Adnexal Masses

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Adnexal Masses

• April 16, 2008
• Erin King, MD

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Outline

• Differential diagnosis
• Diagnostic studies and interpretation
• Benign vs. malignant
• Management
• When it's time to refer to a specialist

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Anatomy

• Adnexa
• Area next to the uterus containing ligaments,
  vessels, tubes, ovaries

http//en.wikipedia.org/wiki/ovarian_artery
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Background

• Prevalence of adnexal masses is 2 to 8
• Random TVUS of 335 asymptomatic premenopausal
  women, 7.8 with adnexal masses 2.5 cm or larger
  (6.6 were ovarian cysts)1
• TVUS in 8794 asymptomatic postmenopausal women,
  2.5 were found to have adnexal cysts2

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Differential Diagnosis

• Physiologic cysts
• Follicle develops but never ruptures, continues
  to grow
• Simple, smooth-walled
• Functional cysts
• Corpus luteum does not involute or continues to
  grow
• Most are small (lt2.5 cm), but can be larger
• Usually no symptoms, unless rupture or torsion

• www.uptodate.com

library.med.utah.edu/WebPath/jpeg4/FEM087.jpg
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Differential Diagnosis (contd)

• PCOS
• Ectopic pregnancy
• PID (TOA/TOC)
• Hydrosalpinx
• Benign neoplasms
• Serous or mucinous cystadenoma
• Endometrioma
• Dermoid
• Fibroids (exophytic, broad ligament)
• Malignancy
• Primary vs. mets

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Non-Gyn Etiology

• GI
• Appendicitis
• Diverticulitis
• Inflammatory bowel disease
• Inclusion cysts
• Peritoneal or omental
• Retroperitoneal masses
• Pelvic kidney

www.geocities.com/.../7780/images/perit_cyst.jpg
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Diagnosis History

• History
• Pain?
• Midcycle? physiologic or functional cyst
• Dysmenorrhea/dyspareunia? endometriosis
• Sudden onset, severe?torsion, rupture, hemorrhage
• Chronic aching, bloating?neoplasm
• Nonspecific GI symptoms
• May suggest ovarian cancer in postmenopausal
  female
• May suggest appendicitis or GI etiology in
  younger women
• FH
• Breast, colon, or ovarian cancer

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Diagnosis Physical Exam

• Physical examshould include bimanual and
  rectovaginal exam
• Fever?PID, appy, diverticulitis
• Shouldnt be able to palpate a postmenopausal
  ovary
• Cul de sac nodularity, tender ligaments?
  endometriosis
• Cervical motion tenderness?PID
• Fixed, irregular, solid may suggest neoplasm
• Do a breast exam!

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Diagnosis Physical Exam

• Will probably need more than an HP to make a
  diagnosis
• 84 women underwent pelvic examination prior to
  surgery, blinded to surgical indication3
• Attending, resident, student examined patient
• Sensitivity at detecting adnexal masses 0.28,
  0.16, 0.04
• Exam is a limited screening tool for detection
  of adnexal masses

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Diagnosis Labs

• Labs
• ß-HCG to exclude ectopic
• CBC if infection suspected
• Tumor makers?
• CA-125 (more to come)
• Others useful in adolescents/premenopaual women
  with adnexal masses and high suspicion
• LDH?Dysgerminoma
• HCG?choriocarcinoma
• AFP?Endodermal sinus tumor

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Benign vs. Malignant

• Your level of suspicion determines what
  diagnostic tests to order

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Malignancy

• Postmenopausal
• Roughly 50 per 100,000 women, relative risk of
  3.5
• 80 of ovarian cancers occur in women over 50
• Family history
• Symptoms
• Vague, chronic aching, bloating, /- GI symptoms
• Physical examination
• Remember. . . Not really useful
• Ultrasound findings
• CA-125

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Family History

• Lifetime risk of ovarian cancer in general
  population 1.5
• In BRCA 1 carrier 45-55
• In BRCA 2 carrier 15-25
• Not all mutations have been identified
• Two to three relatives with ovarian cancer
  increases lifetime risk to 5 (15 if first
  degree relatives)4

