24 HOW TO TREAT: ADNEXAL MASSES ausdoc. com. au
12 DECEMBER 2025
24 HOW TO TREAT: ADNEXAL MASSES ausdoc. com. au
Figure 9. Sagittal CT scan showing large complex pelvic mass extending from the pelvis.
Figure 10. Coronal CT scan showing thickening within the omentum, suspicious for omental caking and metastatic disease.
urinary frequency, pelvic discomfort and new dyspareunia. Examination reveals a significantly distended abdomen without obvious ascites. She undergoes a pelvic ultrasound that shows a large cystic mass with multiple papillary projections.
These findings indicate a concerning pelvic mass. Ruby requires a staging CT chest, abdomen and
How to Treat Quiz.
1. Which THREE statements regarding adnexal masses are correct? a Adnexal masses can occur at any age and vary widely in presentation, symptomatology, examination findings and final diagnosis. b Most ovarian masses are malignant. c The approach to investigation and initial management of asymptomatic and symptomatic lesions is the same. d The patient’ s age will often assist with appropriate investigations and timely referral.
2. Which THREE statements regarding primary ovarian lesions are correct? a Sex cord – stromal tumours arise from the connective tissue of the ovary. b All ovarian masses represent a primary ovarian pathology. c Germ cell tumours arise from the reproductive component of the ovary. d Epithelial tumours arise from the surface of the ovary.
3. Which ONE, aside from genetic factors, is the greatest risk factor for epithelial ovarian cancers? a Menopausal status. b History of endometriosis. c Advancing age. d Use of hormonal contraception.
4. Which THREE may be symptoms of a mass effect of an adnexal mass? a Secondary amenorrhoea. b Dyspareunia. c Bowel symptoms. d Increased abdominal girth and bloating.
5. Which TWO statements regarding the evaluation of an adnexal mass are correct? a All adnexal masses require further investigation following ultrasound. b The involvement of Virchow’ s node confers a poor prognosis. c First-line imaging of a pelvic mass is ultrasonographic assessment. d The ultrasound will differentiate between a benign and a malignant mass.
6. Which THREE statements regarding tumour markers are correct? a An elevated cancer antigen 125( CA125) in combination with a pelvic mass does not always indicate malignancy. b Carcinoembryonic antigen can be elevated in smokers. c A normal CA125 level excludes a malignant process. pelvis, as well as both epithelial and germ cell tumour markers. A referral to a gynaecological oncologist is warranted as she will need a primary staging procedure, likely in the
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d Only request tumour markers when imaging is concerning enough for further investigation.
7. Which THREE statements regarding cascade imaging are correct? a Cascade imaging often depends on the patient’ s age and the initial clinical findings. b CT scanning is the first-line investigation of a pelvic mass found on clinical examination. c CT is required for completion staging of an adnexal mass when an epithelial or stromal malignancy is suspected. d MRI has a select role in investigating adnexal masses.
8. Which THREE statements regarding the management of an adnexal mass are correct? a Mean survival time for women with ovarian malignancy is improved when managed by a gynaecological oncologist. b The most appropriate operation is one that follows an evidence-based protocol. c The mainstay of management of concerning ovarian masses is surgical.
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Case study three
Bianca, a nulliparous 18-year-old,
ADNEXAL MASSES
d Patients will ideally undergo a single surgical procedure.
9. Which THREE statements regarding the management of an adnexal mass are correct? a A neoadjuvant chemotherapy approach before surgery has shown equivalent outcomes with reduced patient morbidity. b Molecular testing of tumour types has become the gold standard. c Surgical management of adnexal masses is generally either fertility sparing or non-fertility sparing. d Removal of ovaries in the presence of benign disease will slightly decrease the risk of both ovarian cancer and overall mortality.
10. Which TWO statements regarding the prognosis of adnexal masses are correct? a Germ cell tumours generally have a favourable prognosis, even in the advanced stage. b Benign ovarian lesions have a very favourable prognosis as they do not undergo malignant transformation. c Sex cord – stromal tumours have significantly varied outcomes, which depend on the type and grade of tumour. d Borderline epithelial tumours have a grim prognosis, even when optimally managed.
presents to her GP with chronic pelvic pain. She undergoes an ultrasound that shows a simple( unilocular with no solid areas or vascularity) 4cm cyst with a normal contralateral ovary.
These findings do not require cascade investigations or referral to a specialist for management of the cyst. Some guidelines suggest no further imaging is required as this will likely resolve spontaneously. Repeat ultrasound in at least six weeks, in another part of the cycle, could be considered to ensure resolution. Tumour markers are not required. It is unlikely the cyst is the source of her symptoms as pain will only arise in the presence of torsion, haemorrhage or rupture. Bianca’ s symptoms require monitoring and management.
CONCLUSION
UNDERSTANDING the likely aetiology of an adnexal mass will aid in cascade decision-making. Knowledge of the most common types of masses in each age group, the required complementary investigations and the referral pathway recommended enables the practitioner to efficiently, effectively and safely manage adnexal masses.
Optimal use of the available resources with effective communication of the findings and explanation of the process will help allay anxiety in patients with an adnexal mass of unknown aetiology.
RESOURCES
• Royal College of Obstetricians and Gynaecologists: Management of suspected ovarian masses in premenopausal women— Green-top Guideline bit. ly / 4lyCiZq
• Royal College of Obstetricians and Gynaecologists: Management of ovarian cysts in postmenopausal women— Green-top Guideline bit. ly / 3IP7B3p
References Available on request from howtotreat @ adg. com. au