Official reprint from UpToDate

www.uptodate.com 2016 UpToDate

Management of an adnexal mass

Author: Michael G Muto, MD

Section Editors: Howard T Sharp, MD, Barbara Goff, MD
Deputy Editor: Sandy J Falk, MD, FACOG

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2016. | This topic last updated: Apr 25, 2016.

INTRODUCTION An adnexal mass (mass of the ovary, fallopian tube, or surrounding connective
tissues) is a common gynecologic problem. In the United States, it is estimated that there is a 5 to 10
percent lifetime risk for women undergoing surgery for a suspected ovarian neoplasm [1]. Adnexal
masses may be found in females of all ages, fetuses to the elderly, and there is a wide variety of types of
masses (table 1). The management of an adnexal mass depends upon the type of mass, urgency of the
presentation (eg, ectopic pregnancy or ovarian torsion require immediate intervention), and degree of
suspicion that the mass is malignant.

The management of patients with an adnexal mass is reviewed here. The initial approach to, and an
overview of, the evaluation of patients with an adnexal mass and other topics related to the management
of an adnexal mass are discussed separately:

(See "Approach to the patient with an adnexal mass".)

(See "Ectopic pregnancy: Clinical manifestations and diagnosis".)
(See "Ovarian and fallopian tube torsion".)
(See "Evaluation and management of ruptured ovarian cyst".)
(See "Ovarian cysts and neoplasms in infants, children, and adolescents".)

OVERVIEW The management of an adnexal mass depends upon the location and etiology of the
mass (table 1) and the characteristics of the patient. In general, there are three options for managing an
adnexal mass:

Surgery Surgery is performed for the following indications: malignancy is suspected; there are
other risks associated with the mass (eg, torsion, infection), or the mass is symptomatic. For ovarian
masses, an oophorectomy or ovarian cystectomy may be performed. For other adnexal masses, the
mass may be biopsied or resected.

Continued surveillance Continued surveillance is indicated if the suspicion of malignancy is low, but
it has not been completely excluded. Surveillance usually includes serial pelvic ultrasounds and/or
measurement of serum tumor markers.

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 Expectant management If the apparent etiology of the mass is benign and there are no other
indications for surgery or surveillance, no further follow-up is needed.

The choice between these management options for different adult patient populations is discussed in the
sections that follow. Management of an adnexal mass in a child or adolescent is discussed separately.
(See "Ovarian cysts and neoplasms in infants, children, and adolescents".)

CLINICAL SCENARIOS FOR OVARIAN MASSES The management of an ovarian mass according to
the clinical presentation and potential for malignancy is discussed in this section.

Suspected malignancy or uncertain etiology Excluding malignancy is a principal goal of the

evaluation of an adnexal mass. For women with a mass that is suspicious for malignancy after an initial
evaluation, surgical exploration is required.

Surgical evaluation is the standard approach to the evaluation of an adnexal mass because there is no
noninvasive technique for the diagnosis of ovarian cancer. Unfortunately, this approach results in many
women undergoing surgery for a benign mass. As an example, in a large ovarian cancer screening
randomized trial, among 570 women who underwent surgical evaluation for suspected ovarian cancer, 20
cases of malignancy were found (3.5 percent) [2]. Another large ovarian cancer screening trial, the United
Kingdom Collaborative Trial of Ovarian Cancer Screening (UKTOCS), found that for each ovarian or
peritoneal cancer detected by ultrasound screening, an additional 10 women underwent surgery for
normal ovaries or benign pathology [3]. However, the prognosis of ovarian cancer is poor unless the
disease is treated at an early stage and the risk of failing to diagnose a life-threatening condition, no
matter how small, must be weighed against the potential morbidity associated with surgical intervention.

In some cases, if malignancy seems unlikely but has not been fully excluded, continued surveillance is
warranted. (See 'Surveillance' below.)

The information used to evaluate an adnexal mass is briefly reviewed here, and is discussed in detail
separately. (See "Approach to the patient with an adnexal mass", section on 'Evaluation for malignancy'.)

Assessing risk The most important factor used to determine the clinical suspicion of malignancy of
an adnexal mass is the appearance of the mass on imaging; transvaginal ultrasound is the preferred
study. The sensitivity of pelvic ultrasound for the diagnosis of ovarian cancer ranged from 86 to 91
percent and the specificity ranged from 68 to 83 percent in a large meta-analysis [4].

Ultrasound morphology associated with malignancy includes (table 2): (1) a solid component or
nodularity, particularly with color or power Doppler demonstration of flow in the solid component; (2) thick
septations (>2 to 3 mm). Based upon the ultrasound morphology, in our practice, we categorize masses
into the following risk groups:

High risk Features of malignancy, ie, solid, nodular, thick septations (table 2)

Intermediate risk Not anechoic and/or unilocular, but no features of malignancy (eg, a mass with

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 thin septations or low level echoes)

Low risk Anechoic unilocular fluid filled cysts with thin walls

Other characteristics of the mass that may contribute to the suspicion of malignancy, but are less
important, are size and bilaterality. Observational series have generally found the average size of
malignant adnexal masses to be >10 cm [5-7]. Large size and bilaterality were not found to impact the
likelihood of resolution of mass in a large prospective study, described below [8] (see 'Surveillance'
below). There are few other data regarding bilateral masses but, in our experience, this is a feature
associated with malignancy. (See "Ultrasound differentiation of benign versus malignant adnexal
masses".)

If imaging findings suggestive of metastatic disease are present, even in the absence of malignant
features in the mass itself, surgical exploration is required. These features include: ascites or evidence of
metastatic disease (eg, peritoneal masses, enlarged lymph nodes). (See "Epithelial carcinoma of the
ovary, fallopian tube, and peritoneum: Clinical features and diagnosis", section on 'Assessing for
metastatic disease'.)

Other factors, such as menopausal status, an elevated tumor marker, symptoms, or risk factors (table 3)
may add to the degree of suspicion.

This discussion is intended to provide a general framework of the indications for surgery. The
management of an individual patient depends upon the clinical features of that patient and upon clinical
judgement. If there is uncertainty about the appropriate management decision, a gynecologic oncologist
should be consulted. (See 'Referral to a specialist' below.)

Women with a hereditary ovarian cancer syndrome (BRCA mutation or Lynch syndrome) are managed
differently than the general population. In these women, the presence of almost any adnexal mass is an
indication for surgical exploration. This is discussed in detail separately. (See "Risk-reducing bilateral
salpingo-oophorectomy in women at high risk of epithelial ovarian and fallopian tubal cancer".)

