Int J Gynecol Cancer: first published as 10.1136/ijgc-2020-001996 on 10 November 2020. Downloaded from http://ijgc.bmj.
com/ on November 15, 2020 at University of N S Wales 1247645.
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Dipartimento Scienze della
Salute della Donna, del
Bambino e di Sanità Pubblica,
Fondazione Policlinico
Universitario A. Gemelli IRCCS,
Rome, Italy
Correspondence to
Dr Floriana Mascilini,
Dipartimento Scienze della
Salute della Donna, del
Bambino e di Sanità Pubblica,
Fondazione Policlinico
Universitario A. Gemelli IRCCS,
Rome, Italy; ​floriana_​mascilini@​
hotmail.​com
Received 22 August 2020
Revised 3 October 2020
Accepted 6 October 2020
© IGCS and ESGO 2020. No
commercial re-­use. See rights
and permissions. Published by
BMJ.
To cite: Testa AC, Mascilini F,
Quagliozzi L, et al. Int J
Gynecol Cancer Published
Online First: [please include
Day Month Year]. doi:10.1136/
ijgc-2020-001996
Management of ovarian masses in pregnancy:
patient selection for interventional treatment
Antonia Carla Testa, Floriana Mascilini ‍ ‍, Lorena Quagliozzi, Francesca Moro ‍ ‍, Giulia Bolomini,
Maria Teresa Mirandola, Maria Cristina Moruzzi, Giovanni Scambia, Anna Fagotti ‍ ‍
HIGHLIGHTS
• International Ovarian Tumor Analysis (IOTA) ultrasound morphological classification seems useful in the characterization
of ovarian masses during pregnancy.
• None of the patients who underwent surgery during pregnancy had complications related to the surgical procedure.
• We designed an algorithm for the management of patients with ovarian masses detected during pregnancy.
ABSTRACT
Objective The management of pregnant women with an
adnexal tumor is still challenging and in the literature few
data are available. The aim of this study was to describe
the management and outcome of patients with ovarian
masses detected during pregnancy. As secondary aims, we
evaluated the prevalence of malignancy in the International
Ovarian Tumor Analysis (IOTA) morphological classes of
ovarian masses diagnosed during pregnancy, and created
an algorithm for the management of patients with adnexal
masses during pregnancy.
Methods This was a retrospective single centered
study including patients with adnexal masses detected at
any trimester during pregnancy between January 2000
and December 2019. Clinical, ultrasound, surgical, and
histological data were retrieved from medical records as
well as information on management (ultrasound follow-­up
vs surgery). Indications for surgery were recorded in terms
of suspicion of malignancy based on pattern recognition
of the ultrasound examiner or on symptoms or prevention
of complications, such as torsion, rupture, or obstacle to
normal full-­term pregnancy. All masses were described
using IOTA terminology.
Results A total of 113 patients were selected for the
analysis. Of these, 48 (42%) patients had surveillance and
65 (58%) patients underwent surgery (11 primary ovarian
tumors, one recurrence of ovarian cancer, four metastases
to the ovary, 20 borderline tumors, and 29 benign lesions).
Indications for surgery were suspicious malignancy in
41/65 (63.1%) cases and symptoms or prevention of
complications in 24/65 (36.9%) cases. All patients in the
surveillance group showed no morphological changes of
the ovarian lesions at 6 months after delivery. According
to the IOTA ultrasound morphological category, the
prevalence of malignancy was 0% (0/37) in the unilocular
cyst group, 27% (4/15) in the multilocular group, 35%
(11/31) in the unilocular solid group, 70% (14/20) in the
multilocular solid group, and 70% (7/10) in the solid group.
Neither obstetric nor neonatal complications were reported
for patients in the surveillance group or in those with
benign, borderline, or primary epithelial invasive histology.
In contrast, two neonatal deaths were observed in patients
with ovarian choriocarcinoma and ovarian metastases.
Three of the four patients with ovarian metastases died
after pregnancy.
Testa AC, et al. Int J Gynecol Cancer 2020;0:1–8. doi:10.1136/ijgc-2020-001996
Original research
Conclusions IOTA ultrasound morphological
classification seems useful in the characterization
of ovarian masses during pregnancy. A clinical and
morphological based algorithm for counseling patients has
been designed.
INTRODUCTION
Ovarian masses complicating pregnancy accounted
for an overall incidence of between 2.4% and 5.7%, as
Protected by copyright.
reported in the early 1990s.11 The detection of adnexal
masses during pregnancy has become increasingly
more evident in the last 20 years due to widespread
use of ultrasound, the technical advancement of such
equipment,2 and the delay of childbearing to an older
age. Most adnexal masses are diagnosed incidentally
at the time of the first trimester ultrasound screening
and the vast majority are benign and resolve sponta-
neously.3 4 Although ovarian cancer is extremely rare
in women of childbearing age, the overall incidence
of malignant adnexal masses diagnosed during preg-
nancy ranges between 0.2–3.8%,5 representing the
fifth most common cancer diagnosed during preg-
nancy.6
The literature on ovarian cancer in pregnancy
mainly consists of case reports or small retrospective
series, and few data are available on the manage-
ment of ovarian masses during pregnancy.5 7 Indeed,
the management of pregnant women with an adnexal
tumor is still challenging and practitioner or surgeon
dependent.
Management may be conservative (ultrasound
surveillance) or surgical. Thus far, the choice of any
surgical intervention is tailored according to (1) clinical
and ultrasound criteria, including size, morphology,
symptoms, and (2) obstetric criteria such as gesta-
tional period and obstetric comorbidities. Ultrasound
imaging plays a fundamental role in preoperative
discrimination between benign and malignant ovarian
masses with a very high accuracy8 based on subjective
assessment and mathematical models.9 10 However,
few studies are reported on ultrasound features in
1
 Int J Gynecol Cancer: first published as 10.1136/ijgc-2020-001996 on 10 November 2020. Downloaded from http://ijgc.bmj.com/ on November 15, 2020 at University of N S Wales 1247645.
Original research

