diagnosis and management of adnexal mass in adolescent 인제대학교 의과대학 부산백병원...

Diagnosis and Management

of Adnexal Mass in Adolescent

인제대학교 의과대학 부산백병원정 대 훈

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)

A woman’s lifetime risk of developing ovarian cancer

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

우리나라 10 대 소녀의 악성종양 분포(2002 년 , 393 명 )

림프종 난소

갑상선,뇌 신경계

뼈결합조직위대장기타

1.3%

17.6%

16.5%

12.5%

10.4%

8.1%3.0%

1.8%

28.8%

한국중앙암등록사업 연례 보고서 . 국립암센터 . 2002

0

2

4

6

8

10

12

14

16

10대미만 20대 40대 60대 80대이상

난소암

우리나라 인구 10 만명 당 난소암의 연령별 분포 (2002 년 , 1572

명 )

2.18 명

15.4 명

한국중앙암등록사업 연례 보고서 . 국립암센터 . 2002

우리나라 난소암의 연령별 분포(2004 년 , 1319 명 )

한국 부인암 등록 사업 조사 보고서 . 대한산부인과학회 . 2007

20 세 이하 여성에서 난소 종양의 조직학적 빈도분류 연령 합계

10 세 미만 11 세 ~15 세 16 세 ~20 세 전체 (%)

생식세포종양 5 10 32 47(55.3)

양성 3 7 27 37

악성 2 3 5 10

상피성 종양 5 29 34(40.0)

양성 5 25 30

경계성 2 2

악성 2 2

성끈간질종양 4 4(4.7)

양성 3 3

악성 1 1

합계 65 85(100)

악성 2(40.0) 3(20.0) 10(15.3) 15(17.6)

부인과학 제 4 판 2007:p1017.

Adnexal mass 연령별 분포( 부산백병원 1997-2007 년 , 3271 명 )

0

5

10

15

20

25

30

35

10대 30대 50대 70대

2.5%

20 세 미만 여성에서 adnexal mass 의 조직학적 빈도 ( 부산백병원 1997-2007 년 , 84

명 )분류 연령 합계

10 세 미만 10 세 ~14 세 15 세 ~19 세 전체 (%)

생식세포종양 35(41.7)

양성 1 3 22 26

악성 1 3 5 9

상피성 종양 25(29.8)

양성 2 14 16

경계성 7 7

악성 2 2

성끈간질종양 3(3.6)

양성 2 2

악성 1 1

자궁내막종 7 7(8.3)

단순 , 기능성 낭종 1 7 8(9.5)

기타 1 5 6(7.1)

합계 2 10 72 84(100)

악성 1(50.0) 3(30.0) 15(20.8) 19(21.3%)

Diagnosis

Symptom

Pelvic Examination

Radiologic Imaging Clinical Laboratory Test

Clinical significance of discriminating benign from malignant differs depending on the clinical setting in which the mas

s 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

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.

Histology of cysts excised at detorsion

Symptoms No (%)

Abdominal pain 40 (47.6)

Abdominal distension 15 (17.9)

Palpable mass 15 (17.9)

Menstrual disorder 11 (13.1)

Incidental 3 ( 3.5)

Total 84 ( 100)

20 세 미만 여성에서 adnexal mass 의 증상

( 부산백병원 1997-2007 년 , 84 명 )

