This document discusses the management of ovarian masses based on clinical situations and recommendations. It covers several key points: 1. Most ovarian masses are benign, but malignancy cannot be ruled out, especially in postmenopausal women. Imaging like ultrasound and tumor markers can help assess risk but surgery is often needed. 2. Simple, unilocular cysts under 10cm seen on ultrasound are almost always benign and can be monitored, even in postmenopausal women. Complex or solid masses raise more concern. 3. The document reviews four case studies to illustrate different clinical presentations and surgical approaches for managing ovarian masses. Complete surgical staging is important to determine prognosis and treatment.

1. Management of ovarian masses
Situations & recommendations
Management of ovarian masses e Clinical
Situations & recommendations
Clinical

2. Review Article
Management of ovarian masses e Clinical
situations & recommendations
Rooma Sinha a,
*, Satyamvada b
, B. Rupa b
a
Senior Gynecologist, Laparoscopic & Robotic Surgeon, Department of Gynecology & Minimally Invasive Surgery,
Apollo Health City, Hyderabad, India
b
Registrar, Department of Gynecology, Apollo Health City, Hyderabad, India
a r t i c l e i n f o
Article history:
Received 25 June 2012
Accepted 3 July 2012
Available online 8 July 2012
Keywords:
Ovarian mass
Aspiration
Ultrasound
Tumor markers
a b s t r a c t
Adenexal mass is a common clinical presentation. This clinical situation is a problem that
affects women of all ages. The biggest challenge is that one should not miss out on a
diagnosis of malignant ovarian tumor. An ovarian mass or cyst that raises the suspicion of
malignancy is a common dilemma in a gynecological practice. In the United States, a
woman has a 5e10% lifetime risk of undergoing surgery for a suspected ovarian neoplasm
and an estimated 13e21% chance of this turning into a diagnosis of ovarian cancer.1
Most
of the adnexal masses are benign but the first responsibility of the treating gynecologist is
to exclude malignancy. Management decisions often are influenced by the age and family
history and presentation of the patient. We purpose to review the most recent data on
imaging modalities, operative assessment of the adnexal mass and preoperative models to
predict the probability of ovarian malignancy. A woman’s lifetime risk of developing
ovarian cancer is approximately 1 in 70.2
The 5-year survival rate in women in whom stage
I ovarian cancer has been diagnosed exceeds 90%; however, only 20% of cancers are
detected at this stage.3
Copyright ª 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Disease & management
An ovarian mass or also known as adenexal mass can arise
from ovaries or fallopian tube. In premenopausal women,
most adnexal masses are caused by ectopic pregnancy,
ovarian cysts, tumors, polycystic ovaries and abscesses. When
a mass is present in women of postmenopausal age group,
there is a greater probability that a mass may be malignant. A
higher index of suspicion for malignancy is warranted when
either the scan shows a complex cyst or the tumor markers
are raised. Any elevation of CA 125 levels is highly suspicious
for malignancy in women in this age group. Ultrasound find-
ings of masses that contain solid areas or excrescences or that
are associated with free fluid in the abdomen or pelvis or both.
With the exception of simple cysts on a transvaginal ultra-
sound finding, most pelvic masses in postmenopausal women
will require surgical intervention. Additionally in such women
CT scan may give more information. Ovary is a relatively
common site for metastases from uterine, breast, colorectal,
* Corresponding author.
E-mail address: drroomasinha@hotmail.com (R. Sinha).
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 7 0 e2 7 5
0976-0016/$ e see front matter Copyright ª 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.apme.2012.07.010

3. or gastric cancers. Any postmenopausal woman with an
ovarian mass should have breast and digital rectal examina-
tions, stool for occult blood, upper and lower gastrointestinal
endoscopy as well as mammography. An endometrial biopsy
should be performed if transvaginal ultrasound findings show
a thickened endometrial lining and abnormal uterine bleeding
is present.
2. Preoperative: ultrasound findings
Unilocular, thin-walled sonolucent cysts with smooth, regular
margins are most often benign. With this kind of ultrasound
features malignancy rates in most series of 0e1%.4,5
In a large
prospective study 2763 postmenopausal women with uniloc-
ular cysts upto 10 cm size were followed up using serial ul-
trasonography at 6-month intervals. Spontaneous resolution
occurred in more than two thirds of patients, and no cancers
were detected after a mean follow-up of 6.3 years, suggesting
that the risk of malignancy in such patients was virtually
nonexistent.6
Some clinical studies have shown association of
such cysts with hypothyroidism. Hence a thyroid profile
should be done in women with simple cysts and treated if
found to be hypothyroid. Once the thyroid levels reach normal
range, the cyst also resolved without any surgical interven-
tion. Therefore, simple cysts up to 10 cm in diameter as
measured by ultrasonography are almost universally benign
and may safely be followed without intervention, even in
postmenopausal patients. Some ultrasound characteristics
may point toward specific benign diagnoses. Typical findings
for endometriomas are a round homogeneous-appearing cyst
containing low-level echoes within the ovary, with sensitivity
of 83% and specificity of 89%. Mature teratomas contain a
hypo echoic attenuating component with multiple small
homogeneous interfaces. Hydrosalpinges appear as tubular-
shaped sonolucent cysts, with a sensitivity of 93% and speci-
ficity of 99.6% for differentiating this diagnosis from other
adnexal masses.
