Managing ovarian masses during pregnancy

The management of adnexal masses during pregnancy can be challenging for the patient and the clinician. The specter of a possible malignancy can sway the decision for intervention versus expectant management. The etiologies of ovarian masses are reflective of the patient's age; and, therefore, benign entities such as functional ovarian cysts, benign cystic teratomas, and serous cystadenomas predominate. In the unusual cases when cancer is present, they are typically germ cell and borderline ovarian tumors, and are commonly low stage and low grade. Ultrasound is the primary modality used to detect ovarian masses and to assess the risk of malignancy. Morphologic criteria more accurately identify benign cysts compared with malignant tumors. Tumor markers are used primarily to monitor disease status after treatment rather than establish the ovarian tumor diagnosis as a result of lack of specificity, because several markers can be elevated inherent to the pregnancy itself (eg, CA-125, beta-hCG). Expectant management is recommended for most pregnant patients with asymptomatic, nonsuspicious cystic ovarian masses. Surgical intervention during pregnancy is indicated for large and/or symptomatic tumors and those that appear highly suspicious for malignancy on imaging tests. The extent of surgery depends on the intraoperative diagnosis of a benign versus a malignant tumor. Conservative surgery is appropriate for benign masses and borderline ovarian tumors. More aggressive surgery is indicated for ovarian malignancies, including surgical staging. Although rarely necessary, chemotherapy has been used during pregnancy with minimal fetal toxicity in patients with advanced-stage ovarian cancer in which the risk of maternal mortality outweighs the fetal consequences.     

Adnexal masses and pregnancy: a 12-year experience

OBJECTIVE: Our purpose was to describe pregnancy-associated adnexal masses in eastern North Carolina. STUDY DESIGN: A retrospective study was performed of 60 adnexal masses resected during pregnancy at a regional referral hospital from January 1990 to March 2002. RESULTS: Adnexal masses occurred in 0.15% of pregnancies. Average gestational age at diagnosis and surgery was 12 and 20 weeks, respectively. Fifty percent of ovarian tumors were mature cystic teratomas, 20% were cystadenomas, and 13% were functional ovarian cysts. Malignancy occurred in 13%. Tumors with low malignant potential comprised 63% of malignancies. Average cyst size was 11.5 cm for malignancies and 7.6 cm for benign lesions (P value <.05). The preterm birth rate was 9%, the miscarriage rate was 4.7% after elective cases, and average Apgar scores were 7.5 and 8.7 at 1 and 5 minutes. CONCLUSION: The incidence of malignancy in pregnancy-associated adnexal masses was high. Ultrasonography detected internal excrescences in the majority of tumors with low malignant potential. Fetal outcomes were not affected.     

Serum soluble Fas levels in ovarian cancer

OBJECTIVE: To determine the value of serum soluble Fas levels as a prognostic marker for survival of women with ovarian cancer and as a discriminator between benign and malignant adnexal masses. METHODS: Serum soluble Fas levels were measured with an enzyme-linked immunosorbent assay in 52 women with ovarian cancer, 30 women with benign ovarian cysts, and 35 healthy women. RESULTS: Median serum soluble Fas levels in women with ovarian cancer, women with benign ovarian cysts, and healthy women were 3.7 (range 1.6-14.5), 2.3 (range 1.3-4.1), and 1.5 ng/mL (range 0.1-5.6), respectively (P <. 001). A univariate logistic regression model showed a significant influence of serum soluble Fas and CA 125 levels on the odds of presenting with ovarian cancer versus benign cysts (P <.001 and P =. 001, respectively). In a multivariable logistic regression model for soluble Fas and CA 125, both markers showed a statistically significant influence on the odds of presenting with ovarian cancer versus benign cysts (P =.01 and P =.01, respectively). Increased pretreatment serum soluble Fas levels were associated with shortened disease-free and overall survival (P =.002 and P =.001, respectively). A multivariable Cox regression model identified serum soluble Fas levels as a significant prognostic factor for disease-free and overall survival, independent of tumor stage (P =. 04 and P =.03, respectively). CONCLUSION: Soluble Fas levels might be useful as a discriminator between benign ovarian cysts and ovarian cancer, adding to the information obtained with the use of the established tumor marker CA 125. Pretreatment serum soluble Fas levels also might be an independent prognostic factor for disease-free and overall survival.     

