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PubMed1994

Management of Selected Adnexal Masses in Postmenopausal Women by Operative Laparoscopy-A Multicentered Study

With careful preoperative assessment we have selected postmenopausal women who were believed to have benign adnexal masses and who were candidates for removal of these masses via operative laparoscopy. Criteria for inclusion were: postmenopausal status; cystic adnexal mass less than 10 cm. with distinct borders and without irregular solid parts or thick septa; CA 125<35 U/ml; and no contraindications for surgery. Sixty-one women were entered into the study. All of the masses were benign, including 27 serous cysts, 15 serous cystadenomas, 1 mucinous cystadenoma, 5 serous cystadenofibromas, 6 paratubal cysts, 3 retroperitoneal cysts, and 4 chronic hydrosalpinges. Fifty-eight patients had successful pelviscopic removal of their adnexal mass. Three patients (5%) required laparotomy. For patients managed by operative laparoscopy, mean operating time was 63 minutes, mean postoperative stay was 12 hours, and mean time to return to normal activity was 5.6 days. We conclude that the combination of CA 125 values and pelvic ultrasound can successfully predict benign masses in postmenopausal women, and removal of these masses by operative laparoscopy is acceptable in carefully selected women.

Journal Article↗
PubMed1994

Preoperative sonographic evaluation and laparoscopic management of persistent adnexal masses: a 1994 review.

Carcinoma of the ovary is a frightening disease because it is a major cause of death due to cancer in women and is the leading cause of deaths from gynecologic malignancies. The disease is associated with a common clinical problem: persistent adnexal masses, most of which are benign. Operative laparoscopy has become an increasingly attractive way of diagnosing and removing adnexal masses. The practicing general gynecologist thus faces two new dilemmas: not to miss an early ovarian cancer or manage an unsuspected one to the patient's detriment, and not to perform extensive major surgery for adnexal masses, most of which can be handled laparoscopically. Fortunately, pertinent data exist on which the resolution of these dilemmas may be based.

Adult↗
PubMed1996

Intermittent partial adnexal torsion after electrosurgical tubal ligation.

Intermittent partial adnexal torsion after electrosurgical tubal ligation has been suggested as a cause of chronic pelvic pain. Little is present in the literature describing this entity or its characteristics. Unlike complete torsion of the fallopian tube, ovary, or paratubal cyst, intermittent adnexal torsion is more subtle in both clinical features and laparoscopic findings. It appears to be an underrecognized cause of pelvic pain in some women after tubal ligation. Thus these women may be subjected to many diagnostic tests and extensive evaluations with negative findings. It is not uncommon for the diagnosis to be overlooked even at the time of pelviscopic evaluation. A woman experienced the characteristic chronic, intermittent, left lower quadrant pain after electrosurgical tubal ligation. At the time of a third laparoscopic evaluation, the diagnosis of intermittent partial adnexal torsion was made, and she was treated with distal salpingectomy and ovarian fixation. She had complete resolution of her long-standing pain.

Adnexa Uteri↗
PubMed1996

Characterization of Adnexal Masses by Transvaginal Sonography and Color Flow Doppler

We assessed the accuracy of transvaginal sonography and color flow Doppler to distinguish benign from malignant adnexal masses and to select patients for laparoscopy. Before surgery, 225 women with adnexal masses were examined by transvaginal sonography and color flow Doppler. Size and morphologic criteria of each mass were determined, and color flow Doppler characteristics were evaluated. Of the 225 patients, 166 were premenopausal (mean age 34.6 &plusmn; 9.2 yrs) and 59 had been postmenopausal for at least 1 year (mean age 61.9 &plusmn; 7.5 yrs). Operative laparoscopy was performed in 22% of postmenopausal and 50% of premenopausal women, for a total of 96 laparoscopies. We observed 32 malignant tumors, 16 in premenopausal (10%) and 17 in postmenopausal women (29%). Analysis of gray scale morphologic findings revealed solid tissue in 77.8% of malignant and 16.1% of benign tumors (p <0.05). The presence of septa within the cysts was not significantly different in malignant and benign tumors. No sonographically simple adnexal cyst was malignant. Color flow Doppler alone seems to be less predictive of malignancy, but if combined with gray scale, is able to improve the diagnosis.

