Adnexal mass

Refers to uterus adnexa, the ovary, fallopian tube, and structures of the broad ligament.

Abnormalities of the ovary and fallopian tube, collectively known as the adnexa, is found in up to 35% of premenopausal and 17% of post menopausal women.

Adnexal lesions occur throughout the lifecycle and range from benign to malignant processes.

Often identified incidentally.

This finding often leads to additional investigations and interventions that could cause morbidity with unknown or questionable clinical benefit.

Adnexal mass management requires assessment of the lesion to determine if it is an acute process that requires urgent surgical intervention, is a malignant process and establish appropriate management compatible with patient’s desires regarding fertility and endogenous hormonal preservation.

Differential diagnosis is large:benign cysts, metastatic disease to the ovary, primary ovarian cancers, tubal cysts, paratubal cysts, hydrosalpinx, uterine masses structural abnormalities and fallopian cancer.

Most lesions are benign.

Generally, ovarian tumors do not undergo preoperative biopsy to avoid disrupting the ovarian capsule, which can cause dissemination of malignant cells.

Therefore without a definitive tissue diagnosis, clinicians need to rely on other tools to determine the clinical implications of a adnexal mass.

The ovaries are located in the ovarian fossa and have a white – gray appearance.

Ovarian size is approximately 4 x 2. 5 cm when women are in their 20s and decrease to almond size by menopause.

Each ovary is nestled against the fallopian tube that is inserted proximately into the uterine cornua.

The mesosalpinx and gonadal vasculature support the tube and the ovary.

The ovary is responsible for steroidogenesis and the genesis, support, and release of oocytes,essential to human reproduction.

There are three types of supporting ovarian tissue: surface epithelium, sex cords and stroma, and primordial germ cells.

Each of these layers has potential to have a pathological, benign or malignant, process.

Surface epithelium is where  epithelioid tumors arise and account for the majority of ovarian tumors, while sex cord or stromal tumors originate in supporting epithelial cells and either secrete hormones or form masses of fibrous tissue. 

Germ cell tumors emanate from the primitive germ cells and range from benign to malignant tumors, such as mature teratomas and yolk sac tumors.

The fallopian tube has an outer muscular layer and an inner mucosal layer with ciliated columnar cells, secretary cells, and intercalated cells.

The fimbriated end of the fallopian tube has an open communication with the peritoneum and is similar to the epithelium of the ovary.

The fimbriated end of the fallopian tube has been implicated in many adenocarcinomas thought previously to have a arisen in the ovary.

The prophylactic removal of apparently normal tubes and ovaries from women would BRCA1 or BRCA2 mutations show that the fimbriated end of the fallopian tube harbors serous carcinoma in 2 to 7% of specimens.

Adnexal lesions are categorized as: benign, malignant, or borderline.

Additional investigations include: serum tumor markers, MRI, and a risk of malignancy index..

Likelihood of the lesion is benign is higher in menstruating women compared to prepubertal females or postmenopausal women.

Imaging studies improve the ability to characterize the structure of the mass-its wall complexity and mass contents.

The ovary produces a follicular cyst 6-7 times yearly and they usually resolve within the duration of a menstrual cycle, when they persist or enlarge they can represent an adnexal mass.

The presence of a complex internal structure or a solid component in an adnexal mass increases the concern for a significant pathologic condition.

In girls younger than 9 years of age adnexal ovarian lesions are malignant in approximately 80% of cases and are generally germ cell tumors.

In adolescence an adnexal mass consists of an adult cystic teratoma in approximately 50% of cases.

Endometriosis in young women is a consideration when pain is present in the adnexal mass.

In young females the possibility of a tubo-ovarian abscess is a diagnostic consideration.

10% of such lesions are malignant in women of reproductive age.

In patients younger than 30 years ovarian tumors of low malignant potential are common.

About one third of neoplastic lesions are adult cystic teratomas.

About 25% of lesions in women of reproductive age are endometriomas.

Lesions may be serous or mucinous cystadenomas.

Risk of a malignant ovarian lesion in a postmenopausal female is about 20-30%.

Pregnancy associated lesions include ectopic pregnancy, corpus luteum cysts and theca lutein cysts .

Lesions thought to be benign preoperatively can be successfully managed laparoscopically in three fourths of cases.

