Table II-5-1. Prepubertal Pelvic Mass



Surgical diagnosis Simple cyst Laparoscopy
     
  Complex mass Laparotomy
     
Management Benign Cystectomy
    Annual followup
     
  Malignant Unilateral S&O
    Staging, chemotherapy
     
Prognosis

95% survival with chemotherapy

     

 

Definition of abbreviations: S&O, Salpingo-oophorectomy.

 

Management

 

Benign histology. A cystectomy should be performed instead of a salpingo-oophorectomy.Because of the patient’s age the surgical goal should be toward conservation of both ovaries. If the frozen section pathology analysis is benign, no further surgery is needed. Follow-up is on an annual basis.

 

 

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GI

USMLE Step 2 l Gynecology

 

 

GYN Triad                     Benign cystic teratoma


 

Benign Cystic Teratoma

 

• Pelvic mass: reproductive years

 

• b-hCG (–)

 

• Sonogram: complex mass, calcifications


 

Dermoid cysts are benign tumors. They can contain cellular tissue from all 3 germ layers. The most common histology seen is ectodermal skin appendages (hair, sebaceous glands), and therefore the name “dermoid.” Gastrointestinal histology can be identified, and carcinoid syn-drome has been described originating from a dermoid cyst. Thyroid tissue can also be identi-fied, and if it comprises more than 50% of the dermoid, then the condition of struma ovarii is identified. Rarely, a malignancy can originate from a dermoid cyst, in which case the most common histology would be squamous cell carcinoma, which can metastasize.


 

GYN Triad

Ovarian Torsion

• Abrupt unilateral pelvic pain

 

• b-hCG (–)

 

• Sonogram: >7 cm adnexal mass


 

PAINFUL ADNEXAL MASS

 

A 31-year-old woman is taken to the emergency department complaining of severe sudden lower abdominal pain for approximately 3 h. She was at work when she suddenly developed lower abdominal discomfort and pain, which got progressively worse. On examination the abdomen is tender, although no rebound tenderness is present, and there is a suggestion of an adnexal mass in the cul-de-sac area. Ultrasound shows an 8-cm left adnexal mass with a suggestion of torsion of the ovary.

 

Diagnosis. Sudden onset of severe lower abdominal pain in the presence of an adnexal mass ispresumptive evidence of ovarian torsion.

Management. The management of the torsion should be to untwist the ovary and observe theovary for a few minutes in the operating room to assure revitalization. This can be performed with laparoscopy or laparotomy.

 

Cystectomy. If revitalization occurs, an ovarian cystectomy can be performed withpreservation of the ovary.

 

Oophorectomy. If the ovary is necrotic, a unilateral salpingo-oophorectomy isperformed.

 

Follow-Up. Patients should have routine examination 4 weeks after the operation and thenshould be seen on a yearly basis. The pathology report should be checked carefully to make sure that it is benign, and if this is the case, then they go to routine follow-up.


 

 

POSTMENOPAUSAL PELVIC MASS

 

A 70-year-old woman comes for annual examination. She complains of lower abdominal discomfort; however, there is no weight loss or abdominal distention. On pelvic examination a nontender, 6-cm, solid, irregular, fixed, left adnexal mass is found. Her last examination was 1 year ago, which was normal.

 

Definition. A pelvic mass identified after menopause. Ovaries in the postmenopausal age groupshould be atrophic; anytime they are enlarged, the suspicion of ovarian cancer arises.

 

 

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GI

Chapter 5 l Disorders of the Ovaries and Oviducts

 

 

Diagnostic Tests

GI tract lesions. Abdominal pelvic CT scan or a pelvic ultrasound, and GI studies(barium enema) to rule out any intestinal pathology such as diverticular disease

 

Urinary tract lesions. IVP to identify any impingement of the urinary tract


 

Screening Test. There is no current screening test for ovarian cancer. Pelvic ultrasound is excel-lent for finding pelvic masses, but is not specific for identifying which are benign and which are malignant. Only 3% of patients undergoing laparotomy for sonographically detected pelvic masses actually have ovarian cancer.

 

Epidemiology. Ovarian carcinoma is the second most common gynecologic malignancy, witha mean age at diagnosis of 69 years. One percent of women die of ovarian cancer. It is the most common gynecologic cancer leading to death.

 

Risk Factors. These include BRCA1 gene, positive family history, high number of lifetime ovu-lations, infertility, and use of perineal talc powder.

 

Protective Factors. These are conditions that decrease the total number of lifetime ovulations:oral contraceptive pills, chronic anovulation, breast-feeding, and short reproductive life.

 


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