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[00:00:00.00]
[00:00:00.27] Hello, my name is Renata Urban and I am one of the GYN oncologists at the
University of Washington Medical Center. This lecture today is about the evaluation and
management of adnexal masses. Let's first define exactly what we're talking about-- what is an
adnexal mass? Adnexa is a term that refers to the appendages of an organ. In gynecology, this
means anything that is next to the uterus and typically involves the fallopian tube and/or ovary.
This term is oftentimes used interchangeably with pelvic mass.
[00:00:32.55] The objectives of this lecture can be addressed by a couple of specific questions.
The first is what is the differential diagnosis of an adnexal mass? How can the patient's history
help you create a differential? For example, how does the patient's age, menstrual status, and
symptoms affect your suspicion as to what this mass might be?
[00:00:54.78] How can the physical exam, imaging, and laboratory tests be helpful? Who needs
surgery for an adnexal mass? And who should do that Surgery
[00:01:05.28] The differential diagnosis of an adnexal mass is extremely broad. It includes noncancerous or benign masses of the ovary, including functional or physiologic cysts such as a
follicular cyst or corpus luteum, a theca lutein cyst, luteoma of pregnancy, endometrioma, and a
swollen ovary due to torsion. It can include neoplastic or growths that are non-cancerous of the
ovary, as well as malignant masses of the ovary. However, an adnexal mass can also include
something that is not the ovary, such as a mass in the fallopian tube, such as an ectopic
pregnancy, a tubal ovarian abscess, hydro or pyosalpinx, meaning fluid or pus in a fallopian tube,
or a fallopian tube carcinoma. Uterine masses it can also be mistaken for pelvic or adnexal
masses, and, most commonly, leiomyoma, or fibroids. Much less commonly, sarcomas.
[00:02:04.50] In addition, there are some non-gynecologic causes that can present as adnexal
masses-- appendicitis, a diverticular abscess, a pelvic kidney. Lastly, you can also have cancers
that spread to the ovaries, leading to an actual adnexal mass, but are actually non-gynecologic
cancer, with breast and colorectal cancer being the most common. Adnexal masses can actually
oftentimes be asymptomatic and detected completely incidentally on imaging. When symptoms
are present, this can include pelvic pain and abdominal discomfort, pelvic pressure or bloating,
gastrointestinal symptoms such as constipation or decreased stool caliber, urinary symptoms
such as frequency and urgency, as well as backache.
[00:02:49.41] In evaluating a patient with an adnexal mass, let's first start with elements of the
patient history that are important. The first is the patient's age. Second is medical history-- does
the patient have a personal history of another cancer? For an OB/GYN history, what is their
reproductive status? Is the patient premenarchal, or have they not yet had their first period? Is the
patient of reproductive age or still menstruating? Lastly, is the patient menopausal? Have they
gone through their menopause?
[00:03:18.51] Should a patient have symptoms, it's important to note the timing of these
symptoms. Did they come on suddenly or acutely, or have these symptoms been present for
some time? If so, how long have the symptoms been present? In addition, it's important to assess
whether the patient has any symptoms that are suggestive of an infectious or non-gynecologic
etiology, such as fevers or more prominent gastrointestinal or genital urinary symptoms. Lastly,
it's important to take a family history as this does impact the likelihood that this mass might be
cancerous. Certainly it is important to assess for a family history of ovarian cancer, but also for a
family history of breast, endometrial, or colon cancers, especially when found at an early age.
[00:04:03.42] Benign adnexal masses are actually quite common and are most commonly made
up of functional or physiologic cysts to the ovary with a follicular cyst being most common, as
well as a corpus luteum cyst, or a persistent cyst after the formation of a corpus luteum, and this
cyst is known as the great imitator, as it can certainly appear to be similar to other types of
masses. The majority of these will actually regress spontaneously. Benign masses also include
endometriomas. This is also known oftentimes as a chocolate cyst, mostly because when these
cysts rupture, they will emanate old blood that appears like chocolate syrup. Patients who present
with endometriomas will very commonly have a history of cyclic or non-cyclic pelvic pain,
dysmenorrhea, dyspareunia, potentially infertility.
[00:04:53.52] When a patient is found to have an adnexal mass as well as a positive pregnancy
test, there is still a list of potential etiologies. The first is a corpus luteum, a luteoma of
pregnancy, or a steroid-producing tumor of the ovaries that is benign, an ectopic pregnancy,
which is important to consider in the differential, a thaco lutein cyst of the ovary, which can be
associated with molar pregnancy and will resolve spontaneously after treatment. When looking
at this picture, let's ask ourselves why is this cyst yellow? The answer is that this is a cyst that
contains steroid or fat, which is why this cyst is yellow. This is commonly seen with a luteoma of
pregnancy.
