Diagnostic evaluation

A. The finding of a pelvic mass usually requires surgery for definitive histologic diagnosis. Tumor markers (eg, serum CA 125) and ultrasound examination can help distinguish between malignant and benign pelvic masses.

B. A complete pelvic examination and assessment of cervical cytology should be performed preopera-tively. Routine hematologic and biochemical assessments should be obtained prior to surgery. Ultrasonography for diagnosis of ovarian malig nancy has a sensitivity of 62 to 100 percent and a specificity of 77 to 95 percent.

C. It is reasonable to pursue a period of observation in a premenopausal woman with an adnexal mass if the mass is not clinically suspicious on ultrasonography. Adnexal masses that are mobile, purely cystic, unilateral, less than 8 to 10 cm in diameter, and have smooth internal and external contours by ultrasound are highly unlikely to be malignant and can be followed for two months; the majority of physiologic cysts will regress during this time.

D. Exploration is indicated if there is no resolution within two months. However, women who have solid, fixed, irregularly shaped, or large masses should undergo surgery. A mass that increases in size or does not regress must be presumed to be neoplastic and should be removed surgically.

E. The threshold for surgical intervention is lower in postmenopausal women; those with cysts greater than 3 cm should undergo exploratory surgery, laparotomy, or laparoscopy.

F. Tumor markers. CA 125: The preoperative evaluation of a woman with suspected ovarian cancer should include measurement of the CA 125 concentration. The serum CA 125 (normal <35 U/mL) is elevated (>65 U/mL) in 80 percent of women with epithelial ovarian cancer. It is also increased in patients with other malignancies, including endometrial cancer and certain pancreatic cancers; in endometriosis, uterine leiomyoma, and pelvic inflammatory disease; and in approximately 1 percent of healthy women.

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