Comparison of Simple Ultrasound Rules by International Ovarian Tumor Analysis (IOTA) with RMI-1 and RMI-4 (Risk of Malignancy Index) in Preoperative Differentiation of Benign and Malignant Adnexal Masses

Background

IOTA proposed Simple Ultrasound Rules in 2009 for preoperative diagnosis of ovarian masses based on ultrasound only. It is an accurate, simple and inexpensive method. RMI, however, requires CA125 level. While RMI-4 is the latest, RMI-1 is still the most widely used method. The present study was done to compare IOTA Rules with RMI-1 and RMI-4.

Purpose

To differentiate benign and malignant adnexal masses preoperatively using IOTA simple rules and compare its accuracy with RMI-1 and RMI-4.

Methods

A prospective observational study was performed from 1st November 2019 to 31st March 2021 in the Department of Obstetrics and Gynaecology, ABVIMS and Dr. RML Hospital, New Delhi. This study was conducted on 70 patients with adnexal masses who underwent pre-operative evaluation using IOTA Simple Rules, RMI-1 and RMI-4. Histopathology was used to compare the results.

Results

Out of 70 patients, 59 (84.3%) cases were benign and 11 (15.7%) were malignant. The IOTA Rules were applicable to 60 cases (85.7%), and the results were inconclusive in 10 cases (14.3%). Where applicable, the sensitivity and specificity of the IOTA Rules (88.9% and 94.1%, respectively) were significantly higher than RMI-1 (45.5% and 93.2%, respectively) and RMI-4 (45.5% and 89.8%, respectively). When inconclusive results were included as malignant, the sensitivity of the IOTA Rules increased (88.9% vs 90.9%); however, the specificity decreased (94.1% vs 81.4%).

Conclusion

IOTA Simple Rules were more accurate at diagnosing benign from malignant adnexal masses than RMI-1 and RMI-4. However, the rules were not applicable to 14% of the cases.

Clinicopathological features and surgical procedures of adnexal masses with abdominal pain in pediatric and adolescent patients

PURPOSE

This study investigated the clinicopathological features and surgical procedures of adnexal masses with abdominal pain in pediatric and adolescent patients. Our objective was to better define the clinical presentation of adnexal torsion and to distinguish characteristics of those with torsion and those with an alternate diagnosis.

METHODS

Retrospective cohort study of 212 pediatric and adolescent patients was performed who admitted for abdominal pain and presenting with an adnexal mass between March 2012 to December 2019.Medical records were reviewed for age at operation, including presentation of symptoms and signs; the levels of tumor markers; imaging examinations; pathologic findings; the size of masses; treatment; and outcome. Data management and descriptive analyses were performed using SPSS 26.0.

RESULTS

The median age of the patients was 14.5 ± 3.6 years at the operation. 126 (59.4%, 126/212) patients presented with an abrupt onset of abdominal pain. A total of 82.1% (174/212) of the participants underwent adnexal conservative surgery. 179 (84.5%, 179/212) patients underwent laparoscopic surgery with an average tumor size of 7.7 ± 3.4 cm, while 33 patients ( 15.6%, 33/212) underwent laparotomy. Rupture of mass and ectopic pregnancy accounted for 7.5% (16/212) and 0.9%(2/212), respectively. Torsion was responsible for 36.8% (78/212) of all patients. Among the patients with torsion, the symptom of nausea and vomiting was more common among girls without torsion (P < 0.0001). 88.5% of the girls with torsion had acute onset of abdominal pain, while 92.3% had persistent pain that could not be relieved or occurred repeatedly, which significantly higher than that in the patients without torsion (P < 0.001). 69.2% of patients with torsion had fixed pain sites, compared with 42.2% in patients without torsion (P < 0.001). 88.5% of girls with torsion had an ovarian cyst/mass ≥ 5 cm, compared with 75.0% in girls without torsion (P = 0.038). 66.7% of girls underwent ovary-preserving surgery, compared with 92.2% in patients without torsion. The most common pathologic types were mature teratoma and simple cyst, accounting for 29.4% and 25.6%, respectively. The multivariate analyses confirmed that mass size greater than 5 cm (OR 4.134, 95% CI: 1.349-12.669,P = 0.013), acute onset pain (OR 24.150,95%CI: 8.398-69.444,P = 0.000), persistent or recurrent pain (OR 15.911,95%CI: 6.164-41.075,P = 0.000) were significantly associated with increased risk of torsion.

CONCLUSIONS

Torsion which is a relatively rare event in the pediatric population was not an uncommon condition and responsible for more than one third of all pediatric and adolescent patients presented with adnexal masses and abdominal pain. Pain assessment in children and adolescents is important to distinguish characteristics of those with torsion and those with an alternate diagnosis.Thus, pediatric and adolescent patients particularly with a pelvic mass size greater than 5 cm, acute onset pain, persistent or recurrent pain have a benign cause and not missing the devastating condition that needs emergent attention. Thus, a strategy of earlier and liberal use of Diagnostic Laparoscopy (DL) may improve ovarian salvage.

Ovarian malignancy in an individual with 46,XY ovotesticular disorder of sexual development - A case report

Disorders of sexual development (DSD) are diseases resulting from aberrations in sex chromosomes, gonadal, and internal/external genitalia development resulting in various phenotypes. Ovotesticular DSD represents a rarer entity in this classification of disorders characterized by simultaneous presence of testicular and ovarian tissue. Gonadal tumors in those with DSDs is a known risk, although ovarian masses discovered in adults with ovotesticular DSD is a rare entity and there is little literature pertaining to this population. We present a case of an incidental adnexal mass discovered in an elderly patient ultimately elucidated as a malignant ovarian mass.

Ovarian hemangioma: Differential diagnosis of ovarian cancer

INTRODUCTION AND IMPORTANCE

Ovarian cavernous hemangioma is a rare benign vascular tumor primarily found as either an isolated ovarian mass or as diffuse abdominopelvic hemangiomatosis. Its discovery is often incidental, but symptomatic presentations can occur, including ovarian torsion, can occur without any specification.

CASE PRESENTATION

We present the case of a 55-year-old menopausal woman with chronic pelvic pain. Initial diagnostic imaging and tumor markers suggested ovarian malignancy. Subsequent investigations, including ultrasound and MRI, revealed a vascularized adnexal mass with characteristics mimicking malignancy. Surgical exploration through laparoscopy unveiled an 8 cm multicystic solid-cystic lesion with histopathological analysis confirming a 9 cm cavernous hemangioma.

