Francesca Lentini

MD V

Gynaecology Case 2: Adnexal Mass

Case Summary
Ms. MLG a 44 year old with a past surgical history of a total abdominal hysterectomy
for fibroid uterus was admitted for bilateral salpingo-oophorectomy. She was referred
for a gynaecology consult following an ultrasound scan (U/S) of her abdomen (which
was taken for an unrelated medical indication) revealed a 12.49cm x 8.43cm left
adnexal mass.

History of Presenting Complaint

Ms. MLG is a 40 year old G0 P0 who was referred to gynaecology following the
incidental identification of a 12.49cm x 8.43cm cystic left adnexal mass on an
abdominal ultrasound done for an unrelated medical indication. The women is
asymptomatic and feels well, however on questioning she admits to mild abdominal
and low back pain (described as 1/10 for severity) for about 5 months. The pain is felt
in the left iliac fossa and radiates down the front of the thigh to the knee. The pain is
not caused by anything in particular and is constant. She denies any dyspareunia.
There is no obvious abdominal distention. The patient has not lost weight and has had
no change in appetite. The patient had a total abdominal hysterectomy for a fibroid
uterus last year, where her ovaries were preserved and she is currently still
premenopausal: there are no menopausal symptoms and the patient describes cyclical
changes in her breast: the same as she had before the surgery. There has been no
recent change in her vaginal discharge, no post coital bleeding, no urinary symptoms
and no prolapse.

Past gynaecological history

Ms. MLG’s menarche was at 14 years of age. Her last menstrual period was on the
18/01/10 after which she performed a total abdominal hysterectomy for a fibroid
uterus preserving her ovaries. She has no menopausal symptoms of hot flushing or
vaginal dryness. Her cycles were always regular with 28 day duration with 5 days of
bleeding in each cycle. Her periods had been heavy since 2007 with clots and
flooding needing to change her pads every 1 hour. She has no history of

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dysmennorhea, inter-menstrual bleeds, post-coital bleeds or any bleeding in the past
year since surgery.

Vaginal discharge is of normal amount, colour and smell and does not itch. There is
no prolapse or incontinence.

The patient is sexually active, using male condoms for contraception. She has no
history of sexually transmitted diseases and her last Smear was in 2010 which was
normal. All previous Smears were also normal.

Past Obstetric History

Nil

Past Medical History

 Hypertension

Drug History
 Enalapril 20mg daily
 Mexazolam 1mg tds
The patient has no known drug allergies.

Family History
 Mother died at age 55 of malignant breast cancer.
 Father suffers from ischemic heart disease.
 Her brother is mentally retarded.

Social History
 The patient is a smoker, smoking ½ a packet of cigarettes daily.

 She does not drink alcohol.

 She works as a clerk.

 She is single and lives with her father.

The patient is very apprehensive and anxious about the U/S findings and fears she
might have a cancer.

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Systems review
 Cardiovascular: nil
 Respiratory: early morning cough with sputum
 Gastrointestinal: nil
 Genitourinary: nil
 Musculoskeletal: nil
 Neurological: nil

Examination
The abdomen was exposed with the patient lying supine. On general inspection the
patient looked well: there was no pallor and no signs of systemic or endocrine disease.

Cardiovascular: Pulse 68 bpm. Blood pressure: 120/70 mmHg. The first and second
heart sounds were auscultated without any added sounds or murmurs.

Respiratory: chest clear; normal air entry left = right.

On inspection of the abdomen a Pfannensteil scar was seen. The abdomen looked
symmetrical and there was no abdominal distention. Hair distribution was gynaecoid.
There were no striae. On palpation the abdomen was non-tender. A 16/40 mass was
palpated in the left lower quadrant. On percussion over the mass there was no
dullness. There was no sign of shifting dullness. On auscultation, the bowel sounds
were normal.

On inspection of the perineum, there were no skin changes, no lumps, lesions or

prolapse. On bimanual pelvic examination a large smooth mobile mass was palpated
in the left lateral fornix. On Cusco’s Speculum Examination the vault appeared
healthy.

Management
Bloods were taken for a complete blood count, urea & electrolytes + creatinine, liver
function tests, CA 125, CEA, CA 19.9, alpha fetoprotein, B HCG. All results were
normal.

