Adnexal masses _when_to_observe,_when_to.2

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Adnexal masses _when_to_observe,_when_to.2

  1. 1. EditorialAdnexal MassesWhen to Observe, When to Intervene, and When to Refer I n 2009, there were an estimated 21,550 new cases of ovarian cancer and 14,600 deaths from this disease.1 Despite many new treatment modal- ities, ovarian cancer death rates have decreased only marginally over the past 15 years. This is attributed in part to the fact that most patients present with advanced disease. However, about 25% of ovarian cancer patients are diagnosed as having stage I disease, with an overall 5-year survival in these patients of between 85% and 94%.2,3 Therefore, it is imperative that every effort is made to diagnose ovarian cancer early and that it is treated appropriately. Ovarian cancer is best managed by gynecologic oncologists. However, most ovarian masses in reproductive- aged women are benign, and many are functional cysts that resolve on their own. This is also the case in many postmenopausal women with simple cysts. Premature surgical intervention in this group has no benefit, only risk, and observation is preferable. The dilemma then is when to Tommaso Falcone, MD, FRCSC observe, when to intervene, and when to refer. In the article by McDonald and colleagues (see p. 687), the authors try to predict the malignant potential of an adnexal mass.4 They defined a high-risk group for ovarian cancer as patients with a complex or solid adnexal mass and a CA 125 of greater than 35 units/mL. The critical role of transvaginal ultrasonography in discriminating between benign and malignant pelvic masses is highlighted in this study. Half the patients with complex or solid masses had ovarian malignancies, and three fourths had malignancy if associated with an elevated CA 125 of more than 35 units/mL. Previous studies have reported a sensitivity between 88% and 100% and a specificity between 62% and 96%.5,6 Doppler ultrasonography does not seem to add to the diagnostic precision of traditional ultrasonography. The patients in this study are not necessarily representative of a typical patient seen in a general obstetrics and gynecology practice, where the most common complex masses are dermoid cysts and endometriosis. Functional cysts also may present as complex masses in young women and can be watched safely over several cycles.7 Age is the most important See related article on page 687. independent risk factor for ovarian cancer.6 The average age of the patients in this study was 51.6Ϯ0.8 years, and 55% were postmenopausal.Dr. Falcone is Professor and Chair of the Ob/Gyn & These patients were referred to a cancer center for suspicious adnexalWomen’s Health Institute, Cleveland Clinic, Cleve- masses, and all had surgery. Fourteen percent of patients had ascites, andland, Ohio; e-mail: falcont@ccf.org. all had malignancy. Exclusion of this group of patients may change theFinancial Disclosure predictive value of the model because these values are dependent on theDr. Falcone has received royalties as an editor of abook that has a chapter on the topic discussed in this prevalence of disease within the sample. In this population, the overallarticle. He is a consultant for a company called prevalence of disease (malignancy) was 33%. In a population of youngerGynesonics Inc., which is developing a device to treat patients, this prevalence would be much lower, and the positive predictiveleiomyomas by ultrasound. value of this model would be substantially lower.© 2010 by The American College of Obstetricians This report confirms the findings of previous studies that adnexaland Gynecologists. Published by Lippincott Williams& Wilkins. masses that are simple cysts are not malignant, even with sizes larger thanISSN: 0029-7844/10 10 cm.8,9 Simple cysts up to 10 cm can be managed expectantly in680 VOL. 115, NO. 4, APRIL 2010 OBSTETRICS & GYNECOLOGY