CLINICAL DISCUSSION

Histologically, the lesion displayed features consistent with a benign vascular malformation. Literature review indicates variability in presentations and diagnostic challenges in distinguishing these lesions from malignant ovarian tumors. Treatment involved successful cystectomy via laparoscopic surgery, ensuring ovarian preservation so as not to increase the cardiovascular risk due to bilateral annexectomy.

CONCLUSION

Ovarian cavernous hemangiomas pose diagnostic challenges due to their rarity and potential mimicry of malignancy. Timely recognition through imaging modalities, especially MRI, and confirmation via histopathological examination remain pivotal. Ovarian-sparing surgical interventions are recommended, particularly for younger patients without suspicious tumor features. Despite their rarity, awareness of these lesions is crucial for accurate diagnosis and appropriate management.

Ovarian torsion masquerading as a ureteral stone

BACKGROUND

Abdominal pain is the most common complaint within the emergency department (ED) and has many varied etiologies. Some of these conditions can be medical emergencies, including ovarian torsion. While representing just 3% of gynecologic emergencies, ovarian torsion should be considered in all females presenting to the ED with abdominal or pelvic complaints.

CASE

A 38-year-old G5P5 female with a past medical history significant for ureterolithiasis presented to a freestanding ED with abdominal pain, nausea, and vomiting. She developed sudden onset of right sided abdominal pain radiating to her right flank upon awakening. The initial differential diagnosis was for ureterolithiasis or appendicitis. Her complete blood count (CBC) was normal, and testing for pregnancy, infection, and hematuria was negative. Computed topography (CT) imaging of the abdomen and pelvis revealed a 9 cm adnexal mass, consistent with a possible dermoid cyst. A pelvic ultrasound was ordered which showed a possible ovarian torsion. She was transferred to a tertiary care hospital where she had a laparoscopy with right-sided oophorectomy and salpingectomy performed.

DISCUSSION

This patient presented with abdominal pain, nausea, and vomiting and was first suspected to have ureterolithiasis or appendicitis. She was found to have an ovarian torsion with a dermoid cyst, which resulted in the loss of her ovary and fallopian tube. This case demonstrates the importance of including gynecologic emergencies in the differential on all female patients presenting with abdominal pain.

Ovarian tumors in the pediatric population: An update

Research reveals that 1% of neoplasms in females under 17 years of age are ovarian neoplasms and though usually benign, malignant tumors may occur in the pediatric age group. This review considers various current concepts of these tumors including the epidemiology, risk factors, clinical presentations, diagnosis, differential diagnosis, and treatment options including the need to provide fertility-sparing surgery as well as their potential impacts on the psychological well-being of children and adolescents. We gathered data from the published articles ranging from studies, meta-analyses, retrospective studies, and reviews. We focused on the articles published in English between January 1, 2000, and August 31, 2023. Only a few articles published prior to 2000 were included for historical perspective.

The clinical significance of laparoscopy in the differentiation of inclusion cysts from ovarian masses: A case report and literature review

INTRODUCTION AND IMPORTANCE

Peritoneal inclusion cysts (PICs) are infrequently encountered cysts within the abdominal and pelvic regions, typically observed in perimenopausal women. They frequently pose a diagnostic challenge as they can be clinically misinterpreted as ovarian-related lesions, owing to their resembling clinical presentations and radiological features.

CASE PRESENTATION

A 30-year-old female patient without significant medical or surgical history sought medical attention for mild left lower abdominal discomfort lasting two days. Initial evaluation ruled out pregnancy, and further tests showed no abnormalities in her blood work. Pelvic ultrasound revealed a 4.5 cm cystic mass in her left ovary while her right ovary and uterus appeared normal. A laparoscopic ovarian cystectomy was planned. During the procedure, it was discovered that the mass was not connected to the left ovary but was, in fact, a peritoneal inclusion cyst. CLINICAL DISCUSSION: previous intraperitoneal surgeries performed within a timeframe ranging from 6 months to 20 years, intraperitoneal inflammation, pelvic inflammatory disease, peritoneal tuberculosis, leiomyoma, tubo-ovarian abscess, among others. However, the absence of these predisposing factors does not minimize the possibility of PICs.

CONCLUSION

This case highlights the diagnostic challenges and the value of laparoscopy in accurately identifying and differentiating such cystic cases.

Accuracy of Frozen Section and Clinical/Radiological Diagnosis with Final Histopathology of Pelvic Masses in a Teaching Institute with a Non-oncology Setup, in Northeast India

Background

Frozen section (FS) is an important decision making intraoperative tool in a non-oncology center especially in a region where women are often "lost to followup".

Objectives

Evaluate the use of FS in non-oncology setup for ovarian and uterine masses.

Methods

A retrospective analysis of women who had undergone surgery with frozen section for large abdominopelvic masses at Central Referral Hospital, Sikkim, India, from July 2017 to July 2021.

Results

22 women were taken into study out of which 18 had FS for ovarian masses while 4 had frozen section for large uterine masses. All ovarian masses looked malignant on imaging while only 7 looked malignant intraoperatively. FS detected 8 women (44%) with ovarian malignancy out of which 2 were suspicious. The 2 suspicious cases were benign on final histopathology. FS was negative for malignancy in 10 women (56%) out of which 2 were borderline sero-mucinous on final histopathology. FS for ovarian masses showed sensitivity: 66.7% specificity: 83.3%, NPV: 83.3% and Accuracy of 80% when compared to the final histopathology. Intraoperatively 3 out of 4 uterine masses looked malignant. However, all of the uterine masses were negative on FS and final histopathology.

Conclusion

Non-oncology centers are burdened with variety of benign surgeries, hence, FS is effective in detecting malignancy in ovarian tumors but not so in large uterine masses. Performing FS prevents "lost to follow ups" in ovarian tumors while avoiding it, saves time of experts while dealing with large uterine masses.

Adnexal Mass Imaging: Contemporary Guidelines for Clinical Practice

Several recent guidelines have been published to improve accuracy and consistency of adnexal mass imaging interpretation and to guide management. Guidance from the American College of Radiology (ACR) Appropriateness Criteria establishes preferred adnexal imaging modalities and follow-up. Moreover, the ACR Ovarian-Adnexal Reporting Data System establishes a comprehensive, unified set of evidence-based guidelines for classification of adnexal masses by both ultrasound and MR imaging, communicating risk of malignancy to further guide management.

Improving diagnostic strategies for ovarian cancer in Filipino women using ultrasound imaging and a multivariate index assay

OBJECTIVE

To evaluate the clinical performance and overall utility of imaging and biomarker assays in discriminating between benign and malignant ovarian masses in a Filipino population.

