2. Case
• 33 yrs old female, presented with acne , hirsutism and menstrual
irregularities
• She had TFT, prolactin and testosterone done for her , all were normal
• US pelvis done:
• Showed Rt ovarian mass of 6.4x4.4 cm , complex features
4. Background
• Women have a 5 to 10 % risk of requiring surgery for ovarian masses.
• With 13 to 21 % chance of being diagnosed with ovarian cancer.
• In premenopausal women almost all ovarian masses and cysts are
benign.
ACOG
5. What is the differential diagnosis of adnexal masses ?
6.
7. • The primary goal of diagnostic evaluation of adnexal masses is to
exclude malignancy.
8. Approach to patient with adnexal mass:
• History
• Examination
• Investigation
• Imaging
• Referral
9. History:
• risk factors for ovarian malignancy
• Symptoms suggestive of malignancy
• family history of ovarian or breast cancer
10. Risk factors
• older age
• family history of breast or ovarian cancer
• hereditary non-polyposis colorectal cancer
• nulliparity
• primary infertility
• Endometriosis
• obesity
• delayed child-bearing
• use of fertility-enhancing medications
• unopposed estrogen exposure
11.
12. Physical examination
• poor sensitivity in the detection of ovarian masses (15–51%)
• But important to evaluate for mass tenderness, mobility, nodularity
and ascites
• 5 studies showed the pooled sensitivity of pelvic examination for
detecting an adnexal mass was 45% with a pooled specificity of 90%.
14. CA 125 antigen
• It has a sensitivity of 61 to 90 %, a specificity of 71 to 93% , a positive
predictive value (PPV) of 35 to 91 % and a negative predictive value of 67 to
90 %.
• Specificity and positive predictive value are consistently higher in
postmenopausal women.
• It is unreliable in differentiating benign from malignant ovarian masses in
premenopausal women.
• It is primarily a marker for epithelial ovarian carcinoma .
• It is only raised in 50% of early stage disease.
15.
16. Other tumor markers
• Lactate dehydrogenase (LDH), α-FP and hCG should be measured in
all women under age 40 with a complex ovarian mass because of the
possibility of germ cell tumours.
18. • A pelvic ultrasound is the single most effective way of evaluating an
ovarian mass .
• Transvaginal ultrasonography is preferable due to its increased
sensitivity over transabdominal ultrasound.
• Combination of the transvaginal and transabdominal routes may be
appropriate for the assessment of larger masses and extra-ovarian
disease.
• The use of colour flow Doppler has generally not been shown to
significantly improve diagnostic accuracy
• combined use of the transvaginal route with colour flow mapping
and 3D imaging may improve sensitivity, particularly in complex cases
19. What is the role of the routine use of CT and MRI in the assessment of
suspected ovarian masses?
20. • At the present time the routine use of CT and MRI for assessment of
ovarian masses does not improve the sensitivity or specificity
obtained by transvaginal ultrasonography in the detection of ovarian
malignancy
• These imaging modalities will have a place in the evaluation of more
complex lesions
21. • What is the best way to estimate the risk of malignancy?
22. Risk of Malignancy Index (RMI)
• It is the most widely used model
• uses menopausal status, ultrasound characteristics, and the CA 125
level in a formula to predict the probability of malignancy
• A systematic review showed the sensitivities and specificities of an
RMI score of 200 in the detection of ovarian malignancies to be:
-sensitivity 78% (95% CI 71-85%)
-specificity 87% (95% CI 83-91%)
23.
24.
25. PREMENARCHAL PATIENTS
• A retrospective study found that approximately 25% of adnexal
masses in patients younger than 18 years were malignant.
• An adnexal mass in a premenarchal patient, or the presence of
symptoms associated with a mass, should prompt referral to a
gynecologist .
26. Take home message
• Women who report abdominal or pelvic pain, increased abdominal size or
bloating, or difficulty eating or feeling full quickly more than 12 times per
month for less than 12 months' duration should be evaluated for ovarian
cancer.
• The U.S. Preventive Services Task Force recommends against routine
screening for ovarian cancer, including use of transvaginal ultrasonography,
cancer antigen 125 testing, and screening pelvic examinations.
• Transvaginal ultrasonography should be the first imaging test used to
identify and characterize an adnexal mass.
• Cancer antigen 125 testing alone should not be used to differentiate
between a benign and a malignant adnexal mass
Up to 10% of women will have some form of surgery during their lifetime for the presence of an ovarian mass. In premenopausal women almost all ovarian masses and cysts are benign. The overall incidence of a symptomatic ovarian cyst in a premenopausal female being malignant is approximately 1:1000 increasing to 3:1000 at the age of 50.
RCOG
However, it is important to note that only in stage III–IV endometriosis is it likely to be raised to several hundreds or thousands of units/ml.21
There is no clear consensus regarding the need for further imaging beyond transvaginal ultrasound in the presence of apparently benign disease. However, these additional imaging modalities will have a place in the evaluation of more complex lesions (see section 6.1).34 If, from the clinical picture and ultrasonographic findings, malignant disease is a possibility, onward referral to a gynaecological oncology multidisciplinary team is appropriate
