Paraovarian/paratubal cysts: comparison of transvaginal sonographic and pathological findings to establish diagnostic criteria

Added value of gadolinium-based contrast agents for magnetic resonance evaluation of adnexal torsion in girls

PURPOSE

Ultrasound is the first-line imaging modality to evaluate adnexa in girls with clinical suspicion of torsion. Patients with equivocal ultrasound findings can undergo MRI for better delineation of adnexal pathology. Here, we assess the utility of intravenous contrast in MRI evaluation of adnexal torsion in children.

METHODS

Two pediatric radiologists (R1, R2) retrospectively reviewed 198 pelvic MRI exams in 172 girls (median age 15 years). Each MRI was reviewed twice. The first review included pre-contrast images only. A second review, at least 1 month later, included both pre- and post-contrast images. Readers concluded if findings were suspicious for torsion or not. Readers' findings were compared to each other's and to surgical and MRI reports and clinical course.

RESULTS

198 MRI exams yielded 354 evaluable ovaries. Surgical and pathological reports were available for 47 patients. 11 patients had adnexal torsion. Both readers accurately diagnosed acutely torsed ovaries during pre- and post-contrast reviews (n = 4). However, readers disagreed on torsed paraovarian cysts (n = 4) and chronically/intermittently torsed ovaries (n = 3). In 21 non-torsed ovaries that had lesions, one or both readers concluded that there were pre-contrast features of torsion. In this set with ovarian lesions, contrast helped readers to correctly conclude no torsion (R1 = 8, R2 = 6) more commonly than to incorrectly conclude torsion (1 each), improving post-contrast specificity for each reader.

CONCLUSIONS

Post-contrast sequences did not provide additional benefit in evaluating acutely torsed ovaries but helped in excluding torsion in patients with adnexal lesions. Therefore, contrast administration should be individualized, potentially reserved only for those with abnormal ultrasound or pre-contrast images.

Clinical, Imaging, Histological and Surgical Aspects Regarding Giant Paraovarian Cysts: A Systematic Review

Paraovarian cysts (POCs) develop within the broad ligament of the uterus. POCs are considered to be giant when the threshold of 150 mm is exceeded. Clinical signs and symptoms occur as a consequence of the pressure effect on adjacent organs or due to complications. Abdominal ultrasonography, computed tomography or magnetic resonance imaging are useful imaging tools, but most often the exact origin of such voluminous cysts is revealed only by surgical exploration. The review aims to appraise and update the diagnostic, the histological aspects and the treatment of the giant POCs in rare cases. We carried out a systematic search in Medline-PubMed, Google Scholar and ResearchGate electronic databases. Twenty-seven papers fulfilling the selection criteria were included in the review. The data extracted included information about first author, year of publication, country, patient age, size and side of the POCs, symptoms, tumoral markers, imaging methods, preoperative diagnosis, surgical management and histopathological findings. Although not very numerous, all the studies highlighted the low incidence of giant POCs, the impossibility of establishing the origin of the cystic mass by clinical and imaging methods even with advanced technical tools and the low risk of torsion (11.1%). Despite the recognized benign nature of POCs, we found an unexpected high percent (25.9%) of borderline giant POCs. Surgical excision is the only treatment option. Ovarian-sparing surgery was performed in 85.1% of the cases, and minimally invasive techniques were applied in only 42.9% of the patients, which demonstrates the need of a high-level laparoscopic expertise. Knowledge of this pathology, its recognition as a possible etiology of an abdominopelvic cyst, and a higher awareness of the possibility of a borderline histology in giant POCs are required for the proper management of these particular cases.

Huge Paratubal Cyst: A Case Report and a Literature Review

Paratubal cysts may mimic ovarian cysts, and most of them are diagnosed postoperatively. They originate from the mesosalpinx between the ovary and the fallopian tube. Only a few are large, and most paratubal cysts are less than 10 cm. We report a huge paratubal cyst in a 30-year-old woman, whose only preoperative complaint was abdominal distention over 4 months. Conservative surgery was performed with cyst removal while preserving the ovaries and tubes. A paratubal cyst should be included in the differential diagnosis of a large pelvic masses, especially in the reproductive age.