Teratomas of the ovary: a clinico-pathological evaluation of 87 patients from one institution during a 10-year period

AIM: To present the classification and diagnostic problems encountered between teratomas and other ovarian tumors as well as with other benign entities diagnosed and treated in our institution. METHODS: We analysed retrospectively the clinical and pathological characteristics of 87 teratomas examined in our hospital during the last ten years. RESULTS: Teratomas constituted 5% of all ovarian tumors. The age range was from 11-69 years old (median: 35). The most frequent symptom was lower abdominal pain in 68% of patients. A pelvic mass was noted in 3% of cases. A pregnancy was present in 3% of patients. In ten cases the tumors were bilateral. Tumor size ranged from 1-16 cm in diameter (median: 7.17 cm). The treatment consisted of cystectomy in 66% of the cases, oophorectomy in 23% or hysterectomy with both adnexa in 11% of cases. Fifty-seven cases presented with a histological diagnosis of mature teratoma, biphasic or triphasic type, three cases with monodermal teratoma, ten cases with ovarian neoplasms of mixed type, 15 cases with epidermal cysts, and two cases with benign cysts. Malignant changes within the teratomas were seen in 5% cases. CONCLUSION: Teratomas are common ovarian tumors at any age, especially during the reproductive age, with a low rate of complications and malignant transformation. The treatment should be based on patient age, fertility status, tumor size, the cystic or solid nature of the tumor and bilaterality.     

A clinico-pathologic study of ovarian neoplasm

A series of 96 patients who were diagnosed with 120 ovarian neoplasms at surgery have been reviewed. Nine types of benign ovarian cysts were encountered. Benign cystic teratoma with an incidence of 30% was the commonest tumor. The majority of these were in the 20-30 year age range. The mean age of the patients with mucinous cyst adenoma and benign cystic teratoma was significantly less (P less than 0.05) than those with serous cyst adenoma. The incidence of ovarian malignancies of 8.3% was low, and none of the malignancies was bilateral. There was a high incidence of 8.3% of malignant change in benign cystic teratomas. Abdominal pain and swelling were the symptoms most frequently experienced in patients with benign ovarian neoplasms.     

Ovarian masses in young adolescents: imaging findings with surgical confirmation

Functional cysts and benign neoplasms are the most common ovarian masses among young adolescents. Ovarian cancer on the other hand, although rare in this age group, is the most common genital tract malignancy. The purpose of this study was to define imaging characteristics of ovarian masses in adolescents between 12 and 21 years old and correlate imaging and surgical findings. Thirty-seven female adolescent patients aged between 12 and 21 years were operated on because of a diagnosed ovarian mass between 1997 and 2002. All patients underwent pelvic ultrasound, five had an abdominal CT scan, two had abdominal MRI, one abdominal X-ray and one intravenous pyelography. Ultrasound was used to define the size of the lesion and to characterize its gross morphologic condition as solid, simple cyst or complex cyst. The records were reviewed for age at presentation, presenting symptoms, diagnostic studies, surgical procedure and pathology findings, which were available for all patients. In our study 32 patients (86.5%) were symptomatic and five asymptomatic (13.5%). The most common presenting symptom was abdominal pain (59.5%). Thirty-four patients (91.1%) had benign lesions, two had malignant tumors (5.4%) and one patient had a borderline lesion (2.7%). The most common ovarian masses detected were germ cell tumors (27.5%) and functional cysts (25%). Twenty patients (54%) underwent operative laparoscopy and 17 patients (46%) exploratory laparotomy. Simple resection of the ovarian mass was achieved in the majority of cases (84%). Bilateral salpingo-oophorectomy was performed in only one case (2.7%).     