Journal Article↗
PubMed1996

Removal of Adnexal Masses by Operative Laparoscopy During Pregnancy

We evaluated the outcomes of pregnancies in nine women who underwent removal of an adnexal mass by operative laparoscopy during pregnancy. These patients, who would otherwise have undergone exploratory laparotomy, were treated by diagnostic and operative laparoscopy using the carbon dioxide laser and electrocoagulation. Gestational ages ranged from 12 to 22 weeks (mean 15 wks). Indications for the surgery were persistent complex or enlarged adnexal mass (7), painful adnexal mass (1), and acute abdomen and intraabdominal hemorrhage (1). Procedures performed were ovarian cystectomy (7), paratubal cyst removal (1), and evacuation of pelvic hematoma (1). Operating time ranged from 55 to 150 minutes (mean 101 min). Peritoneal washings were always obtained. No tocolytics were used during or after surgery. Normal fetal heart tones were auscultated postoperatively in the recovery room. There were no complications secondary to the surgery. Six women delivered at term with weight appropriate for gestational age (AGA). One patient had premature rupture of membranes at 31 weeks' with delivery of a viable AGA infant by emergency cesarean section. Two patients' pregnancies at 26 and 29 weeks are progressing normally. Operative laparoscopy for certain pelvic pathology may be performed safely with no complications to the pregnancy.

Journal Article↗
PubMed1997

Sonographic prediction of malignancy in adnexal masses using multivariate logistic regression analysis.

The aim of the study was to assign a probability of malignancy for any patient with an adnexal tumor by the application of multivariate logistic regression analysis to variables recorded at the time of pelvic sonography. Sixty-seven women with known adnexal masses were examined using transvaginal B-mode and color Doppler imaging. For each patient the variables included: (1) age, (2) maximum tumor diameter, (3) tumor volume, (4) unilocularity (presence (0) or absence(1)), (5) papillary projections (presence (1) or absence (0)), (6) random echogenicity (presence (1) or absence (0)), (7) highest peak systolic velocity (PSV), (8) time-averaged maximum velocity (TAMXV), (9) pulsatility index (PI) and (10) resistance index (RI). The TAMXV, PI and RI were those associated with the highest PSV. These ten independent variables and the final histological diagnosis for each patient (the dependent variable) were used for the regression analysis. Approximately 75% of the entire dataset was randomly selected for generating the regression model. The remaining 25% was used as the testing set for cross-validation of the model. In the entire dataset there were 52 women with benign, three with borderline and 12 with invasive ovarian tumors. Regression analysis on the ten variables resulted in the retention of only 'age', 'papillary projection score' and 'TAMXV' as significantly contributing to predicting the presence or absence of malignancy. The probability of malignancy for any patient was given by solving the equation: Probability = 1/(1 + e-z) where e is the base value for natural logarithms and z = (0.1273 x Age) + (0.2794 x TAMXV) + (4.4136 x Papillary projections score) - 14.2046. Cross-validation of the model on the test set of data gave a 100% sensitivity and specificity. However, for the entire dataset the best sensitivity and specificity were 93.3 and 90.4%, respectively, at a cut-off value of 25% probability of malignancy. In conclusion, multivariate logistic regression analysis enables the calculation of probability of malignancy for any patient with a known adnexal mass. The accuracy of this prediction appears to be better than that of morphological or Doppler criteria when the latter are used independently. The value of this model needs to be tested prospectively.

Adult↗
PubMed1997

[Adnexal torsion with hemorrhagic infarct in early pregnancy. Diagnosis by color-coded vaginal Doppler sonography].

A 25 year-old woman presented with left lower quadrant pain in the 11th week of gestation. Transvaginal sonography showed a 7 x 8 x 5 cm cystic-solid mass with an adjacent 9 mm echogenic structure on the left side corresponding to the adnexal stalk. Color Doppler sonography revealed the absence of central or peripheral flow within the mass suggestive of adnexal torsion and subsequent infarction. Laparoscopic detorsion of the left adnexa was not followed by restoration of perfusion ad a left adnexectomy was performed. Transvaginal color Doppler sonography is useful for preoperative diagnosis of adnexal torsion.

