A guide to management Mitchel S. Hoffman, MD Professor and Director, Division of Adnexal masses in pregnancy Gynecologic Oncology, Department of Obstetrics and Gynecology, Forego surgery in most cases until delivery—or until University of South Florida, Tampa, Fla Robyn A. Sayer, MD the risky fi rst trimester has passed Assistant Professor, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, CASE 1 An enlarging cystic tumor 16 × 12 × 4 cm and determined that it University of South Florida, Tampa, Fla was a corpus luteum cyst. The authors report no fi nancial relationships relevant to this article. A 20-year-old gravida 3 para 1011 visits the emergency department with persistent right Presence of mass raises questions fl ank pain. Although ultrasonography (US) Despite the rarity of malignancy, the dis- shows a 21-week gestation, the patient has covery of an ovarian mass during pregnan- had no prenatal care. Imaging also reveals a® Dowdency prompts several Health important Media questions: right-sided ovarian tumor, 14 × 11 × 8 cm, How should the mass be assessed? How that is mainly cystic with some internal can the likelihood of malignancy be deter- echogenicity. CopyrightFor personalmined as quickly use and only effi ciently as pos- At 30 weeks’ gestation, a gynecologic sible, without jeopardy to the pregnancy? oncologist is consulted. Repeat US reveals When is surgical intervention warranted? the mass to be about 20 cm in diameter and And when can it be postponed? Specifi - cystic, without internal papillation. The pa- cally, is elective operative intervention for IN THIS ARTICLE tient’s CA-125 level is 12 U/mL. Based on this a tumor that is probably benign appro- information, the physicians decide the likely priate during pregnancy? ❙ The most common fi nding is a benign ovarian cystadenoma. When is the best time to operate? And masses detected How should they proceed? what is the optimal surgical route? during pregnancy In this article, we address these ques- Page 28 he discovery of an adnexal mass tions with a focus on intervention. As we’ll during pregnancy isn’t as rare explain, only a small percentage of gravidas ❙ When you discover Tas you might think—depending who have an adnexal mass require surgery a mass during on when and how closely you look, it during pregnancy. When surgery is neces- occurs in about 1 in 100 gestations. In sary, it is usually indicated for an emergent cesarean section most cases, we have found, the mass is problem or suspicion of malignancy. Even Page 32 clearly benign (TABLE 1, page 32), war- when ovarian cancer is confi rmed, we have ranting only observation. found that it is usually in its early stages ❙ Laparoscopy In the case described above, the phy- and therefore has a favorable prognosis or laparotomy? sicians followed the patient and removed (TABLE 2, page 32). Page 43 the mass at term because it was cystic with no other indications of malignancy. At 37 weeks’ gestation, a cesarean section How should a mass was performed through a midline lapa- be assessed? rotomy incision, followed by removal of Ultrasonography and other imaging of- the ovarian tumor, which was benign. ten reveal the presence of a mass and help The pathologist measured the tumor at determine whether it is benign or malig- CONTINUED www.obgmanagement.com March 2007 • OBG MANAGEMENT 27 For mass reproduction, content licensing and permissions contact Dowden Health Media. Adnexal masses in pregnancy Common adnexal tumors found during pregnancy Corpus luteum Benign cystadenoma A persistent corpus luteum is a normal component In an asymptomatic patient with imaging that sug- of pregnancy. Although it usually appears as a small gests a benign cystadenoma (see sonogram below, cystic structure on ultrasonographic imaging, the left), benign cystic teratoma, or other benign tumor, corpus luteum of pregnancy can reach 10 cm in observation is reasonable in most cases.4,6,7,9–11,14,19 size. Other types of “functional” ovarian cysts may Operative intervention is required when there is less also be found during pregnancy. Most functional certainty regarding the benign nature of the tumor, cysts resolve by the early second trimester.4,6 In rare an acute complication develops, or the tumor is cases, a cyst may develop complications such as expected to pose problems because of its large torsion or rupture, causing acute pain or hemor- size alone. rhage. Otherwise, a cystic tumor identifi ed in the fi rst trimester should be characterized and followed Uterine leiomyoma using ultrasonography (US). It is rare for an ovarian tumor detected during preg- nancy to have a solid appearance on US. When it Benign neoplasm does, it may be a uterine leiomyoma mimicking an An adnexal mass that persists beyond the fi rst adnexal tumor (see intraoperative photograph trimester is more likely to be a neoplasm.3–5,10,11,22 below, right). It should be reevaluated with more Such a mass is generally considered clinically detailed US or magnetic resonance imaging.25 signifi cant if it exceeds 5 cm in diameter and has a complex sonographic appearance. Usually such a Malignancy neoplasm will be a benign cystadenoma or cystic About 10% of adnexal masses that persist during teratoma. 