Adnexal mass: Difference between revisions

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==Overview==
==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==
==Historical Perspective==
[Disease name] was first discovered by [name of scientist], a [nationality + occupation], in [year]/during/following [event].
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<ref name="pmid33199990">{{cite journal| author=Zhang X, Meng X, Dou T, Sun H| title=Diagnostic accuracy of transvaginal ultrasound examination for assigning a specific diagnosis to adnexal masses: A meta-analysis. | journal=Exp Ther Med | year= 2020 | volume= 20 | issue= 6 | pages= 265 | pmid=33199990 | doi=10.3892/etm.2020.9395 | pmc=7664593 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33199990  }} </ref>.


The association between [important risk factor/cause] and [disease name] was made in/during [year/event].
==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. <ref name="pmidPMID: 19835343">{{cite journal| author=Givens V, Mitchell GE, Harraway-Smith C, Reddy A, Maness DL| title=Diagnosis and management of adnexal masses. | journal=Am Fam Physician | year= 2009 | volume= 80 | issue= 8 | pages= 815-20 | pmid=PMID: 19835343 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19835343  }} </ref>
{| style="border: 0px; font-size: 90%; margin: 3px;"
| rowspan="1" style="background: #DCDCDC; padding: 5px 5px;" |Gynecological Origin
| rowspan="1;" style="background: #F5F5F5; padding: 5px 5px;" |'''Benign Ovarian:'''


In [year], [scientist] was the first to discover the association between [risk factor] and the development of [disease name].
- [[Corpus luteum cyst]]


In [year], [gene] mutations were first implicated in the pathogenesis of [disease name].
- [[Follicular cyst]]


There have been several outbreaks of [disease name], including -----.
- [[Luteuma of pregnancy]]


In [year], [diagnostic test/therapy] was developed by [scientist] to treat/diagnose [disease name].
- [[Mature teratoma]]


==Classification==
- [[Ovarian torsion]]
There is no established system for the classification of [disease name].


OR
- [[Polycystic ovaries]]


[Disease name] may be classified according to [classification method] into [number] subtypes/groups: [group1], [group2], [group3], and [group4].
- [[Mucinous and serous cystadenoma]]


OR
- [[Theca lutein cyst]]
|-
| rowspan="3;" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |
| style="padding: 5px 5px; background: #F5F5F5;" |'''Malignant Ovarian:'''
- [[Borderline tumors]]


[Disease name] may be classified into [large number > 6] subtypes based on [classification method 1], [classification method 2], and [classification method 3].
- [[Epithelial carcinoma]]
[Disease name] may be classified into several subtypes based on [classification method 1], [classification method 2], and [classification method 3].


OR
- [[Ovarian germ cell tumor]]


Based on the duration of symptoms, [disease name] may be classified as either acute or chronic.
- [[Ovarian Sarcoma]]


OR
- [[Stromal tumor]]
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Benign Nonovarian:'''
- [[Ectopic pregnancy]]


If the staging system involves specific and characteristic findings and features:
- [[Endometrioma]]
According to the [staging system + reference], there are [number] stages of [malignancy name] based on the [finding1], [finding2], and [finding3]. Each stage is assigned a [letter/number1] and a [letter/number2] that designate the [feature1] and [feature2].


OR
- [[Hydrosalpinx]]


The staging of [malignancy name] is based on the [staging system].
- [[Leiomyoma]]


OR
- [[Tubo-ovarian abscess]]
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Malignant Nonovarian:'''


There is no established system for the staging of [malignancy name].
- [[Endometrial carcinoma]]


==Pathophysiology==
- [[Fallopian tube carcinoma]]
The exact pathogenesis of [disease name] is not fully understood.


