Practice Bulletin 174: Evaluation and Management of Adnexal Masses

Overview of Adnexal Masses

• Adnexal masses include lesions of the ovaries, fallopian tubes, and surrounding tissues.
• Most masses are found incidentally during exams or pelvic imaging; symptoms may include acute/intermittent pain.
• Key diagnostic goal is to rule out malignancy, considering patient age and family history.

Age and Risk Factors for Malignancy

• Median age for ovarian cancer diagnosis: 63 years; 69.4% of patients are age 55 or older.
• Postmenopausal women face a higher risk of malignancy compared to premenopausal women.
• Significant personal risk factor: strong family history of breast or ovarian cancer, particularly in BRCA1 and BRCA2 mutation carriers.
• Lifetime ovarian cancer risk: approximately 41-46% for BRCA1 and 10-27% for BRCA2 mutations by age 70.

Differential Diagnosis

• Gynecologic Causes: Benign (functional cysts, endometriomas), malignant (epithelial carcinomas, germ cell tumors).
• Nongynecologic Causes: Infections (tubo-ovarian abscess), gastrointestinal issues (appendiceal abscess, diverticular disease).
• Symptoms can indicate specific conditions; e.g., acute pain may suggest ovarian torsion.

Evaluation and Examination

• Detailed gynecologic and family history is critical.
• Physical examination includes evaluation of vital signs and systematic palpation for lymph nodes and pelvic masses.
• An adnexal mass presenting as irregular, firm, or associated with ascites may indicate malignancy.

Imaging Techniques

• Transvaginal ultrasonography is the preferred method for evaluating adnexal masses.
• Ultrasound assesses size, composition, and vascular characteristics, guiding management decisions.
• CT, MRI, and PET are typically not recommended initially; MRI can help distinguish non-ovarian masses in certain contexts.

Serum Marker Testing

• CA 125 is the most studied serum marker; elevated levels indicate a higher likelihood of malignancy but can also be elevated in benign conditions.
• The measurement of other markers (e.g., β-hCG, alpha-fetoprotein) may assist in specific cases based on risk factors.
• Panels such as the Multivariate Index Assay and Risk of Ovarian Malignancy Algorithm are formally approved for assessing risk.

Management Guidelines

• Initial management should be based on imaging results, serum markers, and patient clinical profile.
• Patients presenting with high-risk features may need referral to gynecologic oncologists.
• The overall approach should be individualized based on patient needs and institutional resources.### Diagnostic Algorithms for Ovarian Cancer
• Cut-off values for menopausal status specific to multivariate index assays and Risk of Ovarian Malignancy Algorithm are established.
• Diagnostic algorithms incorporate serum markers, clinical data, and ultrasound findings to evaluate ovarian masses.
• The UK's National Institute for Health and Clinical Excellence recommends calculating risk of malignancy index I in evaluations.

Transvaginal Ultrasound

• Transvaginal ultrasonography is prevalent due to good patient tolerability, cost-effectiveness, and high interobserver agreement.
• Main limitation includes low specificity and positive predictive value for cancer, particularly in premenopausal women.
• Use of color Doppler ultrasonography adds value by measuring blood flow, enhancing specificity when compared to gray-scale ultrasound.

Risk of Malignancy Index

• The risk of malignancy index combines serum CA 125 level, ultrasound results, and menopausal status to calculate the risk.
• A systematic review indicated a sensitivity of 78% and a specificity of 87% for risk scores based on these parameters.

Ultrasound Findings Suggesting Malignancy

• Key ultrasound indicators include:
  • Cyst size greater than 10 cm
  • Papillary or solid components
  • Irregularity and presence of ascites
  • High color Doppler blood flow

International Ovarian Tumor Analysis (IOTA)

• IOTA models (Logistic Regression model 2 and Simple Rules) assess malignancy risk based on ultrasound features.
• IOTA Logistic Regression model 2 includes age and ultrasound findings for calculating probability of malignancy.
• Prolonged follow-up studies showed low rates of malignancy (0–1%) for unilocular cysts in postmenopausal women.

Scoring Systems for Cancer Risk

• Various systems exist to quantify cancer risk based on ultrasound morphology and clinical factors.
• Morphologic scoring systems generally differentiate benign from malignant masses effectively.
• Specific characteristics for endometriomas observed through ultrasound should be noted for differential diagnosis.

Role of Serum Biomarkers

• Elevated CA 125 levels aid in distinguishing between benign and malignant adnexal masses.
• Specificity of CA 125 is higher in postmenopausal women.
• The multivariate index assay outperforms CA 125 alone for early-stage ovarian malignancy detection.

Surgical Interventions for Benign Masses

• Minimally invasive surgeries are preferred for managing presumed benign adnexal masses.
• Fertility preservation is crucial in young women and those seeking to maintain reproductive health, even in complex cases.

Additional Marker Testing

• Other tumor marker testing may reveal uncommon malignant histopathologies.
• The Risk of Ovarian Malignancy Algorithm successfully classifies patients into risk groups, assisting in clinical decision-making.

Conclusion

• Both transvaginal ultrasound and serum markers are vital in forming a comprehensive evaluation strategy for adnexal masses, enabling differentiation between benign and malignant conditions, facilitating timely referral and intervention decisions.