Adnexal Masses 

Adnexal Masses 

Introduction

• Adnexal masses are masses that arise in the adnexa.
• The adnexa refer to the region adjacent to the uterus that includes the ovary, fallopian tube, and associated structures.

Synonym

• Pelvic mass

ICD-10CM CODES
R19.09	Other intraabdominal and pelvic swelling, mass, and lump
C57.4	Malignant neoplasm of uterine adnexa, unspecified
N83.2	Other and unspecified ovarian cysts
N83.209	Unspecified ovarian cyst, unspecified side

Epidemiology & Demographics

Prevalence

• Because the etiology of adnexal masses is so broad and ranges from benign to malignant and can be gynecologic or nongynecologic in origin, a single prevalence is difficult to establish and not particularly useful in this case.

Predominant Age

• Adnexal masses can be found in females of all ages ranging from childhood to the reproductive year to postmenopause.

Risk Factors

• There are many risk factors for benign adnexal masses, but it is important to consider risk factors for malignancy.
• While age is the most important independent risk factor for ovarian cancer, family history of breast or ovarian cancer is the most important personal risk factor.

Physical Findings & Clinical Presentation

• •The majority of adnexal masses are found incidentally when pelvic imaging is performed or on physical examination.
• •Though less common, they are sometimes detected when a woman presents with acute or intermittent pelvic or abdominal pain.
• •Urgent conditions such as adnexal torsion or ectopic pregnancy typically present with fairly specific symptoms such as severe pain or first trimester bleeding and should be evaluated immediately.

Etiology

The etiology of an adnexal mass depends on the organ from which the mass arises. Masses can be benign or malignant. They can be ovarian, tubal, or uterine in origin. Additionally, nongynecologic etiologies include masses arising from other organs in the pelvis such as the bladder, kidney, bowel, or peritoneum. Masses could also be due to cancer metastases.

Differential Diagnosis

• •The differential diagnosis of adnexal masses is best divided into gynecologic and nongynecologic and then further into benign and malignant
• •Gynecologic:
  • 1.Benign:
    • a.Physiologic cyst
    • b.Corpus luteal cyst
    • c.Theca lutein cyst
    • d.Endometrioma
    • e.Cystadenoma
    • f.Benign ovarian germ cell tumor (mature teratoma)
    • g.Benign sex cord-stromal tumor
    • h.Ectopic pregnancy
    • i.Hydrosalpinx
    • j.Paratubal cyst
    • k.Uterine leiomyoma (pedunculated or cervical)
    • l.Tuboovarian abscess
    • m.Adnexal torsion
    • n.Müllerian anomalies
  • 2.Malignant:
    • a.Epithelial carcinoma
    • b.Epithelial borderline carcinoma
    • c.Germ cell tumor
    • d.Sex-cord or stromal tumor
    • e.Metastatic cancer
• •Nongynecologic:
  • 1.Benign:
    • a.Abscess: Pelvic, appendiceal, diverticular
    • b.Bladder diverticulum
    • c.Ureteral diverticulum
    • d.Pelvic kidney
    • e.Nerve sheath tumors
  • 2.Malignant:
    • a.Bowel neoplasm
    • b.Appendiceal neoplasm
    • c.Retroperitoneal sarcoma
    • d.Metastasis (breast, colon, lymphoma, etc.)

Workup

• •Evaluation of an adnexal mass begins with a thorough history that considers individual patient characteristics and the physical examination.
• •A detailed gynecologic history should be obtained as well as a thorough family history and review of other risk factors.
• •A full set of vital signs, the general physical appearance of the patient, and the patient’s symptoms should be evaluated.
• •A comprehensive physical examination including palpation of lymph nodes (cervical, supraclavicular, axillary, and groin), abdominal examination, and thorough pelvic examination should be performed.
• •Laboratory studies and imaging should be considered as outlined below.

