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PubMed2003

The pre-operative assessment of the adnexal mass: the accuracy of clinical estimates versus clinical prediction rules.

OBJECTIVE: To evaluate the reproducibility of the clinical judgement of gynaecologists, gynaecologists in training and gynaecologic oncologists and to compare the predictive performance of the offhand assessment with the predictive performance of existing mathematical models for the pre-operative assessment of the adnexal mass. DESIGN: Questionnaire with paper cases of women operated on for an adnexal mass. SETTING: Gynaecological unit in a teaching hospital in the South of The Netherlands. POPULATION: Women who underwent surgery for adnexal mass between January 1991 and December 1998. METHODS: We offered 45 gynaecologists five different sets of 34 cases, with data on female age and menopausal status, a written description of the sonography, Doppler flow measurement and serum CA125 measurement. Nine observers for every set were asked to estimate the probability of malignancy. MAIN OUTCOME MEASURES: The reproducibility of the risk estimates as made by the participants was expressed with an intraclass correlation coefficients. The accuracy of the judgement of the clinicians and the result of mathematical models in the prediction of malignancy were expressed with sensitivity, specificity, and receiver-operating characteristic curves. RESULTS: Neither clinically relevant nor statistically significant differences could be found between the accuracy of the risk assessments made by the clinicians and the accuracy of the risk assessments made by prediction models. CONCLUSION: This study demonstrates that at this moment there is no need to introduce complicated predictive scoring systems such as neural networks or logistic regression models for the pre-operative assessment of the adnexal masses.

Adnexa Uteri↗
PubMed2005

Adnexal torsion: experience at a single university center.

OBJECTIVE: To review the management of adnexal torsion over an 11-year period at a single institution and to assess trends in the surgical approach, including laparoscopy vs. laparotomy, and ovarian conservation vs. removal. STUDY DESIGN: A chart review of all patients treated for adnexal torsion at the University of New Mexico from 1990 to 2001 was performed. RESULTS: Sixty-eight cases of adnexal torsion were identified. Laparoscopic management was accomplished in 22 cases (32%) and ovarian conservation in 14 cases (20.6%). There were no differences in the use of laparoscopy (OR 2.24, CI 0.65-7.93), or ovarian conservation (OR 1.24, CI 0.31-5.35) in patients treated before 1996 vs. later in the study period. CONCLUSION: Despite evidence supporting conservative management of adnexal torsion with laparoscopy and ovarian conservation, most cases at our institution are managed with open laparotomy and removal of the affected adnexa.

Adnexal Diseases↗
PubMed1994

[Conservative laparoscopic treatment of adnexal torsion during pregnancy].

Adnexal torsion is an unusual but serious complication in pregnancy, occurring most frequently in the first trimester. The difficult and often delayed diagnosis generally imposed laparotomy and adnexectomy, severely affecting foetal and fertility outcome among young women. In case of early diagnosis, a few authors have recommended conservative treatment by untwisting the adnexa. At the moment, only very few cases of laparoscopic conservative management of adnexal torsion during pregnancy have been reported. The authors report three cases of adnexal torsion during the first trimester of pregnancy, all managed by laparoscopy and discuss the validity of conservative management of adnexal torsion.

Adnexal Diseases↗
PubMed1997

Laparoscopy for adnexal torsion in pregnant women.

OBJECTIVE: To report on six cases of adnexal torsion in pregnant women treated by operative laparoscopy. STUDY DESIGN: A retrospective study. Between January 1989 and March 1996, 26 patients with adnexal torsion were treated by operative laparoscopy. Of these patients, six were pregnant (23%). The types of operative procedure and outcome were studied. RESULTS: Adnexal torsion occurred between 6 and 13 weeks of amenorrhea. Two cases involved hyperstimulation, 3 cases a functional cyst and 1 case a dermoid cyst. In 4 cases laparoscopic treatment consisted of untwisting followed by puncture of the ovarian cyst; in 1 case it involved intraperitoneal cystectomy and in another simple untwisting of the adnexa. The immediate postoperative history was uncomplicated. In one patient with ovarian hyperstimulation, torsion recurred three weeks after the initial operation. No miscarriages occurred. CONCLUSION: In the hands of skilled surgeons, laparoscopy is well suited to the diagnosis and treatment of adnexal torsion occurring during the first trimester of pregnancy. Beyond 16 weeks or when there is any suspicion of torsion on a suspected tumor, it is preferable to use laparotomy.

