How to Manage Ovarian Masses in Asymptomatic Patients

Andrew M. Kaunitz, MD


May 02, 2016

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Hi. I am Andrew Kaunitz, professor and associate chair of the Department of Obstetrics and Gynecology, University of Florida College of Medicine, Jacksonville, Florida. Today I'd like to discuss how to manage an ovarian mass found in an asymptomatic patient.

A CT scan was performed in the emergency department after your patient experienced a motor vehicle accident. No findings related to trauma were noted, but the radiologist reported a unilateral cystic ovarian mass. Now what?

Our challenge as clinicians is to not overreact and proceed with unnecessary surgery, while identifying and referring cases of ovarian malignancy in a timely manner. During their lifetime, about 1 in 5 women will have an ovarian mass identified.[1,2] Given the frequent use of CT, ultrasound, and MRI, many of these masses are identified in asymptomatic women, leading to uncertainty about appropriate next steps. A recently published invited review in Obstetrics and Gynecology describes triage and management of ovarian masses.[3]

Appearance on pelvic ultrasound can classify ovarian masses as likely benign, likely malignant, or indeterminate. Unilocular or simple cysts are common and benign. Likewise, the risk for invasive malignancy is extremely low in women with cystic ovarian masses that include septations < 2 mm thick and no solid areas, papillary projections, or mural nodules. Simple ovarian cysts, as well as those with thin septations, often resolve spontaneously, and a follow-up sonogram should be performed in 3 months and then each year for 5 years if stable.

In contrast with simple ovarian cysts and those with thin septations, the risk for malignancy is greater for tumors in which ultrasound identifies cystic and solid areas, and even higher with solid ovarian masses or when ascites is present. Patients found to have ovarian masses with these ominous features should be referred to a gynecologic oncologist.

With initial ultrasound evaluation, some ovarian masses do not fit into obvious low- or high-risk categories. For women with ovarian masses with such indeterminate morphology, the authors of the review recommend serial monthly ultrasound evaluation, noting that tumor volume and morphologic complexity increase over time in ovarian malignancies. The authors also recommend monthly assessment of serum CA-125 levels for postmenopausal women with indeterminate ovarian masses, pointing out that even when they are in the normal range, increasing levels of serum CA-125 are predictive of malignancy.

We are routinely called upon to address the unexpected finding of an ovarian mass in asymptomatic women. This authoritative review provides practical recommendations that facilitate prompt identification of malignancy while minimizing surgery for benign asymptomatic masses.

I am Andrew Kaunitz, and I thank you for taking the time to watch this video.


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