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The normal functioning ovary produces a follicular cyst 6 to 7 times each year. In most cases, these functional masses are self-limiting and resolve within the duration of a normal menstrual cycle. In rare situations, they persist longer or become enlarged. At this point, they represent a pathological condition.
Adnexal masses present a diagnostic dilemma; the differential diagnosis is extensive, with most masses representing benign processes. However, without histopathologic tissue diagnosis, a definitive diagnosis is generally precluded. Health care providers must evaluate the likelihood of a pathologic process using clinical and radiologic information and balance the risk of surgical intervention for a benign versus malignant process.
Since ovaries produce physiologic cysts in menstruating women, the likelihood of a benign process is higher. In contrast, the presence of an adnexal mass in pre-pubertal girls and postmenopausal women heightens the risk of a pathologic etiology.
In the past, health care providers relied on the findings of a pelvic examination to diagnose an adnexal mass. With the introduction of imaging modalities including transabdominal or vaginal ultrasonography, Doppler color scans, and MRI scans, more characterization of the internal structure of the mass (i.e., wall complexity, mass contents) is possible. Although not definitive, these findings can help determine whether a mass appears more consistent with a physiologic cyst or neoplastic process.
The following masses pose the greatest concern:
- Those that have a complex internal structure.
- Those that have solid components.
- Those that are associated with pain.
- Masses in pre-pubescent or post-menopausal women.
- Large cysts (A variety of cut off sizes have been proposed. In some institutions, unilocular cysts up to 10 cm have been followed conservatively, even in post-menopausal women. However, complex cysts in this same group of patients generally heightens suspicion, regardless of size.)
- In menstruating women, those who persist beyond the length of a normal menstrual cycle without typical characteristics of a benign process such as a hemorrhagic cyst.
FREQUENCY OF ADNEXAL MASSES
Determining the true frequency of adnexal masses is impossible because most adnexal cysts develop and resolve without clinical detection. When assessing the clinical significance of an adnexal mass, considering several age groups is important.
In girls younger than 9 years, 80 percent of ovarian masses are malignant and are generally germ cell tumors. During adolescence, 50 percent of adnexal neoplasms are adult cystic teratomas. Women with gonads that contain a Y chromosome have a 25 percent chance of developing a malignant neoplasm. Endometriosis is uncommon in adolescent women but may be present in as many as 50 percent of those who present with a painful mass. In sexually active adolescents, one must always consider a tubo-ovarian abscess as the cause of an adnexal mass.
In women of reproductive age who have had adnexal masses removed surgically, most are benign cysts or masses. Ten percent of masses are malignant; many tumors in patients younger than 30 years are of low malignant potential. Thirty-three percent are adult cystic teratomas, and 25 percent are endometriomas. The rest are serous or mucinous cystadenomas or functional cysts.
Historically, postmenopausal women with clinically detectable ovaries were felt to be at great risk of having a malignant neoplasm. With the introduction of radiologic testing, many smaller, simple cystic masses have been identified; therefore, the risk of malignancy may be only 20 to 30 percent. The differential includes benign cysts, metastatic versus primary ovarian malignancies, tubal cysts and neoplasms such as paratubal cysts, hydrosalpinx, or rarely fallopian tube cancer. Radiologic testing allows the architecture of the mass to be evaluated, which decreases the need to operate on benign masses in this age group.
In all age groups, the health care provider must also consider the possibility of uterine masses or structural deformities. Pregnancy-related adnexal masses, including ectopic pregnancy, theca lutein cysts, corpus luteum cysts, and luteomas, must be considered in all pre-menopausal women.
The pathophysiology is not well understood for most adnexal masses; however, some theories have been proposed. Functional cysts may be the result of variation in normal follicle formation. Adult cystic teratomas (dermoid) may be the result of an abnormal germ cell. Endometriomas are thought to result from retrograde menstruation or coelomic metaplasia. The exact cause of epithelial neoplasms is unknown, but recent studies have suggested a complex series of molecular genetic changes is involved.