Postmenopausal women The degree of clinical suspicion of ovarian cancer is significantly higher
for postmenopausal than for premenopausal women; thus, surgical exploration is required for many
postmenopausal women with an ovarian mass. (See "Approach to the patient with an adnexal mass",
section on 'Age and reproductive status'.)

If there is evidence on imaging studies of metastatic disease, surgical exploration is required, even in the
absence of malignant features in the mass itself.

Based upon the ultrasound morphology risk categories described above, we manage postmenopausal
patients as follows (see 'Assessing risk' above):

High risk Women with a high risk mass require surgical exploration (table 2).

Intermediate risk Women with an intermediate risk mass are managed based upon coexisting

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 tumor marker levels, risk factors (table 3), and symptoms (table 4). Many women may be managed
with surveillance, but surgical exploration should be performed if clinically significant risk factors or
symptoms are present.

Low risk For most women with a unilocular anechoic ovarian cyst and no other findings suggestive
of malignancy, we suggest surveillance rather than surgery because the risk of malignancy is less
than the risk of complications associated with surgical exploration [9].

For postmenopausal women with a mass with an intermediate or low risk appearance, surgical
exploration is required if a serum tumor marker is elevated. CA 125 is the tumor marker used most
commonly for the detection of epithelial ovarian cancer. CA 125 >35 U/mL has a sensitivity of 69 to 97
percent and a specificity of 81 to 93 percent for the diagnosis of ovarian cancer, based upon data from a
meta-analysis of six studies [4]. The marker algorithms OVA1 and ROMA may be used to decide whether
to refer a patient to a gynecologic oncologist. Other serum markers are used to evaluate women for less
common histologic types, germ cell and sex cord-stromal tumors. (See "Serum biomarkers for evaluation
of an adnexal mass for epithelial carcinoma of the ovary, fallopian tube, or peritoneum", section on
'Referral to a gynecologic oncologist' and "Approach to the patient with an adnexal mass", section on
'Serum markers for other histologic types'.)

Size of the mass must also be considered. There are limited data to establish the size threshold that
requires surgical removal. We suggest surgical exploration rather than surveillance for postmenopausal
women with a mass that is 10 cm in diameter [5-7]. In addition, in our practice, we proceed with surgical
exploration for women with a 5 to 10 cm mass who also have symptoms suggestive of ovarian cancer
(table 4). However, some patients without symptoms or other findings suggestive of malignancy may
request removal of a mass <10 cm. In such cases, removal is reasonable if the patient strongly prefers
surgical evaluation and removal of the mass and is willing to accept the risks of surgical morbidity and
loss of an ovary.

Risk factors (other than a hereditary ovarian cancer syndrome) or symptoms alone are not typically an
indication for surgery in a woman with a mass with an intermediate or low risk appearance. The absence
of risk factors and symptoms helps to support a decision to manage the patient with surveillance.

In some cases, an adnexal mass in a postmenopausal woman was noted on imaging prior to menopause
and is unchanged; this information is reassuring and surveillance is typically appropriate for these
patients.

Premenopausal women An ovarian mass in a premenopausal woman is often a diagnostic

dilemma. The risk of ovarian, fallopian tubal, or peritoneal cancer is low in this age group, but the
possibility of malignancy should be considered in all patients with an adnexal mass [10]. The incidence of
ovarian cancer increases with age (1.8 to 2.2 per 100,000 women for ages 20 to 29 years; 3.1 to 5.1 for
ages 30 to 39 years; and 9.0 to 15.2 for ages 40 to 49 years) [11].

For premenopausal women with an adnexal mass, the decision whether to proceed with surgical

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 evaluation depends upon the characteristics of the mass and the patient. If there is evidence on imaging
studies of metastatic disease, surgical exploration is required, even in the absence of malignant features
in the mass itself. As with postmenopausal women, we categorize patients according to risk of
malignancy based upon ultrasound morphology (see 'Assessing risk' above):

High risk Similar to postmenopausal women, surgery is required for women with a mass with
features associated with malignancy or any adnexal mass combined with ascites and/or evidence of
metastatic disease consistent with ovarian cancer (table 2).

Intermediate/low risk Many masses related to reproductive function occur in premenopausal

women, and thus, there is likely to be a greater proportion of patients with a mass with an
intermediate or low risk appearance. For most premenopausal women with a mass with an
intermediate or low risk appearance, we suggest surveillance rather than surgery. The exceptions to
this are women with a very elevated serum CA 125 or those in whom a germ cell or sex cord-stromal
tumor is suspected. These neoplasms are uncommon, but often occur in younger women. (See
"Ovarian germ cell tumors: Pathology, clinical manifestations, and diagnosis", section on 'Diagnosis
overview' and "Overview of sex cord-stromal tumors of the ovary", section on 'Diagnosis'.)

In premenopausal women, we measure a serum CA 125 only if the ultrasound appearance of a

mass raises sufficient suspicion of malignancy to warrant a repeat ultrasound or surgical evaluation.
In this population, a CA 125 value of >35 U/mL has a sensitivity and specificity of less than 80
percent, and possibly as low as 50 to 60 percent, based upon data from a meta-analysis of six
studies [4]. The low specificity in premenopausal women is because an elevated CA 125 is also
associated with many conditions other than ovarian cancer, and many of these are found in
reproductive age patients (table 5). Based upon the poor diagnostic performance of CA 125 in
premenopausal women, there has been some discussion of using a higher CA 125 level (>200
U/mL), but this has been evaluated in few studies [12]. The markers OVA1 and ROMA may be used
to decide whether to refer a patient to a gynecologic oncologist. (See "Approach to the patient with
an adnexal mass", section on 'Serum markers for epithelial ovarian carcinoma' and 'Referral to a
specialist' below.)

Risk factors (other than a hereditary ovarian cancer syndrome) or symptoms may increase the degree of
suspicion of malignancy, but are not typically the sole indication for surgery in a woman with a mass with
an intermediate or low risk appearance.

Management options

Surgery Surgical exploration for an adnexal mass may be performed laparoscopically

(conventional or robotic) or via a laparotomy. The choice of surgical approach depends upon the degree
of suspicion of malignancy and surgeon and patient preference. Ovarian cancer staging can be
performed using an open or laparoscopic approach, although the majority of surgeons in current practice
prefer laparotomy if there is a high degree of suspicion of malignancy. If there is a low or moderate

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 suspicion of malignancy, a laparoscopic approach is typically used. Laparoscopy is associated with a
shorter recovery and decreased perioperative morbidity compared with laparotomy. When choosing a
surgical approach for a suspected malignancy, it is important to keep in mind that it is unclear if
laparoscopy is as sensitive as laparotomy in the detection of small metastatic implants in small bowel
mesentery and epigastrium. Laparoscopy is clearly superior to laparotomy for inspection of the diaphragm
and for visible peritoneal surfaces.

