Adnexal Masses: Diagnosis and Management.

Pelvic masses occur in up to 20% of women throughout their lifetime. These masses represent a spectrum of gynecologic and nongynecologic conditions. Adnexal masses-found in the fallopian tubes, ovaries, and surrounding areas-are mostly benign. Evaluation includes assessment for symptoms that may suggest malignancy, such as abdominal pain, abdominal bloating, and early satiety. A family history of ovarian, breast, or certain heritable syndromes increases the risk of malignancy. For women of reproductive age, ectopic pregnancies must be considered; a beta human chorionic gonadotropin level should be obtained. Transvaginal ultrasonography is the imaging test of choice for evaluating adnexal masses for size and complexity. Adnexal cysts that are greater than 10 cm, contain solid components, or have high color flow on Doppler ultrasonography are high risk for malignancy. Further imaging, if warranted, should be completed with computed tomography or magnetic resonance imaging, particularly if there is concern for disease outside the ovary. Multimodal assessment tools that use ultrasonography and biomarkers, such as the risk of malignancy index, are useful in the diagnosis and exclusion of malignant causes. Asymptomatic masses that are determined to be benign may be observed and managed expectantly. In symptomatic or emergent cases, such as ectopic pregnancy or ovarian torsion, a gynecologist should be consulted. In any adnexal mass with high risk for malignancy, a consultation with gynecologic oncology is indicated.

Impact of Multiparametric MRI (mMRI) on the Therapeutic Management of Adnexal Masses Detected with Transvaginal Ultrasound (TVUS): An Interdisciplinary Management Approach.

RATIONALE AND OBJECTIVES: Adnexal masses detected incidentally at transvaginal ultrasound (TVUS) are a common and still challenging diagnostic problem. The primary goal of further imaging is an accurate tissue characterization so an optimal treatment plan can be devised including surgery only for lesions that are indeterminate or malignant. The aim of this prospective study was to evaluate the diagnostic utility of complementary multiparametric magnetic resonance imaging (mMRI) for treatment planning in patients with adnexal masses, and to assess how it ultimately correlates with subsequent histopathologic findings. MATERIAL AND METHODS: A total of 126 women (mean age: 54.6 years) with indeterminate adnexal masses underwent mMRI at 3T in addition to TVUS and testing to determine their CA-125 levels. The mMRI protocol consisted of a high-resolution T2-TSE in three planes, diffusion weighted images and dynamic contrast enhanced. First the character of the adnexal mass and the associated management decision (follow-up, laparoscopy or laparotomy) were assessed independently for each diagnostic method (TVUS + CA-125 and mMRI). All methods were then assessed in synopsis. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of each diagnostic method alone and in combination were calculated. The standard of reference was either final histology in women who underwent surgery or follow-up of at least 24 months in women who underwent follow-up. RESULTS: In 67.5% (85/126) of all patients, the adnexal mass was benign; a malignant tumor was diagnosed in 28.6% (36/126) and a borderline tumor in the remaining 4% (5/126) of patients. The diagnostic indices were as follows for TVUS + CA 125 alone, mMRI alone and all three methods combined: sensitivity 86% (31/36), 97% (35/36), and 100% (36/36); specificity 32% (29/90), 83% (75/90), and 80% (68/90); PPV 34% (31/91), 70% (35/50), and 74% (40/54); and NPV 65% (29/44), 98% (75/76), and 100% (72/72). Complementary use of mMRI changed the therapeutic management decision in 34% (41/126) of all patients. In 40.7% (37/91) of patients for whom surgery had been recommended based on TVUS + CA-125, MRI revealed a typical benign finding such that those patients underwent follow-up instead of surgery. None of the examined masses exhibited (tumor) progression or malignancy during the follow-up period. A laparotomy was performed instead of a laparoscopy in 8.7% (11/126) based on the mMRI result. CONCLUSION: MRI helps significantly improve sensitivity and specificity of diagnosis in patients with indeterminate adnexal masses detected at TVUS. Its diagnostic information revised the planned treatment in more than one-third of women.

Adnexal Masses in Pregnancy.

