chapter 13. benign diseases of the female reproductive tract(2) pelvic mass novac page 373-399

Chapter 13. Benign Diseases of the Female Reproductive Tract(2)

Pelvic Mass

Novac page 373-399

Prepubertal Age Group

Adolescent Age Group

Reproductive Age Group

Postmenopausal Age Group


Differential Diagnosis

Diagnosis and Management


Malignancy : < 5% in children and adolescents

☞ malignancy (< 9 years of age ) : 80% of the ovarian neoplasm

Ovarian tumor : 1% of all tumors in these age groups

Germ cell tumors : 1/2 ~ 2/3 of ovarian neoplasms

( <20 years of age)

Epithelial neoplasm : rare

Symptoms : abdominal or pelvic pain (initial symptoms)

pelvic mass very quickly enlarge

☞ D/Dx : Appendicitis, Wilms’ tumor or Neuroblastoma

Acute pain : associated with torsion


Ultrasonography

Imaging studies

: CT scanning, MRI or Doppler flow studies


Diagnosis

Unilocular cysts : always benign and will regress in 3~6months

☞ not require surgical management with oophorectomy or

oophorocystectomy

Recurrence rate after cyst aspiration : 50%

Premature surgical therapy for a functional ovarian mass can result in ovarian and tubal adhesions that can affect future fertility


Management


Management

Ovarian masses

Uterine masses

Inflammatory Masses

Pregnancy


Malignant neoplasm is lower among adolescents than among younger children

Epithelial neoplasms : ↑

Mature cystic teratoma : most common type > ½ of ovarian neoplasms in women younger than 20 yerars of ag

e cf) Germ cell tumor : 1st decade of life

Dysgenetic gonads : malignant tumor in 25% ☞ gonadectomy is recommended for patients with XY gonadal dysgenesis or its mosaic variations


Differential Diagnosis (1) Ovarian masses

Functional ovarian cyst : ↑

- incidental finding on examination or associated with pain

caused by torsion , leakage or rupture

Endometriosis

: less common during adolescence than in adulthood

chronic pain (+) : 50~60% endometriosis

Transverse view of Lt ovarian endometrioma shows a heterogenous appeareance with diffuse low level echoes interspersed with echogenic and anechoic areas


Differential Diagnosis (1) Ovarian masses

Uterine leiomyomas : not common

Obstructive uterovagianal 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


Differential Diagnosis (2) Uterine Masses

Highest rates of PID of any age group

Consist of tuboovarian complex, tuboovarian abscess,

pyosalpinx or chronically hydrosalpinx


Differential Diagnosis (3) Inflammatory Masses

Ectopic pregnancy

discovered before rupture

☞ allowing conservative management with laparoscopic

surgery or medical therapy with methotrexate


Differential Diagnosis (4) Pregnancy

History and pelvic examination

Laboratory studies

- pregnancy test

- CBC

- tumor markers – α-fetoprotein and hCG

Ultrasonography

CT or MRI


Diagnosis

Figure 13.11

Asymptomatic unilocular cystic masses : conservatively

If surgical management is required ☞ attention should be paid to minimizing the risks of subsequent infertility resulting from pelvic adhesion . ☞ conserve ovarian tissue

In the presence of a malignant unilateral ovarian mass ☞ unilateral oophorectomy rather than more radical surgery, even if the ovarian tumor has metastasized

In general, conservative surgery is appropriate ; further surgery can be performed if necessary, after an adequate histologic evaluation of the ovarian tumor


Management

Lparoscopy - management of suspected acute PID - to confirm the diagnosis - to perform irrigation, lysis of adhesions, - draninage and irrigation of unilateral or bilateral pyosalpinx or tuboovarian abscess - extirpation of significant disease

♣ associated with a risk of major complications ( bowel obstruction and bowel or vessel injury)-


Management

Malignancy : 10% of those younger than 30years of age

Most common tumor

: mature cystic teratoma or dermoid (1/3 of women <30years of age)

endometrioma (1/4of women 31-49years of age)

