Adnexal Tumors Treatment & Management

Asymptomatic, small, well-characterized adnexal masses may be observed with regular pelvic examinations and radiologic evaluations. A surgical approach should be used if growth occurs in these masses, if the patient becomes symptomatic, or if the cyst develops more concerning features, such as solid components. As indicated previously, the suspicion for a malignancy is increased in prepubescent and postmenopausal women.

Some controversy exists regarding the use of combined hormonal contraceptives in the prevention and treatment of ovarian cysts. Observational studies in women taking higher-dose, “early-generation” oral contraceptive pills (OCPs) suggested a lower incidence of functional and benign epithelial ovarian cysts. However, more recent data have shown that contemporary oral contraceptive formulations have minimal effects on the incidence of ovarian cysts and that treatment with OCPs does not appear to expedite cyst resolution.^[33]

All adnexal masses that are symptomatic or have characteristics of a malignancy should be considered for surgical evaluation. The extensive differential diagnosis and possible surgical procedures should be discussed with the patient.

Obvious benign masses can be treated with resection of the mass alone or removal of the adnexal structure.

In those cases in which the presence of malignancy is questionable, one should limit the resection to the structures involved unless a preoperative decision has been made that a more aggressive approach should be taken.

When an obvious epithelial ovarian malignancy is encountered, a complete staging protocol must be performed. This generally includes complete exploration of the abdomen, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvic and para-aortic lymph node dissections, biopsies of the undersurface of the right and left diaphragms, and biopsies of the colic gutters followed by a maximal resection of the intra-abdominal tumor.^[34] In select cases involving women with limited, early stage, low-grade ovarian cancers, a fertility sparing procedure may be considered.^[35] In some cases, resecting portions of the small bowel or colon may be necessary; therefore, preoperative bowel preparation may be warranted, as is a discussion about possible colostomy or other bowel changes.

Preoperative preparation is vital to the proper care of a woman with an adnexal mass. This should include the following:

• A complete discussion of the possible procedures and the long-term results
• A complete bowel preparation in selected cases
• A careful evaluation of any associated medical problems or past surgeries
• An evaluation of the woman's nutritional status, particularly when ascites is present
• Consideration of referral to a gynecologic oncologist

Given the limitations of preoperative diagnostic testing in accurately determining the risk of malignancy (see Workup), the American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncologists have established referral guidelines for a newly diagnosed pelvic mass.^{[1, 36]} Women who meet the following criteria would benefit from preoperative consultation with a gynecologic oncologist:

Premenopausal (younger than 50 y)

• CA-125 level greater than 200 units/mL
• Ascites
• Evidence of abdominal or distant metastasis (by results of examination or imaging study)
• Family history of breast or ovarian cancer (in a first-degree relative)

Postmenopausal (older than 50 y)

• Elevated CA-125 levels (any degree of elevation)
• Ascites
• Nodular or fixed pelvic mass
• Evidence of abdominal or distant metastasis (by results of examination or imaging study)
• Family history of breast or ovarian cancer (in a first-degree relative)

During the procedure, several factors must be kept in mind, including the following:

• The dissection depends on the preoperative discussion concerning the nature and extent of the procedure.
• The dissection must be tailored to the woman's desire regarding future fertility. In many cases with benign disease, the dissection should not block future reproductive abilities.
• The presence of extensive disease as seen with cancer or endometriosis alters normal anatomical relations, which can result in a greater chance for injury to surrounding structures such as the ureters or bowel. Such dissections are best performed with the assistance of a gynecologic oncologist.

Intraoperative frozen section analysis should be considered based on a number of factors, as follows^[37] :

• Physical characteristics of the mass (eg, tumor lobularity, visible excrescences, combined solid and cystic components)
• Presence of adhesions noted during surgery (associated with increased risk of malignancy)
• Logistical considerations such as the on-call availability of gynecologic oncologist backup if malignancy is identified

Most adnexal masses can be removed with relative ease and are associated with little postoperative complexity; however, in women with significant preexisting medical problems and/or cancer, major postoperative problems can be encountered. When indicated, intensive care unit admission with close monitoring of fluid balance, electrolyte balance, coagulation status, and cardiopulmonary function may be required.

Most adnexal masses require little more than the normal annual gynecologic examination for follow-up because they rarely recur. On the other hand, women found to have a malignancy require additional therapy, such as chemotherapy or radiation therapy. Their follow-up care should include frequent reexaminations to determine the disease status.

For patient education resources, visit the Women's Health Center, as well as Ovarian Cysts.

The major adverse outcomes in the treatment of adnexal masses are related to complications resulting from surgical therapy. These may include the following:

• Infections of the urinary tract, wound, or lungs
• Blood loss with the resulting need for transfusion and associated blood-borne infections
• Injury to surrounding organs such as the urinary bladder, large or small bowel, ureters, or sidewall blood vessels and nerves
• Pelvic vein thrombosis with associated pulmonary embolism

Most adnexal masses are benign; outcome and prognosis are very good. Generally, no impact on life span or quality of life is noted. In fact, most women treated for adnexal masses have no interruption in their reproductive abilities.

Those women who are found to have malignant adnexal masses fall into 3 groups, as follows:

• Women ranging in age from the late teens (y) to early 20s (y): Germ cell tumors are seen in these women. The tumors are generally confined to the ovary and are cured in 90% of women after chemotherapy.
• Women aged 40-60 years: Epithelial tumors are the most common ovarian cancer in these women. These tumors are advanced (stage III-IV) in more than 50% of women. Even after the use of chemotherapy, only 10-40% of patients survive their disease.^[34]
• Women older than 60 years: Ovarian epithelial malignancies are common in this group of patients. Metastatic malignancies are also common. The incidence of sex-cord stromal tumors also increases in incidence in this age group, although it still accounts for only 5% of tumors. Stromal tumors are often early stage and may have an indolent course.

Future

The future holds several interesting possibilities. First, the rapid expansion of new laparoscopic equipment, including the robotic surgery platform, makes minimally invasive surgery an area that is gaining increasing importance in the treatment of adnexal masses. Second, the development of new radiologic techniques or expansion of the present techniques will allow the clinician to gain additional characterization of adnexal masses without entering the surgical suite. Third, new molecular, genetic, and biologic markers and therapies should become available that will assist in the diagnosis and treatment of adnexal masses, both benign and malignant.

Controversies

The major controversy surrounding adnexal masses is when and how to treat them. While some adnexal masses can be clearly stratified into low- or high-risk for malignancy based on clinical, laboratory, and clinical findings, currently, there are no definitive means of preoperative diagnosis with imaging or laboratory findings.