Today, I review, link to, and excerpt from Adnexal Tumors
Updated: Apr 22, 2022
Author: Nelson Teng, MD, MS, MBA, PhD from emedicine.medscape.com.
All that follows is from the above resource.
The normal functioning ovary produces a follicular cyst 6-7 times each year. In most cases, these functional cysts are self-limiting and resolve within the duration of a normal menstrual cycle. In rare situations, a cyst persists longer or becomes enlarged. At this point, it represents a pathological adnexal mass.
Adnexal masses present a diagnostic dilemma; the differential diagnosis is extensive, and most masses are benign. [1, 2, 3] However, without histopathologic tissue diagnosis, a definitive diagnosis is generally precluded. Physicians must evaluate the likelihood of a concerning pathologic process using clinical and radiologic information and balance the risk of surgical intervention for a benign versus malignant process.
Since ovaries produce physiologic cysts in menstruating women, the likelihood of a benign process is higher in women of reproductive age. In contrast, the presence of an adnexal mass in prepubertal girls and postmenopausal women heightens the risk of a malignant neoplastic etiology.
The following masses pose the greatest concern:
- Those that have a complex internal structure
- Those that have solid components
- Those that are associated with pain
- Masses in prepubescent or postmenopausal women
- Large cysts (A variety of cut-off sizes have been proposed. In some institutions, unilocular cysts up to 10 cm have been followed conservatively, even in postmenopausal women. [8] However, the presence of complex cysts in postmenopausal women generally heightens suspicion, regardless of size.)
- In menstruating women, those who persist beyond the length of a normal menstrual cycle without typical characteristics of a benign process such as a hemorrhagic cyst
The clinical presentation of an adnexal mass can be variable, but patients are often asymptomatic. Patients may present with masses that are found (1) at the time of a pelvic examination, (2) at the time of a radiologic examination for another diagnosis, or (3) at the time of a surgical procedure. Women who have symptoms may note urinary frequency, pelvic or abdominal pressure, and bowel habit changes due to the mass effect on these organs. Girls younger than 10 years frequently present with pain, as do older women who have infected masses or endometriosis. Adnexal torsion classically presents with acute abdominal pain, requiring urgent surgical intervention.
The largest screening trial performed to date (The Prostate, Lung, Colorectal, and Ovarian Cancer Screening Randomized Controlled Trial, or PLCO Trial) found that among the general population, screening with CA-125 and transvaginal ultrasound versus usual care did not decrease ovarian cancer mortality. The study also reported serious complications arising from diagnostic interventions performed to evaluate false-positive screening results. [24]
Possible laboratory tests in the evaluation of adnexal mass include serum markers, Papanicolaou test, CBC count, urinalysis (U/A), stool for blood, and electrolytes.
CA-125 is elevated in approximately 80% of all women with ovarian cancer. In stage I disease, the sensitivity of this biomarker is approximately 50%, which rises to 90% in patients with advanced disease. [32] However, it can also be elevated in many other conditions, including gynecologic etiologies such as endometriosis, uterine fibroids, and pregnancy, and nongynecologic conditions such as gastroenteritis, pancreatitis, cirrhosis, and congestive heart failure. [26, 27, 28] As such, the specificity of CA-125 is limited and is not recommended for routine screening purposes in the general population (see Clinical). [33]
Although elevated, levels of serum CA-125 do not appear to be a significant predictor of malignant transformation of endometriosis. Significant predictive factors for the presence of malignant transformation of endometriosis appear to include age older than 49 years and cysts that are multilocular and have solid components. [34]
Urine or serum beta human chorionic gonadotropin (ß-hCG) should be obtained in women of reproductive age to rule out pregnancy and pregnancy-related etiologies of adnexal masses.
The most commonly performed test to evaluate an adnexal mass is transabdominal or transvaginal ultrasonography. [6, 7, 8, 42] This test helps demonstrate the presence of the mass and its location (eg, ovarian, uterine, bowel). It also provides the mass size, consistency, and internal architecture. Scoring systems, such as that suggested by DePriest and associates, can then be used to determine the likelihood of a malignant component. [43] Hysterosonography (ultrasonography with the presence of fluid in the uterine cavity) may be used to help distinguish between uterine masses and those arising from other pelvic structures. Color Doppler ultrasonographies can be used to evaluate the resistive index of the mass vessels, which, when low, has been indicative of a malignancy.
