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
In cases such as this, the decision is best left to the discretion of the surgeon. If the mass is mobile and small enough to fit into a bag (to prevent spillage if it ruptures), laparoscopic removal is appropriate. As in other settings, laparoscopy speeds recovery and shortens hospitalization.
Laparoscopic removal of an adnexal mass is technically similar to an open procedure. After washings are obtained and the ureter is identified, the infundibulopelvic ligament is ligated or cauterized. The broad ligament anterior to the ureter is separated from the peritoneum. The utero-ovarian ligament is then cauterized, as is the fallopian tube, and the specimen is placed in a sealed bag. The bag is then generally removed through a 10-mm port, and the specimen is sent for pathologic evaluation.
If frozen section analysis indicates that a mass is malignant, a gynecologic oncologist can stage the patient during the same procedure. This staging can be performed laparoscopically if it is technically feasible and if the surgeon feels comfortable using this approach. If it is not possible to stage the patient at the initial surgery, staging should occur within 6 weeks after the original diagnosis.
For a discussion of the advisability of laparoscopy in a pregnant patient, see below.
CASE 2 Resolved
The patient undergoes bilateral salpingo-oophorectomy via a laparoscopic approach. During the procedure, the left ovary is placed into an endoscopic specimen bag and drained to allow adequate removal through the abdominal port site; no rupture occurs. Frozen section is benign, and the final pathology report shows the mass to be a serous cystadenoma.
The pregnant patient
CASE 3 Suspicious mass with abnormal vascularity
B.E. is a 25-year-old gravida 2 para 1001 who has a pelvic mass identified during a 20-week anomaly scan. The mass involves the left ovary and is 7.1 cm in size, well circumscribed, and solid, with multiple cystic spaces and increased flow apparent on color Doppler imaging. The mass is characterized by a large degree of abnormal vascularity, and an experienced ultrasonographer describes it as “worrisome for malignancy.” MRI is performed, and the findings are consistent with those of ultrasonography but without evidence of malignant spread. Tumor markers are within normal limits, except for ß-human chorionic gonadotropin, which is elevated for the obvious reason.
Is surgery appropriate?
Gravidas develop pelvic masses at a significant rate, with a prevalence of approximately 2.3%, according to a study of 18,391 pregnant women who underwent US imaging at Washington University between 1988 and 1993.12 The majority of patients who had an adnexal mass—76%, or 320 women—had a simple cyst that was less than 5 cm in diameter and associated with no adverse events. The other 24%, or 102 women, had a mass larger than 5 cm, either simple or complex in nature. Most masses resolved spontaneously, and only 25 required surgical removal.12 No invasive carcinomas were found.
Despite the long odds of malignancy, an adnexal mass in pregnancy warrants close evaluation and follow-up and, occasionally, surgical management.
Fine-needle aspiration of an adnexal mass is rarely appropriate. In one study, 105 ovarian specimens were removed intact and the results of cyst cytology (from fine-needle aspiration) and final ovarian histology were compared.17 (Cytologic fluid was obtained by the pathologist after intact ovary removal—not preoperatively.) Histology revealed 89 benign ovarian tumors and 13 ovarian carcinomas. The sensitivity of fine-needle aspiration was 25%, with a specificity of 90%. The false-positive rate for fine-needle aspiration was 73%, and the false-negative rate was 12%.
Biopsy is risky
Malignant cystic lesions should be biopsied only in a patient who has advanced disease confirmed, or when it is necessary to check for recurrence, to avoid spreading malignant cells in localized tumors.18
General ObGyns and primary care physicians should not make the decision to biopsy an adnexal mass. The need for such a decision is grounds for referral. Nor does a patient require a diagnosis of cancer to be referred to a gynecologic oncologist. An oncologist may elect to biopsy a woman who is a poor surgical candidate, in whom chemotherapy may be first-line therapy in the neoadjuvant setting.
When is surgery justified?
Cholecystitis, appendicitis, and ovarian torsion are common diagnoses that require operative intervention regardless of gestational age.
Otherwise, when a complex adnexal mass is identified during pregnancy and is symptomatic or large enough to require removal, the gynecologist should proceed with surgery, whenever possible, in the second trimester—the most opportune time for removal. In some women, the ideal time for surgical removal of a mass detected during pregnancy is around 18 weeks’ gestation, but certainly before 24 weeks. Given the position of the gravid uterus, exploratory laparotomy is preferred over laparoscopy at this stage of gestation.