Adult↗
PubMed1996

[Preoperative differential diagnosis of cystic adnexal tumors: double-contrast MRT].

PURPOSE: Preoperative assessment of adnexal lesions as benign or malignant by MRI with gastrointestinal and intravenous contrast. METHODS: 46 patients with benign (n = 42) and malignant (n = 4) cystic adnexal tumours underwent MRI of the pelvis. Transaxial and coronal images were acquired using conventional T1- and T2-weighted SE-sequences after oral administration of superparamagnetic iron oxide particles (Ferristene). Additional T1-weighted SE-images were obtained immediately following gadodiamide (Gd DTPA-BMA) injection. RESULTS: MRI correctly classified the four malignant lesions, whereas nine histologically benign lesions were misdiagnosed as malignant. Intravenous contrast yielded a superior delineation of intratumor architecture. CONCLUSION: Due to exclusion of solid structures. MRI with oral and i.v. contrast enables to dismiss suspected malignity in cystic adnexal lesions. Because of the non-specificity of the macroscopic criteria of dignity, the MR diagnosis "malignity" is of limited value.

Adenocarcinoma↗
PubMed2003

A new scoring system to differentiate benign from malignant adnexal masses.

OBJECTIVE: The purpose of this study was to develop and cross-validate a new sonographic scoring system for differentiation between benign and malignant adnexal masses. STUDY DESIGN: This study was conducted in a tertiary care university hospital. In the first part of the study, we used a multivariate logistic regression analysis to develop a scoring system that was based on morphologic and Doppler sonographic data for 705 adnexal masses in 665 patients who were diagnosed and treated at our institution from January 1995 to June 2001. The scoring system was designed to use only those parameters that are found to be independent predictors of malignancy. In the second part of the study, we prospectively cross-validated this scoring system in a series of 90 adnexal masses in 86 patients between July 2001 and March 2002. With the use of the area under the curve of the respective ROC curves, we compared the new scoring system with other scoring systems. RESULTS: Multivariate logistic regression analysis revealed that the only independent predictor parameters were thick papillary projections, solid areas, central flow, and velocimetric features of high velocity and low resistance. In the prospective cross-validation study, our scoring system had the best diagnostic performance (area under the curve, 0.98) compared with Sassone (area under the curve, 0.89; P =.017), De Priest (area under the curve, 0.92; P =.048), and Ferrazzi (area under the curve, 0.90; P =.013) scoring systems. CONCLUSION: Our new sonographic scoring system had a better diagnostic performance than three previously published scoring systems.

Adnexa Uteri↗
PubMed2005

Male adnexal tumour of probable Wolffian duct origin.

Male adnexal tumours of Wolffian duct origin are very rare. They have variable malignant potential and surgical excision is recommended. We report the case of a 56-year-old male who presented with a swelling in the perineum thought to be a haematoma as the result of a complication of a laparoscopic inguinal hernia repair. It recurred after incision and two attempts at drainage and was then completely excised. Histology revealed the lesion to be an adnexal tumour of probable Wolffian duct origin. To our knowledge there have only been two previous cases of male adnexal tumour of Wolffian duct origin reported in the literature.

Diagnosis, Differential↗
PubMed2001

Alternate methods for laparoscopic management of adnexal masses greater than 10 cm in diameter.

PURPOSE: We describe alternate laparoscopic methods for inspection and removal of large adnexal masses, and report our experience with 18 cases in which these methods were used. PATIENTS AND METHODS: Between April 1994 and January 2000, the first author performed operative laparoscopy on 18 patients, each of whom had at least one adnexal mass with maximum diameter greater than 10 cm. Mean patient age was 32 years (range 11 to 82). Seventeen of the 18 patients were premenopausal. All procedures were performed at one of two community hospitals in Seattle or at Yuan's General Hospital in Taiwan. Preoperative screening included pelvic exam, tumor markers, and ultrasound. RESULTS: One 82-year-old patient underwent planned laparoscopic bilateral oopherectomy. In the other 17 cases the operative goal was cystectomy or unilateral oopherectomy with conservation of reproductive function. Cystectomy was successfully performed in five of these cases (29.4%). The remaining 12 patients underwent either unilateral oopherectomy (10 cases, 58.8%), or unilateral salpingo oopherectomy (2 cases, 8.8%) due to the extent of their mass. Sixteen of the 18 cases in this series were successfully managed by a single laparoscopic surgery, one case required a second-look laparoscopy, and in one case a malignancy was found by histological analysis of permanent section, which required a second laparoscopy for staging and debulking. CONCLUSIONS: Large adnexal masses can be successfully managed with minimal hospital stay using laparoscopic techniques, when care is taken to avoid rupture and spillage of cyst contents, and thorough inspection of the mass and abdominal cavity is made possible. The probability of finding an unexpected malignancy is low. In those cases where a malignancy is found, appropriate cytoreductive staging surgery can be performed immediately.