[00:05:37.25] When looking at the sources of ovarian neoplasms or ovarian growths, 70% of
them are accounted for by growths occurring from the surface epithelium of the ovary, 15% to
20% are growths that come from germ cells, and about 5% to 10% are growths that come from
the sex cord or sex hormone-producing cells of the ovary or stromal or supportive cells of the
ovary. Benign growths of the surface epithelium of the ovary can include serous and mucinous
cystadenomas, and, as demonstrated by the pictures here, can grow to incredibly large sizes.
[00:06:12.62] These masses are oftentimes thin-walled, fluid-filled cysts, although mucinous
masses will be filled with mucin. These masses are oftentimes complex-appearing on ultrasound,
and, as I mentioned, can be anywhere from 5 to more than 20 centimeters in size, with mucinous
cystadenoma, especially, becoming quite large. Serous tumors are bilateral in 20% to 25% of
patients, whereas less than 5% of mucinous cystadenoma will be bilateral.
[00:06:38.48] In reviewing the types of benign germ cell neoplasms, the most common of these
is a mature cystic teratoma, otherwise known as a dermoid. This is a mask that oftentimes will
contain tissue that has been derived from multiple layers of cell types, and can lead to the
presence of fat, hair, or teeth. This is the most common ovarian tumor to be diagnosed in the
second and third decades of life. And as I mentioned, in order to be diagnosed with this, the mass
must have ectodermal, mesodermal, and endodermal elements. These masses are almost always
benign. And ultrasound can be up to 98% accurate in diagnosing the presence of a dermoid.
[00:07:19.88] In reviewing the types of benign sex cord stromal neoplasms, the first of these is a
fibroma or a fibroadenoma. This is a solid, firm, and benign tumor arising from the ovarian
stroma. An uncommon type of syndrome that can arise in the presence of an ovarian fibroma is
Meigs syndrome. This is a syndrome in which patients who have ovarian fibromas actually
develop ascites or a pleural effusion. Thecomas are another type of benign ovarian sex cord
stromal neoplasm. These are oftentimes solid and can actually cause postmenopausal bleeding as
the tumors can produce estrogen.
[00:07:57.24] Borderline ovarian neoplasms account for about 10% to 20% of all epithelial
ovarian tumors. They are not invasive or can be microinvasive. The most common type is serous,
although mucinous and endometrioid borderline neoplasms are also possible. The average age of
diagnosis of a borderline ovarian neoplasm is slightly younger than that of cancer, with an
average age of diagnosis between 40 to 60.
[00:08:24.26] And the treatment of these neoplasms is surgical. It's important to note that when
surgery is done, patients' fertility can be preserved by leaving the uterus and non-effected tube
and ovary. However, when patients are detected to have these, it's important that they have a
staging and careful exam of the mass in order to rule out the possibility that invasive cancer is
present microscopically. 75% of patients with borderline neoplasms will present with stage 1 or
the neoplasm confined to the ovary.
[00:08:57.56] Let's briefly review ovarian cancers. Cancers can be derived from the various
types of the ovarian tissue, including the surface epithelium, germ cells, and sex cord stroma.
The majority of ovarian cancers are epithelial in nature, with an average age of diagnosis of 63.
Germ cell cancers account for about 1% to 2% of ovarian cancers, although as noted earlier, they
do make up about a quarter of all ovarian neoplasms. And germ cell tumors will account for
about 70% of ovarian tumors in females that are between the ages of 1 to 20.
[00:09:34.62] Lastly are sex cord stromal cancers. These account for about 3% of all ovarian
cancers, with an average age of diagnosis in the 40s. It's important to emphasize the age of a
patient when considering the differential diagnosis of an adnexal mass. Age is helpful in
predicting the risk of having malignancy, as well as the type of malignancy. premenarchal, or
girls who have not yet had their period, have a relatively high rate of ovarian malignancy when
they are found to have adnexal masses. However, they are most commonly found to have germ
cell cancers.
[00:10:09.98] In premenopausal, reproductive age, or menstruating women, they are most likely
to actually have a non-cancerous mass when an adnexal mass is detected, as only 6% to 11% of
such patients with ovarian neoplasms will be found to have cancer. This is in contrast to women
who have gone through menopause. The risk of having a malignancy when an adnexal mass is
present in a postmenopausal female is higher with a potential risk of 29% to 35%.
[00:10:39.46] Studies have demonstrated that there are some symptoms that can increase the
suspicion that a patient may have ovarian cancer. Specifically, any of the following symptoms
that have been present more than 12 times a month and present for less than one year have been
found to potentially increase the risk that a patient with an adnexal mass has cancer. These
symptoms include bloating or increased abdominal size, early satiety or difficulty eating, or
pelvic or abdominal pain.