5,10–13,19,23,24 pregnancy are malignant, according to recent series.4,5,7–10,12,13,24,26 Benign cystic teratoma Most of the ovarian cancers diagnosed during This tumor can be identifi ed with a fairly high degree pregnancy are epithelial, and a substantial portion of of specifi city using a variety of imaging techniques, these are low-malignant-potential (LMP) with management based on the presumptive diagno- tumors.5,10,11,13,19,23,24,26,27 This ratio is in keeping with sis. This tumor is unlikely to grow substantially during the age of these women, which also explains the pregnancy. When it is smaller than 6 cm, such a tumor stage distribution (most are stage 1) and the large can simply be observed.14 A larger tumor can oc- percentage of germ-cell tumors detected. The major- casionally rupture or lead to torsion or obstruction of ity of ovarian cancers discovered in pregnant women labor, but such occurrences are rare. have a favorable prognosis. Benign-appearing cystadenoma Leiomyoma mimics an ovarian tumor UT CYST A morphologically benign-appearing, large, cystic adnexal mass can be This 17-week gestation was marked by a large pedunculated leiomyoma seen in association with an 11-week gestation. that at fi rst appeared to be a right adnexal tumor. 28 OBG MANAGEMENT • March 2007 Adnexal masses in pregnancy TABLE 1 Appearance of adnexal masses on US Adnexal masses removed during A functional cyst such as a follicular cyst, pregnancy: Histologic profi le corpus luteum cyst, or theca lutein cyst usually has smooth borders and a fl uid HISTOLOGIC TYPE NUMBER (%) center. Other cysts may sometimes con- Cystadenoma 549 (33) tain debris, such as clotted blood, that Dermoid 451 (27) suggests endometriosis or a simple cyst with bleeding into it. Paraovarian/paratubal 204 (12) A benign cystic teratoma often has mul- Functional 237 (14) tiple tissue lines, evidence of calcifi cation, Endometrioma 55 (3) and layering of fat and fl uid contents. A benign cystadenoma usually has the Benign stromal 28 (2) appearance of a simple cyst without Leiomyoma 23 (1.5) large septates, whereas a cystadenocar- Luteoma 8 (0.5) cinoma often contains septates, abnor- mal blood fl ow, increased vascularity, or Miscellaneous 55 (3) all of these. However, it is impossible to Malignant 68 (4) defi nitively distinguish a cystadenoma Total 1,678 from a cystadenocarcinoma using US Data supplied by the authors from surgical experience imaging alone. Functional cysts usually resolve by the second trimester. A cyst warrants TABLE 2 closer scrutiny when it persists, is larger Malignant adnexal masses than 5 cm in diameter, or has a complex removed during pregnancy appearance on US. HISTOLOGIC TYPE NUMBER (%) CA-125 may be useful Epithelial 101 (28) after the fi rst trimester FAST TRACK Borderline epithelial 147 (40) The serum CA-125 level is typically el- evated during the fi rst trimester, but may The serum CA-125 Germ-cell dysgerminoma 47 (13) be useful during later assessment or for level is typically Other 34 (9) follow-up of a malignancy.1 elevated during the Stromal 24 (7) A markedly elevated serum level of fi rst trimester, but alpha-fetoprotein (fractionated in some Undifferentiated 5 (1.4) may be useful for cases) has been reported in some gravi- Sarcoma 2 (0.5) das with an endodermal sinus or mixed assessment later in 2 pregnancy Metastatic 4 (1.1) germ-cell ovarian tumor. Alpha-feto- Total 364 protein should be measured when there is suspicion for a germ-cell tumor based Data supplied by the authors from surgical experience on clinical or US fi ndings. nant. In fact, most adnexal masses dis- When a mass is discovered covered during pregnancy are incidental during cesarean section fi ndings at the time of routine prenatal Occasionally, an adnexal mass is de- US. (See page 28 for the most commonly tected at the time of cesarean section found tumors.) Operative intervention is (FIGURE 1, page 34).3 This phenomenon required in 3 situations: is increasingly common, given the large • malignancy is suspected number of cesarean deliveries in the Unit- • an acute complication develops ed States. To eliminate the need for future • the sheer size of the tumor is likely to surgery and avoid a delay in the diagno- cause diffi culty. sis of an ovarian malignancy, inspect the 32 OBG MANAGEMENT • March 2007 Adnexal masses in pregnancy FIGURE 1 eral ways.