USMLE Step 2 l Gynecology

PREPUBERTAL PELVIC MASS

An 8-year-old girl is evaluated in the emergency department for sudden onset
of severe lower abdominal pain. A general surgery consult was obtained, and
appendicitis is ruled out. Pelvic ultrasound reveals a 7-cm solid and irregular right
adnexal mass. Pelvic examination is consistent with a 7-cm right adnexal mass, and
there is lower abdominal tenderness but no rebound present.

Etiology. An adnexal mass in the prepubertal age group is abnormal. During the prepubertal
and the postmenopausal years, functional ovarian cysts are not possible because ovarian fol-
licles are not functioning. Therefore any ovarian enlargement is suspicious for neoplasm.

Differential Diagnosis. If sonography shows a complex adnexal mass in a girl or teenager, the
possibility of germ cell tumors of the ovary has to be considered. The following serum tumor
markers should be obtained: lactate dehydrogenase (LDH) for dysgerminoma, b-hCG for cho-
riocarcinoma, and a-fetoprotein for endodermal sinus tumor.

Presentation. Sudden onset of acute abdominal pain is a typical presentation of germ cell
tumors of the ovary. These tumors characteristically grow rapidly and give early symptomatol-
ogy as opposed to the epithelial cancers of the ovary that are diagnosed in advanced stages. Germ
cell tumors of the ovary are most common in young women and present in early stage disease.

Diagnosis. Surgical exploration. In a prepubertal patient who is symptomatic and has ultra-
sound evidence of an adnexal mass, a surgical evaluation is recommended.
• Simple mass. If the ultrasound shows the consistency of the mass to be simple (no
septations or solid components), this mass can be evaluated through a laparoscopic
approach.
• Complex mass. If the mass has septations or solid components, a laparoscopy or lapa-
rotomy should be performed, depending on the experience of the surgeon.

Table II-5-1. Prepubertal Pelvic Mass

Surgical diagnosis Simple cyst Laparoscopy
Complex mass Laparotomy
Management Benign Cystectomy
Annual followup
Malignant Unilateral S&O
Staging, chemotherapy
Prognosis 95% survival with chemotherapy
Definition of abbreviations: S&O, Salpingo-oophorectomy.

Management
• Benign histology. A cystectomy should be performed instead of a salpingo-oophorectomy.
Because of the patient’s age the surgical goal should be toward conservation of both
ovaries. If the frozen section pathology analysis is benign, no further surgery is needed.
Follow-up is on an annual basis.

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 Chapter 5 l Disorders of the Ovaries and Oviducts

• Germ cell tumor. A unilateral salpingo-oophorectomy and surgical staging (peritoneal

and diaphragmatic biopsies, peritoneal cytology, pelvic and para-aortic lymphadenec-
tomy, and omentectomy) should be done. All patients with germ cell tumors require
postoperative chemotherapy. The most active regimen used is vinblastine, bleomy-
cin, and cisplatin. Follow-up after conservative surgery is every 3 months with pelvic
examination and tumor marker measurements.

Prognosis. The current survival is >95% in patients with germ cell tumors managed with con-
servative management and chemotherapy. Before the chemotherapy age the majority of these
patients succumbed to their disease.

PREMENOPAUSAL PELVIC MASS

Complex Mass GYN Triad

Dysgerminoma
A 28-year-old woman is in the emergency department complaining of lower
abdominal discomfort the last 5 days. She has no history of steroid contraceptive • Solid pelvic mass in
reproductive years
use. A year ago, her pelvic exam and Pap smear were negative. Pelvic exam today
shows a 7-cm, mobile, painless right adnexal mass. An endovaginal sonogram in • b-hCG (–)
the emergency department confirms a 7-cm, mobile, irregular complex mass with • ↑ LDH level
prominent calcifications.

Definition. The most common complex adnexal mass in young women is a dermoid cyst
or benign cystic teratoma (discussed below). Other diagnoses include endometrioma, tubo-
ovarian abscess, and ovarian cancer.

Differential Diagnosis
• Pregnancy
• Functional cysts

Diagnosis.
• Qualitative b-human chorionic gonadotropin (b-hCG) test to rule out pregnancy.
• The appearance of a complex mass on ultrasound will rule out a functional cyst.

Management. Patients in the reproductive age group with a complex adnexal mass should be
treated surgically. The surgery can be done by a laparoscopy or a laparotomy according to the
experience of the surgeon.
• Cystectomy. At the time of surgery an ovarian cystectomy should be attempted to
preserve ovarian function in the reproductive age. Careful evaluation of the opposite
adnexa should be performed, as dermoid cysts can occur bilaterally in 10–15% of cases.
• Oophorectomy. If an ovarian cystectomy cannot be done because of the size of the
dermoid cyst, then an oophorectomy is performed, but conservative management
should always be attempted before an oophorectomy is done.

