What is the next step in management for a multiloculated low attenuating right adnexal lesion measuring up to 7.8 cm?

From the Guidelines

The next step in management for a multiloculated low attenuating right adnexal lesion measuring up to 7.8 cm should be referral to a gynecologist or gynecologic oncologist for further evaluation, as the size and multiloculated appearance of the lesion raise concern for potential ovarian neoplasm, which requires thorough assessment, as per the O-RADS US risk stratification and management system 1.

Key Considerations

• The lesion's size (7.8 cm) and multiloculated appearance are concerning features that necessitate further evaluation, as they are associated with a higher risk of malignancy, according to the O-RADS US risk stratification and management system 1.
• The patient should undergo transvaginal ultrasound if not already performed, to better characterize the lesion and assess for any additional concerning features, such as solid components or irregular septations, as recommended by the O-RADS US guidelines 1.
• Serum tumor markers, including CA-125, HE4, AFP, CEA, and CA 19-9, should be obtained to help assess the risk of malignancy, as these markers have been shown to be useful in evaluating adnexal masses, as discussed in the O-RADS US guidelines 1.
• Consideration for pelvic MRI with contrast may be necessary for better characterization of the lesion, particularly if the ultrasound findings are inconclusive or if there are concerns about the lesion's composition or extent, as recommended by the O-RADS US guidelines 1.

Management Options

• Depending on the patient's age, risk factors, and the results of these investigations, surgical intervention may be necessary, ranging from laparoscopic ovarian cystectomy to exploratory laparotomy with possible unilateral salpingo-oophorectomy, as discussed in the O-RADS US guidelines 1.
• If there is significant concern for malignancy based on imaging characteristics, tumor markers, or patient risk factors, a gynecologic oncologist should perform the surgery to ensure appropriate staging and management if cancer is found, as recommended by the O-RADS US guidelines 1.

Importance of Prompt Evaluation

• Prompt evaluation is crucial, as adnexal masses of this size with complex features require definitive diagnosis and treatment to prevent potential complications, such as ovarian torsion or rupture, and to improve outcomes, as emphasized in the O-RADS US guidelines 1.

From the Research

Next Steps in Management

The next steps in managing a multiloculated low attenuating right adnexal lesion measuring up to 7.8 cm involve further evaluation and possible referral to a specialist.

• The patient's symptoms, such as abdominal or pelvic pain, should be taken into account, as these can be indicative of ovarian cancer 2.
• A cancer antigen 125 (CA 125) test may be performed to assist in the evaluation of the adnexal mass, although it is noted that CA 125 levels can be elevated in conditions other than ovarian cancer 2, 3.
• Transvaginal ultrasonography is the first choice for imaging of an adnexal mass, and large mass size, complexity, projections, septation, irregularity, or bilaterality may indicate cancer 2.
• If the adnexal mass is larger than 6 cm, or if findings persist longer than 12 weeks, referral to a gynecologist or gynecologic oncologist is indicated 2.
• Pelvic MRI may be used as a second imaging test to provide confident diagnosis of many benign adnexal lesions and to detect ovarian cancer 4.
• The patient's age, family history, and other risk factors should be considered when determining the next steps in management, with postmenopausal women and those with a strong family history of breast or ovarian cancer potentially requiring more urgent evaluation 3.

Imaging and Diagnostic Considerations

• T2-weighted sequences on MRI can be used to characterize adnexal lesions, with lesions that are at least as dark as skeletal muscle being almost always benign 5.
• A diagnostic algorithm that takes into account the signal intensity of the lesion, as well as the appearances of the lesion with additional pulse sequences, can aid in the correct interpretation of T2-hypointense adnexal lesions 5.
• For postmenopausal women with large unilocular or multilocular ovarian cysts, conservative management with intermittent transvaginal ultrasonography may be appropriate, as the risk of malignancy is low 6.