Understanding Ovarian and Fallopian Tube Lesions: A Patient's Guide

Table of Contents

• Introduction: Why This Matters
• Female Reproductive Anatomy Basics
• How Doctors Evaluate Adnexal Lesions
• Understanding Imaging Results
• Blood Tests and Tumor Markers
• Treatment Approaches
• What This Means for Patients
• Understanding the Limitations
• Patient Recommendations
• Source Information

Introduction: Why This Matters

Lesions of the ovary and fallopian tube (collectively known as the adnexa) are surprisingly common findings that affect many women throughout their lives. Research shows these lesions occur in up to 35% of premenopausal women and 17% of postmenopausal women. They represent a spectrum of conditions ranging from completely benign to malignant cancers.

When doctors discover an adnexal mass, they have three primary goals: determining if the situation requires emergency surgery, assessing the likelihood of cancer, and creating a treatment plan that respects the patient's desires regarding fertility and hormone preservation. This comprehensive guide will help you understand how medical professionals evaluate and manage these conditions.

Female Reproductive Anatomy Basics

Your ovaries are located in what doctors call the ovarian fossae and normally have a whitish-gray appearance. They reach their maximum size of approximately 4 cm by 2.5 cm when women are in their 20s and gradually decrease to about the size of an almond by menopause.

Each ovary sits next to a fallopian tube that connects to the uterus. The blood supply and nerves for both organs are found in the mesosalpinx tissue, which receives blood vessels from both the uterine and ovarian arteries. Since these supporting structures serve both organs, doctors consider them together as adnexal structures when evaluating problems.

The ovary is a remarkably dynamic organ responsible for producing hormones and eggs essential for reproduction. It contains three main tissue types, each with potential to develop different types of tumors:

• Surface epithelium - gives rise to most ovarian tumors
• Sex cords and stroma - can form hormone-secreting tumors or fibrous masses
• Primordial germ cells - develop into various benign and malignant germ-cell tumors

The fallopian tube has both muscular and mucosal layers with several cell types. Importantly, research has discovered that the fimbriated end of the fallopian tube (the part closest to the ovary) is actually the origin point for many serous adenocarcinomas previously thought to start in the ovary.

This discovery came from studying women with BRCA gene mutations who had preventive surgery. Between 2-10% of these women had early cancer found in their fallopian tubes even when their ovaries appeared normal. These serous tubal intraepithelial carcinomas account for 38-62% of all high-grade serous adenocarcinomas and can be missed during routine examination.

Because of this important finding, medical organizations now recommend complete removal of fallopian tubes using a special examination protocol called SEE-FIM (sectioning and extensively examining the fimbriated end) during risk-reducing surgery. Currently, about 91% of gynecologic oncologists follow this recommendation, but only 41% of general obstetrician-gynecologists do so.

How Doctors Evaluate Adnexal Lesions

When doctors discover an adnexal mass, they always categorize it into one of three groups: benign, malignant, or borderline (which means low malignant potential). While getting actual tissue is necessary for a definitive diagnosis, doctors almost always avoid biopsying these masses because of the risk of spreading possible cancer cells within the abdomen.

The evaluation process considers your age, clinical presentation, and uses three main tools: medical history and physical examination, laboratory studies, and most importantly, imaging tests.

Assessing the Need for Emergency Surgery

The first and most critical step is determining whether you need immediate surgery. Emergency situations include:

• Ovarian torsion (where the ovary twists on itself)
• Ruptured ectopic pregnancy
• Bowel obstruction caused by a malignant lesion

Patients with hemodynamic instability, peritonitis, or evidence of bowel or urinary obstruction need emergency department evaluation for possible immediate surgery. Additionally, all women of reproductive age must be tested for pregnancy to rule out ectopic pregnancy, which can cause life-threatening internal bleeding.

Medical History and Physical Examination

Your evaluation begins with age assessment and family history. Older age is the single greatest risk factor for ovarian or tubal cancer. Since approximately 20% of these cancers result from inherited gene mutations, your family history is critically important in assessing your cancer risk.

While doctors perform pelvic examinations as part of the evaluation, these exams have significant limitations. Research shows that pelvic examinations have low sensitivity (only 15-36%) for detecting adnexal masses, and this sensitivity worsens significantly with increasing body weight. The experience of the clinician doesn't improve detection rates either.