Tissue pure procurement is required  for diagnosis but biopsies of an adnexal mass  should be avoided to prevent intra-abdominal spillage and upstaging of a possible cancer.

Evaluation of an adnexal mass consists of history, physical exam, laboratory studies and primarily imaging.

Some patients with an adnexal lesion may require emergent surgery as in the case of an ovarian torsion, a ruptured ectopic pregnancy, or bowel obstruction due to malignancy.

Some patients may have chronic symptoms of pain or bloating as with an endometrioma, mucinous cystadenoma, or a malignant process. 

Functional cysts are documented in laparoscopic studies in 18-55% of cases.

Unilocular cystic adnexal masses under 10 cm in postmenopausal women may be followed with minimal risk of ovarian cancer.

Most patients are asymptomatic at the time of presentation.

Masses are frequently found at the time of routine pelvic examination, at the time of radiographic testing for another process and an incidental finding at surgery.

Patients with symptoms may have urinary frequency, abdominal pressure, pelvic pressure and altered bowel habits secondary to mass effect on surrounding organs.

Females younger than age 10 will frequently present with pelvic pain.

Older women with endometriosis or an infected mass will present with pelvic pain.

Some patients may be asymptomatic with an incidental diagnosis of an adnexal lesion.

The initial evaluation of an adnexal mass is to ascertain the need for immediate surgical procedure, as in patients with hemodynamic instability, peritonitis, bowel or urinary obstruction that require prompt surgical intervention.

Patients of reproductive age should be tested for human chorionic gonadotropin to rule out an ectopic pregnancy.

Once an acute process is ruled out for urgent surgery, an evaluation can proceed to determine the specific nature of the adnexal mass.

Older age is a greater risk for ovarian or tubal cancer.

Approximately 20% of tubal or ovarian cancers are due to a heritable gene mutation and should be evaluated for such a risk.

The sensitivity of a pelvic exam for detecting in an adnexal mass is low ranging from 15 to 36%. and worsens markedly with increased body mass index.

Clinical experience has been shown to have no bearing on the sensitivity of detecting an adnexal mass.

A pelvic examination cannot reliably differentiate between a benign and malignant mass.

Pelvic mass detection by clinical exam is poorer in pre-menopausal patients than in postmenopausal patients, 31% and 59% respectively.

Pelvic exam can determine whether a mass is fixed to the rectum or pelvic sidewall and provides information about whether to use a laparoscopic or open surgical approach.

Imaging  by pelvic ultrasound is the most important imaging tool in evaluating the adnexa and should be the initials radiologic test.

Morphologic features of an adnexal mass helps to categorize the risk of a malignant process. 

The more complex a mass is, the higher the likelihood it is malignant.

MRI I can be a useful adjunct for masses described as indeterminate.

CT is the test of choice for staging of known ovarian cancer and assesses for metastases or recurrence, but has poor performance characteristics in the initial assessment of an adnexal mass.

All women of reproductive age should be screened for pregnancy for consideration of an ectopic pregnancy, gestational trophoblastic neoplasia, or pregnancy concurrent with an adnexal mass.

CA 125 is a large, transmembrane glyco protein secreted go by coelomic (pleural and peritoneal) epithelium mullerian epithelium, and levels are elevated in approximately 80% of women with epithelial ovarian or tubal cancers.

Human epididymis proteins 4 (HE4) can help determine if an adnexal ovarian mass is cancerous. 

HE4 has a sensitivity similar to CA 125 but a superior specificity for ovarian cancer.

The Overa test is a multivariant index based on serum levels of CA 125, transferrin, apolipoprotein A1, HE4, and FSH. 

The test helps decide whether the mass should be surgically removed.

A benign adnexal mass is treated on the basis of where the patients are symptomatic and their individual preferences for surgery, fertility preservation and indigenous hormone production.

Unilocular cysts are invariably benign and 50 to 70% of the time they resolve spontaneously.

Large benign cyst that do not resolve can be surgically removed. 

The presence of thin septations does not increase the risk of cancer.

Complex lesions such as hemorrhagic cyst, endometriomas, and mature teratomas have diagnostic ultrasonic features and are removed if they are symptomatic.

Patients with intermediate or malignant lesions are referred to a GYN oncologist for removal.

Adnexal masses are rare in children and adolescents at three per hundred thousand children and adolescents.

Adnexal mass found during pregnancy is most commonly a dermoid cyst.


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