STUDY OF ADNEXAL MASS IN REPRODUCTIVE AGE GROUP WOMEN AND THEIR OUTCOME

BACKGROUND: Adnexal masses is a significant condition commonly seen in women’sreproductive age. Most common masses arise from ovaries due to their complexembryologic & histologic origin. For diagnosis, ultrasonography is the gold standard.Laproscopy is the gold standard surgical intervention.METHODS: This study was a prospective study that was conducted at a tertiary carehospital in the obstetrics and gynecology department from October 2021 to December2021.RESULTS: In this study, No. 31% of the patients were between the ages of 26 and 35.Of the patients, 12.90% came from the upper socioeconomic class, 72.58% from themiddle, and 14.51% from the lower socioeconomic class. The most common complaintwas abdominal pain (41.93%) followed by menstrual irregularities (25.80%). 46.77% ofpatients were managed medically. In 32.25% of patients, laparoscopy was performed andin 20.96% of patients, laparotomy was performed.CONCLUSION: Adnexal masses are a very common gynecological problem, Presentwith abdominal pain / other symptoms /an incidental finding on ultrasonography done forother purposes. So, the basic approach should be early diagnosis and appropriate medicalor surgical treatment, to minimize morbidity and avoid mortality.

Evaluation of Laparoscopic Management of Adnexal Mass- An Observational Study in a Tertiary Care Hospital

Background: Adnexal masses are of increasing distress among women because of high fatality related to ovarian malignancy. Finding masses at the primary stage is of crucial significance and in these cases, adnexal masses could be dangerous. Laparoscopy has seemed as one of the most feasible surgical procedures and is now recommended as the “gold standard” method for the management of a wide range of gynecological complaints. The study aimed to determine the evaluation of laparoscopic management of adnexal mass. Material & Methods: A prospective observational study was carried out in the Department of Gynecology & Obstetrics, Ibn Sina Medical College and Hospital, Kallyanpur, Dhaka from 1st January 2020 to July 2022. A total of 146 patients (N=146) were enrolled in this study. Data were collected using the predesigned semi-structured questionnaire. Verbal consent was taken before recruiting the study population. Completed data forms were reviewed, edited, and processed for computer data entry. The data analysis was performed using Statistical Package for the Social Sciences (SPSS) Version 25.0. Results: Among the study population (N=146), the majority of the patients (70,48.0%) belonged to 21-30 years old. Most of the patients (124, 85.0%) were of the reproductive age group & only five patients (5, 3.4%) were of postmenstrual age. Most of the patients (38,26.0%) had ectopic mass, and around one-fourth of the patients (35,24.0%) had a simple cyst. around two-fifths of the patients (63,43.1%) underwent ovarian cystectomy, one-fourth of the patients (37,25.3%) underwent salpingectomy, twenty patients (20,13.7%) underwent excision of chocolate cyst, fourteen patients (14,9.6%) underwent salpingo-oophorectomy and two patients (2,1.4%) underwent conversion to laparotomy. Postoperative fever was seen in only three patients (3,2.0%), and minor port-site infection was seen in three patients (3,2.0%). Conclusion: The diagnosis of adnexal masses is indispensable which may upset all age groups of women. The laparoscopic method is an operative and innocuous procedure for managing patients with adnexal masses. An adequate selection of cases, a laparoscopic surgery-based hospital, and a proficient laparoscopic surgical team are vigorous for good patient consequences.

Contrast-enhanced ultrasound combined with Ovarian-Adnexal Reporting and Data System US risk stratification and management system for diagnosis of adnexal masses / 中华超声影像学杂志

Objective:To explore the value of contrast-enhanced ultrasound (CEUS) combined with Ovarian-Adnexal Reporting and Data System (O-RADS US) risk stratification and management system in differential diagnosis of ovarian-adnexal mass.Methods:Fifty-six patients with ovarian-adnexal mass who received transabdominal transvaginal ultrasound and CEUS in the Third People′s Hospital of Longgang District from September 2018 to January 2021 were enrolled. The images were classified by O-RADS US and diagnosed by CEUS by experienced and senior radiologist. On the basis of O-RADS US classification, the enhancement time, enhancement level and enhancement mode of CEUS were combined to upgrade or degrade the classification results of O-RADS US. The diagnostic accuracy was assessed using ROC curve analysis, the area under the ROC curve (AUC) was calculated. The reproducibility of O-RADS US was assessed by another senior radiologist.Results:The AUC of O-RADS US for diagnosing benign and malignant ovarian-adnexal masses was 0.844(0.722, 0.927), the AUC of CEUS was 0.833(0.710, 0.920), the AUC of O-RADS US combined with CEUS was 0.940(0.842, 0.986) (compared with O-RADS US, P=0.020; compared with CEUS, P=0.031). The intra-class correlation coefficient (ICC) was 0.897(0.824, 0.940) for O-RADS US. Conclusions:CEUS combined with O-RADS US classification can effectively improve the diagnostic efficiency for benign and malignant ovarian-adnexal masses.

