ovarian%20mass
OVARIAN MASS
Ovarian cysts are typically noted after clinical screening, or as a result of exam for a suspected pelvic mass, or an incidental finding in investigations done for other reasons.
Most ovarian masses manifest with few or mild nonspecific symptoms.
Ovarian masses in women of reproductive age are mostly benign but the risk of malignancy increases with age.
Ovarian cysts in the prepubertal patients especially after the first week of life are abnormal and likely to be neoplastic. In adolescent patients, majority of ovarian masses are functional cysts.

Diagnosis

  • Ovarian cysts are typically noted after clinical screening, or as a result of exam for a suspected pelvic mass,or an incidental finding in investigations done for other reasons
  • Management of ovarian cysts depends on age, hormonal status and sonographic features
    • The physician’s role in the approach to ovarian masses is largely to exclude cancer

Evaluation

Premenopausal

Significant Pain

  • Rapid onset of acute pain may occur with adnexal torsion which must be treated surgically
  • Cyst rupture can result in a small amount of intraperitoneal bleeding or hemorrhage which can manifest as generalized abdominal pain or sudden, unilateral, sharp pelvic pain
  • If there are findings suggestive of hemoperitoneum, surgical intervention by laparoscopy or laparotomy is required

Clinical and Sonographic Features Suggestive of Malignancy

  • Transabdominal and transvaginal ultrasounds are the primary imaging modality to evaluate adnexal masses
  • Transabdominal ultrasound provides overall assessment of organ size and anatomy while transvaginal ultrasound has higher image resolution and gives more detailed characterization of pelvic structures and masses
  • Malignant masses are irregular, have thick wall or septations, have solid components (eg mural nodules) or at least 4 papillary structures, with increased vascularity and increased pelvic fluid

The following require surgical exploration:

  • Ovarian masses that are persistent, bilateral, solid, fixed, irregular and associated with ascites, cul-de-sac nodules and rapid rate of growth
  • Large cysts (>8 cm) and those with multiloculations, septae, papillae and increased blood flow

Postmenopausal

  • Ovarian cysts in postmenopausal women should be assessed using transvaginal sonography and CA-125
    • CA-125 together with ultrasound findings and menopausal status may be used to determine ovarian cancer risk through the Risk of Malignancy Index (RMI)
    • RMI of 25-200 is moderate risk while RMI of >200 warrants a gynecologic oncology referral
      • A CT scan of the abdomen and pelvis should be done in patients with RMI >200   
    • An alternative to RMI is the International Ovarian Tumor Analysis (IOTA) which has comparable specificity and sensitivity
  • The incidence of ovarian cancer increases with age and is mostly a disease of postmenopausal women

Ultrasound (US)

  • The ovaries become smaller after menopause
    • A postmenopausal ovary that is 2x the size of the contralateral one is suspicious
  • A transabdominal ultrasound may be used if the ovarian cyst is large or outside the field of view of a transvaginal ultrasound

Serum CA-125 Measurement

  • An antigenic determinant found in both benign and malignant lesions
  • Measurement of CA-125 is most useful in risk stratification of postmenopausal women with suspicious pelvic mass observed by US
    • In these patients, a CA-125 level >65 U/mL has a positive predictive value of 97%
    • Levels below 35 U/mL are associated with benign conditions; however, sensitivity and specificity vary
    • However, negative serum CA-125 result also does not rule out ovarian cancer
    • Up to 50% of early-stage ovarian cancer and 20-25% of late-stage cancers are found to have normal CA-125
  • CA-125 is raised in 80% of patients with serous cystadenocarcinoma of the ovary but is raised in only half the patients with stage I disease
  • Serum CA-125 is not recommended as routine screening for ovarian cancer in healthy premenopausal women
    • Elevated CA-125 levels have been observed in pregnancy, endometriosis, fibroids, adenomyosis, cystic teratoma and acute or chronic salpingitis
    • May be measured in premenopausal women if ultrasound findings are suspicious for malignancy
  • Most important use of serum CA-125 is assessing the effectiveness of surgery and other therapies given to the patient; it also allows monitoring for recurrence of ovarian cancer in histologically known cases
  • Other tumor markers include CA-15.3 and CA-19.9

Presurgical

  • In addition to history, pelvic exam, ultrasound and serum CA-125, other tumor markers eg alpha fetoprotein, β−human chorionic gonadotropin and carcinoembryogenic antigen are determined preoperatively
    • Women <40 years should check their lactate dehydrogenase (LDH), alpha fetoprotein, and human chorionic gonadotropin levels for potential germ cell tumors
  • If any result points to malignancy, abdominal and pelvic computed tomography (CT) are requested
  • In patients with CT scan finding showing malignancy, staging laparotomy or chemotherapy is indicated
  • In patients with negative CT scan finding, laparoscopy is planned and consent for possible laparotomy is obtained

Surgery

  • Patients with multilocular, bilateral cysts >3-5 cm, who are symptomatic, have elevated CA-125, and have suspicious or persistent non-simple cyst on US should be investigated further with surgery
    • Elevated CA-125: >200 U/mL in premenopausal women or >35 U/mL in postmenopausal women

Surgery may be considered if the patient has a strong family history of ovarian, breast, endometrial or colon cancer or if the mass appears to be enlarging

Complications

  • Cyst rupture
  • Torsion
  • Consider ovarian cyst rupture, torsion, or hemorrhage in postmenopausal women with acute abdominal pain
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