Maternal adnexal masses in pregnancy.

Ovarian cancer: role of ultrasound in preoperative diagnosis and population screening

Integrating the concept of advanced gynaecological imaging for endometriosis.

To illustrate the imaging appearances of a variety of adnexal masses in pregnancy. Cases of adnexal masses in pregnancy were chosen to illustrate the appearance on ultrasonography and magnetic resonance imaging. Adnexal masses in pregnancy have a wide spectrum of imaging characteristics and clinical manifestations. Sonography is important in diagnosing, monitoring, and determining the malignant potential of these masses. Common adnexal lesions seen in pregnancy include simple cysts, hemorrhagic cysts, leiomyomas, and hyperstimulated ovaries in patients who have undergone assisted fertility. Uncommon adnexal lesions specific to pregnancy include hyperreactio luteinalis, theca lutein cysts with moles, and luteomas. Adnexal masses associated with pain include ovarian torsion and heterotopic pregnancy. Adnexal lesions that are found incidentally include teratomas, endometriomas, hydrosalpinx, cystadenomas, and cystadenocarcinomas. When the diagnosis of the adnexal mass cannot be made on the basis of sonographic appearance alone, magnetic resonance imaging may help. Familiarity with the clinicopathologic and sonographic features of common and uncommon adnexal masses in pregnancy is important for diagnosis and treatment.

Study question How do we classify adnexal masses (ovarian cysts) identified during pregnancy and how should we manage them? Summary answer Adnexal masses (ovarian cysts) should be managed expectantly in pregnancy, given the low rate of complications and low prevalence of malignancy. What is known already Conservative management of adnexal masses (ovarian cysts) is preferable during pregnancy, due to the maternal and fetal risks associated with surgery. Accurate diagnosis is key to safe expectant management. Various ultrasound-based models exist to classify adnexal masses; however, none have been validated for use in pregnancy. Adnexal mass morphology can change during pregnancy due to decidualisation, which is often difficult to distinguish from underlying neoplastic processes. We aim to evaluate:(1) the performance of current methods of adnexal mass classification in pregnancy, (2) understand the natural course of adnexal masses in pregnancy, particularly the presence of decidualisation and incidence of complications. Study design, size, duration Retrospective analysis of prospectively collected data between January 2017- November 2022. To classify adnexal masses (ovarian cysts), we evaluated: Expert subjective assessment (SA), IOTA Simple Rules (SR) and the IOTA Assessment of Different Neoplasias of the Adnexa (ADNEX) model. The end point was either the histological examination of tissue removed at surgery or the subjective classification of adnexal masses at the postnatal scan in women managed conservatively. Participants/materials, setting, methods Women with an adnexal mass identified on gynaecological ultrasound in pregnancy at a tertiary London University Hospital were included. Relevant clinical data was extracted, including age, gestation and cyst-related complications. Adnexal masses were classified at the first antenatal and postnatal ultrasound examination according to SA, SR and the ADNEX model (10% risk of malignancy cut off) and correlated to histology for adnexal masses managed surgically. IOTA simple descriptors were used to classify benign adnexal masses. Main results and the role of chance 254 women (median age 33-years old, range:18-49) with an adnexal mass/cyst were included at a median gestation of 12 weeks, (range:4-36). 13 (5.1%) conceived through assisted reproductive techniques. Spontaneous resolution occurred in 24.5% of cases, and 21 were lost to follow up (8.3%). According to Simple Descriptors, 38.6% were simple, 22.0% were endometriomas and 19.7% were dermoid cysts. Antenatally, SA outperformed ADNEX, based on specificity (94.6 vs.92.2%) and sensitivity (60 vs.55.6%) respectively. SA and ADNEX had a negative predictive value(NPV) of 96.1% and 98.3% respectively. Postnatally, SA had a higher sensitivity than ADNEX (75 vs.50%), but a lower specificity (94.1 vs.96.9%). SA and ADNEX had a NPV of 94.1% and 97.5% respectively. Three (1.3%) underwent acute surgery during pregnancy: one ovarian torsion (9/40), and two cyst ruptures (11/40, 30/40). Presumed decidualisation occurred in 29.5% of endometriomas. Three (1.3%) underwent cyst removal during caesarean section, two for suspicion of BOTs (one had suspected decidualisation) and one for patient preference. On histology, the suspected decidualised mass was a serous BOT, and the suspected BOT was a struma ovarii. In the postnatal period (12 weeks), four underwent surgery for suspicion of BOTs, two were confirmed BOTs and two were benign cystadenomas on histology. Limitations, reasons for caution The dataset as expected contains a relatively small number of malignancies (prevalence 3.9%) and so any analysis of test performance to discriminate between benign and malignant disease must be interpreted with caution. A larger prospective multicentre study is needed to do this. Wider implications of the findings Our data suggest that a number of cysts in pregnancy will resolve, a few will be associated with acute complications and the risk of malignancy is very low. Accordingly, the study supports an expectant management approach for adnexal masses (ovarian cysts) detected in pregnancy. Trial registration number Not applicable

Adnexal masses during pregnancy: diagnosis, treatment, and prognosis

Simple descriptors and simple rules of the International Ovarian Tumor Analysis (IOTA) Group: a prospective study of combined use for the description of adnexal masses

Guideline No. 403: Initial Investigation and Management of Adnexal Masses.

