From the Guidelines
The appropriate management for a patient with complex, multiloculated masses of the left adnexa found on pelvic ultrasonography involves prompt referral to a gynecologist or gynecologic oncologist for further evaluation, as recommended by the most recent study 1.
Initial Evaluation
Initial management should include comprehensive assessment with additional imaging such as contrast-enhanced MRI of the pelvis to better characterize the mass.
- Tumor marker testing including CA-125, HE4, CEA, CA 19-9, and AFP should be ordered to help distinguish between benign and malignant processes.
- The Ovarian-Adnexal Reporting and Data System (O-RADS) US risk stratification and management system can be used to provide consistent interpretations and decrease ambiguity in US reports in assigning risk of malignancy 1.
Management Approach
For premenopausal women with low suspicion for malignancy, observation with repeat imaging in 6-8 weeks may be appropriate if the mass is smaller than 5 cm and tumor markers are normal.
- For postmenopausal women or those with concerning features (solid components, irregular borders, ascites, or elevated tumor markers), surgical intervention is typically recommended.
- Surgery may range from laparoscopic ovarian cystectomy for likely benign lesions to exploratory laparotomy with possible staging procedures if malignancy is suspected.
- This approach is necessary because complex, multiloculated adnexal masses have a higher risk of malignancy compared to simple cysts, particularly in postmenopausal women, and proper characterization and management are essential for optimal outcomes, as highlighted in the study 1.
Importance of Specialist Referral
The initial management by a gynecological oncologist is a crucial prognostic factor in long-term survival in patients with ovarian malignancy, as noted in the study 1.
- Therefore, prompt referral to a specialist is essential to ensure optimal outcomes.
- The use of a standardized lexicon and management system, such as O-RADS, can facilitate consistent and accurate characterization of adnexal masses, leading to improved treatment outcomes 1.
From the Research
Management of Adnexal Masses
The patient's condition, characterized by complex, multiloculated masses of the left adnexa, requires careful evaluation and management. The following steps are recommended:
- Initial detection and evaluation of the adnexal mass should involve a thorough history and physical examination, as well as timely and appropriate laboratory and radiographic studies 2, 3.
- Transvaginal ultrasonography is the standard for evaluating adnexal masses, and findings suggestive of malignancy include a solid component, thick septations, bilaterality, Doppler flow to the solid component, and presence of ascites 2, 3.
- Given the complexity of the mass, referral to a gynecologist or gynecologic oncologist is indicated, especially if the mass is larger than 6 cm or if findings persist longer than 12 weeks 2, 3.
- Further imaging studies, such as computed tomography (CT) or magnetic resonance imaging (MRI), may be necessary to characterize the mass and rule out metastatic disease 4, 5.
- A cancer antigen 125 (CA 125) test may be used to assist in the evaluation of the adnexal mass, but it is not recommended as the sole means of differentiating between benign and malignant masses 3.
- The computed tomography adnexal mass score can be used to estimate the risk of ovarian cancer based on CT scan findings, CA-125 levels, and patient age 6.
Key Considerations
- The patient's symptoms, such as pelvic or abdominal pain, increased abdominal size, bloating, and urinary urgency, should be carefully evaluated and monitored 2, 3.
- The presence of ascites, omental caking, or lymphadenopathy on imaging studies increases the suspicion of malignancy 6.
- The patient's age, menopausal status, and medical history should be taken into account when evaluating the adnexal mass and determining the appropriate management plan 2, 3.