The clinical presentation of an adnexal mass can be variable, but patients are often asymptomatic, presenting with masses that are found (1) at the time of a pelvic examination, (2) at the time of a radiologic examination for another diagnosis, or (3) at the time of a surgical procedure. Women who have symptoms may note urinary frequency, pelvic or abdominal pressure, and bowel habit changes due to the mass effect on these organs. Girls younger than 10 years frequently present with pain, as do older women who have infected masses or endometriosis. Adnexal torsion often presents with acute abdominal pain, requiring urgent surgical intervention.
Many adnexal masses present as asymptomatic, small, and simple cystic masses. Most of these resolve spontaneously; therefore, care must be taken to not overreact to such a finding. Surgeons who rush these women into surgery often create more pathology than they cure. Any surgery performed on adnexal structures can result in impaired fertility.
On the other hand, these same asymptomatic masses can be early ovarian cancers that require immediate attention. The use of radiologic testing often helps determine which women require attention. The use of cancer antigen 125 (CA-125) can be used in combination with radiologic testing to stratify the risk of adnexal masses. However, in the general population, the use of CA-125 to screen for the presence of cancer should be discouraged. A large Swedish study has shown that approximately 50 percent of women with Stage I ovarian cancer have a normal CA-125 test value. In addition, a high false-positive rate can be caused by pregnancy, endometriosis, cirrhosis, and pelvic or other intra-abdominal infections.
The term adnexa is derived from the pleural form of the Latin word meaning "appendage." The adnexa of the uterus include the ovaries, fallopian tubes, and structures of the broad ligament. Most frequently, adnexal masses refer to ovarian masses or cysts; however, paratubal cysts, hydrosalpinx, and other nonovarian masses are also included within the broader definition of adnexal masses.
Several other anatomical structures are important to identify, both for the evaluation of other sources of masses within the pelvis and during surgical procedures to prevent damage to nearby organs and structures. The uterus is central to both adnexal regions and can be the source of a pelvic mass. For instance, exophytic, pedunculated fibroids can mimic adnexal masses on preoperative imaging. The rectum and bladder are located posterior and anterior to the adnexal regions. Both can be the source of pelvic masses, although this is less frequent. In addition, they must be protected from injury when adnexal surgery is performed. The ureters are located near the ovarian blood supply and can be damaged easily during adnexal surgery. Many of the pathologic processes associated with adnexal masses can alter the location of the ureters, increasing the chance of damage.
Many adnexal masses present as asymptomatic, small, simple cystic masses, most of which can resolve spontaneously. Considering non-surgical management and follow-up in patients with low-risk adnexal masses is important to avoid unnecessary procedures, particularly as procedures performed on adnexal structures may result in impaired fertility.
Many adnexal masses can be removed using laparoscopic techniques and are associated with little post-operative complexity. However, in those women with significant pre-existing medical problems and/or cancer, major post-operative problems can be encountered and pre-operative evaluation is important to assess clearance for surgery.
HISTORY: Approximately 10 percent of ovarian cancers are hereditary. As such, patients with a history suspicious for a hereditary breast-ovarian cancer syndrome (BRCA1 or BRCA2) or hereditary nonpolyposis colorectal cancer syndrome, are at increased risk for development of a malignant mass. These patients should also be considered for genetic counseling and evaluation of risk.
PHYSICAL EXAMINATION: As the adnexa are located deep in the pelvis, masses may be palpated with a standard gynecologic examination. However, other factors, such as obesity and size of mass, may limit the use of physical examination.
OVARIAN CYSTS & TUMORS
Ovarian cysts and tumors may be detected as adnexal masses on one or both sides. Later they may grow up out of the pelvis. Cysts tend to be smooth and compressible, tumors more solid and often nodular. They are not usually tender.
PELVIC INFLAMMATORY DISEASE
Acute PID is associated with very tender bilateral adnexal masses although pain and muscle spasm usually make it impossible to delineate them. Movement of the cervix produces pain. Chronic PID is manifested by bilateral, tender, usually irregular and fairly fixed adnexal masses.
RUPTURED TUBAL PREGNANCY
Typically a ruptured tubal pregnancy presents with signs of hemorrhage into the peritoneal cavity; marked pelvic tenderness, and tenderness and rigidity of the lower abdomen. Motion of the cervix produces pain. A tender unilateral adnexal mass may indicate the site of pregnancy. Tachycardia and shock reflect the hemorrhage.
