Dr. Zohreh Yousefi Professor OF Mashhad

University of Medical Sciences Gynecologist Oncologist

Origin of Pelvic mass gynecologic non gynecologic non gynecologic urinary tract Gasterointestinal Otheres

Wilms' tumor or nephroblastoma

cancer of the kidneys that typically occurs in children Most nephroblastomas are unilateral

Typical symptoms are: -large abdomen-abdominal pain -Fever -nausea and vomiting -blood in the urine(20% high blood pressure in some cases)

rupture of Wilms' tumor and hemorrhagerisk of peritoneal dissemination of the tumor metastasis it is usually to the lung It is highly responsive to treatment

90% of patients surviving at least five years

Neuroblastoma

the second most common solid tumour in childhood

8% of the total number of children's cancers

Neuroblastoma is a cancer of specialised nerve cells called neural crest cells

In some children, the neuroblastoma can occur in nerve tissue along side the spinal cord in the neck , chest, abdomen or pelvis

Signs and symptoms

If the tumor is in the abdomen, may be swollen and they may complain of constipation or have difficulty passing urine blood pressure may also be high diagnose neuroblastoma blood, urine, or  bone marrow tests

x-rays; CT or MRI scans; and MIBG

The treatment of neuroblastoma depends on

the age of the child the size position of the tumour the tumour biology (including the MYCN status) and whether the neuroblastoma has spread

Treatment Surgery Chemotherapy

Appendicitis

Appendicitis is most common in teens and young adults in their early 20s

children younger than 4 years are at the highest risk for a rupture. Up to 80 percent of appendicitis cases in this age group occurred with rupture

young children have fewer of the classic symptoms of nausea, vomiting and pain localized in the lower right portion of the abdomen than do teenagers and young adults

making the diagnosis easy to miss or delay

ultrasound and CT scan images can be helpful, but are not always conclusive, even if they are available on an emergency basis

CT scans in particular expose young children to radiation which should be avoided if possible

The only absolute way to diagnose the condition is surgery

Gynecologic causes of pelvic mass

OvaryUterianCervicovaginal

Müllerian duct abnormality congenital entities that result from nondevelopment, defective vertical or lateral fusion, or resorption failure of the müllerian ducts

the majority are asymptomatic

when a müllerian duct becomes obstructed may present with an abdominal mass and dysmenorrhea If the patient is not treated in a timely fashion the consequences can be severe, extending even to infertility

ultrasonography initially to delineate any abnormalities in the genital tract

US cannot help identify the type of MDA

In contrast, MRI is a valuable technique for noninvasive evaluation of the female pelvic anatomy and accurate MDA classification

If obstruction is presentsurgical correction of the MDA may be required

Neonatal hematometrocolpos. (a) Transverse US scan shows a huge cystic mass (C) with a fluid-debris level (arrow)

Duplex uterus with an obstructed hemivagina in a 12-year-old girl Transverse US scan shows a normal left uterus (arrow) and a dilated right uterus (U).

Neonatal uterus Longitudinal US scan shows a prominent cervix (arrows) and a visible endometrium (arrowheads). Some fluid (F) is seen within the vagina

•Wolffian duct Remnant

•Mullerian Dact Remnant

•Wolffian duct Remnant

They are mimic tumor of ovary

They are small but may enlarge and infarct

These are incidental finding at laparotomy and

cause no difficult or symtom

The gynecologic causes of a pelvic mass Neoplastic mass In younger girls

Cervico-vaginal rare

The gynecologic causes of a pelvic mass Neoplastic mass In girls younger than 9 years of age, approximately 80% ovarian tumors were found to be malignant

Fewer than 2% of ovarian malignancies occur in children and adolescents

Non-epithelial tumors predominate

Germ cell tumors

½ -2/3 of ovarian neoplasms in younger than 20 years of age Develop from primordial germ cells