METHODS

This is a prospective cohort study among Filipino women undergoing assessment for an ovarian mass in a tertiary center. All included patients underwent a physical examination before level III specialist ultrasonographic and Doppler evaluation, multivariate index assay (MIA2G), and surgery for an adnexal mass. Ovarian tumors were classified as high-risk for malignancy based on the International Ovarian Tumour Analysis (IOTA) - Logistic Regression 2 (LR2) score. The ovarian imaging and biomarker results were correlated with the reference standard: histological findings.

RESULTS

Among the 379 women with adnexal masses enrolled in this study, 291 were evaluable with ultrasound imaging, biomarker assays, and histopathological results. The risk of malignancy was higher for women classified as high-risk based on IOTA-LR2 (≥10%). The sensitivity, specificity, and diagnostic accuracy for the prediction of malignancy were 81.2%, 81%, and 0.81 (95% CI: 0.77-0.86) for IOTA-LR2; 77.5%, 66.7%, and 0.72 (95% CI: 0.67-0.77) for CA-125; and 91.3%, 41.2%, and 0.66 (95% CI: 0.62-0.71) for MIA2G. A combination of IOTA-LR2 and MIA2G significantly influenced the diagnostic performance and the result. When MIA2G was combined with IOTA-LR2 in parallel, the sensitivity (94.2%) and NPV (87.7%) increased, but the specificity (37.3%) decreased. When combined with IOTA-LR2 in series, there were fewer false positives, which resulted in improved specificity (85%).

CONCLUSION

This study determined the utility of ovarian imaging and a second-generation multivariate index assay in predicting the risk of ovarian malignancy. IOTA-LR2 and MIA2G were useful in classifying patients with a high risk for ovarian malignancy.

Management of peritoneal pseudomyxoma in Pregnant Women: A case report and review of the literature

The incidence of neoplasia during pregnancy is low, 1/1000 pregnancies. The most common cancers diagnosed during pregnancy are breast and cervical cancer. Pseudomyxoma peritonei (PMP) is a rare syndrome (1/1 000 000) characterized by the presence of gelatinous ascites and disseminated intra-peritoneal mucinous tumors. The origin of this syndrome is, in most of cases, a tumor of the appendix. A PMP diagnosis during pregnancy is an extremely rare event. We present the medical history of a 34-year-old woman diagnosed with a PMP at 29 weeks of amenorrhea, during the management of an ovarian masse. We preserved the pregnancy until 37 weeks of amenorrhea. She had a vaginal delivery. At 4 weeks post-partum, she had an extensive cytoreduction with intraperitoneal chemotherapy. We present literature review of PMP discover during pregnancy and a discussion about treatment of these PMP. We also discuss management of an ovarian masse diagnosis during pregnancy.

Krukenberg tumor in pregnancy: a rare case and review of the literature

Krukenberg's tumor diagnosed in pregnancy is an uncommon situation that raises both diagnosis and medical management issues. We performed a review of the existing literature regarding this pathology, diagnostic means and therapeutic approaches, motivated by a case in our own practice. A 35-year-old primigravida was diagnosed with an adnexal mass during the first trimester prenatal ultrasound. Ultrasound revealed a 10 cm right adnexal mass with multiple septae, richly vascularized, whose presence and characteristics were confirmed by magnetic resonance imaging. Due to the progressively increasing tumor size, laparoscopy was performed with right adnexectomy and peritoneal biopsies. Histopathology diagnosed a metastatic ovarian tumor from a mucinous colorectal adenocarcinoma. After delivery the patient was further investigated and diagnosed with sigmoid cancer. Even though ovarian cancer in pregnancy is rare, adnexal ultrasound is mandatory when scanning during the first trimester to rule out the presence of associated fallopian or ovarian masses.

Case report: A CSF pseudocyst

A 51-year-old female with prior history of ventriculoperitoneal shunt presented with worsening abdominal distension. Her abdomen was diffusely tender and firm with a slight fluid wave. CT imaging with IV contrast was notable for a large cystic lesion in the abdominal cavity with the differential of CSF pseudocyst versus ovarian mass. She underwent paracentesis of the cyst with interventional radiology and required a revision of her ventriculoperitoneal shunt. CSF pseudocysts are a rare complication of ventriculoperitoneal shunts, however, are an important consideration in patients presenting with abdominal complaints and require specialized intervention and assessment.

Surgical Management of Adnexal Masses in Pregnancy: A Systematic Review and Meta-analysis

OBJECTIVE

The incidence of adnexal masses in pregnancy is 1% to 6%. Although surgery is often indicated, there are no definitive management guidelines. We aimed to investigate the optimal approach to surgical management of adnexal masses in pregnancy on the basis of a meta-analysis of previous studies.

DATA SOURCES

We performed a systematic review using MEDLINE, Embase, Cochrane Library, and Clinicaltrials.gov from inception to July 17, 2020.

METHODS OF STUDY SELECTION

There were no restrictions on study type, language, or publication date. Comparative and noncomparative retrospective studies that reviewed operative techniques used in surgery of adnexal masses in pregnancy were included. Meta-analyses were performed to assess outcomes. This study was registered in the International Prospective Register of Systematic Reviews (CRD42019129709).

TABULATION, INTEGRATION, AND RESULTS

Comparative studies were identified for laparoscopy vs laparotomy and elective vs emergent surgery (11 and 4, respectively). Elective surgery is defined as a scheduled antepartum procedure. For laparoscopy vs laparotomy, the mean maternal ages and gestational ages at time of surgery were similar (27.8 years vs 27.7 years, p = .85; 16.2 weeks in laparoscopy vs 15.4 weeks in laparotomy, p = .59). Mass size was larger in those undergoing laparotomy (mean 8.8 cm vs 7.8 cm, p = .03). The most common pathologic condition was dermoid cyst (36%), and the risk of discovering a malignant tumor was 1%. Laparoscopy was not associated with a statistically increased risk of spontaneous abortion (SAB) or preterm delivery (PTD) (odds ratio [OR] 1.53; 95% confidence interval [CI], 0.67-3.52; p = .31 and OR 0.95; 95% CI, 0.47-1.89; p = .88, respectively). The mean length of hospital stay was 2.5 days after laparoscopy vs 5.3 days after laparotomy (p <.001). The decrease in estimated blood loss in laparoscopy was not statistically significant (94.0 mL in laparotomy vs 54.0 mL in laparoscopy, p = .06). Operative times were similar in laparoscopy and laparotomy (80.0 minutes vs 72.5 minutes, p = .09). Elective surgery was associated with a decreased risk of PTD (OR 0.13; 95% CI, 0.04-0.48; p = .05). Noncomparative studies were identified for laparoscopy and laparotomy. Laparotomy had more SABs and PTDs than laparoscopy (pooled proportion = 0.02 vs 0.07 and pooled proportion = 0.02 vs 0.14, respectively).