Possible lab tests in the evaluation of adnexal mass include serum markers, Papanicolaou test, CBC count, urinalysis (U/A), stool for blood, and electrolytes.
- CA-125 is a marker that is elevated in approximately 80 percent of women with ovarian cancer with sensitivities of 50 percent in women with stage I disease and 90 percent in patients with advanced disease. However, it can be elevated in many other conditions, including gynecologic etiologies such as endometriosis, uterine fibroids, and pregnancy, and non-gynecologic conditions such as gastroenteritis, pancreatitis, cirrhosis, and congestive heart failure. As such, the specificity of CA-125 is limited and is not recommended for routine screening purposes in the general population.
- Urine or serum beta human chorionic gonadotropin (Beta-hCG) should be obtained in women of reproductive age to rule out pregnancy and pregnancy-related etiologies of adnexal masses.
- Other serum markers such as AFP and LDH can be helpful when a germ cell tumor is suspected.
- A Papanicolaou test should be considered in women undergoing a gynecologic surgery.
- This test should be used to help rule out any unknown cervical pathology.
- In extremely rare situations, this test may reveal the presence of an adnexal malignancy.
- A CBC count helps evaluate for presence of inflammation and anemia.
- An infected mass such as a tubo-ovarian abscess results in an increased WBC count with an associated left shift.
- Adnexal masses rarely cause anemia, but because they often require surgical removal, this information should be known.
- Urinanalysis (U/A) results are generally normal in the presence of an adnexal mass.
- Bladder pathology may present with symptoms of an adnexal mass and may be discovered based on U/A results.
- Appendicitis can present similar to an adnexal mass but is often associated with WBCs in the U/A findings.
- Results from testing stool for blood should be negative for adnexal masses but may be positive in those women with colonic pathology.
- Serum electrolytes should not be altered by an adnexal mass; however, symptoms associated with masses, such as nausea and vomiting, can cause alterations that must be known before anesthesia and surgery are considered.
- Measuring other hormone levels is generally of limited value in the evaluation of adnexal masses. Obtaining estrogen and progesterone levels may be helpful in women suggested to have functional tumors, such as germ cell tumors, or if a girl younger than 12 years is being evaluated.
The most commonly performed test to evaluate an adnexal mass is transabdominal or transvaginal ultrasonography.
- This test helps demonstrate the presence of the mass and its location (eg, ovarian, uterine, bowel). It also provides the mass size, consistency, and internal architecture. Scoring systems, such as that suggested by DePriest and associates, can then be used to determine the likelihood of a malignant component.
- Hysterosonography (ultrasonography with the presence of fluid in the uterine cavity) may be used to help distinguish between uterine masses and those arising from other pelvic structures.
Color Doppler ultrasonographies can be used to evaluate the resistive index of the mass vessels, which, when low, has been indicative of a malignancy.
Pelvic radiographs are generally not helpful in the evaluation of adnexal masses. A dermoid cyst generally contains areas of calcification that may be picked up on a plain radiograph.
CT scans are most useful for assessing the remainder of the abdomen and pelvis when metastatic disease is suspected. Incidental adnexal masses are sometimes found when CT is performed for evaluation of other conditions. As with ultrasonography, CT scan can help identify the size, location, and relationship to other organs. CT scan is less effective than ultrasonography for determining the internal architecture of these masses.
MRI scans can help characterize adnexal mass characteristics in select cases when ultrasonographic findings are limited.
In limited settings, aspiration of the mass can be performed. However, this approach must be reserved for those women in whom an extremely low chance of a malignant mass exists and/or when surgical intervention is contraindicated.
CONVENTIONAL MEDICAL TREATMENT
Asymptomatic, small, well-characterized adnexal masses may be observed with regular pelvic examinations and radiologic evaluations. A surgical approach should be used if growth occurs in these masses, if the patient becomes symptomatic, or if the cyst develops more concerning features, such as solid components. As indicated previously, the suspicion for a malignancy is increased in pre-pubescent and post-menopausal women.
All adnexal masses that are symptomatic or have characteristics of a malignancy should be considered for surgical evaluation. The extensive differential diagnosis and possible surgical procedures should be discussed with the patient.
Obvious benign masses can be treated with resection of the mass alone or removal of the adnexal structure.