Uterine masses

Ovarian masses

Others



m/c benign Uterine tumor

Reproductive Age Group Differential Diagnosis

Uterine leiomyoma

Epidemiology

- 20% of all women of reproductive age

- asymptomatic fibroids of women >35years : 40%~50%

Symptoms

: abnormal bleeding ~ pelvic pressure (<1/2)

discovered incidentally during routine annual

examination

Differential Diagnosis Uterine leiomyoma

Etiology

- unkown

< several studies >

- a single neoplastic cell within the smooth muscle of the

myometrium

- increased familial incidence

- hormonal responsiveness and binding has been demonstrated

in vitro

♠ Fibroid have the potential to enlarge during pregnancy as

well as to regress after menopause


Uterine leiomyoma

Characteristics : hard and stony ~ soft (usually described as firm or rubbery)

Degenerative changes : 2/3 of all specimensLeiomyomas, with an increased number of mitotic figures , may occur in various forms

- during pregnancy or in women taking progestational agents

- with necrosis - a smooth muscle tumor of uncertain malignant potential (defined as having 5~9mitoses /10HPF that do not demonstrate nuclear atypia or giant cells, or with a lower mitotic count (2~4 mitoses/10HPF) that does demonstrate atypical nuclear features or giant cells)


Uterine leiomyoma

Characteristics

malignant degeneration : uncommon <0.5%

♠ Sarcomas that have a malignant behavior have ≥10mitoses/HPF


SymptomMenorrhagia

: initial symptom, one that most frequently leads to surgical intervention

Chronic pelvic pain : dysmenorrhea, dyspareuria or pelvic pressure

Acute pain : d/t torsion of pedunculated leiomyoma or infarction and degeneration



Symptom

Urinary symptoms - frequency - Partial ureteral obstruction - complete urethral obstruction (rare)

Infertility


Pregnancy loss or complications (10% rate of pregnancy complications by one study)

- Although growth of leiomyomas may occur with pregnancy, no demonstrable change in size (base on serial ultrasonographic examination) has been noted in 70~80% of patients - Risk of pregnancy complication : influenced by both myoma location and size



Symptoms (infrequently)Rectosignoid compression with constipation or intestinal obstructionProlapse of a pedunculated submucous tumor through the cervix

→ severe cramping and subsequent ulceration and infection (uterine inversion has also been reported)

Venous stasis of lower extremities and possible thrombophlebitis 2nd to pelvic compression PolycythemiaAscites



Most ovarian tumors(80~85%) : benign

20~44years : 2/3 of ovarian tumors(benign)

Chance that a primary ovarian tumor is malignant in a patient <45years : < 1/15

Symptom

- Nonspecific

- Abdominal distension, abdominal pain or discomfort , lower

abdominal pressure sensation , urinary or gastrointestinal

symptoms

- Vaginal bleeding (related to estrogen production)

- Acute pain

: adnexal torsion , cyst rupture or bleeding into a cyst


Differential Diagnosis Ovarian masses

Pelvic finding

Benign tumor Malingnant tumor

Unilateral Bilateral

Cyst solid

Mobile

smooth

Fixed

Irregular

Ascites

Cul-de-sac nodules

Rapid growth rate



Nonneoplastic Ovarian Masses

Other Benign Masses

Neoplastic Masses

Other adnexal Masses



Functional ovarian cysts

: follicular cysts, corpus luteum cysts, theca lutein cysts

Benign , not cause symptoms or require surgical management

Follicular cysts

- most common fuctional cyst

- diameter >8cm(rare)

- defined as cystic follicle dimeter >3cm

- Rupture : resolve in 4~8wks


Differential Diagnosis Non neoplastic ovarian masses

Corpus luteum cysts

- Less common than follicular cysts

- Rupture

→ leading to hemoperitoneum & surgical management

- Most ruptures occur on cycle days 20 ~ 26


Thecal luteum cysts

- The least common

- Bilateral

- occur with pregnancy, including molar pregnancies, associated multiple gestations, molar pregnancies, choriocarcinoma, diabetes, Rh sensitization, Clomiphene citrate use, hMG-hCG ovulation induction , use of GnRH analogs

- Size

: quite large(~30cm), multicystic, regress spontaneoustly



Combination monophasic oral contraceptive therapy

- markedly reduce the risk of functional ovarian cysts

In comparision with previously available higher-dose pills, the effect of cyst suppression with current low-dose oral contraceptives is attenuated.