discriminating ovarian masses during pregnancy. Moreover, ultra-
sound parameters maybe misinterpreted during pregnancy due to
the effects of the hormonal environment.11 The aim of this study was
to describe the management and outcome of patients with ovarian
masses detected during pregnancy in our institution over a 20 year
period. The prevalence of malignancy in the International Ovarian
Tumor Analysis (IOTA) morphological classes of ovarian masses
diagnosed during pregnancy on ultrasound was also assessed. A
proposed algorithm for the management of patients with adnexal
masses detected during pregnancy is described.
METHODS
Study Design and Participant
This is a retrospective study performed at the Gynecologic
Oncology Unit, Fondazione Policlinico Universitario Agostino
Gemelli, IRCCS, in Rome, and approved by the local institutional
review board (CICOG-30-10-19\60). All patients with an ultrasound
diagnosis of an adnexal mass detected during pregnancy before
delivery between January 2000 and December 2019 were identi-
fied. Clinical, ultrasound, surgical, and histological parameters, as
well as information on the type of management (surveillance vs
surgery) were retrospectively retrieved from the patients’ medical
records. Indications for surgery according to the clinicians’ deci-
sion were recorded in terms of suspicion of malignancy based on
pattern recognition of the ultrasound examiner or symptoms or
prevention of complications such as torsion, rupture, or obstacle
to normal full-­term pregnancy, as reported in the literature.12–14 A
clinical and morphological based algorithm for counseling patients
has been designed (Figure 1A-­C). Information on follow-­up during
and after pregnancy were reported. Finally, obstetrics and perinatal
outcomes were also noted.
Ultrasound Assessment
All patients had been examined preoperatively with transvaginal
ultrasound (supplemented with a transabdominal scan if necessary)
using a standardized examination technique.15 All the ultrasound
examiners had more than 10 years’ experience in gynecological
ultrasound, and the examinations were performed using high-­
quality ultrasound equipment. All masses were described using the
International Ovarian Tumor Analysis (IOTA) terminology.15
The following parameters were assessed: location and size of
the lesion (three orthogonal diameters), unilateral or bilateral mass,
presence of ascites and/or fluid in the pouch of Douglas, type of
mass (unilocular, unilocular-­solid, multilocular, multilocular-­solid
or solid), presence of papillary projections (defined as any solid
protrusion into a cyst cavity with a height ≥3 mm), number of
papillary projections within the cyst, irregularity of the surface of
papillary projections, presence of solid tissue other than papillary
projections, and presence of septa. In case of bilateral masses, the

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Figure 1 (A) An algorithm for the management of symptomatic patients with adnexal masses diagnosed during pregnancy.
(B) An algorithm for the management of asymptomatic patients with adnexal masses diagnosed during pregnancy. (C) An
algorithm for the management of asymptomatic patients with adnexal masses having unilocular-­solid morphology diagnosed
during pregnancy.