Manejo de las lesiones anexiales en el embarazo y actualización del abordaje laparoscópico / Management of adnexal masses in pregnancy and an update of the laparoscopic approach

Resumen El manejo del tumor anexial en embarazadas sigue siendo un desafío. El objetivo del siguiente trabajo es realizar una revisión bibliográfica, en la que se abordarán las diferentes alternativas en cuanto a diagnóstico y manejo del tumor anexial en embarazadas, así como también indicaciones de abordaje quirúrgico y recomendaciones para una cirugía segura. Los tumores anexiales en embarazadas son poco frecuentes, y la mayoría son benignos y tipo funcionales. La ecografía ha sido fundamental para lograr diferenciar su carácter benigno o maligno. El manejo puede ser expectante o quirúrgico. El manejo quirúrgico se reserva para ciertas características de las lesiones anexiales. En cuanto a la vía operatoria, la literatura apoya la laparoscopia mostrando que existen múltiples beneficios al compararla con la laparotomía. Para el abordaje quirúrgico existen opciones en cuanto a la técnica, siendo estas anexectomía o quistectomía. Resulta fundamental tener consideraciones especiales en la técnica debido a los cambios fisiológicos de las embarazadas, como por ejemplo la altura uterina y el tamaño del tumor anexial. A modo de conclusión, el manejo de los tumores anexiales en el embarazo sigue siendo controversial y se extrapola principalmente basándose en la literatura de pacientes no gestantes u otros procedimientos quirúrgicos en embarazadas.

Abstract Nowadays the management of the adnexal tumors in pregnant women is still a challenge. The purpose of this article is to perform a bibliographic review and present the differential diagnosis, management, and surgical approaches for the women in this condition. Adnexal tumors in pregnant women are rare, most of them are benign corresponding to functional cysts. In order to differentiate benign from malignant tumors, Ultrasonography has been one of the most important imaging advances. The management can be either expectant or surgical. Surgical management is referred for tumors with certain specific characteristics. In relation to surgical management, the literature supports laparoscopy, showing greater benefits in comparison to laparotomy. There are different options for this kind of approach. Its mandatory to have special considerations in the technique due to the physiological changes in pregnant women, some examples are the uterine and the tumor size. The management of the adnexal tumors in pregnancy is still controversial, its based on studies of non-pregnant patients or other kinds of surgeries in pregnant women.

Delivering a female with missing cervix: a case report

Authors received a case in our casualty, 26 years old, G2P1L1, with full term pregnancy, spontaneous conception, previous normal vaginal delivery, with labour pain. On evaluation, she was having uterine contraction, fetal heart rate normal, vitally stable, with no cervix on per speculum and per vaginal examination, with solid globular mass per rectum. She was shifted to emergency operation theatre with provisional diagnosis of uterine rupture or rectal perforation or pelvic mass. After delivering a live baby, uterus was intact, but there was an impacted mass in pouch of Douglas, it was a twisted ovarian mass, sent for histopathology examination. Post-operative period was uneventful, and patient was discharged with healthy baby with corrected pelvic anatomy.

Role of risk of malignancy index 4 in evaluation of adnexal masses

Background: The discrimination between benign and malignant adnexal masses is important for clinical management and surgical planning in such patients. Various combined methods of evaluation adnexal mass have also been proposed. Risk of malignancy index (RMI) is a combined parameter which is simple, preclinical and highly sensitive, and more specific. Risk of malignancy index 4 (RMI 4) is calculated as a product of ultrasound score (U)×menopausal score (M)×CA 125×tumor size. Objective of this study was to determine if the RMI (RMI 4) can distinguish between benign and malignant adnexal masses.Methods: A prospective study was conducted on 30 women with an adnexal mass presenting in the OPD and emergency and RMI-4 calculated. Cut off level of 450 was set to differentiate between benign and malignant mass.Results: In this study, the value of RMI-4 is less than 450 in 17 patients with benign disease and 3 patients with malignant disease. The value is more than 450 in 2 patients with benign disease and 8 patients with malignant disease. RMI-4 >450 had a sensitivity of 72.73% and specificity is 89.47%. The positive predictive value is 80% and negative predictive value is 85%. The p-value for RMI-4 in this study is 0.001 which is highly significant.Conclusions: RMI is a reliable, simple, easy to use and cost-effective method in differentiating benign from malignant adnexal masses.