Laboratory Tests

• •A pregnancy test should be obtained on all women of reproductive age.
• •If infection is suspected, CBC and cultures for gonorrhea and chlamydia should be obtained.
• •Other laboratory tests that may be helpful include urinalysis and/or urine culture, fecal occult testing, and serum marker testing such as CA-125, carcinoembryonic antigen (CEA), beta human chorionic gonadotropin (β-hCG), alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH) if malignancy is suspected.

Imaging Studies

• •Transvaginal ultrasonography is the initial imaging modality of choice for evaluation of adnexal masses, including size, composition (cystic, solid, mixed), laterality, presence or absence of septations, and papillary excrescences. Abdominal ultrasonography should also be performed and can be useful if pelvic structures are distorted by prior surgery or if the mass extends above the pelvis.
• •Computed tomography (CT) and MRI are not recommended for initial evaluation.
• •MRI can be helpful to differentiate masses that are not ovarian in origin, especially leiomyomas.
• •CT scans are most useful for evaluating metastasis if cancer is suspected, as well as ascites, pelvic or periaortic lymph node enlargement, obstructive uropathy, or an alternate primary cancer site.

Treatment

Treatment of adnexal masses depends on the etiology of the mass, stability of the patient, and level of suspicion for malignancy.

Acute General Treatment

• •A ruptured ectopic pregnancy or ovarian torsion is a surgical emergency and warrants immediate surgical intervention. Surgical intervention may also be necessary for nongynecologic causes of adnexal masses such as appendicitis. Table 1 summarizes indications for surgery in a patient with adnexal mass.
• •Ultrasound imaging with features concerning for malignancy (mass >10 cm, papillary or solid components, irregularity, ascites, and presence of high color Doppler flow) warrants surgical intervention. The below flow chart illustrates the management of a premenopausal woman with adnexal mass.
• •Masses that appear benign but are greater than 5 cm in size are at increased risk of ovarian torsion; therefore surgical intervention needs to be considered.

Chronic Treatment

Adnexal masses can be observed if imaging suggests benign disease or if there is a compelling reason to avoid surgical intervention. There is no established interval for ultrasound follow-up. Timing of a follow-up ultrasound should be determined on an individual basis considering patient risk factors, symptoms, menopausal status, and suspicion for malignancy. Six-mo follow-up is reasonable for masses larger than 5 cm, for patients who are symptomatic, or when concern for malignancy is higher. For patients who are otherwise asymptomatic, have a small mass, are premenopausal, and in whom suspicion for malignancy is low, repeat ultrasound in 1 yr is reasonable.

Referral

• •A referral to a gynecologic oncologist is recommended when ultrasound findings are suggestive of malignancy. Referral guidelines for women with a newly diagnosed pelvic mass are summarized in the below table E2.
• •A referral to general surgery or surgical oncologist should be considered if the mass is nongynecologic in origin.

TABLE E1 Adnexal Mass: Indications for Surgery

From Disaia PJ et al: Clinical gynecologic oncology, ed 9, Philadelphia, 2018, Elsevier.

•Ovarian cystic structure >5 cm that has been observed 6-8 wk without regression•Any solid ovarian lesion•Any ovarian lesion with papillary vegetation on the cyst wall•Any adnexal mass >10 cm in diameter•Ascites•Palpable adnexal mass in a premenarchal or postmenopausal patient•Torsion or rupture suspected

TABLE E2

Society of Gynecologic Oncologists and American College of Obstetricians and Gynecologists Referral Guidelines for Women With a Newly Diagnosed Pelvic Mass

Adapted from ACOG Practice Bulletin. Management of adnexal mass. Obstet Gynecol 2007;110:207. In Disaia PJ et al: Clinical gynecologic oncology, ed 9, Philadelphia, 2018, Elsevier.

Premenopausal Patients (<50 Yr Old)

CA-125 >200 units/ml Presence of ascites Evidence of intraperitoneal or distant metastasis (based on examination or imaging studies) Family history (first-degree relative) of breast or ovarian cancer

Postmenopausal Patients (>50 Yr)

Elevated CA-125 level Ascites Evidence of intraperitoneal or distant metastasis (based on examination or imaging studies) Family history (first-degree relative) of breast or ovarian cancer

CA-125, Cancer antigen 125.