OR
|-
| rowspan="3;" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Non-Gynecological Origin
| style="padding: 5px 5px; background: #F5F5F5;" |'''Benign:'''


It is thought that [disease name] is the result of / is mediated by / is produced by / is caused by either [hypothesis 1], [hypothesis 2], or [hypothesis 3].
- [[Appendiceal abscess]]


OR
- [[Appendicitis]]


[Pathogen name] is usually transmitted via the [transmission route] route to the human host.
- [[Bladder diverticulum]]


OR
- [[Diverticular abscess]]


Following transmission/ingestion, the [pathogen] uses the [entry site] to invade the [cell name] cell.
- [[Nerve sheath tumor]]


OR
- [[Pelvic kidney]]


- [[Peritoneal cyst]]


[Disease or malignancy name] arises from [cell name]s, which are [cell type] cells that are normally involved in [function of cells].
- [[Ureteral diverticulum]]
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Malignant:'''


OR
- [[Gastrointestinal carcinoma]]


The progression to [disease name] usually involves the [molecular pathway].
- [[Krukenberg tumor]]


OR
- Metastasis


The pathophysiology of [disease/malignancy] depends on the histological subtype.
- [[Retroperitoneal sarcoma]]
|-


==Causes==
|}
Disease name] may be caused by [cause1], [cause2], or [cause3].


OR
<br />


Common causes of [disease] include [cause1], [cause2], and [cause3].
==Pathophysiology==
The pathophysiology of [[adnexal mass]] depends on the histological subtype and varies according to age, reproductive status, and location.


OR
- [[Endometrioma]] is an ectopic endometrial tissue that bleeds in a single or both ovaries leading to the development of hemorrhagic/ chocolate cyst<ref name="pmid8194613">{{cite journal| author=Brosens IA, Puttemans PJ, Deprest J| title=The endoscopic localization of endometrial implants in the ovarian chocolate cyst. | journal=Fertil Steril | year= 1994 | volume= 61 | issue= 6 | pages= 1034-8 | pmid=8194613 | doi=10.1016/s0015-0282(16)56752-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8194613  }} </ref>.


The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].
- Ovarian tumors most commonly have an epithelial origin, leading to[[high-grade serous carcinoma]] in the ovaries, fallopian tubes, or the peritoneum<ref name="pmid11385772">{{cite journal| author=Heintz AP, Odicino F, Maisonneuve P, Beller U, Benedet JL, Creasman WT | display-authors=etal| title=Carcinoma of the ovary. | journal=J Epidemiol Biostat | year= 2001 | volume= 6 | issue= 1 | pages= 107-38 | pmid=11385772 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11385772  }} </ref>. 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<ref name="pmid10636515">{{cite journal| author=Tewari K, Cappuccini F, Disaia PJ, Berman ML, Manetta A, Kohler MF| title=Malignant germ cell tumors of the ovary. | journal=Obstet Gynecol | year= 2000 | volume= 95 | issue= 1 | pages= 128-33 | pmid=10636515 | doi=10.1016/s0029-7844(99)00470-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10636515  }} </ref>.


OR
- [[Krukenberg tumors]] develop as hematogenous of the colon, breasts, and endometrial tumors to the ovaries and fallopian tubes<ref name="pmid19823050">{{cite journal| author=de Waal YR, Thomas CM, Oei AL, Sweep FC, Massuger LF| title=Secondary ovarian malignancies: frequency, origin, and characteristics. | journal=Int J Gynecol Cancer | year= 2009 | volume= 19 | issue= 7 | pages= 1160-5 | pmid=19823050 | doi=10.1111/IGC.0b013e3181b33cce | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19823050  }} </ref>. 
- 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<ref name="pmid12164573">{{cite journal| author=Jain KA| title=Sonographic spectrum of hemorrhagic ovarian cysts. | journal=J Ultrasound Med | year= 2002 | volume= 21 | issue= 8 | pages= 879-86 | pmid=12164573 | doi=10.7863/jum.2002.21.8.879 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12164573  }} </ref>. [[Leutoma of pregnancy]] is the [[corpus leutum cyst]] in a solid form rather than cystic<ref name="pmid8463033">{{cite journal| author=Clement PB| title=Tumor-like lesions of the ovary associated with pregnancy. | journal=Int J Gynecol Pathol | year= 1993 | volume= 12 | issue= 2 | pages= 108-15 | pmid=8463033 | doi=10.1097/00004347-199304000-00004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8463033  }} </ref>.