In those cases in which the presence of malignancy is questionable, one should limit the resection to the structures involved unless a preoperative decision has been made that a more aggressive approach should be taken.
When an obvious epithelial ovarian malignancy is encountered, a complete staging protocol must be performed. This generally includes complete exploration of the abdomen, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvic and para-aortic lymph node dissections, biopsies of the undersurface of the right and left diaphragms, and biopsies of the colic gutters followed by a maximal resection of the intra-abdominal tumor. In select cases involving women with limited, early stage, low-grade ovarian cancers, a fertility sparing procedure may be considered. In some cases, resecting portions of the small bowel or colon may be necessary; therefore, pre-operative bowel preparation may be warranted, as is a discussion about possible colostomy or other bowel changes.
Pre-operative preparation is vital to the proper care of a woman with an adnexal mass. This should include the following:
- A complete discussion of the possible procedures and the long-term results.
- A complete bowel preparation in selected cases.
- A careful evaluation of any associated medical problems or past surgeries.
- An evaluation of the woman's nutritional status, particularly when ascites is present.
During the procedure, several factors must be kept in mind, including the following:
- The dissection depends on the preoperative discussion concerning the nature and extent of the procedure.
- The dissection must be tailored to the woman's desire regarding future fertility. In many cases with benign disease, the dissection should not block future reproductive abilities.
- The presence of extensive disease as seen with cancer or endometriosis alters normal anatomical relations, which can result in a greater chance for injury to surrounding structures such as the ureters or bowel. Such dissections are best performed with the assistance of a gynecologic oncologist.
Most adnexal masses can be removed with relative ease and are associated with little postoperative complexity; however, in women with significant pre-existing medical problems and/or cancer, major post-operative problems can be encountered. When indicated, intensive care unit admission with close monitoring of fluid balance, electrolyte balance, coagulation status, and cardiopulmonary function may be required.
Most adnexal masses require little more than the normal annual gynecologic examination for follow-up because they rarely recur. On the other hand, women found to have a malignancy require additional therapy, such as chemotherapy or radiation therapy. Their follow-up care should include frequent re-examinations to determine the disease status.
The major adverse outcomes in the treatment of adnexal masses are related to complications resulting from surgical therapy. These may include the following:
- Infections of the urinary tract, wound, or lungs.
- Blood loss with the resulting need for transfusion and associated blood-borne infections.
- Injury to surrounding organs such as the urinary bladder, large or small bowel, ureters, or sidewall blood vessels and nerves.
- Pelvic vein thrombosis with associated pulmonary embolism.
OUTCOME & PROGNOSIS
Most adnexal masses are benign; outcome and prognosis are very good. Generally, no impact on life span or quality of life is noted. In fact, most women treated for adnexal masses have no interruption in their reproductive abilities.
Those women who are found to have malignant adnexal masses fall into 3 groups, as follows:
- Women ranging in age from the late teens to early 20s: Germ cell tumors are seen in these women. The tumors are generally confined to the ovary and are cured in 90 percent of women after chemotherapy.
- Women aged 40 to 60 years: Epithelial tumors are the most common ovarian cancer in these women. These tumors are advanced (stage III-IV) in more than 50 percent of women. Even after the use of chemotherapy, only 10 to 40 percent of patients survive their disease.
- Women older than 60 years: Ovarian epithelial malignancies are common in this group of patients. Metastatic malignancies are also common. The incidence of sex-cord stromal tumors also increases in incidence in this age group, although it still accounts for only 5 percent of tumors. Stromal tumors are often early stage and may have an indolent course.
The future holds several interesting possibilities. First, the rapid expansion of new laparoscopic equipment makes minimally invasive surgery an area that is gaining increasing importance in the treatment of adnexal masses. Second, the development of new radiologic techniques or expansion of the present techniques will allow the clinician to gain additional characterization of adnexal masses without entering the surgical suite. Third, new molecular, genetic, and biologic markers and therapies should become available that will assist in the diagnosis and treatment of adnexal masses, both benign and malignant.
The major controversy surrounding adnexal masses is when and how to treat them. While some adnexal masses can be clearly stratified into low- or high-risk for malignancy based on clinical, laboratory, and clinical findings, currently, there are no definitive means of preoperative diagnosis with imaging or laboratory findings.
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