What is the management and diagnosis for a patient with an adnexal cyst and an enlarged lymph node?

Management of Adnexal Cyst with Enlarged Lymph Node

The presence of an enlarged lymph node in conjunction with an adnexal cyst raises significant concern for malignancy and warrants immediate evaluation with transvaginal ultrasound with Doppler followed by CT abdomen/pelvis with IV contrast for staging, with urgent referral to a gynecologic oncologist. 1, 2

Initial Diagnostic Approach

Imaging Strategy

• Transvaginal ultrasound combined with transabdominal ultrasound is the essential first-line imaging modality for characterizing the adnexal mass itself, with sensitivity >90% for detecting adnexal pathology 1, 2, 3

• Color or power Doppler must be included in the ultrasound examination to evaluate vascularity within any solid components, as this helps differentiate benign from malignant masses and is critical when lymphadenopathy is present 1, 3

• The combination of an adnexal mass with lymphadenopathy significantly elevates suspicion for malignancy, making this a high-risk scenario that requires aggressive workup 4

Key Ultrasound Features Suggesting Malignancy

Look specifically for these concerning characteristics on ultrasound:

• Solid components or thick septations within the cyst 1, 3
• Papillary projections or mural nodules 2, 3
• Strong vascularity on color Doppler (color score 3-4) 1
• Cyst size >10 cm 4
• Ascites 1

Staging and Advanced Imaging

Once malignancy is suspected (which the presence of lymphadenopathy strongly suggests), CT abdomen and pelvis with IV contrast becomes the primary modality for staging and identifying extent of disease 1, 3

• CT is superior to ultrasound for evaluating lymph nodes, peritoneal disease, and extra-ovarian spread 1

• MRI pelvis with and without IV contrast can serve as a problem-solving tool if CT findings are equivocal or to better characterize the primary adnexal mass, as it has the highest accuracy (91%) for distinguishing benign from malignant masses 1

• MRI demonstrates superior soft tissue characterization, with identification of vascular vegetations in cystic masses being the best indicator of malignancy 1

Biomarker Considerations

• CA-125 should be obtained but should NOT be used as a standalone test to determine malignancy, as it performs worse than ultrasound alone and may be low in borderline and low-grade malignant tumors 1, 5

• CA-125 improves specificity only in lesions already suspected to be malignant on ultrasound 1

Referral and Surgical Management

Immediate referral to a gynecologic oncologist is mandatory when an adnexal mass is accompanied by lymphadenopathy, as this represents a high-risk scenario (O-RADS 4-5 category with ≥10% risk of malignancy) 3, 6

• Initial management by a gynecologic oncologist is the second most important prognostic factor (after stage) for long-term survival in patients with ovarian malignancy 3

• Comprehensive surgical staging with lymphadenectomy is recommended if malignancy is confirmed, as this improves survival 6

• Frozen section analysis during surgery is recommended in settings where available to guide intraoperative decision-making 6

Critical Pitfalls to Avoid

• Do not rely on simple cyst appearance alone when lymphadenopathy is present - the combination changes risk stratification entirely 2, 5

• Do not use CT as initial imaging for the adnexal mass characterization - ultrasound is superior for this purpose, but CT is essential for staging once malignancy is suspected 1

• Do not delay referral to gynecologic oncology - any adnexal mass with associated lymphadenopathy requires specialist evaluation regardless of cyst appearance 3, 6

• Do not mistake reactive lymph nodes for metastatic disease - correlation with imaging characteristics of the primary mass is essential 4

Management Algorithm

1. Obtain transvaginal + transabdominal ultrasound with color Doppler to characterize the adnexal mass 1, 2

2. Obtain CT abdomen/pelvis with IV contrast to evaluate lymph nodes and stage potential disease 1, 3

3. Check CA-125 (but do not use as sole determinant) 1

4. If lymph node is confirmed enlarged and mass has any suspicious features: immediate gynecologic oncology referral 3, 6

5. If lymph node appears reactive and mass is clearly benign (simple cyst): consider MRI pelvis with contrast to further characterize both findings 1, 2