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CA-125

• Not specific to ovarian cancer, also elevated in
• Other cancers (endometrial, fallopian tube, germ
  cell, cervical, pancreatic, breast, colon)
• Benign conditions (endometriosis, fibroids, PID,
  adenomyosis, functional ovarian cysts, pregnancy)
• Other diseases (renal, heart, liver, and many
  others)
• Also abnormal in 1 of normal females5
• Normal value lt35
• Rarely gt100-200 in benign conditions
• Should be used judiciously, as poor specificity

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CA-125

• Utility as screening tool for ovarian cancer
• CA-125 increased in roughly 80 of ovarian
  cancers
• About 50 sensitivity for Stage I, 90 for Stage
  II
• Study of 5550 healthy Swedish women6
• Followed women with elevated and normal CA-125
  levels
• Serial pelvic exams, U/S, serial CA-125 levels
• Of 175 women with elevated CA-125, 6 with ovarian
  cancer
• Of the remaining women with normal CA-125 levels,
  3 had ovarian cancer

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Ultrasound

• Simple cyst
• Less than 2.5 cm
• Unlikely malignant
• Probably a follicle
• Homogeneous appearance may suggest endometrioma
• Reticular pattern may suggest hemorrhagic cyst

www.uptodate.com
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Ultrasound

• Features suggestive of malignancy
• Solid component
• Doppler flow
• Thick septations
• Size
• Presence of ascites or other peritoneal masses

www.uptodate.com
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Ultrasound The DePriest Score7

• Morphology index
• U/S on 121 patients who underwent exlap
• Morphology score lt5 (80)?all benign, 100 NPV
• Morphology score gt10 (5)? all malignant, 100 PPV
• Morphology score 5, 45 PPV for malignancy
  (but, PPV only 14 for premenopausal women)
• There are other morphology indicesthis is not
  the only one!

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So now what?Management

• Premenopausal females
• If size lt10 cm, mobile, cystic,
  unilateral?follow, place patient on monophasic
  OC, repeat U/S in 2-3 months
• 70 of these will resolve8
• If size gt10 cm, fixed, solid, or other concerning
  features?take it out
• If mass persists or enlarges at repeat scan?take
  it out

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What about the Postmenopausal Female?

• Modesitt study9
• 15,106 asymptomatic women over 50 who underwent
  TVUS
• If no abnormalities?annual screening
• If abnormal?repeat U/S in 4-6 weeks with Doppler
  and CA-125
• 18 with unilocular ovarian cysts lt10 cm in
  diameter
• 69.4 resolved
• 5.8 developed solid component
• 16.5 developed septum
• 6.8 persisted as unilocular
• 10 patients with unilocular lesion who developed
  ovarian cancer, all of whom either
• developed a septum or solid component on U/S,
• underwent complete resolution of the cyst,
• or developed cancer in the contralateral ovary
• Thus. . . The risk of developing ovarian cancer
  in a woman with a unilocular, small cyst is VERY
  low (0.1)

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Management

• Postmenopausal
• If asymptomatic, normal exam, simple cyst on U/S,
  normal CA-125,unilateral, 5 cm
• follow with serial U/S and CA-125 q 3-6 months
  until 12 months, then annually thereafter
• If above except complex appearance and 5 cm
• Repeat U/S and CA-125 in 4 weeks
• Resolution
• Persistence or decreasing complexity?follow q 3-6
  months with U/S and CA-125
• Increasing CA-125 or increasing
  complexity?surgery
• If complex, 5 cm, and elevated CA-125
• Take it out
• If symptomatic, 5 cm, clinically apparent,
  non-simple in appearance, or elevated CA-125?take
  it out.

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Management Algorithm (there are many of these)10
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When should I refer to an oncologist?