IMPORTANCE: Adnexal masses are identified in approximately 0.05% to 2.4% of pregnancies, and more recent data note a higher incidence due to widespread use of antenatal ultrasound. Whereas most adnexal masses are benign, approximately 1% to 6% are malignant. Proper diagnosis and management of adnexal masses in pregnancy are an important skill for obstetricians. OBJECTIVE: The aim of this study was to review imaging modalities for evaluating adnexal masses in pregnancy and imaging characteristics that differentiate benign and malignant masses, examine various types of adnexal masses, and understand complications of and explore management options for adnexal masses in pregnancy. EVIDENCE ACQUISITION: This was a literature review using primarily PubMed and Google Scholar. RESULTS: Ultrasound can distinguish between simple-appearing benign ovarian cysts and masses with more complex features that can be associated with malignancy. Radiologic information can help guide physicians toward recommending conservative management with observation or surgical removal during pregnancy to facilitate diagnosis and treatment. The risks of expectant management of an adnexal mass during pregnancy include rupture, torsion, need for emergent surgery, labor obstruction, and progression of malignancy. Historically, surgical removal was performed more routinely to avoid such complications in pregnancy; however, increasing knowledge has directed management toward conservative measures for benign masses. Surgical removal of adnexal masses is increasingly performed via minimally invasive techniques including laparoscopy and robotic surgery due to a decreased risk of surgical complications compared with laparotomy. CONCLUSIONS AND RELEVANCE: Adnexal masses are increasingly identified in pregnancy because of the use of antenatal ultrasound. Clear and specific guidelines exist to help differentiate between benign and malignant masses. This is important for management as benign masses can usually be conservatively managed, whereas malignant masses require excision for diagnosis and treatment. A multidisciplinary approach, including referral to gynecologic oncology, should be used for masses with complex features associated with malignancy. Proper diagnosis and management of adnexal masses in pregnancy are an important skill for obstetricians.

Recurrent and metastatic female adnexal tumor of probable Wolffian origin: A case report and review of the literature.

RATIONALE: Female adnexal tumors of probable Wolffian origin (FATWOs) are rare gynecologic neoplasms arising from the mesonephric duct remnants. Less than 90 cases have been reported in the English literature. Although most cases of FATWO are considered benign, recurrence and metastasis may occur in very few cases during the course of the disease. Due to the small number of recurrent and metastatic FATWO cases, there are no clear recommendations regarding optimal treatment. PATIENT CONCERNS: A 75-year-old postmenopausal woman, who underwent a mass excision of the right broad ligament three years ago, was found to have a right adnexal mass during a regular postoperative physical examination. DIAGNOSES: Vaginal ultrasound examination revealed a cystic and solid mass approximately 3.6 × 4.4 × 3.8 cm on the right side of the uterus. Three years ago, the mass of the right broad ligament was diagnosed with FATWO in the local hospital. Following extensive immunohistochemistry analysis and after reviewing the histology slides from the primary tumor, the final diagnosis of the mass on the right side of the uterus was recurrent and metastatic FATWO. INTERVENTIONS: The patient underwent laparoscopic mass excision, hysterectomy and resection of the metastatic lesion in the small intestine, and then she received 6 cycles of docetaxel and carboplatin-based chemotherapy. OUTCOMES: The disease has recurred three years after the first surgery in the local hospital. After the second surgery followed by systemic chemotherapy, there is no evidence of recurrence with 24 months of follow-up till now. LESSONS: FATWO is considered a benign entity. However, a few FATWOs have been shown to behave aggressively. Due to only a few reported cases, there are no comprehensive recommendations regarding the optimal clinical management of recurrent and metastatic FATWOs. Complete surgical resection followed by combination chemotherapy is considered to be the most effective therapy for recurrent and metastatic FATWOs. Chemotherapy with docetaxel plus carboplatin, which is most commonly used in malignant cases, may be effective in the treatment of recurrent and metastatic FATWOs.

Imaging as an alternate diagnostic modality in a presumptive case of abdominopelvic TB in a COVID-19 patient.

