Diagnosis and Management of Adnexal Masses

 


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Am Fam Physician. 2016 Apr 15;93(8):676-681.

  Patient information: See related handout on ovarian cysts and ovarian cancer written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Adnexal masses can have gynecologic or nongynecologic etiologies, ranging from normal luteal cysts to ovarian cancer to bowel abscesses. Women who report abdominal or pelvic pain, increased abdominal size or bloating, difficulty eating, or rapid satiety that occurs more than 12 times per month in less than a year should be evaluated for ovarian cancer. Pelvic examination has low sensitivity for detecting an adnexal mass; negative pelvic examination findings in a symptomatic woman should not deter further workup. Ectopic pregnancy must be ruled out in women of reproductive age. A cancer antigen 125 (CA 125) test may assist in the evaluation of an adnexal mass in appropriate patients. CA 125 levels are elevated in conditions other than ovarian cancer. Because substantial overlap in CA 125 levels between pre- and postmenopausal women may occur, this level alone is not recommended for differentiating between a benign and a malignant adnexal mass. Transvaginal ultrasonography is the first choice for imaging of an adnexal mass. Large mass size, complexity, projections, septation, irregularity, or bilaterality may indicate cancer. If disease is suspected outside of the ovary, computed tomography may be indicated; magnetic resonance imaging may better show malignant characteristics in the ovary. Serial ultrasonography and periodic measurement of CA 125 levels may help in differentiating between benign or potentially malignant adnexal masses. If an adnexal mass larger than 6 cm is found on ultrasonography, or if findings persist longer than 12 weeks, referral to a gynecologist or gynecologic oncologist is indicated.

The etiology of adnexal masses ranges from physiologically normal luteal cysts to ovarian cancer. The clinician needs to interpret symptoms and findings from multiple organ systems and use appropriate imaging to differentiate expeditiously between a benign and a malignant cause of an adnexal mass. Ovarian malignancy is diagnosed approximately 22,000 times per year in the United States, making it the second most common gynecologic cancer; in 2010, nearly 14,000 women died of ovarian cancer.1,2 Screening for ovarian cancer has not been demonstrated to be effective in the general population. With no effective screening measures available, 70% of ovarian malignancies are diagnosed at a late stage.3 However, when ovarian cancer is detected at a stage confined to the ovary, survival rates can approach 90% at five years.3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Women who report abdominal or pelvic pain, increased abdominal size or bloating, or difficulty eating or feeling full quickly more than 12 times per month for less than 12 months' duration should be evaluated for ovarian cancer.

C

3

The U.S. Preventive Services Task Force recommends against routine screening for ovarian cancer, including use of transvaginal ultrasonography, cancer antigen 125 testing, and screening pelvic examinations.

A

10

An adnexal mass occurring during pregnancy can be managed expectantly because the risk of malignancy is low.

C

18, 19, 21, 22

Transvaginal ultrasonography should be the first imaging test used to identify and characterize an adnexal mass.

C

6

Cancer antigen 125 testing alone should not be used to differentiate between a benign and a malignant adnexal mass.

C

6, 16


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Women who report abdominal or pelvic pain, increased abdominal size or bloating, or difficulty eating or feeling full quickly more than 12 times per month for less than 12 months' duration should be evaluated for ovarian cancer.

C

3

The U.S. Preventive Services Task Force recommends against routine screening for ovarian cancer, including use of transvaginal ultrasonography, cancer antigen 125 testing, and screening pelvic examinations.

A

10

An adnexal mass occurring during pregnancy can be managed expectantly because the risk of malignancy is low.

C

18, 19, 21, 22

Transvaginal ultrasonography should be the first imaging test used to identify and characterize an adnexal mass.

C

6

Cancer antigen 125 testing alone should not be used to differentiate between a benign and a malignant adnexal mass.

C

6, 16


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

The differential diagnosis for adnexal masses is broad. A previous American Family Physician article gives a complete list.4 The gynecologic causes of adnexal masses include

The Authors

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WENDY S. BIGGS, MD, is an associate professor in the Department of Family Medicine at the University of Kansas School of Medicine, Kansas City....

SARAH TULLY MARKS, MD, is an assistant professor in the Department of Family Medicine at the University of Kansas School of Medicine.

Address correspondence to Wendy S. Biggs, MD, University of Kansas, 3901 Rainbow Blvd., MS 4010, Kansas City, KS 66160 (e-mail: wbiggs@kumc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

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1. American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. Committee Opinion No. 477: the role of the obstetrician-gynecologist in the early detection of epithelial ovarian cancer. Obstet Gynecol. 2011;117(3):742–746....

2. Suh-Burgmann E, Hung YY, Kinney W. Outcomes from ultrasound follow-up of small complex adnexal masses in women over 50. Am J Obstet Gynecol. 2014;211(6):623.e1–623.e7.

3. Goff BA, Mandel LS, Drescher CW, et al. Development of an ovarian cancer symptom index: possibilities for earlier detection. Cancer. 2007;109(2):221–227.

4. Givens V, Mitchell G, Harraway-Smith C, Reddy A, Maness DL. Diagnosis and management of adnexal masses. Am Fam Physician. 2009;80(8):815–820.

5. American Cancer Society Ovarian cancer. http://www.cancer.org/cancer/ovariancancer/detailedguide/ovarian-cancer-risk-factors. Accessed September 13, 2015.