The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click [[Pericarditis causes#Overview|here]].
- [[Tubo-ovarian abscess]], [[hydrosalpinx]], [[pyosalpinx]] are inflammatory complications of untreated [[pelvic inflammatory disease]]<ref name="pmid19230781">{{cite journal| author=Granberg S, Gjelland K, Ekerhovd E| title=The management of pelvic abscess. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2009 | volume= 23 | issue= 5 | pages= 667-78 | pmid=19230781 | doi=10.1016/j.bpobgyn.2009.01.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19230781  }} </ref>.  
 
==Causes==
==Differentiating ((Page name)) from other Diseases==
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. <ref name="pmid26800772">{{cite journal| author=Timmerman D, Van Calster B, Testa A, Savelli L, Fischerova D, Froyman W | display-authors=etal| title=Predicting the risk of malignancy in adnexal masses based on the Simple Rules from the International Ovarian Tumor Analysis group. | journal=Am J Obstet Gynecol | year= 2016 | volume= 214 | issue= 4 | pages= 424-437 | pmid=26800772 | doi=10.1016/j.ajog.2016.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26800772  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=27506445 Review in: Evid Based Med. 2016 Oct;21(5):197] </ref>
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
==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]].
OR
 
[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].


==Epidemiology and Demographics==
==Epidemiology and Demographics==
The incidence/prevalence of [disease name] is approximately [number range] per 100,000 individuals worldwide.
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 <ref name="pmid27421754">{{cite journal| author=Hermans AJ, Kluivers KB, Janssen LM, Siebers AG, Wijnen MHWA, Bulten J | display-authors=etal| title=Adnexal masses in children, adolescents and women of reproductive age in the Netherlands: A nationwide population-based cohort study. | journal=Gynecol Oncol | year= 2016 | volume= 143 | issue= 1 | pages= 93-97 | pmid=27421754 | doi=10.1016/j.ygyno.2016.07.096 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27421754  }} </ref>.
 
OR
 
In [year], the incidence/prevalence of [disease name] was estimated to be [number range] cases per 100,000 individuals worldwide.
 
OR
 
In [year], the incidence of [disease name] is approximately [number range] per 100,000 individuals with a case-fatality rate of [number range]%.
 
 
 
Patients of all age groups may develop [disease name].
 
OR
 
The incidence of [disease name] increases with age; the median age at diagnosis is [#] years.
 
OR
 
[Disease name] commonly affects individuals younger than/older than [number of years] years of age.
 
OR
 
[Chronic disease name] is usually first diagnosed among [age group].
 
OR
 
[Acute disease name] commonly affects [age group].
 
 
 
There is no racial predilection to [disease name].
 
OR
 
[Disease name] usually affects individuals of the [race 1] race. [Race 2] individuals are less likely to develop [disease name].
 
 
 
[Disease name] affects men and women equally.
 
OR
 
[Gender 1] are more commonly affected by [disease name] than [gender 2]. The [gender 1] to [gender 2] ratio is approximately [number > 1] to 1.
 
 
 
The majority of [disease name] cases are reported in [geographical region].
 
OR
 
[Disease name] is a common/rare disease that tends to affect [patient population 1] and [patient population 2].


==Risk Factors==
==Risk Factors==
There are no established risk factors for [disease name].
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]].
 
OR
 
The most potent risk factor in the development of [disease name] is [risk factor 1]. Other risk factors include [risk factor 2], [risk factor 3], and [risk factor 4].
 
