Case Studies

Case 3: Adnexal mass

You are asked to consult on an asymptomatic 46-year-old woman who is currently an inpatient. She had a CT scan performed of the abdomen and pelvis for an unrelated medical indication and a 5-cm adnexal mass was inadvertently seen.

• 1. How commonly do adnexal masses occur?

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  Correct answer: In gynecology, adnexal masses are very common, typically presenting both diagnostic and therapeutic dilemmas. As in this patient, most are detected incidentally. In the USA, a woman has a 5–10% lifetime risk of undergoing surgery for a suspected ovarian neoplasm. Although most are benign, the goal of the evaluation is to exclude malignancy.

• 2. How should this patient be evaluated?

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  Correct answer: Two factors are important to consider. Is the patient symptomatic? In this case she is not. Next, could this adnexal mass be malignant? Masses with a low likelihood of cancer can often be managed conservatively. Conversely, those that are more likely to be malignant are best managed with prompt surgery by a gynecologic oncologist. Masses that are less clearly benign or malignant usually require surgery. The differential diagnosis is limitless, including both gynecologic and non-gynecologic sources. The most important diagnostic factors are the woman’s age and whether she is pre- or postmenopausal. Masses in younger premenopausal women are almost always gynecologic – usually functional cysts. In contrast, adnexal masses in postmenopausal older women are often benign neoplasms (e.g, cystadenoma).

  The initial evaluation should include a physical examination, including a rectal examination. Palpation of a smooth, mobile mass with cystic (compressible) consistency is reassuring for a benign etiology. Examinations in obese women are of limited value.

  Next, the patient should undergo transvaginal ultrasonography (TVU). No alternative imaging modality has comparable accuracy, ease, and availability. However, it is important to recognize that image quality and interpretation vary widely. Each physician should be aware of any limitations in his or her own center and be wary of scans performed elsewhere. The history, pelvic examination, and TVU should provide enough information to develop a plan.

• 3. What TVU findings suggest a benign etiology?

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  Correct answer: Effectively, there are two different types of ovarian cysts – simple and complex. Simple cysts resemble a “water balloon” – they are unilocular, thin-walled sonolucent cysts with smooth regular borders. Overwhelmingly, they are benign. If this patient is found to have a simple cyst, then she could be managed expectantly. Simple cysts <10 cm in size will spontaneously resolve in up to 75% of cases without intervention, regardless of menopausal status. Complex cysts may have any number of findings. Typically, the TVU may indicate the diagnosis of one of a handful of common benign conditions such as a hemorrhagic cyst/endometrioma, dermoid, or hydrosalpinx.

• 4. Is a CA-125 test warranted?

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  Correct answer: The value of the CA-125 measurement is mainly to distinguish between benign and malignant masses in postmenopausal women. CA-125 levels are generally less valuable in premenopausal women due to the numerous benign reasons (fibroids, menses, hepatitis) for non-specific elevation. However, extreme values can be helpful – a markedly elevated CA-125 level would raise a much greater concern for malignancy.

• 5. This patient has a complex cyst, a CA-125 level of 337 U/mL, no ascites, and her CT scan is otherwise normal. Her sister was diagnosed with breast cancer at age 34. Is aspiration of cyst fluid appropriate?

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  Correct answer: No. Aspiration of a malignant mass may induce spillage and seeding of cancer cells in the abdomen, thereby changing the stage and prognosis. The diagnosis is still in question and will require a more definitive procedure.

• 6. What type of operation should be proposed?

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  Correct answer: Minimally invasive laparoscopic surgery is the most appropriate and desirable treatment for most women with an adnexal mass due to the shortened length of hospital stay, decreased pain, and quicker recovery time. At a minimum, this patient with several suspicious findings should be counseled about laparoscopic unilateral salpingo-oophorectomy (USO). Intraoperatively, peritoneal washings are collected, the USO is performed, and a frozen section can determine the diagnosis with reasonable certainty. If a benign diagnosis is confirmed, either the operation may be terminated or – depending on preoperative counseling – a contralateral USO may be performed with or without other indicated procedures (eg, hysterectomy).

  Malignant features would suggest the need for a more comprehensive staging operation that could be completed laparoscopically by skilled providers. Women with ovarian cancer whose care is managed by a gynecologic oncologist have improved overall survival rates. In this case, it would reflect identification of unexpected occult metastases requiring adjuvant chemotherapy.

  Referral guidelines to gynecologic oncology for a newly diagnosed pelvic mass

  Premenopausal (<50 years)

  • (a) CA-125 levels >200 U/mL
  • (b) Ascites
  • (c) Evidence of abdominal or distant metastases (by examination or imaging study)
  • (d) Family history of breast or ovarian cancer (in a first-degree relative)

  Postmenopausal (≥50 years)

  • (a) Elevated CA-125 levels
  • (b) Ascites
  • (c) Nodular or fixed pelvic mass
  • (d) Evidence of abdominal or distant metastases (by examination or imaging study)
  • (e) Family history of breast or ovarian cancer (in a first-degree relative)