Dr.%20Zohreh%20Yousefi

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Pelvic mass in Prepubertal Girls
Dr. Zohreh Yousefi Professor OF Mashhad
University of Medical Sciences
Gynecologist Oncologist
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Origin of Pelvic mass gynecologic

non gynecologic
non gynecologic
urinary tract


Gasterointestinal

Otheres

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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)
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rupture of Wilms' tumor and hemorrhage risk 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
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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
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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
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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
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Appendicitis
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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
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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
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Gynecologic causes of pelvic
mass Ovary Uterian Cervicovaginal
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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
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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
present surgical correction of the MDA may be
required
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Neonatal hematometrocolpos. (a) Transverse US
scan shows a huge cystic mass (C) with a
fluid-debris level (arrow)
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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).
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Neonatal uterus Longitudinal US scan shows a
prominent cervix (arrows) and a visible
endometrium (arrowheads). Some fluid (F) is
seen within the vagina
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• 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

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The gynecologic causes of a pelvic mass
Neoplastic mass In younger girls
Cervico-vaginal
rare
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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
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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
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Germ cell tumors
Germinoma
Teratoma
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• Typically grow rapidly-
• 60 seen in first 2 decades of life
• producing symptoms of distention and abdominal
  fullness
• Torsion may occur, producing an acute abdomen
• obvious malignancy with involvement of opposite
  ovary
• ( Dysgerminoma)
• all have a tendency to spread to the paraaortic
  lymph node
• isosexual precocity reported

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ultrasonographic appearance is very different
with heterogeneous and solid components Karyot
ype Unilateral oophorectomy and
lymphadenectomy followed by adjuvant
chemotherapy Follow up necessary
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Juvenile Granulosa Cell Tumors derive from
granulosa cells tend to be of low malignity
most of them have mixed components both solid
and liquid Present as pelvic mass
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Sex cord stromal tumours
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Secrete estrogen and sometimes prolactin
precocious pseudopuberty , galactorrhea meas
urement of anti-Müllerian hormone (AMH)
and inhibin and carletenin
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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
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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
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• 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

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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
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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  
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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
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Treatment Preferable method in dermoid
cyst in a young woman shell it out from the
ovarian stroma and preserving functioning
tissue
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Autonomous Cyst McCune-Albright Syndrome is a
sporadic disorder in small girls between 2 and
5 years ( early childhood) recurrent ovarian
cysts diffuse anomalies
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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 )
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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  
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Treatment Unilocular cysts lt50mm 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  

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Management of ovarian cysts with endocrine
syndrome hormonal investigations are necessary
ultrasound-guided percutaneous aspiration
Recurrence or
surgically by laparaoscopy in the
individual case.
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• 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
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• investigate the condition of the contralateral
  ovary
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Transrectal ultrasonography For girl who had
not intercourse No alternative imaging
modality has demonstrated sufficient
superiority to USG to justify its routine use

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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
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Transvaginal Ultrasonography

• Ultrasonographic signs of malignancy
• Adnexal pelvic mass with area of complexity
• Irregular border
• solid patterns within the mass
• Dense multiple septae

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Tumor Markers a useful diagnostic aid in
difficult to analyze by ultrasonography and
in surveillance after tumor removal aFP in
endodermal sinus tumor and
embryonic carcinomas and
immature teratomas. (ß-HCG)
in choriocarcinomas and dysgerminoma
CA-125 levels either in peripheral blood or in
the cyst fluid after aspiration LDH in
dysgerminomas
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• 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
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• surgical treatment is required
• complicated cyst
• hemorrhage
• ovarian torsion
• Solid masses
• larger than approximately 8 cm

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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)
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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

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Management of adnexal torsion

• Suspicous adnexal torsion
• Emergency detorsion, only!
• Adnexectomy avoided
• Ovarian function is preserved in 88-100 of cases
• Edema associated torsion
• Interval cystectomy
• Recurrence
• Rare
• Repeat torsion ? ovarian fixation

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Thank you for your attention !