OR
 
Common risk factors in the development of [disease name] include [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
 
OR
 
Common risk factors in the development of [disease name] may be occupational, environmental, genetic, and viral.


==Screening==
==Screening==
There is insufficient evidence to recommend routine screening for [disease/malignancy].
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 <ref name="pmid27175840">{{cite journal| author=Biggs WS, Marks ST| title=Diagnosis and Management of Adnexal Masses. | journal=Am Fam Physician | year= 2016 | volume= 93 | issue= 8 | pages= 676-81 | pmid=27175840 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27175840  }} </ref>.
 
OR
 
According to the [guideline name], screening for [disease name] is not recommended.
 
OR
 
According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
Common complications of adnexal mass include [[hemorrhagic ovarian cysts]], [[ovarian cyst rupture]], and [[adnexal torsion]] with resulting in ischemia and necrosis.
 
OR
 
Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
 
OR
 
Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.


==Diagnosis==
==Diagnosis==
===Diagnostic Study of Choice===
===Diagnostic Study of Choice===
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
There are no established criteria for the diagnosis of adnexal mass.


OR
===History and Symptoms===
 
The most common symptom is lower abdominal or pelvic pain with pressure character that can be associated with vaginal bleeding<ref name="pmid19835343">{{cite journal| author=Givens V, Mitchell GE, Harraway-Smith C, Reddy A, Maness DL| title=Diagnosis and management of adnexal masses. | journal=Am Fam Physician | year= 2009 | volume= 80 | issue= 8 | pages= 815-20 | pmid=19835343 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19835343  }} </ref>. Other associated symptoms such as dyspareunia, bloating, and abdominal distension, urinary symptoms raise suspicion of malignancy<ref name="pmid27175840">{{cite journal| author=Biggs WS, Marks ST| title=Diagnosis and Management of Adnexal Masses. | journal=Am Fam Physician | year= 2016 | volume= 93 | issue= 8 | pages= 676-81 | pmid=27175840 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27175840  }}
The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
 
OR
 
The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
 
OR
 
There are no established criteria for the diagnosis of [disease name].


===History and Symptoms===
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<nowiki><ref name="pmid27175840"></nowiki>{{cite journal| author=Biggs WS, Marks ST| title=Diagnosis and Management of Adnexal Masses. | journal=Am Fam Physician | year= 2016 | volume= 93 | issue= 8 | pages= 676-81 | pmid=27175840 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27175840  }} </ref>
The majority of patients with [disease name] are asymptomatic.


OR
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 torsion]]12


The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].
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<ref name="pmid27175840">{{cite journal| author=Biggs WS, Marks ST| title=Diagnosis and Management of Adnexal Masses. | journal=Am Fam Physician | year= 2016 | volume= 93 | issue= 8 | pages= 676-81 | pmid=27175840 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27175840  }} </ref>.


===Physical Examination===
===Physical Examination===
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
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.  
 
OR
 
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
 
OR
 
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].


===Laboratory Findings===
===Laboratory Findings===
An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].
Some patients with adnexal masses may have elevated concentrations of [[CA125]], which is usually suggestive of [[epithelial ovarian cancer]]<ref name="pmid15590954">{{cite journal| author=Cannistra SA| title=Cancer of the ovary. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 24 | pages= 2519-29 | pmid=15590954 | doi=10.1056/NEJMra041842 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15590954  }} </ref>.
 
OR
 
Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
 
OR
 
[Test] is usually normal among patients with [disease name].
 
OR
 
Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
 
OR
 
There are no diagnostic laboratory findings associated with [disease name].


===Electrocardiogram===
===Electrocardiogram===
There are no ECG findings associated with [disease name].
There are no ECG findings associated with an adnexal mass.
 
OR
 
An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].


===X-ray===
===X-ray===
There are no x-ray findings associated with [disease name].
There are no x-ray findings associated with adnexal masses.


