Diagnosis

Adnexal Mass (Ovarian Cyst)

Description, Classification

An adnexal mass refers to a solid or cystic collection from either the ovaries or tubes (For this discussion, please note that the words cyst and mass are interchangeable). Most often, adnexal masses develop from the ovaries, and are called ovarian cysts or ovarian masses. The vast majority of patients of all ages diagnosed with ovarian masses, cystic or solid, are usually benign. Patients near menopause or past menopause have a higher rate of cancer within an ovarian mass. In general, patients greater than the age of 40 do have a higher risk of ovarian cancer, and must have masses treated sooner to ensure that cancer is not present. Clear cysts to the ovary have a much lower incidence of cancer, whereas complex masses have a higher incidence of being cancerous. A complex cyst is any mass to the ovary having solid and/or cystic components with septations or excressances in the ovary.  Septations are bands or divisions between multiple cysts within the ovary, whereas excressances or mural nodules are growths either on the inside or outside of the ovary. Any patient with a complex mass of the ovary must be evaluated carefully.

"Clear" Cystic Masses

These fluid collections in the ovary are almost always benign at any age, and usually present as follicular cysts in reproductive age women. Follicular means the cyst originated from the follicle, or cyst containing the egg, within the ovary. Follicular cysts form either due to nonovulation, or non release of the egg, with persistence of the cyst or from reformation of the cyst after ovulation. The incidence of cancer is very low in these cysts. Clear cysts to the ovary are not complex and therefore not concerning- they do not have suspicious solid components, septations, excressances, or “hypechoic” areas in the ovary, which refers to a thicker consistency to the fluid.  Most clear cysts can be followed by ultrasound unless they become larger, at which point surgery is usually required.

"Solid" Masses

The most common purely solid mass to the ovary is a fibroma, or fibroid to the ovary. These are benign. Other types of benign solid masses include hormone producing solid masses of the ovary. A common solid tumor to the ovary in younger patients is the dysgerminoma, a germ cell tumor that is usually considered benign. In general, solid masses to the ovary must be considered more suspicious than clear cysts, and are usually treated as complex masses (see below).

"Complex" Masses to the Ovary

Most patients with masses to the ovary have complex structure, meaning the mass is not a clear cyst but has solid components, septations, excressances, or “thick fluid” type areas described by ultrasound as “hypoechoic.” Any complex mass with any of the above features in patients greater than 40 must be evaluated immediately to ensure that cancer is not present.  In patients younger than 40, the cancer risk is lower, but benign masses in these patients can, over time, destroy ovarian function completely, or result in rupture, bleeding, or torsion (twisting) of the ovary (see symptoms below). Cancer can also occur in younger patients. Any complex mass in a patient less than 40 that is enlarging and suspicious must be evaluated to ensure cancer is not present. Evaluation for a diagnosis of cancer requires evaluation of tissue from the ovary. Surgery is necessary to remove at the minimum the cyst or the entire ovary to make this evaluation.

Types of Complex Masses

Dermoid Cysts. These are the most common complex masses of the ovary. They are benign in the vast majority of cases, with only 1% or less of dermoids being malignant. For patients desiring fertility, or for patients wanting to preserve ovarian function, dermoids can be removed from the ovary laparoscopically using either DualportGYN or Triport procedures.

Hemmorhagic Cysts. Hemmorhage refers to bleeding. Hemmorhagic cysts occur when bleeding occurs within the ovary, leading to the formation of a blood clot. These usually develop from follicular cysts that have released the egg, with the rupture of egg  causing bleeding and development of a blood filled cyst. These cysts usually resolve. In cases of severe pain or growth of the cyst, surgery may be required.

Endometriomas. These are not cysts from overgrowth of ovarian tissue, but develop from tissue of the cavity of the uterus, called the endometrium. Movement of tissue from the endometrial lining (from the uterine cavity) through the tubes and implanting on the ovary develops into an endometrioma. Endometriomas are collections of old blood and endometrial tissue that grow monthly through estrogen production. The ovaries make estrogen, and will stimulate the growth of endometriomas which become larger over time. They are categorized here since they are very common, and appear as complex cysts by ultrasound. They are not of ovarian origin are usually always benign.

Serous and Mucinous Cysts. These cyst types are also very common, with serous cysts being composed of thin fluid, and mucinous cysts composed of thicker fluid. They are usually benign, and present as complex masses. The complexity is diagnosed as septations, bands which occur between multiple cysts that have developed in the ovary. Malignancy can occur in either of these types of cysts in older women, with serous being the most common. In cases of malignancy, usually solid components are present along with the fluid, the solid component being the growth of cancer cells.

Serous and Mucinous Cystadeno Fibroma. These masses are just as they sound – serous and mucinous cysts combined with solid fibroid growth on the ovary. They are considered as complex masses, due to the combination of solid and cystic components, but are usually benign.