Pelvic examinations are particularly poor at differentiating benign from malignant masses, especially in premenopausal patients (31% sensitivity versus 59% in postmenopausal patients). However, the pelvic exam can provide valuable information for surgical planning, such as whether a mass feels fixed to other structures.

Understanding Imaging Results

Because physical examinations have limitations, pelvic ultrasonography becomes the most important imaging tool for evaluating adnexal masses. It should be the initial radiologic test ordered. However, ultrasound also has some limitations, including variation between different operators, difficulty performing the exam on some patients, and inability to reliably diagnose ovarian torsion.

Despite these limitations, no other imaging approach matches the performance characteristics, safety profile, and cost-effectiveness of transvaginal ultrasound for evaluating adnexal lesions.

Ultrasound Classification Systems

Doctors use the morphologic features of the mass on ultrasound to categorize cancer risk. Simply put, the more complex a mass appears, the higher the likelihood it might be malignant.

Two promising classification systems help doctors assess risk:

IOTA Simple Rules (International Ovarian Tumor Analysis)
This system categorizes ultrasound features into benign (B features) and malignant (M features), with five characteristics in each category:

• Benign Features:
  • Unilocular cyst (any size)
  • No solid components, or solid components smaller than 7 mm
  • Presence of acoustic shadowing
  • Smooth multilocular cyst smaller than 10 cm
  • No blood flow
• Malignant Features:
  • Irregular solid tumor
  • Ascites (fluid in abdomen)
  • Four or more papillary structures
  • Irregular solid multilocular tumor larger than 10 cm
  • Very strong color Doppler flow

Masses are considered likely benign if only B features are seen, or malignant if only M features are seen. If features are mixed or not clearly categorized, the mass is considered indeterminate. The IOTA rules show 93% sensitivity and 81% specificity for predicting malignant processes.

O-RADS System (Ovarian-Adnexal Reporting and Data System)
This newer system offers a five-tier classification for cancer risk assessment:

• Category 2: Managed by observation or repeat imaging
• Category 3: Referral to a specialist
• Categories 4-5: Require involvement of a gynecologic oncologist

In validation studies analyzing 1,054 adnexal masses, 300 of 304 malignant masses were categorized as O-RADS 4 or 5, showing 98.7% sensitivity and 83.2% specificity for cancer detection.

Additional Imaging Options

Magnetic resonance imaging (MRI) can be useful for masses that appear indeterminate on ultrasound, but it's more expensive and shouldn't be the first-line imaging study. MRI shows 81% sensitivity and 98% specificity for categorizing indeterminate lesions as malignant.

Computed tomography (CT) is primarily used for staging known ovarian cancer and assessing for metastases or recurrence, but it performs poorly in evaluating adnexal masses initially.

Blood Tests and Tumor Markers

All women of reproductive age should be screened for pregnancy when an adnexal mass is discovered. A complete blood count can help guide management if infection or ovarian torsion is suspected. However, the most important laboratory tests for assessing adnexal masses are serum tumor marker tests.

CA-125 Testing

CA-125 is the most extensively studied and commonly used tumor marker for ovarian lesions. This large glycoprotein is secreted by various tissues and elevated in approximately 80% of women with epithelial ovarian or tubal cancers.

While officially approved for monitoring treatment response in ovarian cancer patients, doctors frequently use CA-125 testing to help categorize adnexal masses, particularly in postmenopausal women. Research shows CA-125 testing has 69-87% sensitivity and 81-93% specificity for diagnosing cancer in postmenopausal women, with improved performance when combined with ultrasound.

However, CA-125 testing has important limitations:

• Up to 20% of women with metastatic ovarian/tubal cancers have normal CA-125 levels
• Testing is unreliable in early-stage disease (as low as 25% sensitivity for stage I cancer)
• Less reliable in premenopausal women
• Less accurate for non-serous epithelial cancer subtypes
• Levels can be elevated in many benign conditions including pregnancy, endometriosis, inflammatory bowel disease, and renal failure

For postmenopausal women, doctors generally recommend referral to a gynecologic oncologist if CA-125 levels reach 35 U/mL or higher with a suspicious mass. For premenopausal women, there's no established cutoff point, though very elevated levels should raise concern.

