Conservative Management Can Avert Surgery for Benign Adnexal Masses

In the U.S., more than nine surgeries are performed for each ovarian malignancy diagnosed, a number substantially higher than in Europe. In addition, many surgeries in which ovarian cancer is found are performed by physicians other than gynecologic (GYN) oncologists.

An international panel of obstetricians/gynecologists (OB/GYNs), radiologists, GYN oncologists, and one pathologist has formulated recommendations for assessing malignancy risk when evaluating sonographically detected ovarian masses. In the panel's view, vaginal ultrasound performed by expert physicians and using pattern recognition with color Doppler assessment is the most accurate way to evaluate adnexal masses. This approach facilitates triage of such masses into the following categories:

• Almost Certainly Benign: Includes simple and unilocular cysts, hemorrhagic cysts in premenopausal women, endometriomas, and dermoids or mature cystic teratomas. For asymptomatic low-risk masses, initial 3-month follow-up imaging is recommended with subsequent annual imaging if the mass is stable or diminishing in size.

• Suspicious for Malignancy: Includes solitary mural nodules (>3 mm in size); multiple nodules (≥4 in number) involving >50% of the cyst wall; numerous or irregularly thickened, vascular septations; and cystic masses with large, solid components. These high-risk masses necessitate prompt referral to a GYN oncologist.

• Indeterminate: Does not fit either of the first two categories. Women should be referred to physicians with particular expertise in gynecologic imaging; magnetic resonance imaging as well as serial sonographic follow-up should be considered. In addition, consultation with a GYN oncologist is recommended (not necessarily for surgery, but to benefit from the subspecialist's expertise in evaluating ovarian masses).