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10/1/2015

Evaluation of the Adnexal Mass in an Older Patient

The evaluation and management of an adnexal mass in an older patient is a common clinical challenge. Primary ovarian lesions include functional cysts, neoplasms and solid masses (benign, borderline, and malignant). Ovarian cysts are not unusual during perimenopause and affect up to 17% of postmenopausal patients. Most are benign. Age is the most significant risk factor for ovarian cancer, with a lifetime risk for ovarian cancer of 1 in 70. Adnexal masses can be found incidentally, or during the evaluation of symptoms, either on examination or by imaging.

In this patient population, the goal is to identify malignancy while minimizing unnecessary surgery. Ultrasound is the imaging modality of choice as it offers the ability to characterize the ovarian mass. Magnetic resonance imaging (MRI) may be used in addition to ultrasound in the differentiation of benign versus malignant lesions, but is not cost-efficient. Computed tomography (CT) and positron emission tomography-CT PET-CT) are useful for preoperative imaging of lesions highly suspicious for ovarian cancer to optimize surgical planning, but have limited roles in the initial evaluation of adnexal masses.

Serum markers such as Cancer Antigen 125 (CA125), Human Epididymis 4 (HE4) and newer Multivariate Index Assays (OVA1, OVA2, ROMA) are added tools to evaluate adnexal masses. CA125 can be elevated in both benign and malignant conditions. CA125 and HE4 together may have improved diagnostic value for differentiating benign and malignant masses. The clinical utility of multivariate index assays is unclear and an active area of investigation.

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

1. Ascites
2. Evidence of metastasis
3. Elevated score on a formal risk assessment (CA 125 + risk score of ultrasound findings + menopausal status)
4. Premenopausal patient with very elevated CA125
5. Postmenopausal patient with elevated CA125
6. Fixed/nodular pelvic mass

Asymptomatic simple unilocular cysts up to 10 cm in size have less than 1% risk of malignancy and should be followed with ultrasound imaging in four to six months. 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. Women with asymptomatic multilocular or solid/cystic lesions less than 5 cm and a normal CA125 can undergo repeat imaging and CA125 in four weeks. If the size of the mass or CA125 increases, surgery is appropriate. If the mass shrinks, CA125 falls, or the clinical picture is unchanged, the patient can be followed conservatively with ultrasound at three to six months. Although evidence-based guidance is lacking, if all parameters have been stable for 18 to 24 months, repeat imaging and marker levels can be discontinued. If the tumor is ≥ 5 cm or there is any evidence of papillary projections or ascites, the patient should be referred to a gynecologic oncologist.

Further Reading:

American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology., Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses. Obstet Gynecol. 2016 Nov;128(5):e210-e226.

Rauh-Hain JA, Melamed A, Buskwofie, A, et al, Adnexal mass in the postmenopausal patient. Clin Obstet Gynecol. 2015 Mar;58(1):53-65. doi: 10.1097/GRF.0000000000000085.

Committee on Gynecologic Practice, Society of Gynecologic Oncology., Committee Opinion #716: The role of the obstetrician–gynecologist in the early detection of epithelial ovarian cancer in women at average risk. Obstet Gynecol. 2017 Sep;130(3):e146-e149. doi: 10.1097/AOG.0000000000002299.

Initial Approval October 2015; Revised May 2018; Reaffirmed November 2019; Revised July 2021, Minor Revision January 2023, Revised November 2024.

Previously titled: “Evaluation of the Adnexal Mass in an Older Woman”.  Title changed July 2021

 

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