Commentary on: Timmerman D, Van Calster B, Testa A, et al. Predicting the risk of malignancy in adnexal masses based on the simple rules from the international ovarian tumor analysis...

The incidence of adnexal masses in pregnancy is approximately 1%. Most of them are corpus luteum and benign physiological cysts seen in first trimester. 90% of these cysts are resolved spontaneously in the second trimester. The rate of complication such as torsion and rupture in persisted cysts is about 25%. The risk of malignancy is between 2-5%. It is reasonable to perform surgery in cysts with high risk of malignancy or in cysts susceptible to complication, other masses can be treated conservatively. Suitable time for surgery is between 16th and 18th weeks of gestation. The traditional method of management of adnexal masses in pregnancy is laparatomy but in certain conditions laparoscopy can be performed. Most of the ovarian cancers detected inpregnacy are germ cell tumors and these can be operated conservatively. In this paper management of adnexal masses in pregnancy, difficulties in diagnosis, treatment methods and timing were mentioned. Besides that, 27 adnexal masses diagnosed during pregnancy in our clinic were analyzed under the view of the literature. i

Laparoscopic management of adnexal masses in pregnancy: a case series

Adnexal masses in pregnancy – A case report

Systematic Review and Meta-Analysis of Surgical Interventions of Adnexal Masses in Pregnancy

To compare guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG) based on the Risk of Malignancy Index (RMI) with a protocol based on logistic regression model LR2 developed by the International Ovarian Tumour Analysis (IOTA) group for triaging women with an ovarian mass as low, moderate, or high risk of malignancy. Observational diagnostic study conducted between 2005 and 2007 at 21 oncology referral centres, referral centres for ultrasonography and general hospitals. In all, 1938 women undergoing surgery for an ovarian mass. RCOG guidelines use the RMI to triage women as low (RMI < 25), moderate (25-250), or high (above >250) risk. The IOTA protocol uses LR2s estimated probability of malignancy (<0.05 indicates low risk, ≥ 0.05 but <0.25 moderate risk, and ≥ 0.25 high risk). Percentages of benign, borderline and invasive tumours classified as low, moderate or high risk. The IOTA and RCOG protocols classified 71.1% and 62.1% of benign tumours as low risk, respectively (difference 9.0; 95% CI 6.2-11.9, P < 0.0001). Of invasive tumours, 88.6% and 73.6% were labelled high risk (difference 15.0; 10.6-19.4, P < 0.0001), and 3.0% and 5.2% were labelled low risk (difference -2.2; -4.6 to 0.2, P = 0.07) respectively by each protocol. Similar results were found after stratification for menopausal status. The IOTA protocol was more accurate for triage than the RCOG protocol. The IOTA protocol would avoid major surgery for more women with benign tumours while still appropriately referring more women with an invasive tumour to a gynaecological oncologist.

Predicting the risk of malignancy in adnexal masses based on the Simple Rules from the International Ovarian Tumor Analysis group

To assess the clinical relevance of adnexal masses in pregnancy and the usefulness of ultrasound in their management. A prospective study on pregnancy complicated by adnexal masses. Department of Obstetrics and Gynaecology in Italy. 6636 women with pregnancy in utero followed in our clinic from January 1996 to December 1999. From 1996 to 1999, all ovarian cysts with a diameter exceeding 3 cm were prospectively recorded and followed. The management was expectant except in case of symptoms or suspected malignant features. Cysts suggestive of borderline tumours were treated expectantly. Clinical relevance of adnexal masses in pregnancy, the outcome of these pregnancies and the usefulness of ultrasound examination in their management. We detected 82 cysts in 79 of 6636 women (1.2 in 100 term pregnancies). Sixty-eight women were asymptomatic at the time of diagnosis, whereas 11 (13.9%) were diagnosed because of pain. Diagnosis occurred in the first trimester for 57 cases and in the second or third trimester in 22 (27.8%). One-half of the cysts were simple and anechoic at ultrasound. Fifty-seven had a diameter not exceeding 5 cm. Forty-two cyst resolved in pregnancy without treatment. Three cysts required surgery within few days (torsion). One woman required laparotomy at the 37th week of gestation, due to torsion. When one case of termination was excluded, 78 women delivered at term (66 vaginally, 12 by caesarean section). Nineteen women underwent surgery after pregnancy. We recorded three Stage Ia borderline tumours, accounting for 3/82 cysts (3.6%) and 3/30 persisting masses (10%). Ultrasound allows definition of ovarian cysts in pregnancy and this positively impacts on management. The incidence of cancer among persistent masses is lower than previously reported. Acute complications in stable cysts are extremely uncommon after the first trimester. An expectant management is successful in the majority of cases and should be considered more often. Routine removal of persistent cysts is not justified.