Andrew M. Kaunitz, MD reviewing van Nagell JR Jr and Miller RW. Obstet Gynecol 2016 May.

An ovarian mass will be detected in as many as 20% of women at some point in their lives. As ultrasound imaging becomes more commonly used, many such masses are identified in asymptomatic women, raising uncertainty about appropriate next steps. In a review, gynecologic oncologists detail the roles of ultrasound morphology and serum biomarkers to evaluate ovarian masses.

Ultrasound­determined morphology can classify ovarian masses as likely benign, likely malignant, or indeterminate. Unilocular (simple) cysts are common and essentially all benign. Risk for invasive malignancy is also extremely low for cystic ovarian masses with septations <2 mm thick but without solid areas or papillary projections (mural nodules). These two types of cystic ovarian masses often resolve spontaneously and should be followed sonographically in 3 months, then annually for 5 years if stable. Unlike cystic masses, solid ovarian masses or tumors with cystic and solid areas carry a malignancy risk >30%; this risk is even higher in the presence of ascites. Patients with such high­risk masses should be referred to a gynecologic oncologist.

For patients with sonographically identified ovarian masses of indeterminate morphology, the strategy of monthly serial ultrasound evaluation is based on the observation that in ovarian malignancies, tumor volume and morphologic complexity increase over time. In this setting, monthly assessment of serum CA 125 levels is recommended in postmenopausal patients, as rising levels (even within the normal range) are predictive of malignancy.


As the use and resolution of imaging techniques increases, so must clinicians routinely address unexpected findings in asymptomatic patients. Although we are not yet ready to implement ultrasound imaging (or CA 125 measurement) for screening (NEJM JW Womens Health Jan 2012 and Obstet Gynecol 2011; 118:1212), this review — from an institution that has focused for decades on ultrasonographic evaluation of ovarian masses — provides guidance for identifying malignancy at an early stage while minimizing the likelihood of surgery in women with benign asymptomatic masses.


van Nagell JR Jr and Miller RW.Evaluation and management of ultrasonographically detected ovarian tumors in asymptomatic women. Obstet Gynecol 2016 May; 127:848. (