A 30-year-old, multiparous widow, with postpolio residual paralysis, presented with complaints of dull aching abdominal pain for 15 days. Ultrasound showed a mixed echogenic right adnexal mass with free fluid in the pelvis and abdomen. CT abdomen and pelvis revealed partially defined peripherally enhancing collection in lower abdomen and right adnexa suggestive of tubo-ovarian abscess. There was mild ileal wall thickening and few enlarged mesenteric lymph nodes. Ascitic fluid did not show acid fast bacilli and cultures were sterile. Extensive diagnostic laboratory work was done which was inconclusive. Diagnostic laparoscopy could not be performed due to non-availability of elective operation theatre in the COVID-19 pandemic. Presumptive extrapulmonary tuberculosis was clinically and radiologically diagnosed. She was started on daily anti tuberculosis treatment. This case shows us the importance of imaging as a diagnostic tool and as an alternative for laparoscopy in COVID-19 pandemic to diagnose abdomino-pelvic tuberculosis.

Management of adnexal masses' torsion during pregnancy.

With the increased use and quality of ultrasound in pregnancy, adnexal masses are being encountered with greater frequency. Most of the time such masses are asymptomatic. It can be discovered in an emergency. Surgical intervention may cause risks to the mother and her fetus, while observation without intervention may also lead to unfavorable complications, such as ovarian torsion or the development of a tumor. Therefore, the management requires a balance between the maternal and fetal risks. We report two cases of torsion of adnexal masses during pregnancy, and we provide a brief literature review on the management and prognosis of this condition in pregnancy.

Guideline No. 403: Initial Investigation and Management of Adnexal Masses.

OBJECTIVES: To aid primary care physicians, emergency medicine physicians, and gynaecologists in the initial investigation of adnexal masses, defined as lumps that appear near the uterus or in or around ovaries, fallopian tubes, or surrounding connective tissue, and to outline recommendations for identifying women who would benefit from a referral to a gynaecologic oncologist for further management. INTENDED USERS: Gynaecologists, obstetricians, family physicians, general surgeons, emergency medicine specialists, radiologists, sonographers, nurses, medical learners, residents, and fellows. TARGET POPULATION: Adult women 18 years of age and older presenting for the evaluation of an adnexal mass. OPTIONS: Women with adnexal masses should be assessed for personal risk factors, history, and physical findings. Initial evaluation should also include imaging and laboratory testing to triage women for management of their care either by a gynaecologic oncologist or as per SOGC guideline no. 404 on the initial investigation and management of benign ovarian masses. EVIDENCE: A search of PubMed, Cochrane Wiley, and the Cochrane systematic reviews was conducted in January 2018 for English-language materials involving human subjects published since 2000 using three sets of terms: (i) ovarian cancer, ovarian carcinoma, adnexal disease, ovarian neoplasm, adnexal mass, fallopian tube disease, fallopian tube neoplasm, ovarian cyst, and ovarian tumour; (ii) the above terms in combination with predict neoplasm staging, follow-up, and staging; and (iii) the above two sets of terms in combination with ultrasound, tumour marker, CA 125, CEA, CA19-9, HE4, multivariable-index-assay, risk-of-ovarian-malignancy-algorithm, risk-of-malignancy-index, diagnostic imaging, CT, MRI, and PET. Relevant evidence was selected for inclusion in descending order of quality of evidence as follows: meta-analyses, systematic reviews, guidelines, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. Additional articles were identified through cross-referencing the identified reviews. The total number of studies identified was 2350, with 59 being included in this review. VALIDATION METHODS: The content and recommendations were drafted and agreed upon by the authors. The Executive and Board of the Society of Gynecologic Oncology of Canada reviewed the content and submitted comments for consideration. The Board of Directors of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework (Table A1 of Online Appendix A). See Table A2 of Online Appendix A for the interpretation of strong and weak recommendations. The summary of findings is available upon request. BENEFITS, HARMS, COSTS: Adnexal masses are common, and guidelines on how to triage them and manage the care of patients presenting with adnexal masses will continue to guide the practice of primary care providers and gynaecologists. Ovarian cancer outcomes are improved when initial surgery is performed by a gynaecologic oncologist, likely as a result of complete surgical staging and optimal cytoreduction. Given these superior outcomes, guidelines to assist in the triage of adnexal masses and the referral and management of the care of patients with an adnexal mass are critical. SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES): RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Adnexal Masses in Adolescents.