[00:11:09.01] It's important to emphasize that in the setting of these symptoms, ovarian cancer
should be included on the differential diagnosis. However, these symptoms are not 100%
specific for the presence of ovarian cancer. When examining a patient diagnosed with an adnexal
mass, it is important to first perform an abdominal exam and note for the presence of ascites,
masses, or any prior surgical scars. A pelvic examination should be performed, ideally including
a rectovaginal exam, with attention paid to the size and location of the mass, consistency of the
mass, patient tenderness with exam, mobility of the mass. Lastly, patients should have a lymph
node examination, specifically that of the superclavicular inguinal lymph nodes, as well as a
breast exam to rule out a breast lesion.
[00:11:59.98] It's important to also be aware of any signs on exam that are worrisome for a deep
vein thrombosis or pleural effusion, as either of these can increase the suspicion that cancer is
present. After the detection of an adnexal mass, the study of choice to image it is a transvaginal
ultrasound. Ultrasound has a sensitivity of about 86% to 91% and a specificity of 68% to 83% in
detecting malignancy. In assessing an endometrioma, ultrasound has a sensitivity of 92% and a
specificity of 97%. Lastly, in the imaging of a dermoid cyst in the ovaries, it has a sensitivity of
90% and a specificity of 98%.
[00:12:40.18] What are other imaging options that we could potentially use? CT scans can be
especially important if you suspect an ovarian mass is cancer that has spread. It can also be
helpful in assessing when an infectious process is suspected, such as diverticulitis. MRI can also
be helpful if you're trying to distinguish a uterine fibroid from an adnexal mass, or to distinguish
whether an endometrioma is present.
[00:13:05.59] There are certain characteristics of a mass on imaging that can differentiate as to
whether a mass is benign or malignant. Benign masses tend to be unilateral, to be simple in
appearance with smooth walls, they tend to have very low peripheral Doppler flow or
vascularity. The lack of free fluid or ascites is important. And as noted, these oftentimes will
resolve over four to six weeks. In contrast, malignant masses can be bilateral, they tend to be
complex in appearance on ultrasound, have solid components, including internal papillations,
have central Doppler flow or vascular flow within the mass, ascites or free fluid could be present,
and these masses oftentimes may persist or grow over time.
[00:13:53.17] Here are two ultrasound examples. The picture on the left of your screen is a
normal ovarian follicle. As noted here, this cyst is simple in appearance, it is round, there are no
internal septations, and it is homogeneous in appearance. In contrast, the image on screen right is
an ovarian cancer. This mass is irregular in shape, has a fair amount of solid components within
the mass, and is irregular. In addition, there is fluid noted behind the mass that is within the culde-sac.
[00:14:24.91] When an adnexal mass is diagnosed, there are some laboratory tests that can be
helpful. In a patient who is premenopausal, you can consider the performance of a beta hCG to
rule out the potential for pregnancy-associated causes, as well as a potential germ cell tumor that
might produce beta hCG. If a patient is young and especially if a solid mass is noted, this can
raise the concern for a germ cell tumor. In this case, there are some markers that can be obtained
that can be elevated in the setting of germ cell tumors, including alpha-fetoprotein, lactose
dehydrogenase, beta hCG, and inhibin.
[00:15:02.57] CA 125 should be drawn only if there is a very high suspicion for malignancy, as
the false positive rate with premenopausal females is quite high. In a postmenopausal female, a
CBC can be drawn, as elevated platelets can be seen in the presence of cancer. A CA 125 will
have more sensitivity and specificity for cancer in a postmenopausal female. HE4 is a newer
serum protein that has been found to be more specific than CA-125 from cancer, and is also a
blood test. If there's concern for another malignancy other options for testing include either a
CEA or test for colon cancer, or CA19-9, which can be a tumor marker for pancreatic cancer.
[00:15:47.01] In evaluating CA 125 as a tumor marker, it's important to note that 80% of women
who have advanced stage ovarian cancer or ovarian cancer that has spread into the abdomen or
beyond have an abnormally elevated CA 125. Unfortunately, only 50% of patients with stage 1
cancer or cancer limited to the ovaries will have an elevated CA 125. Therefore, it is not the best
tumor marker, although it certainly can be useful to follow disease status.
[00:16:17.19] The other challenge with CA 125 is that it is not, as I mentioned, entirely specific
for the presence of ovarian cancer when elevated. There are many other causes of an elevated
CA 125, and this includes anything that can involve inflammation of the peritoneal space, such
as other intraperitoneal tumors, peritoneal tuberculosis, cirrhosis, pelvic inflammatory disease or
tubal ovarian abscess, endometriosis, pregnancy, heart failure, liver failure, diverticulitis, colitis,
intra-abdominal abscess, recent abdominal surgery, pancreatitis, and renal failure. The central
hallmark of all of these issues include peritoneal inflammation. So unfortunately, CA 125 is not a
perfectly sensitive nor specific marker for the presence of ovarian cancer.