Innocent until proven guilty: acute on chronic tubal torsion mimicking pelvic inflammatory disease

Acute pelvic pain is a common complaint in reproductive age women and has a large differential diagnosis. Decision for conservative vs. surgical management is often dependent on clinical, biochemical and imaging findings. Isolated tubal torsion is a rare cause of pelvic pain that requires prompt diagnosis and surgical management to avoid morbidity. Here, we report non-pregnant women of reproductive age presenting with acute lower abdominal pain. Raised inflammatory markers and ultrasound findings prompted management for Pelvic Inflammatory Disease. Despite some improvement with antibiotics, the patient had ongoing symptoms. At surgery, bilateral para-tubal cysts and a left sided hydrosalpinx were found, along with an isolated left tubal torsion. Isolated tubal torsion most commonly occurs in reproductive aged women, and risk factors include intrinsic tubal pathology and extrinsic lesions. Clinically, biochemically and radiographically, it is often indistinguishable from other pelvic pathology, potentially leading to diagnostic delay, and necrosis of the tube.

Histopathological Account of Obstetrical and Gynecological Specimens: Retrospective Study at a Tertiary Care Center of Peshawar

Introduction Histopathologic specimen examination of surgically isolated organs and tissues yields valuable information regarding a disease process and plays a vital role in the future management of a patient. Our aim was to account for the common diagnosis yielded from histopathological specimens of the obstetrics and gynecology department and to determine if all the obstetric and gynecological specimens should be routinely sent for histopathology. Methods A retrospective, cross-sectional study was conducted at the histopathology unit of a tertiary care hospital in Peshawar. Data were acquired for all gynecological and obstetric specimens sent for histopathology for analysis to the histopathology unit during August 2018 and July 2019. Any sample that was not sent via surgical excision was excluded from the study. Results A total of 922 samples were sent for histopathological analysis in the tertiary care hospital. The mean age of patients who had their specimens sent for pathology was 40.78 ± 10.81 years. Most of the samples sent were of the uterus (458) and the age 31-50 years (270) had the highest proportion of histopathological specimens. Normal ovaries (64.4%) and fallopian tubes (78.8%) were the main diagnoses for these two specimens while a normal cervix (0.58%) was the least common diagnosis among samples sent for histopathology. Chronic cervicitis (92.4%) in cervix and secretory phase endometrium (30.1%) in the uterus were the other common diagnosis. All the other samples were infrequently sent. Conclusion Uterine specimens are the most common histopathological specimen sent followed by cervix and then fallopian tube. Fallopian tube and ovaries yielded the highest normal diagnosis. Cervix specimens must be biopsied. More data is needed for a certain consensus on the need for routine histopathology.

Non-Tender Huge Abdominal Mass in an Adolescent: Bilateral paraovarian cysts

Paraovarian cysts constitute about 10% of all adnexal masses in females and occur most commonly in the third and fourth decades of life. These cysts are benign and usually uncommon in adolescence. Such cysts pose a diagnostic challenge while distinguishing them from ovarian cysts clinically and during radiological investigations. We report a rare case of a 13-year-old female patient with bilateral paraovarian cysts, including a giant cyst in right mesosalpinx presenting to Sohar hospital, Oman in 2018. The definitive origin of the huge mass on the right side of abdominal cavity could not be established in the current case despite contrast enhanced computerized tomography. It was only on laparoscopic exploration that this mass was identified as a giant paraovarian cyst. Both the giant cyst and a smaller paraovarian cyst on the left side were enucleated with minimally invasive surgery while preserving the fertility of the patient. Only one other similar case of bilateral paraovarian cysts in an adolescent, including a giant cyst managed with laparoscopy, has been documented previously.

Adnexal torsion with paraovarian cysts in pediatric and adolescent populations: A retrospective study

BACKGROUND

Determination of the clinical characteristics associated with adnexal torsion involving paraovarian cysts in pediatric and adolescent populations.

METHODS

Retrospective review of all cases of paraovarian cysts operated on in our department between 2007 and 2019. Demographic characteristics, clinical and sonographic findings were reviewed.

RESULTS

The cohort was composed of 39 pediatric and adolescent patients with an operative diagnosis of adnexal masses located in the paraovarian area. The patients were classified into two groups: 19 girls (48.7%) with a confirmed operative diagnosis of adnexal torsion and 20 girls (51.3%) without torsion. The preoperative diagnosis of adnexal torsion was correct in ≈70% of the cases. The mean BMI were similar in both groups. The preoperative sonographic detection rate of paraovarian cysts was also similar (11/19 [57.9%] vs. 14/20 [70.0%]; P = 0.514). The mean cyst diameter did not differ between groups, nor did the classification into cyst size groups (≤50 mm, 51-99 mm and ≥100 mm).

