The word “adnexa” is derived from the Latin word “adnexus,” meaning “appendage.” The anatomical adnexa comprise the ovaries, fallopian tubes, and the broad ligament [1,2]. Ovarian cancer ranks seventh in terms of cancer-related mortality among women and is one of the most common causes of death from gynaecological malignancies [3,4]. Adnexal masses represent a frequently occurring issue in gynaecology [5,6]. Of all gynaecological malignancies, malignant epithelial ovarian tumours are associated with the highest fatality rate [7]. An early diagnosis can result in a 90% five-year survival rate [8].
The clinical manifestations of adnexal masses vary. Most cancers either show no symptoms at all or present vague symptoms such as abdominal distension, lower abdominal pressure, abdominal pain or discomfort, and gastrointestinal or urinary disturbances. Abnormal vaginal bleeding may occur if the tumour is hormonally active [5,9].
In the reproductive age group, the most typical manifestation is a benign functional cyst. Other benign lesions include hydrosalpinx, ectopic pregnancy, tubo-ovarian abscess, endometriotic cyst, and hydatidiform mole. Benign masses may also include pedunculated fibroids, teratomas, para-ovarian cysts, and serous and mucinous cysts. Malignant masses include ovarian, fallopian tube, and gastrointestinal cancers. Epithelial, stromal, and sex cord tumours are the most common types of tumours found in post-menopausal women. Inflammatory factors in the reproductive age group are the main cause of masses involving the fallopian tubes. Pelvic inflammatory disease may be associated with the presence of a tubo-ovarian abscess [9].
This study aimed to conduct a clinicopathological analysis of adnexal masses among women presenting at a tertiary healthcare centre.
Materials and Methods
A retrospective observational study was conducted in the Department of Obstetrics and Gynaecology at Akash Institute of Medical Science and Research Centre, Devanahalli, Karnataka, India from November 2022 to April 2024.
Inclusion criteria: All patients who underwent surgery for adnexal masses during the study period at our centre were included in the study.
Exclusion criteria: Patients with asymptomatic simple ovarian cysts ≤6 cm were excluded.
Study Procedure
The diagnosis of adnexal masses was based on clinical symptoms, per abdominal and bimanual examinations, and trans-abdominal ultrasound. The CA-125 and other tumour markers (AFP, HCG, LDH) were sent depending on the risk of malignancy. Indications for surgery included large masses >6 cm, masses with symptoms, malignant tumours, and patients presenting with acute ovarian torsion. Demographic details of patients, such as age, parity, and menopausal status, were noted. Presenting symptoms were documented, including abdominal pain, abdominal mass, post-menopausal bleeding, weight loss, loss of appetite, and cases presenting with acute ovarian torsion. For all operated cases, routine pre-operative investigations and pre-anaesthetic check-ups were conducted. All tissues were sent for histopathological examination, and the histopathological diagnosis was documented.
Statistical Analysis
The data was collected and tabulated in a Microsoft excel sheet, and the frequencies and percentages were calculated for analysis.
Results
A total of 38 cases were operated on during the study period. The ages of the patients ranged from 13 to 70 years, with three patients being less than 19 years old, 12 patients belonging to the age category of 20-29 years, 13 patients in the 30-39 year age range, four patients aged 40-49 years, and six patients over 50 years of age. In total, 31 patients were pre-menopausal, and seven patients were post-menopausal [Table/Fig-1].
Demographic details of women with adnexal masses (n=38).
| Total (%) (n=38) | No. of benign cases (%) (n=34) | No. of malignant cases (%) (n=4) |
|---|
| Age in years |
| <19 | 3 (8%) | 3 (9%) | Nil |
| 20-29 | 12 (31%) | 11 (32%) | 1 (25%) |
| 30-39 | 13 (34%) | 13 (38%) | Nil |
| 40-49 | 4 (10%) | 3 (9%) | 1 (25%) |
| >50 | 6 (17%) | 4 (12%) | 2 (50%) |
| BMI in kg/m2 |
| <18.5 | 9 (23%) | 6 (18%) | 3 (75%) |
| 18.5-24.9 | 13 (34%) | 13 (38%) | Nil |
| 25-29.9 | 11 (30%) | 11 (32%) | Nil |
| >30.0 | 5 (13%) | 4 (12%0 | 1 (25%) |
| Parity |
| Nullipara | 8 (21%) | 7 (20.5%) | 1 (25%) |
| Primipara | 7 (18%) | 7 (20.5%) | Nil |
| Multipara | 23 (61%) | 20 (59%) | 3 (75%) |
| Menopausal status |
| Pre-menopausal | 31 (82%) | 29 (85%) | 2 (50%) |
| Post-menopausal | 7 (18%) | 5 (15%) | 2 (50%) |
There were 34 benign cases (89%) and four malignant cases (11%). These cases were classified according to age group, with 11 patients in the 20-29 year age category being benign cases and one being a malignant case (germ cell tumour) [Table/Fig-1].
Out of the 38 cases analysed, benign ovarian and para-ovarian cysts were the most common findings, seen in 21 cases (55.3%) [Table/Fig-2]. The most common presenting complaint was abdominal pain, reported in 21 cases (55.3%) [Table/Fig-3].
