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== | ||
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>. | |||
==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:''' | |||
- [[Corpus luteum cyst]] | |||
- [[Follicular cyst]] | |||
- [[Luteuma of pregnancy]] | |||
- [[Mature teratoma]] | |||
- [[Ovarian torsion]] | |||
- [[Polycystic ovaries]] | |||
- [[Mucinous and serous cystadenoma]] | |||
- [[Theca lutein cyst]] | |||
|- | |- | ||
| rowspan="3;" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | | | rowspan="3;" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | | ||
| style="padding: 5px 5px; background: #F5F5F5;" |'''Malignant Ovarian:''' | | style="padding: 5px 5px; background: #F5F5F5;" |'''Malignant Ovarian:''' | ||
- Borderline tumors | - [[Borderline tumors]] | ||
- Epithelial carcinoma | - [[Epithelial carcinoma]] | ||
- Ovarian germ cell tumor | - [[Ovarian germ cell tumor]] | ||
- Ovarian Sarcoma | - [[Ovarian Sarcoma]] | ||
- Stromal tumor | - [[Stromal tumor]] | ||
|- | |- | ||
| style="padding: 5px 5px; background: #F5F5F5;" |'''Benign Nonovarian:''' | | style="padding: 5px 5px; background: #F5F5F5;" |'''Benign Nonovarian:''' | ||
- Ectopic pregnancy | - [[Ectopic pregnancy]] | ||
- Endometrioma | - [[Endometrioma]] | ||
- Hydrosalpinx | - [[Hydrosalpinx]] | ||
- Leiomyoma | - [[Leiomyoma]] | ||
- Tubo-ovarian abscess | - [[Tubo-ovarian abscess]] | ||
|- | |- | ||
| style="padding: 5px 5px; background: #F5F5F5;" |'''Malignant Nonovarian:''' | | style="padding: 5px 5px; background: #F5F5F5;" |'''Malignant Nonovarian:''' | ||
- Endometrial carcinoma | - [[Endometrial carcinoma]] | ||
- Fallopian tube carcinoma | - [[Fallopian tube carcinoma]] | ||
|- | |- | ||
| Line 73: | Line 65: | ||
| style="padding: 5px 5px; background: #F5F5F5;" |'''Benign:''' | | style="padding: 5px 5px; background: #F5F5F5;" |'''Benign:''' | ||
- Appendiceal abscess | - [[Appendiceal abscess]] | ||
- Appendicitis | - [[Appendicitis]] | ||
- Bladder diverticulum | - [[Bladder diverticulum]] | ||
- Diverticular abscess | - [[Diverticular abscess]] | ||
- Nerve sheath tumor | - [[Nerve sheath tumor]] | ||
- Pelvic kidney | - [[Pelvic kidney]] | ||
- Peritoneal cyst | - [[Peritoneal cyst]] | ||
- Ureteral diverticulum | - [[Ureteral diverticulum]] | ||
|- | |- | ||
| style="padding: 5px 5px; background: #F5F5F5;" |'''Malignant:''' | | style="padding: 5px 5px; background: #F5F5F5;" |'''Malignant:''' | ||
- Gastrointestinal carcinoma | - [[Gastrointestinal carcinoma]] | ||
- Krukenberg tumor | - [[Krukenberg tumor]] | ||
- Metastasis | - Metastasis | ||
- Retroperitoneal sarcoma | - [[Retroperitoneal sarcoma]] | ||
|- | |- | ||
| Line 105: | Line 97: | ||
==Pathophysiology== | ==Pathophysiology== | ||
The pathophysiology of adnexal mass depends on the histological subtype and varies according to age, reproductive status, and location. | 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<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>. | - [[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>. | ||
- 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>. | - 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>. | ||
- 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>. | - [[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>. | - 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>. | ||
- 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>. | - [[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== | ==Causes== | ||
Adnexal mass is most commonly caused by ovaries and fallopian | 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> | ||
==Differentiating | ==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== | ==Epidemiology and Demographics== | ||
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==Risk Factors== | ==Risk Factors== | ||
Common risk factors in the development of adnexal mass include | 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== | ==Screening== | ||
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==Natural History, Complications, and Prognosis== | ==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. | Common complications of adnexal mass include [[hemorrhagic ovarian cysts]], [[ovarian cyst rupture]], and [[adnexal torsion]] with resulting in ischemia and necrosis. | ||
==Diagnosis== | ==Diagnosis== | ||
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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 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 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 | 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 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=== | ||
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. | 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=== | ===Laboratory Findings=== | ||
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>. | 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>. | ||
===Electrocardiogram=== | ===Electrocardiogram=== | ||
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===Ultrasound=== | ===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>. | [[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>. | ||
===CT scan=== | ===CT scan=== | ||
There are no CT scan findings associated with adnexal masses. However, a CT scan may | There are no CT scan findings associated with adnexal masses. However, a CT scan may help stage ovarian cancer. | ||
===MRI=== | ===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<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>. | 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>. | ||
===Other Imaging Findings=== | ===Other Imaging Findings=== | ||
| Line 174: | Line 163: | ||
===Other Diagnostic Studies=== | ===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<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>. | 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>. | ||
==Treatment== | ==Treatment== | ||
===Medical Therapy=== | ===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]]. | |||
Pharmacologic medical therapy is recommended | |||
===Surgery=== | ===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<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>. | |||
Surgery is not the first-line treatment option for patients with | |||
===Primary Prevention=== | ===Primary Prevention=== | ||
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: |
| Malignant Ovarian: | |
| Benign Nonovarian: | |
| Malignant Nonovarian: | |
| Non-Gynecological Origin | Benign: |
| Malignant:
- Metastasis |
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
- ↑ 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). - ↑ 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). - ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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
- ↑ 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.
- ↑ 12.0 12.1 12.2 Biggs WS, Marks ST (2016). "Diagnosis and Management of Adnexal Masses". Am Fam Physician. 93 (8): 676–81. PMID 27175840.
- ↑ 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.
- ↑ Cannistra SA (2004). "Cancer of the ovary". N Engl J Med. 351 (24): 2519–29. doi:10.1056/NEJMra041842. PMID 15590954.
- ↑ 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. - ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.