2 Testa AC, et al. Int J Gynecol Cancer 2020;0:1–8. doi:10.1136/ijgc-2020-001996


mass with the most complex ultrasound morphology was used. If
the masses had similar morphology, the larger mass was used.
The color content of the papillary projections and the solid tissue
other than papillary projections at power Doppler examination were
subjectively estimated, using a color score11 (1=no vascularization;
2=minimal vascularization; 3=moderate vascularization; 4=strong
vascularization). On the basis of subjective assessment of gray-­
scale and color Doppler findings, the lesions were divided into three
groups: benign disease, borderline tumors, and malignant tumors
(primary ovarian cancer and metastatic cancer).
The prevalence of malignancy (including borderline and invasive
tumors) in each morphological category (unilocular, unilocular solid,
multilocular, multilocular solid, solid) was calculated, considering
both patients with histology and those not operated on but with an
ultrasound scan at least 6 months from delivery, confirming benign
characteristics of the lesion.14
Surgical Procedure
Surgery was performed usually after the end of the first trimester
of pregnancy, at cesarean section, or after delivery. During preg-
nancy, laparoscopy was performed whenever possible. Reasons for
laparotomy were discussed by a multidisciplinary team according
to gestational age, size, and type of tumor. All procedures were
performed by an experienced gynecologic oncology surgeon with
at least 10 years’ experience. All surgical information was retrieved.
Statistical Analysis
All clinical and ultrasound information were collected retrospec-
tively and entered into a dedicated Excel file (Microsoft Office Excel
2007, Redmond, WA). Data were expressed as median and range
or n (%). Patients were grouped as patients who did not undergo
surgery (follow-­up group) and patients undergoing surgery (surgery
group). Mann-­ Whitney and Kruskal-­ Wallis tests for continuous
variables and χ2 or Fisher’s exact test for nominal variables were
used as appropriate. A value of p<0.05 was considered statistically
significant.
RESULTS
Clinical characteristics
We identified 113 patients with an ovarian mass detected during
pregnancy (Figure 2). The majority of patients (76/113; 67.3%)
Figure 2 Histogram showing patient enrollment during
study period.
Testa AC, et al. Int J Gynecol Cancer 2020;0:1–8. doi:10.1136/ijgc-2020-001996
Int J Gynecol Cancer: first published as 10.1136/ijgc-2020-001996 on 10 November 2020. Downloaded from http://ijgc.bmj.com/ on November 15, 2020 at University of N S Wales 1247645.
Original research
were examined between 2016 and 2019 (Figure 2). Overall, 65
patients (58%) had pathology reports (64 cases underwent surgery
and one patient underwent ultrasound-­guided biopsy). Indications
for surgical procedure were suspicion of malignancy in 41 of 65
(63.1%) patients and symptoms or prevention of complications in
24 of 65 (36.9%) patients. The remaining 48 (42%) patients under-
went surveillance.
Among 41 patients who underwent surgery for suspicion of
malignancy, 33 (80%) had a final diagnosis of malignancy, whereas
among 24 patients who underwent surgery for symptoms or
prevention of complications, three (12%) had a final diagnosis of
cancer. Among patients undergoing surgery, 36 of 65 (55%) had
a diagnosis of malignant or borderline tumor on final histology:
11 had primary epithelial ovarian tumors, one had a recurrence of
ovarian cancer, and four had a diagnosis of metastases to the ovary,
while 20 patients had a borderline tumor. The remaining 29 patients
(45%) had benign masses.
Clinical and histological data of the study population are shown
in Table 1. Median age at diagnosis was 33 years (range 19–44)
and 67 (59%) patients were diagnosed at their first pregnancy. The
median CA125 tumor marker level was 163 U/mL (range 10–1240).
The median gestational age at diagnosis was 11 weeks (range
5–32) and the median gestational age at surgery was 23 weeks
(range 10–41). Most patients had surgery (or ultrasound-­guided
biopsy) during pregnancy (42/65, 65%), whereas the adnexal mass
was removed during cesarean delivery in 18 patients, after sponta-
Protected by copyright.
neous delivery in two patients, and after abortion in three patients.
Among those 42 patients undergoing surgery during pregnancy,
a laparoscopic approach was performed in 26 (62%) patients, lapa-
rotomy in 15 (36%) patients, and biopsy in one (2%). In six of 15
laparotomy cases (40%), surgery was performed initially via lapa-
roscopy and subsequently converted. No surgical complications
were described.
In particular, among patients with primary invasive ovarian
cancers, six (54.5%) patients underwent surgery during pregnancy
and five patients at the time of delivery (four during cesarean
section and one after spontaneous delivery). Two patients had Inter-
national Federation of Gynecology and Obstetrics (FIGO) stage IA,
four patients had stage IC, one had stage IIB, three had stage IIIC,
and one was stage IV. Histology was epithelial ovarian cancer in all
but one patient (chorioncarcinoma).
Ultrasound Characteristics
Ultrasound characteristics of patients either undergoing surveil-
lance or surgery are shown in Table 2. The median largest diam-
eter of all ovarian masses was 80 mm (range 15–266); the median
largest diameter of ovarian masses in the surveillance group was
lower (median 59, range 15–132 mm) than that of patients under-
going surgery (median 90, range 23–266 mm) (p=0. 00001).
Unilocular morphology was reported in none of the patients
with borderline or invasive tumor. Unilocular-­solid morphology was
described in nine of 20 (45%) patients with borderline tumors, and
in two of 16 (12%) patients with invasive tumors. Multilocular-­solid
and solid morphology was significantly higher in invasive tumors
than in the others (p=0.00008 and p=0.001, respectively). The
same for moderate or rich vascularization: nine of 20 (45%) border-
line and 13 of 16 (81%) invasive tumors versus eight of 29 (27%)
benign masses and four of 48 (8%) masses in the surveillance
3
 Int J Gynecol Cancer: first published as 10.1136/ijgc-2020-001996 on 10 November 2020. Downloaded from http://ijgc.bmj.com/ on November 15, 2020 at University of N S Wales 1247645.
Original research