Smoker: twofold increased risk of developing ovarian cysts.



Endometrioma

: 6~8cm size

PCOS



Reproductive years >80% of benign cystic teratomas (dermoid cysts)

Dermoid cysts : represented 62% of all ovarian neoplasms < 40years women

– Malignant transformation <2% of dermoid cysts ( in all ages)• most cases occur in women >40 years of ages

Risk of torsion : 15%(more frequently than with ovarian tumors in general d/t high-fat content → float within the abdominal and pelvic cavity)Bilateral :10%Ovarian cystectomy is almost always possible, even if it appears that only a small amount of ovarian tissue remainsLaparoscopic cystectomy is often possible , and intraoperative spill of tumor contents is rarely a cause of complications


Differential Diagnosis neoplastic ovarian masses

The risk of epithelial tumors increases with ageSerous tumor Mucinous ovarian

characteristics Psammoma bodies

: fine calcific granulation –

>scattered within the tumor

and visible on radiograph

grow to large dimensionsdifficult to

distinguish histologically

from metastatic gastroi

ntestinal malignancies

sometimes with papillary components

lobulated smooth surface

multilocular,(serous cystadenoma)

multilocular,

bilateral 10%

malignant 20~25%

5~10% : borderline malignant potential

5~10%


Others

- fibromas(a focus of stromal cells)

- Brenner tumors

- cystadenofibroma (mixed forms of tumors)



Tuboovarian abscess

Ectopic pregnancies

Parovarian cysts

: noted either on examination or on imaging studies

- Normal ipsilateral ovary can be visualized using

ultrasonography

- frequency of malignancy: quite low (2% of patients)


Differential Diagnosis Other Adnexal Masses

Pelvic Examination including rectovaginal examination and pap test : estimations of the size of a mass should be presented in centimeters rat

her than in comparison to common objects or fruit (eg. Orange, grapefruit, tennis ball, golf ball)

Other studies - Endometrial sampling with an endometrial biopsy or D&C : when both a pelvic mass and abnormal bleeding are present. - Studies of Urinary tract : cystoscopy, ultrasonography, an intravenou

s pyelogram

Laboratory studies : pregnancy test, cervical cytology, CBC, ESR, testing of stool for occult blood, tumor markers –CA125 - CA125 ↑: uterine leiomyoma, PID, pregnancy, endometriosis → unnecessary surgical intervention


Diagnosis

Imaging Studies - pelvic ultrasonography, transvaginal and transabdominal ultrasonography - CT, abdominal flat plate radiograph – seldom indicated as a primary diagnostic procedure - MRI : diagnosis of uterine anomalies

Scoring system - predict benign versus malignant adnexal masses

Ultrasonographic indices - characterizations of morphology : septations, solid components, ovarian size - demographic factors (ig, age) - color flow imaging and doppler waveform analysis


Diagnosis

Diagnosis

Hysteroscopy - direct evidence of intrauterine pathology or submucous leiomyomas

Hysterosalpingography - demonstrate indirectly the contour of the endometrial cavity and any distortion or obstruction of the uterotubal junction 2nd to leiomyomas an extrinsic mass or peritubal adhesions

Diagnosis

Management should be based on the primary symptoms and may include observation with close follow-up, temporizing surgical therapies, medical management or definitive surgical procedures

Nonsurgical management

Surgical management


Management

Nonsurgical Management judicious patient observation and follow-up are indicated primarily for uterine leiomyomas : intervention is reserved for specific indications and symptoms

GnRH agonists - 40~60% decrease in uterine volume - can be value in some clinical situations - result in hypoestrogenism ☞ reversible bone loss and symptoms such as hot flashes - Limited to short-term use although low-dose hormonal replacement may be effective in minimizing the hypoestrogenic effects.