CONCLUSION

Adnexal torsion is a common complication diagnosed in girls undergoing surgery for paraovarian cysts, and is not associated with sonographic appearance or cyst diameter. In order to prevent torsion, surgical removal of paraovarian cysts should thus be considered in young girls undergoing surgery for paraovarian cysts.

TYPE OF STUDY

Retrospective case series.

LEVEL OF EVIDENCE

IV.

Giant Paratubal Serous Cystadenoma in an Adolescent Female: Case Report and Literature Review

BACKGROUND

Paraovarian/paratubal cysts constitute 5-20% of all adnexal lesions and typically originate from the paramesonephric or Müllerian duct. The primary epithelial tumors arising from paraovarian cysts account for 25% of the cases, but giant cystadenomas of paraovarian origin are extremely uncommon during childhood and adolescence with very few cases reported in the literature.

CASE

We present the case of a 15-year-old female that presented with a bulky mass in the abdomen and pelvis. An initial clinical and radiological examination indicated an ovarian cyst measuring ∼25 × 20 cm. However, explorative laparotomy revealed a giant paratubal cyst that was successfully treated with complete excision using fertility-sparing surgery. Histopathological examination was consistent with a serous cystadenoma. The postoperative course was uneventful and the girl was discharged on the seventh postoperative day. At the follow-up of 6 months, the patient was doing well.

Giant paratubal cyst presenting as adnexal torsion: A case report

Background

Paraovarian/paratubal cysts constitute about 10% of adnexal masses and are usually small and asymptomatic. A huge paratubal cyst complicated by adnexal torsion is a rare cause of acute low abdominal pain.

Case Report

We report the case of an obese 31-year-old nulliparous woman who presented with a large pelvic cyst causing ovarian torsion. The size of the mass (~25 cm) caused pain, and obesity led to explorative laparotomy, which showed a huge central abdominal-pelvic cyst arising from the right adnexa. Cystectomy was technically impossible, so all the adnexa was removed. Pathologic diagnosis revealed a papillary serous cystadenoma with torsion of all structures.

Conclusion

A giant paratubal cystadenoma is a rare condition and management is challenging. If there are clinical and imaging signs of torsion, it should be approached like any other adnexal mass and surgery should be urgent in order to avoid irremediable compromise of ovarian function.

•

Paraovarian/paratubal cysts constitute about 10% of adnexal masses, and are usually small and asymptomatic.

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A huge paratubal cyst complicated by adnexal torsion is a rare cause of acute low abdominal pain.

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Suspected adnexal torsions require prompt surgical treatment in order to avoid compromises of ovarian function.

Paratubal borderline serous tumor in a postmenopausal woman: a case report

Unlike borderline ovarian tumors, paratubal borderline tumors are extremely rare gynecologic tumors. They occur in reproductive-aged females at an earlier stage of disease and have a good prognosis. A 61-year-old woman, gravida 3 para 3, presented with progression of ovarian cyst. Computed tomography revealed a 6-cm simple cystic lesion without enhancing papillary projections. The patient underwent total laparoscopic hysterectomy and bilateral salpingo-oophorectomy. Frozen specimens showed that the tumor was benign, thereby confirming a final diagnosis of paratubal borderline serous tumor. The patient refused comprehensive surgical staging and opted for close follow-up. The patient remains asymptomatic with no evidence of recurrence at the 24-month follow-up. To the best of our knowledge, this is the first reported case of paratubal borderline serous tumor in a postmenopausal patient. The findings of this study and those of other case reports can contribute to the understanding, diagnosis, treatment and prognosis of these rare tumors.

An incidental diagnosis of a giant paraovarian cyst in a female teenager: A case report

RATIONALE

Paraovarian cysts (PCs) are cystic tumors that can be encountered between the ovarian hilum and the ovarian fimbria located within the mesosalpinx and broad ligament, being usually diagnosed within the 3rd and 4th decade of life.

PATIENT CONCERNS

We report the case of a 15-year-old female admitted in our clinic for consciousness loss, who was incidentally diagnosed with a giant pelvic cystic at ultrasound.

