Benign Tumors of the Female Reproductive Tract

1. Benign Tumors of the Female Reproductive Tract 輔仁大學 實習醫師核心課程 新光吳火獅紀念醫院婦產科 黃莉文

2. Benign tumors of the Female Reproductive Tract • Pelvic mass • A pelvic mass may be gynecologic in origin or it may arise from the urinary tract or bowel. • The gynecologic causes of a pelvic mass may be uterine, adnexal, or more specifically ovarian.

4. Prepubertal Age Group - Differential Diagnosis • Differential Diagnosis • < 5% of ovarian malignancies • Germ cell tumors make up 1/2 to 2/3 • 35% of all ovarian neoplasms occurring during childhood and adolescence were malignant • < 9y/o, 80% malignant

5. Prepubertal Age Group - Differential Diagnosis • Symptoms: abdominal or pelvic pain • Pelvic mass very quickly becomes abdominal in location as it enlarges because of the small size of the pelvic cavity. • Diagnosis is difficult because of the rarity of the condition (and therefore a low index of suspicion) • Many symptoms are nonspecific • Acute symptoms are more likely to be attributed to more common entities such as appendicitis.

6. Prepubertal Age Group - Differential Diagnosis • Abdominal palpation • bimanual rectoabdominal examination • Abdominal in location: can be confused with other abdominal masses • Acute pain: torsion. The ovarian ligament becomes elongated as a result of the abdominal location, thus creating a predisposition to torsion.

7. Prepubertal Age Group- Diagnosis and Management • Ultrasonography • Unilocular cysts are virtually always benign and will regress in 3 to 6 months do not require surgical management with oophorectomy or oophorocystectomy.

9. Prepubertal Age Group - Diagnosis and Management • Close observation recommended (discuss risk of ovarian torsion with the child's parents.) • Recurrence rates after cyst aspiration - 50%. • Attention: long-term effects on endocrine functioning, future fertility, preservation of ovarian tissue • Premature surgical therapy - ovarian and tubal adhesions that can affect future fertility.

10. Prepubertal Age Group - Diagnosis and Management • Additional imaging : CT, MRI, Doppler flow studies. • Risk of a germ cell tumor is high, the finding of a solid component mandates surgical assessment.

11. Adolescent Age Group • Differential Diagnosis • Ovarian Masses • Uterine Masses • Inflammatory Masses • Pregnancy

12. Adolescent Age Group- Ovarian masses • The risk of malignant neoplasms lower. • Germ cell tumors - most common tumors of the first decade of life but occur less frequently during adolescence. • Epithelial neoplasms - increasing frequency with age. • Mature cystic teratoma - most frequent neoplastic tumor of children and adolescents, accounting for > 1/2 of ovarian neoplasms in women < 20 y/o

13. Adolescent Age Group - Ovarian masses • Neoplasia can arise in dysgenetic gonads. • 25% of dysgenetic gonads of patients with a Y - malignant. • Gonadectomy - recommended for patients with XY gonadal dysgenesis or its mosaic variations.

14. Adolescent Age Group - Ovarian masses • Functional ovarian cysts • Incidental finding on examination • Pain caused by torsion, leakage, or rupture. • Endometriosis is less common during adolescence than in adulthood. • In series of adolescents referred with chronic pain, 50% to 65% have been found to have endometriosis.

15. Adolescent Age Group - Ovarian masses • Most adolescents with endometriosis do not have associated obstructive anomalies. • In young women, endometriosis may have an atypical appearance, with nonpigmented or vesicular lesions, peritoneal windows, and puckering.

17. Adolescent Age Group- Uterine Masses • Uterine leiomyomas - not common • Obstructive uterovaginal anomalies occur during adolescence, at the time of menarche, or shortly thereafter. • The diagnosis is frequently neither suspected nor delayed, particularly when the patient is seen by a general surgeon.

18. Adolescent Age Group- Uterine Masses • Uterine anomalies - imperforate hymen, transverse vaginal septa, vaginal agenesis with a normal uterus and functional endometrium, vaginal duplications with obstructing longitudinal septa, and obstructed uterine horns. • Cyclic pain, amenorrhea, vaginal discharge, or an abdominal, pelvic, or vaginal mass. • Hematocolpos, hematometra

19. Obstructive Genital Anomalies

21. Hematocolpos

22. Bulging vaginal mass

23. Bulging vaginal mass

24. Bulging vaginal mass

25. Cruciate/Circular Incision

26. Uterine anomalies

27. Adolescent Age Group- Inflammatory Masses • Adolescents have the highest rates of PID • An adolescent who has pelvic pain may be found to have an inflammatory mass. • The diagnosis is primarily clinical, based on the presence of lower abdominal, pelvic, and adnexal tenderness; cervical motion tenderness; a mucopurulent discharge; elevated temperature, white blood cell count, or sedimentation rate

28. Adolescent Age Group - Inflammatory Masses • Associated with the risks STD • Inflammatory masses may consist of • Tuboovarian complex • Tuboovarian abscess • Pyosalpinx • Hydrosalpinx

29. Adolescent Age Group - Inflammatory Masses

30. Adolescent Age Group- Pregnancy • Pregnancy should always be considered • Adolescents more likely to deny the possibility of pregnancy. • Ectopic pregnancies may cause pelvic pain and an adnexal mass. • Quantitative measurements of b-hCG, ectopic pregnancies are being discovered before rupture, allowing conservative management with laparoscopic surgery or medical therapy with methotrexate.

