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  1. 1. Chapter 13. Benign Diseases of theFemale Reproductive Tract(2)Pelvic MassNovac page 373-399
  2. 2. Prepubertal Age GroupAdolescent Age GroupReproductive Age GroupPostmenopausal Age Group
  3. 3. Prepubertal Age GroupDifferential DiagnosisDiagnosis and Management
  4. 4. Differential DiagnosisMalignancy : < 5% in children and adolescents☞ malignancy (< 9 years of age ) : 80% of the ovarian neoplasmOvarian tumor : 1% of all tumors in these age groupsGerm cell tumors : 1/2 ~ 2/3 of ovarian neoplasms( <20 years of age)Epithelial neoplasm : rareSymptoms : abdominal or pelvic pain (initial symptoms)pelvic mass very quickly enlarge☞ D/Dx : Appendicitis, Wilms’ tumor or NeuroblastomaAcute pain : associated with torsionPrepubertal Age Group
  5. 5. UltrasonographyImaging studies: CT scanning, MRI or Doppler flow studiesPrepubertal Age GroupDiagnosis
  6. 6. Unilocular cysts : always benign and will regress in 3~6months☞ not require surgical management with oophorectomy oroophorocystectomyRecurrence rate after cyst aspiration : 50%Premature surgical therapy for a functional ovarian mass canresult in ovarian and tubal adhesions that can affect futurefertilityPrepubertal Age GroupManagement
  7. 7. Prepubertal Age GroupManagement
  8. 8. Adolescent Age GroupDifferential DiagnosisDiagnosis and Management
  9. 9. Ovarian massesUterine massesInflammatory MassesPregnancyDifferential Diagnosis
  10. 10. Malignant neoplasm is lower among adolescents than amongyounger childrenEpithelial neoplasms : ↑Mature cystic teratoma : most common type> ½ of ovarian neoplasms in women younger than 20 yerars ofagecf) Germ cell tumor : 1stdecade of lifeDysgenetic gonads : malignant tumor in 25%☞ gonadectomy is recommended for patients with XY gonadaldysgenesis or its mosaic variationsAdolescent Age GroupDifferential Diagnosis(1) Ovarian masses
  11. 11. Functional ovarian cyst : ↑- incidental finding on examination or associated with paincaused by torsion , leakage or ruptureEndometriosis: less common during adolescence than in adulthoodchronic pain (+) : 50~60% endometriosisTransverse view of Ltovarian endometriomashows a heterogenousappeareance withdiffuse low levelechoes interspersedwith echogenic andanechoic areasAdolescent Age GroupDifferential Diagnosis(1) Ovarian masses
  12. 12. Uterine leiomyomas : not commonObstructive uterovagianal anomalies- imperforate hymen ~ transverse vaginal septa- vaginal agenesis with a normal uterus and functionalendometrium- vaginal duplications with obstructing longitudinal septaand obstructed uterine hornsAdolescent Age GroupDifferential Diagnosis(2) Uterine Masses
  13. 13. Highest rates of PID of any age groupConsist of tuboovarian complex, tuboovarian abscess,pyosalpinx or chronically hydrosalpinxAdolescent Age GroupDifferential Diagnosis(3) Inflammatory Masses
  14. 14. Ectopic pregnancydiscovered before rupture☞ allowing conservative management with laparoscopicsurgery or medical therapy with methotrexateAdolescent Age GroupDifferential Diagnosis(4) Pregnancy
  15. 15. History and pelvic examinationLaboratory studies- pregnancy test- CBC- tumor markers – α-fetoprotein and hCGUltrasonographyCT or MRIAdolescent Age GroupDiagnosis
  16. 16. Figure 13.11Asymptomatic unilocular cystic masses : conservativelyIf surgical management is required☞ attention should be paid to minimizing the risks ofsubsequent infertility resulting from pelvic adhesion .☞ conserve ovarian tissueIn the presence of a malignant unilateral ovarian mass☞ unilateral oophorectomy rather than more radical surgery,even if the ovarian tumor has metastasizedIn general, conservative surgery is appropriate; further surgery can be performed if necessary, after an adequatehistologic evaluation of the ovarian tumorAdolescent Age GroupManagement
  17. 17. Lparoscopy- management of suspected acute PID- to confirm the diagnosis- to perform irrigation, lysis of adhesions,- draninage and irrigation of unilateral or bilateral pyosalpinxor tuboovarian abscess- extirpation of significant disease♣ associated with a risk of major complications( bowel obstruction and bowel or vessel injury)-Adolescent Age GroupManagement
  18. 18. Reproductive Age GroupDifferential DiagnosisDiagnosis and Management
  19. 19. Reproductive Age GroupDifferential Diagnosis