Germ Cell and Stromal Cell Tumors, Low Malignant Potential Tumors (LMP). Tumor refers to a growth, either malignant or benign, of the ovary. Most of these tumors are benign, but low grade malignancy does occur within this group. Low grade malignant tumors are generally considered benign, since they do not spread from the ovary in most cases. Germ cell, stromal and LMP tumors are in general very rare, and diagnosis can only be made with evaluation of tissue from the ovary. The most common germ cell tumor is a dysgerminoma, usually occurring in younger patients. The most common stromal cell tumor is a granulosa cell tumor occurring in patients of all ages.

Malignancy

Ovarian cancer is a rare disease, with an incidence in the entire population of 1.4%. Patients diagnosed with ovarian cancer are usually between the ages of 50 and 70. Within this age range, the incidence of ovarian cancer is higher.

Complex masses or solid masses of the ovary must be ruled out for ovarian cancer. This is a priority in patients greater than the age of 40, or in any patient less than 40 in which a complex mass of the ovary has NOT decreased in size with follow up ultrasound. Ultrasound, MRI, or CT scan cannot make the diagnosis of malignancy. The reason for this is that the diagnosis has to be made ‘histologically”, or through a diagnosis of the tissue from the ovary, which requires surgery. Since ovarian cancer has much higher success rates for long term survival in the earlier stages, it is important that complex masses be evaluated, followed closely in certain patients, or removed to rule out ovarian cancer and prevent progression of disease to higher stages. Stage I disease, for example, has five year survival rates in the range of 75 to 95%.  Most patients diagnosed with ovarian cancer are stage IIIc, an advanced stage that leads to survival rates as low as 10 to 20% over a 10 year period.  Diagnosis of ovarian cancer with CA-125 levels or newer protein analysis studies are not sensitive enough as a screening tool to identify those patients with early stage disease.

Symptoms

Benign Masses.

Pain. Pain from benign masses is due to the increasing size of the mass. As the mass becomes larger, the ovarian capsule distends and stretches, causing pain. Rupture of masses is rare, but can also cause significant pain when accompanied by bleeding. Torsion, or “twisting”, of the ovary causes sharp, stabbing, immediate pain. Torsion results from a sudden movement that results in the ovary twisting several times on its stalk, or blood supply. The twisting kinks the stalk.  Arterial blood under pressure continues to enter the ovary through the thick walled arteries that do not collapse due to the twisting. Thin walled veins, however, collapse and become obstructed, leading to blood entering the ovary from the arteries but not leaving through the veins. The result is a rapidly enlarging ovary that causing very sharp, stabbing pain. Torsion is very painful, but does not need to result in immediate “open” surgery. They are easily managed laparoscopically with removal of the ovary usually required in most cases. If the ovary still has blood flow through it as seen by laparoscopy, sometimes the ovary can be “untwisted” and function will be preserved.

Abdominal Distension. Distension of the abdomen, or belly, results from continuous growth of ovarian masses. The masses become so large that they move out of the pelvis and distend the mid and upper abdomen. Most patients note that the mass “suddenly” grew. This is usually not the case – the mass becomes more noticeable once it moves out of the pelvis after it reaches a certain size. When that occurs, the mass can be felt or seen much easier even though its rate of growth has stayed the same. Requiring larger shirt and pant sizes, or feeling like you have gained weight or are pregnant are common symptoms from increased growth of larger pelvic masses.

Pelvic Pressure. Through increased growth, masses will also push down on pelvic structures and cause a pressure sensation. This is sometimes described as a continuous dull pressure in the pelvis or lower back.

Urinary Frequency, Back Pain, Constipation, Bowel and Stomach Symptoms.

Very large masses will eventually compress the bladder, decreasing the capacity of the bladder causing frequent urination. The same compressive effect can cause constipation as the mass blocks flow of feces to the rectum. Back pain is a common symptom from pressure on the back. In some cases of very large masses, small intestine and stomach function can also be affected by compressive effects on these organs.

Diagnosis

Ultrasound remains the best method to identify and “characterize” ovarian masses. Characterization refers to the identification of septations, solid components, excressances, mural nodules, or hypechoic or irregular areas, as well as the  size of the mass. This helps to determine if the mass is a complex cyst or a clear cyst, and to determine management for the patient. Transvaginal ultrasound allows the transducer of the ultrasound machine to be placed very close to the mass and allows for an accurate characterization. Because of this, ultrasound is a very accurate and relatively inexpensive imaging method. MRI is also useful in some cases in which ultrasound is indeterminate, but should not be used as the primary method for characterization of ovarian masses. CT scan is less reliable than either MRI or Ultrasound, but can be used to help with the diagnosis of advanced ovarian cancer.