Adnexal masses in pregnancy: occurrence by ethnic group

Two hundred twenty-eight adnexal masses during pregnancy were discovered among 37,159 deliveries occurring between January 1, 1983 and October 31, 1988 at Kapiolani Medical Center for Women and Children in Honolulu. Hydatid cysts of morgagni (45.6%) occurred most frequently, followed by benign cystic teratomas (15.8%), epithelial cystadenomas (15.4%), and paraovarian cysts (13.6%). There were no malignant or borderline tumors. The patients were categorized as 22.1% part Hawaiian, 18.5% white, 17% Filipino, and 16% Japanese. We demonstrated an increased incidence of benign cystic teratomas in Filipinas (P less than .01). There was no significant predisposition for the occurrence of non-neoplastic or other neoplastic lesions among any of the other ethnic groups studied.     

Ovarian masses in pediatric patients: a multicenter study of 98 surgical cases in Tunisia

Ovarian masses requiring surgical intervention are uncommon in the pediatric population. Our aim is to report results of a multicentric Tunisian study concerning the clinical practice and the management of pediatric ovarian masses and to identify the factors that are associated with ovarian preservation. Between January 2000 and December 2015, 98 pediatric patients (<14 years) were surgically treated for ovarian masses at the five pediatric surgery departments in Tunisia. Ninety-eight patients were included in this study. The mean age of the patients at time of surgery was 8.46?±?4.87?years. Sixty-three ovarian masses (64.3%) were non-neoplastic lesions, 24 (24.5%) were benign tumors, and 11 (11.2%) were malignant neoplasms. Conservative surgery (ovarian-preserving surgery) was successfully performed in 72.4% of the benign lesions, whereas only three patients (27.3%) with malignant tumors underwent ovary-sparing tumor resection (p?p?=?.001). In our study, the risk factors for oophorectomy were a malignant pathology and large tumor size. In accordance with the Gynecologic Cancer Intergroup consensus, we recommend that surgical management of ovarian masses in children should be based on ovarian-preserving surgery.     

子宫切除术后不同病理类型盆腔包块56例临床特点及诊疗分析#br#

目的分析子宫切除术后不同病理类型盆腔包块的临床特点及诊疗方案。方法回顾分析2017年1月至2021年6月因良性疾病行子宫切除后发现盆腔包块,于首都医科大学附属北京妇产医院就诊行手术的56例患者临床资料。结果子宫切除术后盆腔包块最常见病例类型为盆腔炎症性疾病39.3%(22/56),其次为卵巢良性肿瘤19.6%(11/56)、卵巢子宫内膜异位囊肿16.1%(9/56),卵巢输卵管瘤样病变12.5%(7/56),卵巢输卵管恶性肿瘤8.9%(5/56)。盆腔炎症性疾病及卵巢子宫内膜异位囊肿患者发病时间距离子宫切除后年限及发病年龄低于其他组(P<0.05)。盆腔炎性疾病组盆腹腔手术次数多于其他组(P<0.05)。随着子宫切除术后间隔延长,卵巢良恶性肿瘤比例增加。结论子宫切除术后盆腔包块病理类型多样,以良性为主,术后5年以上出现的盆腔包块,多为卵巢肿瘤,建议尽早手术。     

Risk Factors and a Risk Scoring System for the Prediction of Malignancy in Ovarian Cysts