  20. 20. Malignancy : 10% of those younger than 30years of ageMost common tumor: mature cystic teratoma or dermoid (1/3 of women <30years of age)endometrioma (1/4of women 31-49years of age)Uterine massesOvarian massesOthersReproductive Age GroupDifferential Diagnosis
  21. 21. m/c benign Uterine tumorReproductive Age GroupDifferential DiagnosisUterine leiomyoma
  22. 22. 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 annualexaminationDifferential DiagnosisUterine leiomyoma
  23. 23. Etiology- unkown< several studies >- a single neoplastic cell within the smooth muscle of themyometrium- increased familial incidence- hormonal responsiveness and binding has been demonstratedin vitro♠ Fibroid have the potential to enlarge during pregnancy aswell as to regress after menopauseReproductive Age GroupDifferential DiagnosisUterine leiomyoma
  24. 24. 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 progestationalagents- with necrosis- a smooth muscle tumor of uncertain malignant potential(defined as having 5~9mitoses /10HPF that do notdemonstrate nuclear atypia or giant cells, or with a lowermitotic count (2~4 mitoses/10HPF) that does demonstrateatypical nuclear features or giant cells)Reproductive Age GroupDifferential DiagnosisUterine leiomyoma
  25. 25. Characteristicsmalignant degeneration : uncommon <0.5%♠ Sarcomas that have a malignant behavior have≥10mitoses/HPFDifferential DiagnosisUterine leiomyoma
  26. 26. SymptomMenorrhagia: initial symptom, one that most frequently leads to surgicalinterventionChronic pelvic pain: dysmenorrhea, dyspareuria or pelvic pressureAcute pain: d/t torsion of pedunculated leiomyoma or infarction anddegenerationReproductive Age GroupDifferential DiagnosisUterine leiomyoma
  27. 27. SymptomUrinary symptoms- frequency- Partial ureteral obstruction- complete urethral obstruction (rare)InfertilityDifferential DiagnosisUterine leiomyoma
  28. 28. Pregnancy loss or complications(10% rate of pregnancy complications by one study)- Although growth of leiomyomas may occur withpregnancy, no demonstrable change in size (base on serialultrasonographic examination) has been noted in 70~80%of patients- Risk of pregnancy complication: influenced by both myoma location and sizeReproductive Age GroupDifferential DiagnosisUterine leiomyoma
  29. 29. Symptoms (infrequently)Rectosignoid compression with constipation or intestinalobstructionProlapse of a pedunculated submucous tumor throughthe cervix→ severe cramping and subsequent ulceration andinfection (uterine inversion has also been reported)Venous stasis of lower extremities and possiblethrombophlebitis 2ndto pelvic compressionPolycythemiaAscitesReproductive Age GroupDifferential DiagnosisUterine leiomyoma
  30. 30. Most ovarian tumors(80~85%) : benign20~44years : 2/3 of ovarian tumors(benign)Chance that a primary ovarian tumor is malignant in apatient <45years : < 1/15Symptom- Nonspecific- Abdominal distension, abdominal pain or discomfort , lowerabdominal pressure sensation , urinary or gastrointestinalsymptoms- Vaginal bleeding (related to estrogen production)- Acute pain: adnexal torsion , cyst rupture or bleeding into a cystReproductive Age GroupDifferential DiagnosisOvarian masses
  31. 31. Pelvic findingBenign tumor Malingnant tumorUnilateral BilateralCyst solidMobilesmoothFixedIrregularAscitesCul-de-sac nodulesRapid growth rateReproductive Age GroupDifferential DiagnosisOvarian masses
  32. 32. Nonneoplastic Ovarian MassesOther Benign MassesNeoplastic MassesOther adnexal MassesReproductive Age GroupDifferential DiagnosisOvarian masses
  33. 33. Functional ovarian cysts: follicular cysts, corpus luteum cysts, theca lutein cystsBenign , not cause symptoms or require surgical managementFollicular cysts- most common fuctional cyst- diameter >8cm(rare)- defined as cystic follicle dimeter >3cm- Rupture : resolve in 4~8wksReproductive Age GroupDifferential DiagnosisNon neoplastic ovarian masses
  34. 34. Corpus luteum cysts- Less common than follicular cysts- Rupture→ leading to hemoperitoneum & surgical management- Most ruptures occur on cycle days 20 ~ 26Differential DiagnosisNon neoplastic ovarian masses
