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Investigation and Management of an Ovarian Mass Melissa Yeoh

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Investigation and Management of an Ovarian Mass Melissa Yeoh CLINICAL Investigation and management of an ovarian mass Melissa Yeoh 1000, increasing to 3 in 1000 at the age Background of 50 years.1 The purpose of this article Ovarian masses are very common in pre- and postmenopausal women and are is to provide a systematic approach to typically an incidental finding. an ovarian mass for general practitioners Objective (GPs), outlining appropriate investigations This article aims to provide a systematic approach to an ovarian mass for and recommendations for specialist general practitioners including investigations, risk of ovarian cancer and referral referral. considerations. 2 Discussion Initial assessment Investigation for an ovarian mass includes both transvaginal and transabdominal A thorough history should be taken, with specific ultrasound. Simple, anechoic cysts <5 cm in premenopausal women are likely to attention to: be benign and do not require further follow-up. The use of the cancer antigen 125 • Risk factors: (Ca125) tumour marker can be unreliable in premenopausal women given the low – family history of breast, colon, uterine or sensitivity for ovarian cancer; however, it is useful in postmenopausal women. ovarian cancer, hereditary ovarian cancer Ca125 is used in conjunction with ultrasound findings and is used to determine syndrome (BRCA gene mutation/Lynch risk of ovarian cancer through the risk of malignancy index (RMI). Gynaecological syndrome) oncology referral is reqired if RMI is >200. Complications of ovarian cysts include • Protective factors cyst rupture and torsion. Torsion is a gynaecological emergency and requires – parity and breastfeeding (50% reduced urgent review. risk) Keywords – combined oral contraceptive pill ovarian neoplasms; ovarian diseases • Menopause status • Symptoms, including those of endometriosis or malignancy (persistent abdominal distension, change in appetite, pelvic pain, Ovarian masses or cysts are very urinary urgency). common and 10% of women have A careful examination, including an abdominal an operation during their life for and vaginal examination, should be undertaken investigation of an ovarian mass.1 and the presence of lymphadenopathy assessed. These masses are typically found in asymptomatic women who have Investigations imaging for another reason, or for Imaging investigation of non-specific abdominal or pelvic pain. In premenopausal Ultrasonography women, these cysts are typically benign; Transvaginal and transabdominal ultrasound however, it is important to determine views should be obtained.1,3 This allows better if further investigation is required. The differentiation and characterisation of the mass. overall incidence of a symptomatic The only definitive diagnosis of an ovarian mass ovarian cyst in a premenopausal female is through histology; however, there are typical being malignant is approximately 1 in characteristics of certain structures seen on an 48 REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 44, NO. 1–2, JANUARY–FEBRUARY 2015 Investigation and management of an ovarian mass CLINICAL ultrasound. Although ultrasonography is the best a positive predictive value of 95% for ovarian Tumour markers mode of imaging we have for assessment of cancer.6 Serum Ca125 ovarian pathology, its sensitivity and specificity Computed tomography and for the diagnosis of ovarian cancer is only Serum Ca125 is a glycoprotein antigen and magnetic resonance imaging 86–91% and 68–81% respectively.3 is the most widely used tumour marker The International Ovarian Tumor Ovarian masses may be seen on computed in the assessment of ovarian masses. In Analysis (IOTA) Group has developed a list tomography (CT) and magnetic resonance imaging premenopausal women, Ca125 should be of characteristics for benign and malignant (MRI). These are typically incidental findings. measured only if the ultrasound appearance masses.1,4,5 These rules are used in Assessment with ultrasonography is required of a mass raises suspicion of malignancy. It premenopausal women; however, similar to further assess the character of the mass. is unreliable in differentiating malignant from characteristics are also used in the risk of The use of CT or MRI in the assessment of an benign, as Ca125 >35 U/ml has a sensitivity malignancy index (RMI), which is discussed later. ovarian mass does not improve the sensitivity and specificity for ovarian cancer of <80% The IOTA Group rules are defined as benign or or specificity obtained through ultrasonography (potentially as low as 50–60%).3 It can also B-rules and malignant or M-rules (Table 1). Any in the detection of ovarian cancer. MRI may be be raised in conditions such as endometriosis, patient with an M-rule should be referred