Dr. Zohreh Yousefi Professor OF Mashhad University of Medical Sciences Gynecologist Oncologist.
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Transcript of Dr. Zohreh Yousefi Professor OF Mashhad University of Medical Sciences Gynecologist Oncologist.
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 !