What is the management for an adnexal mass?

Management of Adnexal Masses

Transvaginal ultrasound combined with transabdominal ultrasound is the essential first-line imaging modality for evaluation and characterization of adnexal masses, with subsequent management determined by imaging features, patient age, and risk factors for malignancy. 1, 2

Initial Evaluation

• Imaging approach:

  • Transvaginal ultrasound is the primary diagnostic tool with >90% sensitivity 1
  • Transabdominal ultrasound should complement transvaginal imaging, especially for large masses (>10 cm) or those not optimally visualized transvaginally 1, 2
  • Color or power Doppler should be included to evaluate vascularity of solid components 1

• Ultrasound risk stratification systems:

  • International Ovarian Tumor Analysis (IOTA) simple rules
  • Ovarian-Adnexal Reporting and Data System (O-RADS)
  • Society of Radiologists in Ultrasound (SRU) consensus statement 1

Characterization of Adnexal Masses

Benign Features

• Simple cysts (anechoic, unilocular with smooth thin wall)
• Single thin septation <3 mm
• Specific patterns for:
  • Dermoid/teratoma (echogenic components with distal shadowing)
  • Endometrioma (low-level internal echoes)
  • Hemorrhagic cyst (hypoechoic internal debris)
  • Pedunculated fibroid (blood supply from uterine vessels) 1, 2

Suspicious Features

• Solid components with irregular contours
• Thick septations (>3 mm)
• Papillary projections or mural nodules
• Increased vascularity in solid components
• Presence of ascites
• Bilateral masses 1, 2

Management Algorithm

Premenopausal Women

1. Simple cysts:

   • <5 cm: No follow-up required
   • 5-7 cm: Follow-up ultrasound in 8-12 weeks 2

2. Benign-appearing complex masses:

   • <5 cm: Follow-up ultrasound in 8-12 weeks
   • 5-10 cm: Consider MRI with contrast or follow-up ultrasound in 6-8 weeks 1

3. Suspicious masses:

   • Any size: Refer to gynecologic oncologist

   • 10 cm: Refer to gynecologic oncologist regardless of appearance 1, 2

Postmenopausal Women

1. Simple cysts:

   • <1 cm: No follow-up required
   • 1-7 cm: Follow-up ultrasound in 8-12 weeks 1, 2

2. Complex masses:

   • Any size: Consider MRI with contrast for further characterization
   • If suspicious features: Refer to gynecologic oncologist 1

3. All solid masses: Refer to gynecologic oncologist 1

Advanced Imaging

When ultrasound findings are indeterminate:

• MRI with contrast:

  • Superior to both ultrasound and non-contrast MRI for confirming enhancing tissue components
  • Particularly useful for characterizing indeterminate adnexal masses
  • Can determine organ of origin (uterine, ovarian, or tubal) 1, 2

• CT abdomen and pelvis with IV contrast:

  • Not recommended for initial characterization due to poor soft-tissue discrimination
  • Appropriate for staging if malignancy is suspected 1

• FDG-PET/CT:

  • May be useful to identify other sites of disease in patients with suspected malignancy 1

Special Populations

Pregnant Women

• Ultrasound remains first-line imaging
• Most adnexal masses in pregnancy are benign (dermoid 32%, endometrioma 15%, functional cyst 12%)
• Only 2% of surgically managed adnexal masses during pregnancy are malignant 1
• Management is generally conservative unless suspicious features are present

Critical Considerations

• Initial management by a gynecologic oncologist is a key prognostic factor in ovarian cancer survival 1
• Only 33% of women with eventual diagnosis of ovarian cancer are appropriately referred to gynecologic oncologists initially 1
• Surgical exploration of benign lesions carries complication rates of 3-15%, emphasizing the importance of accurate preoperative characterization 1
• Contrast-enhanced MRI has demonstrated higher accuracy (94%) than conventional ultrasound (83%) for differentiating benign from malignant lesions 1

Pitfalls to Avoid

• Relying solely on CA-125 for diagnosis (performs worse than ultrasound alone)
• Misdiagnosing pedunculated fibroids as ovarian masses
• Delaying referral for suspicious masses
• Failing to recognize that small, complex masses can be malignant 1, 2