DIAGNOSES

The magnetic resonance image showed a cystic mass of 170/140/85 mm, suggesting an origin from the left ovary, reaching the subhepatic area.

INTERVENTIONS AND OUTCOMES

The surgical intervention revealed 3 PCs, a giant one and 2 smaller ones within the large ligament. The cysts were removed by laparoscopic approach, and the histologic examination did not reveal any signs of neoplasia.

LESSONS

In addition to their rarity, giant PCs can be an incidental diagnosis in patients presenting unrelated symptoms resulting in increased difficulties related to the diagnosis. Moreover, the imagistic tools might not establish precisely the origin of these cysts, and therefore, the final diagnosis and treatment approach could be determined sometimes only during the surgical intervention.

Sonographic Tips for Evaluation of Adnexal Masses in Pregnancy

Pregnancy is frequently a women's first contact with the health care system and often her first pelvic ultrasound examination. This first sonogram can reveal previously unknown adnexal pathology. Approximately 4% of pregnant women will have an adnexal mass detected by sonography and 1% to 2% of these masses will persist. It is estimated that up to 7% of these persistent masses will be malignant. Sonography plays an important role in differentiating benign from malignant adnexal masses and physiological from pathologic masses and should be used judiciously to complement evaluation and help guide treatment.

Spontaneously Ruptured Paraovarian Tumor of Borderline Malignancy with Extremely Elevated Serum Carbohydrate Antigen 125 (CA125) Levels: A Comparison of the Imaging and Pathological Features

Patient: Female, 22

Final Diagnosis: Paraovarian tumor of borderline malignancy

Symptoms: Hypochondriac pain

Medication: —

Clinical Procedure: —

Specialty: Radiology

An adolescent with an asymptomatic adnexal cyst: To worry or not to worry? Medical versus surgical management options

Paraovarian cysts or paratubal cysts (PTCs) arise from either the mesothelium or from paramesonephric remnants. These present as either adnexal mass or as an incidental finding. Diagnosis is usually established on ultrasound and it is important to differentiate these from ovarian cysts. Typically PCTs appear as simple cysts by ultrasound and are indistinguishable from ovarian cysts if one does not recognize the extraovarian location. Occasionally, PTCs have internal echoes due to hemorrhage. PTCs are usually asymptomatic and benign. The differential diagnosis includes a simple ovarian cyst, peritoneal inclusion cyst and hydrosalpinx. Malignant changes have been reported in about 2% to 3%, and it should be suspected if papillary projections are present. PTCs management depend upon the presence and severity of the symptoms, the cyst size and US characteristics, CA 125 results, age of the patient and the risk of malignancy. Simple PTCs can be expected to regress and may be managed expectantly. When surgery is indicated, a joint multidisciplinary management by the paediatric surgeons and trained paediatric gynaecologists should be the gold standard. (www.actabiomedica.it)

Clinical, radiological, and histopathological analysis of paraovarian cysts

Introduction:

Paraovarian cyst arise from either mesothelium or from paramesonephric remnant. These present as either adneal mass or as an incidental finding. Diagnosis is usually established on ultrasound and it is important to differentiate these from ovarian cyst.

Material and Methods:

The present study is a retrospective analysis of 32 women with a confirmed diagnosis of paraovarian cyst after surgery. The clinical profile, symptoms and radiological findings of these patients were noted from the hospital records. A correlation was made with the surgical findings and the final histopathological diagnosis.

Results:

Only 2 patients were postmenopausal and one case was diagnosed during pregnancy. Ultrasound accurately diagnosed paraovarian cyst in 87.5% patients. 78% paraovarian cysts were found to be simple and none had any malignant change. We reported a higher incidence of cystic adenomatoid tumor in these paraovarian cysts.

Conclusion:

In our study, most paraovarian cysts occur in reproductive age group and present as an adnexal mass. Ultrasound is the diagnostic modality and a paraovarian cyst needs to be differentiated from ovarian cyst. Most of them were simple cysts on histopathology.

Isolated Fallopian Tube Torsion With Fimbrial Cyst In A 10 Year-old Girl Diagnosed By Ultrasound: A Case Report

Torsion of the fallopian tube without the involvement of the ipsilateral ovary is a rare but important cause of acute abdominal pain in women as it is a surgical emergency. Although uncommon, it should be considered as one of the differential diagnosis in female children presenting with acute lower abdominal or pelvic pain. The diagnosis of isolated fallopian tube torsion is difficult pre-operatively and is often made during laparoscopic or surgical exploration because diagnostic features are usually non-specific. In this report, we present a case of isolated fallopian tube torsion with fimbrial cyst in a young female patient diagnosed pre-operatively by ultrasound.