The surgical technique used must minimize the potential for tumor disruption or dissemination. If
malignancy is suspected, oophorectomy is required rather than ovarian cystectomy. Patients with early
stage ovarian cancer (ie, no malignant cells in ascites or peritoneal cytology) benefit from removal of the
adnexal mass intact, since opening the mass results in a more advanced stage and adversely affects
prognosis (table 6) [13,14]. In addition, every attempt must be made to provide the pathologist with an
ovarian specimen with an intact cortex. If a laparoscopic approach is used, the ovary can be placed in a
tissue recovery bag. If the specimen is too large to remove through the existing incisions, cyst fluid may
be aspirated (but the collapsed cyst should not be disrupted) or the incision may be enlarged. The
practice of morcellating an ovarian mass in a bag is discouraged because it may compromise pathology
evaluation. In general, aspiration of cyst contents is not advisable as the sole surgical intervention
because no tissue is obtained for histopathology and cytology of cyst fluid is not reliable for exclusion of
malignancy, and there is a high rate of recurrence. (See "Oophorectomy and ovarian cystectomy", section
on 'Aspiration and fenestration versus cystectomy'.)

For premenopausal women, ovarian cystectomy is reasonable if the preoperative suspicion of malignancy
is low, the mass appears benign intraoperatively, and there is no evidence of metastatic disease. Every
safeguard against intraoperative rupture of the mass should be taken.

Surveillance Women for whom the likelihood of ovarian cancer appears low, but has not been
fully excluded, should be managed with continued surveillance with serial pelvic ultrasounds, and, if
appropriate, a serum tumor marker. There is no evidence to establish the best approach to surveillance of
an ovarian mass. The approach we use in our practice is presented here.

Physiologic cysts typically resolve on follow-up, non-physiologic non-neoplastic benign simple cysts
usually remain unchanged, and neoplastic simple cysts enlarge over time [15].

The largest study to-date to evaluate use of serial pelvic sonography for adnexal masses was a
prospective study of over 39,000 asymptomatic women followed with annual transvaginal pelvic
sonography during the 25-year period of the study (average duration of follow-up was 7.3 years) [8]. The
criteria for inclusion were: (1) age 50 years or older or (2) age 25 years or older with a family history of
ovarian cancer (genetic testing was not part of the study protocol); mean age was 58.6 years (range 25 to
95). Over the period of follow-up, 17.3 percent were found to have an ovarian abnormality on their first or
later visits and 42.1 percent of abnormalities resolved within one year. As expected, the prevalence of
abnormalities was significantly higher in premenopausal than postmenopausal women (34.9 versus 17.0
percent) and low-risk abnormalities (unilocular cyst, cyst with septation) were more common than high-

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 risk (cyst with solid area, solid mass) (prevalence 21.3 versus 8.9 percent). Interestingly, low-risk
compared with high-risk abnormalities were less likely to resolve within one year and took longer to
resolve (resolved at one year: 33 to 44 percent versus 77 to 81 percent; median time to resolution 53 to
56 weeks versus 8 to 9 weeks). Surgery was performed on 557 women for 85 ovarian malignancies and
472 nonmalignant abnormalities.

This study also evaluated the impact of bilaterality and ovarian mass size for high-risk abnormalities [8].
Most masses resolved, whether unilateral or bilateral, but bilateral solid masses compared with cysts with
a solid area resolved more quickly (approximately one versus seven years). Similarly, larger masses (>10
cm3) resolved more slowly, but this effect was most notable in solid masses (<5 cm3 resolved in three
years versus 10 to 19.9 cm3 in five years). The findings of this study support the practice of serial
sonography to evaluate indeterminate adnexal masses, but dont provide data regarding the frequency of
surveillance. The ability to generalize these results to the general population is somewhat limited, since
the premenopausal participants were chosen based upon a family history of ovarian cancer. The biologic
basis of the finding that complex masses resolved more quickly is uncertain, unless the majority of these
were hemorrhagic cysts. This warrants further analysis of these data and further study.

For postmenopausal women with a simple ovarian cyst, several studies have examined the role of pelvic
examination, ultrasound, and tumor marker measurement (particularly CA 125) [16-22]. In the largest of
these studies, 2763 postmenopausal women were diagnosed with 3259 simple cysts up to 10 cm in
diameter [21]. Serial follow-up ultrasounds were performed every three to six months. Spontaneous
resolution of the simple cysts occurred in 2261 women (69 percent) over a mean follow-up of six years.
Ten patients were subsequently diagnosed with ovarian cancer: 7/10 had additional abnormal areas
which were identified on an interval ultrasound examination, 2/10 developed ovarian cancer after the cyst
in question had resolved on sonographic follow-up, and 1/10 developed cancer in the ovary opposite the
cyst being followed.

In premenopausal women, 70 percent of adnexal masses will resolve over the course of several
menstrual cycles [6].

When patients with an adnexal mass are managed with surveillance, it is important to counsel the patient
about what morphologic or size changes would prompt surgical exploration and when surveillance will be
stopped if there are no significant changes. During surveillance, if the mass develops features of
malignancy, increases in size to 10 cm, or the CA 125 increases to >35 U/mL, we proceed with surgery.
If the mass resolves, we discontinue surveillance. If the mass remains unchanged or decreases in size
and the CA 125 remains <35 U/mL, surveillance continues until the planned stopping point is reached.

For postmenopausal women:

Intermediate risk mass We repeat a transvaginal ultrasound and CA 125 in six weeks and then
again six weeks later. We then repeat the ultrasound and CA 125 every three to six months for a
year. We do a final ultrasound and CA 125 one year later.

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 For low risk masses, we repeat an ultrasound and CA 125 at three months then six months.

For premenopausal women:

Intermediate risk masses We repeat a transvaginal ultrasound in six weeks. This allows
visualization of the mass at a different point of the menstrual cycle. We then repeat an ultrasound in
three months and then six more months. We then do a final ultrasound one year later.

Low risk masses We repeat an ultrasound in three months and then six more months.

We do not routinely follow with CA 125 in premenopausal women. If an initial level was drawn and was
very elevated, we proceed with surgery. If the initial level was <35 U/mL, we do not repeat it. If it was
moderately elevated (35 to <200 U/mL), we draw it with each ultrasound until a pattern emerges. If it is
consistently low or moderately elevated, we discontinue CA 125 testing.