CONCLUSION

Laparoscopy for the surgical management of adnexal masses in pregnancy is associated with shorter length of hospital stay and similar risk of SAB or PTD. Elective surgery is associated with a decreased risk of PTD.

A novel diagnostic nomogram based on serological and ultrasound findings for preoperative prediction of malignancy in patients with ovarian masses

OBJECTIVE

To develop a novel diagnostic nomogram model to predict malignancy in patients with ovarian masses.

METHODS

In total, 1277 patients with ovarian masses were retrospectively analyzed. Receiver operating characteristic (ROC) analysis was performed to identify valuable predictive factors. Univariate and multivariate logistic regression analyses were used to identify risk factors for ovarian cancer. Subsequently, a predictive nomogram model was developed. The performance of the nomogram model was assessed by its calibration and discrimination in a validation cohort. Decision curve analysis (DCA) was applied to assess the clinical net benefit of the model.

RESULTS

Overall, 496 patients (38.8%) had ovarian cancer. Eighteen parameters were significantly different between the malignant and benign groups. Five parameters were identified as being most optimal for predicting malignancy, including age, carbohydrate antigen 125, fibrinogen-to-albumin ratio, monocyte-to-lymphocyte ratio, and ultrasound result. These parameters were incorporated to establish a nomogram model, and this model exhibited an area under the ROC curve (AUC) of 0.937 (95% confidence interval [CI], 0.920-0.954). The model was also well calibrated in the validation cohort and showed an AUC of 0.925 (95%CI, 0.896-0.953) at the cut-off point of 0.298. DCA confirmed that the nomogram model achieved the best clinical utility with almost the entire range of threshold probabilities. The model has demonstrated superior efficacy in predicting malignancy compared to currently available models, including the risk of ovarian malignancy algorithm, copenhagen index, and the risk of malignancy index. More importantly, the nomogram established here showed potential value in identification of early-stage ovarian cancer.

CONCLUSION

The cost-effective and easily accessible nomogram model exhibited favorable accuracy for preoperative prediction of malignancy in patients with ovarian masses, even at early stages.

Ovarian torsion in utero diagnosed at 37 weeks of pregnancy: A case report

Background

Fetal ovarian masses are common abdominal anomalies in female fetuses, often diagnosed in the third trimester. Most masses are benign and tend to resolve spontaneously within a few months after birth, but larger masses may present complications such as torsion.

Case

A 21-year-old primagravid woman was noted to have a complex avascular solid mass in the fetal left pelvis, which was consistent with complex fetal left ovarian torsion. The patient underwent induction of labor at 39 weeks for possible intervention. The infant underwent surgery at 5 weeks of age and a torsed, necrotic ovary was discovered.

Conclusion

The diagnosis of ovarian torsion in utero is rare, and prenatal and postnatal guidelines are needed on frequency of monitoring, timing of delivery, and postnatal follow-up.

•

Diagnosis of ovarian torsion antenatal is rare.

•

Counseling is a balance of the risk-benefit of timing of delivery and surgical intervention.

•

How long an ovary has been torsed is unpredictable, aggressive management may not be optimal.

•

Multidisciplinary planning is beneficial for postnatal counseling and management.

•

More research is necessary for optimal timing of delivery in cases of in-utero ovarian torsion.

The role of preoperative imaging and tumor markers in predicting malignant ovarian masses in children

PURPOSE

To investigate the clinicopathololgic characteristics and the predicting value of preoperative imaging and tumor markers in children with ovarian masses.

METHODS

Patients admitted in Shanghai children's hospital with ovary neoplasms between 2010.01 and 2015.12 were retrospectively analyzed. The medical records including age at operation, presentation of symptoms and signs, tumor marker, imaging, pathology, tumor diameter and surgical choice were reviewed. All data were analyzed using SPSS 17.0 RESULTS: A total of 139 patients were included, among which 116 were benign neoplasms and 23 malignant tumors. There was significance difference relation with the tumor diameter, character, torsion and tumor markers, but not the age, position, calculi, and symptoms. The risk factors include tumor diameters ≥ 10 cm, the odds ratio (OR) was 11, 95% confidence interval (CI) was 3-36, solid/complex tumor (OR 6, 95% CI 2, 14) and positive in tumor markers (OR 84, 95% CI 20, 345). Among the patients with benign neoplasms, 77 of them had laparoscopic ovarian cystectomy while 23 patients with malignant tumors had salpingo-oophorectomy and omentum resection.

CONCLUSION

Preoperative imaging and tumor markers could help identifying the malignant ovarian masses in children. If tumor diameter ≥ 10 cm, solid/complex in imaging and tumor markers abnormal, a radical resection is mandatory; otherwise, an ovarian-sparing surgery is recommended.

Approaches to the management of pediatric ovarian masses in the 21st century: Systematic review and meta-analysis

BACKGROUND

Laparoscopy is increasingly being adopted for the treatment of ovarian pathologies in adults. However, its implementation for the management of pediatric ovarian masses varies and the evidence, to date, has not been comprehensively analyzed. This review aims to compare laparoscopic and open surgical management of pediatric ovarian masses.

METHODS

We searched PubMed, Cochrane Library and Google Scholar from the year 2000 till April 2017. Studies selected for this included those on epidemiological trends of pediatric ovarian lesions, assessing outcomes of laparoscopic management and comparison of laparoscopic and open surgical techniques for pediatric ovarian masses. A meta-analysis comparing outcomes of both modalities was performed using standard methodology.

RESULTS

A total of 44 studies met the inclusion criteria of which 15 were on histological types of ovarian lesions, 24 assessed laparoscopic management only and five compared laparoscopy with open surgery for pediatric ovarian masses. Nonneoplastic lesions were the most common ranging from 36.5% to 73.7%, with cystic lesions being the most prevalent. Neoplastic lesions ranged between 26.3% and 63.5%, with germ cell tumors being the most common, while malignancy ranged between 3.5% and 10.8%. Laparoscopic management was generally advocated for managing benign lesions with a cautious approach for suspicion of malignant lesions. In comparison to open surgery, laparoscopic surgery had shorter operating time (MD = -33.24 min, 95% CI = -34.29 to -32.19, p < 0.0001), less intraop bleeding (MD = - 61.46 ml, 95% CI = -62.69 to -60.24, p < 0.0001), and reduced length of hospital stay (MD = -2.78 days, 95% CI= -2.82 to -2.74, p<0.0001). Complication rates were equivocal between the two approaches. Spillage rates could not be assessed.

