Intraoperative Management of Adnexal Cystic Masses Suspicious for Malignancy

The early diagnosis of ovarian cancer continues to evade us and remains the second most common gynecologic malignancy in the United States [1]. Given the lack of effective screening tools, the majority of these cancers are discovered in their advanced stages, making it the most fatal gynecologic cancer in our society.

As practicing general obstetrician-gynecologists, we frequently encounter benign adnexal masses. When a patient presents to the office or the hospital with what appears to be a benign ovarian cyst, we do all we can to rule out its malignant counterpart. Thorough histories are obtained, physical examinations are performed, laboratory values are investigated, and imaging tests are reviewed. These steps are all focused toward filtering out a malignant process. From an extensive evaluation, we reassure ourselves of the likely benign etiology of our patients’ symptomatic adnexal mass before taking them to surgery for a cystectomy or adnexectomy. Unfortunately, we do not detect them all, as one study found 0.4% of preoperatively diagnosed benign cysts were later confirmed to be malignancies [2]. After appropriate modern preoperative screening, another study described the risk of an unexpected malignancy to be between 0.9 to 13% [3]. Others report a range as wide as 0.38 to 18.67% malignant likelihood among ovarian masses [4].

It is those rare instances in which a previously surmised benign ovarian cyst now looks questionably cancerous, when exposed to the naked eye or the unflattering camera lens, in the operating room. So what do we do, or more appropriately, what should we do as generalists when face-to-face in the OR with a suspicious looking adnexal mass?

ACOG Committee Opinion 280 offers an algorithm for triaging adnexal masses. Intraoperatively, the minimum recommendation is to obtain washings and perform a thorough assessment of the peritoneal cavity at the beginning of any operative procedure. If suspicious for a malignancy, obtain additional biopsies or frozen sections and consider a complete cystectomy or oophorectomy [5]. Obtaining an intraoperative frozen section diagnosis will lead to appropriate management of the cyst in 90% of cases [6,7]. Regardless of what samples are collected, all suspected malignancies necessitate immediate referral to a gynecologic oncologist. In a retrospective study of 48 cases involving invasive ovarian cancer, a delay of greater than 17 days in surgical staging resulted in a worse prognosis [8]. If available, a specialist in gynecologic oncology should be consulted intraoperatively for evaluation and appropriate surgical management, preferably during the initial surgery or in the immediate future. A leading and controversial issue is the concern for potential intraoperative ovarian cyst rupture. If incidentally malignant, does it play any role in patient morbidity or mortality?

With the updated 2014 FIGO classification, intraoperative rupture or surgical spillage results in upstaging the cancer from a potentially innocuous stage IA to stage IC1. This could portend a worse prognosis and necessitate more therapeutic interventions, including chemotherapy. This re-classification also suggests cystic rupture to be similar to malignant cells in peritoneal washings and ovarian surface tumor invasion. However, one study suggests that patients assigned to stage IC on the basis of intraoperative tumor rupture alone could represent a minority of early-stage ovarian cancer. These patients have better survival and recurrence risk profiles than patients assigned to stage IC3 based on other factors, such as washings or malignant cells in as cites [9].

Discordance in the literature exists regarding the relationship between prognosis and intraoperative rupture or spillage. In a study with 519 cases of stage I epithelial ovarian cancer, they found no difference in survival among patients with intraoperative cystic rupture compared to their non-ruptured counterparts. However, they did demonstrate a difference in quality of life as the former group underwent more aggressive therapy consisting of whole abdominal radiotherapy [10]. Another study retrospectively analyzed 53 patients with stage I cancer and found a statistical difference in five-year survival, 56% among the capsular rupture group [11] compared to 78% among the intact capsule group. One study observed a shorter duration of disease-free progression and disease- specific survival. They concluded a worse disease prognosis associated with intraoperative capsule rupture [12].

Despite the conflicting evidence on prognosis and intraoperative cyst rupture, most agree it would be prudent to avoid rupture during ovarian tumor surgery. If intraoperative rupture or spillage occurs, it is essential to irrigate the abdominal cavity thoroughly. Great care should be taken to avoid rupture, puncture, biopsy or morcellation of the cyst or mass. Use of retrieval bags is paramount in safeguarding against spillage. Cyst aspiration can be performed within the bag for easier retrieval through the incision site [13].

