Clinical Review

How to manage an adnexal mass

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What imaging is best? Are tumor markers informative? When is surgery indicated? And when is it time to refer?


 

References

The authors report no financial relationships relevant to this article.

CASE 1 Ovarian mass in a perimenopausal patient

A.R. is a 50-year-old gravida 3 para 3 who complains to her primary gynecologist of perimenopausal bleeding. A pelvic examination suggests an ovarian mass, and ultrasonography (US) reveals a myomatous uterus, thickened endometrium (34 mm), and a left ovarian cyst, with debris, that is 3.5×3.4×3.9 cm in size. The mass is thought to be a hemorrhagic cyst. Endometrial biopsy is benign.

Five weeks later, repeat US reveals that the mass has increased in size to 5.6×5.3×4.3 cm. It now appears complex in nature, with smooth walls and a single solid projection. The patient’s CA-125 level is 15 U/mL, which is in the normal range.

How should the mass be managed?

This scenario isn’t uncommon: Approximately one in every 10 women undergoes surgery for an adnexal mass, and an even higher percentage develop a mass that ultimately resolves or requires no surgery.1 Most of these lesions occur in women of reproductive age and are benign, often functional. The two groups at highest risk of malignancy are prepubescent and postmenopausal females.2,3 The rate of malignancy among prepubescent girls who have an adnexal mass is 35%; in postmenopausal women who have an adnexal mass, 30%.2,3

In this article, we describe how to evaluate and manage an adnexal mass in perimenopausal and postmenopausal women, as well as in the pregnant population, and outline the fundamentals of excision and surgical staging. Whenever possible, we base our observations on comprehensive guidelines and reliable data.

In the case just described, the increasing size of the mass and the complex appearance on follow-up imaging justify a surgical approach. Conservative management and definitive surgical treatment are the two treatment options for any adnexal mass.

Multipronged assessment is vital

Pelvic examination alone is insufficient to accurately assess ovarian size and internal characteristics of the mass, especially in postmenopausal and obese women.4 Nevertheless, the pelvic exam is a critical component of evaluation and often detects pathology. Pelvic examination also can assist in determining the best route of removal, depending on the mobility and size of the mass.

US yields the most information

US is the most effective tool for evaluating pelvic structures. It helps characterize masses and differentiates uterine, ovarian, and extraovarian tissues (FIGURE). If there is a high suspicion of malignancy, the next step is computed tomography (CT) to rule out metastatic disease.

US findings that suggest a malignant process are:

  • solid component, not hyperechoic; usually nodular or papillary
  • thick septations (2–3 mm)
  • bilaterality
  • positive flow to the solid component of the mass
  • ascites.5

If a pregnant patient requires further evaluation for an adnexal mass, she should undergo magnetic resonance imaging (MRI) without contrast, not CT, to avoid radiation exposure. Although we lack studies of the safety of contrast agents in pregnant women, animal studies have demonstrated an increased rate of miscarriage, skeletal dysplasia, and visceral abnormalities with the use of contrast.6

FIGURE The complex nature of a mass comes to light via ultrasonography

This complex mass of the right ovary, seen from different vantage points in A and B, contains multiple cysts and septations. Minimal blood flow is apparent in C.

An incidental mass may not require immediate surgery

A small (<5 cm in diameter), simple, asymptomatic mass may be followed conservatively (TABLE).7 Follow-up consists of repeat US, beginning within 4 to 6 weeks after detection.

Any postmenopausal woman who has a complex mass identified by US should undergo CA-125 testing and surgical excision. A mass in a premenopausal woman should also be removed if it has these characteristics—provided the mass is not functional and the complexity does not arise from hemorrhage associated with ovulation.

A program at the University of Kentucky enrolled 15,106 women older than 50 years to undergo annual transvaginal US for ovarian cancer screening.8 Of these, 18% were given a diagnosis of unilocular ovarian cysts, with an initial mean diameter of 2.7 cm; 69.4% of the cysts resolved spontaneously. No woman with an isolated unilocular cystic ovarian tumor developed ovarian cancer during the 6.3-year follow-up; the risk of malignancy was less than 0.1% with a 95% confidence interval. It therefore appears safe to follow small simple cysts in women of any age.

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