Benign mass Some benign ovarian masses have characteristic sonographic features and the
diagnosis is fairly certain without surgical exploration, including: follicular or corpus luteal cysts,
endometriomas, and mature teratomas (dermoid). Surgery is not required for follicular or corpus luteal
cysts. Surgical treatment of endometriomas depends upon whether the patient is symptomatic. Most
mature teratomas are benign, but surgery is indicated to exclude malignancy and prevent malignant
transformation (see "Ovarian germ cell tumors: Pathology, clinical manifestations, and diagnosis", section
on 'Mature cystic teratoma (dermoid cyst)'). For any ovarian mass, however, if the diagnosis is uncertain,
further evaluation is required. (See 'Suspected malignancy or uncertain etiology' above.)

Acute pain Women who present with acute pain and an ovarian mass should be evaluated without
delay and may require urgent intervention. (See "Approach to the patient with an adnexal mass", section
on 'Evaluation for urgent conditions'.)

In addition to the conditions listed below, an ectopic pregnancy is a common gynecologic emergency, but
ectopic gestations are usually located in the fallopian tube, and are discussed below. Rarely, an ovarian
pregnancy is present. (See 'Ectopic pregnancy' below.)

Ovarian torsion Torsion of the ovary or fallopian tube requires urgent surgical treatment to avoid
ischemic injury. The evaluation and management of adnexal torsion are discussed separately. (See
"Ovarian and fallopian tube torsion" and "Approach to the patient with an adnexal mass", section on
'Adnexal torsion'.)

Ruptured or hemorrhagic ovarian cyst Ovarian masses may rupture or become hemorrhagic.
This occurs most commonly in physiologic cysts that are associated with the menstrual cycle (follicular
cysts, corpus luteal cysts).

A ruptured or hemorrhagic ovarian cyst is occasionally accompanied by significant bleeding. Women with
uncomplicated cyst rupture (hemodynamically stable, no evidence ongoing blood loss on laboratory
evaluation or pelvic imaging) can be managed expectantly. Women with complicated cyst rupture require

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 hospital admission for close monitoring, with a possible need for surgical intervention and/or blood
product replacement.

The evaluation and management of a ruptured ovarian cyst are discussed separately. (See "Evaluation
and management of ruptured ovarian cyst" and "Approach to the patient with an adnexal mass", section
on 'Ruptured or hemorrhagic ovarian cyst'.)

Persistent pain or pressure Ovarian cysts may cause pain or pressure symptoms. Since many
cysts are transient and the pain will resolve with the cyst, these symptoms are best managed with
analgesics in the short term while the patient is evaluated and it is determined whether surgery is needed
for another indication (eg, suspicion of malignancy, infertility).

A particular type of ovarian mass, an endometrioma, may be associated with dysmenorrhea, pelvic pain,
or dyspareunia. These masses are usually recognized by their characteristic appearance on ultrasound.
They are also often associated with endometriosis at other sites within the pelvis. Surgical removal is the
usual treatment of a symptomatic endometrioma. (See "Ovarian endometriomas: Management", section
on 'Our approach'.)

Some women will have an ovarian mass with an indeterminate appearance on ultrasound, but with no
features of malignancy. In such cases, other sources of pelvic pain should be investigated. However, if no
other etiology of the pain is identified and the pain is persistent and not relieved by analgesics, we
suggest ovarian cystectomy or oophorectomy.

Infertility Endometriomas are a type of ovarian mass that is associated with infertility, and these
should be removed in infertile patients. (See "Ovarian endometriomas: Management", section on 'Our
approach'.)

Other types of ovarian masses are not typically removed for the indication of treating infertility. However,
an ovarian mass may adversely affect fertility if it undergoes torsion or ruptures.

On the other hand, removal of an adnexal mass in a premenopausal woman may lead to adhesion
formation and/or reduce ovarian reserve, potentially adversely impacting fertility.

A hydrosalpinx is another type of adnexal mass that is associated with infertility. (See 'Hydrosalpinx'
below.)

Recurrent physiologic cysts Some patients with a history of recurrent painful ovarian cysts are
managed with hormonal contraceptives to inhibit ovulation. This prevents the formation of new
physiologic ovarian cysts. Oral contraceptives (OCs) do not decrease the size of existing cysts [23].
Numerous studies have investigated the effects of OCs on follicular cyst development and ovulation [24-
31]. In general, current OCs with a dose of 35 mcg ethinyl estradiol resulted in the development of fewer
follicular cysts, but to a lesser extent than higher dose formulations (50 mcg ethinyl estradiol). There was
no difference in the suppression of cyst development between monophasic and multiphasic OCs.

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 The typical regimen is an OC once daily; this can be continued for as long as the patient desires to
remain on an OC. Other types of estrogen-progestin contraceptives (eg, patch, ring) have not been
studied for this indication, but are likely to have the same effect.

Pregnant women Ovarian or other adnexal masses in pregnant women are managed by the same
principles as in other patients, although the choice of treatment depends upon issues of maternal and
fetal safety.

The evaluation and management of adnexal masses in pregnant women is discussed in detail separately.
(See "Adnexal mass in pregnancy".)

OTHER ADNEXAL MASSES An adnexal mass may involve the fallopian tube or the connective tissue
surrounding the ovary and tube.

Fallopian tubal cancer High grade serous epithelial ovarian carcinoma, fallopian tubal, and peritoneal
carcinomas are considered a single clinical entity due to their shared clinical behavior and treatment.
There is also accumulating evidence of a common pathogenesis for these carcinomas. Fallopian tubal
cancer rarely presents as a tubal mass alone; ovarian involvement is typically also present at time of
diagnosis. (See "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and
diagnosis".)

The management of fallopian tubal cancer is discussed in detail separately. (See "Cancer of the ovary,
fallopian tube, and peritoneum: Staging and initial surgical management" and "First-line chemotherapy for
advanced (stage III or IV) epithelial ovarian, fallopian tubal, and peritoneal cancer".)

Ectopic pregnancy Ectopic pregnancy is a potentially life-threatening condition; the fallopian tube is
the most common site of an ectopic pregnancy, although ovarian or cervical pregnancy may also occur.

The management of ectopic pregnancy is discussed in detail separately. (See "Ectopic pregnancy:
Clinical manifestations and diagnosis" and "Ultrasonography of pregnancy of unknown location".)

Tuboovarian abscess The classic presentation of a tuboovarian abscess includes acute lower
abdominal pain, fever, chills, vaginal discharge, and an adnexal mass. Pelvic imaging typically shows a
complex multilocular mass that obliterates normal adnexal architecture. Timely diagnosis and
management are required to diagnose or avoid sepsis and to prevent further damage to the ovary and
fallopian tubes.

The diagnosis and management of a tuboovarian abscess are discussed in detail separately. (See
"Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess" and "Management and
complications of tubo-ovarian abscess".)