Adolescent↗
PubMed1996

Benign cutaneous adnexal tumors with combined folliculosebaceous, apocrine, and eccrine differentiation. Clinicopathologic and immunohistochemical study of eight cases.

Benign cutaneous adnexal tumors displaying divergent differentiation are rare, with very few well-documented cases reported in the literature. We describe eight cases of benign adnexal tumors showing a variable combination of eccrine, apocrine, and folliculosebaceous differentiation. Clinically, all tumors presented as solitary, slowly enlarging dermal or subcutaneous nodules located in the head and neck and the extremities. Histologically, they were characterized by well-circumscribed, unencapsulated nodules composed of a lobular proliferation of epithelial cells displaying a spectrum of trichogenic, sebaceous, apocrine, and eccrine differentiation. The histological spectrum included lobules and trabeculae of basaloid cells with glandular and ductal elements, well-formed folliculosebaceous units, primitive follicles, and foci of tricholemmal keratinization. Immunohistochemical evaluation in four cases showed similar cytokeratin, carcinoembryonic antigen, and epithelial membrane antigen staining profiles as those reported for sweat gland adenomas; in addition, focal S-100 protein positivity and GCDFP-15 positivity could also be demonstrated, suggesting eccrine-apocrine differentiation. The tumors were most frequently confused histologically with other adnexal neoplasms, including sebaceoma, sebaceous adenoma, basal cell carcinoma, chondroid syringoma, and trichoepithelioma. The present series highlights the capability.

Adenoma↗
PubMed2006

Evaluation and management of adnexal masses during pregnancy.

An increase in the incidence of adnexal masses uncovered during pregnancy has occurred concurrently with the adoption of near universal use of prenatal ultrasound. The majority of these masses resolve by the second trimester. Persistent masses continue to be at risk for significant sequelae such as torsion, rupture, and obstruction of labor. These events may result in the need for emergent surgical intervention with increased risk of adverse outcome for both mother and fetus. In addition a small risk of cancer exists and extended delay in diagnosis should be avoided. As such, surgical excision of persistent adnexal masses should be entertained at approximately 16 to 20 weeks of gestation. In the approximately 5% of cases in which an adnexal masses proves to be a malignancy, appropriate staging may be safely performed. In selected cases, chemotherapy should at least be entertained.

CA-125 Antigen↗
PubMed2006

Laparoscopic management of the adnexal mass.

Ovarian neoplasms are common in women of all ages. As many as 10% of women in the United States will undergo surgical removal of an adnexal mass sometime in their lifetime. Gynecologic surgeons have pioneered laparoscopic surgery, developing what was originally a diagnostic tool into a safe and effective approach to management of adnexal masses. Accumulating scientific data support the laparoscopic approach to the adnexal mass as the preferred treatment.

CA-125 Antigen↗
PubMed1989

Microcystic adnexal carcinoma (sclerosing sweat duct carcinoma).

Microcystic adnexal carcinoma (MAC) is a recently described malignant neoplasm of the adnexal structures of skin that shows a marked propensity for early infiltrative and locally aggressive growth. Its banal clinical appearance may lead to a delay in diagnosing the tumor by biopsy, and its multifaceted histologic features may lead to an incorrect tissue diagnosis. Confusion with benign tumors and less aggressive malignancies can lead to inadequate initial treatment and extensive recurrences. We describe three cases of microcystic adnexal carcinoma and review the clinical and histologic features, treatment, and prognosis of this neoplasm.

