The authors report no financial relationships relevant to this article.
CASE 1: Cystic mass in patient’s only remaining ovary
Mrs. R is a 29-year-old G1P1 who underwent a right oophorectomy, with a midline incision, for a dermoid cyst at the time of cesarean delivery. She now has a left ovarian cyst. Preoperative ultrasonography (US) reveals that it measures 3.5×4.2×3.7 cm and has both solid components and a multiloculated appearance, consistent with a dermoid cyst.
How common is this scenario?
Studies predict that one of every three women will undergo surgical management of an adnexal mass at some point in her life.1 This troubling statistic prompts several critical questions:
- How do we handle the workup for these women so that only appropriate patients undergo surgery?
- How often will a mass be malignant?
- How can we safely remove an adnexal mass to maximize patient safety, reduce overall recovery time, and prevent less favorable outcomes in women who are eventually found to have a malignancy?
A thorough workup and, sometimes, conservative management can prevent unnecessary surgery that may lead to early menopause or surgical complications. And maximizing the use of minimally invasive techniques in women who do require surgery can shorten hospital stay and recovery time. At the time of surgery, careful abdominal entry and meticulous surgical dissection and mass removal can limit the potential risks of laparoscopic excision in women who have an ultimate diagnosis of cancer.
In this article, we review the workup for women who have an adnexal mass, describe patient-selection criteria for laparoscopic surgery, including the risks and benefits of this approach ( TABLE 1 ), and present several techniques to safely manage a mass with potentially malignant histology via laparoscopy.
TABLE 1
There are benefits and risks to managing an adnexal mass laparoscopically
| Benefit | Risk |
|---|---|
| Shorter recovery Fewer adhesions Decreased overall cost Magnification Decreased pain and narcotic use Fewer wound complications | Expensive equipment* Loss of tactile sensation Concern for malignancy Risk of tumor dissemination/spillage/chemical peritonitis Trocar-site metastasis |
| *Though greater expense is not a risk per se, it does enter into decision making. | |
Begin with the physical
When a woman is known to have a pelvic mass, the aim of the office exam is to 1) identify characteristics that suggest malignancy and 2) rule out nongynecologic causes of the mass. Physical findings that are worrisome for a malignant process include:
- fixed or nodular pelvic mass
- bilateral masses
- nodular abdominal mass
- ascites
- pleural effusion on auscultation or percussion of the lung.
Although these findings can be present under benign conditions, they increase the risk that a malignancy will be detected at surgery.
Other causes of a pelvic mass should also be considered, including infection (pelvic abscess) and tumors of the colon, particularly when the pelvic mass occurs on the left side.
Some symptoms, though vague, are worth noting
Although ovarian cancer was once thought to be a silent disease, recent research has shown that bloating, pelvic or abdominal pain, early satiety, and urinary frequency and urgency are more common among women with ovarian cancer than among healthy controls and patients in high-risk screening clinics.2-4 Although these symptoms are generally nonspecific, they merit attention if they occur more than 12 times a month and have been present for less than 1 year. When they meet these criteria, the symptoms have a sensitivity for diagnosing early- and late-stage ovarian cancer of 56.7% and 79.5%, respectively.4
Sensitivity for the diagnosis of early-stage ovarian cancer may be as high as 80% when the symptom index score is combined with an elevated level of the tumor marker CA 125.3
Transvaginal US is crucial
Transvaginal US is now standard practice to obtain high-resolution images of an adnexal mass. Grayscale US has traditionally been used alone for evaluation.
Specificity is typically lower in women who are premenopausal because many benign lesions, such as endometrioma, have a similar sonographic appearance to cancer.
A number of US scoring algorithms have now been proposed to aid in the triage of women who have an adnexal mass. Sensitivity of these algorithms ranges from 65% to 100%; specificity, from 77% to 95%.5