Table 1 Clinical and histological characteristics of patients with ovarian masses during pregnancy

Follow-­up Surgery group, n=65 (58) P value

Characteristic All group Benign Borderline Cancer (overall)
Number of cases (%) 113 48 (42) 29 (45) 20 (31) 16 (25)
Median age at diagnosis (years) 33 (19–44) 33 (22–43) 32 (19–44) 32 (23–42) 32 (24–42) 0.3
(range)
Nulliparous 67 (59) 34 (70.8) 15 (51.7) 7 (35) 11 (68.7) 0.03*†
Median gestational age at 11 (5–32) 14 (5–27) 15 (5–30) 14 (5–28) 17 (6–32) 0.3
diagnosis (weeks) (range)
Median gestational age at 23 (10–41) 22 (12–41) 19 (12–39) 22 (10–37) 0.7
surgery (weeks) (range)
Time of surgery‡
 During cesarean section 18 (27.6) 8 (27.5) 4 (20) 6 (37.5) 0.5
 Ante-­partum 42 (64.6) 21 (72.4) 13 (65) 8 (50) 0.3
 Post-­abortion 3 (4.6) 0 2 (10) 1 (6.2) 0.1
 Post-­partum 2 (3) 0 1 (5) 1 (6.2) 0.3
Type of surgery‡
 Ultrasound-­guided biopsy 1 (1.5) 0 0 1 (6.2) 0.2
 Laparoscopy 29 (44.6) 17 (58.6) 9 (45) 3 (18.7) 0.03§
 Laparotomy (including 35 (5.8) 12 (41.3) 11 (55) 12 (75) 0.09
cesarean section)
Median CA125 (U/mL) at 163 (10–1240) – 162 (18–556) 115 (10–707) 200 (10–1240) 0.1

