Manejo de Masas Ovaricos
Manejo de Masas Ovaricos
Manejo de Masas Ovaricos
of Adnexal Masses
WENDY S. BIGGS, MD, and SARAH TULLY MARKS, MD, University of Kansas, Kansas City, Kansas
Adnexal masses can have gynecologic or nongynecologic etiologies, ranging from normal luteal cysts to ovarian can-
cer to bowel abscesses. Women who report abdominal or pelvic pain, increased abdominal size or bloating, difficulty
eating, or rapid satiety that occurs more than 12 times per month in less than a year should be evaluated for ovarian
cancer. Pelvic examination has low sensitivity for detecting an adnexal mass; negative pelvic examination findings in
a symptomatic woman should not deter further workup. Ectopic pregnancy must be ruled out in women of reproduc-
tive age. A cancer antigen 125 (CA 125) test may assist in the evaluation of an adnexal mass in appropriate patients. CA
125 levels are elevated in conditions other than ovarian cancer. Because substantial overlap in CA 125 levels between
pre- and postmenopausal women may occur, this level alone is not recommended for differentiating between a benign
and a malignant adnexal mass. Transvaginal ultrasonography is the first choice for imaging of an adnexal mass. Large
mass size, complexity, projections, septation, irregularity, or bilaterality may indicate cancer. If disease is suspected
outside of the ovary, computed tomography may be indicated; magnetic resonance imaging may better show malig-
nant characteristics in the ovary. Serial ultrasonography and periodic measurement of CA 125 levels may help in dif-
ferentiating between benign or potentially malignant adnexal masses. If an adnexal mass larger than 6 cm is found
on ultrasonography, or if findings persist longer than 12 weeks, referral to a gynecologist or gynecologic oncologist
is indicated. (Am Fam Physician. 2016;93(8):676-681. Copyright © 2016 American Academy of Family Physicians.)
T
CME This clinical content he etiology of adnexal masses tubo-ovarian abscess. Malignant causes
conforms to AAFP criteria ranges from physiologically nor- include endothelial carcinoma, sarcoma, and
for continuing medical
education (CME). See mal luteal cysts to ovarian cancer. borderline tumors. Because adnexal masses
CME Quiz Questions on The clinician needs to interpret can have gastrointestinal, urinary, or meta-
page 648. symptoms and findings from multiple organ static sources, ovarian origin should not be
Author disclosure: No rel- systems and use appropriate imaging to dif- assumed. Abscesses, cysts, and cancers of the
evant financial affiliations. ferentiate expeditiously between a benign gastrointestinal tract or other abdominal or
Patient information: and a malignant cause of an adnexal mass. pelvic organs can appear as adnexal masses
▲
A handout on this topic, Ovarian malignancy is diagnosed approxi- on imaging or examination, and breast and
written by the authors of mately 22,000 times per year in the United colon cancer can metastasize in ovaries.
this article, is available
States, making it the second most common
at http://www.aafp.org/
afp/2016/0415/p676-s1. gynecologic cancer; in 2010, nearly 14,000 History
html. women died of ovarian cancer.1,2 Screening Clinical history is vital in the diagnosis of an
for ovarian cancer has not been demon- adnexal mass (Table 1).4 Risk of ovarian can-
strated to be effective in the general popula- cer increases with age. The patient’s repro-
tion. With no effective screening measures ductive status and contraception method
available, 70% of ovarian malignancies must be determined; ectopic pregnancy can
are diagnosed at a late stage.3 However, be a life-threatening adnexal mass. Women
when ovarian cancer is detected at a stage with a family history of breast and gyneco-
confined to the ovary, survival rates can logic cancers, those with known or suggested
approach 90% at five years.3 presence of BRCA or other hereditary cancer
The differential diagnosis for adnexal syndromes, and women of Ashkenazi Jew-
masses is broad. A previous American Fam- ish descent are at increased risk of ovarian
ily Physician article gives a complete list.4 cancer. Other risk factors for ovarian cancer
The gynecologic causes of adnexal masses include nulliparity, obesity, delayed child-
include benign sources, such as luteal cysts, bearing, use of fertility-enhancing medica-
polycystic ovaries, ectopic pregnancy, and tions, and unopposed estrogen exposure.4,5
676 American
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Adnexal Masses
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation rating References
Women who report abdominal or pelvic pain, increased abdominal size or bloating, or difficulty C 3
eating or feeling full quickly more than 12 times per month for less than 12 months’ duration
should be evaluated for ovarian cancer.
