|
appropriate investigations, avoid
ordering unnecessary tests and per-
|
Alamy |
5cm will likely resolve without intervention, and surveillance imaging at |
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form timely referral as needed. For example, the finding of a complex adnexal mass in an adolescent should |
another time in the menstrual cycle will often show resolution. 2 Where resolution does not occur, the clini- |
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trigger the medical practitioner to |
cian can be reassured that a delay |
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perform germ cell tumour mark- |
in subsequent diagnosis is unlikely |
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ers, whereas the same investigations |
to cause an adverse patient out- |
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would not be required for a postmen- |
come. Provided no adverse features |
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opausal patient with a similar mass as |
are found, the risk of malignancy is |
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they are extremely unlikely to have a |
extremely low, and serial ultrasound |
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germ cell tumour. |
imaging can provide valuable infor- |
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Ultimately, the only way to accu- |
mation regarding the mass while |
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rately diagnose the source of an |
exposing the patient to little or no |
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adnexal mass is via histopathological |
clinical risk. Serial assessments pro- |
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assessment after surgical interven- |
vide critical information regarding |
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tion, although by using an informed |
change in size or morphology, which |
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and evidenced-based approach to |
aids in narrowing the differential |
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investigation and initial management, |
diagnosis. |
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surgical intervention is often not |
In contrast, complex-appearing |
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required and a conservative approach |
masses, bilateral masses or concern- |
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to masses of low malignant potential |
ing extra ovarian features on imaging |
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can be safely undertaken when no |
— such as ascites, peritoneal disease, |
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risk factors are identified. |
omental disease, lymphadenopa- |
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This How to Treat covers how |
thy or liver or lung lesions— always |
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to systematically approach adnexal |
require further investigation. Referral |
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masses in the community and aims to |
is needed in most situations, and in |
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ensure GPs can confidently navigate |
cases with suspected metastatic dis- |
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the pathway that enables an efficient |
ease, direct referral to a gynaecolog- |
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and safe outcome. |
ical oncologist is most appropriate. |
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AETIOLOGY
PELVIC masses can be considered gynaecological or non-gynaeco-
|
Figure 1. Mature cystic teratoma of ovary. |
Overall, no test or algorithm is superior in terms of accuracy when determining whether a mass is benign or malignant. 2 |
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logical in origin, with further subdivisions |
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|
of malignant and benign causes. Not all adnexal masses found on imaging are ovarian in origin, and it is critical to consider this when assessing the possible sources. One in 10 suspected ovarian masses on imaging is found to be non-ovarian in origin at the time of surgical assessment. 3
Age is a crucial factor to consider
|
Mikael Häggström / CC BY: bit. ly / 44zoJTh |
INTERPRETATION OF IMAGING There are systems the clinician can use to assess pelvic masses found on imaging. These include the Risk of Malignancy Index( RMI, see table 3) and the International Ovarian Tumor Analysis( IOTA, see table 4) rules. 9, 10 The GP can use these to determine what action is required and to decide if further investigation is appropri- |
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when assessing the possible aetiology |
ate and to whom the patient is best |
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of a pelvic mass. The likelihood of a mass being malignant increases with |
referred for management. The National Institute for Health |
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age, particularly when a new mass is |
and Care Excellence( NICE) guidelines |
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found in a postmenopausal patient. |
for the management of women with |
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When considering aetiology, understanding the common malignancies at each stage of life will allow for |
adnexal masses recommend using the RMI. 11 The RMI combines three pre-surgical features: serum can- |
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focused investigation and treatment. |
cer antigen 125( CA125), menopausal |
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The ovary is a hormonally driven |
status( M) and ultrasound score( U) |
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and dynamic organ. Some masses are |
to differentiate between benign and |
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|
more common at different phases of the menstrual cycle, such as the finding of luteal cysts, which are benign and self-limiting.