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diagnosis
(range)¶
Histology
 Borderline tumors  
  Serous 14
  Mucinous intestinal type 5
  Mucinous endocervical 1
type
 Invasive ovarian tumor   12
  High grade serous 4
carcinoma
  Endometrioid 3
adenocarcinoma
  Low grade serous 1
carcinoma
  Mucinous ovarian   1
carcinoma
  Clear cell carcinoma 1
  Choriocarcinoma 1
  Recurrent granulosa   1
ovarian tumor
 Metastatic carcinoma   4
  Small cell lung carcinoma 1
  Burkitt lymphoma 1
  Krukenberg 1
  Melanoma   1
 Benign  
  Teratoma   12
Continued

4 Testa AC, et al. Int J Gynecol Cancer 2020;0:1–8. doi:10.1136/ijgc-2020-001996


Table 1 Continued
Follow-­up
Characteristic All group
  
Decidualized   6
endometrioma
  
Cystoadenofibroma
  
Functional cyst
Mucinous cystoadenoma
   3
Serous cystoadenoma
   1
  
Myoma
Bold type indicates significant differences (p<0.05) in the post hoc comparisons among the four groups.
*Between follow-­up and borderline groups.
†Between borderline and cancer groups.
‡Data available for 65 patients.
§Between benign and cancer groups.
¶Data available for 29 patients.
group. Papillary projections were present in 15 of 20 (75%) border-
line tumors and in six of 16 (37%) invasive tumors versus 13 of 48
(27%) patients in the surveillance group, and in nine of 29 (31%)
patients with benign histology.
Among patients undergoing surgery, 10 of 13 masses (77%)
described as invasive were confirmed at histology, whereas three
were borderline tumors. In 13 of 23 tumors classified as borderline
at ultrasound, this was confirmed on final histology, whereas five
had invasive tumors and five were benign. All five benign tumors
misclassified as borderline were decidualized endometriomas on
final histology. Among cases classified as benign tumors on ultra-
sound, 21 were confirmed on final histology, while three cases
were borderline tumors and all were falsely suspected to be decid-
ualized endometriomas. All patients in the surveillance group had
no morphological changes of the ovarian lesions at 6 months after
delivery. According to the IOTA ultrasound morphological category,
the prevalence of malignancy was 0% (0/37) in the unilocular cyst
group, 35% (11/31) in the unilocular solid group, 27% (4/15) in the
multilocular group, 70% (14/20) in the multilocular solid group, and
70% (7/10) in the solid group.
Follow-up Data
Obstetrics and perinatal outcomes are described in Figure 3.
Regarding patients with primary invasive FIGO stage I–III ovarian
cancers, all patients are still alive and only two had recurrences
which were successfully treated with secondary cytoreduction;
the patient with FIGO stage IV ovarian choriocarcinoma with liver
metastases died 1 month after delivery and the newborn died within
3 months after delivery from cerebral metastases. Among four
patients with ovarian metastases from other primary tumors, three
died at 3, 8, and 24 months from the diagnosis, respectively, and one
has been in surveillance for 36 months. An intrauterine death at 24
weeks was observed for the patient with ovarian Burkitt lymphoma,
and one neonatal death was observed after cesarean section at 28
weeks of pregnancy in a patient with ovarian melanoma.
Management Algorithm Design
The algorithm designed in our institution for the management of patients
with adnexal masses detected during pregnancy is summarized in
Testa AC, et al. Int J Gynecol Cancer 2020;0:1–8. doi:10.1136/ijgc-2020-001996
Int J Gynecol Cancer: first published as 10.1136/ijgc-2020-001996 on 10 November 2020. Downloaded from http://ijgc.bmj.com/ on November 15, 2020 at University of N S Wales 1247645.
Original research
Surgery group, n=65 (58) P value
Benign Borderline Cancer (overall)
3
3
1
Figure 1A–C. In particular, for patients with symptoms, surgery is indi-
cated at any time. For asymptomatic patients, the counseling should be
performed at the end of the first trimester in order to plan the surgical
procedure with a minimally invasive approach. The counseling is mainly
based on morphological assessment of the adnexal mass at ultrasound.
In the presence of a unilocular cyst measuring <10 cm in size, a surveil-
Protected by copyright.
lance strategy should be planned. In case of a unilocular cyst with a
diameter ≥10 cm or a multilocular mass, observational versus interven-
tional management may be considered, noting the low risk of torsion
and malignancy (Figure 1B). In case of a mass with unilocular solid
morphology, counseling should consider the possibility of borderline
(30%) or invasive (7%) histology. However, the management in preg-
nancy should consider other information, including history of unilocular
cyst with ground glass echogenicity before pregnancy suggestive of
endometriomas, presence of papillary projections at early pregnancy
scan, and morphology of papillations (regular or irregular surface,
vascularization, number and size of papillary projections, shadowing)
Figure 1C. In patients with a unilocular solid cyst characterized by
papillary projections with an irregular surface, especially when already
detected at early pregnancy (Beryl Benacerraf, pre-­congress course on
endometriosis at the International Congress of Ultrasound in Obstetrics
and Gynecology, Singapore 2018),16 with no evidence of morphological
changes during the first half of pregnancy, a borderline histology should
be considered.
Management options include either surgery or surveillance, due to the
good prognosis in terms of neonatal and maternal outcomes for patients
with borderline tumors detected during pregnancy Figure 1C. In the
presence of a unilocular solid cyst with papillary projections increasing
in size and in the number of papillations from the first trimester during
pregnancy, an invasive tumor cannot be excluded, and surgical explora-
tion should be considered Figure 1C. When the patient with a unilocular
solid tumor has been triaged to surveillance, a scan after 32 weeks of
gestation could offer additional information. Indeed, in cases of reduction
in the size of the cyst, the hypothesis of decidualization is confirmed; in
cases of no change in cyst morphology, benign or borderline histology
should be considered. On the other hand, a further enlargement of the
cyst and papillary projections raises the suspicion of invasive histology.
In case of multilocular solid or solid masses, the risk of malignancy is
5
 Int J Gynecol Cancer: first published as 10.1136/ijgc-2020-001996 on 10 November 2020. Downloaded from http://ijgc.bmj.com/ on November 15, 2020 at University of N S Wales 1247645.
Original research