Pelvic exams are still performed in many OBGYN offices for general evaluation of the pelvis. At CGS, pelvic exams are not considered an accurate assessment of the pelvis. Examples include fibroids on stalks thought to be ovarian masses, difficulty in evaluation of heavier patients, and poor assessment of patients with prior surgery. Pelvic exams are not only inaccurate, but also uncomfortable and sometimes painful for patients. Ultrasound is recommended for all patients to fully assess the uterus, tubes, and ovaries annually and before surgery is required.

Treatment

The majority of patients with ovarian cysts will be clear (follicular) or hemmorhagic cysts and will not require surgical treatment. Patients in their reproductive years with clear and hemmorhagic cysts will usually resolve these cysts on their own. The only treatment necessary for these types of cysts are follow up ultrasounds as indicated to ensure the cysts are decreasing in size and resolving. Medical therapy for the treatment of ovarian cysts is not helpful. Birth control pills do NOT help to resolve ovarian cysts and will not help prevent many types of cysts from forming.

Surgical treatment for ovarian cysts is usually performed for patients with complex masses or for symptoms such as pain, abdominal distension, pressure, or bleeding. Surgery is also sometimes required for patients with enlarging follicular or hemmorhagic cysts. Ovarian malignancy is a less common cause of complex cyst formation, but should always be considered in the management of these cysts due to the very poor prognosis of patients with this disease. Early stage ovarian cancer presenting as a complex mass in the ovary with no evidence of disease outside the ovary is a treatable, potentially curable condition. Advanced stage ovarian cancer has very low survival rates, and is considered by many to be a terminal condition.

Simple Cysts

Most simple cysts resolve with time. Treatment consists of follow up ultrasound to ensure resolution. Development of complexities in a simple cyst with follow up ultrasound usually indicates that the prior cyst completely resolved, with development of a new complex cyst. Enlarging cysts, or cysts causing pain or symptoms consistent with torsion (twisting and pain) should be removed. Postmenopausal patients can elect to remove cysts surgically to rule out cancer and eliminate the need for continuous ultrasound follow up.

Complex Cysts, Solid Cysts

All complex or solid masses in patients greater than 40 years of age will require surgical therapy to remove the mass and rule out ovarian cancer. Complex masses in patients less than 40 that are suspicious or have enlarged as evidenced by follow up ultrasound also require surgery. Those patients less than 40 years newly diagnosed with a complex cyst that appears to be a hemmorhagic cyst can be followed closely by repeat ultrasound in one to two months. If the cyst stays the same size, increases in size, becomes more complex, or is causing pain, the cyst should be removed.

Surgery for complex ovarian masses serves several purposes. For benign masses, removal of the mass itself and preservation of the ovary is important to prevent destruction of the remaining ovarian tissue. Also, surgical removal helps to prevent further enlargement of the mass with resulting symptoms, rupture of the mass and bleeding, to treat pain, and to prevent torsion.

For more suspicious complex masses, removal of the cyst or the ovary ensures that cancer is not present. All masses that are suspicious for cancer are sent for frozen section at the time of surgery. Frozen section evaluation of the tissue confirms the presence of cancer while the patient is still asleep. This evaluation occurs during surgery, and if cancer is identified staging is accomplished at that time. Staging refers to evaluation of the pelvic and aortic lymph nodes, removal of the omentum – the fat pad off the colon, as well as hysterectomy and removal of the opposite ovary. The purpose of staging is to identify if the cancer has spread to other sites. If it has, chemotherapy is recommended to make sure that appropriate treatment has been given.

Surgical Procedures

At CGS, patients with ovarian masses usually undergo either cystectomy – removal of the ovarian cyst only, or oophorectomy – removal of the entire ovary using Dualport GYN laparoscopic procedures. These procedures use the latest technology available, including Advanced Retroperitoneal Laparoscopic Surgical procedures to ensure the safest and most effective surgical treatment possible. DualportGYN requires only two ¼ inch incisions, and has the fastest recovery available.  Removal of larger cysts or masses will usually require extension of one of the Dualport incisions to ½ inch for removal of the mass. CGS doctors can remove masses up to 30 cm in size with the same small incisions using ARLS techniques with a recovery of only 3 to 5 days.  These techniques prevent the use of a very large open abdominal incision, requiring recovery times of 6 to 8 weeks or more.  Should cancer be identified at the time of surgery, surgical staging procedures to include hysterectomy, removal of both ovaries, lymph node dissection, and omentectomy are performed immediately to prevent the need for a second surgery.

If you are patient with an ovarian mass of any size, we encourage you to make an appointment with CGS now to fully understand what minimally invasive options are available to you. Robotic or open surgical procedures are not necessary for any patient with an ovarian mass with the use of ARLS techniques and Dualport procedures.

Click here to learn about laparoscoic removal of pelvic mass.