Management of Adnexal Mass
Oct 2010 – by V. von Gruenigen, MD
A 63 year-old G.P. complains of a constant dull ache in her left lower pelvis over one week. Her medical and family history with review of systems is not significant. Pelvic exam is suspicious for an enlarged nodular left ovary. An ultrasound reveals a left 5 cm solid and cystic adnexal mass.
The differential diagnosis of an adnexal mass includes both gynecologic and nongynecologic sites and, when arising from the ovary, may be benign, or malignant. In premenopausal women the most common are functional cysts. The most common masses in postmenopausal women are benign neoplasms, such as cystadenomas but the risk of malignancy is greater. A woman's lifetime risk of developing ovarian cancer is approximately 1 in 70.
All postmenopausal women with an adnexal mass should have a breast and rectal exam along with mammography. In addition, colonoscopy should be considered. If the patient also has postmenopausal bleeding then an office endometrial biopsy should be performed.
Age is the most important risk factor for ovarian cancer. A family history of breast or ovarian cancer increases the lifetime risk for ovarian cancer. BRCA1 carriers have a 60-fold increased risk, BRCA2 carriers a 30-fold increased risk and women affected with the hereditary non-polyposis colorectal cancer or Lynch II syndrome have approximately a 13-fold greater risk of developing ovarian cancer. Prophylactic oophorectomy decreases the risk of ovarian cancer, along with combined oral contraceptives.
Although most adnexal masses are benign, the purpose of the evaluation is to exclude malignancy. Pelvic and transvaginal ultrasound is the preferred imaging modality to evaluate an adnexal mass. The appearance of septations, mural nodules, papillary excrescences, and free fluid in the pelvis suggests malignancy. A computed tomography (CT) can be utilized when the leading differential diagnosis is ovarian cancer to evaluate the abdomen for metastatic disease.
Presently, the most clinically applicable tumor marker is the CA 125. It is elevated in 80% of patients with epithelial ovarian cancer but in only 50% of patients with stage I disease. ß-hCG, L-lactate dehydrogenase (LDH), and alpha-fetoprotein (AFP) levels may be elevated in the presence of certain malignant germ cell tumors, and inhibin A and B sometimes are markers for granulosa cell tumors of the ovary. Other novel serum markers, such as HE4, and multimarker assays are being explored to aid in the early diagnosis of ovarian cancer.
The Society of Gynecologic Oncologists (SGO) and the American College of Obstetricians and Gynecologists (ACOG) have both developed referral guidelines which are located on their websites. Women with suspected ovarian cancer should be managed with gynecologic oncologists as studies have revealed improved overall survival rates compared with those treated without such collaboration.