Ovarian Mass



Ovarian Mass


Sara M. O’Hara, MD, FAAP



DIFFERENTIAL DIAGNOSIS


Common



  • Functional Ovarian Cysts


  • Hemorrhagic Cyst


  • Endometrioma


  • Ovarian Torsion


  • Mature Teratoma


  • Tuboovarian Abscess


  • Polycystic Ovary Syndrome


Less Common



  • Ectopic Pregnancy


  • Dysgerminoma


  • Yolk Sac Tumor


  • Sertoli-Leydig Cell Tumor


Rare but Important



  • Ovarian Fibroma


  • Granulosa Cell Tumor, Juvenile


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Ovarian masses can be



    • Benign


    • Borderline (low malignant potential)


    • Malignant


  • Benign



    • Functional cysts


    • Hemorrhagic cysts/endometriomas


    • Serous and mucinous cystadenomas


    • Mature teratomas


    • Fibromas


  • Borderline (low malignant potential)



    • Serous tumors (65%)


    • Mucinous tumors (30%)


    • Endometrioid tumors


    • Clear cell, Brenner cell


    • Monodermal teratoma (struma ovarii, carcinoid, neural tumors)


    • Mixed neoplasms


  • Malignant



    • Epithelial ovarian carcinoma



      • 70% of all ovarian tumors


      • Postmenopausal women


    • Germ cell tumors



      • 20% of all ovarian tumors


      • These cell types more common in adolescents/young adults


      • Dysgerminoma


      • Yolk sac/endodermal sinus


      • Embryonal carcinoma


      • Choriocarcinoma


      • Immature teratoma


      • Mixed


    • Sex cord stromal tumor, including



      • 8% of all ovarian tumors


      • Sertoli-Leydig cell


      • Granulosa theca cell


    • Metastatic spread to ovary


  • Clues to malignancy on imaging



    • Persistent or growing mass


    • Solid tumors or mixed solid and cystic


    • Size > 8 cm


    • Local invasion


    • Peritoneal fluid


    • Nodular omentum (implants)


    • Adenopathy


Helpful Clues for Common Diagnoses



  • Functional Ovarian Cysts



    • Most are “simple” cysts


    • Large cysts with diameter > 3 cm should be re-imaged


    • Physiologic cysts will involute in 6-8 weeks


  • Hemorrhagic Cyst



    • Complex cysts containing debris ± echogenic free fluid


    • Should resolve with next menstrual cycle


  • Endometrioma



    • Low-level, homogeneous echoes (“chocolate” cyst)


    • Endometriosis in childhood or adolescence associated with genital tract anomalies


  • Ovarian Torsion



    • Excessive rotation of ovary, fallopian tube, or both


    • Causes ischemia and pain


    • Not typically associated with masses in pediatrics, unlike adult population


    • 1/2 of cases occur in premenarchal girls


    • ˜ 10% occur neonatally


    • Ultrasound



      • Unilateral enlarged ovary; 5x volume highly predictive


      • Stromal edema: Peripheral follicles


      • Free pelvic fluid/blood


      • Areas of hemorrhage


      • Normal Doppler exam does not exclude torsion


    • Treatment: Urgent surgical detorsion, conservation of ovarian tissue


    • Salvage rates for ovarian torsion are much better than for testicular torsion



    • Length of symptoms does not predict viability


  • Mature Teratoma



    • Benign germ cell tumor


    • ˜ 60% of ovarian neoplasms in women < 40 years old


    • Contains all 3 germ cell lines


    • Hair, fat, teeth, calcification seen on imaging


    • Cysts may contain oily, milky, or serous fluid


    • Generally have well-defined capsule


    • Bilateral in up to 15%


  • Tuboovarian Abscess



    • Fever, cervical tenderness, vaginal discharge


    • Ultrasound shows inflammation and ill-defined structures


    • Focal fluid/pus collections in tubes and adnexal spaces with thick hyperemic rim


    • Generally treated medically, not surgically


  • Polycystic Ovary Syndrome



    • Ovarian dysfunction, hyperandrogenism, polycystic ovary


    • ≥ 12 follicles per ovary


    • Ovarian volume > 10 mL


Helpful Clues for Less Common Diagnoses



  • Ectopic Pregnancy



    • Check quantitative β-hCG level


    • Decidual reaction in uterus with no intrauterine gestational sac


    • Enlarged, hyperemic adnexa


    • Gestational sac may be visible in adnexa



      • Usually on same side as corpus luteum


    • Occasionally implant distant from uterus


  • Dysgerminoma



    • ˜ 50% of all germ cell tumors


    • 5% secrete β-hCG


    • Similar to male seminoma


    • Masses tend to be large and heterogeneous


    • 15% recur but are re-treated with good prognosis


  • Yolk Sac Tumor



    • a.k.a. endodermal sinus tumor


    • ˜ 25% of all germ cell tumors


    • May secrete α-fetoprotein


    • Poor prognosis without adjuvant chemotherapy



      • 5-20% survival with surgery alone


  • Sertoli-Leydig Cell Tumor



    • Sex cord stromal tumor


    • ˜ 75% occur in women < 40 years old


    • May cause virilization


    • Heterosexual precocious puberty


    • Recurrence and malignant behavior seen with poorly differentiated subtypes


Helpful Clues for Rare Diagnoses



  • Ovarian Fibroma



    • ˜ 4% of all ovarian tumors


    • Meigs syndrome with ascites and pleural effusions


  • Granulosa Cell Tumor, Juvenile



    • ˜ 2% of all ovarian tumors


    • < 5% of these are juvenile type


    • Often secrete estrogen

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Aug 10, 2016 | Posted by in PEDIATRICS | Comments Off on Ovarian Mass

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