Table 2 Ultrasound characteristics of the study population

Follow-­up Surgery group, n=65 (58) P value

Characteristics All group Benign Borderline Cancer (overall)
Number of cases (%) 113 48 (42) 65 (58)
Number of cases (%) 113 48 (42) 29 (45) 20 (31) 16 (25)
Median maximum diameter 80 (15–266) 59 (15–132) 89 (23–266) 88 (37–216) 115 (43–182) 0.00001*†‡§¶
(mm) (range)
Bilateral masses 16 (14.1) 5 (10.4) 3 (10.3) 2 (10) 6 (37.5) 0.06
Type of cyst
 Unilocular 37 (32.7) 27 (56.2) 10 (34.4) 0 0 1.1
 Unilocular-­solid  31 (27.4) 13 (27) 7 (24.1) 9 (45) 2 (12.5) 0.1
 Multilocular 15 (13.2) 5 (10.4) 6 (20.6) 4 (20) 0 0.1
 Multilocular-­solid 20 (17.7) 1 (2) 5 (17.2) 6 (30) 8 (50) 0.00008*†‡§
 Solid 10 (8.8) 2 (4.1) 1 (3.4) 1 (5) 6 (37.5) 0.001‡§¶
Number of locules if present 35 6 11 10 8
 ≤10 26 (74.2) 6 (100) 9 (81.8) 6 (60) 5 (62.5) 0.3
 >10 9 (25.7) 0 2 (18.1) 4 (40) 3 (37.5) 0.3
Color score
 *1 48 (42.4) 30 (62.5) 14 (48.2) 4 (20) 0 1.7
 2 31 (27.4) 14 (29.1) 7 (24.1) 7 (35) 3 (18.7) 0.7
 3  27 (24) 3 (6.2) 7 (24.1) 9 (45) 8 (50) 0.0002*†‡

