Ovarian tumors in pregnancy. A private hospital ten year survey

Adnexal masses in pregnancy: An updated review

Adnexal masses in pregnancy are not commonly encountered. The majority of these masses are discovered incidentally during routine follow-up. However, some of these masses become symptomatic due to their size, location, and impingement of adjacent structures. Several diagnostic modalities can be utilized for the detection of adnexal masses with different sensitivity and specificity rates. The differential diagnosis of adnexal masses discovered during pregnancy is broad and includes both benign and malignant lesions. The management of such lesions has been a subject of debate for years with no consensus regarding the best management plan. Tumor size, site, and the trimester of mass detection are all crucial in management. In this account, we review adnexal masses discovered in pregnancy, the diagnostic modalities utilized for detecting these lesions, their differential diagnosis, and management strategies.

Management of incidental adnexal masses on caesarean section

BACKGROUND

The reported incidence of adnexal masses during pregnancy vary from 1 in 81 pregnancies to 1 in 8000 pregnancies. There is still a debate on management of incidental adnexal masses during the caesarean section concerning the risk of this additional procedure on postoperative morbidity and mortality. The aim of our study was to investigate the management of incidental adnexal masses which were observed during caesarean section in a tertiary health care centre.

MATERIALS AND METHODS

The medical records of the patients who had incidental adnexal masses during caesarean section at Bakirkoy Dr. Sadi Konuk Teaching and Research Hospital, Department of Obstetrics and Gynecology from January 2006 to September 2011 were evaluated retrospectively. The data was processed with the SPSS 16.0 statistical software.

RESULTS

The number of total live births was 17341 and 6624 of them were done by caesarean section (31%). There were 38 cases of incidental adnexal masses which were discovered at caesarean section. The most common pathologic diagnosis of the masses were paraovarian-paratubal cysts with the rate of 23.7% (n=9). Cystectomy procedure during caesarean section did not alter the morbidity of the patient.

CONCLUSIONS

In conclusion for detecting adnexal masses during pregnancy follow-up of growth rate of adnexal mass will be a useful reference during the observation period if ideally all pregnant women have a first-trimester ultrasound examination with regular adnexa check-up.

Bilateral Ovarian Endometriomas Presenting as Nonprogress of Labor: First Case Report in the Literature Is Concomitant Surgical Excision during Cesarean Section Advisable?

Objective. To report the first case of bilateral ovarian endometriomas, leading to nonprogress of labour, successfully excised during cesarean section. Design. Case report. Setting. Department of Obstetrics & Gynecology of Dr. RPGMC Tanda, Kangra, India. Patients. A primigravida in labour at term gestation. Interventions. Surgical management. Main Outcome Measures. Description and treatment of a pregnant woman with bilateral ovarian endometriomas during cesarean section. Results. Successful excision of ovarian endometriomas and reconstruction of the ovaries during cesarean section. Conclusion. Management of incidentally detected endometriomas during cesarean section should be individualized, taking into account the symptoms, size, bilaterality, and adhesion with adjacent organs.

The role of 3-dimensional power Doppler imaging in the assessment of ovarian teratoma in pregnancy: a case report

Background. Conventional sonography is the primary imaging tool for these pregnant women who present with an ovarian teratoma. In some cases, however, sonography diagnosis is difficult. We report a case of ovarian teratoma during pregnancy diagnosed by three-dimensional Power Doppler. The cyst was removed via laparotomy without fetal or maternal complications. Three-dimensional ultrasound with multiplanar view can better discriminate a benign ovarian teratoma from complex ovarian lesions or malignant tumors. Its role is significant especially during pregnancy as it may assist in determining which patients are requiring surgery and which are not. The results of three-dimensional sonography and magnetic resonance (MR) were equal but the role of MR imaging is limited in early pregnancy. Conclusions. Three-dimensional technique is a reliable diagnostic modality for preoperative assessment of an ovarian teratoma as it can be performed during the first trimester of pregnancy.