A CT scan of the pelvis was performed were a large 13cm x 10cm cystic mass was
observed. The wall was generally thin but there were scattered focal wall thickenings

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together with the presence of a few septations. The mass was seen to occupy the lower
part of the abdomen. On the right side of the pelvis there was a small amount of free
fluid and two cystic nodules about 1.8cm in diameter each. Because of the distortion
caused by the large cystic mass it was difficult to evaluate the origin of these and they
may therefore be either originating from the right ovary or enlarged lymph nodes.
However, the overall appearance suggested a right ovary origin and they may be
related to the cystic mass seen centrally and is likely to be originating from the left
ovary.

A surgical exploration was performed through a Pfannensteil incision. There were a

lot of adhesions and the bowel was dissected from the adhesions. The right ovary was
normal. A left pseudo-cyst was present with the left ovary embedded in the cyst wall.
A bilateral salphino-ophorectomy was performed and they were sent for histology,
with fluid from the cyst sent for cytology.

Haemostasis was ensured. A Redivac drain was left in the pelvis. The abdomen was
closed in layers. All counts were correct.

Post-operatively, Ms. MLG was watched fully until awake especially for bleeding.
Parameters were checked four hourly. She was kept nil by mouth. An intravenous
infusion of Hartmann’s running at 1L 6 hourly was set up. Input/Output charting was
monitored.

She made an uneventful recovery post-operatively. She was discharged 5 days post-
operatively. She was given a gynaecology outpatient review in 6 weeks were the
results of the histology and cytology will be discussed.

Discussion
Adnexal masses are very common, typically presenting both diagnostic and
therapeutic dilemmas. As in Ms. MLG, most are detected incidentally. In the USA, a
woman has 5-10% lifetime risk of undergoing surgery for suspected ovarian
neoplasm. Although most are benign, the goal of evaluation is to exclude malignancy.

When evaluating adnexal masses one needs to consider two factors. Firstly, is the
patient symptomatic? In this case she has mild low back pain radiating down forward
to the thigh and knee- typical of ovarian pain. Secondly, one has to consider if the
adnexal mass could be malignant. This is important because masses with a low

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likelihood of cancer can be managed conservatively. On the other hand, those that are
more likely malignant are best removed by surgery. In this case the mass was less
clearly benign or malignant, so surgery was performed. The differential diagnosis
includes: ovarian cysts, ectopic pregnancies (not in this case), benign or malignant
tumours, endometriomas, polycystic ovaries, tubo-ovarian cysts, uterine fibroid (not
in this case) and also non-gynaecological causes including a diverticular abscess. The
most important diagnostic factors are the women’s age and whether she is pre- or post
menopausal. Masses in young premenopausal women as in Ms. MLG are almost
always gynaecologic.

The patient should have ideally undergone a trans-vaginal ultrasound examination. No

alternative imaging modality has comparable accuracy, ease and availability.
However, one must keep in mind that the value of this study is interpreter dependant.

The CA 125 was measured in Ms. MLG. CA 125 is a non-specific test. The value of
this test is mainly to distinguish between benign and malignant masses in
postmenopausal women. CA 125 levels are generally less valuable in cases such as in
Ms. MLG where she is pre-menopausal, because elevations in the CA125 levels can
be caused by numerous benign reasons, e.g. hepatitis, congestive heart failure or renal
failure. However, extreme values would have been helpful- a markedly elevated
CA125 level would raise much greater concern for malignancy.

Aspiration of cyst fluid for cytology is not to be performed as aspiration of a

malignant mass may induce spillage and seeding of cells in the abdomen, thereby
changing the stage and prognosis.

Risk factors for ovarian cancer include increasing age, family history and incessant
ovulation, e.g. the fact that Ms MLG is nulliparous is a risk factor.

References
 In Jameson JN, Kasper DL, Harrison TR, Braunwald E, Fauci AS, Hauser SL,
Longo DL. Harrison’s principles of internal medicine (16th ed.). New York:
McGraw-Hill Medical Publishing Division. ISBN 0-07-140235-7.
 Goff BA, Mandel LS, Melancon CH, Muntz HG (June 2004). “Frequency of
symptoms of ovarian cancer in women presenting to primary care clinics”

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 Bandera CA (June 2005). “Advances in the understanding of risk factors for

ovarian cancer”. J Reprod Med 50 (6): 399–406. PMID 16050564