Diagnosis and Management of Adnexal Mass in Adolescent

1. Diagnosis and Management of Adnexal Mass in Adolescent 인제대학교 의과대학 부산백병원 정 대 훈

2. Adnexal mass • Enlarged structure in the uterine adnexa • palpated on a bimanual pelvic examination or • visualized using radiographic imaging • Conditions associated with adnexal mass. • Benign conditions • Malignancies • Ovary • Fallopian tube • Metastatic disease (breast or G-I tract)

3. A woman’s lifetime risk of developing ovarian cancer

4. Agency for Healthcare Research and Quality. AHRQ Publication No. 06-E004. 2006

5. 우리나라 10대 소녀의 악성종양 분포(2002년, 393명) 1.3% 1.8% 8.1% 3.0% 28.8% 10.4% 12.5% 17.6% 16.5% 한국중앙암등록사업 연례 보고서. 국립암센터. 2002

6. 우리나라 인구 10만명 당 난소암의 연령별 분포(2002년, 1572명) 15.4명 2.18명 한국중앙암등록사업 연례 보고서. 국립암센터. 2002

7. 우리나라 난소암의 연령별 분포(2004년, 1319명) 한국 부인암 등록 사업 조사 보고서. 대한산부인과학회. 2007

8. 20세 이하 여성에서 난소 종양의 조직학적 빈도 부인과학 제4판 2007:p1017.

9. Adnexal mass 연령별 분포(부산백병원 1997-2007년, 3271명) 2.5%

10. 20세 미만 여성에서 adnexal mass의 조직학적 빈도(부산백병원 1997-2007년, 84명)

11. Diagnosis Symptom Pelvic Examination Radiologic Imaging Clinical Laboratory Test

12. Clinical significanceof discriminating benign from malignant • differs depending on the clinical setting in which the mass is initially detected. • If, symptoms • surgical management • appropriate whether or not the mass is malignant. • referral and management by gynecolgic oncologist • in malignancy • If, asymptomatic • to avoid unnecessary diagnostic procedures, including surgery • in asymptomatic benign conditions • referral and management by gynecolgic oncologist • in malignancy

13. Symptoms • Abdominal pain • Abdominal distension • Palpable mass • Back pain • Dysuria • Vomiting, nausea, anorexia, constipation • Fever/chills • Menstrual disorder Schultz KA, et al. Clin Obstet Gynecol 2006.

14. 20세 미만 여성에서 adnexal mass의 증상(부산백병원 1997-2007년, 84명) Histology of cysts excised at detorsion

15. Pelvic Examination • History and pelvic examination • critical in the diagnosis of a pelvic mass • Considerations in adolescents • anxiety associated with a first P/Ex • issues of confidentiality related to questions about sexual activity

16. Pelvic Examination • Features associated with an adnexal malignancy • Fixed • Nodular • Irregular • Solid consistency • Bilateral • Ascites • Limited ability to identify an adnexal mass • esp. Obesity • Use radiologic imaging for girl who had not intercourse ACOG practice bulletin. Obstet & Gynecol 2007

17. P/Ex in detecting adnexal mass • not a sensitive testfor detecting the presence of adnexal masses Agency for Healthcare Research and Quality. AHRQ Publication No. 06-E004. 2006

18. P/Ex in discriminating benign from malignant adnexal masses • limited ability to discriminate benign from malignant masses Agency for Healthcare Research and Quality. AHRQ Publication No. 06-E004. 2006

19. Radiologic Imaging • Ultrasonography • Color Doppler Ultrasonography • Computed tomography • Magnetic resonance imaging • Positron emission tomography

20. Modalities for the Evaluation of Adnexal Masses ACOG practice bulletin. Obstet & Gynecol 2007 Agency for Healthcare Research and Quality. AHRQ Publication No. 06-E004. 2006