Conservative management of ovarian cysts in pregnancy during third trimester and intrapartum

We treated two patients with large ovarian cysts in pregnancy conservatively. In both cases, aspiration of the cysts under ultrasound guidance allowed successful vaginal delivery. In one case, the cyst fluid reaccumulated, and required further aspiration in labour. In both cases, benign ovarian cysts were removed laparoscopically at a later date. Various strategies for dealing with ovarian cysts in pregnancy are discussed.

The value of ultrasound visualization of the ovaries during the routine 11–14 weeks nuchal translucency scan

OBJECTIVE

To investigate the feasibility and possible value of routine screening for ovarian pathology in asymptomatic pregnant women at 11-14 weeks' gestation.

STUDY DESIGN

A policy of routine ovarian visualization was implemented in 2925 pregnant women attending for a nuchal translucency scan at 11-14 weeks' gestation. In all cases, an attempt was made to visualize the ovaries on transabdominal ultrasound scan. Simple cysts were defined as unilocular cysts with regular internal walls and no solid components, which contained clear anechoic fluid. All other cysts were classified as complex. Simple cysts<5 cm in diameter were all managed expectantly with no further follow-up. All women with large simple cysts>or=5 cm in diameter or complex cysts had further detailed follow-up scans. Surgical intervention during pregnancy was offered to women with clinical symptoms suggestive of cyst complications or those with ultrasound features suggestive of malignancy. All other women were managed expectantly until after delivery.

RESULTS

Adnexal cysts were found in 728/2925 (24.9%) pregnant women. 400/728 (55%) women had simple cysts<5 cm in diameter, whilst 328/728 (45%) women had large simple or complex cysts requiring follow-up. On subsequent scans, cysts resolved spontaneously in 278/328 (84.8%) women. A total of 33/728 (4.5%) women with ultrasound evidence of adnexal cyst underwent surgery. In one woman the intervention was required because of pain, one woman had suspected cancer on ultrasound scan and the remaining 31/33 (94%) of operations were performed at patients' requests. All the cysts were found to be benign on histological examination. The overall intervention rate was 1.1/100 screened pregnant women or 4.5/100 cysts detected on ultrasound scan.

CONCLUSION

Asymptomatic adnexal cysts detected in the first trimester of pregnancy are unlikely to be malignant or to cause clinical symptoms antenatally. The policy of routine ultrasound visualization of the ovaries in pregnancy cannot be justified.

Malignant Adnexal Masses in Pregnancy

Ovarian tumors during pregnancy are very rare; however, a cancer diagnosis causes distress to the couple. Reassurance is paramount, and the first consideration should be given to the safety of the mother. If both mother and fetus can be preserved, treatment to minimize the risks to both should be planned accordingly. It is imperative to care for the patient with a multidisciplinary team that includes a high-risk obstetrician, a gynecologic oncologist, and a medical oncologist specialized in gynecologic cancers.

Laparoscopy for adnexal masses in the second trimester of pregnancy

STUDY OBJECTIVE

To assess the safety of laparoscopic treatment of adnexal masses in the second trimester of pregnancy.

DESIGN

Retrospective chart review (Canadian Task Force classification II-3.

SETTING

Large tertiary care medical center.

PATIENTS

Eleven women.

INTERVENTION

Laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

All masses were identified by ultrasound. The average gestational age at the time of surgery was 17 weeks, 4 days. In seven women the primary cannula was inserted in the left upper quadrant of the abdomen. Procedures were eight ovarian cystectomies, two oophorectomies, and one exploratory laparoscopy. Average operating time was 135 minutes (range 95-195 min). Average time exposed to carbon dioxide was 78 minutes (range 59-135 min). None of the masses was malignant. There were no fetal complications or malformations. No patients had preterm labor and all delivered at term.

CONCLUSIONS

The increasing number of reported cases and our experience suggest that laparoscopic treatment of adnexal masses in the second trimester is safe and effective, but the surgeon must be skilled in advanced techniques of laparoscopic surgery.