The ovary is the most common source of adnexal masses found on imaging. When considering primary ovarian lesions, the three sources to
|
Figure 2. Ectopic pregnancy( this can easily be mistaken for an ovarian mass). Laparoscopic view, looking from superiorly to inferiorly in the peritoneal cavity, which has been distended with carbon dioxide gas to visualise the uterus( blue arrows). In the left fallopian tube, there is an ectopic pregnancy and haematosalpinx( red arrows). The right tube is normal. |
malignant masses. A score greater than 200 prompts the practitioner to refer directly to a gynaecological oncologist for an opinion. The RMI has value, with a sensitivity of 78 % and specificity of 87 % in determining the malignant potential of masses on imaging. 2 |
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consider are epithelial, stromal and |
The IOTA group has developed |
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germ cell. Within these sources, dif- |
examination and an assessment of |
cervical lymphadenopathy. Palpate |
of age, never previously being sex- |
ultrasound features without the |
ferential diagnoses can be further |
imaging to determine flow-on inves- |
for Virchow’ s node( the enlargement |
ually active, trauma, sexual abuse, |
use of CA125 to determine if there |
divided into malignant, borderline |
tigations and the need for specialist |
of the left supraclavicular lymph |
comfort or patient wishes, and this |
are malignant( M-rules) or benign |
and benign pathologies( see table 2). |
referral. |
node, associated with metastatic |
should be respected. In these circum- |
( B-rules) features present, with a sen- |
Sex cord – stromal tumours arise from the connective tissue of the ovary; germ cell tumours arise from |
History
When taking a patient history, focus
|
abdominal malignancy); involvement of Virchow’ s node confers a poor prognosis as this reflects advanced |
stances, despite its inferior resolution, transabdominal assessment is an appropriate first step. It is impor- |
sitivity of 95 % and a specificity of 91 %. 10 The IOTA rules to classify as benign or malignant are presented |
the reproductive component of the |
on symptomatology. Even when a |
stage disease. 7, 8 |
tant to remember that no single |
in table 4. The presence of any of the |
ovary; and epithelial tumours arise from the surface of the ovary or fallopian tube. Of note, the most common malignant epithelial cancer is a high-grade serous carcinoma that |
mass is found incidentally, symptoms that have previously been downplayed may be elicited from the patient. There are multiple causes for symptoms from adnexal masses( see |
Imaging
First-line imaging of a pelvic mass is ultrasonographic assessment( see figure 7)— ideally via both transabdom-
|
ultrasound finding differentiates categorically between benign and malignant masses. 2
The finding of an adnexal mass does not always mean further inves-
|
M-rules requires a referral to a gynaecology oncologist.
Tumour markers
Age is a critical factor in determining
|
commonly arises from the epithelial lining of the fallopian tube and can also rarely occur as a primary in the peritoneal cavity. 4 |
box 1).
Examination
Abdominal examination includes
|
inal and transvaginal imaging with colour doppler assessment. 1, 2 Do not underestimate the benefits of ultrasound as it provides crucial informa- |
tigations are required, and not all ovarian cysts identified need tumour markers as a standard reflex investigation. Sonographic findings in |
cascade investigations. Evaluate all women of reproductive age for pregnancy as an ectopic pregnancy can present as an adnexal mass. Identi- |
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DIAGNOSIS AND INVESTIGATION
THE steps involved in assessing a
|
assessment for ascites, palpable masses, mobility of the mass and any omental disease. Perform a pelvic examination to assess for fixed or pal- |
tion regarding the character of the mass, is readily available and carries no risk of ionising radiation.
It is important to counsel patients
|
combination with patient age and symptoms will indicate if further investigation is needed and whether subsequent interventional manage- |
fication of a synchronous pregnancy and non-related adnexal mass is also of importance because the management of adnexal masses will differ |
pelvic mass are the same regardless |
pable masses, nodularity in the pouch |
before imaging regarding the indi- |
ment or surveillance imaging is more |
based on pregnancy status and gesta- |
of whether the mass was diagnosed |
of Douglas and opportunistic cervical |
cation and reasoning for transvag- |
appropriate. |
tional age. |
through investigation of symptoms |
cancer screening if indicated. |
inal assessment. Not all patients |
In ovulating patients, a simple-ap- |
Only request tumour markers |
or found incidentally. Each patient |
Evaluate for lymph nodes, with |
are suitable or comfortable with |
pearing cyst( thin walled, no solid |
when imaging is concerning enough |
requires a thorough history, a focused |
particular focus on inguinal and |
transvaginal procedures because |
internal structures) that is less than |
for further investigation. Tumour |