Role of risk of malignancy index for evaluation and preoperative detection of pelvic malignancies compared with pathological diagnosis

Background: Risk of malignancy index (RMI) is widely employed in the developed world in predicting malignant pelvic masses. The present study designed to confirm the effectiveness of the RMI to identify cases with high potential of ovarian malignancy, among patients with an adnexal mass.Methods: This was a cross-sectional study was conducted over a period of two years in a government run tertiary healthcare centre of Srinagar, Kashmir, Jammu and Kashmir, India. Study included 72 patients who underwent surgery due to adnexal mass and were evaluated for ovarian malignancy by comparing RMI with histopathological diagnosis. Data collected included demographic characteristics, ultrasound findings, menopausal status, CA125 levels, and histopathological diagnosis. For each patient, RMI was calculated as per the standard formula.Results: Analysis revealed ultrasound score had the highest sensitivity of 72.7%, while an RMI score ≥250 had the highest specificity of 88.5%. The latter also had the highest positive predictive value of 50%, while negative predictive value was highest for an ultrasound score of 3 (94%). The cut off points based on ROC analysis demonstrates significant predictive ability for ovarian cancer for both RMI and CA125 with AUC to the tune of 82.9% and 80.1% respectively.Conclusions: RMI is a simple score system which can be applied directly into clinical practice and might be of value in pre-operative assessment, and hence selecting patients who need surgical team including gynecologic oncologists.

Endosalpingiosis with concurrent endometriosis of ovary masquerading as ovarian malignancy

Endosalpingiosis is a rare gynecological disorder of müllerian origin, characterized by the presence of tubal epithelium outside the fallopian tube, which involves structures of the female genital tract, peritoneum, and sub-peritoneal tissues. Endosalpingiosis can be associated with endometriosis or endocervicosis, although it often appears alone. Authors report a case of endosalpingiosis with concurrent endometriosis in a 42-year-old P2L1 patient. The patient presented to us with complaints of heaviness in lower abdomen, a feeling a lump in the lower abdomen and low-grade fever for 15 days. On per abdominal examination, a large solid cystic mass up to 20 weeks size was felt, which was more on the left side. Cervix was normal on speculum examination, the same mass was felt on per vaginal examination, separate from the uterus, the right fornix appeared free. Patient was asked to get a set of investigations done and to review as early as possible. An exploratory laparotomy with peritoneal wash cytology, total abdominal hysterectomy, bilateral salpingo-ophorectomy with supracolic and infracolic omentectomy and bilateral pelvic lymph nodes dissection was done on 18/07/18. Per operatively, there was a large cystic mass occupying the abdominal cavity adhered to the bowel and to posterior wall of the uterus, adhesiolysis followed by staging laparotomy was done.Patient’s postoperative course was uneventful and she was discharged on the 5th day of surgery in stable condition. The final histopathology report was suggestive of endosalpingiosis with concurrent endometriosis.

Successful conservative surgical management of ovarian mucinous cystadenoma with silent torsion in pregnancy: a case report

To report the successful conservative surgical management of Ovarian mucinous cystadenoma with silent torsion in a 24 years old pregnant woman in a tertiary care center in Delhi. An antenatal woman came for a routine visit to the OPD of the hospital at 13 weeks gestation. She had a vague, mild pain in lower abdomen since the last four weeks. A cystic mass was discovered during an abdominal examination. Further on sonography, a multisepatated cystic mass was seen, likely to be mucinous cystadenoma. Routine tumor markers came out to be negative. A laparotomy was planned at 15 weeks. On laparotomy a 20 × 15 cm multiloculated cyst with one and half turns of torsion was found. Detorsion, cystectomy of the intact cyst followed by ovarian reconstruction was done after due consent. On histopathological examination the cyst was found to be Benign mucinous cystadenoma. The pregnancy continued without any adverse effects. The woman delivered vaginally at 38 weeks without any feto-maternal complications. She was able to conceive again spontaneously at 18 months post-delivery. After 16 weeks of gestation in the second pregnancy she went to her home town and no further follow-up was possible. This case emphasizes the importance of a thorough examination in all pregnant woman to rule out any adnexal mass separate from the gravid uterus. Big ovarian masses in pregnancy, if not diagnosed can cause growth retardation, preterm deliveries, acute abdomen due to infection, rupture or torsion. Sonography, MRI and tumor markers can facilitate diagnosis before surgery. Torsion and rupture of mucinous cystadenoma need prompt surgery. Wherever possible conservative surgery (detorsion and cystectomy) should be done especially in young women.

