Clinical Review

How to manage an adnexal mass

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When an adnexal mass is detected, possibilities are many

Pedunculated fibroid
Tubo-ovarian abscess or diverticular abscess
Inclusion cyst
Fallopian tube cancer
Appendicial tumor
Pelvic kidney
  • follicular
  • corpus luteum
  • endometrioma
  • breast
  • gastrointestinal
  • lymphoma
Malignant, borderline, or benign
  • epithelial
  • germ cell*
  • sex-cord
* Three percent of germ-cell ovarian neoplasms are malignant; the majority are mature teratomas.7

Medical therapy might facilitate regression of the mass

Conservative management might also include medical therapy. Follicular cysts are very common in menarchal and perimenopausal women, and a trial of hormones, in the form of an oral contraceptive (OC) for 4 to 6 weeks, is a common strategy to prevent new cysts by suppressing ovulation. Such a trial is appropriate only for a premenopausal woman who has a simple cyst, however. A complex mass should generally not be observed unless the complexity is thought to be the result of a physiologic process. Six weeks of OC use is long enough to cause physiologic cysts to regress and to reveal which patients should proceed to surgery.9

Surgical treatment, staging

A mass that is suspicious for malignancy should be removed as soon as possible. If frozen section histology confirms the diagnosis, total abdominal hysterectomy with bilateral salpingo-oophorectomy is appropriate. If the patient desires childbearing and the cancer is of low grade and confined to the ovary, unilateral oophorectomy with ipsilateral nodes and staging is appropriate.

Surgical staging of ovarian malignancy should be carried out by a gynecologic oncologist. It involves removal of all mullerian structures, bilateral pelvic and periaortic lymph node sampling, peritoneal biopsies, and cytology or biopsy of the diaphragm. If there is no evidence of gross tumor, comprehensive staging with peritoneal biopsies, lymph node dissection, and cytology of the diaphragm is crucial.

Pathologic findings may necessitate upstaging of the patient and indicate the need for chemotherapy. Approximately 20% of patients who appear to have stage I or II localized disease have occult dissemination within the abdomen.10

If there is gross disease within the abdomen, the goal of surgery is to remove it.

When should you refer?

According to guidelines from the American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncologists, a postmenopausal woman with an adnexal mass should be referred to a gynecologic oncologist when she has one or more of the following:

  • nodular or fixed mass
  • elevated CA-125 level (>35 U/mL)
  • ascites
  • evidence of metastasis on imaging
  • strong family history of breast or ovarian cancer.11

A premenopausal woman should be referred if she has an adnexal mass and one or more of the following:

  • elevated CA-125 (>200 U/mL)
  • evidence of metastatic disease
  • ascites.

Referral may also be appropriate if there is a first-degree relative with breast or ovarian cancer.11

CASE 1 Resolved

After the patient is counseled about the likelihood of malignancy, she undergoes exploratory laparotomy with frozen section. The ovary ruptures, and analysis of a frozen section is consistent with mullerian adenocarcinoma.

She then undergoes total abdominal hysterectomy and bilateral salpingooophorectomy. Gynecologic oncology is consulted, and complete staging follows, including omentectomy, peritoneal biopsies, and pelvic and periaortic lymph node dissection. Pathology reveals stage IC poorly differentiated adenocarcinoma, endometrioid type. Combination chemotherapy with carboplatin and a taxane is recommended.

Selecting a surgical approach

CASE 2 Elderly patient with a complex mass

P.W., an 86-year-old gravida 9 para 4043, has an incidental adnexal mass detected during CT imaging. The left ovarian mass is complex and 7 cm in diameter at its largest point. The CA-125 level is 23 U/mL, and the carcinoembryonic antigen level is 4.5 ng/mL—both within normal range. A colonoscopy—performed as routine screening, not as part of the workup for the mass—is normal.

Because the mass is complex, surgery is indicated, and the physician prefers the laparoscopic approach—but is it reasonable?

Deciphering tumor markers

Tumor markers should not be drawn reflexively with every adnexal mass. Clinical findings and diagnostic imaging must be considered to minimize false-positive test results. Do not order tumor markers without performing a thorough clinical evaluation.

A tumor isn’t the only pathology that produces elevated CA-125

Malignant epithelial tumors produce an elevated CA-125 level in 80% of cases.14 However, any disease state that causes inflammation of peritoneal surfaces will also produce an elevated CA-125 level. A few examples of disease states that cause inflammation of mesothelium-derived tissue are endometriosis, pancreatitis, colitis, pericarditis, diverticulitis, and ascites.15

Women who have an adnexal mass identified by pelvic exam should undergo US imaging. If imaging suggests that the mass is anything other than a simple cyst or functional, CA-125 measurement should follow. If imaging does not suggest malignancy, repeat US is indicated within 4 to 6 weeks to assure that the mass is resolving or is not increasing in size. Some masses in a postmenopausal woman may be followed if they are simple, less than 4 cm, and associated with a normal CA-125 level.

What level is cause for concern?

The normal CA-125 level for a postmenopausal woman is less than 30 to 35 U/mL, depending on the laboratory used. For a premenopausal woman, a normal level falls below 200 U/mL.

Young females who have a low likelihood of epithelial cancer do not need to undergo CA-125 measurement. CA-125 assessment has low sensitivity (0.5) and specificity (0.5) for epithelial cancer in premenarchal girls.16 Pubescent and prepubescent females should undergo measurement of the appropriate tumor markers for germ-cell or sex-cord tumors. Germ-cell tumor markers include α-fetoprotein, lactate dehydrogenase, and human chorionic gonadotropin. The sex-cord tumor marker is inhibin.

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