Paratubal or paraovarian cyst A paratubal or paraovarian cyst arises from the broad ligament in the
area of the fallopian tube or ovary. The most common findings in this area are simple cysts that originate
from the remnants of paramesonephric (Mllerian) or mesonephric (Wolffian) ducts that are present

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 during urogenital embryologic development. (See "Differential diagnosis of the adnexal mass", section on
'Paraovarian/paratubal cysts and tubal and broad ligament neoplasms'.)

A simple, asymptomatic paratubal or paraovarian cyst can be managed expectantly without further follow-
up. Surgical removal is indicated for these lesions if they undergo torsion, cause persistent pain or
pressure symptoms, or appear neoplastic. (See "Ovarian and fallopian tube torsion", section on
'Paratubal or paraovarian cyst torsion'.)

Hydrosalpinx A hydrosalpinx is an edematous fallopian tube, typically caused by an infection. A

hydrosalpinx may be asymptomatic or may result in chronic pelvic pain or infertility and sometimes be the
source of chronic pelvic pain [32]. Other etiologies of chronic pelvic pain should be excluded before
salpingectomy is performed. An asymptomatic hydrosalpinx does not generally need to be removed or
followed with imaging. The exception to this is women undergoing in vitro fertilization. (See "Reproductive
surgery for female infertility", section on 'Salpingectomy before in vitro fertilization'.)

Broad ligament leiomyoma A broad ligament leiomyoma may be located proximal to the ovary and
fallopian tube. These are usually diagnosed with pelvic ultrasound and are managed in the same manner
as other leiomyomas. (See "Overview of treatment of uterine leiomyomas (fibroids)".)

REFERRAL TO A SPECIALIST For masses that are highly suspicious for ovarian, fallopian tubal, or
peritoneal cancer, referral to a gynecologic oncologist is advised, since outcomes of staging and
cytoreduction have been shown to be better than when the procedure is performed by other surgeons
[33-37]. This was illustrated in a systematic review of observational studies that found that, in patients
with advanced disease, there was a six- to nine-month median survival benefit for patients operated on by
gynecologic oncologists and that, in patients with early stage disease, gynecologic oncologists were
significantly more likely to perform optimal staging [36].

The American College of Obstetricians and Gynecologists (ACOG) and the Society of Gynecologic
Oncologists (SGO) have published a joint guideline about referral of women with an adnexal mass to a
gynecologic oncologist (table 7) [33]. For premenopausal women, the guideline advises referral for those
with a very elevated CA 125, but a specific value is not given. A version of the guideline published in
2002 used a value of >200 U/mL, but this was removed in the 2011 guideline [38].

Studies have evaluated the performance of this guideline for the diagnosis of ovarian cancer, and found
the following: premenopausal women (sensitivity 70 to 79 percent and specificity 70 percent) and
postmenopausal women (sensitivity 93 to 94 percent and specificity 60 percent) [12,39].

INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The
Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, at
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 patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on patient info and the keyword(s) of interest.)

Basics topics (see "Patient education: Ovarian cancer (The Basics)" and "Patient education: Ovarian
cysts (The Basics)")

Beyond the Basics topics (see "Patient education: Ovarian cysts (Beyond the Basics)" and "Patient
education: Ovarian cancer diagnosis and staging (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

An adnexal mass (mass of the ovary, fallopian tube, or surrounding connective tissues) is a common
gynecologic problem. The management of an adnexal mass depends upon the type of mass,
urgency of the presentation, and degree of suspicion that the mass is malignant. (See 'Introduction'
above.)

Excluding malignancy is a principal goal of the evaluation of an adnexal mass. The most important
factor used to determine the clinical suspicion of malignancy of an adnexal mass is the sonographic
appearance of the mass. Other factors, such as menopausal status, an elevated tumor marker,
symptoms, or risk factors (table 3) may add to the degree of suspicion. (See 'Suspected malignancy
or uncertain etiology' above.)

Based upon the ultrasound morphology, in our practice, we categorize masses as high (features of
malignancy, ie, solid, nodular, thick septations (table 2)), intermediate (not anechoic and/or unilocular,
but no features of malignancy, eg, a mass with thin septations or low level echoes), or low risk
(anechoic unilocular fluid filled cysts with thin walls). (See 'Suspected malignancy or uncertain
etiology' above.)

If malignancy has not been excluded, we manage patients according to these risk categories (see
'Postmenopausal women' above and 'Premenopausal women' above):

Women with a high risk mass require surgical exploration. In addition, surgical exploration is
required if imaging findings suggestive of metastatic disease are present, even in the absence of
malignant features in the mass itself.

For most women with an intermediate risk mass, we suggest surveillance rather than surgical
exploration (Grade 2C).

For postmenopausal women with an intermediate risk mass, we suggest surgical exploration if
clinically significant risk factors or symptoms are present or if the patient places a higher value
on a definitive diagnosis than on avoiding surgery (Grade 2C). For premenopausal women, risk
factors or symptoms do not typically determine management.

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 Size of the mass is an important factor. We suggest surgical exploration rather than surveillance
for women with a mass that is 10 cm in diameter (Grade 2C). In addition, in our practice, we
proceed with surgical exploration for postmenopausal women with a 5 to 10 cm mass who also
have symptoms suggestive of ovarian cancer (table 4).

For most women with a low risk mass, we suggest surveillance rather than surgical exploration
(Grade 2C).

Tumor markers influence the management of women with an intermediate or low risk mass.
Surgical exploration is required if a serum tumor marker is elevated in a postmenopausal
woman. For premenopausal women, surgical exploration is reasonable if a serum CA 125 is
very elevated or if a germ cell or sex cord stromal tumor is suspected.

Oophorectomy rather than ovarian cystectomy is required for women with an ovarian mass that is
suspicious for malignancy. For premenopausal women, ovarian cystectomy is reasonable if the
preoperative suspicion of malignancy is low, the mass appears benign intraoperatively, and there is
no evidence of metastatic disease. (See 'Surgery' above.)

Women who present with acute pain and an ovarian mass should be evaluated without delay and
may require urgent intervention. Etiologies that present in this manner include ovarian torsion and
rupture of an ovarian mass. (See 'Acute pain' above.)

For women with an ovarian mass with no clinical features of malignancy who have persistent pain,
analgesics are first line therapy. For those with persistent pain despite analgesics, we suggest
surgical treatment (Grade 2C). (See 'Persistent pain or pressure' above.)

