Review
Paul C. Lin, M.D., Seattle Reproductive Medicine

This review article provides basic information with which any gynecologist should be familiar and compiles the most recent data regarding the management of adnexal masses. The facts that 80% of masses in women <55 years of age are benign and that only 0.4% are carcinomas, can be reassuring to patients when discussing treatment options. Even in postmenopausal women, data indicate that 3-18% have an adnexal mass and when it is unilocular with a size <10 cm, 70% resolve, with persistence in only 30%. The overall risk of malignancy of these lesions is less than 0.1% and when complex, ranges from 6-39%. A history and physical is generally unreliable with a bimanual exam providing virtually no benefit in making a diagnosis. Measurement of serum CA-125 levels is unreliable but when >65 U/mL has a 50% sensitivity in premenopausal women and a 98% sensitivity in postmenopausal women for carcinoma. Therefore, CA-125 should be evaluated only in postmenopausal women. Ultrasound has an overall sensitivity of 81% for malignancy but that figure is reduced in stage I ovarian cancer to 52% as ultrasonographic findings are less distinct. Routine screening with ultrasound and CA-125 is not recommended due to the high risk of unnecessary operation with possible surgical complications in combination with the low likelihood that screening will detect an early-stage ovarian cancer. 

Laparoscopy is deemed to be a feasible option for large adnexal masses > 10 cm for both simple and complex adnexal masses depending on the comfort level of the surgeon. However, there is often some reluctance to evaluate these larger lesions with laparoscopy due to concerns regarding the rate of malignancy, risk of tumor spillage, the incidence of port-site metastasis, the uncertain role of laparoscopy in gynecologic oncology and the amount of additional training perceived to be required to perform laparoscopy safely, efficiently and effectively. The risk of malignancy ranges from 1-14%, with the risk of malignancy in complex adnexal masses in postmenopausal women being 6%. In one study of 247 women prospectively managed with laparoscopy, 83% were managed adequately without the use of laparotomy. The authors propose that a CA-125 >50 IU/L, ascites and evidence of abdominal or distant metastasis can be used as reasonable guidelines for referral to a gynecologic oncologist without significantly delaying appropriate treatment. While the rupture of stage I ovarian disease significantly affected disease-free interval is concerning, cyst rupture and potential tumor spillage can be avoided in laparoscopy by the use of proper surgical technique, i.e., endobag to retrieve the mass and liberally extending the trocar incisions, to safely remove the mass intact. Increased risk of port-site metastasis has not been shown to be increased as compared with laparotomy. Although large multicenter prospective randomized clinical trials are necessary, treatment of patients with low malignant potential or early-stage ovarian cancers with laparoscopy has been found to have excellent disease-free survival of 92% and overall survival of 100% in 46 months of follow-up and should be considered.

Comments 
Daniel B. Williams, M.D., Cincinnati, OH

This review article describes gynecologic management of large and small adnexal masses. Masses less than 10 cm have a relatively low likelihood of carcinoma, and this risk is extremely low in women < 55 y/o. Therefore, routine management by a gynecologist who is experienced in operative laparoscopy is reasonable. Larger masses may be able to managed laparoscopically be particularly skilled surgeons. Measurement of CA-125 appears to be useful only in postmenopausal patients. Importantly, the authors also present reasonable guidelines for prompt referral to a gynecologic oncologist.

You may also want to visit Highlights from Fertility and Sterility taken from the ASRM medical journal and ASRM Journal Highlights to read summaries of current articles from other medical journals in the field of reproductive medicine. 

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