  2. 2. premenopausal and postmenopausal women if the considered and recommended in older women. Sim-serum CA 125 concentration is normal and the ple cysts smaller than 10 cm can be watched carefullypatient is asymptomatic. in all women regardless of age if the CA 125 is less The assessment of the malignant potential of an than 35 units/mL. Nevertheless, in view of our inabil-ovarian cyst is also critical in the surgical management ity to detect ovarian cancer at an early stage and theof any adnexal mass. Laparoscopic management of an limited predictive value of preoperative assessment,adnexal mass has become the standard for all pre- every physician should have a contingency plan ifsumed benign ovarian neoplasms. If the capsule of a malignancy is discovered.stage 1A or 1B ovarian cancer is ruptured intraop-eratively, the patient is upstaged to stage 1C. There REFERENCESis evidence to suggest that intraoperative capsule 1. Jemal A, Siegel R, Ward E, Hao Y, Xu J, Thun MJ. Cancer statistics, 2009. CA Cancer J Clin 2009;59:225– 49.rupture leads to higher risk of disease recurrence 2. Fader AN, Rose PG. Role of surgery in ovarian carcinoma.and death, and many oncologists would recom- J Clin Onc 2007;25:2873– 83.mend adjuvant treatment in these upstaged cases.10 3. Bell J, Brady MF, Young RC, Lage J, Walker JL, Look KY, etTherefore, preoperative assessment is critical to al. Randomized phase III trial of three versus six cycles of adjuvant carboplatin and paclitaxel in early stage epithelialoperative planning. ovarian carcinoma: a Gynecologic Oncology Group study. The American College of Obstetricians and Gy- Gynecol Oncol 2006;102:432–9.necologists’ and the Society of Gynecologic Oncolo- 4. McDonald JM, Doran S, DeSimone CP, Ueland FR, DePriestgists’ referral guidelines do not include ultrasono- PD, Ware RA, et al. Predicting risk of malignancy in adnexal masses. Obstet Gynecol 2010;115:687–94.graphic characteristics.11 In these guidelines, a CA 5. Valentin L, Hagen B, Tingulstad S, Eik-Nes S. Comparison of125 of more than 200 units/mL in premenopausal “pattern recognition” and logistic regression models for dis-women and more than 35 units/mL in postmeno- crimination between benign and malignant pelvic masses. A prospective cross-validation. Ultrasound Obstet Gynecol 2001;pausal women were used as referral criteria to an 18:357– 65.oncologist. The negative predictive values of these 6. Management of adnexal masses. ACOG Practice Bulletin No.criteria were 92% in premenopausal women and 83. American College of Obstetricians and Gynecologists.91.1% in postmenopausal women. McDonald et al Obstet Gynecol 2007;110:201–14.recommend lowering the CA 125 cutoff value for 7. Grimes DA, Jones LB, Lopez LM, Schulz KF. Oral contracep- tives for functional ovarian cysts. The Cochrane Database ofreferral from 60 units/mL to 35 units/mL because it Systematic Reviews 2006, Issue 4. Art. No.: CD006134. DOI:increased the sensitivity of their model. This may be 10.1002/14651858.CD006134.pub3.true in this subset of patients in this report because 8. Roman LD, Muderspach LI, Steijn SM, Laifer-Narim S, Gro-they are an older age group and mostly postmeno- shen S, Morrow CP. Pelvic examination, tumor marker, level, gray-scale and Doppler sonography in the prediction of pelvicpausal. However, half the patients with endometrio- cancer. Obstet Gynecol 1997;89:493–500.mas had an elevated CA 125. Because patients in their 9. Modesitt SC, Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ,reproductive years have more endometriomas than van Nagell JR Jr. Risk of malignancy in unilocular ovarianovarian malignancies, adopting this guideline would cystic tumors less than 10 centimeters in diameter. Obstet Gynecol 2003;102:594 –9.increase referrals of endometriosis patients. It is 10. Bakkum-Gamez JN, Richardson D, Seamon L, Aletti G, Pow-within the context of an older population, a serum CA less C, Keeney G, et al. Influence of intraoperative capsule125 higher than 35, and a complex or solid adnexal rupture on outcomes in stage 1 epithelial ovarian cancer.mass that merits referral to an oncologist. Obstet Gynecol 2009;113:11–7. In summary, this study confirms that complex 11. The role of the generalist obstetrician-gynecologist in the early detection of ovarian cancer. ACOG Committee Opinion No.adnexal masses should be assessed carefully and that 280. American College of Obstetricians and Gynecologists.referral to a gynecologic oncologist always should be Obstet Gynecol 2002;100:1413– 6.VOL. 115, NO. 4, APRIL 2010 Falcone Adnexal Masses 681

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