The adnexa are those structures which lie along the uterus, the most important of which are the tubes and ovaries. The portions of the broad ligaments and mesosalpinx which contain embryonic remnant may also, at times, be palpable and therefore must be considered in any differential diagnosis

Goplerud, Dean R.

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Evaluation and Management of Adnexal Masses DEAN R. GOPLERUD, M.D. Department of Obstetrics and Gynecology, Health Sciences Division of Virginia Commonwealth University, Richmond, Virginia The adnexa are those structures which lie along the uterus, the most important of which are the tubes and ovaries. The portions of the broad ligaments and mesosalpinx which con­tain embryonic remnants may also, at times, be palpable and therefore must be considered in any differential diagnosis Evaluation of the Adnexal Mass Bimanual Pelvic Examination. The sim­plest, least expensive, and most fundamental technique in evaluating the adnexal mass is a bimanuai pelvic examination. The normal ovary in a prepubertal female is usually not palpable and the normal postmenopausal ovary is so small and atrophic that it, too, is not often felt. The ovary in women between the ages of men­arche and menopause, however, is about 1 Y2 X 2 X 3 Y2 cm. The experienced examiner can usually feel ovaries of this size in a cooperative patient of average body build. During bimanual pelvic examination sev­eral determinations concerning the adnexal mass should be made. First, size should be esti­mated in reference to an absolute standard such as a centimeter ruler; comparison to fruits and. vegetables lacks precision and should be avoided. It is important to differentiate cystic masses from those that are solid . The location The follow·n · · . G I g 1s an edited transcript of remarks by Or Oplerud at th 51 . cal C e . .st Annual McGuire Lecture Series. Medi-allege of Virginia, Richmond, Virginia. G Correspondence and reprint requests to Dr. Dean R. oplerud Bo 3 4 . VA �3298. x · Medical College of Virginia, Richmond, of the mass and its position in reference to the uterus, rectum and bladder should be de­scribed; mobility and tenderness on palpation may also be extremely important in differentiat­ing neoplasms from inflammatory masses. Intravenous urogram. ultrasound, and computerized tomography. There are several technical procedures using modern medical technology which are available today including intravenous urograms, ultrasonography, and computerized tomography. An intravenous urogram will often provide helpful information about an adnexal mass as well as outline important portions of the urinary tract. Solid adnexal masses that are extremely vascular may take up the contrast material whereas cystic masses are not likely to do so. Any deviation of the bladder and ureters can readily be seen. The usual scout film of the ab­domen taken prior to the injection of contrast material will occasionally show a tooth or por­tion of bone most commonly associated with a benign cystic teratoma (dermoid cyst). Ultrasonography is useful in determining the size and location of adnexal masses as well as differentiating solid from fluid components of a mass. Computerized tomography is considerably more expensive but will precisely delineate cer­tain characteristics of an adnexal mass, espe­cially attachments to bladder and bowel, when used in combination with contrast enhancement techniques . In spite of the current interest in these newer screening techniques the bimanual pelvic exc1min:1tion is still the most pr::ictic::il mc:ins 1 ,ClPI I HI IU 1\PNF X/\1 MASSf :; / '19 whereby most adnexal masses are found and is the basis for most therapeutic decisions. Etiology Physiologic. The ovaries and tubes may be enlarged owing to a number of causes. Physiologic enlargement of the ovary occurs with the formation of the corpus luteum of men­struation and to a greater extent with the corpus luteum of pregnancy. Enlargement because of normal cyclic function should be recognized. Theca lutean cysts are commonly found in as­sociation with gestational trophoblastic disease. Bilateral enlargement of the ovaries is the usual finding in the polycystic ovary of Stein-Le­venthal syndrome. Evaluation and treatment are usually medical and directed towards the under­lying hormonal problem Inflammatory. Inflammatory disease in­volving adnexal structures is due to gonorrhea, the most commonly reported communicable disease in our country today. Acute salpingitis of gonococcal origin may result in a tubo-ovar­ian abscess which may occupy the entire pelvis These inflammatory enlargements are usually bilateral, tender, and are accompanied by the usual signs and symptoms of pelvic gonococcal infection. Neoplastic The third major category of adnexal masses is neoplastic which may be ei­ther benign or malignant The benign cystic teratoma is the most common benign neoplasm of the ovary in the young adult woman. The identification of a tooth within the mass on a pel­vic roentgenogram may be diagnostic, but most dermoid cysts are not identifiable in this man­ner. The dermoid cyst is often bilateral and arises in the central portion of the ovary. As it enlarges the ovarian cortex is compressed. In dermoid cysts up to 1 0 cm or 1 5 cm in diame­ter it is frequently possible to find a cleavage plane between the cyst and the ovarian sub­stance. Ovarian conservation by cystectomy rather than oophorectomy may be practical. A paraovarian cyst arises from embryonic remnants within