OR
===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<ref name="pmid20505067">{{cite journal| author=Levine D, Brown DL, Andreotti RF, Benacerraf B, Benson CB, Brewster WR | display-authors=etal| title=Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. | journal=Radiology | year= 2010 | volume= 256 | issue= 3 | pages= 943-54 | pmid=20505067 | doi=10.1148/radiol.10100213 | pmc=6939954 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20505067 }} </ref>. 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<ref name="pmid10207476">{{cite journal| author=Patel MD, Feldstein VA, Chen DC, Lipson SD, Filly RA| title=Endometriomas: diagnostic performance of US. | journal=Radiology | year= 1999 | volume= 210 | issue= 3 | pages= 739-45 | pmid=10207476 | doi=10.1148/radiology.210.3.r99fe61739 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10207476 }} </ref>. While, hydrosalpinx emerges as a septated or nodular tube<ref name="pmid9697286">{{cite journal| author=Timor-Tritsch IE, Lerner JP, Monteagudo A, Murphy KE, Heller DS| title=Transvaginal sonographic markers of tubal inflammatory disease. | journal=Ultrasound Obstet Gynecol | year= 1998 | volume= 12 | issue= 1 | pages= 56-66 | pmid=9697286 | doi=10.1046/j.1469-0705.1998.12010056.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9697286 }} </ref>. Malignancy is suspected when a grey scale solid mass with thick irregular septations is seen<ref name="pmid9646799">{{cite journal| author=Brown DL, Doubilet PM, Miller FH, Frates MC, Laing FC, DiSalvo DN | display-authors=etal| title=Benign and malignant ovarian masses: selection of the most discriminating gray-scale and Doppler sonographic features. | journal=Radiology | year= 1998 | volume= 208 | issue= 1 | pages= 103-10 | pmid=9646799 | doi=10.1148/radiology.208.1.9646799 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9646799  }} </ref>.  
An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
 
===Echocardiography or Ultrasound===
There are no echocardiography/ultrasound  findings associated with [disease name].
 
OR
 
Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===CT scan===
===CT scan===
There are no CT scan findings associated with [disease name].
There are no CT scan findings associated with adnexal masses. However, a CT scan may help stage ovarian cancer.
 
OR
 
[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===MRI===
===MRI===
There are no MRI findings associated with [disease name].
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<ref name="pmid20720065">{{cite journal| author=Spencer JA, Ghattamaneni S| title=MR imaging of the sonographically indeterminate adnexal mass. | journal=Radiology | year= 2010 | volume= 256 | issue= 3 | pages= 677-94 | pmid=20720065 | doi=10.1148/radiol.10090397 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20720065  }} </ref>.
 
OR
 
[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===Other Imaging Findings===
===Other Imaging Findings===
There are no other imaging findings associated with [disease name].
There are no other imaging findings associated with an adnexal mass.
 
OR
 
[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].


===Other Diagnostic Studies===
===Other Diagnostic Studies===
There are no other diagnostic studies associated with [disease name].
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]]<ref name="pmid20926540">{{cite journal| author=Rosner W, Vesper H, Endocrine Society. American Association for Clinical Chemistry. American Association of Clinical Endocrinologists. Androgen Excess/PCOS Society | display-authors=etal| title=Toward excellence in testosterone testing: a consensus statement. | journal=J Clin Endocrinol Metab | year= 2010 | volume= 95 | issue= 10 | pages= 4542-8 | pmid=20926540 | doi=10.1210/jc.2010-1314 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20926540  }} </ref>. Surgical exploration either through a laparotomy or laparoscopic approach aids in staging and prognosis of suspected malignancy<ref name="pmid8008300">{{cite journal| author=Sainz de la Cuesta R, Goff BA, Fuller AF, Nikrui N, Eichhorn JH, Rice LW| title=Prognostic importance of intraoperative rupture of malignant ovarian epithelial neoplasms. | journal=Obstet Gynecol | year= 1994 | volume= 84 | issue= 1 | pages= 1-7 | pmid=8008300 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8008300  }} </ref>.
 