Adnexal mass evaluation in the emergency department

Female patients who have stable vital signs presenting to the emergency department with abdominopelvic pain and an adnexal mass can be extremely difficult to manage. However, by performing a rapid problem-oriented history and physical with emphasis on the age of patient, menstrual history, and pelvic exam, a detailed differential diagnosis can be compiled. With the addition of a complete blood count and HCG, if appropriate, and a CA-125 for your consultant, additional information can be obtained while a ultrasound examination is being performed. With the above information, consultation and disposition should be readily accomplished.

Adnexal masses in pregnancy: a review of 130 cases undergoing surgical management

OBJECTIVE

Our purpose was to determine maternal and fetal outcome in patients undergoing surgery for pelvic mass in pregnancy.

STUDY DESIGN

Maternal and fetal records of 130 cases of adnexal masses associated with intrauterine pregnancy that required laparotomy or aspiration or that were diagnosed incidentally at the time of cesarean section were reviewed. The chi(2) and Fisher's exact tests were used for statistical analysis. A P value of </=.05 was considered significant.

RESULTS

The incidence of adnexal masses in pregnant women who required surgical management was 1 in 1312 live births. A malignant tumor or a tumor of low malignant potential was found in 6.1% of cases. In 10 patients the only finding at the time of laparotomy was leiomyomas. Ultrasonography was not helpful in distinguishing tumors of low malignant potential from benign neoplasms or in identifying the source of the pelvic mass in patients found to have only leiomyomas. There were 2 intrauterine fetal deaths and 1 neonatal death in this cohort of patients. Patients who underwent laparotomy after 23 weeks' gestation had a significantly higher adverse pregnancy outcome compared with those who underwent laparotomy earlier in pregnancy (P =.005).

CONCLUSION

The incidence of an adnexal mass during pregnancy in our population was consistent with what has been reported in the literature. However, the percentage of malignant tumors or tumors of low malignant potential was 2-fold greater than previously reported. Preoperative ultrasonography was not helpful in differentiating tumors of low malignant potential from benign neoplasms.

Ultrasound-guided fine needle aspiration of ovarian cysts during pregnancy

OBJECTIVE

To evaluate the safety and efficacy of ultrasound-guided fine needle aspiration in the treatment of ovarian cysts during pregnancy.

STUDY DESIGN

Nine out of twenty-nine patients between the 6th and the 16th week of gestation with unilateral ovarian cysts ranging between 65 and 540 cm3 in volume were selected for sonographically-guided fine needle aspiration.

RESULTS

No complications were observed at either short or long-term follow-up; all patients delivered healthy infants at term. Clinical and sonographic post-partum follow-up was uneventful in all cases. In three cases it was necessary to repeat the procedure once and in one case twice during pregnancy. In one case a recurrent serous cyst was excised at operative laparoscopy performed 3 months after delivery.

CONCLUSIONS

Ultrasound-guided fine needle aspiration was safely performed in nine patients as an alternative treatment to surgery when persistent monolateral and unilocular ovarian cysts with regular borders and completely anechoic structure are detected during pregnancy.

Ovarian cancer complicating pregnancy

Ovarian cancer is the second most frequent gynecologic cancer complicating pregnancy. Although uncommon, this is a topic that encompasses multiple aspects of obstetrics and gynecology. The management of the adxenal mass in pregnancy, surgery for ovarian cancer, chemotherapy during gestation, and the use of tumor markers during pregnancy are discussed.

Ovarian tumors associated with pregnancy

OBJECTIVE

The clinical characteristics of ovarian tumors associated with pregnancy were investigated.

METHOD

A series of 106 cases of ovarian tumor surgically resected during pregnancy was investigated with respect to incidence, clinicopathologic features and outcome.

