Conservative Management of Asymptomatic Adnexal Masses Classified as Benign by the IOTA ADNEX Model: A Prospective Multicenter Portuguese Study

Abstract

This prospective multicentric study aiming to determine the incidence of complications (malignant transformation, torsion or rupture) during conservative management of adnexal masses was performed in two Portuguese tertiary referral hospitals. It included ≥18-year-old, non-pregnant patients with asymptomatic adnexal masses (associated IOTA ADNEX risk of malignancy < 10%) sonographically diagnosed between January 2016 and December 2020. Conservative patient management consisted of serial clinical and ultrasound assessment up to 60 months of follow-up, spontaneous resolution of the formation or surgical excision (median follow-up: 17.8; range 9-48 months). From the 573 masses monitored (328 premenopausal and 245 postmenopausal adnexal masses), no complications were observed in 99.5%. The annual lesion growth rates and increases in morphological complexity were similar in the premenopausal and postmenopausal patients. Spontaneous resolution, evidenced in 16.4% of the patients, was more common in the premenopausal group (p < 0.05). Surgical intervention was performed in 18.4% of the cases; one borderline and one invasive FIGO IA stage cancer were diagnosed. There was an isolated case of ovary torsion (0.17%). These data support conservative management as a safe option for sonographically benign, stable and asymptomatic adnexal masses before and after menopause and highlight the need for expedite treatment of symptomatic or increased-morphological-complexity lesions.

Keywords: IOTA ADNEX model; adnexal mass; benign lesions; conservative management; ultrasound.

Figure 1

Study Design.

Figure 2

Ultrasound features of borderline ovarian tumor initially classified as a benign lesion. (a) Unilocular ovarian formation with “ground glass” content and color score 1 with 35 × 30 × 20 mm, observed in an asymptomatic post-menopausal woman (age: 52 years), classified as a benign by the IOTA ADNEX model and assumed to be a sequel. (b) The same lesion with increased sonographic morphological complexity observed at the 3rd evaluation, 9 months after the diagnosis (multilocular—solid tumor with color score 3, CA-125 14.1 U/mL).

Figure 3

Ultrasound features of an ovarian mucinous carcinoma (FIGO IA stage) initially classified as a benign lesion. (a), Unilocular ovarian formation with “ground glass” content and color score 1 with 72 × 69 × 46 mm, observed in an asymptomatic pre-menopausal woman (age: 46 years), classified as benign by the IOTA ADNEX model and labeled as a possible endometrioma. (b) The same lesion with increased sonographic morphological complexity observed at the 2nd evaluation, 3 months after the initial diagnosis (multilocular—solid tumor with color score 3, CA-125 46 U/mL), associated with persistent pelvic pain referred by the patient as moderate with two weeks duration.