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Evaluation of the Adnexal Mass in an Older Woman

10/1/2015 - Todd R. Griffin, MD

Editor:  Martin E. Olsen, MD

The evaluation and management of an adnexal mass in an older woman is an important clinical challenge. Adnexal masses arise in gynecologic and nongynecologic sites. Primary ovarian lesions include functional cysts and neoplastic cysts and masses (benign, serous borderline tumor, and malignant). Ovarian cysts are not unusual during perimenopause and menopause. Most adnexal masses are benign. Age is the most significant risk factor for ovarian cancer, with a lifetime risk of developing ovarian cancer of 1 in 70. Adnexal masses can be found in the course of evaluation for symptoms or incidentally on exam or imaging.

The clinical goal is to identify malignancy while minimizing intervention in patients with benign lesions. Ultrasound is the imaging modality of choice. It offers the ability to characterize the ovarian mass, whether simple, multilocular, cystic/solid or solid. The addition of color Doppler sonography for characterization of benign versus malignant tumors has not been shown to be sufficiently sensitive or specific. MRI may be used in addition to ultrasound in the differentiation of benign versus malignant lesions, but the additional cost may not be justifiable. CT and or PET-CT imaging is useful for preoperative imaging of lesions highly suspicious for ovarian cancer to optimize surgical planning. They have limited role in the initial evaluation of adnexal masses.

Serum markers such as Cancer Antigen 125 (CA 125), Human Epididymis 4 (HE4) and newer Multivariate Index Assays (OVA1) are added tools in the evaluation of adnexal masses. CA 125 can be elevated in both benign and malignant conditions (see recommendations below). CA125 and HE4 together may have improved diagnostic value. The clinical significance of OVA1 is not clear. Measuring LDH, Β-HCG, and AFP is of limited value as most cancers in this age group are epithelial in origin.

Primary management of ovarian cancer by a gynecologic oncologist has improved survival rates. Currently ACOG and SGO (Society of Gynecologic Oncology) recommend that patients presenting with the following be referred to a gynecologic oncologist:

  1. Ascites
  2. Evidence of metastasis
  3. First degree relative with breast or ovarian cancer
  4. Premenopausal patient with CA 125 > 200
  5. Postmenopausal patient with CA 125 > 35
  6. Fixed / nodular pelvic mass

Asymptomatic simple unilocular cysts up to 10cm in size have less than 1% risk of malignancy and should be followed clinically, usually by ultrasound imaging in 4 to 6 months. Spontaneous resolution will occur in up to two thirds of patients. Multilocular and solid/cystic masses are seen in up to 3.2% of postmenopausal woman. Many of these are cystadenofibromas. Woman with asymptomatic multilocular or solid/cystic lesions less than 5cm in size and a normal CA 125 can undergo repeat imaging and CA 125 in 4 weeks. If the size of the mass or CA 125 increases, surgery is appropriate. If the mass shrinks, CA 125 falls, or if the clinical picture is unchanged, the patient can be followed conservatively with ultrasound at 3-6 months. Although evidence based guidance is lacking, if all parameters have been stable for 18 to 24 months, repeat scans and marker levels can be discontinued. If the tumor is ≥ 5cm or there is any evidence of papillary projections or ascites, the patient should be referred to a gynecologic oncologist.

Further Reading:

Evaluation and Management of Adnexal Masses ACOG Practice Bulletin (Obstet Gynecol 2016;128:e210–226)

Rauh-Hain JA, Melamed A, Buskwofie, A, Schorge JO. Adnexal mass in the postmenopausal patient. Clin Obstet Gynecol. 2015;58:53-65.

Initial Approval October 2015; Updated January 2017

 

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