RESULTS

Among 106 cases undergoing ovarian surgery, 31 (29.2%), 70 (66%) and five (4.7%) were diagnosed as physiologic, benign and malignant, respectively. The incidence of benign neoplastic tumor was 1:112 deliveries and that of malignant neoplastic tumor was 1:1684 deliveries. Dermoid cyst was the most common lesion found. Of the 70 benign tumors, 51 (72.9%) were greater than 8 cm in diameter and 55 (78.6%) were preoperatively diagnosed before the 10th gestational week; 44 (62.9%) were operated before the 15th gestational week. The spontaneous abortion rate in 80 cases followed up after surgery was only 10%, 61 patients (76.3%) progressing to full-term delivery. Five malignant tumors included three epithelial carcinomas, one embryonal carcinoma and one dysgerminoma.

CONCLUSION

Ovarian surgery in the first trimester for persistent or enlarging masses is important to obtain a final histologic diagnosis and rule out malignancy.

Cancer in pregnancy: a review of the literature. Part I

Cancer is an important cause of death in the United States in women of childbearing age. Approximately 1 per 1000 pregnant women will develop cancer. This review (Part II follows in this issue) examines the diagnosis, prognosis, and management of cancer during pregnancy; both in terms of the cancer's effect on the pregnancy, and the pregnancy's effect on the cancer. Some diagnostic modalities and some therapies are problematic to the fetus and placenta. However, in most cases and the pregnancy can be managed concurrently with a good outcome for the baby and without compromising the mother's prognosis.

Ovarian cancer in pregnancy

A pelvic mass in pregnancy is a relatively common entity, especially considering the increased use of ultrasound or early fetal evaluation. These masses can derive from multiple gynecologic and nongynecologic origin, and fortunately the majority will resolve with observation into the second trimester. Masses persisting into the second trimester should be surgically evaluated given the decreased risk to both mother and fetus at this time. For masses persisting into the third trimester, a 2% to 5% risk of malignancy is to be expected. Documentation of disease (FIGO stage) is critically important in defining need for adjuvant cytotoxic chemotherapy. Above all, potentially lifesaving therapy should not be withheld from patients because they are pregnant, especially considering that chemotherapy is apparently safe in the second and third trimesters.

Cisplatin protein binding in pregnancy and the neonatal period

The most effective combination regimes for ovarian cancer contain cisplatin, but there is little knowledge about cisplatin use during pregnancy. The high protein binding of cisplatin means that small changes in protein binding result in large changes in the fraction of free drug. It is the free form of cisplatin that crosses the placenta and may contribute to fetal toxicity. The purpose of the present study was to compare protein binding of cisplatin in pregnant women, non-pregnant women, and newborn infants. We found that babies and pregnant women had significantly lower concentrations of both protein and albumin compared to non-pregnant women. Analysis of variance found overall significant differences in protein binding among the three groups over time (P < .05). Babies had statistically less cisplatin protein binding than non-pregnant women at 80 minutes and all time points thereafter (P < .05). In contrast, pregnant women had statistically less cisplatin protein binding than non-pregnant women at 3.3 and 8 hours (P < .05). Of interest, at 75.2 hours, the percentage of free cisplatin was 15% in babies as compared with 9% in non-pregnant women and 10% in pregnant women. This means that the fetus is exposed to 50% higher platinum levels at equal total concentration. Cisplatin protein binding significantly correlated with albumin concentrations at 3.3, 8, and 24 hours (P < .01). Our analysis reveals that pregnancy and fetal changes in cisplatin protein binding are caused in large part by lower albumin levels. The resulting higher levels of free drug in the mother and fetus may increase the risk of toxicity in both.

Ovarian tumours in pregnancy

Ovarian tumours associated with pregnancy were reviewed for the period 1982-1991. The overall incidence of this complication was 1:653 deliveries; 62.7% of the tumours were diagnosed in the first and second trimesters of pregnancy. The value of routine pelvic examination and ultrasonic scan as a diagnostic aid in early pregnancy is emphasized; 25.4% of patients presented as an acute emergency; 23.9% of the tumours were incidentally discovered at Caesarean section which underlines the importance of examining the ovaries at operation. Benign cystic teratomas were the most common ovarian tumours found, followed by serous cystadenomas. The incidence of malignant tumours was 4.5%. Whenever an ovarian tumour is found, the possibility of malignancy should always be borne in mind. Treatment of ovarian tumours in pregnancy should be tailored according to the age of the patient, parity, clinical presentation, gestational age and biology of the tumour.

