Adnexal Tumors Workup

Updated: Feb 14, 2017
  • Author: Nelson Teng, MD, MS, MBA, PhD; Chief Editor: Michel E Rivlin, MD  more...
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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. [30] 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. [25, 26, 27] As such, the specificity of CA-125 is limited and is not recommended for routine screening purposes in the general population (see Clinical). [31]

Although elevated, levels of serum CA-125 do not appear to be a significant predictor of malignant transformation of endometriosis. Significant predictive factors for the presence of malignant transformation of endometriosis appear to include age older than 49 years and cysts that are multilocular and have solid components. [32]

Several predictive models which combine multiple serum markers with or without ultrasound, such as the Copenhagen Index (CPH-I), Risk of Malignancy Index (RMI), and Risk of Ovarian Malignancy Algorithm (ROMA), and OVA-1 have been developed to differentiate benign from malignant adnexal masses.  In various studies, the sensitivities of these indices for epithelial ovarian cancer range from 53-89% and the specificities range from 67-85%, with the highest sensitivity and specificity in post-menopausal women. The superiority of any one particular algorithm has not yet been demonstrated. [33, 34, 35, 36, 37, 38, 39]

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. An ovarian mass in the setting of a thickened endometrial stripe or abnormal uterine bleeding, inhibin A and B may help with diagnosis of a granulosa cell tumor.

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.


Imaging Studies

The most commonly performed test to evaluate an adnexal mass is transabdominal or transvaginal ultrasonography. [6, 7, 8, 40] 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. [41] 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. [5]


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.