Adnexal mass
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# Overview
Adnexal mass is a disease with multiple gynecological and nongynecological causes. It affects females of all ages, from childbirth to postmenopause.  It is critical to early detect malignant causes such as ovarian cancer. Most causes are benign and either remain stable or spontaneously resolve within few weeks. complications such as ovarian torsion and cyst rupture necessitate immediate surgical intervention.

# Historical Perspective
In 2007, transvaginal ultrasound was considered by the American College of Obstetricians and Gynecologists to be the first imaging tool to rule out adnexal mass malignancy.

# Classification
Adnexal masses are divided into two types based on their origin: gynecological origin and non-gynecological origin. Each group is further subdivided into benign and malignant. 

# Pathophysiology
The pathophysiology of adnexal mass depends on the histological subtype and varies according to age, reproductive status, and location.
- Endometrioma is an ectopic endometrial tissue that bleeds in a single or both ovaries leading to the development of hemorrhagic/ chocolate cyst.
- Ovarian tumors most commonly have an epithelial origin, leading tohigh-grade serous carcinoma in the ovaries, fallopian tubes, or the peritoneum. The second common origin is primordial germ cells developing teratoma ( dermoid cyst), which is the most common benign germ cell tumor in the ovaries, dysgerminomas, mixed germ cell tumors and yolk sac tumors which are malignant.
- Krukenberg tumors develop as hematogenous of the colon, breasts, and endometrial tumors to the ovaries and fallopian tubes.
- Physiologic cysts, such as follicular cysts, which form due to the failure of formed follicles to rupture, and corpus leutum cysts, which form due to the failure of corpus leutum involution during early pregnancy. Leutoma of pregnancy is the corpus leutum cyst in a solid form rather than cystic.
- Tubo-ovarian abscess, hydrosalpinx, pyosalpinx are inflammatory complications of untreated pelvic inflammatory disease.

# Causes
Adnexal mass is most commonly caused by ovaries and fallopian tube masses, with etiologies that differ depending on the patient's age and reproductive status.  Endometrioma is the most common benign cause of the adnexal mass. While ovarian epithelial carcinoma is the most common malignant cause. 

# Differentiating Adnexal mass from other Diseases
Adnexal mass must be differentiated from other causes of pelvic mass such as uterine carcinoma/sarcoma, colorectal cancer, diverticular abscess,iliopsoas abscess, and renal tumors.

# Epidemiology and Demographics
At the age of 35, the prevalence of adnexal mass in the United States of America is approximately 153 per 100,000 women. However, Women of all ages can develop adnexal mass with no racial preference .

# Risk Factors
Common risk factors in the development of adnexal mass include induction of ovulation, increasing age, genital tract infection, and family history of ovarian/endometrial cancer.

# Screening
According to the American College of Physicians and the United States Preventive Services Taskforce, do not recommend screening for ovarian cancer with a bimanual pelvic examination in asymptomatic and non-pregnant women .

# Natural History, Complications, and Prognosis
Common complications of adnexal mass include hemorrhagic ovarian cysts, ovarian cyst rupture, and adnexal torsion with resulting in ischemia and necrosis.

# Diagnosis

## Diagnostic Study of Choice
There are no established criteria for the diagnosis of adnexal mass.

## History and Symptoms
The most common symptom is lower abdominal or pelvic pain with pressure character that can be associated with vaginal bleeding. Other associated symptoms such as dyspareunia, bloating, and abdominal distension, urinary symptoms raise suspicion of malignancy
The onset and duration of the pain dictate the urgency of intervention. Sudden onset of severe pelvic pain during the first trimester of pregnancy, or associated with fever require immediate evaluation in the urgent care clinic or the emergency department to exclude ruptured ectopic pregnancy, ruptures ovarian cyst, tubo-ovarian abscess, or ovarian torsion12
The broad spectrum of diseases causing adnexal mass is guided by age, parity, contraception methods, use of ovulation induction medication, and family history of breast or gynecological tumors particularly of associated with BRCA1/BRCA2 mutations.

## Physical Examination
The presence of a palpable mass on pelvic examination is diagnostic of adnexal mass. Although not palpating any mass does not exclude the diagnosis and still requires imagining studies.

## Laboratory Findings
Some patients with adnexal masses may have elevated concentrations of CA125, which is usually suggestive of epithelial ovarian cancer.

## Electrocardiogram
There are no ECG findings associated with an adnexal mass.

## X-ray
There are no x-ray findings associated with adnexal masses.

## Ultrasound
Transvaginal ultrasound is necessary to diagnose adnexal mass. The best modality is to combine transvaginal ultrasound with transabdominal ultrasound to better realize the characteristics of the mass and whether benign or malignant. Findings on a transvaginal ultrasound suggestive of simple cyst include thin-walled, anechoic/black, and rounded shape. Endometrioma appears as a homogenous cystic mass with medium echogenicity. While, hydrosalpinx emerges as a septated or nodular tube. Malignancy is suspected when a grey scale solid mass with thick irregular septations is seen.

## CT scan
There are no CT scan findings associated with adnexal masses. However, a CT scan may help stage ovarian cancer.

## MRI
A series of basic T1 and T2 pelvic MRIs may be helpful in the diagnosis of ultrasonically indeterminant adnexal masses such as hemorrhagic cysts with a mural clot, atypical mature teratoma, and solid ovarian neoplasms. This can be a cost-effective approach to avoid unnecessary surgical intervention.

## Other Imaging Findings
There are no other imaging findings associated with an adnexal mass.

## Other Diagnostic Studies
Other diagnostic studies for adnexal mass include serum or urine BHCG for all women of premenopausal age, which is positive in cases of ectopic pregnancy. Estradiol and total testosterone levels should be measured with signs of excess estrogen as virilization and hirsutism. Surgical exploration either through a laparotomy or laparoscopic approach aids in staging and prognosis of suspected malignancy.

# Treatment

## Medical Therapy
Most benign causes of adnexal masses need frequent follow-up with transvaginal ultrasound and symptomatic treatment as they self-resolved within a few weeks of intervention. Pharmacologic medical therapy is recommended for patients with polycystic ovarian syndrome.

## Surgery
Surgery is not the first-line treatment option for patients with an adnexal mass. Surgery is usually reserved for patients with either complication and urgent presentations as ectopic pregnancy, Tubo ovarian abscess, ovarian torsion, hemorrhagic cysts, and cyst rupture. At the early stages of ovarian cancer, oophorectomy is recommended.

## Primary Prevention
There are no established measures for the primary prevention of adnexal mass.

## Secondary Prevention
There are no established measures for the secondary prevention of adnexal mass. However, in low malignancy risk masses, follow up with ultrasound at a frequency of 6 weeks to 6 months can be beneficial.