Ovarian endodermal sinus tumor associated with pregnancy: review of the literature

Endodermal sinus tumor is the second most common malignant germ cell tumor of the ovary and its reported concurrence with pregnancy is extremely rare. This report is the 10th case of endodermal sinus tumor associated with pregnancy and also reviews the previous literature regarding the subject.

Conservative management of an ovarian cyst in late pregnancy

We report a case of concomitant ovarian tumor and pregnancy. Sonographic examination indicated that the tumor was benign and obstructed the birth canal. After conservative treatment (puncture of the cyst), a normal vaginal delivery was possible. Two days after delivery, salpingo-oophorectomy was performed because of torsion of the cyst. Pathological examination confirmed the benign nature of the cyst.

Ovarian carcinoma during pregnancy: a study of 23 cases in Israel between the years 1960 and 1984

Data from a study on malignant ovarian tumors in pregnancy in Israel are presented. During the 25-year period of the survey, 23 new cases of malignant ovarian tumors during pregnancy were diagnosed, representing an incidence of 0.12/100,000 females over the age of 14; over half of the patients were in their third decade of life at the time of diagnosis of the tumor. Ovarian malignant tumors during pregnancy are more prevalent in Jewish women of European-American origin than in those of Asian-African descent. Borderline carcinomas were found in 35% of our patients; epithelial invasive tumors were found in 30%; the other tumors were dysgerminoma (17%), granulosa cell tumor (13%), and undifferentiated carcinoma (5%). Most of the patients (74%) were diagnosed in stage I. In three cases, ovarian cancer was diagnosed during surgery for tubal pregnancy, and in two during cesarean section at term. In early-stage disease and low-potential-malignancy tumors, surgery can be conservative; thus, 14 of 23 bore a live child. In advanced disease, aggressive surgery, chemotherapy, and/or radiotherapy should be instituted. Factors affecting prognosis were age of patient, histologic type of tumor, and clinical stage of disease. Overall, the survival is much better than that for ovarian tumors in general, because most of the tumors are of low potential malignancy and are diagnosed at an early stage.

Malignant ovarian tumors associated with pregnancy: report of six cases

Six cases of pregnancy associated malignant ovarian tumors, four epithelial cancers, one immature teratoma and one metastatic cancer of colon origin, are reported. One patient with mucinous cystadenocarcinoma had a history of persistent ovarian tumor during her past three pregnancies. Another patient was found to have mucinous cystadenocarcinoma after an emergency operation for twisted ovarian tumor. Immature teratoma associated with pregnancy is very rare and our case seems to be the 8th reported such case.

Ovarian tumors in pregnancy

Thirty-eight women were operated for an ovarian tumor diagnosed during pregnancy, with an incidence of 1/2328 deliveries. The diameter of all tumors was above 5 cm. Of the 31 women operated before delivery, seven were untreated and 24 received supportive progestational therapy. The rate of abortions was 85.7% in the untreated group and 10% in the hydroxy-progesterone-caproate group (HPC) (P less than 0.02). When the women received a total dose of HPC of more than 300 mg, 9 of 10 pregnancies reached term with a live child. Two ovarian malignancies were found, 5.3% of all cases. In 42.9% of the women there were fertility problems later in life. Ovarian tumors during pregnancy should be removed as soon as possible, irrespective of the age of the pregnancy. If fully progesterone therapy is given, the danger of abortions is reduced to a minimum. Prophylactic antibiotic treatment should also be administered.

