Laparoscopic Management of Adnexal Masses Suspicious at Ultrasound

Abstract & Commentary

Synopsis: Laparoscopic diagnosis of adnexal masses suspicious at ultrasound avoids many laparotomies for the treatment of benign masses.

Source: Canis M, et al. Obstet Gynecol 1997;89:679-683.

To evaluate the laparoscopic management of adnexal masses suspicious at ultrasound, Canis and associates conducted a prospective study. Indications for laparotomy included general contraindications to laparoscopy, obviously disseminated ovarian cancer, and technically impossible laparoscopic treatment. After laparoscopic diagnosis, frozen sections were used to confirm a diagnosis of malignancy. Treatment was performed by laparoscopy whenever feasible. Over a three-year period, 247 of the 599 adnexal masses (41.2%) treated in the authors' institution were suspicious or solid at ultrasound. Seventeen patients were evaluated by laparotomy and 230 by laparoscopy. Overall, 204 women (82.6%) were treated by laparoscopy, including seven of the 37 malignant tumors (18.9%) and 197 of the 210 benign masses (93.8%). One case of tumor dissemination occurred after a laparoscopic adnexectomy and morcellation of a grade 1 immature teratoma.

Canis et al conclude that laparoscopic diagnosis of adnexal masses suspicious at ultrasound avoids many laparotomies for the treatment of benign masses and allows an improved inspection of the upper abdomen. They further recommend that the laparoscopic treatment of adnexal masses suspicious at surgery should be evaluated further in carefully designed prospective studies.

COMMENT BY DAVID M. GERSHENSON, MD

As I have discussed previously, the laparoscopic management of adnexal masses remains controversial, with no universal consensus about criteria for selection of candidates for such a procedure. However, most agree that when an adnexal mass has sonographic characteristics of a benign mass, laparoscopy is an acceptable method of surgical management. Such patients were excluded from this provocative study, in which Canis et al attempted to manage suspicious or solid masses laparoscopically. The basis for this study was the authors' contention that the sonographic diagnosis of malignancy has a high false-positive rate. In designing this study, they appropriately excluded patients with obvious disseminated ovarian cancer and informed the patients undergoing laparoscopy about the possibility of immediate laparotomy if a malignancy were diagnosed. Predictably, 210 of the 247 masses (85%) proved to be benign.

The management strategy proposed by Canis et al, however, is predicated on the accuracy of frozen section analysis. In fact, there was one case of tumor dissemination of an immature teratoma after morcellation of the mass; it had been diagnosed as benign on frozen section. Another case of possible tumor dissemination of a grade 1 invasive serous carcinoma occurred after a frozen section diagnosis of "uncertain." Although imperfect, studies such as this move us closer toward establishing safe criteria for selecting a laparoscopic approach for the management of adnexal masses. Of course, we must always keep in mind that the level of the gynecologist's expertise in laparoscopic techniques and the pathologist's ability to accurately predict malignancy on frozen section have an impact on this approach. In summary, I agree with the authors' recommendation that more prospective clinical trials in this area are needed to allow us to refine our criteria for laparoscopy.