21. Transvaginal Ultrasonography • Advantages • widespread availability • good patient tolerability • cost-effectiveness • the most widely used imaging modality to evaluate adnexal masses. • No alternative imaging modality has demonstrated sufficient superiority to TV-USG to justify its routine use • Transrectal ultrasonography • For girl who had not intercourse

22. Transvaginal Ultrasonography • Ultrasonographic signs of malignancy • Adnexal pelvic mass with area of complexity • Irregular border • solid patterns within the mass • Dense multiple septae

23. TV-USG Scoring System(Morphologic Index) • < 5 : benign • ≥ 5 : malignant DePriest PD, et al. Gynecol Oncol, 1993

24. TV-USG Scoring System(Morphologic Index) Prospective validation studies have provided consistently lower figures Agency for Healthcare Research and Quality. AHRQ Publication No. 06-E004. 2006

25. Color Doppler Ultrasonography • Hypoxic tissue in tumors • will recruit low-resistance, high-flow blood vessels • measurement of blood flow in and around a mass • resistive index • pulsatility index • maximum systolic velocity

26. Color Doppler Ultrasonography • The ultimate goal of color Doppler ultrasonography • to increase the specificity of TV-USG • The current role in evaluating pelvic masses • controversial • because the ranges of values of blood flow indicies between benign and malignant masses overlap considerably

27. 3D TV-USG & PowerDoppler • To overcome the overlap among color Doppler USG blood flow indices • Vascular sampling of suspicious area • Papillary projection • Solid area • Thick septation • Vascular architecture • Chaotic (correlated highly malignancy) Geomini P, et al. Obstet Gynecol 2006 ACOG practice bulletin. Obstet & Gynecol 2007

28. CT, MRI, PET • Not recommended for use in the initial evaluation (highly cost, no clear advantage over TV-USG) • CT • to detect and characterize pelvic masses • to evaluate the abdomen for metastasis when a cancer is suspected • MRI • helpful in differentiating the origin of nonadnexal pelvic masses (esp,leiomyoma) • Most useful in the diagnosis of uterine anomaly • PET • not use in the preoperative assessment of adnexal masses ACOG practice bulletin. Obstet & Gynecol 2007

29. Clinical Laboratory Test • Pregnancy test • CBC, ESR • Serum tumor marker • helpful with solid or complex or persistent cystic masses. • Preoperative diagnosis and follow-up • Germ cell tumor • AFP • hCG • LDH • Epithelial tumors • CA-125

30. Agency for Healthcare Research and Quality. AHRQ Publication No. 06-E004. 2006

31. Differential Diagnosis Functional ovarian cyst Benign neoplasm Inflammatory mass Others Gynecologic emergency

32. Differential Diagnosis Nongynecologic Benign • Diverticular abscess • Appendiceal abscess or mucocele • Nerve sheath tumors • Ureteral diverticulum • Pelvic kidney • Paratubal cysts • Bladder diverticulum Malignant • Gastrointestinal cancers • Retroperitoneal sarcomas • Metastases Gynecologic Benign • Functional cyst • Leiomyomata • Endometrioma • Tuboovarian abscess • Ectopic pregnancy • Mature teratoma • Serous cystadenoma • Mucinous cystadenoma • Breast cancer • Hydrosalpinx Malignant • Germ cell tumor • Sex-cord or stromal tumor • Epithelial carcinoma ACOG practice bulletin. Obstet & Gynecol 2007

33. Functional ovarian cyst • Commonly, large majority of adnexal masses in adolescents • Follicular cyst • Corpus luteum cyst

34. Follicular cyst • Etiology • Excessive response to FSH • USG • Simple (sonolucent) cyst • Symptoms • Asymptomatic • dull pain, pelvic heaviness • Urinary frequency, constipation

35. Follicular cyst • Management • Observation (Self-limited) • 66.6%, regress over several weeks to months • Repeat USG after 8-10 weeks • Shortly after menstrual cycle begin • Hormone therapy • 71.6% resolution within 6 weeks • 28.4% remaining cyst → no physiologic cyst • Oral contraceptives with 35 ㎍ formulation • Surgery • ≥ 8 cm • Enlarging over time • Solid • Severely symptomatic • Persist ≥ 3-4 months