Computed tomography features of benign adnexal mass lesions

Background: Adnexal masses originating from gynaecologic and nongynecologic sources may be benign or malignant. The objective of this study was to describe multi-detector computed tomography features of benign adnexal masses for diagnostic accuracy and disease understanding.Methods: Study retrospectively evaluates the multidetector computed tomography features of benign adnexal mass lesions, which were referred for MDCT examination with a primary diagnosis of adnexal masses on clinical or USG. Patients who underwent MDCT and subsequently underwent surgery and proved to benign adnexal mass lesion on histopathological examination were included in this study.Results: Forty five percent benign adnexal mass were in the age group of 36-50 years followed by 32.7% in the age group of 21-35 years. Common presenting symptoms of benign adnexal masses were pain abdomen or pelvic pain (65.5%) followed by mass abdomen (42%) while in one fourth of the patients it was asymptomatic and detected as incidental finding. Pathologic diagnosis of most common benign adnexal mass detected were serous cyst adenoma (54.5%), followed by mature cystic teratoma (18.2%), mucinous cyst adenoma (14.5%) and par ovarian cyst (9.1%). Benign ovarian mass had a characteristic CT appearance of cystic lesion (83.6%), unilocular (65.5%) with regular/well defined and thin wall (83.6%) with occasional septations (21.8%) and papillary projections (14.5%). Ascitis (5.5%) was an uncommon finding of a benign adnexal mass lesion. Computed tomography was most accurate to characterize mature cystic teratoma with a typical cystic lesion having fat deposition and calcifications.  Serous cyst adenoma had a CT appearance of thin walled cyst mass with no septations or solid component. Mucinous cyst adenoma ovary had a characteristic multilocular cystic lesion with different fluid attenuation and thin septations.  Endometrioma had a variable CT appearance with uni or multilocular cystic lesion and hyperdense lesion with focal calcifications.Conclusions: Multi detector computed tomography may provide accurate and valuable diagnostic information about benign nature of an adnexal mass lesion.

A case of postmenopausal bleeding with an unusual finding

Authors report the case of a 55-year-old patient who presented with postmenopausal bleeding. On clinical evaluation uterus was 12 weeks size with a left sided adnexal cystic mass of 8 × 6 cm size. Further imaging studies revealed uterus size of 11.5 × 6.7 × 6.3 cm, left ovarian mass of size 8.4 × 6.7 × 6 cm and endometrial thickness of 17 mm on ultrasonography. She underwent endometrial biopsy to exclude endometrial cancer. The report of which came to be endometrial hyperplasia without atypia. Further MRI study confirmed the findings of USG of a complex cystic lesion of left adnexa 75 × 57 × 60 mm. Tumor marker for ovarian tumors were sent and inhibin B was found to be markedly raised. A provisional diagnosis of GCT (Granulosa cell tumour) was made and staging laparotomy was done. The uterus was found to be 12 × 8 cm size and a left sided ovarian cyst of 8-9 cm size with smooth wall and intact capsule was found. Patient had an uneventful postoperative recovery.

Diagnostic accuracy of ultrasonography with laparoscopy for assessment of benign adnexal masses

Background: Adnexal masses are one of the most common pathologies among women of all age groups. Objective of this study was to assess efficacy of ultrasonography in diagnosing adnexal pathology, rule out malignancy and its comparison with laparoscopy and pathology results.Methods: A total 32 women with benign adnexal mass were evaluated by clinical examination, ultrasonography and laparoscopy. Findings of ultrasound were compared with laparoscopy and histopathology reports and diagnostic accuracy was calculated.Results: Sensitivity of USG in diagnosing simple ovarian cyst is 20% and specificity is 88.9% while laparoscopy has sensitivity of 100% and specificity of 94.4%. USG versus laparoscopy has sensitivity of 50% versus 100% and specificity of 94.1% versus 100% in diagnosing endometrioma. Sensitivity of USG in diagnosing dermoid cyst is 66.7% and specificity is 95% while laparoscopy has both sensitivity and specificity of 100%. USG and laparoscopy, both have 100% sensitivity and specificity in diagnosing ectopic pregnancy, para-ovarian cyst and TO abscess. Benign serous cystadenoma is a histopathological diagnosis and is missed by both laparoscopy and ultrasonography.Conclusions: Ultrasonography should be the primary imaging modality used to identify and characterize adnexal masses, as it is readily available, and noninvasive.