The characteristic ultrasound features of specific types of ovarian pathology (review)

Characterizing ovarian masses enables patients with malignancy to be appropriately triaged for treatment by subspecialist gynecological oncologists, which has been shown to optimize care and improve survival. Furthermore, correctly classifying benign masses facilitates the selection of patients with ovarian pathology that may either not require intervention, or be suitable for minimal access surgery if intervention is required. However, predicting whether a mass is benign or malignant is not the only clinically relevant information that we need to know before deciding on appropriate treatment. Knowing the specific histology of a mass is becoming of increasing importance as management options become more tailored to the individual patient. For example predicting a mucinous borderline tumor gives the opportunity for fertility sparing surgery, and will highlight the need for further gastrointestinal assessment. For benign disease, predicting the presence of an endometrioma and possible deeply infiltrating endometriosis is important when considering both who should perform and the extent of surgery. An examiner’s subjective assessment of the morphological and vascular features of a mass using ultrasonography has been shown to be highly effective for predicting whether a mass is benign or malignant. Many masses also have features that enable a reliable diagnosis of the specific pathology of a particular mass to be made. In this narrative review we aim to describe the typical morphological features seen on ultrasound of different adnexal masses and illustrate these by showing representative ultrasound images.

Assessment of adnexal masses using ultrasound: a practical review

Pelvic ultrasound is commonly used as part of the routine gynecologic exams, resulting in diagnosis of adnexal masses, the majority of which are functional or benign. However, due to the possible complications involving benign adnexal cysts (ie, adnexal torsion, pelvic pain) and the utmost importance of early diagnosis and treatment of ovarian cancer, the correct ultrasound diagnosis of adnexal masses is essential in clinical practice. This review will describe the typical ultrasound appearance of the common physiologic, benign, and malignant adnexal masses with the aim of aiding the clinician to reach the correct diagnosis.

Prevalence of extrauterine pelvic lesions on transvaginal ultrasound in asymptomatic 20-39-year-old women

OBJECTIVES

To estimate the prevalence of extrauterine pelvic lesions on transvaginal ultrasound examination of gynecologically asymptomatic women of fertile age, and to compare this prevalence between women with spontaneous menstrual cycles, those using the combined oral contraceptive (COC) pill and those using a gestagen intrauterine contraceptive device (IUD).

METHODS

Six hundred and forty-four gynecologically asymptomatic 20-39-year-old Caucasian women with no current or previous gynecological problems, who were recruited from a Swedish population registry, were examined with transvaginal ultrasound on cycle day 4-8. Our definition of ovarian cyst was a unilocular cyst with anechoic cyst contents ≥ 35 mm in mean diameter, or any other type of intraovarian lesion. The prevalence of extrauterine pelvic lesions was compared between women not using hormonal contraception and those using COC or a gestagen IUD.

RESULTS

Ovarian lesions were found in 24 (3.7%) women. One woman had bilateral ovarian lesions. An ultrasound diagnosis of paraovarian cyst was made in 41 (6.4%) women, of peritoneal cyst in four (0.6%) women and of hydrosalpinx in one (0.2%) woman. All incidentally detected lesions had a mean diameter of ≤ 5 cm. One 17-mm intraovarian lesion was suspicious for malignancy, and histology confirmed a Sertoli-Leydig cell tumor. The ultrasound diagnoses in the remaining 23 women were endometrioma (n = 10 (1.6%)), dermoid cyst (n = 5 (0.8%)), cystadenofibroma (n = 1 (0.2%)), mature teratoma (n = 1 (0.2%)) and functional cyst, i.e. a cyst that resolved within 3-5 months (n = 6 (0.9%)). Four women with an ultrasound diagnosis of a benign lesion were operated on, and the ultrasound diagnoses of endometrioma (n = 2), dermoid cyst (n = 1) and mature teratoma (n = 1) were confirmed histologically. The prevalence of persisting ovarian lesions was highest in women with spontaneous menstrual cycles (4.4% vs 0.9% and 0% in women using COC and gestagen IUD, respectively; P = 0.025), but age was the only factor independently associated with persisting ovarian masses, the prevalence increasing with age.