Adnexal masses in adolescents, such as functional cysts, are often benign and can usually be managed expectantly since they typically regress on their own. The most common ovarian neoplasm in adolescents is a benign cystic teratoma. Both functional cysts and benign cystic teratomas are associated with ovarian torsion. Of concern, ovarian torsion requires a high level of suspicion when adolescents present with acute abdominal pain, as almost one-half of cases have no associated adnexal masses. The most common malignant adnexal masses in this age group include germ cell tumors, followed by epithelial cell tumors. Finally, ectopic pregnancy and tubo-ovarian abscesses must be considered in the differential diagnosis of adnexal mass, as delays in treatment may seriously affect an adolescent's health and future fertility. Obtaining an accurate history, including a sexual history, requires reviewing this history with the adolescent privately. Management of adnexal mases should prioritize fertility preservation. [Pediatr Ann. 2020;49(4):e183-e187.].

Icon immunoconjugate treatment results in regression of red lesions in a non-human primate (Papio anubis) model of endometriosis.

Endometriosis is a common condition in reproductive-aged women characterized by ectopic endometrial lesions of varied appearance, including red, white, blue, black or powder burn coloration, which contribute to chronic pain and infertility. The immunoconjugate molecule (Icon) targets Tissue Factor, a transmembrane receptor for Factor VII/VIIa that is aberrantly expressed in the endothelium supporting ectopic endometrial tissue. Icon has been shown to cause regression of endometriosis in a murine model of disease but prior to this study had not been tested in non-human primates. This study evaluated Icon as a novel treatment for endometriosis in non-human primates (Papio anubis) using an adenoviral vector (AdIcon) delivery system. Female baboons (n = 15) underwent surgical induction of endometriosis. After laparoscopic confirmation of endometriosis lesions 6-weeks post-surgery, the treatment group (n = 7) received weekly intraperitoneal injections of viral particles carrying the sequence for Icon, resulting in expression of the protein, while the control group (n = 8) received no treatment. Icon preferentially reduced the number and volume of red vascularized lesions. Icon may present a novel treatment for endometriosis by degrading red vascularized lesions, likely by targeting tissue factor aberrantly expressed in the lesion vasculature.

Vesico-Adnexal Fistula Treated with Transurethral Embolization Under Fluoroscopic Guidance.

BACKGROUND Vesico-adnexal fistulae are rare. Potential causes of such fistulae include infection, endometriosis, and iatrogenic causes following pelvic surgeries. To the best of our knowledge, only 3 cases of vesico-adnexal fistulae have been reported, and all these patients were treated surgically by removing the involved adnexa, excising the fistulous duct, and suturing the bladder. We describe the first case of vesico-adnexal fistula that developed after pelvic surgery, and it was successfully treated by transurethral embolization under fluoroscopic guidance. CASE REPORT Our patient was a 27-year-old woman with a history of hysterectomy. She presented to our institution with urethral discharge and a recurrent urinary tract infection. The cystogram showed a fistula tract connecting the urinary bladder and left adnexal cystic cavity. She was treated conservatively with antibiotics and prolonged Foley catheterization to allow for spontaneous closure of the fistula; however, conservative management failed. The patient was successfully treated with transurethral embolization of the tract under fluoroscopic guidance. CONCLUSIONS In such a rare scenario with limited treatment options, interventional radiology offers an alternative minimally invasive treatment strategy.

Risk Stratification of Adnexal Cysts and Cystic Masses: Clinical Performance of Society of Radiologists in Ultrasound Guidelines.