Role of multi-detector computed tomography in the detection and differentiation of adnexal mass lesions

Background: The objective of this study was to evaluate the role of multi-detector computed tomography (MDCT) in the detection and differentiation of adnexal masses using post-operative histopathology findings as the gold standard.Methods: One hundred and forty five cases that were referred with a primary diagnosis of adnexal masses on clinical or USG examination were evaluated by MDCT in the Department of Radiodiagnosis from January 2013 to December 2013. One hundred twelve cases subsequently underwent surgical exploration and histopathological examination, which was used as a control for the evaluation of MDCT findings, were included in this study.Results: Majority (54.5%) of the patients were in the age group of 31-50 years. MDCT detected   adnexal masses as malignant in 56 cases, while in other 56 cases it read adnexal masses as benign. Final histopathology revealed adnexal masses in 57 (51%) cases as malignant while in 55 (49%) cases as benign. There were three cases which on MDCT appeared as malignant were subsequently found to be benign in histopathology. Similarly there were four cases which on MDCT appeared as benign were subsequently proved to malignant in histopathology. The sensitivity, specificity, Positive predictive value and negative predictive value of MDCT for diagnosing a malignant adnexal mass was 93.0%, 94.5%, 94.6% and 92.8% respectively. MDCT findings more predictive of malignancy were solid or cystic-solid mass, necrosis in a solid lesion, cystic lesion with thick, irregular walls or septa, and/or with papillary projections. The presence of ascites, peritoneal metastases, and lymphadenopathy were also helpful to confirm malignancy.Conclusions: MDCT is an excellent and accurate non-invasive modality in the detection and characterization of adnexal masses from benign and malignant

Criterios sonográficos de evaluación de malignidad del tumor de ovario Metodología IOTA (International Ovarian Tumor Analysis Group)

The detection of an adnexal mass by ultrasound is the starting point of a long way of anxiety for the gynecological patient. Ovarian cancer is one of the most frequent gynecological neoplasms in the world; 75% of ovarian cancers are diagnosed in advanced stages (III or IV), when 5-year survival does not exceed 10%. Multiple attempts have been done to unify criteria of ovarian cancer screening, and no consensus has been achieved. Combined methods have been described, including gray-scale and color Doppler ultrasound screening, that consider quantitative scores to evaluate the risk of cancer in ovarian tumors. Despite its increasing predictive value, this method is not frequently used by gynecological diagnostic units in our country. The International Tumor Analysis Group (IOTA) has developed and validated predictive models based on multicenter data series with measurements and standardized data collection that have achieved predictable and quite acceptable estimation of malignant pathology. Considering the high rate of false positivity with current methods, it is important to improve the rate of ultrasound detection of pathologies for correct derivation and surgical oncologic approach as required.

La detección de una masa anexial durante una sonografía es el punto de partida de un largo camino de ansiedad para las pacientes en ginecología. El cáncer de ovario es una de las neoplasias ginecológicas más frecuentes en el mundo. El 75% de los cánceres de ovario es diagnosticado en estadios avanzados (III o IV), cuya sobrevida a los 5 años no sobrepasa el 10% en promedio. Se han realizado múltiples intentos para unificar el cribado clínico del cáncer ovárico, sin haberse logrado consenso para la pesquisa de esta enfermedad. Los métodos combinados incluyen la ecografía en escala de grises y la flujometría Doppler, que consideran puntuaciones cuantitativas para evaluar el riesgo de cáncer en los tumores ováricos. A pesar de su creciente valor predictivo, este método no es usado frecuentemente por las unidades de diagnóstico de ginecología en el país. El International Tumor Analysis Group (IOTA) ha desarrollado y validado modelos predictivos basados en series de datos multicéntricos con mediciones y recolección de información estandarizada que han logrado un nivel de predicción de patología maligna bastante aceptable. Considerando la alta tasa de falsos positivos de los actuales métodos, es importante mejorar la tasa de detección sonográfica de esta patología para una correcta derivación y abordaje quirúrgico con enfoque oncológico, cuando el caso lo requiera.

