1. Editorial
Adnexal Masses
When 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 adnexal
Women’s Health Institute, Cleveland Clinic, Cleve- masses, and all had surgery. Fourteen percent of patients had ascites, and
land, Ohio; e-mail: falcont@ccf.org. all had malignancy. Exclusion of this group of patients may change the
Financial Disclosure predictive value of the model because these values are dependent on the
Dr. Falcone has received royalties as an editor of a
book that has a chapter on the topic discussed in this
prevalence of disease within the sample. In this population, the overall
article. He is a consultant for a company called prevalence of disease (malignancy) was 33%. In a population of younger
Gynesonics Inc., which is developing a device to treat patients, this prevalence would be much lower, and the positive predictive
leiomyomas 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 adnexal
and Gynecologists. Published by Lippincott Williams
& Wilkins. masses that are simple cysts are not malignant, even with sizes larger than
ISSN: 0029-7844/10 10 cm.8,9 Simple cysts up to 10 cm can be managed expectantly in
680 VOL. 115, NO. 4, APRIL 2010 OBSTETRICS & GYNECOLOGY

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 carefully
patient 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 the
of 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 if
sumed 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 REFERENCES
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