnosed.
 95% of borderline ovarian tumors have diploid deoxyribonucleic
acid (DNA)
 If the tumor is aneuploid, the recurrence rate is high
 Although TP 53 positivity and HER2 over expression in invasive
cancer have been associated with a worse prognosis, the same gene
profile has conferred a survival advantage in borderline tumors.
 Invasive implants

78. Recurrence and Survival
 Stage I disease confirmed by comprehensive staging have
a recurrence rate of approximately 15%. The 5-year
survival rate for such patients approaches 100%.
 With stage II-IV disease, the prognosis is different; an
increased stage is associated with a worse prognosis and
only age at diagnosis and the presence of invasive
implants are shown to influence prognosis.

79. IMAGING - USG
 Intratumoral blood flow in borderline tumors (90%) is
similar to that of malignant neoplasms (92%). The
resistance and pulsatility indexes are also significantly
reduce

80. IMAGING - CT
 Preoperatively to identify possible foci of metastasis. CT
scanning can
 For follow up of the patient in the future.
 However,no distinguishing characteristics that clearly identify
a borderline ovarian tumor.

81. IMAGING - MRI
 In a retrospective study looking at MRI characteristics of
known borderline tumors, Bent et al the investigators were
not able to identify any key imaging characteristics that
would distinguish borderline tumors from other ovarian
tumors.
MRI appearances of borderline ovarian tumours.
Clin Radiol. Apr 2009;64(4):430-8.

82. BIOMARKERS
 CA-125 levels are not shown to aid in the diagnosis or
follow-up care
 In mucinous borderline ovarian tumors serum CA 19-9
probably is a more accurate marker than CA 125 for the
early detection of recurrence

83. TREATMENT

84. Treatment
 Most important factors in deciding treatment options is
stage of the disease.
 Proper staging consists of a
 thorough exploration of the entire abdominal cavity with
peritoneal washings,
 infracolic omentectomy,
 removal of all macroscopic suspicious peritoneal lesions,
and
 multiple peritoneal biopsies.

85.  No consensus concerning treatment of patients with stage II-IV
disease
 The postoperative management protocol is far from clear. To date,
no medical therapy has been shown to clearly improve outcomes
 An increased stage is associated with a worse prognosis
 Stage (II vs III vs IV), type of surgery, postoperative treatment,
postoperative platinum-based chemotherapy, and even the number of
noninvasive implants have no effect on progression-free survival.
 Only age at diagnosis and the presence of invasive implants are
shown to influence prognosis.

86.  Owing to the high association between surface proliferations
and peritoneal implants, exploration of the peritoneum should
be extensive and thorough.
 If possible, carefully evaluate and remove the implants.
 The type of implant (ie, invasive, noninvasive) should be
noted by pathology, as it has significant prognostic value.
 “Lymphadenectomy can be omitted for BOTs, even for the
advanced disease, because there is no difference in
recurrence or survival rate.”
Gynecol Oncol 98:390-395, 2005

87. * No further chemotherapy (in all stages.)

88. CHEMOTHERAPY
 Evidence is insufficient to determine exactly which
therapy is indicated for borderline ovarian tumors.
 Platinum-based agents used, but with varying results
 Borderline tumors with noninvasive implants do not
require any further therapy and should be observed.