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

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

P/Ex in detecting adnexal mass

Study N Sensitivity Specificity

Jacobs, 1988 1,010 84.6% 98.3%

Andolf, 1990 801 33.7% 92.0%

Padilla, 2005 252 15.6% 93.8%

Ong, 1996 86 71.9% 59.1%

Overall 0.45 0.90

not a sensitive test for detecting the presence of adnexal masses


P/Ex in discriminating benign from malignant adnexal masses

Study N Sensitivity Specificity

Adonakis 1996 2,000 66.7% 97.2%

Grover 1995 2,623 0% 98.5%

Jacobs 1988 1,010 100.0% 97.3%

Roman 1997 200 51.2% 83.6%

Balbi 2001 72 90% 74%

Overall 0.72 0.92

limited ability to discriminate benign from malignant masses


Radiologic Imaging

• Ultrasonography

• Color Doppler Ultrasonography

• Computed tomography

• Magnetic resonance imaging

• Positron emission tomography

Modalities for the Evaluation of Adnexal Masses

Modalities Sensitivity Specificity

Gray-scale transvaginal ultrasonography

0.82-0.91 0.68-0.81

Doppler ultasonography 0.86 0.91

Computed tomography 0.90 0.75

Magnetic resonance imaging 0.91 0.88

Positron emission tomography 0.67 0.79

CA 125 level measurement 0.78 0.78



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

Ultrasonographic signs of malignancy– Adnexal pelvic mass with area of complexity

• Irregular border• solid patterns within the mass• Dense multiple septae

Transvaginal Ultrasonography

TV-USG Scoring System(Morphologic Index)

Parameter 0 1 2 3 4

Volume < 10 cm3 10-50 cm3 50-200 cm3 200-500 cm3 > 500 cm3

Cyst wall structure(thickness)

Smooth< 3 mm

Smooth≥ 3 mm

Papillary projection< 3 mm

Papillary projection≥ 3 mm

Predominantly solid

Septa structure(thickness)

No septa Thin septa< 3 mm

Thick septa3-10 mm

Solid septa≥ 10 mm

Predominantly solid

DePriest PD, et al. Gynecol Oncol, 1993

• < 5 : benign•≥ 5 : malignant

TV-USG Scoring System(Morphologic Index)

Scoring system

Pooled sensitivity

Pooled specificity

Range of sensitivity in

individual studies

Range of specificity in

individual studies

Sassone 1991

0.86 0.77 0.65-1.00 0.65-0.93

DePreiest 1993

0.91 0.68 0.88-1.00 0.40-0.81

Ferrazzi 1997

0.87 0.81 0.84-0.87 0.67-0.88

Other 0.86 0.83 0.43-1.00 0.29-1.00

Prospective validation studies have provided consistently lower figures


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

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

3D TV-USG & Power Doppler

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


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 sus

pected

– MRI• helpful in differentiating the origin of nonadnexal pelvic masse

s (esp,leiomyoma)• Most useful in the diagnosis of uterine anomaly

– PET• not use in the preoperative assessment of adnexal masses


Clinical Laboratory Test

• Pregnancy test

• CBC, ESRSerum 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

Diagnostic test Pooled sensitivity Pooled specificity

USG: Morphology

Scoring system: Sassone 0.86 0.77

Scoring system: DePriest 0.91 0.68

Scoring system: Ferrazzi 0.87 0.81

Scoring system: Other 0.86 0.83

USG: Doppler

Resistive index 0.72 0.90

Pusatility index 0.80 0.73

Maximum systolic velocity 0.74 0.81

Presendce of vessels 0.88 0.78

Morphology plus Doppler 0.86 0.91

Computed tomography 0.90 0.87

Magnetic resonance imaging 0.91 0.75

Positron emission tomography 0.67 0.79

CA-125 (threshold > 35) 0.78 0.78Agency for Healthcare Research and Quality. AHRQ Publication No. 06-E004. 2006

Differential Diagnosis

Functional ovarian cystBenign neoplasmInflammatory massOthersGynecologic emergency

Differential DiagnosisGynecologic

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

NongynecologicBenign

• Diverticular abscess

• Appendiceal abscess or mucocele

• Nerve sheath tumors

• Ureteral diverticulum

• Pelvic kidney

• Paratubal cysts

• Bladder diverticulum

Malignant• Gastrointestinal cancers

• Retroperitoneal sarcomas

• Metastases


Functional ovarian cyst

Commonly, large majority of adnexal masses in adolescents– Follicular cyst– Corpus luteum cyst

Follicular cyst

Etiology– Excessive response to FSH

USG– Simple (sonolucent) cyst

• Symptoms– Asymptomatic– dull pain, pelvic heaviness– Urinary frequency, constipation

Follicular cyst Management

1. Observation (Self-limited)• 66.6%, regress over several weeks to months• Repeat USG after 8-10 weeks

– Shortly after menstrual cycle begin

2. Hormone therapy• 71.6% resolution within 6 weeks

– 28.4% remaining cyst → no physiologic cyst• Oral contraceptives with 35 ㎍ formulation

3. Surgery• ≥ 8 cm• Enlarging over time• Solid• Severely symptomatic• Persist ≥ 3-4 months

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

Benign neoplasm

Not regress– Should be treated surgically !