CONCLUSION

Limited evidence suggests that laparoscopic approach to presumptively benign ovarian masses have better outcomes when compared to open surgery with regards to operating time, blood loss and hospital stay. However, complication rates were similar between the two approaches. Studies with rigorous scientific methods are needed for a definitive recommendation, especially in resource limiting settings. However malignant lesions should still be managed with an open surgical approach to avoid upstaging of disease status.

LEVEL OF EVIDENCE

II.

Imaging of Benign Adnexal Disease

This article provides an overview of the imaging evaluation of benign ovarian and adnexal masses in premenopausal and postmenopausal women and lesions discovered during pregnancy. Current imaging techniques are discussed, including pitfalls and differential diagnosis when necessary, as well as management. It also reviews the now well-established American College of Radiology (ACR)/Society of Radiologists in Ultrasound consensus guidelines and covers the more recently introduced Ovarian-Adnexal Reporting and Data System by the ACR and the recently published ADNEx Scoring System.

A diagnostic approach for differentiating abdominal tuberculosis from ovarian malignancy: a case series and literature review

Background

Abdominal tuberculosis is an uncommon variant of extrapulmonary tuberculosis. It accounts for 3.5% of extrapulmonary tuberculosis. Diagnosis of abdominal tuberculosis is still a challenge due to its non-specific symptoms. Abdominal tuberculosis and ovarian cancer may show similar symptoms, laboratory and imaging features. The goal of our report is to emphasize for the need of a diagnostic approach based on clinical manifestations, laboratory, imaging findings, and additional tests for considering a diagnosis of abdominal tuberculosis rather than ovarian cancer.

Case presentation

We report 3 cases of abdominal tuberculosis in our Onco-gynaecology Division, Department of Obstetrics and Gynaecology, Sardjito Hospital, Yogyakarta, Indonesia in 2018 which were previously diagnosed as ovarian malignancy and managed surgically. All of our patients experienced abdominal pain and enlargement but only two of them had significant weight loss. The general symptoms were typically found in onco-gynaecology patients, especially in those with ovarian malignancy. Ultrasound examination showed multilocular masses, 2 of them with solid parts and ascites. Cancer antigen 125 (CA-125) levels were found increasing in those three patients. All of them were treated surgically and diagnosis of abdominal tuberculosis was established through the histopathological result of tissue biopsy. Based on our cases and literature, we consider the need of a diagnostic approach to differentiate abdominal tuberculosis from ovarian malignancy, an attempt to avoid unnecessary invasive procedures that put burden risk for the patients.

Conclusion

Minimally invasive tests to establish the diagnosis of abdominal tuberculosis should be optimized to reduce the burden risk of laparotomy. Careful diagnostic steps should be followed to avoid wrong diagnosis.

Ovarian Cancer Presenting as Cryptogenic Stroke from Patent Foramen Ovale

A woman, aged 52 years, experienced severe headache, confusion, nausea, dizziness, and diplopia for three days. Magnetic resonance imaging of the brain showed multiple acute and subacute infarcts suggestive of embolic events. Dermatological examination was notable for splinter hemorrhages and macular patches on the fingernails and feet, respectively. Further diagnostic imaging of the chest and abdomen revealed pulmonary emboli and an ovarian mass with omental deposits and splenic infarcts. Fine-needle aspiration cytology and surgery confirmed a diagnosis of high-grade serous adenocarcinoma of the ovary with clear cell features. Extensive evaluation for malignancy should be considered on a case-by-case basis for patients with thromboembolic disease and an initial negative diagnostic evaluation for stroke. Consideration of patent foramen ovale closure is reasonable in patients with malignancy who are at risk for recurrent strokes.

A rare case of Krukenberg tumor by gallbladder cancer

INTRODUCTION

Gallbladder cancer commonly spreads by direct extension to the liver and adjacent organs of the gastrointestinal tract. Ovarian metastases by biliary origin, though known, are a very uncommon finding.

PRESENTATION OF CASE

We report a rare metastatic localization by gallbladder cancer, Krukenberg tumor mimicking a primitive ovarian cancer. A comprehensive critical review was performed and suggested strategies were analyzed.

DISCUSSION

The prognosis of ovarian metastastes by biliary origin is very poor with an overall survival estimated at around 6 months. The variable clinical presentation, radiology and serum markers make the appropriate histological diagnosis mandatory.

CONCLUSION

The presence of Krukenberg tumor should be considered in the work-up of gallbladder cancer.

Evaluation of the optimal laparoscopic method for benign ovarian mass extraction: a transumbilical route using a bag made from a surgical glove versus a lateral transabdominal route employing a standard endobag

We compared two transumbilical (TU) routes of surgical specimen retrieval in women with ovarian masses treated via laparoscopy: a bag made from a surgical glove and lateral transabdominal (LTA) retrieval employing a standard endobag. A total of 109 women undergoing laparoscopic surgery to treat benign adnexal masses were retrospectively evaluated between 2014 and 2017. In total, 57 masses were removed via the TU route and 52 via the LTA route. We recorded the ovarian mass size; additional postoperative analgesic drug requirements. Postoperative incisional pain scores were assessed using a 10-cm visual analogue scale (VAS), time to discharge and procedure type. The mean VAS scores at 1 h (5.0 ± 1.7 vs. 6.3 ± 1.3; p < .001); 12 h (0.7 ± 0.8 vs. 1.2 ± 1.1; p = .004); and 24 h (0.1 ± 0.3 vs. 0.7 ± 0.6; p < .001) were lower in the TU-removal group. Furthermore, additional postoperative analgesic drug requirements were significantly higher in the LTA-removal group (10 (19.2%) vs. 3 (5.3%); p = .03). During laparoscopic surgery, removal of an ovarian mass via an umbilical port (compared to a lateral port) causes less postoperative pain and does not increase the risk of wound complications such as infection or hernia.Impact statementWhat is already known on this subject? Laparoscopy has been used for the last 30 years. Constant improvement in the technique and equipment has allowed extensive, laparoscopic pelvic and abdominal surgery affording better outcomes than open surgery, an improved recovery, less pain, and fewer postoperative complications. However, mass removal remains a concern. Most laparoscopic specimens are larger than the initial trocar incision. Minimally invasive, adnexal mass surgery usually requires a trocar at least 10 mm wide to remove the mass. Alternatively, adnexal mass extraction from the abdominal cavity can proceed via a suprapubic, umbilical, or vaginal route.What do the results of this study add? During laparoscopic surgery, ovarian mass removal through an umbilical port using an endobag made from a surgical glove is useful due to the method requiring little funds, is easy to do, and results in a lower amount of postoperative pain than a removal via a lateral port using a standard endobag.What are the implications of these findings for clinical practice and/or further research? A transumbilical route using a bag made from a surgical glove is easy, economical, and causes less postoperative pain to the patient than removal via a lateral port employing a standard endobag.

