Postmenopausal Ovarian Mass – Feb 2009

A 72 year old woman presents with a CT scan report indicating that she has a 2.5cm ovarian mass. She is concerned that she may have cancer. What is the appropriate way to evaluate this patient?

In the era of frequent imaging tests, incidental ovarian masses, especially ovarian cysts, are being found more and more frequently in postmenopausal women. The estimated prevalence, based on community based ultrasound screening studies, is 18%¹. The vast majority of these ovarian cysts are benign. How can the clinician proceed to perform a reasonable, prudent workup that is not wasteful of health care dollars and provide a reasonable level of reassurance to the patient?

Masses identified on CT scan can be best evaluated for echogenicity and septation using ultrasound. Therefore, the most appropriate next step in the valuation of the CT-identified incidental mass is a transvaginal ultrasound imaging. The size and echotexture of the mass should be noted along with the presence or absence of ascites. A unilocular mass without ascites has a low risk of malignancy. Pain in the pelvis or abdomen, urinary urgency or frequency, increased abdominal girth or bloating, and early satiety are relatively non-specific symptoms, but when they are consistently present they appear to raise the concern for a malignant process. In one logistic regression analysis, presence of any of these symptoms for more than 12 days a month over one year had 80% sensitivity and 90% specificity for advanced ovarian carconima².

The physical examination will also provide support for or against reassurance. A non-nodular, mobile cystic mass is more likely to be benign. A combined recto-vaginal examination is the best method to evaluate potential pelvic pathology.

Beyond the transvaginal ultrasound, further imaging with Doppler flow studies does not appear to enhance diagnostic ability³.

A patient with a negative history and examination and a benign transvaginal imaging study can be re-evaluated periodically. Screening with tumor markers can also be done⁴. An elevated Ca-125 is the postmenopausal patient raises concern. Nothing further need be done as long as the mass remains stable. Follow up ultrasounds can be scheduled and a repeat within 6 months is cautious and once stability is confirmed, the frequency should probably be no more than annually.

Masses that appear complex are of more concern and will usually require surgical evaluation. Did the patient have any pelvic surgeries, or known pelvic masses when she was premenopausal? A further evaluation with serum tumor markers may be helpful. If these are positive, referral to a gynecologic oncologist should be considered. A negative result does not definitively rule out a malignancy, as up to 50% of early stage cancers are associated with a normal CA-125⁵.

Complex masses may also be evaluated with Doppler flow studies, but as for benign masses, these studies add expense without enhancing diagnostic accuracy. Palpation of a fixed, nodular mass, presence of excrescences within a cystic complex structure that is within the ovary, the presence of a positive CA-125 (>200 pg/ml), or ascites warrants prompt surgical evaluation of the mass⁶. Referral to a Gynecologic Oncologist when possible is most likely to result in superior patient outcomes, secondary to more comprehensive staging and optimal removal of hair⁷.

1. McDonald JM, Modesitt SC. The incidental postmenopausal adnexal mass. Clinical obstetrics and gynecology 2006;49(3):506-16.
2. Goff BA, Mandel LS, Drescher CW, et al. Development of an ovarian cancer symptom index: possibilities for earlier detection. Cancer 2007;109(2):221-7.
3. Jokubkiene L, Sladkevicius P, Valentin L. Does three-dimensional power Doppler ultrasound help in discrimination between benign and malignant ovarian masses? Ultrasound Obstet Gynecol 2007;29(2):215-25.
4. Oyelese Y, Kueck AS, Barter JF, Zalud I. Asymptomatic postmenopausal simple ovarian cyst. Obstetrical & gynecological survey 2002;57(12):803-9.
5. ACOG Committee Opinion, 280, December 2002: The Role of the Generalist Obstetrician-Gynecologist in the Early Detection of Ovarian Cancer.
6. ACOG Practice Bulletin 83, July 2007: Management of Adnexal Masses.
7. Im, SS, Gordon AN, Buttin BM, Leath CA 3rd, Gostout BS, Shah C, et al. Validation of referral guidelines for women with pelvic masses. Obstet Gynecol 2005; 105:35-41.

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