  35. 35. Thecal luteum cysts- The least common- Bilateral- occur with pregnancy, including molar pregnancies,associated multiple gestations, molar pregnancies,choriocarcinoma, diabetes, Rh sensitization, Clomiphenecitrate use, hMG-hCG ovulation induction , use of GnRHanalogs- Size: quite large(~30cm), multicystic, regress spontaneoustlyReproductive Age GroupDifferential DiagnosisNon neoplastic ovarian masses
  36. 36. Combination monophasic oral contraceptive therapy- markedly reduce the risk of functional ovarian cystsIn comparision with previously available higher-dose pills,the effect of cyst suppression with current low-dose oralcontraceptives is attenuated.Smoker: twofold increased risk of developing ovariancysts.Reproductive Age GroupDifferential DiagnosisNon neoplastic ovarian masses
  37. 37. Endometrioma: 6~8cm sizePCOSReproductive Age GroupDifferential DiagnosisNon neoplastic ovarian masses
  38. 38. 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 agesRisk of torsion : 15%(more frequently than with ovarian tumors ingeneral d/t high-fat content → float within the abdominal and pelviccavity)Bilateral :10%Ovarian cystectomy is almost always possible, even if it appears that onlya small amount of ovarian tissue remainsLaparoscopic cystectomy is often possible , and intraoperative spill oftumor contents is rarely a cause of complicationsReproductive Age GroupDifferential Diagnosisneoplastic ovarian masses
  39. 39. The risk of epithelial tumors increases with ageSerous tumor Mucinous ovariancharacteristics Psammoma bodies: fine calcific granulation –>scattered within the tumorand visible on radiograph grow to large dimensionsdifficult todistinguish histologicallyfrom metastatic gastrointestinal malignanciessometimes with papillarycomponentslobulated smooth surfacemultilocular,(serouscystadenoma)multilocular,bilateral 10%malignant 20~25%5~10% : borderline malignantpotential5~10%Differential Diagnosisneoplastic ovarian masses
  40. 40. Others- fibromas(a focus of stromal cells)- Brenner tumors- cystadenofibroma (mixed forms of tumors)Reproductive Age GroupDifferential Diagnosisneoplastic ovarian masses
  41. 41. Tuboovarian abscessEctopic pregnanciesParovarian cysts: noted either on examination or on imaging studies- Normal ipsilateral ovary can be visualized usingultrasonography- frequency of malignancy: quite low (2% of patients)Reproductive Age GroupDifferential DiagnosisOther Adnexal Masses
  42. 42. Pelvic Examination including rectovaginal examination and pap test: estimations of the size of a mass should be presented in centimetersrather 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, anintravenouspyelogramLaboratory studies: pregnancy test, cervical cytology, CBC, ESR, testing of stool foroccult blood, tumor markers –CA125- CA125 ↑: uterine leiomyoma, PID, pregnancy, endometriosis→ unnecessary surgical interventionReproductive Age GroupDiagnosis
  43. 43. Imaging Studies- pelvic ultrasonography, transvaginal and transabdominalultrasonography- CT, abdominal flat plate radiograph – seldom indicated as aprimary diagnostic procedure- MRI : diagnosis of uterine anomaliesScoring system- predict benign versus malignant adnexal massesUltrasonographic indices- characterizations of morphology: septations, solid components, ovarian size- demographic factors (ig, age)- color flow imaging and doppler waveform analysisReproductive Age GroupDiagnosis
  44. 44. Diagnosis
  45. 45. Hysteroscopy- direct evidence of intrauterine pathology or submucous leiomyomasHysterosalpingography- demonstrate indirectly the contour of the endometrial cavity and anydistortion or obstruction of the uterotubal junction 2ndto leiomyomasan extrinsic mass or peritubal adhesionsDiagnosis
  46. 46. Management should be based on the primary symptoms and mayinclude observation with close follow-up, temporizing surgicaltherapies, medical management or definitive surgical proceduresNonsurgical managementSurgical managementReproductive Age GroupManagement
  47. 47. Nonsurgical Managementjudicious patient observation and follow-up are indicated primarilyfor uterine leiomyomas : intervention is reserved for specificindications and symptomsGnRH 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 hormonalreplacement may be effective in minimizing thehypoestrogenic effects.Reproductive Age GroupManagementLeiomyoma