CONCLUSIONS

Benign ovarian lesions are found in about 1 in 25 gynecologically asymptomatic women aged 20-39 years with no history of gynecological disease. To be able to offer optimal management of such masses, their natural history needs to be elucidated in a large prospective observational study.

[Sonographic diagnosis of presumed benign ovarian tumors]

To discriminate ovarian lesions is of particular importance in gynecological practice. Two main problems need answers: discrimination of benign and malignant adnexal masses and choice of the appropriate surgical treatment if necessary. Nearly 2% of the adnexal masses are ovarian carcinomas or borderline tumors. It is now, well established that ultrasonography is the gold standard for ovarian cyst diagnosis. The purpose of this data was to review the literature and to establish, with the evidence base medicine model, which parameters and existing diagnostic models using ultrasound and Doppler perform best in the evaluation of adnexal masses. Transvaginal sonography has demonstrated considerable advantage over conventional transabdominal sonography. However, transparietal sonography is still useful in large tumors. Definition of the nomenclature and classification was done and should be used. Unilocular ovarian cyst characterization seems easy using sonography and Doppler. In front of complication, discrimination of such functional cyst may be difficult but spontaneous regression confirms usually the expectative management. Dermoid cysts and endometriomas seem to be easier to discriminate from other adnexal masses. Ultrasound and morphologic parameters have a sensitivity of about 90% and a specificity of 80%; that makes this exam the gold standard for ovarian masses diagnosis. Only 50% of ovarian masses are characterized by sonography. Scoring systems help to differentiate benign from malignant masses (sensitivity of about 90%). Logistic regression and models are good methods especially for LR1 and 2 and RMI and may be useful for malignancy prediction but are difficult to use in current practice. Expert diagnosis is a subjective but most important performing parameter. Any suspicious ovarian mass or not easily diagnosed mass requires sonography by an expert, which can first use all the techniques and the different parameters to discriminate benign and malignant tumors. An explicit report will help the physician to define the right attitude for an appropriate management. Six to 16% of adnexial masses are complex or not classified and will result in MRI prescription or surgery.

Bilateral inflamed paratubal cysts

Paramesonephric duct remnants are an infrequent cause of abdominal symptoms in childhood. Preoperative diagnosis is often difficult and diagnosis is usually made at surgery. We report a rare presentation of an acute abdomen in a child with bilateral inflamed fimbrial cysts. Ultrasound revealed the presence of a multicystic lesion behind bladder. It was only at laparotomy the diagnosis of bilateral inflamed fimbrial cysts was establsihed. These were excised and the child made an uneventful post operative recovery.

Clinical diagnosis and complications of paratubal cysts: review of the literature and report of uncommon presentations

INTRODUCTION

Paraovarian or paratubal cysts (PTCs) constitute about 10 % of adnexial masses. Although they are not uncommon; they rarely cause symptoms and are usually incidentally found. Actual incidence is not known. The symptoms occur when they grow excessively, or in case of hemorrhage, rupture or torsion.

METHODS

Here, literature review reporting the incidence, presentation and complications of PTCs is performed. Uncommon presentations of PTCs in three different cases, a giant PTC, torsion of PTC and borderline paratubal tumor, are also reported and discussed.

RESULTS

Ultrasonography, CT or MRI may be performed in preoperative evaluation; but none of these imaging techniques have specific criteria for diagnosis. So, in most cases misdiagnosis as an ovarian mass remains to be a problem.

CONCLUSION

Paratubal cysts can become extremely big before causing symptoms. Torsion is another urgent issue regarding PTCs, necessiating urgent surgery for preservation of the ovary and the tube. Although malignancy is rare, borderline paratubal tumors have been reported in the literature.

Histology and prevalence of ovarian tumours in postmenopausal women: is follow-up required in all cases?