the mesosalpinx and can usu­ally be identified because it is separate from the ovary The fallopian tube is often stretched across the cyst as the mesosalpinx is dis­tended. In this instance, also, a cystectomy will preserve a functioning ovary and tube on the in­volved side. Approximately 1 7,000 cases of ovarian 50 / GOPLERUD: ADNEXAL MASSES cancer are diagnosed in the United States an­nually. Each year between 11,000 and 12,000 women die from this disease. The majority ol these patients have extensive disease involving structures out of the pelvis at the time of initial laparotomy. Most ovarian cancers are epithelial tumors and a smaller number are of stromal and germ cell origin. The scope of this discussion does not include the total management of ovar­ian cancer, but the importance of adequate evaluation at the time of initial laparotomy can­not be overemphasized The cell type and de­gree of differentiation of the tumor. together with the clinical extent of disease determined ai laparotomy, are critical in planning manage­ment and forming a prognosis It is impossible to evaluate the upper abdomen adequately through a Pfannenstiel incision. While the cos­metic advantages are obvious, the critical im­portance of adequate staging must be the major consideration at the time of surgery. Many ovarian cysts can be removed intacl through an adequate incision. The ma1or advan· tage of the vertical midline incision is that it can be extended from the symphysis pubis beyond the umbilicus (to the xyphoid cartilage if neces· sary) to remove a large cyst and to satisfactorily explore the upper abdomen. In the patient with Stage Ill ovarian cancer with involvement of the omentum and peritoneal surfaces it is neces· sary to palpate and visualize the liver and d1a· phragm so that biopsies can be performed It is also important in the patient with ovarian cancer which appears to be grossly limited to the pelvis to evaluate the organs of the upper abdomen. II biopsies are taken from the inferior surface ol the diaphragm, the omentum and para-aortic lymph nodes, between 1 0% and 25% of pa· tients will be found to have microscopic disease even though grossly evident tumor is limited tr the pelvis The adolescent and young adult womar with unilateral ovarian tumor presents a uniquE problem It is natural for most of these patient: to wish to preserve their childbearing capacity and it is reasonable that the operating surgeor will respect their desire. Conservative surgen consisting of unilateral salpingo-oophorecton1, is certainly justified in young patients with Ill mors such as dysgerminomas and granulosa theca cell tumors. It is particularly important ir such patients. when conservative surgery is ini lially done, that adequate inspection and biops, of the contralateral ovary be carried out. It is usually preferable, in the young patient, to per­form a more conservative operation if there is any doubt about the final pathologic diagnosis A more radical procedure can usually be safely done at a later time if careful pathologic exami­nation proves it to be necessary Metastatic cancer. Ovarian cancer may be secondary to primary tumors in the gastroin­testinal tract, the breast, and the endometrium as well as other less common sites. Usually, the primary site is obvious; however, in some pa­tients with endometrioid cancer of the ovary (re­sembling endometrial malignancy) it may be ex­ceedingly difficult to differentiate a primary endometrial cancer which is metastatic to the ovary from a primary endometrioid cancer of the ovary metastatic to the uterus. Fallopian tube. The fallopian tube must also be regarded as a primary site for an ad­nexal mass. Aside from inflammatory cond'i­tions, ectopic pregnancy is probably the mass most commonly seen. The presence of pain, the tender mass, and the history o.f overdue menses together with a positive pregnancy t.est and blood in the cul-de-sac will often help in making this diagnosis Primary carcinoma of the fallopian tube is seldom suspected prior to operation Occasion-ally, a history of intermittent watery discharge from the vagina and an oval-shaped pelvic mass are noted in cancers of the tube. Management Guidelines Certain guidelines should be kept in mind in evaluating adnexai masses. Any adnexal en­largement in the postmenopausal woman should be an indication for removal. In the adult woman prior to the menopause a cystic mass 5 cm or 6 cm in size that persists through one or more complete menstrual cycles is an indication for exploration. If the mass is enlarging during }hat time o.f observat.ion, the indication for sur­g,ery is more urgent; solid, bilateral masses are mo.re suspicious than cystic unilateral masses. · F·ina,IJ.y, there are a few situations in which emergency exploration 1s indicated. Torsion of an ovafian cyst, characterized by pelvic pain of increasing severity, ·is often accompanied by a mi'ld teukocytosis and low-grade fever; the pain is usually ag:g.ravated by motion. Hemorrhage from a rnptured ectopic pregnancy demands immedi-a.le ·surgery as soon as the diagnosis is made as does a ruptured tuba-ovarian abscess; the latter is best treated by complete hysterec­tomy a1nd bilateral, salpingo-oophorectomy. Fail­ure to act promptly in such instances may result in g,en�ralized peritonitis. GOPLERUO ADNEXAL MASSES / 51 

Evaluation and Management of Adnexal Masses

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Evaluation and Management of Adnexal Masses

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