Surgically Managed Ovarian Masses at the Royal Children's Hospital, Melbourne -19 Year Experience

BACKGROUND/PURPOSE

To describe the clinicopathological characteristics and management of surgically removed ovarian masses at the Royal Children's Hospital, Melbourne from 1993 to 2012.

METHODS

Medical records were reviewed retrospectively. Data regarding clinical findings, imaging and surgical management were evaluated.

RESULTS

There were 266 ovarian masses found in 258 surgeries (eight had bilateral masses). Most were benign (246/266, 92.5%), 2.3% (6/266) were borderline, and 5.3% (14/266) were malignant. The most common presenting symptom was abdominal pain for benign masses (169/246, 68.7%), and a palpable mass for borderline and malignant masses (12/20, 60.0%). Sensitivity and specificity of ultrasound for detection of malignancy was 64.7% and 52.9% respectively. Ovarian torsion occurred in 22.1% (n=57), none with malignancy, with seven cases diagnosed under one year of age. Sensitivity and specificity of ultrasound for ovarian torsion was 22.0% and 91.9%, respectively. The proportion undergoing ovarian cystectomy rather than oophorectomy has increased from 56.3% during 1993-1997 to 93.8% during 2008-2012 (p<0.005). Ovarian torsion was managed with ovarian conservation in 82.6% of cases between 2008-2012.

CONCLUSION

The majority of pediatric and adolescent ovarian masses were benign. Sensitivity of ultrasound was fair for detection of malignancy, and poor for ovarian torsion. Conservative surgeries are increasingly common.

LEVEL OF EVIDENCE

Level IV - case series with no comparison group TYPE OF STUDY: Retrospective Study.

Management of ovarian lesions diagnosed during infancy

PURPOSE

Prior studies of infant ovarian cysts have recommended intervention for those larger than 4 cm. We reviewed the natural history and features of those managed operatively versus nonoperatively.

METHODS

A retrospective study was performed of ovarian lesions in children <1 year-old from 2000 to 2014.

RESULTS

Forty patients were identified. Twenty-eight (70%) underwent operative management, while 12 (30%) were managed conservatively, including one undergoing aspiration. The mean age at surgery was 125 days. All but one patient (96%) had evidence of antenatal torsion intraoperatively or on final pathology. All resected lesions were benign. Ultrasound findings more common in those undergoing surgery included intracystic debris (p < 0.001), fluid-fluid or fluid-debris levels (p = 0.002), absence of Doppler flow (p = 0.014), solid components (p = 0.04), and calcifications (p = 0.001). Cysts managed nonoperatively had an average diameter of 2.5 cm, compared to 5.1 cm in the operative group (p < 0.001). Three of the lesions managed nonoperatively had a diameter greater than 3.5 cm (mean 5.1 cm) and were followed for an average of 153 days until resolution.

CONCLUSIONS

The majority of infant ovarian lesions were excised, although none were malignant. Aspiration or observation of larger cysts was feasible and safe. Ovarian cysts in this age group should be considered for nonoperative management and closely followed.

LEVEL OF EVIDENCE

IIC.

Ovarian masses in the child and adolescent: An American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee systematic review

BACKGROUND

The treatment of ovarian masses in pediatric patients should balance appropriate surgical management with the preservation of future reproductive capability. Preoperative estimation of malignant potential is essential to planning an optimal surgical strategy.

METHODS

The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee drafted three consensus-based questions regarding the evaluation and treatment of ovarian masses in pediatric patients. A search of PubMed, the Cochrane Library, and Web of Science was performed and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to identify articles for review.

RESULTS

Preoperative tumor markers, ultrasound malignancy indices, and the presence or absence of the ovarian crescent sign on imaging can help estimate malignant potential prior to surgical resection. Frozen section also plays a role in operative strategy. Surgical staging is useful for directing chemotherapy and for prognostication. Both unilateral oophorectomy and cystectomy have been used successfully for germ cell and borderline ovarian tumors, although cystectomy may be associated with higher rates of local recurrence.

CONCLUSIONS

Malignant potential of ovarian masses can be estimated preoperatively, and fertility-sparing techniques may be appropriate depending on the type of tumor. This review provides recommendations based on a critical evaluation of recent literature.

TYPE OF STUDY

Systematic review of level 1-4 studies.

LEVEL OF EVIDENCE

Level 1-4 (mainly 3-4).

Van Wyk Grumbach Syndrome: A Rare Consequence of Hypothyroidism

Long standing hypothyroidism presenting as an ovarian mass has been well described in literature as the Van Wyk Grumbach syndrome (hypothyroidism, isosexual precocious puberty and ovarian mass). Here, authors report this entity in a 11 y 7 mo old girl child who was referred to a surgeon in view of intestinal obstruction along with a multiloculated ovarian cyst. On evaluation, she was found to have raised serum creatinine, short stature, delayed bone age and pituitary enlargement. She was diagnosed with autoimmune thyroiditis and was started on replacement therapy with thyroxine, after which the ovarian cysts regressed. This entity should be kept in mind in cases of ovarian cysts, especially those with isosexual precocity, to prevent unnecessary evaluation and surgical misadventures.

[Diagnosis and management in pediatric patients with ovarian masses]

OBJECTIVE

Review of the diagnosis and management of ovarian masses in children, through the identification of preoperative risk factors of malignancy, the evaluation of surgical management and its results.

METHODS

Retrospective study in pediatric patients under 18 years old, managed surgically by ovarian masses. Analyzed data were symptoms, imagining, tumor markers, treatment, outcomes and pathology. The primary endpoint was ovarian malignancy.

RESULTS

We identified 54 patients with ovarian masses between 2014 and 2017, of which 49 were benign and 5 malignant; The malignant ovarian masses were significantly larger than the benign, with an average of 19.4 cm vs 6.49 cm (p = 0.0001); had greater solid component in the imaging and positive tumor markers (p = 0.001) and were treated with oophorectomy plus tumor staging surgery. Forty-three patients with benign tumors underwent ovarian preservation surgery. The postoperative follow-up of all the patients was on average 3.4 months (1-25 months) and 20.3% presented pelvic pain associated with alterations of the menstrual cycle in their postoperative control. There are no reports of recurrence or contralateral ovarian tumor.