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 USMLE Step 2 l Gynecology

GYN Triad Benign cystic teratoma

Dermoid cysts are benign tumors. They can contain cellular tissue from all 3 germ layers. The
Benign Cystic Teratoma
most common histology seen is ectodermal skin appendages (hair, sebaceous glands), and
• Pelvic mass: reproductive therefore the name “dermoid.” Gastrointestinal histology can be identified, and carcinoid syn-
years drome has been described originating from a dermoid cyst. Thyroid tissue can also be identi-
• b-hCG (–) fied, and if it comprises more than 50% of the dermoid, then the condition of struma ovarii
is identified. Rarely, a malignancy can originate from a dermoid cyst, in which case the most
• S onogram: complex mass,
common histology would be squamous cell carcinoma, which can metastasize.
calcifications

PAINFUL ADNEXAL MASS

A 31-year-old woman is taken to the emergency department complaining of severe
sudden lower abdominal pain for approximately 3 h. She was at work when she
suddenly developed lower abdominal discomfort and pain, which got progressively
worse. On examination the abdomen is tender, although no rebound tenderness
is present, and there is a suggestion of an adnexal mass in the cul-de-sac area.
Ultrasound shows an 8-cm left adnexal mass with a suggestion of torsion of the ovary.

GYN Triad Diagnosis. Sudden onset of severe lower abdominal pain in the presence of an adnexal mass is
presumptive evidence of ovarian torsion.
Ovarian Torsion
• Abrupt unilateral pelvic pain Management. The management of the torsion should be to untwist the ovary and observe the
ovary for a few minutes in the operating room to assure revitalization. This can be performed
• b-hCG (–) with laparoscopy or laparotomy.
• Sonogram: >7 cm adnexal • Cystectomy. If revitalization occurs, an ovarian cystectomy can be performed with
mass preservation of the ovary.
• Oophorectomy. If the ovary is necrotic, a unilateral salpingo-oophorectomy is
performed.

Follow-Up. Patients should have routine examination 4 weeks after the operation and then
should be seen on a yearly basis. The pathology report should be checked carefully to make sure
that it is benign, and if this is the case, then they go to routine follow-up.

POSTMENOPAUSAL PELVIC MASS

A 70-year-old woman comes for annual examination. She complains of lower
abdominal discomfort; however, there is no weight loss or abdominal distention.
On pelvic examination a nontender, 6-cm, solid, irregular, fixed, left adnexal mass
is found. Her last examination was 1 year ago, which was normal.

Definition. A pelvic mass identified after menopause. Ovaries in the postmenopausal age group
should be atrophic; anytime they are enlarged, the suspicion of ovarian cancer arises.

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 Chapter 5 l Disorders of the Ovaries and Oviducts

Diagnostic Tests
• GI tract lesions. Abdominal pelvic CT scan or a pelvic ultrasound, and GI studies
(barium enema) to rule out any intestinal pathology such as diverticular disease
• Urinary tract lesions. IVP to identify any impingement of the urinary tract

Screening Test. There is no current screening test for ovarian cancer. Pelvic ultrasound is excel-
lent for finding pelvic masses, but is not specific for identifying which are benign and which
are malignant. Only 3% of patients undergoing laparotomy for sonographically detected pelvic
masses actually have ovarian cancer.

Epidemiology. Ovarian carcinoma is the second most common gynecologic malignancy, with
a mean age at diagnosis of 69 years. One percent of women die of ovarian cancer. It is the most
common gynecologic cancer leading to death.

Risk Factors. These include BRCA1 gene, positive family history, high number of lifetime ovu-
lations, infertility, and use of perineal talc powder.

Protective Factors. These are conditions that decrease the total number of lifetime ovulations: GYN Triad
oral contraceptive pills, chronic anovulation, breast-feeding, and short reproductive life.
Serous Carcinoma
Classification of Ovarian Cancer • Postmenopausal woman
• Epithelial tumors—80%. The most common type of histologic ovarian carcinoma
• Pelvic mass
is epithelial cancer, which predominantly occurs in postmenopausal women. These
include serous, mucinous, Brenner, endometrioid, and clear cell tumors. The most • ↑ CEA or CA-125 level
common malignant epithelial cell type is serous.
• Germ cell tumors—15%. Another histologic type of ovarian cancer is the germ cell GYN Triad
tumor, which predominantly occurs in teenagers. Examples are dysgerminoma, endo- Choriocarcinoma
dermal sinus tumors, teratomas, and choriocarcinoma. The most common malignant
germ cell type is dysgerminoma. It is uniquely x-ray sensitive. • Postmenopausal woman
• Stromal tumors—5%. The third type of ovarian tumor is the stromal tumor, which is • Pelvic mass
functionally active. These include granulosa-theca cell tumors, which secrete estrogen • ↑ hCG level
and can cause bleeding from endometrial hyperplasia and Sertoli-Leydig cell tumors,
which secrete testosterone and can produce masculinization syndromes. Patients with GYN Triad
stromal tumors usually present with early stage disease and are treated either with
removal of the involved adnexa (for patients who desire further fertility) or a TAH Sertoli-Leydig Tumor
and BSO (if their family has been completed). They metastasize infrequently, and then • Postmenopausal pelvic
they require chemotherapy (vincristine, actinomycin, and Cytoxan). mass
• Metastatic tumor. These are cancers from a primary site other than the ovary. The • Masculinization
most common sources are the endometrium, GI tract, and breast. Krukenberg tumors
are mucin-producing tumors from the stomach or breast metastatic to the ovary. • ↑ testosterone level

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