A retrospective study was carried out on 396 patients who presented with ovarian masses. Sixty five (16%) patients were found to have ovarian malignancy while the rest either had benign ovarian tumours (n = 159), endometriotic cysts (n = 130), physiological cysts (n = 20) or inflammatory masses (n = 7). The relative risk for ovarian malignancy among these patients increased significantly (p < 0.001) after the age of 40 years. The presence of ascites, abdominal distension, urinary complaints and loss of appetite and weight were significant individual risk factors for malignancy. Ultrasound image of a complex cyst is also associated with increased risk of malignancy in an ovarian mass. None of the individual risk factors was discriminatory between a benign and malignant cyst. However, these factors can be combined to form a 20-point risk scoring system. The risk of malignancy in an ovarian cyst increased with increasing scores. In this study, the median scores were 3 for benign cyst, 7 for borderline malignancy and 12 for malignant cysts. Using a total score of 7 as a cut off point, one can detect 75% of malignant cysts with a specificity of 84.1%, a positive predictive value of 47.5% and a negative predictive value of 94.6%. It is concluded that the majority of malignant ovarian cysts can be identified preoperatively to allow arrangement and planning of an optimal surgery.     

637例直径≤5cm卵巢肿块的病理组织学类型分析及处理

目的:调查分析直径≤5cm卵巢肿块的病理组织学类型。方法:回顾分析经手术剔除且经常规病理组织学检查确诊的直径≤5cm卵巢肿块的临床资料。结果:卵巢肿瘤323例(50.71%),其中,良性肿瘤297例(46.62%),恶性肿瘤23例(3.61%),交界性肿瘤3例(0.47%)。瘤样病变314例(49.29%)。结论:直径≤5cm卵巢肿块中卵巢肿瘤和卵巢瘤样病变占绝大多数,卵巢瘤样病变中黄体囊肿、黄素囊肿、滤泡囊肿、卵巢冠囊肿、卵泡囊肿和包涵囊肿等占44.27%,可不必处理,但临床上应予以重视。     

Transvaginal sonographic characterization of ovarian disease: evaluation of a new scoring system to predict ovarian malignancy

With the advent of high-frequency transvaginal ultrasonography, new opportunities are presented to better define ovarian lesions. The goal of this study was to develop a scoring system using transvaginal sonographic characterization of pelvic/ovarian lesions. Our purpose was to maximize the discrimination between benign and malignant entities. Transvaginal sonographic pelvic images of 143 patients were correlated with surgical findings or histopathology. Of 281 ovaries, 108 had benign lesions (30 endometriomas, 24 teratomas, 21 simple cysts, and 33 other abnormalities) and 20 had malignancies. The scoring system devised was useful in distinguishing benign from malignant masses, with a specificity of 83%, sensitivity of 100%, and positive and negative predictive values of 37 and 100%, respectively. Further experience and refinements of this method of scoring should maximize the benefit of high-resolution transvaginal sonography of ovarian lesions.     

Ovarian masses during adolescence: clinical, ultrasonographic and pathologic findings, serum tumor markers and endocrinological profile.

This retrospective study was undertaken to assess the epidemiological and clinical features, laboratory findings, preoperative work-up, surgical treatment and pathologic findings in adolescents with ovarian cysts. All adolescents who were referred to our institution and had been operated on because of a diagnosed ovarian mass, from January 1997 to June 2003, were included in this study. Forty-four cases of women with an ovarian mass were retrospectively analyzed. These patients, aged between 12 and 21 years, had 47 ovarian masses (three patients had bilateral lesions), of which 49% were non-neoplastic and 51% were neoplastic. Of the neoplastic lesions, 62.5% were germ cell tumors, 20.8% were epithelial and 16.7% were sex cord-stromal tumors. Of the neoplastic tumors, 95.8% were benign while 4.2% were malignant. Procedures included 30 operative laparoscopies (68.20%) and 14 exploratory laparotomies (31.8%). Simple excision of the ovarian cyst was performed in 39 cases (88.6%). According to our study, most of the adolescents with an ovarian cyst underwent an operation because of a neoplastic lesion. The majority of ovarian tumors occurring in adolescents are non-epithelial in origin, and germ cell tumors are the most common histological type. Ultrasound examination is one of the most important diagnostic tools. Preoperative diagnostic approach of these patients should always include careful history taking, physical examination, imaging and evaluation of serum assays. Gynecologists who care for young girls must be familiar with the differential diagnosis of ovarian masses whose surgical treatment should be conservative when appropriate, so that hormonal status and future fertility are not compromised in this group of patients.     

