Adnexal Tumors Workup

  • Author: Nelson Teng, MD, PhD; Chief Editor: Michel E Rivlin, MD   more...
 
Updated: Oct 17, 2011
 

Laboratory Studies

Possible lab tests in the evaluation of adnexal mass include serum markers, Papanicolaou test, CBC count, urinalysis (U/A), stool for blood, and electrolytes.

CA-125 is elevated in approximately 80% of all women with ovarian cancer. In stage I disease, the sensitivity of this biomarker is approximately 50%, which rises to 90% in patients with advanced disease.[27] However, it can also be elevated in many other conditions, including gynecologic etiologies such as endometriosis, uterine fibroids, and pregnancy, and nongynecologic conditions such as gastroenteritis, pancreatitis, cirrhosis, and congestive heart failure.[22, 23, 24] As such, the specificity of CA-125 is limited and is not recommended for routine screening purposes in the general population (see Clinical).[28]

OVA1 is a commercially available biomarker assay designed to help determine the risk of malignancy in a known pelvic mass. Approved by the US Food and Drug Administration (FDA) in 2009, the test is not intended to screen for or definitively diagnose cancer. Instead, the test is indicated as an adjunct to imaging and physical examination in women older than 18 years who have an ovarian mass for which surgery is already planned.[29]

OVA1 is a qualitative serum test that combines the results of 5 immunoassays (apolipoprotein A1, CA-125, transthyretin, beta-2 microglobulin, and transferrin) into a single numerical score (range 1-10). For premenopausal women, a score of greater than or equal to 5.0 raises concern for malignancy. In postmenopausal women, a cut-off score of 4.4 is used. A recently published prospective, double-blinded study demonstrated that the OVA1 multivariate index assay was more sensitive (98% vs 78%) but less specific (73% vs 43%) than physician assessment and CA-125 testing in identifying ovarian malignancy.[30] These results were most pronounced in premenopausal women and early-stage cancers. An elevated OVA1 score can help a general gynecologist determine which patients would benefit most from preoperative referral to a gynecologic oncologist.

Urine or serum beta human chorionic gonadotropin (ß-hCG) should be obtained in women of reproductive age to rule out pregnancy and pregnancy-related etiologies of adnexal masses.

Other serum markers such as AFP and LDH can be helpful when a germ cell tumor is suspected.

A Papanicolaou test should be considered in women undergoing a gynecologic surgery. This test should be used to help rule out any unknown cervical pathology. In extremely rare situations, this test may reveal the presence of an adnexal malignancy.

A CBC count helps evaluate for presence of inflammation and anemia. An infected mass such as a tubo-ovarian abscess results in an increased WBC count with an associated left shift. Adnexal masses rarely cause anemia, but because they often require surgical removal, this information should be known.

U/A results are generally normal in the presence of an adnexal mass. Bladder pathology may present with symptoms of an adnexal mass and may be discovered based on U/A results. Appendicitis can present similar to an adnexal mass but is often associated with WBCs in the U/A findings.

Results from testing stool for blood should be negative for adnexal masses but may be positive in women with colonic pathology.

Serum electrolytes should not be altered by an adnexal mass; however, symptoms associated with masses, such as nausea and vomiting, can cause alterations that must be known before anesthesia and surgery are considered.

Measuring other hormone levels is generally of limited value in the evaluation of adnexal masses. Obtaining estrogen and progesterone levels may be helpful in women suggested to have functional tumors, such as germ cell tumors, or if a girl younger than 12 years is being evaluated.

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Imaging Studies

The most commonly performed test to evaluate an adnexal mass is transabdominal or transvaginal ultrasonography.[5, 6, 7, 31] This test helps demonstrate the presence of the mass and its location (eg, ovarian, uterine, bowel). It also provides the mass size, consistency, and internal architecture. Scoring systems, such as that suggested by DePriest and associates, can then be used to determine the likelihood of a malignant component.[32] Hysterosonography (ultrasonography with the presence of fluid in the uterine cavity) may be used to help distinguish between uterine masses and those arising from other pelvic structures. Color Doppler ultrasonographies can be used to evaluate the resistive index of the mass vessels, which, when low, has been indicative of a malignancy.

Pelvic radiographs are generally not helpful in the evaluation of adnexal masses. A dermoid cyst generally contains areas of calcification that may be picked up on a plain radiograph.

CT scans are most useful for assessing the remainder of the abdomen and pelvis when metastatic disease is suspected. Incidental adnexal masses are sometimes found when CT is performed for evaluation of other conditions. As with ultrasonography, CT scan can help identify the size, location, and relationship to other organs. CT scan is less effective than ultrasonography for determining the internal architecture of these masses.

MRI scans can help characterize adnexal mass characteristics in select cases when ultrasonographic findings are limited.[4]

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Diagnostic Procedures

In limited settings, aspiration of the mass can be performed. However, this approach must be reserved for those women in whom an extremely low chance of a malignant mass exists and/or when surgical intervention is contraindicated.

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Contributor Information and Disclosures
Author

Nelson Teng, MD, PhD  Associate Professor, Department of Gynecology and Obstetrics, Division of Gynecologic Oncology, Stanford School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Elise J Simons, MD  Clinical Instructor, Department of Obstetrics and Gynecology, Stanford University School of Medicine

Elise J Simons, MD is a member of the following medical societies: Alpha Omega Alpha and American College of Obstetricians and Gynecologists

Disclosure: Nothing to disclose.

Specialty Editor Board

John J Kavanagh Jr  MD, Chief, Professor, Department of Internal Medicine, Section of Gynecological and Medical Therapeutics, MD Anderson Cancer Center, University of Texas Medical School at Houston

John J Kavanagh Jr is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association for the History of Medicine, American College of Physicians, American Federation for Medical Research, American Medical Association, Society of Gynecologist Oncologists, Southern Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

A David Barnes, MD, PhD, MPH, FACOG  Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)

A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association

Disclosure: Nothing to disclose.

Frederick B Gaupp, MD  Consulting Staff, Department of Family Practice, Hancock Medical Center

Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD  Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Margrit Juretzka, MD, to the development and writing of this article.

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