• Mature cystic teratoma

• Epithelial tumor

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 s

hadowing, often thought to be hair fibers within the cyst– calcification within an ovarian mass

• pathognomonic

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%

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

Inflammatory mass

• Tuboovarian abscess

• Hydrosalpinx

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

• “Cogwheel” sign

“Beads-on-a string” sign

Tuboovarian abscess

• Management– Broad spectrum IV antibiotics– Drainage

• CT guided or surgically

– Excision• Rarely, late-resort option

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.

Others

• Endometrioma

• Parovarian cyst

• Peritoneal inclusion cyst

• Mullerian anomaly

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 wit

h complete removal of the cyst wall• not regress with hormonal therapy

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

Peritoneal inclusion cyst• Pseudocysts

– not actually cysts– the result of trapped peritoneal or ovarian fluid in enclosed adhesions involvin

g 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 contraceptives if the patient is sympto

matic

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 noncommunicatin

g rudimentary uterine horn

MRI – helpful in further delineating the pelvic anatomy to det

ermine the best surgical plan

Gynecologic emergency

• Ovarian cyst rupture

• Adnexal torsion

Ovarian cyst rupture

• Peritoneal signs– severe, sudden-onset pelvic pain, nausea and vomitin

g

• Symptomatically anemic – significant associated bleeding from the site of the cys

t rupture in the ovary

• USG– cyst fluid and associated blood or blood clot in the cul

de sac• If ruptured recently

Ovarian cyst rupture Management

– Indications for inpatient observation• management of severe pain• treatment of nausea or vomiting• concern regarding hemorrhage

– should be kept NPO until improves• it is determined that surgical intervention is not needed

If an adolescent with ≥ 5 cm ovarian cyst• should be advised of the risks of cyst rupture or torsion

– seek care immediately if symptomatic

• should be counseled about increased risk of rupture with certain physical activities

running, jumping, contact sports, and sexual intercourse.

Adnexal torsion

Classical signs – Sudden, continuous of lower abdominal pain with perit

onial irritation– the presence of an adnexal mass– Nausea, vomiting; 70%

Delay and misdiagnosis are rather common– may result in loss of the ovary, fallopian tube, or both– When suspected, urgent surgical intervention

• Etiology – Unknown

• Large and heavy ovarian cysts – such as benign cystic teratoma or PCO

Cysts < 5 cm rarely cause

Adnexal torsion Pathophysiology

– impaired Venous flow → arterial blood flow • congestion, adnexal edema, discolorization, ischemia, necrosis

– The adnexal damage may be irreversible

USG– an enlarged, edematous ovary with decreased or absent Dopple

r blood flow

CT & MRI– fallopian tube thickening– smooth wall thickening of the twisted adnexal cystic mass– Ascites– Uterine deviation towards the twisted side

Management of adnexal torsion

Emergency laparoscopy! – should still be performed in all cases of

suspected torsion • delay in diagnosis may result in ovarian damage

Management of adnexal torsion Detorsion!

– Only procedure which should be performed • Estimation of the degree of necrosis during surgery → inaccurate• Color, size, and edema → not reflect the true damage to ovarian tissue• Ischemic-hemorrhagic, black bluish appearance

– result of venous and lymphatic stasis rather than gangrene

– Any additional procedure should be avoided • Ovarian cystectomy of the black-bluish ischemic should be avoided

– handling of the edematous friable and ischemic adnexa is risky – additional damage to the ovary– a high percentage of functional cysts

Cass DL. Semin Pediatr Surg 2005;14:86-92.