Homemade Glove Retrieval Bag in Laparoscopic Complete Excision of Benign Ovarian Teratoma with Ovarian Tissue Preservation in Children: A Case Series

Study ObjectiveTo present our experience of laparoscopic resection of pediatric benign ovarian teratomas with gonadal preservation, using a homemade glove retrieval bag.Design, Setting, Participants, Interventions, and Main Outcome MeasuresReview of all girls with benign ovarian teratomas who were managed with laparoscopic ovarian-sparing surgery (OSS) at our hospital between January 2013 and December 2018.ResultsEleven patients were included for analysis with a mean age of 6.1 years. Ten patients received elective surgery, whereas 1 patient received emergency surgery because of ovarian torsion. Main indication for OSS was the existence of a dissection plane between tumor margins and healthy ovarian tissue. Postoperative outcome and follow-up were uneventful with a median follow-up of 30.1 months (range; 12-60 months).ConclusionLaparoscopic OSS can be safely performed for these tumors. Laparoscopic magnification with energy devices are excellent tools in such procedures. The homemade glove bag can be used to retrieve the tumor effectively in countries with limited resources.     

Diagnostic efficacy of tumor markers, sonography, and intraoperative frozen section for ovarian tumors

Using sonography, we classified the adnexal masses of 292 patients into 4 patterns. Pattern A was benign cystic tumors; B was benign mixed tumors (cysts with a smooth solid component); C was malignant mixed tumors (cysts with an irregular solid component or thickened septum), and D was solid tumors. We diagnosed tumors showing patterns A and B as benign, while patterns C and D represented tumors with low malignant potential or actual malignancy. The sensitivity and specificity of sonography was 82.2 and 82.1%, respectively, and these values were superior to those for tumor markers (CA125, CA19-9, CA72-4). Both the sensitivity and specificity of intraoperative frozen sections were the highest, showing that this is the most reliable examination. However, 15 of 191 patients undergoing frozen section were upgraded by the final pathological diagnosis. If sonography is performed by an experienced gynecologic oncologist, this examination is more reliable than tumor markers. However, intraoperative frozen section should still be performed during surgery for patients with ovarian tumors.     

Accuracy of CA 125 in the diagnosis of ovarian tumors: a quantitative systematic review

A quantitative systematic review was performed to estimate the accuracy of CA 125 assay in the diagnosis of ovarian tumors. Studies that evaluated CA 125 levels for the diagnosis of ovarian tumors and compared them with paraffin-embedded sections as the diagnostic standard were included. Seventeen studies were analyzed, which included 2374 women. The pooled sensitivity for the diagnosis of borderline tumors or ovarian cancer was 0.80 (I.C. 95% 0.76-0.82) and the specificity was 0.75 (I.C. 95% 0.73-0.77). The diagnostic odds ratio for ovarian cancer and borderline lesions vs. benign lesions was 21.2 (95% C.I., 12-37). Summary receiver operating characteristic curves were constructed due to heterogeneity in the diagnostic odds ratio. For malignant and borderline ovarian tumors vs. benign lesions the area under the curve was 0.8877. A CA 125 level of >or= 35 U/ml is a useful preoperative test for predicting the benign or malignant nature of pelvic masses. The accuracy of CA 125 in the diagnosis of ovarian tumors is high and very important in helping the surgeon to decide what kind of surgery should be performed.     

Differentiating malignant from benign ovarian tumors with transvaginal color flow imaging.