Protected by copyright.
 4 7 (6.1) 1 (2) 1 (3.4) 0 5 (31.2) 0.0003‡§¶
Median largest solid 39.2 (2–165) 26 (7–132) 35 (2–134) 26.6 (7–160) 68.2 (17–165) 0.00079‡§¶
component (mm) (range)
Presence of papillary 43 13 9 15 6 0.002†**¶
projections
 1 11 5 3 2 1
 2–3 6 2 1 3 0
 >3 26 6 5 10 5
Papillation flow 39 11 7 15 6
Median height of the largest 11.8 (4–31) 9.8 (5–28) 9 (4–16) 13.2 (5–31) 16.8 (9–22) 0.3
papillary projection (mm)
(range)
Subjective assessment
 Benign 70 (61.9) 46 (95.8) 21 (72.4) 3 (15) 0
  
Endometrioma 25 (35.7) 19 (41.3) 5 (23.8) 1 (33.3) 0
  
Others (teratoma, 45 (64.2) 27 (58.6) 16 (76.2) 2 (66.6) 0
cystadenoma)
 Borderline 24 (21.2) 1 (2) 5 (17.2) 13 (65) 5 (31.2)
 Malignant 13 (11.5) 0 0 3 (23) 10 (62.5)
  Primary ovarian tumor 9 (69.2) 0 0 3 (100) 6 (60)
  Metastases 4 (30.7) 0 0 0 4 (40)
 Not available 6 (5.3) 1 (2) 3 (10.3) 1 (5) 1 (6.2)
Bold type indicates significant differences (p<0.05) in the post hoc comparisons among the four groups.
*Between follow-­up and benign groups.
†Between follow-­up and borderline groups.
‡Between follow-­up and cancer groups.
§Between benign and cancer groups.
¶Between borderline and cancer groups.
**Between benign and borderline groups.

6 Testa AC, et al. Int J Gynecol Cancer 2020;0:1–8. doi:10.1136/ijgc-2020-001996


Figure 3 Obstetric and neonatal outcomes, follow up data.
significant and surgical management should be considered. Ultrasound-­
guided biopsy could also represent an option to obtain the histology
when the suspicion of metastases is evident.
DISCUSSION
We have described ultrasound features, management, and outcome of
patients with ovarian masses detected during pregnancy in a tertiary
referral center. We observed that the prevalence of malignancy in these
pregnant patients was similar to that reported in non-­pregnant patients
having unilocular, unilocular solid, and solid morphology, but it was
higher for ovarian masses with multilocular and multilocular-­solid. We
found that all patients who underwent surgery during pregnancy had
no complications related to the procedure. Two neonatal deaths and
one intrauterine fetal death were observed in patients with one primary
ovarian choriocarcinoma and two metastatic tumors. Finally, patients
with borderline tumors had no recurrence during follow-­up after preg-
nancy, whereas recurrences and maternal deaths were reported in
patients with primary ovarian choriocarcinoma and metastatic tumors.
Our results are in agreement with those previously reported in the
literature17 18 in terms of incidence of malignancy, management, and
surveillance. Regarding the prevalence of malignant histology in patients
operated on because of adnexal mass detected in pregnancy, our data
differ from those previously reported by Schmeler et al5 who reviewed
59 pregnant patients from 1990 to 2003 undergoing either surgical or
observational management for an adnexal mass of 5 cm or larger. In
their study, 17 patients underwent antepartum surgery (15 laparotomy,
two laparoscopy), and five of them (29%) had a diagnosis of malignancy
(four invasive, one borderline). This discrepancy could be related to the
study period in which the patients have been selected, and the type of
Testa AC, et al. Int J Gynecol Cancer 2020;0:1–8. doi:10.1136/ijgc-2020-001996
Int J Gynecol Cancer: first published as 10.1136/ijgc-2020-001996 on 10 November 2020. Downloaded from http://ijgc.bmj.com/ on November 15, 2020 at University of N S Wales 1247645.
Original research
Protected by copyright.
center—our institution being a referral center for oncological disease
during pregnancy.
Our results are in line with those described by Blake et al18 in a
systematic review of the literature delineating the feto-­ maternal
outcomes of pregnancy complicated by epithelial ovarian cancer. The
authors showed data on 105 pregnant patients diagnosed with epithe-
lial ovarian cancers: the majority of pregnancies resulted in a live birth
(81.3%), and the majority of births were via cesarean section (71.6%).
The investigators reported five (6.4%) neonatal deaths. Similarly, we
reported that most patients with invasive ovarian cancer had cesarean
section (11/16, 69%), but we observed no case of newborn death in
patients with epithelial ovarian cancer. Other authors reported series of
patients with adnexal masses3 19 or with ovarian cancer5 20 21 detected
during pregnancy, but none proposed management based on specific
morphological aspects of adnexal masses at ultrasound examination.
For example, Hoover et al3 proposed an algorithm chart on the manage-
ment of adnexal mass in pregnancy suggesting that patients with
“complex masses” should undergo another imaging method such as
magnetic resonance imaging. Amant et al5 20 described the manage-
ment of patients with gynecological cancers, with no specific informa-
tion about a possible management of all ovarian cysts detected during
pregnancy. Indeed, the algorithm reported in this manuscript represents
a proposal in this challenging scenario.
Our results provided the prevalence of malignancy for each IOTA
morphological category of ovarian masses detected during pregnancy,
allowing us to design an algorithm for the management of patients with
adnexal masses detected during pregnancy. The counseling of asymp-
tomatic patients is mainly based on morphology of the ovarian masses
on ultrasound examination (Figure 1). The present algorithm represents
the clinical standard of management of pregnant women with adnexal
7