Adnexal Diseases↗
PubMed1998

Diagnosis and management of the adnexal mass.

Adnexal masses are frequently found in both symptomatic and asymptomatic women. In premenopausal women, physiologic follicular cysts and corpus luteum cysts are the most common adnexal masses, but the possibility of ectopic pregnancy must always be considered. Other masses in this age group include endometriomas, polycystic ovaries, tubo-ovarian abscesses and benign neoplasms. Malignant neoplasms are uncommon in younger women but become more frequent with increasing age. In postmenopausal women with adnexal masses, both primary and secondary neoplasms must be considered, along with leiomyomas, ovarian fibromas and other lesions such as diverticular abscesses. Information from the history, physical examination, ultrasound evaluation and selected laboratory tests will enable the physician to find the most likely cause of an adnexal mass. Measurement of serum CA-125 is a useful test for ovarian malignancy in postmenopausal women with pelvic masses. Asymptomatic premenopausal patients with simple ovarian cysts less than 10 cm in diameter can be observed or placed on suppressive therapy with oral contraceptives. Postmenopausal women with simple cysts less than 3 cm in diameter may also be followed, provided the serum CA-125 level is not elevated and the patient has no signs or symptoms suggestive of malignancy.

Adnexal Diseases↗
PubMed1986

Microcystic adnexal carcinoma. Report of a case with 30-year follow-up.

Microcystic adnexal carcinoma is a recently described neoplasm characterized by a locally aggressive growth pattern. The tumor usually affects the upper lip of middle-aged women, but occurs in other facial areas and in men. Histologically, a distinctive combination of keratin-filled cysts, islands and strands of basaloid and squamous cells, and ducts and glandlike structures is seen. A dense, hyalinized stroma is also a feature as well as frequent perineural invasion by tumor cells. While microcystic adnexal carcinoma is deeply infiltrating in its growth, metastasis has not been reported. However, recurrences with extensive local tumor spread are often observed. We describe a middle-aged man who initially had a lesion of microcystic adnexal carcinoma excised 30 years prior to definitive treatment for a recurrence at the original site. To our knowledge, this is the longest follow-up of a patient with microcystic adnexal carcinoma and confirms its locally infiltrating, indolent biologic behavior.

Biopsy↗
PubMed1995

Intratumoral peak systolic velocity as a new possible predictor for detection of adnexal malignancy.

OBJECTIVE: Our purpose was to evaluate whether intratumoral blood flow velocity measured by transvaginal Doppler ultrasonography would afford better discrimination between benign and malignant adnexal tumors. STUDY DESIGN: One hundred two patients with adnexal tumors (72 benign, 30 malignant) were studied with transvaginal B-mode, color, and pulsed Doppler ultrasonography before surgery. RESULTS: Sixty-five benign tumors (90.3%) had abnormal morphologic features suggesting malignancy, and blood flow was detected in 29 (40.3%). The peak systolic velocity was 13.1 +/- 9.1 cm/sec and the resistance index was 0.563 +/- 0.177. All malignant tumors had abnormal morphologic features and blood flow was detectable in all cases. The peak systolic velocity was 23.9 +/- 11.5 cm/sec and the resistance index was 0.488 +/- 0.118. When 16 cm/sec was considered as the cutoff value of peak systolic velocity, the sensitivity and specificity of peak systolic velocity in detecting malignant adnexal tumors were 83.3% and 91.6%, respectively. The sensitivity and specificity of the resistance index (cutoff value 0.72) was 93.3% and 68.1%, respectively. There was no significant difference in sensitivity between peak systolic velocity and resistance index. The specificity of the peak systolic velocity was significantly higher than that of the resistance index (p < 0.05). Moreover, the sensitivity of the peak systolic velocity did not significantly differ from that with transvaginal ultrasonography diagnosis (86.7%), and the specificity of the peak systolic velocity was significantly higher than that of transvaginal ultrasonography (69.4%). CONCLUSION: These results suggest that peak systolic velocity obtained from intratumoral abnormal morphologic features provides a superior means for differentiating malignant from benign adnexal tumors.

