Practice Bulletin 174: Evaluation and Management of Adnexal Masses
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Questions and Answers

What is the specificity of the Risk of Ovarian Malignancy Algorithm in postmenopausal women?

  • 75% (correct)
  • 74.8%
  • 92.3%
  • 93.8%

    • What is the sensitivity of the Risk of Ovarian Malignancy Algorithm in postmenopausal women?

  • 66.9%
  • 85.9%
  • 92.3% (correct)
  • 96.4%

    • What is the preferred surgical intervention for a presumed benign adnexal mass?

    Minimally invasive procedures

    The multivariate index assay was found to be less sensitive than the Risk of Ovarian Malignancy Algorithm.

    <p>True</p> Signup and view all the answers

    The sensitivity and specificity of an elevated CA 125 for cancer diagnosis in the setting of a pelvic mass is highest after _____

    <p>menopause</p> Signup and view all the answers

    What percent of epithelial ovarian cancer cases were classified as high risk before surgical exploration using additional tumor marker testing?

    <p>93.8%</p> Signup and view all the answers

    What are adnexal masses?

    <p>Masses of the ovary, fallopian tube, or surrounding tissues.</p> Signup and view all the answers

    What is the primary goal of diagnostic evaluation for adnexal masses?

    <p>To exclude malignancy</p> Signup and view all the answers

    Most adnexal masses are malignant.

    <p>False</p> Signup and view all the answers

    What is age's role in ovarian cancer risk?

    <p>Age is the most important independent risk factor for ovarian cancer.</p> Signup and view all the answers

    Which personal risk factor significantly increases the likelihood of ovarian cancer?

    <p>Strong family history of breast or ovarian cancer</p> Signup and view all the answers

    What is the common imaging technique used for evaluating adnexal masses?

    <p>Transvaginal ultrasonography.</p> Signup and view all the answers

    Women who report ______ pain may have an endometrioma.

    <p>acute or chronic dysmenorrhea</p> Signup and view all the answers

    CA-125 is most useful in which group of women?

    <p>Postmenopausal women</p> Signup and view all the answers

    Imaging techniques such as CT and MRI are recommended for the initial evaluation of adnexal masses.

    <p>False</p> Signup and view all the answers

    What is the role of ultrasonography in the initial evaluation of a patient with a suspected adnexal mass?

    <p>Transvaginal ultrasonography is the recommended imaging modality for evaluation.</p> Signup and view all the answers

    Does transvaginal ultrasonography alone have high specificity for cancer diagnosis?

    <p>False</p> Signup and view all the answers

    What ultrasound findings suggest malignancy?

    <p>Cyst size greater than 10 cm, papillary or solid components, irregularity, presence of ascites, and high color Doppler flow.</p> Signup and view all the answers

    What are the ultrasound findings characteristic of benign masses?

    <p>Thin, smooth walls; absence of solid components, septations, or internal blood flow.</p> Signup and view all the answers

    What is the role of serum marker testing in the initial evaluation of an adnexal mass?

    <p>Serum marker testing evaluates the likelihood of malignancy and the need for surgery.</p> Signup and view all the answers

    Which serum tumor marker assays are approved for assessing ovarian cancer risk?

    <p>Both A and B</p> Signup and view all the answers

    What is the significance of an elevated CA 125 level in postmenopausal women?

    <p>It is highly suspicious for malignancy and suggests the need for referral to a gynecologic oncologist.</p> Signup and view all the answers

    The risk of malignancy index is calculated using the product of the serum CA 125 level (U/mL), the ultrasound scan result, and the ______.

    <p>menopausal status</p> Signup and view all the answers

    Study Notes

    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.

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    Description

    This quiz covers the clinical management guidelines for obstetricians and gynecologists regarding the evaluation and management of adnexal masses. Gain insights into the latest practices and recommendations put forth by the American College of Obstetricians and Gynecologists in their November 2016 bulletin.

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