Purpose To evaluate the performance of the 2010 Society of Radiologists in Ultrasound (SRU) consensus guidelines in the risk stratification of symptomatic and asymptomatic adnexal cysts. Materials and Methods An institutional review board-approved retrospective review was performed, including adnexal cysts detected with ultrasonography (US) with surgical diagnosis or at least 2 years of imaging or clinical follow-up, from January to June 2011. SRU management recommendations were scored as 0, no follow-up; 1, US follow-up; 2, magnetic resonance (MR) imaging follow-up; and 3, surgical evaluation. Distribution of outcomes (nonneoplastic cyst, benign neoplasm, malignant neoplasm) was compared in each rating group by using the Cochran-Armitage trend test. Where SRU guidelines allow more than one management option, they were classified as being interpreted in either a "surgically focused" environment, with limited MR imaging availability, or an "MR-capable" center, where MR imaging is selected whenever it is an option. Predictors of neoplasms and malignancy were evaluated by using multivariate logistic regression. Results A total of 570 cysts in 500 women aged 18-90 years (mean, 42 years) were included. There were 475 (83.3%) nonneoplastic cysts, 77 (13.5%) benign neoplasms, and 18 (3.2%) malignant neoplasms. Of the 500 women, 161 (32.2%) were asymptomatic. In the surgically focused interpretation of guidelines, proportions of any neoplasm and malignant neoplasm, respectively, were 1% and 0% in SRU 0, 17% and 1% in SRU 1, 48% and 0% in SRU 2, and 48% and 16% in SRU 3 (P < .0001 for both trends). In the interpretation of SRU guidelines with MR imaging when it was an option, proportions of any neoplasm and malignant neoplasm, respectively, were 1% and 0% in SRU 0, 17% and 1% in SRU 1, 38% and 5% in SRU 2, and 81% and 52% in SRU 3 (P < .0001, both trends) and 82 (89.1%) fewer benign cysts would have gone directly to surgical evaluation. In multivariate regression, SRU rating predicted both any neoplasm (odds ratio, 2.58; P < .0001) and malignant neoplasm (odds ratio, 4.94; P = .005). Conclusion SRU consensus guidelines effectively stratified the risk of neoplasia and malignancy. Selecting MR imaging when it is an option in the guidelines would have reduced the number of benign cysts sent for surgical evaluation. © RSNA, 2017.

Gynandroblastoma with a Juvenile Granulosa Cell Component in an Adolescent: Case Report and Literature Review.

BACKGROUND: Gynandroblastoma is an extremely rare ovarian sex cord tumor with malignant potential. CASE: An 18-year-old adolescent experienced intermittent vaginal bleeding. A year later, a right adnexal mass with a heterogeneous imaging appearance was identified. Laparoendoscopic single-site ovarian tumorectomy was performed. A histopathological examination showed gynandroblastoma composed of juvenile granulosa and Sertoli-Leydig cells. Because the tumor was upstaged to stage Ic because of cyst rupture during surgery, three cycles of adjuvant chemotherapy with carboplatin and paclitaxel were added. Three years after surgery, no signs of recurrence have been noted. SUMMARY AND CONCLUSION: The present findings can help clinicians make an accurate preoperative imaging diagnosis of gynandroblastoma with a juvenile granulosa cell component and plan an adequate treatment strategy for this rare, potentially malignant neoplasm.

Practice Bulletin No. 174 Summary: Evaluation and Management of Adnexal Masses.

Adnexal masses (ie, masses of the ovary, fallopian tube, or surrounding tissues) commonly are encountered by obstetrician-gynecologists and often present diagnostic and management dilemmas. Most adnexal masses are detected incidentally on physical examination or at the time of pelvic imaging. Less commonly, a mass may present with symptoms of acute or intermittent pain. Management decisions often are influenced by the age and family history of the patient. Although most adnexal masses are benign, the main goal of the diagnostic evaluation is to exclude malignancy. The purpose of this document is to provide guidelines for the evaluation and management of adnexal masses in adolescents, pregnant women, and nonpregnant women and to outline criteria for the identification of adnexal masses that are likely to be malignant and may warrant referral to or consultation with a gynecologic oncologist.

Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses.

Adnexal masses (ie, masses of the ovary, fallopian tube, or surrounding tissues) commonly are encountered by obstetrician-gynecologists and often present diagnostic and management dilemmas. Most adnexal masses are detected incidentally on physical examination or at the time of pelvic imaging. Less commonly, a mass may present with symptoms of acute or intermittent pain. Management decisions often are influenced by the age and family history of the patient. Although most adnexal masses are benign, the main goal of the diagnostic evaluation is to exclude malignancy. The purpose of this document is to provide guidelines for the evaluation and management of adnexal masses in adolescents, pregnant women, and nonpregnant women and to outline criteria for the identification of adnexal masses that are likely to be malignant and may warrant referral to or consultation with a gynecologic oncologist.

