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  • Nathan Riley, MD

Obgyno Wino Podcast Episode 31 - Evaluation and Management of Adnexal Masses

"Disease and death, if we may judge by the records of creation, are inherently and essentially necessary in the present order of things. A perfect intelligence, trained by a perfect education, could do no more than keep the laws of the physical and spiritual universe. An imperfect intelligence, imperfectly taught — and this is the condition of our finite humanity — will certainly fail to keep all these laws perfectly. Disease is one of the penalties of one of the forms of such failure. It is prefigured in the perturbations of the planets, in the disintegration of the elemental masses; it has left its traces in the fossil organisms of extinct creations." - Oliver Wendell Holmes, in his 1860 address to the Massachusetts Medical Society

2016 Educated Guess Cabernet Sauvignon by Roots Run Deep Winery

PB#174 - Published November 2016

Five Pearls

  1. Most adnexal masses aren't cancer.

  2. Simple, fluid-filled masses, especially in women of reproductive age, will resolve spontaneously without the need for surgery

  3. Physical exam, imaging, biomarkers, history, and review of systems are all critical components to the evaluation of adnexal masses

  4. If you are suspicious of malignancy, consult gynecology oncology before operating. And call for them intraoperatively when in doubt.

  5. Masses that result in a torsed ovary should be managed surgically and removed when indicated; even ovaries with significant ischemia or necrosis will usually bounce right back to normal function

Overview of ovarian cancer incidence...since that's what we're all worried about

- incidence in general population: 1/70 (1.6%)

- family history of the single most important risk factor

- if first-degree relative: 5%

- if BRCA mutation: 45% (BRCA1) and 25% (BRCA2)

- if Lynch syndrome: 10%

- mean age at presentation: 63 years

- additional risk factors: primiparity, endometriosis, early menarche, late menopause, white race


Not all adnexal masses are cancer, though...


- consideration of age, location of mass, and reproductive status is helpful for narrowing down your differential diagnosis

- remember that metastatic breast and GI cancers can often pop up first as adnexal masses


Fun fact: metastatic GI tumors that arise on the surface of an ovary are known as Krukenberg tumors


When found...you may need a history, exam, imaging, and blood work

- ovarian cancer often creeps up over years, and we have no serial screening tests for patients at low risk

- most adnexal masses are found incidentally


History

- if a mass is noted on pelvic exam or imaging, get a thorough medical and history (See ACOG CO#478 for a great risk assessment tool), review of systems, and additional studies as needed

- if of reproductive age, don't forget to evaluate for pregnancy! (beware ectopics, which often present with unilateral, sudden-onset pain)

- unilateral, intermittent severe pain w/ a mass may point to ovarian torsion (look for the absence of arterial waveforms on ovarian artery doppler)

- fever, chills, vomiting, and cervical discharge? might be a tubo-ovarian abscess

- bloating and early satiety are early signs of malignancy (which is why it may go undiagnosed for so long!)

- a mass that's associated with abnormal uterine bleeding could be a sex cord stromal tumor (they produce estrogen, which leads to endometrial hyperplasia)


Exam

- bimanual exam and help distinguish is the mass is confluent with the uterus and can reveal firmness and tenderness, shape, size, and texture

- rectovaginal exam may also reveal nodulatiry of uterosacrals, which usually indicates endometriosis

- check for lymphadenopathy


Pearl: A thorough physical exam is critical for surgical planning and narrowing your differential diagnosis. Having said that, consent goes a long way when it comes to the physical exam. True consent includes describing why certain elements of the exam are helpful diagnostics as well as gaining a patient's permission


Imaging

- endovaginal ultrasound remains the gold standard (advantage: can also evaluate blood flow)

- MRI can be further helpful in distinguishing confluence between the mass and other organs, particularly in large masses and especially for leiomyomas

- CT is notoriously bad at evaluating the ovaries, but it can be helpful in identifying metastases, ascites, omental caking, lymphadenopathy, obstructive uropathy, and potentially even suggest an alternate primary source if the mass is malignant


Serum biomarkers

- CA-125 is most sensitive biomarker for non-mucinous ovarian cancer (the most common type) in postmenopausal women (80% of postmenopausal women w/ ovarian malignancy will have an elevated CA-125)

- It's no longer considered a useful biomarker for premenopausal women due to poor sensitivity (it can be elevated in PID, pregnancy, endometriosis, and non-gyn malignancy)

- The risk of malignancy index (RMI) is a validated multimodal risk assessment tool for determining likelihood of malignancy of adnexal masses

- it takes into account serum biomarkers, clinical information, and ultrasound findings

- b-HCG, L-LDH, and AFP can be elevated in certain malignant germ cell tumors

- inhibin and estrogen may be elevated in Granulosa cell tumors


Which ultrasound findings might suggest malignancy?

