1. Malignancy was discovered in 1.5% of patients undergoing laparoscopic surgery for removal of a suspicious or persistent adnexal mass.
2. Among patients with newly discovered malignancy, prognosis was unchanged by surgical approach, upstaging at time of initial procedure or delay to second surgery.
Evidence Rating Level: 2 (Good)
Study Rundown: The standard of care for symptomatic, persistent or complex-appearing adnexal masses is laparoscopic removal. In the instance of malignancy, intraoperative rupture of an adnexal mass can upstage cancer from Stage IA to IC, portending a worse prognosis and often more aggressive or longer courses of adjuvant chemotherapy. In fact, upstaging to Stage IV by spread to trochanteric sites has also been described. For this reason, the frequency of malignancy among these cases is important and if high, might change practice. Prior studies have evaluated the predictive value of transvaginal ultrasound for determining malignancy. Sonographic features of adnexal masses concerning for malignancy include solid components, internal septations or papillary structures, loculations and Doppler flow (internal vascularity).
Despite the identification of useful characteristics on imaging, the incidence of malignancy among women undergoing surgery for benign-appearing adnexal masses is not known. In this retrospective study, researchers determined the incidence of malignancy among women undergoing cystectomy for presumed benign disease (e.g. hemorrhagic cysts, dermoid cyst). The present work reviewed records of nearly 2,000 women in Japan who underwent laparoscopic cystectomy for symptomatic or persistent adnexal masses and identified an incidence of malignant ovarian neoplasm of 1.5%. Findings were limited by retrospective design and generalizability to other ethnicities and countries may be limited. The malignancies identified in this study were few (n=13) and have more favorable outcomes, so findings with regard to prognosis may not be consistent across other types of early malignancy. Future investigations might randomize patients to undergo cystectomy with or without gynecologic oncology surgeons on backup to assess whether involvement of these highly specialized surgeons at the time of initial diagnosis impacts prognosis.
In-Depth [retrospective cohort]: Researchers at the Aichi Medical University Hospital in Nagakute Japan enrolled 884 women undergoing laparoscopic cystectomy for presumed benign indications (symptomatic, persistent or large benign-appearing adnexal masses) from 2007-2013. Outcomes included final pathology, conversion to open procedure, upstaging (intraoperative cyst rupture) and need for repeat procedure.
Among 884 women undergoing laparoscopic cystectomy, 13 (1.5%) were found to have and ovarian malignancy. Of the 13 patients with malignancy, 9 were upstaged from stage IA to IC due to intraoperative cyst rupture. There was an average delay between initial surgery and surgical staging laparotomy of 88.9 days. Yet, identification of an early-stage ovarian neoplasm did not alter prognosis. Nearly half of the identified neoplasms (46%) were epithelial. Elevated CA-125 was not predictive of malignancy.
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