Mazouni C, et al. Gynecol Obstet Fertil 2005;33:102-6.

Oelsner G, et al. Clin Obstet Gynecol 2006;49: 459-63.

Histology of cysts excised at detorsion

Type of cyst No (%)

Corpus luteum 12 (38.7)

Follicular 6 (19.4)

Dermoid 9 (29.0)

Mucinous cystadenoma 3 ( 9.7)

Serous cystadenoma 1 ( 3.2)

Total 31 ( 100)

Oelsner G, et al. Human Reprod 2003;18:2599-2602.

20 대 미만 Type of cyst No (%)

Simple, funtional 20 (35.7)

Dermoid 18 (32.1)


Mucinous cystadenoma 3 ( 5.4)

Endometrioma 1 ( 1.8)

Parovarian 8 (14.3)

Hematosalpinx 1 ( 1.8)

Total 56 ( 100)

Adnexal torsion 의 조직학적 형태 ( 부산백병원 2003-2007 년 , all age, 56

명 )

40 세 이전 : 31 명중 27 명이 Oophrectomy (87.1%)

20 대 미만

Type of cyst No (%)

Dermoid 6 (50.0)

Follicular 2 (16.7)

Parovarian 2 (16.7)


Hematosalpinx 1 ( 8.3)

Total 12 ( 100)

20 세 미만 여성에서 adnexal torsion 의 조직학적 형태

( 부산백병원 1997-2007 년 , 12 명 )

Oophrectomy: 8명

Detorsion of Twisted Adnexaand Subsequent Ovarian Function

Author No. of patients Subsequent Functioning

ovary

Mage et al. 27 94%

Levy et al. 3 100%

Shalev et al. 58 94%

Pansky et al. 8 88%

Oelsner et al. 102 91%

Total 198 93%

Oelsner G, et al. Clin Obstet Gynecol 2006;49: 459-63.

Management of adnexal torsion

• Suspicous adnexal torsionEmergency laparoscopic detorsion, only!

• Adnexectomy avoided– Ovarian function is preserved in 88-100% of cases

• Edema associated torsion– Interval cystectomy

• Recurrence– Rare– Repeat torsion → ovarian fixation

Management

Mass : Sx or P/Ex

USG (TVS or TRS)

Ovarian Non-Ovarian

Multiloculated

Appropriate F/U

Premenarchal

Karyotype

Postmenarchal

• Unilocular < 10 cm• Thin-walled cyst

• Observe x 2-3 mos• OC - optional

• Increased size• Persistent

Tumor markersAFP, hCG, LDH, CA125

Observe x 2-3 mos

Decreased size

Clinical F/U Surgery

• Solid suspicious• > 8 -10 cm

Premenarchal

Tumor markersAFP, hCG, LDH, CA125

Management of adnexal masses in adolescents

Depends on – initial symptom– suspected diagnosis

Management of adnexal masses in adolescents

Symptoms & TV-USG1. Asymptomatic unilocular cystic masses <10cm

best managed conservatively – likelihood of malignancy is 0-1% (virtually noexistent)

» 2,763 명 , Modesitt SC, et al. Obstet Gynecol 2003.

2. Symptoms or suspected malignancy (complex, large) Surgical management

– to minimizing the risks of subsequent infertility resulting from pelvic adhesions

– every effort should be made to conserve ovarian tissue

• In malignant unilateral ovarian mass– unilateral oophorectomy rather than more radical surgery

Surgery

• Laparotomy– high suspicion for malignancy– large cysts

– morbid obesity – history of or risk factors for abdominopelvic adhesions– hypovolemia – hemodynamically unstable patient – significant cardiopulmonary disease

Laparoscopy – minimizing the risks of subsequent infertility resulting f

rom pelvic adhesions– every effort should be made to conserve ovarian tissu

e

Thank you for your attention !

diagnosis and management of adnexal mass in adolescent 인제대학교 의과대학 부산백병원...

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