Frequency of type of adnexal mass among women (n=38).
| Type of adnexal mass | No. of cases | Percentage |
|---|
| Simple ovarian cyst/Benign ovarian cyst | 16 | 42.1% |
| Paraovarian cyst | 5 | 13.2% |
| Benign serous cystadenoma | 6 | 15.8% |
| Mucinous cystadenoma | 1 | 2.6% |
| Teratoma | 3 | 7.9% |
| High-grade serous carcinoma | 2 | 5.3% |
| Mixed germ cell tumour | 1 | 2.6% |
| Cystic degeneration of fibroid | 1 | 2.6% |
| Serous intraepithelial Carcinoma of B/l fallopian tube | 1 | 2.6% |
| Endometriotic cyst | 2 | 5.3% |
Clinical presentation of the study participants (n=38).
| Presentation | No. of cases (%) |
|---|
| Asymptomatic | 4 (10.5%) |
| Abdominal pain | 21 (55.3%) |
| Abdominal mass | 6 (15.8%) |
| Postmenopausal bleeding | 2 (5.3%) |
| Weight loss | 4 (10.5%) |
| Loss of appetite | 4 (10.5%) |
| Acute ovarian torsion | 5 (13.2%) |
For most of the simple ovarian cysts, ultrasound reports indicated simple unilocular ovarian cysts. The mature teratoma on ultrasound showed heterogeneous solid cystic hyperechoic lesion. Cystic degeneration of a fibroid on ultrasound showed mixed echogenicity of ovarian origin. A case of fallopian tube carcinoma on ultrasound demonstrated normal adnexa with a bulky uterus.
The CA-125 was measured for 23 cases with suspicion of malignancy. For all the benign ovarian tumours (19 cases), the value was <35 U/mL. For three cases of ovarian malignancy, the CA-125 values were >35 U/mL. In the case of fallopian tube carcinoma, the CA-125 value was 103.5 U/mL. Among the patients with benign ovarian tumours, 16 patients underwent laparoscopic cystectomy, eight patients underwent open cystectomy, and total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH with BSO) was performed on 10 patients. For all four malignant cases, staging laparotomy was performed.
Discussion
According to studies, ovarian cancer ranks third among female cancer sites in the majority of India’s population-based cancer registries, following breast and cervical cancer [10,11]. This study encompasses the highest number of patients, with 29 (76.3%) in the age category of 20 to 49 years. This finding is consistent with research conducted by Rai R et al., (78.7%), Khandelwal S et al., (84.42%), and Badkur P and Gupta K (78.93%), which indicated that patients were primarily in the 20-49 age range [9,12,13].
In the current study, most benign tumours (70.6%) were observed in the age group of 20-39 years, while most malignant tumours were seen in the menopausal age group (75%). However, in this study, benign tumours (89.5%) were higher than those reported by Deshmukh V et al., (30%) and Garg R and Suboohi A, (56%), but similar to studies conducted in Karnataka by Divya KP et al., (76%) and Radhamani S (90.46%) [11,14-16].
Additionally, another finding corroborated by the present study showed that among the four malignant patients, two (50%) were older than 50, one (25%) was in the age group of 40-49 years, and one (25%) was younger, representing the age group of 20 to 29 years. Given that there is a 1-1.5 percent lifetime risk of ovarian carcinoma, it is advised that women over 50 should be examined for ovarian malignancy when they present with suggestive symptoms [5]. Malignancy is more common in post-menopausal women. In this study, two of the four malignant patients were post-menopausal, while the remaining two were pre-menopausal. This finding aligns with studies by Khandelwal S et al., and Rai R et al., which reveals that postmenopausal individuals had malignant lesions in 55.5% and 47% of cases, respectively [9,12].
In this study, abdominal pain was the most common presentation, occurring in 55.3% of cases. A comparable incidence was reported by Khandelwal S et al., (63.8%), Bhagde AD et al., (92%), Hassan SA (58.2%), Champawat C and Wani RJ (79.5%), Manivasakan J and Arounassalame B (70.5%), and Neelgund S and Hiremath P (67.5%) [9,17-21]. An abdominal mass was detected in 15.8% of the patients in our study. However, contrary to our findings, Kim SI et al., observed that the most prevalent presenting symptoms were abdominal discomfort (66.92%) and abdominal mass (28.11%) [22]. Additionally, Deshmukh V et al., reported an abdominal mass in 37.5% of their patients [11].
According to the current study, the simple ovarian cyst (42.1%) was the most prevalent benign tumour, followed by serous cystadenoma (15.8%) and paraovarian cyst (13.2%). However, present findings did not correlate with results reported by Das MJ et al., and Kanthikar SN et al., who discovered that 41.89% and 35.71% of their subjects had serous cystadenoma, respectively [4,23]. Furthermore, Sharma I et al., found serous cystadenoma to be the most prevalent tumour (34%) [24].
As seen in this study, most ovarian tumours present with vague symptoms such as abdominal pain (55.3%), abdominal mass (15.8%), weight loss (10.5%), and loss of appetite (10.5%) in both benign and malignant cases. Therefore, it is essential to screen patients with these symptoms using ultrasound for early detection of ovarian tumours. Early detection can also change the treatment modality depending on the size and nature of the tumour, as most benign cases can be managed with laparoscopic procedures.
Limitation(s)
The study had a limited sample size, which may mean that the results do not accurately reflect the histological patterns and clinical symptoms of all women in India with adnexal masses; instead, they are specific to our region. Additionally, the retrospective study design poses an inherent limitation.
Conclusion(s)
Adnexal masses encompass a variety of forms, ranging from benign cysts to advanced carcinoma. These masses have a range of histopathological diagnosis that present clinically with vague and non-specific symptoms. They also exhibit a bimodal presentation with extremes of age. As a result, by the time most malignancies are diagnosed, they are often at an advanced stage. Therefore, prompt diagnosis of adnexal masses is crucial in determining the appropriate treatment modality, as most benign masses can be managed through minimally invasive procedures.