3. Tumor markers
The most extensively studied serum marker to distinguish
benign from malignant pelvic masses is CA 125. It is most
useful when nonmucinous epithelial cancers are present.
The serum marker CA 125 level is elevated in 80% of patients
with epithelial ovarian cancer but only in 50% of patients with
stage I disease at the time of diagnosis, hence its lack of utility
as a screening test.1
The value of elevated CA 125 levels is in
distinguishing between benign and malignant masses in
postmenopausal women. Whereas CA 125 level measurement
is less valuable in premenopausal than postmenopausal
women in predicting cancer risk, extreme values can be
helpful. Additionally, b-hCG, L-lactate dehydrogenase (LDH),
and alpha-fetoprotein (aFP) levels may be elevated in the
presence of certain malignant germ cell tumors, and inhibin
A and B sometimes are markers for granulosa cell tumors of
the ovary.
4. Aspiration of ovarian cyst
Aspiration of nonunilocular ovarian cyst fluid is not recom-
mended either for diagnosis or treatment when there is a
suspicion for cancer. Aspiration cytology has poor sensitivity
to detect malignancy, ranging from 25% to 82%,7
and aspira-
tion is never therapeutic and in 25% there is recurrence of the
cyst within 1 year of the procedure. This is especially contra-
indicated in postmenopausal women. Aspiration of a malig-
nant mass may induce spillage and seeding of cancer cells
into the peritoneal cavity, thereby changing the stage and
prognosis. There have also been reports of aspirated malig-
nant masses recurring along the needle tract through which
the aspiration was done. Spillage decreases overall survival of
stage I cancer patients compared with patients with tumors
that were removed intact. Women with clinical and radio-
graphic evidence of advanced ovarian cancer and who are
medically unfit to undergo surgery, in such situation one can
do aspiration to confirm the diagnosis with malignant
cytology thereby permitting initiation of neoadjuvant
chemotherapy.
5. Surgery
How extensive the surgery should be done in women with
ovarian mass depends on the diagnosis, age, and patient
wishes for ovarian function or future fertility. In premeno-
pausal women, with diagnosis of benign disease cystectomy is
the operation of choice, especially in case of teratomas,
endometriomas and cystadenomas. When ovarian tissue
cannot be preserved, a unilateral oophorectomy or salpingo-
oophorectomy is indicated.
Below are some cases illustrating these conditions and
how one can approach, observe and manage patient care and
safety.
5.1. Case 1
A 63-year lady was presented with postmenopausal bleeding.
Her USG reported as thickened endometrium of 12 mm with
left ovarian cyst of 6 cm. All tumor markers were normal.
She underwent hysteroscopy and endometrial biopsy for
postmenopausal bleeding. Histopathology was reported as
endometrial hyperplasia without atypia. The lady was
advised and hence underwent laparoscopic hysterectomy
with BSO. Final HPE showed granulosa cell, tumor of left
ovary (Fig. 1).
5.1.1. Learning points
Whenever there is postmenopausal bleeding one must
raise this question e what is the source of hormone in post-
menopausal women with endometrial hyperplasia? Should
serum estradiol be done as part of evaluation of all such cases?
5.2. Case 2
A 16-year girl with Turner syndrome and primary amenorrhea
was referred from endocrinology department for bilateral
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4. oophorectomy, as there is increased chance of developing
malignant transformation in ovaries in future. She was
advised laparoscopic bilateral oophorectomy but did not
report for the procedure due to class 10th board exam. She
reported 6 months later with abdominal distension. Her CT
scan showed a large solid ovarian tumor 10 Â 12 cm size
(Fig. 2). On laparotomy right ovarian mass was removed along
with left oophorectomy (Fig. 3). Final histopathology was re-
ported as dysgerminoma.
5.3. Case 3
A 21-year lady presented with history of delayed cycles for last
2 years. She was being treated as PCOS. Subsequently she had
secondary amenorrhea and hirsuitism and at presentation
had frank virilization, alopecia and clitaromegaly (Fig. 4). She
was also anxious to conceive. Her TST & DHEAS levels were
markedly high. The ultrasound and CT scan showed a 5 cm
mass from right ovary with complex features. She was advised
laparoscopy with frozen section (Figs. 5 and 6). The frozen
section showed steroid cell-producing tumor and a right
salpingo-oophorectomy was done. Her final diagnosis was
also steroid cell-producing tumor. Her response to tumor was
remarkable as depicted by her total testosterone levels. She is
12 weeks pregnant at the time this article is being written
(Table 1).
