How are benign adnexal masses differentiated from ovarian cancer?

Updated: Aug 10, 2020
  • Author: Andrew E Green, MD; Chief Editor: Yukio Sonoda, MD  more...
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Adnexal masses present a diagnostic dilemma; the differential diagnosis is extensive, with most masses representing benign processes. [39, 40, 41] However, without histopathologic tissue diagnosis, a definitive diagnosis is generally precluded. Physicians must evaluate the likelihood of a pathologic process using clinical and radiologic information and balance the risk of surgical intervention for a benign versus malignant process.

Since ovaries produce physiologic cysts in menstruating women, the likelihood of a benign process is higher. In contrast, the presence of an adnexal mass in prepubertal girls and postmenopausal women heightens the risk of a pathologic etiology.

A review by Suh-Burgmann and Kinney suggests that surgical evaluation of adnexal masses is appropriate in the following circumstances [41] :

  • Symptomatic masses
  • Masses associated with other signs of malignancy (eg, elevated cancer antigen 125 [CA125] levels in a postmenopausal patient, ascites)
  • Women at high genetic risk for ovarian cancer
  • Large masses (>10 cm), which are less likely to regress, have a higher risk of symptoms, and are often more difficult to characterize on ultrasound

Ultrasound features associated with malignancy include the following [41] :

  • Irregular solid tumor
  • Ascites
  • At least four papillary projections
  • Irregular multilocular solid tumor ≥10 cm
  • Very strong intratumoral blood flow

These authors note that measurable benefits of monitoring are realized within the first year of observation. If an adnexal mass is small, lacks suspicious ultrasound features, and remains stable, the likelihood of malignancy and therefore, the potential benefit of observation wanes with time, while potential harms increase. [40]

A systematic review concluded that pelvic magnetic resonance Imaging (MRI) with contrast is the preferred advanced second imaging test for assessment of ultrasound-indeterminate adnexal masses. In particular, the high specificity of MRI in this setting provides confident identification of many benign lesions. [42]

A study of a second-generation multivariate index assay designed to improve the detection of ovarian cancer in women undergoing surgery for a pelvic mass found that a single cut-off separated high and low risk of malignancy regardless of patient menopausal status, with a specificity of 69% and positive predictive value of 40%. The assay includes five markers: CA125, apolipoprotein A-1, follicle-stimulating hormone, and human epididymis protein 4. [43]

For more information, see Adnexal Tumors.

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