The objective of this study was to determine if follow-up is required for all ovarian tumours incidentally diagnosed in postmenopausal women, by studying the prevalence and histology of ovarian tumours in postmenopausal women undergoing hysterectomy. The histopathology of adnexa in 100 consecutive postmenopausal women who underwent an abdominal hysterectomy with bilateral salpingo-oophorectomy for various indications, was reviewed. A total of 200 adnexa were examined. Ovarian pathology was found in 62/200 (31%). Of these 34/62 (53%) were unilocular cystic tumours, 9/62 (15%) were multilocular tumours, 11/62 (18%) were solid tumours and 8/62 (11%) were uni or multilocular with solid elements. The prevalence of borderline tumours was 4% and that of malignant tumours was 5%. All tumours < 2 cm were found to be benign. All unilocular cysts < 5 cm were benign. In conclusion, a vast majority of ovarian tumours in this group of women were benign. It may be reasonable not to follow-up women with unilocular ovarian tumours < 5 cm who have a normal CA125.

The incidence and surgical management of paratubal cysts in a pediatric and adolescent population

PURPOSE

The aim of this study is to determine the incidence of paratubal cysts (PTCs) in a pediatric and adolescent population.

METHODS

An institutional review board-approved retrospective chart review was performed between the years of 1998 and 2008 at a single children's hospital. Inclusion criteria were met if pathology reports demonstrated diagnosis of PTC, hydrosalpinx, or hydatid of morgagni.

RESULTS

One hundred ten patients had confirmed diagnoses of hydatid of morgagni, hydrosalpinx, or PTC. The incidence of PTCs was 7.3%. Mean age of PTC diagnosis was 13.7 ± 2.82 years, with 12.6% diagnosed premenarchal. Mean age menarche was 11.7 ± 1.34 years among pubertal females. The age of menarche and diagnosis of PTC correlated (Pearson, 0.54) (P < .0001). There was a small correlation between body mass index and size of PTC (r = 0.36; P ≤ .001).

CONCLUSION

The incidence of PTCs was 7.3% in this pediatric and adolescent population. In addition, this is the first study to confirm presence of PTCs in prepubertal females. Surgeon should be aware of these benign cysts because they are frequently a source of abdominal pain in young girls. As nonphysiologic cysts, these will not resolve spontaneously and may increase in size and/or be at risk for adnexal torsion. Ultimately, surgical management is required for definitive resolution.

Paratubal borderline tumor diagnosed in the adolescent period: a case report and review of the literature

BACKGROUND

Borderline paratubal cysts are rare entities. These tumors are identified as epithelial proliferation without stromal invasion.

CASE

A 19-year-old virgin patient was admitted to our clinic with abdominal pain and nausea. The sonographic evaluation showed a left adnexal mass 89 × 80 mm in diameter with solid tissue projections. Doppler examination revealed no significant blood supply. At surgery, a torsed left paratubal cyst 10 cm in diameter and normal bilateral ovaries were encountered. Cystectomy was performed and of frozen section revealed a borderline Fallopian tube neoplasm. Final pathology review was reported as a serous borderline paratubal tumor.

CONCLUSION

The evaluation of the structure of cyst by ultrasound and the performance of intraoperative frozen section analysis are two important issues to diagnose the nature of a cyst. Fertility-sparing surgery is the main point of management.

Tumors and pseudotumors of the secondary müllerian system: review with emphasis on cross-sectional imaging findings

OBJECTIVE

Microscopic structures lined by müllerian epithelium are frequently seen outside the uterus and fallopian tubes and are termed "müllerian rests" or "secondary müllerian system." Varied entities ranging from benign endosalpingosis to highly malignant ovarian tumors are thought to be derived from the secondary müllerian system. Cross-sectional imaging findings of diseases and disorders of the secondary müllerian system are presented here.

CONCLUSION

Familiarity with a wide spectrum of diseases and disorders of the secondary müllerian system allows accurate diagnosis and management.

One-Step Laparoscopic Management of a Female Adnexal Tumor of Wolffian Origin

We report a case of female adnexal tumor of Wolffian origin (FATWO), a rare neoplasm arising from the mesonephric ducts. A 48-year-old woman came first to our center for a recent discovery of a pelvic mass. Transvaginal ultrasonographic findings suggested a solid right para-ovarian mass suspected to be malignant. After thorough counseling, the patient underwent operative laparoscopy for excision of the para-ovarian mass with frozen section (FS) examination resulting in the diagnosis of a poorly differentiated adenocarcinoma. In this case, FS results allowed performing a comprehensive oncological staging, through a totally laparoscopic extrafascial hysterectomy, bilateral adnexectomy, total omentectomy, pelvic wall peritonectomy, and pelvic, parasacral and para-aortic lymphadenectomy. Final pathological and immunohistochemical results confirmed the diagnosis of FATWO. To our knowledge, this is the first case of FATWO managed entirely by a minimally invasive laparoscopic approach in a single surgical session.