• ACOG Guidelines11
• Premenopausal (lt 50 Years Old)
• CA-125 gt 200 U/mL
• Ascites
• Evidence of abdominal or distant metastasis (by
  exam or imaging study)
• Family history of breast or ovarian cancer (in a
  first-degree relative)
• Postmenopausal (gt 50 Years Old)
• CA-125 gt 35 U/mL
• Ascites
• Nodular or fixed pelvic mass
• Evidence of abdominal or distant metastasis (by
  exam or imaging study)
• Family history of breast or ovarian cancer (in a
  first-degree relative)

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Summary

• Most adnexal masses are found incidentally
• Adnexal masses in the premenopausal and
  postmenopausal female are handled differently
• Your index of suspicion, combined with the
  patients risk factors, clinical examination, and
  test findings should determine which diagnostic
  studies to order and how to manage the mass
• Use your clinical judgment to determine who you
  should take to the OR and who to refer to an
  oncologist

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Question 1

• You are consulted by the ED at 0300 on a Friday
  evening for pelvic pain. The patient is a 20
  year-old G0 with a negative HCG. She is afebrile,
  and she has a benign exam. Ultrasound shows a
  left-sided simple 3 cm ovarian cyst with no free
  fluid in the pelvis. Your next step is to
• Ask the ED resident if a pelvic exam was done
• Tell the patient this is likely the source of her
  pelvic pain and she will need surgery
• Recommend follow up in the PCC in 4-6 weeks with
  a repeat U/S

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Question 1

• The answer is C. 70 of simple cysts in
  premenopausal females will resolve spontaneously,
  and the current recommendation is to follow these
  every three months by ultrasonography until
  resolution. Should the lesion increase in size
  or develop complex features, surgery would be
  warranted.

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Question 2

• A 56 year-old female presents to your clinic
  with an incidental finding of a 4 cm simple left
  ovarian cyst. Her CA-125 is 113. The best option
  is
• Repeat ultrasound in 4 weeks
• Referral to a gyn oncologist
• Exploratory laparotomy

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Question 2

• The answer is B. Although the cyst is lt5 cm and
  simple, the patient has an elevated CA-125.
  Referral to a gyn oncologist is recommended.

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References

• Borgfeldt C Andolf E. Transvaginal sonographic
  ovarian findings in a random sample of women
  25-40 years old. Ultrasound Obstet Gynecol 1999
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• Castillo G Alcazar JL Jurado M. Natural history
  of sonographically detected simple unilocular
  adnexal cysts in asymptomatic postmenopausal
  women. Gynecol Oncol 2004 Mar92(3)965-9.
• Padilla L, Radosevich D, Milad M. Limitations of
  the pelvic examination for evaluation of the
  female pelvic organs . Int J of Gyn 2005 88 (1)
  84 88.
• Carlson KJ Skates SJ Singer DE. Screening for
  ovarian cancer. Ann Intern Med 1994 Jul
  15121(2)124-32.
• Bast R Klug T St John E Jenison E Niloff J
  Lazarus H Berkowitz R Leavitt T Griffiths C
  Parker L Zurawski V Knapp R. A radioimmunoassay
  using a monoclonal antibody to monitor the course
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  Oct 13309(15)883
• Einhorn N Sjovall K Knapp RC Hall P Scully
  RE Bast RC Jr Zurawski VR Jr. Prospective
  evaluation of serum CA 125 levels for early
  detection of ovarian cancer. Obstet Gynecol 1992
  Jul80(1)14-8.
• De Priest PD, Shenson D, Fried A, Hunter JE,
  Andrew SJ, Gallion HH, et al A morphology index
  based on sonographic findings in ovarian cancer.
  Gynecol Oncol. 1993 Oct51(1)7-11.
• Mishell DR Jr. Noncontraceptive benefits of oral
  contraceptives. J Reprod Med 199338(12 Suppl)
  1021-9.
• Modesitt SC, Pavlik EJ, Ueland FR, et al. Risk of
  malignancy in unilocular ovarian cystic tumors
  less than 10 centimeters in diameter. Obstet
  Gynecol. 2003102594599.
• Van Nagell, JR, et al. Am J of Obstet Gynecol
  2005193,30-35.
• ACOG Committee Opinion number 280, December
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  obstetrician-gynecologist in the early detection
  of ovarian cancer. Obstet Gynecol
  200210014136.

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