Adnexal mass: a clinicopathological study at a tertiary care centre in Assam, India

Background: An adnexal mass may be found in females of all ages with significantly variable prevalence, but more common among women of reproductive age. Adnexal masses pose a special dilemma to the attending gynaecologist because the diagnosis is often difficult and differential diagnosis is vast. Clinical examination is the first step in evaluation of patients with adnexal mass. Pelvic masses which are undetected or overlooked on physical examination can be identified by Ultrasonography. The aims and objectives of the study were to: to find out different types of adnexal pathology clinically, correlation of clinical finding with histopathology, correlation of ultrasonography finding with histopathology.Methods: The present study was carried in the Department of Obstetrics and Gynecology, Assam medical college and hospital, Dibrugarh from 1st July 2017 to 30th June 2018. This study was a hospital based observational study which included 145 patients of adnexal mass attending the GOPD who required admission and operative intervention. All cases underwent an abdominal ultrasound examination with color Doppler. Transvaginal sonography was done wherever feasible. Following surgery, specimens were sent for histopathological examination and the reports were correlated with pre-operative clinical and ultrasonography findings.Results: The most common site of origin of adnexal mass was ovary (92.41%) followed by fallopian tube (6.20%) and broad ligament (1.39%). Majority (79.31%) were non neoplastic or benign adnexal masses. All cases of adnexal malignancy were of ovarian origin. The sensitivity and specificity of clinical examination for diagnosis and discriminating benign and malignant ovarian neoplasms were 70% and 86.6% and that of ultrasonography was 86.67% and 96.65% respectively.Conclusions: Adnexal mass in reproductive age group were mostly non neoplastic and benign, whereas malignancy was mostly seen in peri and post-menopausal age group. Ultrasonography is a useful adjunct to clinical examination for diagnosis and proper management of patients with adnexal mass in low resource setup.

Diagnostic accuracy of the risk of malignancy index 1 compared to the more recent IOTA ADNEX model in discriminating benign from malignant adnexal masses: a multi-centric study

Background: Identification of the nature of an adnexal mass can ensure optimum management. Single parameters as well as diagnostic models using a combination of several parameters are in use. The International Ovarian Tumor Analysis (IOTA) consortium has developed and published the Assessment of Different NEoplasias in the adneXa (ADNEX) model, which differentiates between benign and malignant masses. Authors conducted this study with the aim of finding a cut off value for this model in the study population and comparing the diagnostic accuracy of this model to that of the risk of malignancy (RMI).Methods: Women with adnexal masses admitted to the 3 medical college affiliated hospitals for surgical management were included in this study. Appropriate investigations were done to calculate the RMI-I and ADNEX score for each participant. A cut off score for the ADNEX model was determined and diagnostic accuracy tests were done for comparison.Results: At a cut-off of 29 for the ADNEX model and 200 for RMI model the sensitivity was 75% and 77.8, specificity 100% and 80.6%; Positive Predictive Value (PPV) 100%and 60%; Negative Predictive Value (NPV) 91% and 90.6%; Positive Likelihood ratio of infinity and 4 and a negative Likelihood Ratio of 2.8 and 2.5 respectively.Conclusions: The ADNEX model rates higher than the RMI in almost all tests of diagnostic accuracy and can be used for triaging, framing a referral policy and prioritizing surgery.

Valoración preoperatoria de la masa anexial

The adnexal mass is the tumor that can be located in the ovary, fallopian tube or the surrounding connective tissue (mesosalpinx, mesoovarian tissue and broad ligament). It is a common gynecological problem. The previous determination of benignancy or malignancy is essential for an adequate management. There is a variety of radiological methods, biomarkers and pre-surgical clinical methods and predictive models that have been studied and validated in the world to differentiate the etiology of the adnexal masses. J Kaijser et al performed a systematic review and meta-analysis on the use of predictive mathematical models in the presurgical diagnosis of adnexal masses. At present, the review of the different studies and systematic reviews show that both IOTA LR2 and Simple Rules are the best diagnostic methods available to differentiate benign and malignant adnexal masses preoperatively. In women in reproductive age this disquisition is of vital importance for the preservation of fertility. Likewise, the predictive results of benign disease could be treated by gynecologists-obstetricians or in the general hospitals, and patients with suspected malignancy can be referred and treated by gynecologist oncologists.