Surgical treatment of some types of adnexal masses (eg, endometrioma, hydrosalpinx) may be
therapeutic in women with infertility. (See 'Infertility' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

1. National Institutes of Health Consensus Development Conference Statement. Ovarian cancer:

screening, treatment, and follow-up. Gynecol Oncol 1994; 55:S4.
2. Buys SS, Partridge E, Greene MH, et al. Ovarian cancer screening in the Prostate, Lung, Colorectal
and Ovarian (PLCO) cancer screening trial: findings from the initial screen of a randomized trial. Am
J Obstet Gynecol 2005; 193:1630.
3. Jacobs IJ, Menon U, Ryan A, et al. Ovarian cancer screening and mortality in the UK Collaborative
Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial. Lancet 2016;
387:945.
4. Myers ER, Bastian LA, Havrilesky LJ, et al. Management of Adnexal Mass. Evidence

https://www-uptodate-com.bdigital.ces.edu.co:2443/contents/management-of-an-adnexal-mass/print?source=see_link 18/09/16 12:07 a.m.

Pgina 13 de 27
 Report/Technology Assessment No.130 (Prepared by the Duke Evidence-based Practice Center
under Contract No. 290-02-0025). AHRQ Publication No. 06-E004, Agency for Healthcare Research
and Quality, Rockville, MD February 2006.
5. Roman LD, Muderspach LI, Stein SM, et al. Pelvic examination, tumor marker level, and gray-scale
and Doppler sonography in the prediction of pelvic cancer. Obstet Gynecol 1997; 89:493.
6. Curtin JP. Management of the adnexal mass. Gynecol Oncol 1994; 55:S42.
7. Koonings PP, Campbell K, Mishell DR Jr, Grimes DA. Relative frequency of primary ovarian
neoplasms: a 10-year review. Obstet Gynecol 1989; 74:921.
8. Pavlik EJ, Ueland FR, Miller RW, et al. Frequency and disposition of ovarian abnormalities followed
with serial transvaginal ultrasonography. Obstet Gynecol 2013; 122:210.
9. Saunders BA, Podzielinski I, Ware RA, et al. Risk of malignancy in sonographically confirmed
septated cystic ovarian tumors. Gynecol Oncol 2010; 118:278.
10. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Management of
adnexal masses. Obstet Gynecol 2007; 110:201.
11. http://seer.cancer.gov/ (Accessed on September 07, 2012).
12. Im SS, Gordon AN, Buttin BM, et al. Validation of referral guidelines for women with pelvic masses.
Obstet Gynecol 2005; 105:35.
13. Webb MJ, Decker DG, Mussey E, Williams TJ. Factor influencing survival in Stage I ovarian cancer.
Am J Obstet Gynecol 1973; 116:222.
14. Sainz de la Cuesta R, Goff BA, Fuller AF Jr, et al. Prognostic importance of intraoperative rupture of
malignant ovarian epithelial neoplasms. Obstet Gynecol 1994; 84:1.
15. Alczar JL, Castillo G, Jurado M, Garca GL. Is expectant management of sonographically benign
adnexal cysts an option in selected asymptomatic premenopausal women? Hum Reprod 2005;
20:3231.
16. Strigini FA, Gadducci A, Del Bravo B, et al. Differential diagnosis of adnexal masses with
transvaginal sonography, color flow imaging, and serum CA 125 assay in pre- and postmenopausal
women. Gynecol Oncol 1996; 61:68.
17. Maggino T, Gadducci A, D'Addario V, et al. Prospective multicenter study on CA 125 in
postmenopausal pelvic masses. Gynecol Oncol 1994; 54:117.
18. Schutter EM, Kenemans P, Sohn C, et al. Diagnostic value of pelvic examination, ultrasound, and
serum CA 125 in postmenopausal women with a pelvic mass. An international multicenter study.
Cancer 1994; 74:1398.
19. Bailey CL, Ueland FR, Land GL, et al. The malignant potential of small cystic ovarian tumors in
women over 50 years of age. Gynecol Oncol 1998; 69:3.
20. Nardo LG, Kroon ND, Reginald PW. Persistent unilocular ovarian cysts in a general population of
postmenopausal women: is there a place for expectant management? Obstet Gynecol 2003;
102:589.
21. Modesitt SC, Pavlik EJ, Ueland FR, et al. Risk of malignancy in unilocular ovarian cystic tumors less

https://www-uptodate-com.bdigital.ces.edu.co:2443/contents/management-of-an-adnexal-mass/print?source=see_link 18/09/16 12:07 a.m.

Pgina 14 de 27
 than 10 centimeters in diameter. Obstet Gynecol 2003; 102:594.
22. Castillo G, Alczar JL, Jurado M. Natural history of sonographically detected simple unilocular
adnexal cysts in asymptomatic postmenopausal women. Gynecol Oncol 2004; 92:965.
23. Grimes DA, Jones LB, Lopez LM, Schulz KF. Oral contraceptives for functional ovarian cysts.
Cochrane Database Syst Rev 2006; :CD006134.
24. Spanos WJ. Preoperative hormonal therapy of cystic adnexal masses. Am J Obstet Gynecol 1973;
116:551.
25. Functional ovarian cysts and oral contraceptives. Negative association confirmed surgically. A
cooperative study. JAMA 1974; 228:68.
26. Caillouette JC, Koehler AL. Phasic contraceptive pills and functional ovarian cysts. Am J Obstet
Gynecol 1987; 156:1538.
27. Holt VL, Daling JR, McKnight B, et al. Functional ovarian cysts in relation to the use of monophasic
and triphasic oral contraceptives. Obstet Gynecol 1992; 79:529.
28. Mishell DR Jr. Noncontraceptive benefits of oral contraceptives. J Reprod Med 1993; 38:1021.
29. Grimes DA, Godwin AJ, Rubin A, et al. Ovulation and follicular development associated with three
low-dose oral contraceptives: a randomized controlled trial. Obstet Gynecol 1994; 83:29.
30. Egarter C, Putz M, Strohmer H, et al. Ovarian function during low-dose oral contraceptive use.
Contraception 1995; 51:329.
31. Holt VL, Cushing-Haugen KL, Daling JR. Oral contraceptives, tubal sterilization, and functional
ovarian cyst risk. Obstet Gynecol 2003; 102:252.
32. Okaro E, Condous G, Khalid A, et al. The use of ultrasound-based 'soft markers' for the prediction
of pelvic pathology in women with chronic pelvic pain--can we reduce the need for laparoscopy?
BJOG 2006; 113:251.
33. American College of Obstetricians and Gynecologists Committee on Gynecologic Practice.
Committee Opinion No. 477: the role of the obstetrician-gynecologist in the early detection of
epithelial ovarian cancer. Obstet Gynecol 2011; 117:742.
34. Chan JK, Kapp DS, Shin JY, et al. Influence of the gynecologic oncologist on the survival of ovarian
cancer patients. Obstet Gynecol 2007; 109:1342.
35. Engelen MJ, Kos HE, Willemse PH, et al. Surgery by consultant gynecologic oncologists improves
survival in patients with ovarian carcinoma. Cancer 2006; 106:589.
36. Giede KC, Kieser K, Dodge J, Rosen B. Who should operate on patients with ovarian cancer? An
evidence-based review. Gynecol Oncol 2005; 99:447.
37. Earle CC, Schrag D, Neville BA, et al. Effect of surgeon specialty on processes of care and
outcomes for ovarian cancer patients. J Natl Cancer Inst 2006; 98:172.
38. American College of Obstetricians anf Gynecologists. ACOG Committee Opinion: number 280,
December 2002. The role of the generalist obstetrician-gynecologist in the early detection of ovarian
cancer. Obstet Gynecol 2002; 100:1413.