Adult↗
PubMed2005

Comparison of 2-dimensional and 3-dimensional power-Doppler imaging in complex adnexal masses for the prediction of ovarian cancer.

OBJECTIVE: The purpose of this study was to compare 2-dimensional and 3-dimensional power-Doppler imaging diagnostic performance for the prediction of ovarian cancer in complex adnexal masses. STUDY DESIGN: Sixty-nine complex adnexal masses in 60 women (mean age, 48.4 years [range, 17-82 years]) were evaluated by 2-dimensional and 3-dimensional power-Doppler imaging for differentiating benign from malignant masses. Complex adnexal mass was defined in the presence of at least 1 of the following features: solid areas, thick papillary projections, thick septa, or purely solid echogenicity. One examiner performed 2-dimensional power-Doppler imaging, and a second examiner performed 3-dimensional power-Doppler imaging. All masses were removed surgically, and definitive diagnosis was obtained. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for both techniques. RESULTS: Forty-five tumors (65.2%) were proved to be malignant, and 24 tumors (34.8%) were proved to be benign. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for 2-dimensional power-Doppler imaging were 97.8%, 87.5%, 93.6%, 95.5%, and 94.2%, respectively. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for 3-dimensional power-Doppler imaging were 97.8%, 79.2%, 89.9%, 95%, and 91.3 % respectively. There were no statistical differences in sensitivity and specificity (McNemar test: P = .250) CONCLUSION: Three-dimensional power-Doppler imaging did not have a better diagnostic performance than 2-dimensional power-Doppler imaging for the discrimination of benign from malignant complex adnexal masses.

Adnexa Uteri↗
PubMedDate not supplied

Laparoscopic surgery in 12 cases of adnexal disease occurring in girls aged 15 years or younger.

STUDY OBJECTIVE: To evaluate the treatment by laparoscopic surgery of adnexal disease occurring in young girls. DESIGN: Retrospective analysis (Canadian Task Force classification II-1). SETTING: Department of gynecology at a general hospital. PATIENTS: Twelve consecutive girls aged 15 years or younger. INTERVENTIONS: Laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS: Seven patients had dermoid cysts, and three of these were associated with adnexal torsion. Two patients had ruptured lutein cysts with ovarian bleeding, and one of them was pregnant. Torsion of the tube with paraovarian cyst, torsion of normal ovary, and serous cystadenoma were noted in one patient each. Although the underlying diseases varied, the chief symptom in each of these patients was lower abdominal pain. Because the symptom is nonspecific, the clinical features were confusing, especially in emergency cases; in two patients with adnexal torsion with dermoid cysts and one patient with adnexal torsion of a normal ovary, there was substantial delay in diagnosis, and salpingo-oophorectomy was required as a result. CONCLUSION: Even in young girls, laparoscopic surgery can be performed in an acceptable manner using regular instruments designed for adults.

Abdominal Pain↗
PubMed1998

The role of ultrasonography in the detection and management of adnexal masses during the second and third trimesters of pregnancy.

