How are benign adnexal tumors that extend beyond clinical margins managed?

From the Guidelines

Benign adnexal tumors that extend beyond clinical margins are typically managed conservatively with observation or partial removal, as the risk of malignancy is extremely low, ranging from 0.3% to 0.6% in average-risk women, as demonstrated by studies such as Gupta et al 1 and Parazzini et al 1. The management approach for benign adnexal tumors prioritizes minimizing unnecessary surgical interventions and their associated risks, given that the vast majority of these lesions are benign and can be accurately diagnosed using ultrasound (US) techniques, as outlined in the ACR Appropriateness Criteria 1. Key considerations in the management of these tumors include:

• The risk of malignancy in benign-appearing lesions on US is less than 1%, with a recent study by Gupta et al 1 demonstrating a risk of 0.3% to 0.4% for malignancy and 0.2% to 0.4% for acute complications.
• Unilocular cysts in premenopausal women have a very low risk of malignancy, with a meta-analysis by Parazzini et al 1 showing a risk of 0.6% in 987 surgically removed cysts.
• Classic benign lesions, such as endometriomas, hemorrhagic cysts, and dermoids, have characteristic appearances on US and can be safely followed with yearly US, with a low risk of malignant transformation, as noted in studies such as Valentin et al 1. Therefore, the primary goal in managing benign adnexal tumors that extend beyond clinical margins is to balance the risk of local recurrence, functional preservation, and cosmetic outcomes, while minimizing unnecessary surgical interventions and their associated risks, as supported by the most recent and highest quality studies, including those published in the Journal of the American College of Radiology 1.

From the Research

Benign Adnexal Tumors Extending Beyond Clinical Margins

• The management of benign adnexal tumors that extend beyond clinical margins is not directly addressed in the provided studies 2, 3, 4, 5, 6.
• However, the studies discuss the management of adnexal masses in general, including benign and malignant tumors.
• According to 3, adnexal masses are usually asymptomatic, but sometimes can be responsible for abdominal or pelvic pain, and treatment options consist of observational management or surgery.
• The study 5 highlights the increasing sensitivity of ultrasound imaging in diagnosing rare malignant lesions, allowing for antenatal expectant management of benign asymptomatic adnexal masses until delivery or postpartum.
• The First International Consensus Report on Adnexal Masses 6 recommends a more conservative approach to many benign adnexal masses and optimization of physician referral patterns to a gynecologic oncologist in cases of suspected ovarian malignancies.

Management of Benign Adnexal Tumors

• The study 4 suggests that a two-step strategy using ultrasound-based benign simple descriptors and the Assessment of Different NEoplasias in the adneXa (ADNEX) model can be used to estimate the risk of malignancy in ovarian tumors.
• According to 2, in patients of reproductive age, detorsion with ovarian conservation is recommended, even in cases where the tissue appears necrotic, given poor intraoperative diagnostic rates of tissue death.
• The study 6 concludes that patients would benefit from a more conservative approach to many benign adnexal masses and from optimization of physician referral patterns to a gynecologic oncologist in cases of suspected ovarian malignancies.

Surgical Management

• The study 3 states that surgery can be offered as a primary tool when cancer is suspected or when acute complications such as ovarian torsion occur.
• According to 5, laparoscopy can be safely performed in pregnancy for the antenatal removal of suspicious or symptomatic masses.
• The study 2 emphasizes that the risk of ovarian damage/loss outweighs the risk of a diagnostic laparoscopy in patients of reproductive age.