CONCLUSIONS

Large masses with solid components and positive tumor markers were significant predictors of malignancy. Minimally invasive ovarian preserving surgery should be considered as the first treatment option in masses with low risk of malignancy. On the other hand, oophorectomy plus tumor staging surgery should be considered for ovarian tumors with a high risk of malignancy.

A hydatic cyst of the appendix mimicking a uterine lateral mass: a case report

Background

Hydatic cyst is a zoonotic disease caused by Echinococcus granulosus. It is a public health problem in Tunisia and remains endemic. It occurs in intra-abdominal organs in 10–15% of the cases, particularly in the liver representing the most common affected organ. The aim of the case is to highlight the scarcity of this appendicle origin and to consider it among the differential diagnosis of any intra-abdominal cystic lesion.

Case presentation

A 45-year-old Tunisian woman, with no past medical history, was admitted for a pelvic cystic mass. The clinical manifestation as well as the imaging findings were toward a lateral uterine mass. Our patient underwent appendectomy and resection of the mass. The patient had no recurrence at 2 years of follow-up.

Conclusions

An extrahepatic hydatid cyst should be recognized among the differential diagnosis of any intra-abdominal cystic lesion. Treatment should be based on surgical excision. Due to the risk of recurrence, a close follow-up is mandatory.

Laparoscopic-extracorporeal surgery performed with a fixation device for adnexal masses complicating pregnancy: Report of two cases

The potential complications associated with an adnexal mass discovered during early pregnancy call for surgical treatment. Ideally, surgery is performed after gestational week 12, but uterine expansion after the first trimester makes surgery difficult. We report two pregnancies complicated by adnexal masses for which we used an organ fixation device for safe performance of single-site umbilical laparoscopic surgery. Pelvic magnetic resonance imaging depicted a dichorionic, diamniotic twin pregnancy and 60-mm right adnexal mass in the first patient and bilateral adnexae in the second. All three masses were suspected mature cystic teratomas. Both patients underwent laparoscopic surgery during gestational week 14. With use of an organ fixation device, traction was applied until the mass reached the umbilicus; tumor resection was performed extracorporeally. In the second patient, the second mass was simply aspirated because adhesions were encountered. Our single-site laparoscopic-extracorporeal technique proved to be a safe approach to an otherwise high-risk situation.

An ovarian mass after breast cancer: Metachronous carcinoma or metastasis? A case report

•

In the presence of an ovarian mass after breast cancer, differentiating between primary and secondary lesions can be a difficult task.

•

This case report presents a 45-year-old patient with an ovarian mass two years after the diagnosis of breast cancer.

•

Imaging, histology and predominantly immunohistochemistry may provide valuable tools in the assessment of ambiguous cases.

•

Differences in the immunohistochemical profile of primary tumor and metastases should be anticipated.

Introduction

Differentiating between primary and secondary ovarian cancer can be a difficult task. In hereditary conditions breast malignancies and primary ovarian cancer often coexist.

Presentation of case

We present a 45-year-old patient with an ovarian mass two years after the diagnosis of a lobular, triple negative breast carcinoma. There was concern whether the lesion represented a metachronous ovarian cancer or a metastasis of the lobular carcinoma. The final histological examination showed a metastatic lesion, deriving from the lobular breast carcinoma, as evidenced by the immunohistochemical profile; nevertheless, there were changes in hormonal receptor expression in the metastatic lesion compared to the primary, triple negative tumor. The patient underwent genetic testing for BRCA1 and BRCA2 mutations and was negative. In the adjuvant setting the patient received 6 cycles of chemotherapy with carboplatin and paclitaxel; eighteen months later, the patient remains without disease recurrence.

Discussion and conclusion

This case report highlights the role of imaging, histology and predominantly immunohistochemistry as valuable tools in the assessment of ambiguous ovarian lesions after breast cancer.

Simulated impact of pelvic MRI in treatment planning for pediatric adnexal masses

BACKGROUND

There are no studies on utility of MRI in management of pediatric adnexal masses.

OBJECTIVE

To determine the diagnostic and therapeutic impact of pelvic MRI in adnexal masses in children and adolescents.

MATERIALS AND METHODS

We included 32 females age 18 years and younger who had adnexal masses and who underwent both pelvic ultrasound (US) and MRI. A radiologist retrospectively reviewed US and MR images and created a standard radiologic report for each patient. In a prospective theoretical fashion, two pediatric gynecologists reviewed the clinical data and US report for each patient and indicated conservative versus surgical management; in surgical cases the options were laparoscopy versus laparotomy, midline versus Pfannenstiel incision, and oophorectomy versus cystectomy. Subsequently, the gynecologists were presented the MRI report and were asked to indicate their treatment options again. A binomial test was conducted to determine the effect of adding MRI findings to the management plan.

RESULTS

The addition of MRI significantly changed management in 10 of 32 patients (P=0.0322), with a change in surgical versus conservative treatment in 5, a change in laparotomy vs. laparoscopy in 2, and a change from oophorectomy to cystectomy along with change in incision in 3 cases. This was based on additional information provided by MRI regarding the nature of the mass in 8 cases and origin of the mass in 2 cases.

CONCLUSION

Preoperative pelvic MRI findings might change the surgical management of pediatric patients with adnexal masses, so it is a valuable addition to the conventional workup in the clinical management.

Retrospective analysis of suspicious pelvic masses using the Pelvic Mass Index (PMI) scoring system from 2007 to 2014

OBJECTIVES

This study aims to validate the accuracy of the Pelvic Mass Index (PMI) by comparing it with Risk of Malignancy Index (RMI) in a large patient cohort.

STUDY DESIGN

This retrospective study used data of women with ovarian masses collected from 2007 to 2014, referred to the Pelvic Mass Clinic (PMC) at University Hospital of Wales in Cardiff. The locally developed PMI was used to triage patients for surgery, surveillance or discharge. Performance measures for PMI, RMI and CA125 are reported as sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), receiver operating characteristic (ROC) curves and area under the curve (AUC) for premenopausal and postmenopausal women alike.

RESULTS

PMI was calculated on 1468 patients of whom 497 underwent surgery, 176 (71.0%) were in the high risk group, 63 (68.0%) intermediate and 258 (23%) amongst low risk women. Compared to RMI, PMI had a higher sensitivity (90.4%) and NPV (96.9%) for the entire cohort, as well as in the premenopausal (88.9%; 97.6%) and postmenopausal (91.5%; 95.6%) subcategories. ROC curves indicated better performance in the total group (AUC 0.823 vs. 0.770) and the premenopausal group (AUC 0.847 vs. 0.728), though AUC in the postmenopausal group was similar (0.779 vs. 0.791) - likely due to increased specificity of CA125 after menopause. Histology revealed PMI significantly outperforms RMI in diagnosing malignancy, missing only 1 compared to 20 cancers.