OR
 
[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
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]].
 
OR
 
Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
 
OR
 
The majority of cases of [disease name] are self-limited and require only supportive care.
 
OR
 
[Disease name] is a medical emergency and requires prompt treatment.
 
OR
 
The mainstay of treatment for [disease name] is [therapy].
 
OR
 
The optimal therapy for [malignancy name] depends on the stage at diagnosis.
 
OR
 
[Therapy] is recommended among all patients who develop [disease name].
 
OR
 
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
 
OR
 
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
 
OR
 
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
 
OR
 
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].


===Surgery===
===Surgery===
Surgical intervention is not recommended for the management of [disease name].
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<ref name="pmid4704002">{{cite journal| author=Webb MJ, Decker DG, Mussey E, Williams TJ| title=Factor influencing survival in Stage I ovarian cancer. | journal=Am J Obstet Gynecol | year= 1973 | volume= 116 | issue= 2 | pages= 222-8 | pmid=4704002 | doi=10.1016/0002-9378(73)91054-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4704002  }} </ref>.
 
OR
 
Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]
 
OR
 
The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].
 
OR
 
The feasibility of surgery depends on the stage of [malignancy] at diagnosis.
 
OR
 
Surgery is the mainstay of treatment for [disease or malignancy].


===Primary Prevention===
===Primary Prevention===
There are no established measures for the primary prevention of [disease name].
There are no established measures for the primary prevention of adnexal mass.
 
OR
 
There are no available vaccines against [disease name].
 
OR
 
Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
 
OR
 
[Vaccine name] vaccine is recommended for [patient population] to prevent [disease name]. Other primary prevention strategies include [strategy 1], [strategy 2], and [strategy 3].


===Secondary Prevention===
===Secondary Prevention===
There are no established measures for the secondary prevention of [disease name].
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<ref name="pmid12962948">{{cite journal| author=Modesitt SC, Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ, van Nagell JR| title=Risk of malignancy in unilocular ovarian cystic tumors less than 10 centimeters in diameter. | journal=Obstet Gynecol | year= 2003 | volume= 102 | issue= 3 | pages= 594-9 | pmid=12962948 | doi=10.1016/s0029-7844(03)00670-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12962948  }} </ref>.
 
OR
 
Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].


==References==
==References==

Latest revision as of 04:30, 14 May 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sarah Elsayed, MD., MPH.[2]

Synonyms and keywords:

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[1].

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. [2]

Gynecological Origin Benign Ovarian:

- Corpus luteum cyst

- Follicular cyst

- Luteuma of pregnancy

- Mature teratoma

- Ovarian torsion

- Polycystic ovaries

- Mucinous and serous cystadenoma

- Theca lutein cyst

Malignant Ovarian:

- Borderline tumors

- Epithelial carcinoma

- Ovarian germ cell tumor

- Ovarian Sarcoma

- Stromal tumor

Benign Nonovarian:

- Ectopic pregnancy

- Endometrioma

- Hydrosalpinx

- Leiomyoma

- Tubo-ovarian abscess

Malignant Nonovarian:

- Endometrial carcinoma

- Fallopian tube carcinoma

Non-Gynecological Origin Benign:

- Appendiceal abscess

- Appendicitis

- Bladder diverticulum

- Diverticular abscess

- Nerve sheath tumor

- Pelvic kidney

- Peritoneal cyst

- Ureteral diverticulum

Malignant:

- Gastrointestinal carcinoma

- Krukenberg tumor

- Metastasis

- Retroperitoneal sarcoma


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[3].

- Ovarian tumors most commonly have an epithelial origin, leading tohigh-grade serous carcinoma in the ovaries, fallopian tubes, or the peritoneum[4]. 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[5].