The U.S. Preventive Services Task Force recommends against routine screening for ovarian cancer, A 10
including use of transvaginal ultrasonography, cancer antigen 125 testing, and screening pelvic
examinations.
An adnexal mass occurring during pregnancy can be managed expectantly because the risk of C 18, 19, 21,
malignancy is low. 22
Transvaginal ultrasonography should be the first imaging test used to identify and characterize an C 6
adnexal mass.
Cancer antigen 125 testing alone should not be used to differentiate between a benign and a C 6, 16
malignant adnexal mass.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.
org/afpsort.
Table 1. Selected Clinical Entities in the Differential Diagnosis of Adnexal Tenderness or Mass
Ectopic pregnancy Lower abdominal (usually unilateral and severe) or pelvic pain Adnexal mass or tenderness,
hypotension, tachycardia
Endometrioma Abnormal uterine bleeding, dyspareunia, worsening pain Adnexal mass or tenderness,
with menses tenderness over uterosacral ligaments
Functional ovarian cyst Unilateral pelvic pain, pain during middle of menstrual cycle Adnexal mass or tenderness
(corpus luteum) (mittelschmerz), pain with intercourse
Leiomyoma Dysmenorrhea, menorrhagia Abdominal mass, uterine enlargement
Ovarian cancer Pelvic or abdominal pain, abdominal fullness and pressure, Abdominal or adnexal mass, ascites,
bloating, difficulty eating, early satiety, increased abdominal lymphadenopathy, nodularity of
size, indigestion, dyspareunia, urinary urgency or frequency, uterosacral ligaments, pleural
incontinence effusion
Ovarian torsion Sudden onset of unilateral and severe lower abdominal or Abdominal or adnexal tenderness
pelvic pain, associated with nausea or vomiting
Pelvic inflammatory Fever, lower abdominal or pelvic pain, nausea, vaginal Abdominal or adnexal tenderness,
disease or tubo- discharge, vomiting cervical motion tenderness, fever,
ovarian abscess vaginal discharge
Polycystic ovary Oligomenorrhea, amenorrhea, or menorrhagia associated Unilateral or bilateral adnexal fullness
syndrome with obesity and hirsutism or enlarged ovary or ovaries
Adapted with permission from Givens V, Mitchell G, Harraway-Smith C, Reddy A, Maness DL. Diagnosis and management of adnexal masses. Am
Fam Physician. 2009;80(8):817.
Adhesions from previous abdominal or pelvic surgery than benign causes 7 (Table 2 8). More severe, frequent
can cause symptomatology similar to an adnexal mass. symptoms of shorter duration may also indicate cancer.
Common symptoms associated with adnexal masses Studies have investigated the creation of a symptom
include irregular vaginal bleeding, bloating, increased index to evaluate the constellation of possible indicators
abdominal girth, dyspareunia, urinary symptoms, pelvic and their presence over time, but no single index is widely
pain, and abdominal pain.1,6,7 Ovarian cancer can occur accepted.1,3 One symptom index study recommends that
in a premenarchal patient, and symptoms suggestive of an women who report abdominal or pelvic pain, increased
adnexal mass should not be ignored in that population. abdominal size or bloating, or difficulty eating or feeling
Pain, increased abdominal size, bloating, and urinary full quickly more than 12 times per month for less than
symptoms may be more indicative of malignant rather 12 months’ duration be evaluated for ovarian cancer.3
April 15, 2016 ◆ Volume 93, Number 8 www.aafp.org/afp American Family Physician 677
Adnexal Masses
Table 2. Sensitivity and Specificity of Symptoms
to Identify Patients with Ovarian Cancer
Sensitivity Specificity
Symptom (%) (%) LR+ LR– and abdomen. A digital rectal examination
Four or more symptoms 27 96 6.75 0.76 should also be considered.
Three or more symptoms 43 92 5.38 0.62
Laboratory Testing
Increased abdominal size 64 81 3.37 0.44
Bloating 70 62 1.84 0.48 Laboratory testing should be directed by
Urinary tract symptoms 55 68 1.72 0.66 associated symptoms. In all peri- and pre-
Abdominal pain 50 70 1.67 0.71 menopausal women, pregnancy must be
Pelvic pain 41 74 1.58 0.80 ruled out with a urine test. Serial quantita-
Constipation 50 64 1.39 0.78 tive beta human chorionic gonadotropin
Diarrhea 25 68 0.78 1.10 (β-hCG) tests are helpful in evaluating sus-
Menstrual irregularity 18 75 0.72 1.09 pected ectopic pregnancy. In a normal preg-
Nausea 14 78 0.64 1.10 nancy, the β-hCG level should increase by
Postmenopausal bleeding 2 96 0.50 1.02 more than 50% in two days.13 An intrauter-
ine pregnancy is indicated when the β-hCG
NOTE: See http://www.aafp.org/journals/afp/authors/ebm-toolkit/glossary.html for a
definition of likelihood ratios.
level is greater than the discriminatory zone
of 1,500 to 2,000 mIU per mL (1,500 to 2,000
LR+ = positive likelihood ratio; LR– = negative likelihood ratio.