La masa anexial es la tumoración que puede localizarse en ovario, trompa de Falopio y el tejido conectivo que los rodea (mesosálpinx, mesoovario y ligamento ancho). Es un problema ginecológico común. La determinación del riesgo de benignidad o malignidad previa es esencial para un manejo posterior adecuado. Existe gran variedad de métodos radiológicos, biomarcadores o métodos clínicos prequirúrgicos y modelos predictivos que han sido estudiados y validados en diversas partes del mundo para poder diferenciar la etiología de las masas anexiales. J Kaijser y col. realizaron una revisión sistemática y metaanálisis del uso de modelos matemáticos predictivos en el diagnóstico prequirúrgico de masas anexiales. En la actualidad, la revisión de los diferentes estudios y revisiones sistemáticas muestran que ambos IOTA LR2 y Simple Rules son los mejores métodos de diagnóstico disponibles para poder diferenciar masas anexiales benignas y malignas en forma preoperatoria. En mujeres en edad reproductiva, esta disquisición es de vital importancia para la preservación de la fertilidad. Asimismo, los resultados predictivos de enfermedad benigna podrían ser tratados por especialistas ginecoobstetras o en hospitales generales y las pacientes con sospecha de malignidad ser referidas y tratadas por ginecólogos oncólogos.

Evaluation of Probably Benign Adnexal Masses in Postmenopausal Women / Avaliação de massas anexiais benignas em mulheres pós-menopáusicas

Abstract Background Preoperatively identification of malignancy potential of a postmenopausal adnexal masses is important. Aim To evaluate the effectiveness of the Risk of Malignancy Index-2 in presumably benign adnexal masses in postmenopausal women. Study Design Retrospective, observational study. Methods 119 women with postmenopausal adnexal masses with a preliminary diagnosis of benign tumors according to the Risk of Malignancy Index-2 were included. Age, duration of menopause, ultrasonographic findings, and serum CA-125 levels were recorded preoperatively. The definitive diagnosis was based on postoperative histopathological examination. Results Of 119 adnexal mass, 10 were malignant and 109 were benign. There was no statistically significant difference with regard to age and tumor size between the groups. The two significant ultrasonographic parameter between groups were the presence of solid area in the mass and bilaterality. Moreover, if the cut off point for serum CA-125 was adjusted to 14.75 IU/mL according to ROC curve, a sensitivity value of 80% and a specificity value of 72% could be achieved to discriminate benign and malign cysts. Conclusion In the differential diagnosis of benign and malignant adnexal masses in postmenopausal women, the presence of a solid component, bilaterallity based on ultrasonography and high CA-125 values may be used as discriminative criteria. There is no direct relation between the size of the adnexal mass and malignancy potential. Therefore, in the malignancy indexes of postmenopausal women, we recommend lower cut-off values of CA-125 to increase the sensitivity of preoperative evaluation tests without having a great impact on negative predictive values.

Resumo Introdução É fundamental identificar o potencial maligno de massas anexiais pósmenopáusicas no período pré-operatório. Objetivo Avaliar a efetividade do risco de malignidade (risk of malignancy index-2, RMI2) em massas anexiais benignas presumíveis em mulheres na pós-menopausa. Desenho do Estudo Estudo observacional retrospectivo. Métodos Este estudo foi conduzido em nossa clínica de cirurgia de endoscopia e endoscopia de nosso hospital entre janeiro de 2013 e setembro de 2015. Um total de 119 mulheres com massas anexiais pós-menopausa com diagnóstico preliminar de tumores benignos de acordo com o RMI-2. A idade, a duração da menopausa, os achados ultrassonográficos e os níveis séricos de CA-125 foram registados no préoperatório. O diagnóstico definitivo foi baseado no exame histopatológico pósoperatório. Resultados A média de idade dos pacientes foi de 55,4 6,71 anos. O exame histopatológico revelou que 8,4% das massas anexiais eram tumores malignos ou limítrofes, enquanto 91,6% eram benignos. Não houve diferença estatisticamente significante quanto ao tamanho do tumor e do tamanho das lesões entre patologias malignas e benignas. Não houve diferença estatisticamente significativa entre pacientes benignos e malignos quanto à idade e tamanho do tumor. Os dois parâmetros ultrasonográficos estatisticamente significativos entre os grupos foram a presença de área sólida na massa e bilateralidade. Além disso, se o ponto de corte para CA-125 sérico fosse ajustado para 14,75 UI/mL de acordo com a curva receiver operating characteristic (ROC), um valor de sensibilidade de 80% e um valor de especificidade de 72% poderiam ser conseguidos para discriminar cistos benignos e malignos (área sob a curva [ASC]: 0,89). Conclusão No diagnóstico diferencial de massas anexiais benignas e malignas em mulheres pós-menopáusicas, a presença de um componente sólido, bilaterais com base na ultra-sonografia e valores elevados de CA-125 podem ser utilizados como critério discriminatório. Parece que não há relação direta entre o tamanho da massa anexial eo potencial maligno. Portanto, nos índices de malignidade de mulheres pósmenopáusicas, recomendamos valores de corte mais baixos de CA-125 para aumentar a sensibilidade dos testes de avaliação pré-operatória sem ter grande impacto em valores preditivos negativos.