- cysts >10 cm in size, papillary or solid components, irregularity in shape, presence of ascites, and high color Doppler flow around the cyst

papillary excrecences

nodules

Which ultrasound findings might suggest benignity (yes, it's a word...)?

- thin, smooth walls, absence of solid components, septations, or no internal blood flow on Doppler

- simple cysts carry of malignancy risk of 0-1% depending on who you ask

- even if >10 cm simple cysts will likely regress spontaneously (though cysts >10 cm are officially an indication for surgical removal)

- endometriomas ("chocolate cysts") are classically filled with a ground glass appearing fluid (blood) (ultrasound is 83% specific, 89% sensitive)

endometriomas have a gound glass appearance

- mature cystic teratomas ("dermoid cysts") generally have solid/fluid/fatty components (no internal blood flow as you would with malignancies) (ultrasound is 58% sensitive, 99% specific)

mature cystic teratoma: chunk of hard stuff in a pool of speckly black fluid/fat


Ewww: gross path of a dermoid

Does every mass need to be surgically excised?

- No. In the absence of symptoms, abnormal biomarkers or concerning ultrasound findings, simple cysts will most likely resolve spontaneously, especially if <10 cm in diameter, even in postmenopausal patients

- serial ultrasound can help to evaluate masses not removed surgically; the jury is not out yet regarding optimal imaging intervals, but probably safe to aim for 6-12 months


How should a mass be removed?

- Get it out intact, especially if you are concerned about malignancy (yes, even if this means converting to laparotomy)

- but if you can keep it laparoscopic, remember that patient will have faster recovery, spend less time in the hospital, will lose less blood, and will require less opioids post-operatively


When should you refer to gynecology oncology?

- post-menopausal with elevated CA-125 >35 or ultrasound findings suspicious for malignancy, or presence of ascites, or a nodular or fixed pelvic mass on physical exam, or evidence of abdominal or distant metastasis

- pre-menopausal? same only the CA-125 must be SIGNIFICANTLY elevated to prompt referral without any of the other items

- pre- or post-menopausal women with an elevated RMI or ROMA score (see table 1 above)

- debulking surgery will be required in the event that you are dealing with an ovarian malignancy (~75% of patients diagnosed with ovarian cancer will have advanced disease at time of diagnosis)

- if you suspect malignancy intraoperatively, get an intraop gyn/onc consult if available; otherwise leave it alone if you can't remove it intact


Recall: If the mass is malignant and you break it open leaking its contents into the abdomen, a stage IA ovarian cancer gets upstaged to stage IC


Anything special to consider w/ adolescents?

- transabdominal ultrasound preferred over endovaginal (less traumatic, especially if the patient is pre-pubescent or virginal)

- most masses don't need to be removed

- indications for surgery: acute pain, suspected torsion, suspected malignancy, or persistent masses

- of the malignancy categories, germ cell tumors are more commonly the culprit in adolescents, so check biomarkers (AFP, LDH, and bHCG)

- ovaries should be preserved when possible, though unilateral oophorectomy has not been found to be associated with decreased live birth rates or impaired menstrual regularity in the future

- if you do surgery on a malignant mass: preserve the tube if not adherent, sample ascites, removal of the tumor intact, biopsy of other suspicious lesions in peritoneal cavity or suspicious lymph nodes


When is fine needle aspiration indicated?

- suspected TOA (drainage may actually shorten hospital stay and decrease need for surgical intervention in women of reproductive age in confirmed TOA compared to antibiotics alone)


Note: postmenopausal women w/ pelvic abscesses should have surgical intervention, as they may harbor malignancy


- diagnosis of suspected cancer if adjuvant chemo is planned (particularly in patients unfit for surgery)

- don't go crazy: aspiration can seed the peritoneal cavity with malignant cells

- FNA is not therapeutic; cysts have 20-40% chance of recurrence when merely drained


How to manage torsion?

- un-torse the ovary, silly

- preserve the ovary if possible, removal a mass if present

- masses <3cm in size are unlikely to cause torsion

- even in cases where necrosis or ischemia were noted intra-operatively, 90% of women experience preservation of ovarian function w/in 3 months of intervention

- fixation might be helpful, but limited evidence


What do I do with dermoids?

- they won't resolve spontaneously; take it out

- perform copious irrigation of peritoneal cavity when spillage occurs (it's almost always does), otherwise it may cause severe peritonitis


How about endometriomas?

- removal may affect ovarian reserve, but they should still be removed if a patient is experiencing symptoms from the mass itself or if the mass is growing on serial ultrasound (though still low absolute risk of malignancy)


Lastly, what about an adnexal mass in pregnancy?

- up to 90% of adnexal masses will resolve spontaneously during pregnancy

- extremely low risk of malignancy (<5% of masses that don't resolve spontaneously)

- mature teratomas and persistent corpus luteal cysts are most likely culprits

- acute complications w/ adnexal masses managed expectantly in pregnancy is low (<2%)


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