to a useful in assessment of large cysts that are fibroids, adenomyosis and pelvic infection. gynaecologist.4,5 The presence of ascites has difficult to assess on an ultrasound.1 If Ca125 is elevated, consider repeating 4–6 weeks after the initial test.7 Rapidly rising levels are more likely to be associated with Table 1. IOTA Group ultrasound rules to classify masses as benign or malignancy rather than levels that do not malignant1,4,5 change. Discussion with a gynaecological Benign (B-rules) Malignant (M-rules) oncologist is recommended in patients with a 1,3 Unilocular cysts Irregular solid tumour Ca125 >250 U/ml. In postmenopausal women, Ca125 should Presence of solid components where the Ascites largest solid component <0.7 cm be measured routinely. Ca125 of >35 U/ml has a sensitivity of 69–97% and specificity Presence of acoustic shadowing At least four papillary structures 81–93% for the diagnosis of ovarian cancer.3 Smooth multilocular tumour with largest Irregular multilocular solid tumour with This result should then be used in conjunction diameter <10 cm largest diameter >10 cm with ultrasound findings and menopause status No blood flow Very good blood flow in RMI. Human epididymis protein 4 Table 2. Risk of malignancy index1,6,15 Human epididymis protein 4 (HE4) is another tumour marker currently available for the Risk of malignancy index (RMI) = ultrasound findings x menopause status x Ca125 (U/ml) assessment of ovarian cancer. It has a similar sensitivity as that of Ca125 in comparing Findings Points ovarian cancer to healthy controls, but is Ultrasound findings include: 0 points: no features (unilocular) not elevated in as many common benign • multilocular cyst 1 point: 1 feature gynaecological conditions. It is used in • solid area 3 points: 2–5 features conjunction with Ca125 in the Risk of • metastases Malignancy Algorithm (ROMA).8,9 HE4 can • ascites be falsely elevated in patients with impaired • bilateral lesions renal function, and can also be elevated in Menopausal status 1 point – premenopausal endometrial, primary liver and non-small cell 3 points – postmenopausal* lung cancer.10 The American, UK and Australian Ca125 (U/ml) Actual level guidelines do not address the usefulness of HE4 or ROMA in assessing risk for ovarian cancer. Example For a postmenopausal* woman with a left multilocular cyst and Ca125 of 40 U/ml: An HE4 level in isolation is difficult to interpret, RMI = 1 point for ultrasound x 3 points for postmenopausal x 40 U/ml and its usefulness in a clinical setting is being RMI = 120, therefore, gynaecology referral would be recommended reviewed. HE4 is currently used in the USA *Postmenopausal = no period for 1 year, or over 50 years in women who have had a for monitoring recurrence or progression of hysterectomy epithelial ovarian cancer.3,8 HE4 is not currently REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 44, NO. 1–2, JANUARY–FEBRUARY 2015 49 CLINICAL Investigation and management of an ovarian mass covered by Medicare and costs approximately cystic teratomas; however, its usefulness in Management $45 for the patient.11 It is not recommended as a differentiating mature cystic teratomas from There are three main forms of management screening test for ovarian cancer. ovarian cancer is unclear.12,13 CEA seems to be – conservative, surveillance and surgical an independent prognostic factor for mucinous management. Deciding which is the appropriate Other biochemical markers ovarian cancer.14 Further investigation is required. management is based on assessment of Alpha-feta protein (AFP), human chorionic symptoms, ultrasound findings, menopausal Risk of malignancy index gonadotropin (hCG) and lactate dehydrogenase status, RMI (if applicable) and risk factors. An (LDH) are also recommended in women under 40 The risk of malignancy index (RMI) is the approach to management is outlined in Figure 1. years who have a complex mass on ultrasound, as most widely used risk assessment for ovarian Premenopausal women these can be elevated in germ cell tumours.1,9 malignancy. Developed in 1990, it uses serum Carcinoembryonic antigen (CEA) and cancer Ca125, menopausal status and findings on Asymptomatic women with a simple ovarian antigen 19.9 (Ca19.9) are two other tumour ultrasound (RMI = ultrasound findings x cyst <5 cm on ultrasound do not require markers that are commonly ordered for the menopause status x Ca125 U/ml). It is particularly follow-up. These simple cysts will resolve investigation of an ovarian mass; however, useful in the assessment of postmenopausal within three menstrual cycles. For simple their application to clinical practice is unclear. women. Moderate risk is a RMI value between cysts of 5–7 cm, a repeat ultrasound should The usefulness of these tests is not discussed 25–200, and RMI >200 is considered high risk. An be obtained, and for cysts of >7 cm
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