Management

Leiomyoma

Indication of GnRH agonists

- Preservation of fertility in women with large leiomyomas before attempting conception, or preoperative treatment before myomectomy

- Treatment of anemia to allow recovery of normal hemoglobin levels before surgical management, minimizing the need for transfusion or allowing autologous blood donation

- Treatment of women approaching menopause in an effort to avoid surgery

- Preoperative treatment of large leiomyomas, to make vaginal hysterectomy, hysteroscopic resection or ablation or laparoscopic destruction more feasible

- Treatment of women with medical contraindications to surgery

- Treatment of women with personal or medical indications for delaying surgery

Reproductive Age Group Management

Leiomyoma

Newer therapies combining GnRH agonists with estrogen add-back therapy

RU486 - progesterone antagonist ☞ decrease the size of uterine leiomayoma


Management

Leiomyoma

Surgical Therapy Asymptomatic leiomyomas : not usually require surgery

Indication - Abnormal uterine bleeding with resultant 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


Leiomyoma

Uterine sarcoma

- rapid enlargement of the uterus during the premenopausal years

- any increase in uterine size in a postmenopausal woman

→ indication for surgery

☻ Fibroid uterus → absolute risk of uterine sarcoma : < 2~3/1000


Leiomyoma

Hysterectomy : definitive management of symptomatic uterine leiomyoma

Myomectomy : for patient who desire childbearing , who are young, who prefer that the uterus be retained

* Morbidity of abdominal myomectomy and hysterctomy are similar (recent studies) - previous reports had suggested higher risks for myomectomy, including to risks of hemorrhage and transfusion requirements

Management

Leiomyoma

Laparoscopic myomectomy

Vaginal myomectomy indicated in the case of a prolapsed pedunculated submucous fibroid

Hysteroscopic resection : small submucosal leiomyoma * Recurrence (after myomectomy) : > 50% → ~1/3 : requiring repeat surgery

Endometrial ablasion : decrease bleeding for women with primary intramural fibroids

Preop GnRH agonists : decreased uterine size

Management

Leiomyoma

Nonextirpative approaches

- Myolysis

- uterine artery embolization


Management

Leiomyoma

functional tumors : expectant

* oral contraceptions

number of randomized prospective studies have shown no acceleration of the resolution of functional ovarian cysts

With oral contraceptives are effective in reducting the risk of subsequent ovarian cysts

Symptomatic cysts : evaluated promptly Mildly symptomatic masses (suspected functional) → management with analgesics rather than surgery to avoid the development of adhesions (→ impair subsequent fertility)


Management

Ovarian Masses


Indication of surgery

severe pain

supicion of malignancy

torsion

Management

Ovarian Masses

large cysts, multiloculations, septa, papillae and increased blood flow(on ultrasonography ) → suspected of neoplasia

Ovarian tumor torsion requires oophorectomy on the basis that the untwisting(detorsion) of the ovarian pedicle would lead to emboli

Recent studies have suggested that the primary management should be detorsion with ovarian cystectomy if a cyst is present

: Normal ovarian function frequently results even in ovaries that do not initially appear to be viable. - This management is particularly important in prepubertal and young women

Oophoropexy may be helpful in preventing recurrent torsion

Ultrasonographic or CT-directed aspiration procedures should not be used in women in whom there is a suspicion of malignancy

Laparoscopic management


Ovarian Masses

The choice of surgical approach (laparotomy or laparoscopy) based on - the surgical indications

- the patient’s condition

- the surgeon’s expertise and training

- informed patient preference

- the most recent data supporting the chosen

approach


Ovarian Masses

Ovarian masses During the postmenopausal years, the ovaries become smaller - Before menopuse, the dimension are approximately3.5X2X1.5cm - In early menopause, the ovaries are approximately 2X1.5X0.5cm - In late menopause they are even smaller : 1.5X0.75X0.5

PMPO (postmenopausal palpable ovary) syndrome - Ovary that is palpable on examination beyond the menopuse is abnormal and deserves evaluation - Not predictor of malignancy

Ovarian cancer - predominant - average patient age : 56~60 years




: women with a strong family history of ovary, breast,

endometrial or colon cancer or a mass that appears to be

enlarging

Uterine and other Masses


History : personal and family medical Hx

Pelvic Examination

Ultrasonography

Serum CA125


Diagnosis

Benign : nonoperative management


- based on characteristics of the mass

- a family or personal medical history

- the patient’s desire for definitive diagnosis

- selection of the appropriate surgical procedure is

critical for effective therapy


Management

chapter 13. benign diseases of the female reproductive tract(2) pelvic mass novac page 373-399

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