IU per L).14 Heterotopic pregnancy, when
Information from reference 8.
both an intra- and extrauterine pregnancy
exist, occurs in an estimated one per 30,000
pregnancies from spontaneous conceptions,
Physical Examination whereas it can occur in up to 1% of pregnancies after
In 2014, the American College of Physicians recom- assistive reproductive methods.15
mended against screening pelvic examinations in A complete blood count with differential may help
asymptomatic, nonpregnant adult women.9 For women to evaluate an adnexal mass. An elevated white blood
without known genetic mutations that increase the risk cell count may suggest pelvic inflammatory disease, a
of ovarian cancer, such as BRCA mutations, the U.S. tubo-ovarian abscess, or a pelvic abscess from colonic
Preventive Services Task Force and the American Acad- or appendiceal sources.
emy of Family Physicians recommend against screen- Although cancer antigen 125 (CA 125) testing should
ing for ovarian cancer, including pelvic examination.10 not be used as a screening tool, a CA 125 level may assist
No ovarian cancers were detected by bimanual pelvic in the evaluation of an adnexal mass in select patients.
examination in the Prostate, Lung, Colorectal and Ovar- CA 125 levels may be elevated in a number of conditions
ian cancer screening trial; thus, the trial discontinued other than ovarian cancer (Table 3).16 There is substan-
annual bimanual pelvic examination.11 tial overlap in CA 125 levels between pre- and post-
In a review of five studies, the pooled sensitivity of menopausal women.16 Stage 1 invasive ovarian cancers
pelvic examination for detecting an adnexal
mass was 45% with a pooled specificity of
90%.12 The American College of Physicians’ Table 3. Causes of Elevated Cancer Antigen 125 Levels
systematic review did not find any studies on Not Associated with Ovarian Cancer
the diagnostic accuracy of the pelvic exami-
nation for asymptomatic pelvic inflam- Benign gynecologic Benign Malignancies
causes nongynecologic Breast cancer
matory disease, gynecologic cancer other
Endometriosis, especially causes
than ovarian or cervical cancer, or benign Endometrial cancer
endometriomas Caffeine use
conditions. Additional evaluation should
9 Lung cancer
Large uterine fibroids Liver cirrhosis
be directed by the patient’s symptoms. For Pancreatic cancer
Menstruation with or without
physical symptoms suggestive of an adnexal ascites Peritoneal implants
Ovarian fibroma of nonovarian
mass, a pelvic examination, including a Lung disease
Pelvic inflammatory cancers
speculum examination, should be done. disease Obesity
Careful assessment of superficial lymph Previous hysterectomy Tuberculosis
nodes throughout the body is prudent. Dys-
pnea or abdominal symptoms should trigger Information from reference 16.
auscultation and examination of the chest
678 American Family Physician www.aafp.org/afp Volume 93, Number 8 ◆ April 15, 2016
Adnexal Masses
may have lower levels of CA 125.9 A strict laboratory abdominal or pelvic symptoms, especially if the symp-
cutoff value of CA 125 alone, therefore, cannot predict toms are new or progressive. Because the sensitivity of
malignancy.6,16 pelvic examination is low, further workup in symp-
tomatic women should occur even with negative pelvic
Management examination results.
PREMENARCHAL PATIENTS
A retrospective study found that approxi-
mately 25% of adnexal masses in patients
younger than 18 years were malignant.17 An Evaluation and Management of an Adnexal Mass
adnexal mass in a premenarchal patient, or Postmenopausal?
the presence of symptoms associated with a
mass, should prompt referral to a gynecologist
with expertise in evaluating these patients. No or not sure Yes
April 15, 2016 ◆ Volume 93, Number 8 www.aafp.org/afp American Family Physician 679
Adnexal Masses
Transvaginal ultrasonography is the first choice for or magnetic resonance imaging. Transvaginal ultraso-
imaging to differentiate between a benign and a malig- nography should be performed to further characterize
nant adnexal mass, with a sensitivity of 93.5% and a the adnexal mass. The American College of Radiology
specificity of 91.5%.25 The addition of Doppler to ultra- recommendations are stratified based on menopausal
sonography can also aid in differentiation. If disease is status, benign-appearing characteristics, and size of the
suspected outside of the ovary, computed tomography mass28 (Figure 14).