Adenocarcinoma↗
PubMed2000

Ocular adnexal lymphoid tumors.

This year, advances in the management of ocular adnexal lymphoid tumors have been based on the distinction between MALT and non-MALT lymphomas. MALT lymphomas have a more indolent course than non-MALT lymphomas, and in the conjunctiva a more conservative approach can be taken than has been recommended previously. In the orbit the likelihood of progression to systemic disease seems high, even with MALT lymphomas, and treatment with radiation is still recommended in all cases. The REAL classification system has replaced the Rappaport and Lukes-Collins system for classifying ocular adnexal lymphomas. Most ocular adnexal lymphomas are composed of neoplastic B-lymphocytes. Additional cases of T-cell lymphoma involving the orbit and conjunctiva were reported in the literature this past year.

Conjunctival Neoplasms↗
PubMed2003

Ocular surface, ocular adnexal, and lacrimal complications associated with the use of systemic 5-fluorouracil.

PURPOSE: To determine the prevalence rates and associated characteristics of patients who have ocular surface, ocular adnexal, and lacrimal complications associated with the systemic use of the cancer chemotherapeutic agent 5-Fluorouracil (5-FU). METHODS: An exposure-based cohort study was designed. Adult patients who had completed at least 3 months of systemic 5-FU therapy within the past 5 years were eligible for enrollment. Study subjects had a detailed medical history taken with emphasis on preexisting conditions known to be associated with the development of ocular surface, ocular adnexal, and lacrimal complications. An ocular examination was then performed. A complete nasolacrimal system evaluation was performed if symptoms or findings were identified. The prevalence was then determined for each ocular symptom and each ocular finding identified that was not present pretreatment. An exploratory analysis was then performed to identify patient characteristics that might influence the likelihood of developing any of the above complications. RESULTS: Fifty-two patients were enrolled in the study. The prevalence rates of the following ocular abnormalities were calculated: ocular irritation, 5.8%; blepharitis, 3.8%; conjunctivitis, 3.8%; keratitis, 3.8%; eyelid dermatitis, 5.8%; cicatricial ectropion, 1.9%; tearing, 26.9%; punctal-canalicular stenosis, 5.8%; and blurred vision, 11.5%. Blacks had tearing at a significantly higher rate when compared with whites (P = 0.022, 2-sided Fisher exact test). Three patients had permanent complications that will require surgery for correction. Of the 7 patients who had a single abnormality, 6 had tearing and one had eyelid dermatitis. All of the 8 patients who had multiple findings had tearing as one of their abnormalities. CONCLUSIONS: Ninety-three percent of the patients who had an ocular abnormality had tearing as one of the complications. Patients who are receiving systemic 5-FU and begin to tear should have an ocular examination, looking for ocular surface, ocular adnexal, and lacrimal complications.

Adult↗
PubMed2005

Orbital and periorbital microcystic adnexal carcinoma.

PURPOSE: To review the clinical and histopathologic features of patients with microcystic adnexal carcinoma of the orbital and periorbital tissues. METHODS: This study was designed as a noncomparative interventional case series of three patients seen and treated at two oculoplastic surgical departments and a review of the literature. Clinical presentation, histopathologic findings, outcome of surgery, and clinical recurrence are presented. RESULTS: Three patients underwent surgery for lesions temporal to the lateral canthus. All had initial histopathology diagnosed as squamous cell carcinoma but were subsequently diagnosed as microcystic adnexal carcinoma after clinical recurrence. All patients had multiple recurrences and extensive perineural spread. Two patients required radiotherapy. CONCLUSIONS: Review of the literature shows that microcystic adnexal carcinoma affecting the orbital and periorbital tissues is difficult to differentiate clinically and microscopically from other conditions including squamous cell carcinoma. Eighty-one percent of cases that have histopathology checked in the initial assessment are still misdiagnosed. A high degree of suspicion is necessary if the lesion extends beyond an apparently adequate surgical margin, multiple recurrences occur, or superficial perineural spread is present. Mohs technique is the treatment of choice and may be improved if paraffin sections or immunohistocytochemistry are performed. Wide excision should be carried out once clear margins are obtained. Radiotherapy may be necessary in cases with multiple recurrences.

Aged↗