What is the appropriate management for a patient with ultrasonography findings of complex, multiloculated masses of the left adnexa (annexation)?

From the Guidelines

The patient with complex, multiloculated masses of the left adnexa found on pelvic ultrasonography should be referred to a gynecologist or gynecologic oncologist for further assessment and possible surgical intervention, as the risk of malignancy cannot be ruled out without tissue diagnosis. The management of such a patient should prioritize minimizing morbidity, mortality, and optimizing quality of life. According to the O-RADS US risk stratification and management system 1, a complex, multiloculated mass would likely fall into a higher risk category, necessitating a more thorough evaluation.

Initial Evaluation

The initial evaluation should include:

• Additional imaging such as MRI or CT scan to better characterize the mass
• Serum tumor markers including CA-125, HE4, CEA, CA 19-9, and AFP
• A comprehensive gynecological evaluation to assess for any signs or symptoms suggestive of malignancy

Surgical Intervention

Surgical intervention may be necessary for definitive diagnosis and treatment, which could involve:

• Laparoscopy or laparotomy
• Possible left salpingo-oophorectomy or cystectomy
• Intraoperative frozen section analysis to guide the extent of surgery If malignancy is suspected based on imaging characteristics, elevated tumor markers, or patient risk factors, a more extensive staging surgery may be required 1.

Preoperative Evaluation

Prior to surgery, the patient should undergo preoperative evaluation including:

• Complete blood count
• Comprehensive metabolic panel
• Coagulation studies The urgency of intervention depends on the level of suspicion for malignancy, with higher suspicion warranting more expedited care 1.

Importance of Tissue Diagnosis

Tissue diagnosis is essential for appropriate treatment planning, as complex, multiloculated adnexal masses can represent various conditions ranging from benign entities like endometriomas or dermoid cysts to malignant ovarian tumors. The O-RADS US risk stratification and management system provides a framework for categorizing adnexal masses based on their risk of malignancy, guiding clinicians in making informed decisions about patient management 1.

From the Research

Diagnosis and Management of Adnexal Masses

• The patient's condition, which shows complex, multiloculated masses of the left annexation on ultrasonography, requires careful evaluation and management 2.
• The initial detection and evaluation of an adnexal mass require a high index of suspicion, a thorough history and physical examination, and careful attention to subtle historical clues 2.
• Transvaginal ultrasonography is the standard for evaluation of adnexal masses, and findings suggestive of malignancy include a solid component, thick septations, bilaterality, Doppler flow to the solid component of the mass, and presence of ascites 2.

Imaging Modalities for Adnexal Masses

• Multimodality imaging, including ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI), can be used to characterize adnexal masses and determine the site of origin of a pelvic mass 3, 4.
• MRI is an essential problem-solving tool to determine the site of origin of a pelvic mass, to characterize an adnexal mass, and to detect local invasion 5.

Management of Complex Adnexal Masses

• Complex adnexal masses, such as the one described in the patient's condition, should be referred to a gynecologist or gynecologic oncologist for further treatment, especially if the patient is prepubescent or postmenopausal 2.
• However, for postmenopausal women with unilocular or multilocular cysts larger than 5cm, conservative management with intermittent transvaginal ultrasonography may be considered, as the risk of malignancy is low 6.
• The management of adnexal masses should be individualized based on the patient's age, symptoms, and imaging characteristics, as well as the presence of any risk factors for malignancy 2, 6.