How to manage an adnexal mass
What imaging is best? Are tumor markers informative? When is surgery indicated? And when is it time to refer?
IN THIS ARTICLE
Intraoperative evaluation of the mass by pathology with frozen section is recommended. Even though immediate staging may not be feasible, owing to the pregnancy, pathology results can reassure the patient and her family and also facilitate planning of the optimal time and route of delivery.
If the mass is determined to be malignant, the patient should undergo surgical staging after completion of the pregnancy. At 37 weeks, labor should be induced, with staging performed within the next 2 to 4 weeks, or a cesarean section should be performed, with staging carried out at that time.
Because laparoscopy can be difficult to perform during pregnancy, it should be used judiciously; uterine size can limit visibility and hinder safe placement of trocars. The first trimester is the least problematic period for laparoscopy.
A large study in Sweden compared laparoscopy with laparotomy between 4 and 20 weeks’ gestation and assessed fetal outcomes.13 In the study, 2,181 women underwent laparoscopy and 1,522 underwent laparotomy. Low birth weight (<2,500 g), intrauterine growth restriction, and delivery before 37 weeks’ gestation increased among all surgical patients, with no differences attributed to the route of the procedure. Nor were there significant differences between surgical and nonsurgical patients in either infant survival at 1 year or the incidence of fetal malformation.
As long as the anesthesiologist is aware of the pregnancy, a general surgeon can safely perform either laparoscopy or laparotomy during the first or second trimester. Care should be taken not to remove a corpus luteum before the 14th week of gestation. Pregnancy should not alter the surgeon’s preferred treatment approach at this time, unless uterine size is the limiting factor.
CASE 3 Resolved
B.E. safely undergoes exploratory laparotomy and left oophorectomy at 23-4/7 weeks’ gestation. Frozen section indicates that the mass is a malignant neoplasm. The final pathology report describes a highly unusual constellation of histologic findings, including juvenile granulosa cell tumor, dysgerminoma, and gonadoblastoma. A cesarean delivery with completion of cancer staging is planned when the fetus achieves lung maturity, with preservation of the contralateral ovary and uterus nodal sampling, peritoneal biopsies, and omentectomy.