Simulated impact of pelvic MRI in treatment planning for pediatric adnexal masses.

BACKGROUND: There are no studies on utility of MRI in management of pediatric adnexal masses. OBJECTIVE: To determine the diagnostic and therapeutic impact of pelvic MRI in adnexal masses in children and adolescents. MATERIALS AND METHODS: We included 32 females age 18 years and younger who had adnexal masses and who underwent both pelvic ultrasound (US) and MRI. A radiologist retrospectively reviewed US and MR images and created a standard radiologic report for each patient. In a prospective theoretical fashion, two pediatric gynecologists reviewed the clinical data and US report for each patient and indicated conservative versus surgical management; in surgical cases the options were laparoscopy versus laparotomy, midline versus Pfannenstiel incision, and oophorectomy versus cystectomy. Subsequently, the gynecologists were presented the MRI report and were asked to indicate their treatment options again. A binomial test was conducted to determine the effect of adding MRI findings to the management plan. RESULTS: The addition of MRI significantly changed management in 10 of 32 patients (P=0.0322), with a change in surgical versus conservative treatment in 5, a change in laparotomy vs. laparoscopy in 2, and a change from oophorectomy to cystectomy along with change in incision in 3 cases. This was based on additional information provided by MRI regarding the nature of the mass in 8 cases and origin of the mass in 2 cases. CONCLUSION: Preoperative pelvic MRI findings might change the surgical management of pediatric patients with adnexal masses, so it is a valuable addition to the conventional workup in the clinical management.

Adnexal masses in pregnancy.

With the advent of routine obstetrical ultrasound, the diagnosis of an adnexal mass in pregnancy has become increasingly common. Although the reported incidence and expected clinical course varies based on the gestational age at the time of diagnosis and the criteria used to define an adnexal mass, the majority of adnexal masses diagnosed in pregnancy are benign and are likely to resolve without complication or intervention. This review will discuss the epidemiology of adnexal masses in pregnancy, diagnostic tools, potential complications, and management options during pregnancy.

Adnexal masses in children and adolescents.

Adnexal masses in children encompass a variety of lesions of the ovaries and fallopian tubes, including ovarian cysts and tumors (benign or malignant), fallopian tube cysts and abscesses, paratubal cysts, and endometriomas. When developing a differential diagnosis for adnexal masses in childhood, the clinician must have a broad understanding of adnexal pathology and consider the patient's age, presenting complaints, physical examination findings, and imaging results to generate a list of possible diagnoses and the appropriate treatment plan. We review the clinical presentation of these lesions and discuss the current recommendations for their management.

Management of adnexal masses in pregnancy: our experience from a tertiary referral perinatal centre in South India.

PURPOSE: Adnexal masses in pregnancy are often incidentally detected during sonography and most resolve spontaneously by early second trimester. This study aimed to look at the prevalence and management of adnexal masses in pregnancy at a tertiary care referral perinatal hospital. METHODS: This is a retrospective study of all women with adnexal masses (excluding ectopic gestations and non-gynaecological lesions) identified pre-pregnancy or during pregnancy (antepartum/intrapartum) from January 2006 to August 2013 at the study institute. RESULTS: The study identified 252 women (0.6, 95 %, CI: 0.5, 0.7) with adnexal masses and mean (SD range) age of 27.1 (4.21, 18-39) years. Majority (80 %) of the masses were diagnosed incidentally. 170 (67.5 %) women were offered conservative management and cysts resolved in half of them. 87 (34.5 %) women had adnexal surgery and 15.1 % were operated during the antepartum period because of persistent abdominal pain or suspicious sonographic findings. Three (1.2 %) malignancies and five (2.0 %) borderline ovarian tumours were diagnosed on histopathological examination. 16 (6.3 %) women were lost to follow-up antenatally. Pregnancy carried to term in 175 (69.4 %) women. Perinatal mortality rate was 31.1/1,000 total births (caused by prematurity). Complications encountered were torsion (7.1 %), malignancy (1.2 %), rupture (0.4 %) and infection (0.4 %). CONCLUSION: Although conservative management was appropriate in the majority of cases, the study identifies the need to standardize diagnosis, investigations and management for a better evaluation of outcomes.