- Krukenberg tumors develop as hematogenous of the colon, breasts, and endometrial tumors to the ovaries and fallopian tubes[6].

- 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[7]. Leutoma of pregnancy is the corpus leutum cyst in a solid form rather than cystic[8].

- Tubo-ovarian abscess, hydrosalpinx, pyosalpinx are inflammatory complications of untreated pelvic inflammatory disease[9].

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. [10]

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 [11].

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 [12].

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[13]. Other associated symptoms such as dyspareunia, bloating, and abdominal distension, urinary symptoms raise suspicion of malignancy[12]

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[12].

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[14].

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[15]. 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[16]. While, hydrosalpinx emerges as a septated or nodular tube[17]. Malignancy is suspected when a grey scale solid mass with thick irregular septations is seen[18].

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[19].

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[20]. Surgical exploration either through a laparotomy or laparoscopic approach aids in staging and prognosis of suspected malignancy[21].

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[22].

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[23].

References

  1. ↑ Zhang X, Meng X, Dou T, Sun H (2020). "Diagnostic accuracy of transvaginal ultrasound examination for assigning a specific diagnosis to adnexal masses: A meta-analysis". Exp Ther Med. 20 (6): 265. doi:10.3892/etm.2020.9395. PMC 7664593 Check |pmc= value (help). PMID 33199990 Check |pmid= value (help).
  2. ↑ Givens V, Mitchell GE, Harraway-Smith C, Reddy A, Maness DL (2009). "Diagnosis and management of adnexal masses". Am Fam Physician. 80 (8): 815–20. PMID 19835343 PMID: 19835343 Check |pmid= value (help).
  3. ↑ Brosens IA, Puttemans PJ, Deprest J (1994). "The endoscopic localization of endometrial implants in the ovarian chocolate cyst". Fertil Steril. 61 (6): 1034–8. doi:10.1016/s0015-0282(16)56752-1. PMID 8194613.
  4. ↑ Heintz AP, Odicino F, Maisonneuve P, Beller U, Benedet JL, Creasman WT; et al. (2001). "Carcinoma of the ovary". J Epidemiol Biostat. 6 (1): 107–38. PMID 11385772.
  5. ↑ Tewari K, Cappuccini F, Disaia PJ, Berman ML, Manetta A, Kohler MF (2000). "Malignant germ cell tumors of the ovary". Obstet Gynecol. 95 (1): 128–33. doi:10.1016/s0029-7844(99)00470-6. PMID 10636515.
  6. ↑ de Waal YR, Thomas CM, Oei AL, Sweep FC, Massuger LF (2009). "Secondary ovarian malignancies: frequency, origin, and characteristics". Int J Gynecol Cancer. 19 (7): 1160–5. doi:10.1111/IGC.0b013e3181b33cce. PMID 19823050.
  7. ↑ Jain KA (2002). "Sonographic spectrum of hemorrhagic ovarian cysts". J Ultrasound Med. 21 (8): 879–86. doi:10.7863/jum.2002.21.8.879. PMID 12164573.
  8. ↑ Clement PB (1993). "Tumor-like lesions of the ovary associated with pregnancy". Int J Gynecol Pathol. 12 (2): 108–15. doi:10.1097/00004347-199304000-00004. PMID 8463033.
  9. ↑ Granberg S, Gjelland K, Ekerhovd E (2009). "The management of pelvic abscess". Best Pract Res Clin Obstet Gynaecol. 23 (5): 667–78. doi:10.1016/j.bpobgyn.2009.01.010. PMID 19230781.