6. Dodge JE, Covens AL, Lacchetti C, et al.; Gynecology Cancer Disease Site Group. Management of a suspicious adnexal mass: a clinical practice guideline. Curr Oncol. 2012;19(4):e244–e257.

7. Goff BA, Mandel LS, Melancon CH, Muntz HG. Frequency of symptoms of ovarian cancer in women presenting to primary care clinics. JAMA. 2004;291(22):2705–2712.

8. Essential Evidence Plus. Ovarian cancer suspected. September 2004. https://www.essentialevidenceplus.com/content/hpcalc/132 (subscription required). Accessed December 16, 2015.

9. Qaseem A, Humphrey LL, Harris R, Starkey M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Screening pelvic examination in adult women: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161(1):67–72.

10. U.S. Preventive Services Task Force. Final recommendation statement. Ovarian cancer: screening. July 2015. http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/ovarian-cancer-screening?ds=1&s=ovarian. Accessed January 5, 2016.

11. Buys SS, Partridge E, Black A, et al.; PLCO Project Team. Effect of screening on ovarian cancer mortality: the prostate, lung, colorectal and ovarian (PLCO) cancer screening randomized controlled trial. JAMA. 2011;305(22):2295–2303.

12. Agency for Healthcare Research and Quality. Evidence report/technology assessment. Management of adnexal mass. Rockville, Md. February 2006. http://archive.ahrq.gov/downloads/pub/evidence/pdf/adnexal/adnexal.pdf. Accessed March 8, 2015.

13. Silva C, Sammel MD, Zhou L, Gracia C, Hummel AC, Barnhart K. Human chorionic gonadotropin profile for women with ectopic pregnancy. Obstet Gynecol. 2006;107(3):605–610.

14. Barnhart KT, Simhan H, Kamelle SA. Diagnostic accuracy of ultrasound above and below the beta-hCG discriminatory zone. Obstet Gynecol. 1999;94(4):583–587.

15. Oron G, Tulandi T. A pragmatic and evidence-based management of ectopic pregnancy. J Minim Invasive Gynecol. 2013;20(4):446–454.

16. Van Calster B, Valentin L, Van Holsbeke C, et al. A novel approach to predict the likelihood of specific ovarian tumor pathology based on serum CA-125: a multicenter observational study. Cancer Epidemiol Biomarkers Prev. 2011;20(11):2420–2428.

17. Hermans AJ, Kluivers KB, Wijnen MH, Bulten J, Massuger LF, Coppus SF. Diagnosis and treatment of adnexal masses in children and adolescents. Obstet Gynecol. 2015;125(3):611–615.

18. Barash JH, Buchanan EM, Hillson C. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2014;90(1):34–40.

19. Goh W, Bohrer J, Zalud I. Management of the adnexal mass in pregnancy. Curr Opin Obstet Gynecol. 2014;26(2):49–53.

20. Bernhard LM, Klebba PK, Gray DL, Mutch DG. Predictors of persistence of adnexal masses in pregnancy. Obstet Gynecol. 1999;93(4):585–589.

21. Leiserowitz GS, Xing G, Cress R, Brahmbhatt B, Dalrymple JL, Smith LH. Adnexal masses in pregnancy: how often are they malignant? Gynecol Oncol. 2006;101(2):315–321.

22. Zanetta G, Mariani E, Lissoni A, et al. A prospective study of the role of ultrasound in the management of adnexal masses in pregnancy. BJOG. 2003;110(6):578–583.

23. Alcázar JL, Olartecoechea B, Guerriero S, Jurado M. Expectant management of adnexal masses in selected premenopausal women: a prospective observational study. Ultrasound Obstet Gynecol. 2013;41(5):582–588.

24. Han SN, Lotgerink A, Gziri MM, Van Calsteren K, Hanssens M, Amant F. Physiologic variations of serum tumor markers in gynecological malignancies during pregnancy: a systematic review. BMC Med. 2012;10:86.

25. Dodge JE, Covens AL, Lacchetti C, et al.; Gynecology Cancer Disease Site Group. Preoperative identification of a suspicious adnexal mass: a systematic review and meta-analysis. Gynecol Oncol. 2012;126(1):157–166.

26. Kaijser J, Sayasneh A, Van Hoorde K, et al. Presurgical diagnosis of adnexal tumours using mathematical models and scoring systems: a systematic review and meta-analysis. Hum Reprod Update. 2014;20(3):449–462.

27. Kondalsamy-Chennakesavan S, Hackethal A, Bowtell D, Obermair A; Australian Ovarian Cancer Study Group. Differentiating stage 1 epithelial ovarian cancer from benign ovarian tumours using a combination of tumour markers HE4, CA125, and CEA and patient's age. Gynecol Oncol. 2013;129(3):467–471.

28. Patel MD, Ascher SM, Paspulati RM, et al. Managing incidental findings on abdominal and pelvic CT and MRI, part 1: white paper of the ACR Incidental Findings Committee II on adnexal findings. J Am Coll Radiol. 2013;10(9):675–681.

29. Yavuzcan A, Caglar M, Ozgu E, et al. Should cut-off values of the risk of malignancy index be changed for evaluation of adnexal masses in Asian and Pacific populations? Asian Pac J Cancer Prev. 2013;14(9):5455–5459.



 

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