Fig. 1 e Operative picture showing granulosa cell tumor of
left ovary.
Fig. 2 e Showing CT scan showed a large solid ovarian
tumor 10 3 12 cm size.
Fig. 3 e Showing right ovarian mass final histopathology e
dysgerminoma.
Fig. 4 e Showing cliteromegaly.
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5. 5.3.1. Learning points
In this procedure the risk of bilaterality is always there and the
woman should be counseled about this at the time of the
surgery. The risk of bilaterality, is as high as 25% for benign
serous tumors, approximately 15% for benign teratomas, and
as low as 2e3% for benign mucinous tumors.
5.4. Case 4
A 22-year-old unmarried girl came with complaints of lower
abdominal distension. The USG report showed large masses
of 5.8 Â 3.2 cm and 13.8 Â 7.4 cm size in right and left
ovaries respectively. She had undergone laparoscopic cys-
tectomy 6 months ago for similar complaints, which was
reported as mucinous cyst adenoma. She had CT scan,
which reported large septated low-density tumor measuring
16.1 Â 6.3 Â 10.1 cm, extending from retro umbilical area to
pelvis involving both parametria, left more than right
(Fig. 7). She underwent laparoscopy with frozen section
(Figs. 8 and 9) and once the frozen section report confirmed
benign mucinous cyst she underwent bilateral cystectomy.
5.4.1. Learning points
In such cases wedge biopsy of a normal appearing contralat-
eral ovary should not be advised because this can lead to se-
vere adhesions as well as loss of normal ovarian tissue
and doing so might adversely affect fertility. One can choose
cystectomy or unilateral salpingo-oophorectomy even in
perimenopausal or postmenopausal patients also. But hys-
terectomy or bilateral salpingo-oophorectomy or both are
considered appropriate options in this age group. This is rec-
ommended to reduce the risk of developing uterine, cervical,
or ovarian cancer thus reducing the need of future pelvic
surgery. It is unclear whether the potential benefits of ovarian
preservation outweigh the risks of leaving them in situ. One
decision-analysis model performed in women at average risk
demonstrated excess mortality especially due to coronary
heart disease and hip fracture if oophorectomy is performed
before age 59 years.8
6. Take home message
The majority of adnexal masses are benign, but diagnosis of
an adnexal mass is difficult because there are many forms
Fig. 5 e Laparoscopic picture showing steroid cell
producing tumour.
Fig. 6 e Showing steroid cell-producing tumor e removal in
endo bag to avoid spillage.
Fig. 7 e Showing CT scan e large septated low-density
tumor measuring 16.1 3 6.3 3 10.1 cm extending from
retro umbilical area to pelvis involving both parametria,
left more than right.
Table 1 e Levels of testosterone pre and post surgery.
Total testosterone
Preserver 360.40 ng/dl
Post surgery e 15 days 0.04 ng/dl
Post surgery e 60 days 0.32 ng/dla
a
2 months post surgery she reported with a positive pregnancy
test.
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6. that a mass can take. The following situations are appropriate
indication to observe with serial ultrasound screening:
Ultrasound finding suggests benign disease.
Functional cysts in ovulating women.
Suspected endometriomas in asymptomatic women with
normal or elevated, but not increasing, CA 125 levels.
Simple cysts in any age group.
Hydrosalpinges.
Women who are at substantial risk for perioperative
morbidity and mortality.
7. Recommendations according to ACOG
1. In asymptomatic women with pelvic masses (premen-
opausal or postmenopausal), transvaginal ultrasonog-
raphy is the imaging modality of choice. No other
imaging modality has demonstrated sufficient superi-
ority to transvaginal ultrasonography to justify its
routine use.
2. Specificity and positive predictive value of CA 125 level
measurements are more useful in postmenopausal women
compared with premenopausal women. Any CA 125
elevation in a postmenopausal woman with a pelvic mass
is highly suspicious for malignancy.
3. Simple cysts up to 10 cm in diameter on ultrasound
findings are almost usually benign and may safely be
followed without intervention, even in postmenopausal
patients.
4. Unilateral salpingo-oophorectomy or ovarian cys-
tectomy in patients with germ cell tumors, stage I
stromal tumors, tumors of low malignant potential, and
stage IA, grade 1e2 invasive cancer who undergo com-
plete surgical staging and who wish to preserve fertility
does not appear to be associated with compromised
prognosis.
Conflicts of interest
All authors have none to declare.
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