What is the recommended workup and management for an ovarian growth?

Workup and Management of Ovarian Growth

For any ovarian growth, ultrasound is the essential first-line imaging modality, with transvaginal approach preferred when technically feasible, followed by risk stratification based on morphology, menopausal status, and cyst size to determine whether observation, gynecologic management, or gynecologic oncology referral is appropriate. 1, 2

Initial Diagnostic Workup

Imaging Evaluation

• Transvaginal ultrasound should be the first-choice modality for evaluating an isolated ovarian mass, as it provides superior characterization of adnexal structures 2, 1
• Ultrasound reports must include standardized descriptors: size, laterality, origin, septation thickness, presence of excrescences, internal solid components, vascular flow patterns, and ascites 3
• MRI is recommended when ultrasound is unreliable or inconclusive for clarifying malignant potential 2
• CT imaging is indicated when extra-ovarian disease is suspected or needs to be ruled out 1, 2
• Chest imaging should be part of overall evaluation before surgical staging, despite lack of direct evidence 1

Laboratory Studies

• CA-125 should be measured in perimenopausal and postmenopausal women presenting with an adnexal mass 3
• CA-125 alone is not recommended as a standalone test for distinguishing benign from malignant masses 2
• In younger women with suspected germ cell tumors, measure AFP, β-hCG, and LDH 1
• Consider CEA and CA 19-9 when unclear whether mass is of gastrointestinal versus primary ovarian origin 1

Critical Contraindications

• Fine-needle aspiration is absolutely contraindicated for solid or mixed ovarian masses to prevent rupturing the cyst and spilling malignant cells into the peritoneal cavity 1, 4
• Transvaginal aspiration is contraindicated for purely fluid cysts >5 cm in postmenopausal women 1, 4

Risk Stratification and Management Algorithm

Premenopausal Women

Simple Cysts:

• ≤3 cm: Physiologic, no follow-up needed 5

• 3 cm to ≤5 cm: No additional management required 5

• 5 cm but <10 cm: Follow-up ultrasound in 8-12 weeks to confirm functional nature 5

• ≥10 cm: Gynecologist management required (malignancy risk 1-10%) 5
• If cyst persists or enlarges at follow-up, gynecologist management indicated 5

Complex Masses:

• Morphology scoring systems (incorporating septation thickness, wall thickness, excrescences, solid components) should be used to differentiate benign from malignant 2
• Doppler technology must be combined with morphology assessment, not used alone 2

Postmenopausal Women

Simple Cysts:

• ≤3 cm: No further management 5

• 3 cm but <10 cm: At least 1-year follow-up showing stability or decrease in size 5

• Annual follow-up for up to 5 years if cyst remains stable 5
• ≥10 cm: Gynecologist management required 5

High-Risk Features Requiring Gynecologic Oncology Referral:

• Elevated CA-125 6
• Nodular or fixed pelvic mass 6
• Ascites or metastatic disease 6
• Family history of breast or ovarian cancer 6
• Complex or solid tumors with high morphology index score 7

Surgical Management

When Surgery is Indicated

Primary surgery should be performed by a gynecologic oncologist (category 1 recommendation based on published improved outcomes) 1

Comprehensive surgical staging includes:

• Total abdominal hysterectomy and bilateral salpingo-oophorectomy 1
• Aspiration of ascites or peritoneal lavage for cytology 1
• Omentectomy 1
• Peritoneal biopsies 1
• Lymphadenectomy for early-stage disease to improve survival 2

Fertility-Preserving Options

• Unilateral salpingo-oophorectomy may be adequate for young patients with stage I and/or low-risk tumors (early-stage, low-grade invasive tumors; low malignant potential lesions) 1
• Comprehensive surgical staging must still be performed, as approximately 30% of patients are upstaged 1
• Fertility-preserving surgery is acceptable for low-malignant-potential tumors and well-differentiated stage I ovarian cancer after discussion with gynecologic oncologist 2

Surgical Approach

• Laparoscopy is reasonable alternative to laparotomy provided appropriate surgery and staging can be accomplished 2
• Minimally invasive techniques may be considered in select stage I patients if performed by experienced gynecologic oncologist 1
• Intraoperative frozen section is recommended when availability and patient preference allow 2
• Maximal effort should be made to remove all gross disease and achieve optimal cytoreduction 1

Common Pitfalls to Avoid

• Overtreatment of simple cysts in postmenopausal women, as malignancy risk is only 1.5% in surgically removed unilocular cysts 5
• Performing fine-needle aspiration on solid or mixed masses, risking peritoneal dissemination 1, 4
• Using CA-125 alone without imaging for risk assessment 2
• Failure to refer high-risk patients to gynecologic oncologist, as specialized surgical staging improves outcomes 1, 3
• Inadequate surgical staging in early disease, missing occult metastases in 30% of cases 1
• Not considering germ cell tumors in younger patients, which require different tumor markers and fertility-sparing approaches 1