The impedance to blood flow was examined by transvaginal color flow imaging in 53 ovarian masses before exploratory laparotomy. Serum CA 125 levels were measured in all subjects. Thirty-six had benign ovarian tumors and 17 had malignant ovarian tumors confirmed by histopathologic examination. Intratumoral blood vessels, detected in 16 of the malignant tumors, consistently demonstrated low impedance to flow, with a pulsatility index (PI) always below 1. The PI of the intraovarian or intratumoral blood vessels was greater than 1 in 35 of the 36 benign tumors, although 11 had suspicious sonographic findings (P less than .01) and 14 had elevated CA 125 levels (P less than .001). The sensitivity and specificity of the preoperative PI in detecting malignant ovarian tumors were 94 and 97%, respectively. The sensitivity and specificity of preoperative suspicious sonographic findings in detecting malignant ovarian tumors were 94 and 69%, and those of elevated preoperative serum CA 125 levels were 82 and 61%, respectively. Our results suggest that transvaginal color flow imaging may be a useful clinical tool in the preoperative evaluation of ovarian masses.     

Multi-Institutional Review of the Preoperative Diagnostic Accuracy for Pediatric Ovarian Mature Cystic Teratomas

Study ObjectiveTo assess the preoperative imaging impression and surgeon diagnostic accuracy for pediatric ovarian mature cystic teratomas (MCTs)DesignRetrospective reviewSettingEleven pediatric hospitalsParticipantsPatients ages 2 to 21 who underwent surgical management of an ovarian neoplasm or adnexal torsion with an associated ovarian lesionInterventionNoneMain Outcome MeasuresPreoperative imaging impression, surgeon diagnosis, tumor markers, and pathologyResultsOur cohort included 946 females. Final pathology identified 422 (45%) MCTs, 405 (43%) other benign pathologies, and 119 (12%) malignancies. Preoperative imaging impression for MCTs had a 70% sensitivity, 92% specificity, 88% positive predictive value (PPV), and 79% negative predictive value (NPV). For the preoperative surgeon diagnosis, sensitivity was 59%, specificity 96%, PPV 92%, and NPV 74%. Some measures of diagnostic accuracy were affected by the presence of torsion, size of the lesion on imaging, imaging modality, and surgeon specialty. Of the 352 masses preoperatively thought to be MCTs, 14 were malignancies (4%). Eleven patients with inaccurately diagnosed malignancies had tumor markers evaluated and 82% had at least 1 elevated tumor marker, compared with 49% of those with MCTs.ConclusionsDiagnostic accuracy for the preoperative imaging impression and surgeon diagnosis is lower than expected for pediatric ovarian MCTs. For all ovarian neoplasms, preoperative risk assessment including a panel of tumor markers and a multidisciplinary review is recommended. This process could minimize the risk of misdiagnosis and improve operative planning to maximize the use of ovarian-sparing surgery for benign lesions and allow for appropriate resection and staging for lesions suspected to be malignant.     

Intracystic evaluation of tumor markers in benign and malignant ovarian pathology

OBJECTIVE: To evaluate, in patients with benign and malignant ovarian cysts, serum samples and ovarian intracystic fluids for the presence of tumor markers such as CA 125, CA 15.3, tissue polypeptide antigen (TPA), CA 19.9 and the carcinoembryonic antigen (CEA). MATERIAL AND METHOD: We studied overall 64 patients with ovarian pathology. Sixteen patients were affected by functional cysts, 28 women by benign cystic tumors and 20 by cystoadenocarcinomas. RESULTS: Average serum levels of all but CA 15.3, TPA and CEA tumor markers of benign cystic ovarian tumors were higher than those of functional cysts. All but CA 19.9 mean intracystic fluid markers levels were more elevated in benign tumors than in functional cysts. In patients with malignant cystic tumors, all but CEA mean serum marker levels were higher than those of benign tumors; furthermore even all mean intracystic levels of markers were more elevated than those of benign tumors. CONCLUSION: This study confirmed the high positivity of tumor markers such as CA 125, CA 15.3, TPA, CA 19.9 and CEA in both the serum and intracystic fluid of patients with malignant epithelial ovarian tumors.