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 39. Dearking AC, Aletti GD, McGree ME, et al. How relevant are ACOG and SGO guidelines for referral
of adnexal mass? Obstet Gynecol 2007; 110:841.

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 GRAPHICS

Differential diagnosis of an adnexal mass

Gynecologic:
Gynecologic: Gynecologic:
Extraovarian and Nongynecologic
Ovarian Tubal
extratubal
Benign

Functional Ectopic pregnancy Paraovarian cyst Constipation

(physiologic) cyst Hydrosalpinx Paratubal cyst Appendiceal abscess
Corpus luteal cyst Uterine leiomyoma Diverticular abscess
Luteoma of (pedunculated or Pelvic abscess
pregnancy cervical) Bladder diverticulum
Theca lutein cyst Tubo-ovarian abscess Ureteral diverticulum
Polycystic ovaries Pelvic kidney
Endometrioma Peritoneal cyst
Cystadenoma Nerve sheath tumor
Benign ovarian
germ cell tumor
(eg, mature
teratoma)
Benign sex cord-
stromal tumor

Malignant or borderline

Epithelial Epithelial carcinoma Metastatic Appendiceal

carcinoma Serous tubal endometrial neoplasm
Epithelial intraepithelial carcinoma Bowel neoplasm
borderline neoplasia Metastasis (eg,
neoplasm breast, colon,
Malignant ovarian lymphoma)
germ cell tumor Retroperitoneal
Malignant sex sarcoma
cord-stromal
tumor

Modified from: Rauh-Hain JA, Melamed A, Buskwofie A, Schorge JO. Adnexal mass in the postmenopausal
patient. Clin Obstet Gynecol 2015; 58:53.

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 Sonographic findings suggestive of malignancy in patients with a pelvic mass

Solid component that is not hyperechoic and is often nodular or papillary

Septations, if present, that are thick (>2 to 3 mm)

Color or power Doppler demonstration of flow in the solid component

Presence of ascites (any peritoneal fluid in postpostmenopausal women and more than a small amount of
peritoneal fluid in premenopausal women is abnormal)

Peritoneal masses, enlarged nodes, or matted bowel (may be difficult to detect)

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 Risk factors for ovarian cancer

Lifetime probability,
Relative risk
percent [1]
General population 1.0 1.4 [1]

BRCA1 gene mutation 35 to 46 [2]

BRCA2 gene mutation 13 to 23 [2]

Lynch syndrome (hereditary 3 to 14 [3,4]

nonpolyposis colon cancer)

Family history of ovarian cancer (with Uncertain [5,6]

negative testing for a familial ovarian
cancer syndrome)

Infertility 2.67 [7]

Polycystic ovarian syndrome 2.52 [8]

Endometriosis (increase in risk of clear 2.04 to 3.05 [9]

cell, endometrioid, or low grade serous
carcinomas)

Cigarette smoking (increase in risk of 2.1 [10]

mucinous carcinoma)

Intrauterine device 1.76 [11]

Past use of oral contraceptives 0.73 [12]

Past breast feeding (for >12 months) 0.72 [13]

Tubal ligation 0.69 [14]

Previous pregnancy 0.6

References:
1. http://seer.cancer.gov/statfacts/html/ovary.html.
2. Chen S, Parmigiani G. Meta-analysis of BRCA1 and BRCA2 penetrance. J Clin Oncol 2007; 25:1329.
3. Koornstra JJ, Mourits MJ, Sijmons RH, et al. Management of extracolonic tumours in patients with Lynch
syndrome. Lancet Oncol 2009; 10:400.
4. Barrow E, Robinson L, Alduaij W, et al. Cumulative lifetime incidence of extracolonic cancers in Lynch
syndrome: A report of 121 families with proven mutations. Clin Genet 2009; 75:141.
5. Kauff ND, Mitra N, Robson ME, et al. Risk of ovarian cancer in BRCA1 and BRCA2 mutation-negative
hereditary breast cancer families. J Natl Cancer Inst 2005; 97:1382.
6. Lee JS, John EM, McGuire V, et al. Breast and ovarian cancer in relatives of cancer patients, with and
without BRCA mutations. Cancer Epidemiol Biomarkers Prev 2006; 15:359.
7. Ness RB, Cramer DW, Goodman MT, et al. Infertility, fertility drugs, and ovarian cancer: A pooled
analysis of case-control studies. Am J Epidemiol 2002; 155:217.
8. Chittenden BG, Fullerton G, Maheshwari A, Bhattacharya S. Polycystic ovary syndrome and the risk of
gynaecological cancer: A systematic review. Reprod Biomed Online 2009; 19:398.
9. Pearce CL, Templeman C, Rossing MA, et al. Association between endometriosis and risk of histological
subtypes of ovarian cancer: A pooled analysis of case-control studies. Lancet Oncol 2012; 13:385.
10. Jordan SJ, Whiteman DC, Purdie DM, et al. Does smoking increase risk of ovarian cancer? A systematic

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 review. Gynecol Oncol 2006; 103:1122.
11. Tworoger SS, Fairfield KM, Colditz GA, et al. Association of oral contraceptive use, other contraceptive
methods, and infertility with ovarian cancer risk. Am J Epidemiol 2007; 166:894.
12. Collaborative Group on Epidemiological Studies of Ovarian Cancer, Beral V, Doll R, et al. Ovarian cancer
and oral contraceptives: Collaborative reanalysis of data from 45 epidemiological studies including 23,257
women with ovarian cancer and 87,303 controls. Lancet 2008; 371:303.
13. Ip S, Chung M, Raman G, et al. A summary of the Agency for Healthcare Research and Quality's evidence
report on breastfeeding in developed countries. Breastfeed Med 2009; 4 Suppl 1:S17.
14. Cibula D, Widschwendter M, Mjek O, Dusek L. Tubal ligation and the risk of ovarian cancer: Review and
meta-analysis. Hum Reprod Update 2011; 17:55.

