Evaluation of the Adnexal Mass

Masses of the ovary, fallopian tube or other pelvic organs may be incidental findings on examination or may present with symptoms of pain. The diagnostic evaluation determines need for and type of surgical or medical intervention.

CLINICAL ACTIONS:

• Obtain a medical, gynecologic and family history and review of systems
• Evaluate vital signs and general appearance
• Exam should include assessment of cervical, supraclavicular, axillary and groin nodes as well as breast, abdominal and pelvic examination
• Clinical findings suggestive of malignancy include
  • Irregular contour
  • Firm
  • Fixed
  • Nodular
  • Bilaterality
  • Ascites

Imaging

Ultrasound

• Obtain transvaginal ultrasound to assess mass for findings suggestive of malignancy including
  • Size and composition of mass
  • Laterality
  • Septations
  • Solid components
  • Excrescences
  • Pelvic free fluid
• Abdominal ultrasound is a ‘useful addition’ if
  • Anatomic distortion present (e.g., previous surgeries)
  • Mass extending beyond pelvis
  • Transvaginal sono is not possible (e.g., young, virginal or prepubertal)
• Ultrasound algorithms to predict malignancy (see ‘Related ObG Topics’ below)
  • IOTA group: Simple Rules
  • Other algorithms also available

Other Imaging Modalities

• CT, MRI and PET are not recommended as ‘first line’ imaging modalities
  • MRI can help differentiate origin of mass when unclear
  • CT scan can be helpful to evaluate abdomen when cancer is suspected
  • MRI and CT may be used to as an adjunct in the work up of suspected cystic teratomas (differentiates lipid densities)

Serum Markers

• Biomarkers can be used in the evaluation of a pelvic mass but are not currently recommended for use in population based screening for ovarian cancer

CA 125

• Overall wide range of sensitivity and specificity, especially in premenopausal women
  • PPV: 5% to 91%,
  • NPV: 67% to 90%
• Postmenopausal
  • PPV of CA 125 is higher in postmenopausal women
  • Elevated CA 125 and pelvic mass in postmenopausal woman warrants referral to Gyn Oncologist
• Premenopausal
  • Less valuable but extreme values warrant caution and raised suspicion
  • No evidence-based threshold currently exists for premenopause
  • Other causes: Fibroids |  Endometriosis | PID | Ascites (not necessarily related to ovarian cancer) | Medical disorders with inflammatory component

Biomarker Panels

Two FDA approved serum tumor marker panel tests, for use in women >18 years with an already identified adnexal mass that requires surgery

• Multivariate index assay
  • Combination of CA 125 II | Transferrin | Transthyretin (prealbumin) | Apolipoprotein A-1 | ß 2-microgloblin
  • Translates into a malignancy risk score of 0-10 using proprietary algorithm
  • “…higher sensitivity and negative predictive value for ovarian malignancy when compared with clinical impression and CA 125 alone”
  • Sensitivity increases with additional clinical assessment and inclusion of ultrasound findings

• Risk of Ovarian Malignancy Algorithm
  • Combination of CA 125 | Human epididymis protein 4 | Menopausal status
  • Algorithm based on variable cut-off values related to menopausal status
  • Epididymis protein 4 is more sensitive and specific than CA 125
• ACOG states

Serum biomarker panels may be used as an alternative to CA 125 level alone in determining the need for referral to or consultation with a gynecologic oncologist when an adnexal mass requires surgery

Other Markers

• If suspicious for less common tumors (e.g. germ cell), consider
  • ß-hCG | L-LDH | AFP
• Granulosa cell tumors (solid mass and postmenopausal bleeding)
  • Inhibin | Estrogen

SYNOPSIS:

Evaluation of the patient with an adnexal mass is intended to exclude malignancy, identify patients in need of emergent surgery and allow appropriate scheduling for those who need nonemergent surgery.  Patients with tubo-ovarian abscesses may respond to medical management or interventional radiologic drainage. Those with small cysts can often be followed with ultrasound in anticipation of spontaneous resolution. Metastatic cancers, especially from breast, colon or stomach may present as adnexal masses.  Those with findings suggestive of malignancy should have consultation with or referral to a gynecologic oncologist.

KEY POINTS:

• Age and a strong family history of breast or ovarian cancer remain important risk factors for ovarian malignancy
• Transvaginal ultrasonography is the recommended imaging for pelvic masses
  • Findings of concern include: cyst size greater than 10 cm, papillary or solid components, irregular shape, ascites, high color Doppler flow
• Benign masses will generally show the following on ultrasound
  • Thin, smooth walls, no solid components or septation, no internal blood flow on color Doppler
• Simple cysts over 10 cm are generally considered an indication for surgery but may resolve over time
• Serum marker testing in combination with other tests can be used to evaluate likelihood of malignancy

Note: The ESGO/ISUOG/IOTA/ESGE Consensus Statement (see ‘Learn More – Primary Sources’ below) provides excellent summary tables on clinical and ultrasound features of adnexal masses

When to Observe

• Ultrasound suggests benign disease
• Ultrasound findings unclear but there is a good reason to try and avoid surgery
• Normal CA 125 level and no suspicious ultrasound findings
• <10 cm simple cysts, even in postmenopause can be observed with repeat imaging
• Benign disease: Endometriomas | Mature teratomas | Hydrosalpinx
• Repeat ultrasound
  • ACOG states

The ideal interval and duration for ultrasound follow-up has yet to be defined. However, in one study, masses that were monitored and eventually diagnosed as malignancies all demonstrated growth by 7 months . Some experts recommend limiting observation of stable masses without solid components to 1 year, and stable masses with solid components to 2 years.

When to Refer to Gyn Oncology

• Postmenopausal
  • Elevated CA 125 | Suspicious ultrasound or clinical findings
• Premenopausal
  • Very elevated CA 125 level | Suspicious ultrasound or clinical findings
• Premenopausal or postmenopausal
  • Elevated score on a formal biomarker risk assessment test or ultrasound-based scoring systems from the IOTA group

Learn More – Primary Sources:

ACOG Practice Bulletin No. 174: Evaluation and management of adnexal masses

NEJM Case 18-2019: A 24-Year-Old Woman with a Pelvic Mass

ESGO/ISUOG/IOTA/ESGE Consensus Statement on preoperative diagnosis of ovarian tumors