Other Tumor Markers

Human epididymis protein 4 (HE4) is another tumor marker approved for determining ovarian cancer likelihood. It shows similar sensitivity to CA-125 but better specificity. HE4 is included in two assessment tools:

• ROMA (Risk of Malignancy Algorithm) - A nonproprietary online calculator using CA-125, HE4, and age
• Overa test - A commercial multivariate index assay using five biomarkers

Another test called OVA1 is also FDA-approved for this purpose. However, economic studies suggest these multimodal tests are both more expensive and less effective than simply referring women with indeterminate or suspicious lesions directly to gynecologic oncologists.

Treatment Approaches

Once doctors determine that emergency surgery isn't needed and have assessed cancer risk, treatment decisions depend on whether patients have symptoms and their personal preferences regarding surgery, fertility preservation, and hormone production.

Simple Cysts

The most straightforward lesions are simple, unilocular cysts (cysts with a single chamber). These are almost never cancerous. Management options include:

• Observation with periodic monitoring
• Repeat imaging to ensure stability
• Surgical removal if causing symptoms or concerning changes occur

The approach varies based on menopausal status, cyst size, and patient preferences.

What This Means for Patients

This research has several important implications for patients facing adnexal masses:

First, understanding that many ovarian cancers actually originate in the fallopian tubes has revolutionized preventive strategies. Women with BRCA mutations should discuss complete fallopian tube removal using the SEE-FIM protocol during any gynecologic surgery.

Second, the development of sophisticated imaging classification systems (IOTA and O-RADS) means doctors can better stratify cancer risk without immediate surgery for low-risk lesions. This prevents unnecessary procedures while ensuring high-risk cases receive appropriate specialist care.

Third, patients should understand the limitations of both physical examinations and blood tests. Pelvic exams miss many masses, especially in women with higher body mass indexes. CA-125 testing has significant limitations, particularly in premenopausal women where many benign conditions can elevate levels.

Finally, the research emphasizes that treatment should be individualized based on symptoms, cancer risk, and personal priorities regarding fertility and hormone preservation.

Understanding the Limitations

While this review provides comprehensive information, several limitations should be acknowledged:

The IOTA simple rules were primarily validated in high-volume medical centers with experienced clinicians. They may not perform as well in lower-volume centers with less experienced operators.

The O-RADS classification system is relatively new, and while initial data shows excellent performance, more validation studies are needed across diverse healthcare settings.

For premenopausal women, there remains no clear CA-125 cutoff level that reliably distinguishes benign from malignant masses, creating clinical challenges.

Multimodal laboratory tests like ROMA and OVA1 show promise but are expensive and their clinical benefit compared to specialist referral remains uncertain according to economic analyses.

Finally, while the SEE-FIM protocol for fallopian tube examination is recommended for high-risk women, adoption remains inconsistent between gynecologic oncologists (91%) and general obstetrician-gynecologists (41%).

Patient Recommendations

Based on this comprehensive review, here are key recommendations for patients:

1. Understand your risk factors - Age is the strongest risk factor, but family history is critically important since 20% of ovarian/tubal cancers come from inherited mutations.
2. Choose appropriate imaging - Transvaginal ultrasound should be your first imaging test for adnexal masses due to its excellent balance of accuracy, safety, and cost-effectiveness.
3. Interpret CA-125 results appropriately - Understand that this test has limitations, especially if you're premenopausal or have conditions like endometriosis that can elevate levels.
4. Consider specialist referral - If you have a complex mass or concerning features, ask about referral to a gynecologic oncologist, which economic models suggest may be more effective than additional biomarker testing.
5. Discuss preventive options - If you have BRCA mutations or strong family history, talk to your doctor about risk-reducing surgery with complete fallopian tube removal using the SEE-FIM protocol.
6. Advocate for appropriate care - If you're postmenopausal with a suspicious mass and CA-125 above 35 U/mL, current guidelines recommend evaluation by a gynecologic oncologist.
7. Consider your personal priorities - Treatment decisions should incorporate your desires regarding fertility preservation and maintaining natural hormone production when possible.

Source Information

Original Article Title: Lesions of the Ovary and Fallopian Tube
Authors: Rachel C. Sisodia, M.D., and Marcela G. del Carmen, M.D., M.P.H.
Publication: The New England Journal of Medicine, August 25, 2022
DOI: 10.1056/NEJMra2108956

This patient-friendly article is based on peer-reviewed research from Massachusetts General Hospital and Harvard Medical School. It preserves all original data, statistics, and clinical recommendations while translating the information into accessible language for patients.