36. Corpus luteum cyst • USG • Simple (sonolucent) with thick hyperechoic wall • typically • Complex (solid and fluid; internal echo or fluid level) • Hemorrhage inside cyst at the time ovulation • Clotted blood • Management • Observation (Self-limited) • Resorbed over a few weeks • Repeat USG after 8-10 weeks • Shortly after menstrual cycle begin

37. Benign neoplasm • Not regress • Should be treated surgically ! • Mature cystic teratoma • Epithelial tumor

38. Mature cystic teratoma • M/C neoplastic cyst in adolescents • Symptoms • Dull abdominal pain • frequently asymptomatic • often found by exam or incidental imaging • USG • Fat fluid levels • diffuse or focal areas of increased echogenicity with acoustical shadowing, often thought to be hair fibers within the cyst • calcification within an ovarian mass • pathognomonic

39. Mature cystic teratoma • Management • Surgery • risk of ovarian torsion, 15% • Rarely spontaneous rupture • Chemical peritonitis • Foreign body reaction • Dense adhesion • Careful evaluation of both ovaries imaging & at surgery • bilateral in 10%

40. Epithelial tumor • Infrequently in adolescents → 29.8 ~ 40% in Korea • Serous/mucinous cystadenoma • Should be considered DDx of a persistent ovarian cyst • Extremely large • Possibility of borderline malignancy

41. Inflammatory mass • Tuboovarian abscess • Hydrosalpinx

42. Tuboovarian abscess • PID • Common cause for severe abdominal pain • Not responding to antibiotics after 24-48hrs • USG • Look for pyosalpinx or TOA • Multi-loculated fluid-density mass with thick wall • “Cogwheel” sign • “Beads-on-a string” sign

43. “Cogwheel” sign “Beads-on-a string” sign

44. Tuboovarian abscess • Management • Broad spectrum IV antibiotics • Drainage • CT guided or surgically • Excision • Rarely, late-resort option

45. Hydrosalpinx • Postinflammatory abnormality of the fallopian tube. • USG • a fluid-filled, serpentine structure • Often mistaken for a complex adnexal mass • Management • Usually asymptomatic • No intervention is necessary.

46. Others • Endometrioma • Parovarian cyst • Peritoneal inclusion cyst • Mullerian anomaly

47. Endometrioma • Likely develop with long-standing endometriosis • infrequently in adolescents • USG • a ground glass appearance • cystic ovarian masses with low, homogeneous echogenicity • Management • Ovarian cystectomy with complete removal of the cyst wall • not regress with hormonal therapy

48. Parovarian cyst • Cysts that hang off the sides of the fallopian tubes • Etiology • Congenital • vestigial remnants of the embryological male Wolffian system • Hydatid cysts of Morgagni • Acquired • following inflammation in the pelvis • postsurgical or PID • USG • Simple (sonolucent) cyst adjacent to the ovary • Management • No intervention is necessary • Unless, large or risk for torsion or uncertain diagnosis

49. Peritoneal inclusion cyst • Pseudocysts • not actually cysts • the result of trapped peritoneal or ovarian fluid in enclosed adhesions involving the uterus, adnexa, and bowels • Etiology • previous peritonitis of any etiology • postsurgical healing • USG • Irregular and lobulated cystic lesion • Normal ovary in cyst or cyst wall • mistaken for a complex adnexal mass • Management • may be reduced by treatment with oral contraceptivesif the patient is symptomatic

50. Mullerian anomaly • When a solid adnexal mass in an adolescent • important to consider a mullerian anomaly in DDx • Bicornuate uterus • Uterus didelphys • Bicornuate uterus with a communicating or noncommunicating rudimentary uterine horn • MRI • helpful in further delineating the pelvic anatomy to determine the best surgical plan