Gynecologic Specialties
| The Adnexal Mass It has been estimated that 5-10% of women in the United States will undergo a surgical procedure for a suspected ovarian neoplasm during their lifetime. The majority of adnexal masses are benign. The natural history of an adnexal mass is not well understood, and it is unknown whether these benign lesions are precursors of malignancies. Thus, the exclusion of malignancy is the primary goal in the evaluation of an adnexal mass. Despite increases in the number of surgical procedures for ovarian cysts, the incidence of ovarian cancer has not decreased. The most common benign neoplasms of the ovary are benign mature cystic teratomas and serous cystadenomas. Benign mature cystic teratomas, otherwise known as dermoid cysts, can contain fat, hair and even teeth. They have a peak incidence in the reproductive years. 15-20% of benign lesions are bilateral. If found in the postmenopausal period, they may have been present for years. Malignant degeneration occurs in 1-2% of mature teratomas, usually after 40 years of age. Cystadenomas are filled with a clear fluid and can grow to large sizes. The majority of patients present with symptoms related to compression of local pelvic organs. Some ovarian masses are discovered during a routine pelvic examination. In patients with malignancy, common symptoms are usually non-specific and include bloating and abdominal discomfort. However, without findings associated with advanced disease, the differential diagnosis of an adnexal mass can be difficult to make. Besides a history and physical examination, a pelvic ultrasound would be warranted to examine the characteristics of the mass. Size of the mass, wall structure, presence of septations, and echogenicity are some of the important elements seen on an ultrasound that can be used to help predict malignancy. A serum CA-125 is often included in the diagnostic evaluation of an adnexal mass. However, it can be elevated in various benign conditions and is not always warranted. In women of reproductive age, asymptomatic cystic adnexal masses less than 10 cm in diameter can be followed expectantly. A follow-up ultrasound is usually obtained in 6 weeks to evaluate this mass at a different point in a woman's menstrual cycle. Persistence of the mass or a change to a more complex mass is an indication for surgery. For women who are postmenopausal, most require surgical evaluation. In those women whose cyst is unilocular, less than 5 cm in diameter, and whose serum CA-125 is within normal limits, expectant management is likely safe. However, further studies are needed. Under certain conditions, benign adnexal masses can be managed laparoscopically. This technique of minimally invasive surgery can be performed on an outpatient basis, and it reduces the postoperative recovery period. For a suspicious mass, further imaging studies may be needed as well as a referral to a gynecologic oncologist. |
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