What is the workup for a multiloculated complex cystic adnexal mass?

From the Guidelines

The workup for a multiloculated complex cystic adnexal mass typically involves ultrasound (US) imaging, specifically transabdominal and transvaginal US, to characterize the mass and assess the risk of malignancy.

Initial Evaluation

• The initial evaluation of a multiloculated complex cystic adnexal mass should include a thorough medical history and physical examination, followed by US imaging to determine the size, location, and characteristics of the mass 1.
• US can accurately diagnose benign adnexal lesions, including simple cysts, hemorrhagic cysts, endometriomas, and dermoids, as well as extraovarian cystic lesions such as paraovarian cysts, hydrosalpinx, and peritoneal inclusion cysts 1.

Risk Stratification

• The Ovarian-Adnexal Reporting and Data System (O-RADS) US risk stratification and management system can be used to assign a risk of malignancy to the mass, based on its characteristics and features 1.
• The risk of malignancy in multiloculated complex cystic adnexal masses is generally low, but it increases with the size of the mass and the presence of solid components or septations 1.

Further Imaging

• If the mass is indeterminate or suspicious for malignancy, further imaging with MRI may be necessary to better characterize the mass and assess the risk of malignancy 1.
• MRI can provide more detailed information about the mass, including its size, location, and characteristics, and can help to identify potential malignancies 1.

Management

• The management of a multiloculated complex cystic adnexal mass depends on the risk of malignancy and the patient's symptoms and medical history 1.
• If the mass is benign and asymptomatic, it can be monitored with serial US imaging, while malignant or symptomatic masses may require surgical intervention 1.
• It is essential to refer patients with suspected ovarian cancer to a gynecologic oncologist for initial management, as this can improve treatment outcomes 1.

From the Research

Workup for Multiloculated Complex Cystic Adnexal Mass

The workup for a multiloculated complex cystic adnexal mass involves several steps, including:

• Evaluation of symptoms and signs suggestive of malignancy, such as persistent pelvic/abdominal pain, urinary urgency/frequency, increased abdominal size/bloating, and difficulty eating 2, 3
• Measurement of cancer antigen 125 (CA 125) levels, which may be elevated in conditions other than ovarian cancer 2, 3, 4
• Transvaginal or transabdominal ultrasound examination to characterize the adnexal mass, including size, location, septations, excrescences, and internal solid components 2, 3, 5, 6
• Standardized ultrasound reports to include size and unilateral/bilateral location of the adnexal mass, thickness of septations, presence of excrescences and internal solid components, vascular flow distribution pattern, and presence or absence of ascites 3
• Calculation of the risk of malignancy index II score to identify pelvic masses with high malignant potential 3
• Consideration of referral to a gynecologic oncologist for assessment and optimal surgical management if the risk of malignancy is high 2, 3, 4

Imaging Characteristics

Imaging characteristics of a multiloculated complex cystic adnexal mass may include:

• Large mass size (> 6 cm) 2
• Complexity, projections, septation, irregularity, or bilaterality 2
• Presence of excrescences, internal solid components, or vascular flow distribution pattern 3, 5
• Ascites or other signs of malignancy 3

Referral Guidelines

Referral guidelines for a multiloculated complex cystic adnexal mass include:

• Referral to a gynecologic oncologist if the adnexal mass is larger than 6 cm or if findings persist longer than 12 weeks 2
• Referral to a gynecologic oncologist if the risk of malignancy is high, based on symptoms, CA 125 levels, and imaging characteristics 2, 3, 4