Current diagnostic approach to patients with adnexal masses: which tools are relevant in routine praxis?

Objective： The aim of the study was to investigate which anamnestic, laboratory and ultrasound parameters used in routine practice could predict the nature of adnexal mass, thus enabling referral to relevant specialist. Methods： Study involved the women treated for adnexal tumors throughout a period of 2 years. On admission, detailed anamnestic and laboratory data were obtained, expert ultrasound scan was performed, and power Doppler index （PDI）, risk of malignancy index （RMI） and body mass index （BMI） were calculated for all patients. Obtained data were related to histopathological findings, and statistically analyzed. Results： The study included 689 women （112 malignant, 544 benignant, and 33 borderline tumors）. Malignant and borderline tumors were more frequent in postmenopausal women （P=0.000）. Women who had benignant tumors had the lowest BMI （P=0.000）. There were significant （P〈0.05） differences among tumor types regarding erythrocyte sedimentation rate, CA125 and carcinoembryonic antigen （CEA） levels. Among ultrasound findings, larger tumor diameter and ascites were more frequent in malignant tumors （P=0.000）. Women with malignant tumors had highest values of RMI and PDI （P=0.000）. Conclusions： Anamnestic data, ultrasound parameters and laboratory analyses were all found to be good discriminating factors among malignant, benignant and borderline tumors.

Single Port Transumbilical Laparoscopic Surgery versus Conventional Laparoscopic Surgery for Benign Adnexal Masses： A Retrospective Study of Feasibility and Safety

Background： Single port laparoscopic surgery （SPLS） is an innovative approach that is rapidly gaining recognition worldwide. The aim of this study was to determine the feasibility and safety of SPLS compared to conventional laparoscopic surgery for the treatment of benign adnexal masses. Methods： In total, 99 patients who underwent SPLS for benign adnexal masses between December 2013 and March 2015 were compared to a nonrandomized control group comprising 104 conventional laparoscopic adnexal surgeries that were performed during the same period. We retrospectively analyzed multiple clinical characteristics and operative outcomes of all the patients, including age, body mass index, size and pathological type of ovarian mass, operative time, estimated blood loss （EBL）, duration of postoperative hospital stay, etc. Results： No significant difference was observed between the the pathological results between the two groups were found to two groups regarding preoperative baseline characteristics. However, be slightly different. The most common pathological type in the SPLS group was mature cystic teratoma, whereas endometrioma was more commonly seen in the control group. Otherwise, the two groups had comparable surgical outcomes, including the median operation time （51 min vs. 52 min, P = 0.909）, the median decreased level of hemoglobin from preoperation to postoperation day 3 （10 g/L vs. 10 g/L, P = 0.795）, and the median duration of postoperative hospital stay （3 days vs. 3 days, P = 0.168）. In SPLS groups, the median EBL and the anal exsufftation time were significantly less than those of the conventional group （5 ml vs. 10 ml, P〈 0.001; 10 h vs. 22 h, P〈 0.001）. Conclusions： SPLS is a feasible and safe approach for the treatment of benign adnexal masses. Further study is required to better determine whether SPLS has significant benefits compared to conventional techniques.

An improved risk of malignancy index in diagnosis of adnexal mass

Background With the advent of color Doppler flow imaging （CDFI） and technological development of detection of serum tumor markers,new opportunities are presented to the improved risk of malignancy index （RMI） based on Jacobs＇research for predicting ovarian malignancy in patients with adnexal masses.Methods One hundred and eighty women with an adnexal mass admitted for primary laparotomy were studied.Tumor specific growth factor （TSGF） adjusted ultrasound scores and the results of Doppler blood flow analysis were obtained before the operation.Based on the parameters which had been studied in Jacobs＇ research,TSGF levels and the findings of color Doppler flow imaging,the risk of malignancy model was redesigned using a binary Logistic regression model.The diagnostic efficacy of the improved risk of malignancy index （improved RMI） was compared with the Jacobs＇model RMI by receiver operator characteristic （ROC） curve.Results The ROC curve showed a higher sensitivity （Mcnamer＇s test,P 〈0.05） in the discrimination between benign and malignant adnexal masses for the improved RMI than the RMI.Compared with the RMI,the improved RMI had an advantage in prediction of ovarian germ cell tumors and granular cell tumor （28.57% vs.71.43%,P 〈0.05） and the early stage tumors and borderline tumors （33.33% vs.66.67%,P〈0.05）.Conclusion The predictability of the improved RMI is better than the classic Jacobs＇ model,especially in diagnosis of the ovarian germ cell tumors and granular cell tumor and other early stage adnexal tumors.