Peri- and post-menopausal incidental adnexal masses and the risk of sporadic ovarian malignancy: new insights and clinical management

Adnexal masses are common among peri- and post-menopausal women. Although ovarian cancer is a significant cause of mortality in menopausal women, large population-based studies demonstrate that the majority of adnexal masses are benign. Despite this, the appearance of an adnexal mass is a concern for the patient and an insight exercise for physicians. In most cases, an adnexal enlargement is an incidental finding, generally corresponding to a benign cyst and easily diagnosed by conventional ultrasound. Exceptionally an ovarian tumour may be malignant and should be treated as early as possible. When conventional ultrasound renders complex morphology other diagnostic tools must be used such as: colour Doppler and functional tumour vessel properties, serum CA 125 levels, nuclear magnetic resonance imaging and in some cases laparoscopy. Several new tumour markers are being studied for clinical application, although there are presently no clear recommendations. Adnexal masses with benign morphological and functional properties must be periodically monitored as an alternative to surgery since malignant transformation is exceptional.

Imaging of benign adnexal masses: characteristic presentations on ultrasound, computed tomography, and magnetic resonance imaging

Adnexal masses are common in the general population. Although ovarian cancer is a significant cause of mortality, large screening studies demonstrate that the majority of adnexal masses are benign. These benign masses include physiologic cysts, paraovarian masses, and benign ovarian lesions. It is important that gynecologists and radiologists appreciate the appearance of these lesions on multiple imaging modalities, including ultrasound, computed tomography, and magnetic resonance imaging to avoid unnecessary intervention.

Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement

The Society of Radiologists in Ultrasound convened a panel of specialists from gynecology, radiology, and pathology to arrive at a consensus regarding the management of ovarian and other adnexal cysts imaged sonographically in asymptomatic women. The panel met in Chicago, Ill, on October 27-28, 2009, and drafted this consensus statement. The recommendations in this statement are based on analysis of current literature and common practice strategies, and are thought to represent a reasonable approach to asymptomatic ovarian and other adnexal cysts imaged at ultrasonography.

Isolated fallopian tube torsion: sonographic and CT features

BACKGROUND

Isolated fallopian tube torsion (IFTT) rarely occurs in pediatric patients and is difficult to diagnose preoperatively.

OBJECTIVE

To determine the common sonographic and CT findings in girls with IFTT.

MATERIALS AND METHODS

We retrospectively reviewed the hospital charts and imaging studies of the eight girls diagnosed with and treated for IFTT at Columbus Children's Hospital between January 1995 and June 2006 whose final diagnosis was IFTT.

RESULTS

The mean age was 13 years with a range of 12 to 15 years. Two girls were premenarcheal. The most common presenting symptom was acute pelvic pain (n = 5). All patients were imaged. Six girls were imaged first with US, and the most common finding was a complex cystic pelvic mass in the midline (n = 5) and normal uterus and ovaries. Three of the eight girls had imaging with CT. In two girls, the torsed tube could be identified. In 63% of the girls, the uterus was deviated toward the side of torsion. The correct preoperative diagnosis was made in only one girl. None of the torsed fallopian tubes was salvaged at surgery. Pathological findings included ipsilateral adnexal cysts associated with the torsed tube (n = 7).

CONCLUSION

IFTT should be considered in the differential diagnosis for perimenarcheal girls who present with acute pelvic pain and who demonstrate a cystic mass in a midline position (either in the cul-de-sac or superior to the uterus) associated with a normal ipsilateral ovary.

A Practical Approach to the Ultrasound Characterization of Adnexal Masses

Because pelvic ultrasound is commonly used to evaluate adnexal masses, it is important to understand the most useful sonographic features for predicting benign and malignant masses. Determining whether an adnexal mass is of ovarian or extraovarian origin is key in arriving at the most likely diagnosis. Most adnexal masses are benign, and each of the most common benign ovarian lesions has a typical sonographic appearance. Additionally, most malignant ovarian neoplasms have a solid component with detectable flow by Doppler ultrasound, allowing one to strongly suggest the diagnosis. We will review an approach to the ultrasound diagnosis of adnexal masses that progresses through a series of 4 questions to help lead one to the most likely diagnosis.