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 Frequency of symptom categories in women with ovarian cancer

Type of symptom Percent

Abdominal 77

Gastrointestinal 70

Pain 58

Constitutional 50

Urinary 34

Pelvic 26

Adapted from Goff BA, Mandel L, Muntz HG. Melancon CH. Cancer 2000; 89:2068.

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 Conditions associated with an elevated serum CA 125 concentration

Gynecologic malignancies Nongynecologic conditions

Epithelial ovarian, fallopian tube, and primary Cirrhosis and other liver disease
peritoneal cancers
Ascites
Endometrial cancer
Colitis
Benign gynecologic conditions Diverticulitis
Benign ovarian neoplasms Appendicular abscess
Functional ovarian cysts Tuberculosis peritonitis
Endometriosis Pancreatitis
Meig syndrome Pleural effusion
Adenomyosis Pulmonary embolism
Uterine leiomyomas Pneumonia
Pelvic inflammatory disease Cystic fibrosis
Ovarian hyperstimulation Heart failure
Pregnancy Myocardiopathy
Menstruation Myocardial infarction

Pericardial disease

Renal insufficiency

Urinary tract infection

Recent surgery

Systemic lupus erythematosus

Sarcoidosis

Nongynecologic cancers
Breast

Colon

Liver

Gallbladder

Pancreas

Lung

Hematologic malignancies

CA: cancer antigen.

Data from:
1. Buamah P. Benign conditions associated with raised serum CA-125 concentration. J Surg Oncol 2000;
75:264.
2. Miralles C, Orea M, Espana P, et. al. Cancer antigen 125 associated with multiple benign and malignant

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 pathologies. Ann Surg Oncol 2003; 10:150.
3. Moss EL, Hollingworth J, Reynolds TM. The role of CA125 in clinical practice. J Clin Pathol 2005; 58:308.

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 Staging ovarian, fallopian tubal, and peritoneal cancer (TNM and International
Federation of Gynecology and Obstetrics [FIGO])

Primary tumor (T)

TNM FIGO
Definition
categories stages

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

T1 I Tumor confined to ovaries or fallopian tubes

T1a IA Tumor limited to one ovary (capsule intact) or fallopian tube; no tumor on ovarian or
fallopian tube surface; no malignant cells in ascites or peritoneal washings
T1b IB Tumor limited to both ovaries (capsules intact) or fallopian tubes; no tumor on ovarian or
fallopian tube surface; no malignant cells in ascites or peritoneal washings
T1c IC Tumor limited to one or both ovaries or fallopian tubes, with any of the following:
IC1 Surgical spill
IC2 Capsule ruptured before surgery or tumor on ovarian or fallopian tube surface
IC3 Malignant cells in the ascites or peritoneal washings

T2 II Tumor involves one or both ovaries or fallopian tubes with pelvic extension (below
pelvic brim) or peritoneal cancer*
T2a IIA Extension and/or implants on uterus and/or tube(s) and/or ovaries
T2b IIB Extension to other pelvic intraperitoneal tissues

T3 III Tumor involves one or both ovaries or fallopian tubes, or peritoneal cancer, with
cytologically or histologically confirmed spread to the peritoneum outside the
pelvis and/or metastasis to the retroperitoneal lymph nodes
T3a IIIA Positive retroperitoneal lymph nodes and/or microscopic metastasis beyond pelvis
IIIA1 Positive retroperitoneal lymph nodes only (cytologically or histologically proven)
IIIA1 (i) Metastasis up to 10 mm in greatest dimension
IIIA1 (ii) Metastasis more than 10 mm in greatest dimension
IIIA2 Microscopic extrapelvic (above the pelvic brim) peritoneal involvement, with or without
positive retroperitoneal lymph nodes
T3b IIIB Macroscopic peritoneal metastasis beyond pelvis up to 2 cm in greatest dimension, with or
without positive retroperitoneal lymph nodes
T3c IIIC Macroscopic peritoneal metastasis beyond pelvis more than 2 cm in greatest dimension
(includes extension of tumor to capsule of liver and spleen without parenchymal
involvement of either organ), with or without positive retroperitoneal lymph nodes

Regional lymph nodes (N)

TNM FIGO
Definition
categories stages

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 III Regional lymph node metastasis

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 Distant metastasis (M)
TNM FIGO
Definition
categories stages

M0 No distant metastasis

M1 IV Distant metastasis (excludes peritoneal metastasis)

IVA Pleural effusion with positive cytology

IVB Parenchymal metastases and metastases to extra-abdominal organs (including

inguinal lymph nodes and lymph nodes outside the abdominal cavity)

pTNM pathologic classification. The pT, pN, and pM categories correspond to the T, N, and M
categories.

Anatomic stage/prognostic groups

Stage I T1 N0 M0

Stage IA T1a N0 M0

Stage IB T1b N0 M0

Stage IC T1c N0 M0

Stage II T2 N0 M0

Stage IIA T2a N0 M0

Stage IIB T2b N0 M0

Stage IIC T2c N0 M0

Stage III T3 N0 or N1 M0

Stage IIIA T3a N0 M0

T3a N1

Stage IIIB T3b N0 or N1 M0

Stage IIIC T3c N0 or N1 M0

Stage IV Any T Any N M1

NOTE: cTNM is the clinical classification, pTNM is the pathologic classification.

* Dense adhesions with histologically proven tumor cells justify upgrading to stage II.
Transmural bowel infiltration or umbilical deposit are stage IVB.

References:
1. The American Joint Committee on Cancer, AJCC Cancer Staging Manual, Seventh Edition, New York:
Springer, 2010.
2. Prat J. Staging classification for cancer of the ovary, fallopian tube, and peritoneum. Int J Gynaecol
Obstet 2014; 124:1.

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 Referral of women with a pelvic mass to a gynecologic oncologist: ACOG
guidelines

Premenopausal women (refer if any are present)

Very elevated CA 125 level

Ascites

Evidence of abdominal or distant metastases

Postmenopausal women (refer if any are present)

Elevated CA 125 level

Ascites

Nodular or fixed pelvic mass

Evidence of abdominal or distant metastases

ACOG: American Congress of Obstetricians and Gynecologists.

The role of the obstetriciangynecologist in the early detection of epithelial ovarian cancer. Committee Opinion
No. 477. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011; 117:742.

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 Contributor Disclosures
Michael G Muto, MD Nothing to disclose Howard T Sharp, MD Nothing to disclose Barbara Go,
MD Consultant/Advisory Boards: Roche Diagnostics [Biomarkers for ovarian cancer (HE4)]. Employment
(Spouse): Lilly [General oncology (Gemcitabine, pemetrexed)]. Sandy J Falk, MD, FACOG Nothing to
disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for references
to be provided to support the content. Appropriately referenced content is required of all authors and
must conform to UpToDate standards of evidence.

Conflict of interest policy

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