Adnexal Masses

Question 1

When to report and how to follow ovarian cysts

Answer 1

Simple cysts in women of reproductive age:
– ≤ 3 cm: Discretion of radiologist to report
– 3‐5 cm: No need for follow‐up
– 5‐7 cm: Yearly follow‐up recommended
– >7cm: Consider additional imaging or surgery
10 cm from ACOG

• In postmenopausal women:
– ≤ 1 cm: Discretion of radiologist to report
– 1‐7 cm: Yearly follow‐up recommended
– >7cm: Additional imaging or surgery

Question 2

Appearance of endometrioma

Answer 2

Sonographic findings
‐ Well‐circumscribed , uniform
‐ “Ground‐glass” texture
‐ May appear solid, but no flow

Question 3

Predicting Malignancy

Answer 3

History: Family history, age, nulliparous

Physical Exam Features associated with malignancy:
‐ Irregular, nodular
‐ Solid consistency
‐ Fixed
‐ Presence of ascites

Multilocular cystic
Multilocular solid 
Papillary projections
Malignant tumors recruit low‐resistance, highflow
blood vessels.

– Septation ≥ 3mm
– Nodule with blood flow
– Focal wall thickening ≥ 3 mm
• Especially associated with ascites or other
peritoneal mass

Question 4

ova-1

Answer 4

– Combines CA‐125 with β2‐microglobulin,
transferrin, apolipoprotein A1, and transthyretin
– Highest negative predictive value
– Equally accurate for mucinous tumors

Question 5

roma

Answer 5

CA‐125 plus HE4
– Improved sensitivity (up to 100%) and specificity
(74‐76%), especially in premenopausal women

Question 6

other serum markers

Answer 6

BHCG Choriocarcinoma
LDH Dysgerminoma
AFP Endodermal sinus tumor
Inhibin A & B Granulosa cell tumor
CEA Mucinous ovarian cancer
CA‐125 Endometrioma

Question 7

neoplastic lesion in young women

Answer 7

≤ 20 years old: Germ cell tumors > epithelial
> 20 years old: Epithelial > germ cell

all greater than 8cm

Question 8

teratoma

Answer 8

50% of pediatric ovarian tumors
‐ Mostly asymptomatic
‐ Average growth rate = 1.8 mm/year
‐ Torsion in 3.2 – 16%
‐ Rupture in 1.2 ‐3.8%

Risk of malignancy 1%
– Usually menopausal and almost all >30
– Immature teratoma also 1%, avg age = 26
The

Question 9

adnexal masses in pregnancy

Answer 9

(7%) large or complex persistent

• Torsion
– Ligaments stretched by advancing gestation
– Estimated risk 3 – 15%
• Hemorrhage/ rupture
– Increasing intraabdominal pressure

Mature cystic teratoma 37%
Cystadenoma 24%
Malignancy or LMP 2 – 6%

Question 10

When to operate in pregnancy?

Answer 10

Prevents unnecessary surgery
• Allows anatomic survey to rule out preexisting
anomalies
• Recommended unless acute symptoms or high
suspicion for malignancy
(if it needs to be done at all!)

• Entry with Hassan preferred
• Trocar placement above fundus/ in LUQ
• Abdominal pressures up to 15 mm Hg safe