Masa anexial complicada en mujer postmenopáusica: tumor de Brenner de ovario izquierdo torcido / Dough adnexal complicated in woman postmenopausal: ovarian Tumor Brenner left twisted Case Report And Review

Los tumores anexiales representan una patología ginecológica frecuente e importante. El tumor de Brenner es una neoplasia poco frecuente que constituye 1.5-2.5% del total de neoplasias ováricas. Se presenta una paciente de sexo femenino de 62 años que acude por dolor intenso en flanco izquierdo, indicándose estudios complementarios, entre ellos, ecografía abdominal que informa masa de contenido mixto. Se realiza laparotomía exploradora, se constata tumor de ovario izquierdo, torcido, procediéndose a anexo ooforectomía izquierda. Posteriormente, estudio de biopsia informa diagnóstico de tumor de Brenner. Los tumores anexiales pueden representar un verdadero desafío, y requieren un diagnóstico certero y manejo adecuado. Es fundamental sospechar malignidad. El presente caso manifestó numerosos rasgos de malignidad, resultando fortuitamente ser benigno. Se optó por cirugía de laparotomía exploradora más anexo ooforectomia izquierda, decisión bastante controversial debido a la falta de un diagnóstico anatomopatólogico, pero necesaria por la presentación complicada del cuadro.

The adnexal tumors represent a frequent and important gynecological pathology. The Brenner tumor is a rare neoplasm constituting 1.5-2.5% of all ovarian neoplasms. A 62-year-old female patient is presents intense pain in the left flank, and complementary studies are indicated, including abdominal ultrasound that reports mass of mixed content. Exploratory laparotomy is performed, left ovary tumor is twisted, and left oophorectomy is performed. Subsequently, biopsy study reports diagnosis of Brenner's tumor. Adnexal tumors can be a real challenge, requiring accurate diagnosis and proper management. It is fundamental to suspect malignancy.The present case manifested numerous traits of malignancy, being fortuitously benign.We opted for exploratory laparotomy surgery plus left oophorectomy, a rather controversial decision due to the lack of an anatomopathological diagnosis, but necessary due to the complicated presentation of the picture.

Cirugía mínimamente invasiva de tumoración quística abdominal gigante en paciente puérpera / Minimally invasive surgery of a giant abdominal cyst tumor in a puerperal patient

La incidencia de masas anexiales diagnosticadas durante el embarazo varía según las diferentes series consultadas; sin embargo, masas de tamaño superior a 6 cm suponen casos excepcionales en la literatura. El manejo de este tipo de pacientes supone un reto para el equipo multidisciplinario, ya que se debe tener en cuenta el riesgo de cáncer de ovario en este tipo de pacientes. Se trata de una gestante de 34 años a la que se le diagnostica una masa anexial gigante durante el control ecográfico del primer trimestre. Ante la ausencia de sufrimiento fetal y teniendo en cuenta las características radiológicas de la lesión, se decide mantener una actitud expectante a la espera de un parto vía vaginal y poder realizar una cirugía electiva para la exéresis de la lesión. Tras el parto, la paciente sufre una anemización progresiva, por lo que se decide priorizar la intervención quirúrgica. Se llevó a cabo una exéresis de la masa mediante un abordaje mínimamente invasivo. Tanto la paciente como el recién nacido, tuvieron una evolución favorable. La paciente fue dada de alta tres días después de la cirugía(AU)

The incidence of adnexal masses diagnosed in pregnancy varies by the different consulted series; however, over 6cm long masses represent exceptional cases in literature. The management of this type of patients is a challenge for the multidisciplinary team since the risk of ovarian cancer should be taken into consideration in this type of patients. This is a 34 years-old pregnant patient who was diagnosed with giant adnexal mass during the echographic control of the first trimester. Due to the lack of fetal distress and the radiological characteristics of the lesion, it was decided to keep surveillance to wait for the vaginal delivery and to perform an elective surgery to remove the lesion. After the childbirth, the patient suffered a process of anemia, so it was decided to prioritize surgery. The mass was excised through a minimally invasive approach. Both the mother and the newborn had favorable recovery and the patient was discharged from hospital three days after surgery(AU)