Original research
masses, diagnosed during pregnancy at our institution. It should be
prospectively tested in a multicenter based setting. A comparison with
MRI could also be of interest in defining the best imaging modality, espe-
cially for those patients with adnexal masses with inconclusive diagnosis
at ultrasound examination.
The strength of our study is the large series of ovarian masses
detected during pregnancy in one institution with a significant number
of malignant tumors (36 cases), allowing us to describe their ultrasound
features and obstetrical outcomes. The high number of malignant
tumors managed during pregnancy, and the experience developed as
referral center in the last 4 years (2016–2019) (Figure 2), allowed us to
design, in a multidisciplinary team, an algorithm for the management
of patients with adnexal masses detected during pregnancy (Figure 1).
The main limitation of the study is its retrospective nature, leading to the
lack of some clinical information. This means that parameters such as
clinical, ultrasound and obstetrical information were not available in all
cases and the analysis has been calculated for smaller numbers. More-
over, ultrasound images or video clips were not always available, and this
has limited our possibility to review images and detect typical ultrasound
features.1
In conclusion, our study demonstrated that the management of
patients with ovarian masses detected during pregnancy should be
based on ultrasound examination, and a centralization of these pregnant
patients in a referral center for ovarian masses should be considered.
Second, our findings allowed us to design an algorithm for counseling
patients in order to define either a conservative or an interventional
management.
Twitter Anna Fagotti @annafagottimd
Contributors Each author of this original paper contributed to the work in the
following ways: ACT contributed to conception of the study, interpretation of data,
and drafting the article. FM contributed to acquisition of data, interpretation of data,
statistical analysis and drafting the article. LQ contributed to acquisition of data,
interpretation of data, statistical analysis and drafting the article. FM contributed
to acquisition and interpretation of data. GB contributed to acquisition of data.
MTM contributed to acquisition of data. MCM contributed to acquisition of data.
GS contributed to review the article critically for important intellectual content and
final approval of the version to be published. AF contributed to review the article
critically for important intellectual content and final approval of the version to be
published.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in the
article or uploaded as supplementary information.
Supplemental material This content has been supplied by the author(s). It has
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
peer-­reviewed. Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
ORCID iDs
Floriana Mascilini http://​orcid.​org/​0000-​0003-​0736-​3114
8 Testa AC, et al. Int J Gynecol Cancer 2020;0:1–8. doi:10.1136/ijgc-2020-001996
Int J Gynecol Cancer: first published as 10.1136/ijgc-2020-001996 on 10 November 2020. Downloaded from http://ijgc.bmj.com/ on November 15, 2020 at University of N S Wales 1247645.
Francesca Moro http://​orcid.​org/​0000-​0002-​5070-​7245
Anna Fagotti http://​orcid.​org/​0000-​0001-​5579-​335X
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