Role of minimally invasive surgery in complex adnexal tumours and ovarian cancer

Ovarian cancer is one of the most common causes of cancerrelated death in women. Adnexal masses are frequently diagnosed during reproductive age and often require surgical removal. The risk of malignancy when dealing with a complex adnexal mass should be defned prior to surgery and several scoring systems may be useful for this purpose. Laparoscopic management of ovarian tumours allows a minimally invasive approach with respect to several oncological assumptions. In the last decade concerns have been raised regarding the risk of cyst rupture and tumour spillage as a con-sequence of the laparoscopic technique itself both in early and advanced stages of ovarian cancer. Although limited data have been reported in the literature on the use of minimally invasive techniques in ovarian cancer, the clear benefits of this approach must be balanced with the potential hazards in different clinical situations. Laparoscopic staging in borderline tumours and presumed early-stage ovarian cancer performed by a laparoscopic oncologist seems to be safe and effec-tive when compared to laparotomy. The precise role of laparoscopy in patients with more advanced cancer is still to be defned, and the risk of suboptimal surgery should never outweigh the potential benefits of mini-mally invasive surgery. Thus, a tailored prediction of optimal laparoscopic debulking is mandatory in these patients.

Low-grade mucinous appendiceal neoplasm mimicking an ovarian lesion: A case report and review of literature

BACKGROUND Appendiceal tumors are rare lesions that may not be easily differentiated from primary ovarian lesions preoperatively,despite the use of advanced diagnostic methods by experienced clinicians.CASE SUMMARY A 59-year-old G2P2 woman,with chronic pelvic pain,underwent a pelvic ultrasound that revealed an adnexal mass measuring 58 mm×34 mm×36 mm,with irregular borders,heterogeneous echogenicity,no color Doppler vascularization and without acoustic shadowing.Normal ovarian tissue was visualized in contact with the lesion,and it was impossible to separate the lesion from the ovary by applying pressure with the ultrasound probe.Ascites,peritoneal metastases or other alterations were not observed.With the international ovarian tumor analysis ADNEX model,the lesion was classified as a malignant tumor(the risk of malignancy was 27.1%,corresponding to Ovarian-Adnexal Reporting Data System category 4).Magnetic resonance imaging confirmed the presence of a right adnexal mass,apparently an ovarian tumor measuring 65 mm×35 mm,without signs of invasive or metastatic disease.During explorative laparotomy,normal morphology of the internal reproductive organs was noted.A solid mobile lesion involved the entire appendix.Appendectomy was performed.Inspection of the abdominal cavity revealed no signs of malignant dissemination.Histopathologically,the appendiceal lesion corresponded to a completely resected low-grade mucinous appendiceal neoplasm(LAMN).CONCLUSION The appropriate treatment and team of specialists who should provide health care to patients with seemingly adnexal lesions depend on the nature(benign vs malignant)and origin(gynecological vs nongynecological)of the lesion.Radiologists,gynecologists and other pelvic surgeons should be familiar with the imaging signs of LAMN whose clinical presentation is silent or nonspecific.The assistance of a consultant specializing in intestinal tumors is important support that gynecological surgeons can receive during the operation to offer the patient with intestinal pathology an optimal intervention.

Unicentric Castleman’s Disease Presenting as Retroperitoneal Pelvic Lymph Node in Young Female—Laparoscopic Excision: A Case Report

Unicentric Castleman’s disease (UCD) is localized lymphoproliferative disease and has favourable prognosis. Surgery offers complete cure of unicentric Castleman disease. Radiotherapy offers either complete response or variable clinical response and cure in selected patients. The present case report is of a young unmarried obese girl presented with pain in right iliac fossa for 2 months. On pelvic ultrasound and MRI performed for diagnosis only single enlarged right external iliac lymph node was the positive finding. The CT scan guided biopsy was performed and the histopathological finding was lymphoid lesion-reactive lymphoid hyperplasia is favoured over Hodgkin’s lymphoma. Successful laparoscopic complete excisional surgery was performed for this single enlarged external iliac lymph node. The final histopathological report of the lymph node removed was unicentric Castleman’s disease, hyaline vascular type. This is the 16th such reported case of pelvic retroperitoneal UCD of hyaline vascular type treated by surgical excision, and 3rd case treated by Laparoscopic excisional surgery. By now at the time of reporting this case 4 months of follow up has been completed and patient does not have any symptom nor not show any sign of residual disease locally on transabdominal ultrasound examination and whole-body PET CT scan is also normal.

Ovarian Pregnancy: A Case Report

Background: Ovarian pregnancy is a rare entity of ectopic pregnancy, with a prevalence in the literature estimated between 1/2500 to 1/5000 births. The majority of ovarian pregnancies are diagnosed in the 1st trimester due to the noisy symptomatology. However, in small proportions, they may continue into the 2nd or 3rd trimester, making their diagnosis more difficult. Aim: We report a case of ovarian pregnancy in a 26-year-old patient, discovered intraoperatively as a large unruptured ovarian mass. Case report: A 26-year-old woman referred to the maternity ward for management of fetal death in utero at 31 weeks of amenorrhea associated with overlying placenta previa. Ultrasound performed in the department, was in favor of an abdominal pregnancy stopped at 31 SA with a placenta that seemed to adhere to the posterior wall of the uterus, which was empty. A Laparotomy was performed, on exploration, a large right ovarian mass was found, the site of the pregnancy. A right adnexectomy, after adhesiolysis, was performed. The incision of the operative part revealed a macerated female fetus. The clinical evolution was favorable. Conclusion: We report on a case of unruptured ovarian pregnancy, discovered in the 3rd trimester of pregnancy. The ultrasound diagnosis of an ovarian pregnancy beyond the 2nd trimester remains a challenge, the management remains surgical.