CONCLUSIONS

The high sensitivity and NPV of PMI makes it a useful tool in triaging patients with suspicious ovarian masses.

Management of Large Ovarian Neoplasms in Pediatric and Adolescent Females

The overwhelming majority of ovarian cysts in pediatric and adolescent girls are physiologic; however, large simple and complex ovarian lesions often require surgical intervention due to the increased risk of neoplasia. In this review article, we discuss the preoperative evaluation and intraoperative management of large ovarian neoplasms. We review the current literature regarding long term ovarian function and fertility, rates of recurrence and residual disease, and novel surgical approaches. Managing large ovarian neoplasms in the pediatric and adolescent population requires careful preoperative and intraoperative care to optimally resect neoplasia while maximizing fertility and minimizing pain.

HE4 in the differential diagnosis of ovarian masses

Ovarian masses, a common finding among pre- and post-menopausal women, can be benign or malignant. Ovarian cancer is the leading cause of death from gynecologic malignancy among women living in industrialized countries. According to the current guidelines, measurement of CA125 tumor marker remains the gold standard in the management of ovarian cancer. Recently, HE4 has been proposed as emerging biomarker in the differential diagnosis of adnexal masses and in the early diagnosis of ovarian cancer. Discrimination of benign and malignant ovarian tumors is very important for correct patient referral to institutions specialized in care and management of ovarian cancer. Tumor markers CA125 and HE4 are currently incorporated into the "Risk of Ovarian Malignancy Algorithm" (ROMA) with menopausal status for discerning malignant from benign pelvic masses. The availability of a good biomarker such as HE4, closely associated with the differential and early diagnosis of ovarian cancer, could reduce medical costs related to more expensive diagnostic procedures. Finally, it is important to note that HE4 identifies platinum non-responders thus enabling a switch to second line chemotherapy and improved survival.

Comparison of robotic-assisted and conventional laparoscopy in the management of adnexal masses

STUDY OBJECTIVE

To compare the outcome of robotic-assisted laparoscopy vs conventional laparoscopy in the management of ovarian masses.

DESIGN

Retrospective cohort (Canadian Task Force classification II-3).

SETTING

Academic medical centre in the northeast United States.

PATIENTS

Retrospective medical record review of 71 consecutive patients with presumed benign ovarian masses.

INTERVENTION

Robotic-assisted laparoscopy in 30 patients with presumed benign ovarian masses was compared with conventional laparoscopy in 41 patients.

MEASUREMENTS AND MAIN RESULTS

Operative outcomes including operative time, estimated blood loss, length of hospital stay, and complications were recorded. Standard statistical analysis was used to compare the outcomes in the 2 groups. Mean (SD) operative time in the robotic group was 1.95 (0.63) hours, which was significantly longer than in the conventional laparoscopic group, 1.28 (0.83) hours (p = .04). Estimated blood loss in the robotic group was 74.52 (56.23) mL, which was not significantly different from that in the conventional laparoscopic group, 55.97 (49.18) mL. There were no significant differences in length of hospital stay between the robotic and conventional laparoscopic groups: 1.20 (0.78) days and 1.48 (0.63). Conversion to laparotomy was not necessary in either group of patients. Intraoperative and postoperative complications were similar between the 2 groups.

CONCLUSION

Robotic-assisted laparoscopy is a safe and efficient technique for management of various types of ovarian masses. However, conventional laparoscopy is preferred for management of ovarian masses because of shorter operative time. Prospective studies are needed to evaluate the outcomes of robotic-assisted laparoscopic management of benign and malignant ovarian neoplasms.

Predictors of ovarian malignancy in children: overcoming clinical barriers of ovarian preservation

BACKGROUND/PURPOSE

Ovarian preservation is desirable in girls with benign ovarian masses. We aimed to 1) identify clinical predictors of malignant ovarian masses, 2) investigate how often ovarian tissue is present to preserve in benign masses, and 3) identify factors associated with successful ovarian preservation.

METHODS

Retrospective analysis (1997-2012) of girls age 1-18years with an ovarian mass managed operatively. Data on presenting symptoms, imaging, biochemical markers, treatment, outcome, and pathology were extracted.

RESULTS

We identified 150 patients. Large mass size, solid components, and elevated tumor markers (AFP, βHCG, and/or LDH) were significantly predictive of malignancy. All masses <10cm, predominantly cystic, and with negative tumor markers were benign. Masses with all three of these characteristics would decrease a 20% malignancy pretest probability to a posttest probability of 0.25%. Benign masses managed by oophorectomy contained normal ovarian tissue in 76% of the specimens. For benign masses, successful ovarian preservation was significantly associated with size <10cm, predominantly cystic, laparoscopy, and absence of torsion or calcifications.

CONCLUSION

Ovarian masses that are <10cm, primarily cystic, and have negative tumor markers are most likely benign. Viable ovarian tissue is frequently present in benign masses, so significant efforts should be made for ovarian preservation.

Ovarian masses in children and adolescents in China: analysis of 203 cases

Objective

The true incidence of ovarian tumors in children is unknown. Few studies beyond case reports and case series have been published concerning pediatric ovarian tumors. Herein we review a large number of ovarian tumor cases.

Methods

The charts of 203 patients who presented with adnexal masses were reviewed.

Results

The patient’s ranged in age from 2 to 18 years (mean = 15.6 years), with 30 being premenarchal (14.8%). The incidence of ovarian tumor increases with age, especially in patients older than 14 years. The main complaint was abdominal pain or abdominal distension in 117 patients (57.7%). A high AFP level in a pre-pubic girl with an adnexal mass is indicative of a malignant ovarian tumor. The 214 adnexal masses (11 patients had bilateral cysts) consisted of benign tumorous oophoropathy (107 masses, 50.0%), borderline and malignant tumors (29 masses, 13.6%), and nontumorous oophoropathy (78 masses, 36.5%). Of the 136 neoplasia, germ cell tumors accounted for 71.5%. Surgical intervention was performed in 98.5% of cases. There were statistically decreased blood loss, surgery duration and days of hospitalization with the laparoscopic procedure when compared with open surgery.

Conclusions

Abdominal pain is the most common complaint in young patients with adnexal masses. AFP is the most useful diagnostic biomarker of ovarian tumors in young females. Laparoscopic resection of ovarian cysts is an alternative operation approach.