There is a higher incidence of cyst rupture in laparoscopy compared to laparotomy [14,15]. This could stem from inaccessibility and difficulty from the presence of adhesions or tumor complexity. It could also depend on the skill and comfort of the surgeon in laparoscopic techniques as well as the availability of appropriate surgical equipment.

Management of an incidental intraoperative finding of ovarian malignancy rests on one main objective-to maintain the best possible prognosis for the patient. Consensus evidence may currently be lacking, but future prospective studies may help to elucidate the role of intraoperative cystic ruptures in patient prognosis. In the meantime, we should aim to collect thorough intraoperative samples to aid in diagnosis, to retrieve the cystic or adnexal mass intact, and to obtain timely consultation from gynecologic oncologists for appropriate staging. With the prepared anticipation that a malignancy may rear its ugly head in the operative setting, a clear systematic approach for diagnosis and early intervention should be initiated so we may provide our patients with the best possible outcomes.

1. Siegel RL, Miller KD, Jemal A (2018) Cancer statistics. CA Cancer J Clin 68(1): 7-30.
2. Nezhat F, Nezhat C, Welander CE, Benigno B (1992) Four ovarian cancers diagnosed during laparoscopic management of 1011 women with adnexal masses. Am J Obstet Gynecol 167(3): 790-796.
3. Munzi L, Angioli R, Zullo M, Panici PB (2005) The unexpected ovarian malignancy found during operative laparoscopy, incidence, management, and implications for prognosis. J Min Invasive Gynecol 12(1): 81-89.
4. Demir RH, Marchand GJ (2012) Adnexal masses suspected to be benign treated with laparoscopy. JSLS 16(1): 71-84.
5. ACOG (2002) Committee Opinion. The role of the generalist obstetrician-gynecologist in the early detection of ovarian cancer. Obstet Gynecol 100(6): 1413-1416.
6. Bensaid C, Le Frere BMA, Metzger U (2006) Performance of laparoscopy in identifying malignant ovarian cysts. Surg Endosc 20: 1410-1414.
7. Cross PA, Naik R, Patel A, Nayar AG, Hemming JD, et al. (2012) Intra-operative frozen section analysis for suspected early-stage ovarian cancer: 11 years of Gateshead Cancer Centre experience. BJOG 119(2): 194-201.
8. Lehner R, Wenzl H, Husslein P, Sevelda P (1998) Influence of delayed staging laparotomy after laparoscopic removal of ovarian masses later found malignant. Obstet Gynecol 92(6): 967-971.
9. Goudge CS, Li Z, Downs LS (2009) The influence of intraoperative tumor rupture on recurrence risk in stage IC epithelial ovarian cacner. Eur J Gynaecol Oncol 30(1): 25-28.
10. Dembo AJ, Davy M, Stenwig AE, Berle EJ (1990) Prognostic factors in patients with stage I epithelial ovarian cancer. Obstet Gynecol 75(2): 263-272.
11. Webb MJ, Decker DK, Mussey E (1973) Factors influencing survival in Stage I ovarian cancer. Am J Obstet Gynecol 116(2): 222-228.
12. Bakkum Gamez JN, Richardson DL, Seamon LG, Aletti GD (2009) Influence of intraoperative capsule rupture on outcomes in stage I epithelial ovarian cancer. Obstet Gynecol 113(1): 11-17.
13. Vaisbuch E, Dgani R, Ben AA, Hagay Z (2005) The role of laparoscopy in ovarian tumors of low malignant potential and early-stage ovarian cancer. Obstet Gynecol Surv 60(5): 326-330.
14. Shiota M, Kotani Y, Umemoto M, Tobiume T, Hoshiai H (2012) Study of the correlation between tumor size and cyst rupture in laparotomy and laparoscopy for benign ovarian tumor: is 10 cm the limit for laparoscopy? J Obstet ynaecol Res 38(3): 531-534.
15. Iglesias DS, Ramirez PT (2011) Role of minimally invasive surgery in staging of ovarian cancer. Curr Treat Options Oncol 12(3): 217-229.