With the increased use of transvaginal sonography more adnexal masses are

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• With the increased use of transvaginal sonography
  more adnexal masses are
• being detected in postmenopausal patients.
• Screening studies have indicated that
  approximately 3 to 5 of asymptomatic
  postmenopausal women will have an adnexal mass
  confirmed sonographically.
• Pelvic examination is inadequate in assessing
  ovarian size. Therefore, ultrasound is often used
  in addition to clinical examination.

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• Management of benign ovarian tumors and ovarian
  cancer is quite different.
• Accurate preoperative assessment of the risk of
  malignancy in adnexal tumors is very important.
• An effective system for predicting risk of
  malignancy in ovarian tumors will allow proper
  individualization of treatment.

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Ultrasound Evaluation

• More than 3000 postmenopausal women with
• unilocular ovarian cysts were monitored. The
• majority of which were less than 5 cm in
  diameter.
• During US follow up for an average of 6 years
• approximately 70 of these ovarian cysts resolved
• Spontaneously. No patient had ovarian cancer
• develop.
• The risk of malignancy in unilocular cystic
  ovarian
• tumors less than 5 cm in diameter was essentially
• nonexistent.

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• 250 complex ovarian tumors were identified in the
  same screening population. Spontaneous resolution
  occurred in 135 (54) of these tumors, but 115
  (45) persisted and were removed surgically. 8 of
  them (3) had ovarian or primary peritoneal
  cancers
• All persisting complex ovarian tumors in
  postmenopausal women should be removed surgically
  as soon as possible.

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Morphology Index

• Based on tumor volume, wall structure, and septal
  structure.
• Wall structure was the most reliable morphologic
  criterion
• A modified MI based on tumor volume and wall
  structure.
• Tumor volume lengthwidth height x0.523
• This MI was easy to interpret and interobserver
  variation was minimal.

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• MI 5 indicative of malignancy was associated
  with sensitivity 0.981, specificity 0.808, PPV
  0.409, NPV 0.997.
• Morphologic indexing, based on sonographically
  derived images, is a relatively accurate and
  cost-effective method to predict risk of
  malignancy in an ovarian tumor.

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Doppler Flow Studies

• PI S D/A,
• RI S D/S.
• Benign ovarian tumors had high systolic flow, and
  a high PI ( 1.0) and RI ( 0.4)
• Malignant ovarian tumors had a low PI
• ( 1.0) and RI( 0.4).
• Recent studies showed there is a significant
  overlap in Doppler flow indices between benign
  and malignant ovarian tumors.

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Contrast-enhanced power Doppler

• Intravascular contrast agents are used to enhance
  depiction of tumor vessels by providing a
  stronger Doppler signal.
• This method is time-consuming and require
  sophisticated ultrasound equipment and
  sonographer skill.

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Tumor Markers

• Serum levels of CA 125 are elevated (gt35 u/mL) in
  approximately 50 of patients with stage I
  epithelial ovarian cancer and in more than 90 of
  those with advanced disease.
• CA 125 is also elevated in a number of benign
  gynecologic conditions, but these conditions
  occur less frequently in postmenopausal women.
• CA 125 135 u/mL was necessary to achieve 100
  specificity in distinguishing ovarian cancer from
  benign ovarian neoplasms.

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• Serum CA 125 values rise over time in patients
  with ovarian cancer, whereas they remain stable
  or decrease in patients with benign ovarian
  tumors.
• Serial CA 125 values at 2 to 4-week intervals can
  be helpful in deciding whether a sonographically
  confirmed ovarian tumor can be monitored safely
  or should be removed surgically.

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Management Strategy

• Ovarian tumor morphology and marker production
  often change with time, therefore the importance
  of adequate follow-up cannot be over emphasized

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