31. Adolescent Age Group- Diagnosis • A history and pelvic examination • Anxiety associated with a first pelvic examination • Issues of confidentiality related to questions of sexual activity. • Always include a pregnancy test (regardless of stated sexual activity) • CBC/DC. • Tumor markers (AFP, hCG…)

32. Adolescent Age Group - Diagnosis • Ultrasonography. • TVS provide more detail than Abd sonography • TVS may not be well tolerated by adolescents • CT or MRI

33. Adolescent Age Group - Management • Laparoscopy • Acute PID to confirm the diagnosis • Persisted symptoms in patient with the clinical diagnosis of PID or TOA • The surgical management of inflammatory masses is rarely necessary in adolescents, except ruptured TOA or failure of medical management with broad-spectrum antibiotics

34. Reproductive Age Group • Differential Diagnosis • Uterine Masses • Ovarian Masses • Nonneoplastic Ovarian Masses • Other Benign Masses • Neoplastic Masses • Other Adnexal Masses

35. Reproductive Age Group- Uterine Masses • Uterine leiomyomas - most common benign uterine tumors. • Usually diagnosed on physical examination. • Incidence: 20% (reproductive age) • 40% to 50% of women older than 35 years of age.

36. Types of fibroids

37. Reproductive Age Group- Uterine Masses • Malignant degeneration < 0.5% • Leiomyosarcoma -rare malignant neoplasm composed of cells that have smooth muscle differentiation. • Most diagnoses are determined (postoperatively) after microscopic examination.

38. Reproductive Age Group- Uterine Masses • Symptoms • Menorrhagia • Chronic pelvic pain • Acute pain • Urinary symptoms: Frequency, Partial ureteral obstruction, complete urethral obstruction • Infertility

39. Reproductive Age Group- Uterine Masses • Symptoms • Rectosigmoid compression, with constipation or intestinal obstruction • Prolapse of a pedunculated submucous tumor • Venous stasis of the lower extremities and possible thrombophlebitis secondary to pelvic compression • Polycythemia • Ascites

40. Reproductive Age Group- Uterine Masses • Management of Leiomyomas • Nonsurgical Management • Intervention is reserved for specific indications and symptoms. • Periodic examinations • GnRH agonists

41. Reproductive Age Group- Uterine Masses GnRH agonists • 40% to 60% decrease in uterine volume • Hypoestrogenism: reversible bone loss and symptoms: hot flashes. • limited to short-term use • Regrowth of leiomyomas within a few months after stopping therapy in about 1/2 women treated

42. Reproductive Age Group- Uterine Masses • Indications for GnRH agonist: • 1.Preservation of fertility in women with large leiomyomas before attempting conception, or preoperative treatment before myomectomy • 2.Treatment of anemia to allow recovery of normal hemoglobin levels before surgical management, minimizing the need for transfusion or allowing autologous blood donation • 3.Treatment of women approaching menopause in an effort to avoid surgery • 4.Preoperative treatment of large leiomyomas to make vaginal hysterectomy, hysteroscopic resection or ablation, or laparoscopic destruction more feasible • 5.Treatment of women with medical contraindications to surgery • 6.Treatment of women with personal or medical indications for delaying surgery.

43. Reproductive Age Group- Uterine Masses Indications for surgery : • Abnormal uterine bleeding - anemia, unresponsive to hormonal management • Chronic pain with severe dysmenorrhea, dyspareunia, or lower abdominal pressure or pain • Acute pain, as in torsion of a pedunculated leiomyoma, or prolapsing submucosal fibroid • Urinary symptoms or signs such as hydronephrosis after complete evaluation • Infertility, with leiomyomas as the only abnormal finding • Markedly enlarged uterine size with compression symptoms or discomfort.

44. Reproductive Age Group- Uterine Masses • Indications for surgery because of the inability to exclude uterine sarcoma: • Rapid enlargement of the uterus during premenopausal years • or any increase in uterine size in a postmenopausal woman

45. Reproductive Age Group- Uterine Masses • Hysterectomy has long been viewed as the definitive management of symptomatic uterine leiomyomas. • Myomectomy is an alternative to hysterectomy for patients who desire childbearing, who are young, or who prefer that the uterus be retained. Recent studies suggest that the morbidity of abdominal myomectomy and hysterectomy are similar • Laparoscopic myomectomy minimizes the size of the abdominal incision, although several small incisions are required.

46. Reproductive Age Group- Uterine Masses • Vaginal myomectomy is indicated in the case of a prolapsed pedunculated submucous fibroid. • Hysteroscopic resection of small submucous leiomyomas • The recurrence risk for leiomyomas has been reported to be as high as 50% after myomectomy, with up to 1/3 requiring repeat surgery. • Endometrial ablation can decrease bleeding for women with primary intramural fibroid

47. hysteroscopy

48. Reproductive Age Group- Uterine Masses • Nonextirpative approaches: • Myolysis - use of lasers to coagulate or needle electrodes to deliver an electrical current to individual leiomyomas • Uterine artery embolization - have serious consequences, including infection, massive bleeding, and necrosis requiring emergency surgery. Still consider investigational. • Long-term safety and efficacy have not yet been demonstrated.

49. Reproductive Age Group- Ovarian Masses • During the reproductive years, the most common ovarian masses are benign. • About 2/3 ovarian tumors are encountered during the reproductive years. • Most ovarian tumors (80% to 85%) are benign, and 2/3 of these occur in women between 20 and 44 y/o. • The chance that a primary ovarian tumor is malignant in a patient < 45 y/o is less than 1 in 15.

50. Reproductive Age Group- Ovarian Masses • Pelvic findings in patients with benign and malignant tumors differ. • Benign - unilateral, cystic, mobile, and smooth • Malignant -bilateral, solid, fixed, irregular, and associated with ascites, cul-de-sac nodules, and a rapid rate of growth