  10. ↑ Timmerman D, Van Calster B, Testa A, Savelli L, Fischerova D, Froyman W; et al. (2016). "Predicting the risk of malignancy in adnexal masses based on the Simple Rules from the International Ovarian Tumor Analysis group". Am J Obstet Gynecol. 214 (4): 424–437. doi:10.1016/j.ajog.2016.01.007. PMID 26800772. Review in: Evid Based Med. 2016 Oct;21(5):197
  11. ↑ Hermans AJ, Kluivers KB, Janssen LM, Siebers AG, Wijnen MHWA, Bulten J; et al. (2016). "Adnexal masses in children, adolescents and women of reproductive age in the Netherlands: A nationwide population-based cohort study". Gynecol Oncol. 143 (1): 93–97. doi:10.1016/j.ygyno.2016.07.096. PMID 27421754.
  12. ↑ 12.0 12.1 12.2 Biggs WS, Marks ST (2016). "Diagnosis and Management of Adnexal Masses". Am Fam Physician. 93 (8): 676–81. PMID 27175840.
  13. ↑ Givens V, Mitchell GE, Harraway-Smith C, Reddy A, Maness DL (2009). "Diagnosis and management of adnexal masses". Am Fam Physician. 80 (8): 815–20. PMID 19835343.
  14. ↑ Cannistra SA (2004). "Cancer of the ovary". N Engl J Med. 351 (24): 2519–29. doi:10.1056/NEJMra041842. PMID 15590954.
  15. ↑ Levine D, Brown DL, Andreotti RF, Benacerraf B, Benson CB, Brewster WR; et al. (2010). "Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement". Radiology. 256 (3): 943–54. doi:10.1148/radiol.10100213. PMC 6939954 Check |pmc= value (help). PMID 20505067.
  16. ↑ Patel MD, Feldstein VA, Chen DC, Lipson SD, Filly RA (1999). "Endometriomas: diagnostic performance of US". Radiology. 210 (3): 739–45. doi:10.1148/radiology.210.3.r99fe61739. PMID 10207476.
  17. ↑ Timor-Tritsch IE, Lerner JP, Monteagudo A, Murphy KE, Heller DS (1998). "Transvaginal sonographic markers of tubal inflammatory disease". Ultrasound Obstet Gynecol. 12 (1): 56–66. doi:10.1046/j.1469-0705.1998.12010056.x. PMID 9697286.
  18. ↑ Brown DL, Doubilet PM, Miller FH, Frates MC, Laing FC, DiSalvo DN; et al. (1998). "Benign and malignant ovarian masses: selection of the most discriminating gray-scale and Doppler sonographic features". Radiology. 208 (1): 103–10. doi:10.1148/radiology.208.1.9646799. PMID 9646799.
  19. ↑ Spencer JA, Ghattamaneni S (2010). "MR imaging of the sonographically indeterminate adnexal mass". Radiology. 256 (3): 677–94. doi:10.1148/radiol.10090397. PMID 20720065.
  20. ↑ Rosner W, Vesper H, Endocrine Society. American Association for Clinical Chemistry. American Association of Clinical Endocrinologists. Androgen Excess/PCOS Society; et al. (2010). "Toward excellence in testosterone testing: a consensus statement". J Clin Endocrinol Metab. 95 (10): 4542–8. doi:10.1210/jc.2010-1314. PMID 20926540.
  21. ↑ Sainz de la Cuesta R, Goff BA, Fuller AF, Nikrui N, Eichhorn JH, Rice LW (1994). "Prognostic importance of intraoperative rupture of malignant ovarian epithelial neoplasms". Obstet Gynecol. 84 (1): 1–7. PMID 8008300.
  22. ↑ Webb MJ, Decker DG, Mussey E, Williams TJ (1973). "Factor influencing survival in Stage I ovarian cancer". Am J Obstet Gynecol. 116 (2): 222–8. doi:10.1016/0002-9378(73)91054-5. PMID 4704002.
  23. ↑ Modesitt SC, Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ, van Nagell JR (2003). "Risk of malignancy in unilocular ovarian cystic tumors less than 10 centimeters in diameter". Obstet Gynecol. 102 (3): 594–9. doi:10.1016/s0029-7844(03)00670-7. PMID 12962948.


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