[00:17:06.30] In looking at CA 125 as a potential tumor marker, in premenopausal patients, its
sensitivity for malignancy is between 50% to 74%. The specificity ranges anywhere from 26 to
92%, so it's quite variable. In postmenopausal patients, it tends to be both more sensitive and
specific. The sensitivity for malignancy is between 69% to 87% and the specificity is between
81% to 100%.
[00:17:33.57] There are other tumor markers that I mentioned in prior slides. Germ cell cancers
can oftentimes be associated with elevated LDH-- for example, in dysgerminomas of the ovary.
Choriocarcinomas and embryonal carcinomas of the ovary can be associated with elevated beta
hCG. Endodermal sinus or yolk sac tumors are associated with elevated alpha-fetoprotein. Sex
cord stromal tumors of the ovary can also be associated with other tumor markers-- namely,
granulosis cell cancers of the ovary can be associated with elevated inhibin-A and -B. And
Sertoli-Leydig cell tumors can produce testosterone, androstenedione, or
dehydroepiandrostenedione.
[00:18:15.46] Adnexal masses are often surgically managed, and why should we operate on such
patients? The first is to provide a diagnosis. Second reason is to rule out the potential of cancer.
And the third is to potentially relieve symptoms. Lastly, masses in the adnexa can tors and/or
rupture, which can be a more emergent circumstance. And operating to remove adnexal masses
can prevent this from occurring. Should cancer, infection, and/or ectopic pregnancy be present,
surgery provides a mode of treatment.
[00:18:49.08] However, what are some reasons to not operate? The first is that an operation for
an adnexal mass will be a major surgery, in a young woman there may be fertility concerns as to
the ability to preserve the ovary, as well as the cost of surgery. So it's important to consider are
there any patients who can safely be followed with observation or repeat imaging?
[00:19:10.14] And a key to follow-up is adequate follow-up. In a patient who is premenopausal
with an adnexal mass, there is a triage strategy that you can utilize to determine whether a mass
can be followed or not. In a patient who has a mass that is less than 10 centimeters in size, simple
in appearance, that is cystic with fluid in the middle, mobile, as well as the absence of ascites,
patients can be followed with a repeat ultrasound in about four to six weeks, and the use of OCPs
can be considered to prevent subsequent cyst formation. When the ultrasound is repeated, if the
mouse is gone or is smaller, these patients can simply be followed. However, if the mass is
persistent or larger, surgical exploration is warranted. In contrast, in a premenopausal female
who has an adnexal mass on ultrasound that is greater than 10 centimeters, has nodular or solid
components, is complex, fixed, and/or has ascites, surgical exploration is warranted.
[00:20:08.67] In a postmenopausal female with an adnexal mass, most of these patients will need
surgery, primarily to exclude the possibility of malignancy. However, some patients can be
followed with surveillance. If a cyst is small, meaning less than 5 centimeters, and simple in
appearance, unilateral, and the pelvic exam is not concerning for malignancy, as well as the CA
125 being normal, patients can be followed. However, if a patient is symptomatic, surgery is
warranted. Lastly, if there is any fluid seen on ultrasound or any ascites, surgery is also
warranted. If patients are chosen to have observation, an ultrasound should be repeated in 6 to 12
weeks.
[00:20:49.26] The American Congress of OB/GYN has guidelines for when a patient with an
adnexal mass should be referred from a gynecologist to a gynecologic oncologist for a pelvic
mass. This includes any patient who has an adnexal mass and the setting of ascites or any other
evidence of metastasis, the mass is nodular or fixed on pelvic exam, the patient has a first-degree
relative who has ovarian cancer, the mass is in a postmenopausal woman and a CA 125 is greater
than 35, or there is a pelvic mass in a premenopausal woman with a CA 125 of greater than 200.
[00:21:27.00] I'd like to summarize about adnexal masses by first reminding you to think about
the differential diagnosis of an adnexal mass and to stay open-minded. That patient does need
evaluation with both a history and physical exam with specific attention paid to the age, medical
and reproductive history, exam, imaging, and laboratory findings. And the options in
management include either to operate or to follow closely. Lastly, if there are indications present,
such patients should be referred to a gynecologic oncologist, a physician who has specialization
in the treatment and management of gynecologic cancers.
[00:22:06.09] Thank you very much for your attention. Should you have any questions, please
feel free to email me with any questions based on this lecture or any patient-based questions.