From the Guidelines
The approach to managing an ovarian mass involves a systematic evaluation using the O-RADS US risk stratification and management system, which provides a means to consistently interpret ultrasound reports and decrease ambiguity in assigning risk of malignancy 1.
Key Components of Evaluation
- A thorough history and physical examination
- Transvaginal ultrasound as the initial imaging modality of choice, with attention to mass characteristics such as size, solid components, septations, and vascularity
- CA-125 testing, particularly in postmenopausal women, though it has limitations in premenopausal patients
- Risk stratification tools like the Risk of Malignancy Index (RMI) or IOTA Simple Rules to determine the likelihood of malignancy
Management Strategies
- Management depends on patient age, menopausal status, and risk assessment
- Low-risk masses in premenopausal women may be observed with follow-up ultrasound in 6-12 weeks
- Higher-risk masses require gynecologic oncology referral
- Surgical management includes laparoscopic or open approaches depending on suspicion of malignancy
- For suspected malignancy, a staging procedure with hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and lymph node assessment is performed
- Fertility-sparing surgery may be considered in young patients with early-stage disease
Importance of Accurate Staging
- Accurate staging is crucial for determining the initial treatment for ovarian cancer
- Referral to a gynecologic oncologist for optimal staging and debulking is the second most important determinant for survival after tumor stage in patients with ovarian carcinoma 1
- Imaging modalities such as CT, FDG-PET/CT, and MRI are used to assess the resectability of tumors and the need for postoperative chemotherapy 1
From the Research
Approach to Managing an Ovarian Mass
The approach to managing an ovarian mass involves a systematic evaluation and referral process to determine the risk of malignancy and appropriate management. Key steps include:
- Initial workup of a perimenopausal or postmenopausal woman presenting with an adnexal mass, including evaluation of symptoms and signs suggestive of malignancy, such as persistent pelvic/abdominal pain, urinary urgency/frequency, increased abdominal size/bloating, and difficulty eating, as well as CA125 measurement 2
- Transvaginal or transabdominal ultrasound examination as part of the initial workup of a complex adnexal/ovarian mass 2, 3
- Standardized ultrasound reports to include size and unilateral/bilateral location of the adnexal mass, possible origin, thickness of septations, presence of excrescences and internal solid components, vascular flow distribution pattern, and presence or absence of ascites 2
- Calculation of the risk of malignancy index II score to identify pelvic mass with high malignant potential 2
- Referral to a gynaecologic oncologist for assessment and optimal surgical management for patients deemed to have a high risk of an underlying malignancy 2, 4, 5
Investigation and Management
Investigation for an ovarian mass includes:
- Transvaginal and transabdominal ultrasound 3
- Doppler ultrasonography to discriminate ovarian lesions and evaluate adnexal masses 6
- Consideration of complications such as cyst rupture and torsion, with torsion being a gynaecological emergency requiring urgent review 3 Management may involve:
- Conservative management for benign ovarian masses, with the aim of reducing unnecessary surgery and long-term health complications, maintaining fertility, and decreasing operative costs 4
- Surgical management for malignant or potentially malignant masses, with referral to a gynaecologic oncologist for optimal management 2, 4, 5