OBJECTIVE: Our purpose was to determine the effect of routine second-trimester and third-trimester ultrasonographic examinations on the prevalence of detectable and operable adnexal disease. STUDY DESIGN: The study group consisted of 7996 pregnant women between 13.0 and 42.8 weeks' gestation. The size and architectural pattern of any detectable adnexal masses were noted. RESULTS: A total of 328 of the 7996 (4.1%) women in the study group had 335 ultrasonographically detectable adnexal masses; 309 of the masses were unilocular or had a single thin septation and 26 were architecturally complex. Of the ovarian cysts 252 of 309 (81.6%) had a mean diameter < 3.0 cm; 60% of the 252 patients in this subgroup had serial ultrasonographic examinations; 43 of the unilocular cysts resolved, and 17 have persisted for up to 2 years. There is a statistically significant trend toward decreasing frequency of ovarian cysts with increasing gestational age (chi2 for linear trend; P < .00001). Eighteen of the 7996 had an exploratory laparotomy (1 operation per 444 deliveries) during pregnancy or in the postpartum period. In addition, 1 patient had a paratubal cyst excised at the time of postpartum bilateral tubal ligation. Pathologically confirmed lesions included 8 benign cystic teratomas, 3 mucinous cyst adenomas, 2 paratubal cysts, 2 corpus lutea, 1 serous cystadenoma, 1 follicular cyst, 1 endometrioma, and 1 ovarian fibroma. CONCLUSION: Ovarian cysts are found in 4.1% of second-trimester and third-trimester obstetric ultrasonographic examinations. Most ultrasonographically detectable cysts are < 3.0 cm in diameter and usually resolve. The frequency of exploratory laparotomy for adnexal disease is not significantly different from that in reports before the widespread use of obstetric ultrasonography.

Adnexa Uteri↗
PubMed1984

Microcystic adnexal carcinoma.

We describe a patient with microcystic adnexal carcinoma, a recently recognized cutaneous neoplasm. The patient, a middle-aged woman, had an induration of the left side of her upper lip. At the time of initial resection, the neoplasm also involved the left side of the nose. An extensive recurrence, 27 months later, involved the left turbinates and left orbit. Microscopically the tumor consisted of nests, strands, and cysts composed of mildly to moderately atypical squamous cells that lacked connections with the epidermis. The cysts contained dense, laminated keratin. The tumor was distributed throughout the dermis and infiltrated subcutaneous tissue, skeletal muscle, perichondrium, periosteum, vascular adventitia, and perineural spaces. A few fields contained nests of clear cells, but ductular differentiation, prominent in some microcystic adnexal carcinomas, was not found. There was a distinctive, dense, sclerotic stroma. The foregoing clinical and pathologic findings are characteristic of microcystic adnexal carcinoma. Our observations and available information from the literature suggest the existence of an important family of locally aggressive carcinomas of the face characterized by squamous nests and cysts, variable ductular differentiation, and perineural growth. Such tumors must be clearly differentiated from the more common forms of epidermal and adnexal neoplasia.

Carcinoma↗
PubMed2002

The conservative management of adnexal torsion--a case-report and review of the literature.

In clinical routine adnexal torsion tends to be subject to adnexectomy to prevent embolism of thrombosed ovarian veins and its sequelae. This therapeutic intervention can be derogatory especially for young women during the reproductive years. As seen in animal models with adnexal torsion, restitution of the adnexa next to reperfusion is possible until 36 h after interruption of venous and arterial blood perfusion. We report about the successful management of a case of adnexal torsion, which was detorsed laparoscopically. We also reviewed 214 cases with conservative management of adnexal torsions reported in the literature.

Abdominal Pain↗
PubMed2004

[Laparoscopic management of adnexal tumors after the first trimester of pregnancy].

