Ask Dr. Pat · Health

Diagnosis and Management of Ovarian and Fallopian Tube Masses

Gynecologic cancers that can present with adnexal masses include ovarian/fallopian tube cancer or uterine/cervical cancer that has metastasized to the ovaries. There are three main subtypes of ovarian cancer: 1) Epithelial ovarian cancer (which includes ovarian, fallopian tube and primary peritoneal cancer); 2) Germ cell tumors; and 3) Sex-cord stromal tumors. Examples of germ cell tumors include dysgerminomas, endodermal sinus tumors, choriocarcinomas and immature teratomas. Examples of sex-cord stromal tumors include granulosa cell tumors and Sertoli-Leydig tumors.

A thorough evaluation and physical exam can be very useful in the evaluation of an adnexal mass. When considering a woman’s medical history, it is important to remember the risk factors for ovarian cancer including older age, menopause, nulliparity (not having prior pregnancies), endometriosis and family history of ovarian cancer. For women with a strong family history of breast and/or ovarian cancer, the possibility of a BRCA1/2 mutation should be considered. BRCA1/2 mutations are present in 0.25% of the population (2.5% of Ashkenazi Jewish populations) and result in a significantly increased risk for breast and ovarian cancers. A focused physical exam is necessary. Features of a physical exam that would be concerning for malignancy include enlarged lymph nodes, abdominal swelling or bloating and a pelvic mass that is bilateral, firm, fixed or nodular. Reassuring exam findings are absence of abdominal swelling and lymph node enlargement and pelvic masses that are small, smooth and mobile (moved easily on exam).

After an exam the next step is imaging and blood laboratory tests. Imaging for pelvic masses should begin with a pelvic ultrasound. The ultrasound can assess the size and location of the mass and provide information on the composition of the mass. Findings that are concerning for malignancy include masses that are larger than 10cm, have solid or papillary components, increased blood flow and surrounding fluid in the pelvis called ascites. Masses that are simple without these features are less worrisome and likely benign. Depending on the ultrasound findings, a pelvic magnetic resonance imaging (MRI) or computed tomography (CT) scan can be used to further evaluate a mass and offer more information on the possibility of an underlying malignant condition.

Tumor markers are blood tests that can raise the concern for malignancy if elevated. Cancer antigen 125 (CA 125) is frequently used to evaluate ovarian masses. An elevated CA 125 can be a sign of malignancy but can also be related to non-cancerous conditions like endometriosis, pregnancy, pelvic inflammatory disease, pancreatic disease and non-gynecologic malignancies. Furthermore, CA 125 can be normal in up to 50% of early stage ovarian cancers. Therefore, while CA 125 can be a helpful tool, it must be used in concert with physical exam, imaging and pathologic diagnosis and cannot by itself rule-in or rule-out ovarian cancer. There are other panels of serum biomarkers that can be used to help raise or lower the suspicion for ovarian cancer. The United States Food and Drug Administration (FDA) currently approves of two serum markers panels: 1) The multivariate index assay (MIA); and 2) The Risk of Ovarian Malignancy Algorithm (ROMA). Of note, these biomarkers and biomarker panels are not meant to determine whether or not surgery is necessary but instead should be used to raise the level of suspicion for malignancy so that a woman can be referred to a gynecologic oncologic surgeon if malignancy is likely.

After completing a thorough history and physical exam and reviewing the imaging results, the physician and patient must come to a decision about management of the adnexal mass. The American College of Obstetricians and Gynecologists published the following guidelines outlining which adnexal masses require surgery and which can be managed with observation.

Observation is acceptable based on the following criteria:

  • A woman does not have symptoms due to the adnexal mass
  • Imaging (ultrasound, CT, and/or MRI) suggests benign disease
  • Normal CA 125
  • Simple cysts up to 10cm in diameter
  • Imaging suggestive of benign lesions including endometriomas, mature teratomas and hydrosalpinx

Surgical intervention is recommended based on the following criteria:

  • Imaging, exam or tumor markers suspicious for malignancy

In summary, adnexal masses are a common gynecologic problem. The goal of evaluation is to determine the most likely etiology. This evaluation process should include obtaining a medical and family history, physical examination and imaging, starting with a pelvic sonogram. If the adnexal mass is causing symptoms or is concerning for malignancy it should be surgically removed. If there is concern for a malignancy the surgery should be performed by a gynecologic oncologist.

 

Reference:

Evaluation and management of adnexal masses. Practice Bulletin No. 174. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016; 128:e 210–26.

 

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