We report a case of a 33 year-old pregnant woman who was diagnosed at the time of the first trimester ultrasound with a multilocular solid arising form the right ovary. An abdominal MRI was performed afterwards and it revealed a pelvic mass, developing from the right ovary, with a liquid component but with a major solid area. CA 125 was within the normal range values. A laparotomy followed by right salpingo-oophorectomy was performed at 14 weeks of gestation and both the frozen section and the definitive histology revealed a borderline mucinous ovarian tumor. Ovarian tumors of low malignant potential comprise 10%–20% of all ovarian malignancies. They carry an excellent prognosis with 95%–99% long-term survival. Whereas in the past, radical surgery (hysterectomy and bilateral salpingo-oophorectomy with peritoneal staging) was standard regardless of the age of the patient, unilateral salpingo-oophorectomy with or without staging has become the recommended management for women who desire childbearing. In the absence of large prospective randomized trials it is difficult to know which are the best management practices and especially to determine the right moment during pregnancy to perform surgery in these patients.
The incidental finding of an adnexal mass in pregnancy is becoming more common with the increased use of ultrasound. Data from the literature supports a high rate of spontaneous resolution and an extremely low rate of clinically relevant pathology. It is also important to note that no prospective, randomized trials are available to evaluate the various diagnostic and therapeutic options. The overall incidence of adnexal masses in pregnancy can vary greatly based on study population, use of sonography, and gestational age at presentation [
We report a case of a 33-year-old gravida 2 para 1 that was referred to our department after the first trimester ultrasound scan (performed in another institution) had revealed a huge ovarian mass. The patient was asymptomatic, denying weight loss and abdominal pain or distention. A more detailed medical record was obtained and there was a positive family history of borderline ovarian tumors (BOTs). The physical examination showed a palpable abdominal mass that reached the umbilicus. The ultrasound performed in our institution showed a 12-week singleton pregnancy and an adnexal mass, measuring approximately 17 × 11.5 cm, with a heterogeneous and highly vascular solid component, arising from the right ovary (Figure
Ultrasound showing a complex mass, with a solid component.
MRI demonstrating the relation between the adnexal mass and the pregnant uterus.
MRI showing the solid component of the adnexal mass.
After discussion with the patient secondary staging surgery (peritoneal washing, total abdominal hysterectomy, unilateral salpingo-oophorectomy, omentectomy, appendectomy, and peritoneal biopsies) was performed and no evidence of disease was found. Currently the patient is being followed (36 months after the first surgery) and all imaging data show no signs of disease relapse.
BOTs are a distinct histological entity and they account for nearly 10%–20% of all ovarian epithelial tumors [
According to the literature, BOTs are frequently diagnosed during the first trimester and usually they are detected in routine ultrasound exams. When symptomatic, patients may refer to unspecific abdominal pain [
Pelvic ultrasound remains the mainstay for evaluating the adnexa. The primary purpose is to characterize the mass and identify features that have been associated with an increased risk of malignancy, such as size >7 cm, solid components, “complex” appearance, papillary structures, internal septations, bilaterality, irregular borders, ascites, increased vascularity, and low-resistance blood flow. Bearing these features in mind, in our patient, all sonographic features were highly suspicious of malignancy. Accordingly, when there is a strong suspicion for malignancy, surgery is often indicated [
Another point of discussion is the surgical route. Laparotomy is usually the most definitive and traditional approach to remove adnexal masses during pregnancy. A midline vertical incision is often indicated to maximize visualization and to allow an optimal exploration of the abdomen. Bearing in mind once again the imaging features of the adnexal mass of our patient, a midline vertical laparotomy was performed not only due to the size of the tumor but also due to the high risk of malignancy. Laparoscopy may be an option because it has been shown as an effective and safe method for removing adnexal masses during pregnancy [
Confirmed low malignant potential tumors (in the frozen section examination) during pregnancy can be treated conservatively by salpingo-oophorectomy, peritoneal washing, and abdominal exploration [
In conclusion, data from the literature is not consensual on the management of BOTs during pregnancy.
The authors declare that there is no conflict of interests.