PURPOSE OF THE STUDY: To study the feasibility, advantages and risks of laparoscopic management of adnexal tumors in the course of the last two trimesters of the pregnancy. MATERIAL AND METHODS: Retrospective study of a series of 25 cases of adnexal tumors operated by laparoscopy in the course of the second and the third trimester of pregnancy, during a period of 49 Months from 1st January 1999 to 30 January 2003. RESULTS: Mean gestational age at surgery was 16 weeks 3 days (range 12-29 weeks). The adnexal tumor was an ovarian cyst in 24 cases and in a paratubal cyst in a single case. Conversion was necessary in only one case due to difficult hemostasis. One revision required for borderline malignancy cystadenoma was performed laparoscopically during the same pregnancy. No operative complication was noted. Average post-operative stay was 36 hours (range 24-72 hours). There was one situation of eminent abortion in early the postoperative period but no thromboembolic complications. The pregnancy progress was normal after laparoscopy. CONCLUSION: Laparoscopic treatment of adnexal tumors is feasible in the course of the last two trimesters of the pregnancy in the hands of an experienced surgeon using advanced techniques. The well-known advantages of laparoscopy are particularly important during the pregnancy.

Adolescent↗
PubMed1994

Laparoscopic adnexal surgery during pregnancy.

Adnexal masses diagnosed in a gravid woman sometimes must be surgically evaluated and treated during the pregnancy. A laparoscopic approach may have several advantages over laparotomy, but only one case of laparoscopic adnexal surgery during pregnancy has been previously reported. Two pregnant patients with acute pelvic pain and adnexal masses were treated by operative laparoscopy. One patient had a large benign cystic teratoma and the other had torsion of the fallopian tube secondary to a paratubal cyst. Cystectomies were performed in both women, and in the second patient the tube was reduced and conserved. It appears that with proper care of surgical technique and caution to exclude malignancy, laparoscopy may be performed successfully to remove adnexal masses during the second trimester of pregnancy.

Adolescent↗
PubMed1999

Complications and long-term outcomes after adnexal surgery by laparotomy and laparoscopy.

STUDY OBJECTIVE: To assess complications and subjective outcomes after adnexal surgery by laparotomy and laparoscopy. DESIGN: Observational study (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: Two-hundred twenty-eight women requiring adnexal surgery for benign indications. INTERVENTIONS: The 114 patients who underwent laparotomy and 114 having laparoscopy were followed prospectively for 1 year. Two questionnaire-based evaluations were undertaken to determine subjective outcomes. To evaluate possible later surgical procedures, hospital records were reviewed 4 years after operation. MEASUREMENTS AND MAIN RESULTS: No major complications occurred in the laparotomy group. The two (1.8%) in the laparoscopy group were intestinal injury and aortal injury, both in women who had previously undergone laparotomy. Rates of minor complications were 11.4% for laparotomy and 7.0% for laparoscopy. Two patients in both groups were readmitted. No difference was found between groups in need for additional adnexal procedures up to 4 years after operation. After 1 year, frequencies of subjective complaints and satisfaction with surgical procedure did not differ significantly. Mean hospital cost per patient was less for laparoscopy than for laparotomy. CONCLUSION: No statistically significant differences were seen after adnexal surgery by laparoscopy and laparotomy with regard to frequency of complications and subjective outcomes. Laparoscopy in women who have previously undergone laparotomy may be associated with a slightly greater risk of major complications than another laparotomy.

Adnexa Uteri↗
PubMed2002

Orbital and adnexal cysticercosis.

Orbital and adnexal cysticercosis is emerging as a far commoner disease than previously considered, both in endemic and nonendemic areas of cysticercosis. A review of the literature on orbital and adnexal cysticercosis found that it has a predilection for children and young adults with no definite sex predilection. The extraocular muscle form is the commonest type of orbital and adnexal cysticercosis. Lodgement of cysts in the subconjunctival space is another common site, followed by the eyelid, optic nerve, retro-orbital space and lacrimal gland. Association of orbital cysticercosis with systemic cysticercosis is quite rare. The clinical manifestations of orbital or adnexal cysticercosis are entirely different and depend on the location, size, relation to adjacent structures and stage of evolution of the cyst. Diagnosis of cysticercosis is based mainly on orbital imaging because of its highly specific appearance. Tissue diagnosis is not essential for initiating treatment. Medical therapy is the recommended treatment for the extraocular muscle form and retro-orbital cysticer-cosis. Surgical removal is advocated for subconjunctival and eyelid cysticercosis. Because of the limited number of cases of optic nerve and lacrimal gland cysticercosis, their treatment is controversial.