may be indicated, whereas magnetic resonance imaging Gynecologic oncologists are trained to appropriately
may show malignant characteristics in the ovary more stage and debulk ovarian cancers. Prompt referral to a
clearly.25 gynecologic oncologist is recommended for postmeno-
CA 125 testing is not recommended as the sole factor for pausal women with an elevated CA 125 level, a pelvic
differentiating between a benign and a malignant adnexal mass, evidence of abdominal or distant metastases, or
mass.6,26 CA 125 levels are normally higher in premeno- ascites; and for premenopausal women with highly ele-
pausal women. In most benign conditions, CA 125 levels vated CA 125 levels, ascites, or evidence of abdominal or
are less than 20 U per mL (20 kU per L); however, levels distant metastases.1 Despite being ineffective and unvali-
up to 45 U per mL (45 kU per L) may be present in women dated as a screening tool, serial ultrasonography should
with endometriomas and abscesses.16 Endometriomas are
more prevalent in premenopausal vs. postmenopausal
women (32% vs. 2.2%), whereas invasive ovarian malig- Table 4. Risk of Malignancy Index Scoring
nancies occur three times more often in postmenopausal System in the Evaluation of an Adnexal Mass
women (10.5% vs. 39.4%, respectively).16 In postmeno-
RMI* = U × M × CA 125
pausal women, a CA 125 level greater than 35 U per
mL (35 kU per L) warrants diagnostic ultrasonography, Ultrasound characteristics
based on a meta-analysis of 49 cohort studies and two Bilateral lesions
case-control studies that found an overall sensitivity of Evidence of metastases
78.7% and a specificity of 77.9% at a threshold of 35 U per Evidence of solid areas
mL.6 At a CA 125 level of 100 U per mL (100 kU per L), Multilocular cyst
a premenopausal woman has only a 21.1% likelihood of Presence of ascites
having a malignant ovarian tumor, whereas a postmeno- If none of these characteristics are found, U = 0
pausal woman with the same CA 125 level has a 74.3% If one, U = 1
likelihood of a malignant ovarian tumor.16 If two or more, U = 3
Ultrasonography has the possible advantage of earlier
Menopausal status
detection and, therefore, improved survival and avoid-
If premenopausal, M = 1
ance of unnecessary surgery. Risk of ovarian malignancy
If postmenopausal, M = 3
increases with ovarian mass size greater than 6 cm, bilat-
erality, septation, and presence of ascites.2,27,28 Ultrasound Serum CA 125 level (U per mL [kU per L])
characteristics can be assessed with the CA 125 level
Variations on RMI†
and clinical decision-making tools. Several studies have
In RMI2, postmenopausal status = 4, and if two or more
attempted to develop a formula to predict the probability radiologic characteristics are present, U = 4
of an adnexal mass. In RMI3, postmenopausal status = 3, and if two or more
The Risk of Malignancy Index (RMI) uses menopausal radiologic characteristics are present, U = 3
status, ultrasound characteristics, and the CA 125 level
in a formula to predict the probability of malignancy CA 125 = cancer antigen 125; M = menopausal status; RMI = Risk of
Malignancy Index; U = ultrasound-based morphology score.
(Table 4).6 Although there is a commonly accepted RMI
*—The most common threshold for probability of malignancy is
threshold of greater than 200, studies suggest that differ- greater than 200.
ent races and ethnicities may have different cutoff val- †—The sensitivity and specificity of RMI2 and RMI3 are comparable
ues to predict malignancy risk.29 For example, studies of with the original index (79.2% and 91.7%, respectively). Clinician
preference should guide selection of which version to use in practice.
Asian Pacific populations demonstrate that a cutoff value
Adapted with permission from Dodge JE, Covens AL, Lacchetti C,
of 250 showed higher predictability of malignant lesions
et al.; Gynecology Cancer Disease Site Group. Management of a
than the cutoff of 200 used in other populations.29 suspicious adnexal mass: a clinical practice guideline. Curr Oncol.
Adnexal findings, such as ovarian cysts, are often dis- 2012;19(4):e257.
covered incidentally on pelvic computed tomography
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Adnexal Masses
April 15, 2016 ◆ Volume 93, Number 8 www.aafp.org/afp American Family Physician 681