Termed as malignant, though do not have high malignant potential

Germ cell tumorsGerminoma Teratoma

ultrasonographic appearance is very different

with heterogeneous and solid components

Karyotype

Unilateral oophorectomy and lymphadenectomy followed by adjuvant chemotherapy

Follow up necessary

Juvenile Granulosa Cell Tumors

derive from granulosa cells

tend to be of low malignity

most of them have mixed componentsboth solid and liquid

Present as pelvic mass

Sex cord stromal tumours

Secrete estrogen and sometimes prolactin

precocious pseudopuberty , galactorrhea

measurement of anti-Müllerian hormone (AMH) and inhibin and carletenin

Treatment

-unilateral oophorectomy

-cystectomy and surgical staging

careful examination of the contralateral ovary

Postoperative follow-up consists of

ultrasonography

and tumor marker for several years

-Good prognosis

NON NEOPLASTIC MASS

Ovarian Cysts

more common in the neonatal and adolescent periods ( 3 and 8 years )

decreases of frequency functional cysts in early childhood

then increases as puberty

The Various Etiologies of Ovarian Cysts in Prepubertal Girls

•Derived degenerated follicular cysts

•ovarian gonadotropin stimulation

•failure of follicular apoptosis

•interaction with other hormonal secretion

Small cysts are more frequent than large cysts

Small cysts asymptomatic discovered incidentally on ultrasonography

elongated ovarian ligament of the abdominal

location of tumor a predisposition to torsion

symptomatic cases:

( Abdomino -Pelvic pain) acute or sub acute

non-specific signs (nausea, vomiting,

urinary disorders)

Precocious development may be transient onset breast development

increasing during ovarian cyst formation

 

Benign Teratoma

Dermoid cysts most frequent neoplasms in childhood mean age of diagnosis being 10 years

heterogeneous appearance in ultrasonography

a solid cystic component containing ectodermal tissue (skin, hair, dentin)

calcifications are also clearly visible on plain radiographs

Treatment

Preferable method

in dermoid cyst in a young woman shell it out from the ovarian stroma

and preserving functioning tissue

Autonomous Cyst

McCune-Albright Syndrome is a sporadic disorder

in small girls between 2 and 5 years( early childhood)

recurrent ovarian cysts

diffuse anomalies

skin pigmentation skin spots café-au-lait

polyostotic fibrous dysplasia characterizes the McCune-Albright syndrome

symptoms bone and cutaneous signs detected several years later

confirm the diagnosis by molecular studies ( mutations of Gs proteins )

The best known type of precocious pseudopuberty metrorrhagia and rapid breast development

premature thelarche Central precocious puberty

(elevated estradiol) Very low LH and FSH levels  

Treatment

Unilocular cysts <50mm may be followed conservatively

This is a gonado-independent form of puberty

usual puberty inhibiting treatments are ineffective

Only aromatase inhibitors seem to have a certain efficacy  

Management of ovarian cysts with endocrine syndrome

hormonal investigations are necessary

ultrasound-guided percutaneous aspiration

Recurrence

or surgically by laparaoscopy in the individual case.

Diagnostic Arguments of Ovarian Cysts in Prepubertal Girls

Limitation of pelvic capacity in prepubertal child

• pelvic mass very quickly becomes abdominal location

Examination abdominal palpation

bimanual rectoabdominal investigate the condition of the contralateral ovary 

Transrectal ultrasonography For girl who had not intercourse No alternative imaging modality has demonstrated sufficient superiority to USG to justify its routine use

Ultrasonographic signs of malignancy

Adnexal pelvic mass with area of complexity

-Irregular border -solid patterns within

the mass -Dense multiple septae color Doppler

hypervascularized tumor

Transvaginal Ultrasonography

Ultrasonographic signs of malignancy Adnexal pelvic mass with area of complexity

Irregular border solid patterns within the mass Dense multiple septae

Tumor Markers

a useful diagnostic aid in

difficult to analyze by ultrasonography

and in surveillance after tumor removal

αFP in endodermal sinus tumor and embryonic carcinomas and

immature teratomas.

(β-HCG) in choriocarcinomas and dysgerminoma

CA-125 levels either in peripheral blood or in the cyst fluid after aspiration

LDH in dysgerminomas

Management•clinical signs •sonographic appearance •volume of the mass•finally its persistence

Unilocular cysts are virtually always benign

Will regress in 3 to 6 months Close observation is recommended

surgical therapy for a functional ovarian mass can result adhesions and adversely affect future fertility  

surgical treatment is required

• complicated cyst • • hemorrhage • • ovarian torsion• •Solid masses

•larger than approximately 8 cm

Torsion of a normal ovary in a 10-year-old girl with severe acute pelvic pain

Transverse US scan shows a markedly enlarged right ovary with peripheral follicles (arrows)

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

Management of adnexal torsion

Suspicous adnexal torsionEmergency detorsion, only!

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

Edema associated torsion Interval cystectomy

Recurrence Rare Repeat torsion → ovarian fixation

Thank you for your attention !