Ultrasound study of ovarian cysts in pregnancy: prevalence and significance

Previous surveys of the prevalence and natural history of ovarian cysts have been based on those ascertained by clinical examination. This study examines the fate of 137 adnexal cysts discovered during the course of 26 110 ultrasound scans in early pregnancy. Of these 10% were operated on in the first instance, and a further 2% required operation during pregnancy for painful complications. In 3% cysts were removed at caesarean section or in the puerperium. Half the removed cysts were neoplastic including one low grade carcinoma. Of the 120 cysts treated conservatively, 89% could not be detected on ultrasound examination later in pregnancy. All cysts greater than 8 cm should be removed, as should smaller cysts that are multilocular, thick-walled or semi-solid.

Pregnancy in association with a newly diagnosed cancer: a population-based epidemiologic assessment

Cancer patients who were pregnant at the time of cancer diagnosis were identified by the National Cancer Registry of the German Democratic Republic for the years 1970 through 1979. A total of 355 such cases occurred in women aged 15-44, and during the same period 2, 103, 112 live births were registered. Rank by site in order of decreasing frequency was cervix, breast, ovary, lymphoma, melanoma, brain and leukemia. On the basis of general female population rates, 555.8 cases were expected, giving a significantly reduced observed to expected ratio (O/E) of 0.64. O/E ratios rose with age. The O/E for invasive carcinoma of the cervix was significantly elevated at 1.15; carcinoma in situ of the cervix occurred significantly less frequently than expected (O/E = 0.57). For breast, brain, melanoma and leukemia, significantly fewer cases were observed than expected. Explanations considered for the low number of pregnancy-associated incident cancer cases include underreporting of pregnancy-associated cancer, altered tumor progression in pregnancy or decreased fertility in women with early neoplastic disease.

Ovarian tumors associated with pregnancy termination patients

One hundred adnexal masses were discovered at the time of pregnancy termination among a total of 55,278 pregnancy terminations performed at the Los Angeles County/University of Southern California Medical Center between 1970 and 1982. Seven patients were found to be not pregnant, and 93 masses were associated with pregnancy, for an incidence of one adnexal mass for every 594 (0.17%) terminations. Benign cystic teratoma was the most common lesion found (46;50%). There were two (2.2%) ovarian malignancies, 15 masses were bilateral, 11 masses were associated with pain, and torsion of the adnexa had occurred in seven cases. The preoperative diagnosis was made more commonly in the first trimester (86%) than in the second trimester (29%). Since many ovarian tumors are small, the true incidence is unknown. In a series of 998 abortion hysterectomies, 13 ovarian tumors were found, for an incidence of 1.3%.

Granulosa cell, Sertoli-Leydig cell, and unclassified sex cord-stromal tumors associated with pregnancy: a clinicopathological analysis of thirty-six cases

Seventeen granulosa cell, thirteen Sertoli-Leydig cell and six unclassified sex cord-stromal tumors diagnosed during pregnancy or the puerperium were reviewed. Eleven patients presented with abdominal pain or swelling, five in shock, two with virilization, and one with vaginal bleeding. Three asymptomatic patients were explored because of a palpable mass and one because of an adnexal mass found on ultrasound examination. In thirteen patients the tumor was discovered during a cesarean section; five of them had had dystocia and in eight of them the tumor was an incidental finding. All the tumors were Stage I but 13 of them had ruptured; all but one were unilateral. Hemoperitoneum was present in seven cases. On microscopical examination many of the tumors differed from tumors in the same diagnostic categories occurring in the absence of pregnancy by having a disorderly arrangement of their cells, lacking recognizable differentiation in many areas, showing prominent edema, and containing unusually large numbers of lutein or Leydig cells. The last two features were most obtrusive in tumors removed at term. With one exception the patients were initially treated by conservative surgical procedures. Two of them received chemotherapy and two radiation therapy postoperatively. A hysterectomy and salpingo-oophorectomy was performed at a second operation in eight cases; no residual tumor was found in any of the specimens. Only one patient had a recurrence, which was treated surgically. Follow-up for an average of 4.7 years is available for 30 of the 36 patients; all of them were alive and free of disease at the time of the last examination.