Adult↗
PubMed2002

Color Doppler energy prediction of malignancy in adnexal masses using logistic regression models.

OBJECTIVE: The aim of this study was to assess the usefulness of color Doppler energy in the preoperative diagnosis of ovarian malignancy using multivariate logistic regression analysis. METHODS: One hundred and thirty adnexal masses were studied with transvaginal B-mode, color energy, and pulsed Doppler ultrasonography before surgery in order to develop a model that could be used to determine malignancy. Each ultrasonographic variable (tumor size, wall thickness, septal structure, echogenicity, papillary projection, density (solid or not)) was included individually or combined together as part of the Sassone ultrasound score. Intratumoral blood flow velocity waveforms were obtained to determine pulsatility index and resistance index and a more subjective parameter, location of tumor vascularity, was also assessed. Menopausal status and serum CA 125 levels were also entered as categorical variables. Sonographic parameters were entered alone, then associated with menopausal status and CA 125 serum levels, and finally with Doppler energy measurements. Our model was then validated in a group of 68 adnexal masses and compared to the model of Alcazar. RESULTS: Eighteen adnexal masses (13.8%) were malignant or of low malignant potential. Multivariate analysis showed that papillary projection of the tumor wall, cyst with solid parts, resistance index with a cut-off value of 0.53, CA 125, and central blood flow location, were the only factors to be independent predictors of malignancy. Menopausal status was not an independent factor. For the final model including the Doppler energy parameter the best sensitivity and specificity were 83% and 93%, respectively, at a cut-off value of 10% probability of malignancy compared to 83% and 87% for the morphological variables alone. Validation of the model showed its diagnostic performance to be as good as that reported in the original population and better than the model of Alcazar. CONCLUSION: Sonographic analysis of adnexal masses including color Doppler energy shows the best predictive properties according to histological diagnosis, and improves preoperative diagnosis of malignancy.

Adolescent↗
PubMed1994

[Diagnosis and therapy of adnexal tumors in postmenopause. A prospective study].

The management of postmenopausal adnexal tumours is still controversially discussed. Approximately 30% of all postmenopausal tumours are malignant. The standard operative approach for these adnexal masses is still the exploratory laparotomy although the advantages of laparoscopic procedure are obvious, even in older patients. The aim of this prospective study was to find out to what extent diagnostic-operative laparoscopy is able to replace laparotomy in the therapy of postmenopausal adnexal masses. From January 1990 to August 1992, 169 postmenopausal patients entered the prospective study. After careful preoperative diagnostics, 63 patients underwent a laparotomy (group B) and 106 patients a laparoscopy (group A). 10 of these 106 cases underwent laparotomy after diagnostic laparoscopy (group Ab). The main operative procedure in group Aa was laparoscopic adnexectomy after Semm. Mean operative time and mean postoperative hospital stay were significantly lower in patients, who only underwent laparoscopic operation (group Aa). One case (0.9%) of the laparoscopically operated patients was subsequently found to be malignant (histologic assessment) and immediately treated by laparotomy with hysterectomy and contralateral adnexectomy. The combination of vaginal examination, vaginal/abdominal ultrasonography (tumor marker CA 125) and a sufficient preoperative diagnostic during endosurgery (no proliferations on the ovary or peritoneal surface, no ascites) reduces the risk of operating a malignant tumour by laparoscopy to a minimum. We believe that operative laparoscopy of postmenopausal adnexal masses is a safe and efficient method in carefully selected women.

Aged↗