  48. 48. Indication of GnRH agonists- Preservation of fertility in women with large leiomyomas before attemptingconception, or preoperative treatment before myomectomy- Treatment of anemia to allow recovery of normal hemoglobin levels beforesurgical management, minimizing the need for transfusion or allowingautologous 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 delayingsurgeryReproductive Age GroupManagementLeiomyoma
  49. 49. Newer therapies combining GnRH agonists with estrogen add-back therapyRU486- progesterone antagonist☞ decrease the size of uterine leiomayomaReproductive Age GroupManagementLeiomyoma
  50. 50. Surgical TherapyAsymptomatic leiomyomas : not usually require surgeryIndication- Abnormal uterine bleeding with resultant anemia, unresponsive tohormonal management- Chronic pain with severe dysmenorrhea, dyspareunia, or lowerabdominal pressure or pain- Acute pain, as in torsion of a pedunculated leiomyoma, or prolapsingsubmucosal 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 discomfortReproductive Age GroupManagementLeiomyoma
  51. 51. 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 : < 2~3/1000Reproductive Age GroupManagementLeiomyoma
  52. 52. Hysterectomy: definitive management of symptomatic uterine leiomyomaMyomectomy: for patient who desire childbearing , who are young, who preferthat 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 requirementsManagementLeiomyoma
  53. 53. Laparoscopic myomectomyVaginal myomectomyindicated in the case of a prolapsed pedunculated submucous fibroidHysteroscopic resection: small submucosal leiomyoma* Recurrence (after myomectomy) : > 50%→ ~1/3 : requiring repeat surgeryEndometrial ablasion: decrease bleeding for women with primary intramural fibroidsPreop GnRH agonists: decreased uterine sizeManagementLeiomyoma
  54. 54. Nonextirpative approaches- Myolysis- uterine artery embolizationReproductive Age GroupManagementLeiomyoma
  55. 55. functional tumors: expectant* oral contraceptionsnumber of randomized prospective studies have shown noacceleration of the resolution of functional ovarian cystsWith oral contraceptives are effective in reducting the risk ofsubsequent ovarian cystsSymptomatic cysts : evaluated promptlyMildly symptomatic masses (suspected functional)→ management with analgesics rather than surgery to avoid thedevelopment of adhesions(→ impair subsequent fertility)Reproductive Age GroupManagementOvarian Masses
  56. 56. Reproductive Age GroupIndication of surgerysevere painsupicion of malignancytorsionManagementOvarian Masses
  57. 57. large cysts, multiloculations, septa, papillae and increased blood flow(onultrasonography ) → suspected of neoplasiaOvarian tumor torsion requires oophorectomy on the basis that theuntwisting(detorsion) of the ovarian pedicle would lead to emboliRecent studies have suggested that the primary management should bedetorsion with ovarian cystectomy if a cyst is present: Normal ovarian function frequently results even in ovaries that do notinitially appear to be viable.- This management is particularly important in prepubertal and youngwomenOophoropexy may be helpful in preventing recurrent torsionUltrasonographic or CT-directed aspiration procedures should not be usedin women in whom there is a suspicion of malignancyLaparoscopic managementReproductive Age GroupManagementOvarian Masses
  58. 58. 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 chosenapproachReproductive Age GroupManagementOvarian Masses
  59. 59. Postmenopausal Age GroupDifferential DiagnosisDiagnosis and Management
  60. 60. Ovarian massesDuring 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 : 1.5X0.75X0.5PMPO (postmenopausal palpable ovary) syndrome- Ovary that is palpable on examination beyond the menopuse is abnormaland deserves evaluation- Not predictor of malignancyOvarian cancer- predominant- average patient age : 56~60 yearsPostmenopausal Age GroupDifferential Diagnosis
  61. 61. Indication of surgery: women with a strong family history of ovary, breast,endometrial or colon cancer or a mass that appears to beenlargingUterine and other MassesDifferential Diagnosis
  62. 62. History : personal and family medical HxPelvic ExaminationUltrasonographySerum CA125Postmenopausal Age GroupDiagnosis
  63. 63. Benign : nonoperative managementIndication of surgery- 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 iscritical for effective therapyPostmenopausal Age GroupManagement