Computed tomography scan of the abdomen shows a large cystic mass in the abdomen and pelvis without solid tissue or septations (measurement: 43×20×31-cm ). (+) R hydronephrosis Computed tomography scan of the abdomen shows a large cystic mass in the abdomen and pelvis without solid tissue or septations.

Postsurgical specimen showing a large cyst filled with fluid.

Eleven liters of clear fluid were aspirated from a paraovarian cyst arising from the left fallopian tube. A left salpingectomy was performed with ovarian sparing. The surgical pathology report defined the mass as a serous cystadenoma with no malignant cells. The hydronephrosis was believed to be due to compression by the mass.

Ovarian Tumors Myra Lalas Pitt

Ovarian tumors comprise 1% of neoplasms in children and adolescents, and 75% of such lesions are benign. Ovarian neoplasms are categorized based on their tissue of origin: epithelial, germ cell, or stromal. The most common ovarian neoplasm in adolescents is a benign teratoma, a germ cell tumor.

Signs & Symptoms Increased abdominal girth Menstrual irregularities Pelvic pain Urinary frequency Constipation Pelvic heaviness Signs of ovarian torsion: lower abdominal pain of sudden onset, nausea, vomiting, low-grade fever

Differentials Constipation Pregnancy Leiomyoma Imperforate hymen Tubal cysts, tubo-ovarian abscesses Ectopic pregnancies Appendiceal abscess

Diagnosis The primary imaging study for assessment of ovarian cysts specifically is transabdominal or transvaginal ultrasonography.

On ultrasonography, a benign cyst typically is unilocular, with a thin, smooth wall and no solid elements. 4.4 x 3.4 cm clear ovarian cyst

Features of malignant masses: Thickened walls Septations Solid components Ultrasound examination revealed a mass of mixed echogenicity in the right adnexa (arrows). UB = urinary bladder

Diagnosis In cases when lesions are indeterminate, MRI or CT scan can provide clarification. A mass is diagnosed definitively by histologic examination.

Stage I: Growth limited to the ovaries Stage IA: Growth limited to 1 ovary, no tumor on the external surface, capsule intact, no ascites present containing malignant cells Stage IB: Growth limited to both ovaries, no tumor on the external surfaces, capsules intact, no ascites present containing malignant cells Stage IC: Tumor either stage IA or IB, but with tumor on surface of 1 or both ovaries with capsule ruptured,* with ascites present containing malignant cells, or with positive peritoneal washings

Stage II: Growth involving 1 or both ovaries with pelvic extension Stage IIA: Extension and/or metastases to the uterus and/or tubes Stage IIB: Extension to other pelvic tissues Stage IIC: Tumor either stage IIA or IIB, but with tumor on surface of 1 or both ovaries, with capsule(s) ruptured,* with ascites present containing malignant ovaries, or with positive peritoneal washings

Stage III: Tumor involving 1 or both ovaries with histologically confirmed peritoneal implants outside pelvis and/or positive retroperitoneal or inguinal nodes; superficial liver metastasis; tumor limited to true pelvis, but with histologically proven malignant extension to small bowel and omentum Stage IIIA: Tumor grossly limited to the true pelvis, with negative nodes, but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces or histologically proven extension to small bowel mesentery Stage IIIB: Tumor of 1 or both ovaries with histologically confirmed implants, peritoneal metastasis of abdominal peritoneal surfaces ≤ 2 cm in diameter; nodes are negative Stage IIIC: Peritoneal metastasis beyond the pelvis > 2 cm in diameter and/or positive retroperitoneal or inguinal nodes

Stage IV: Growth involving 1 or both ovaries with distant metastases; if pleural effusion is present, positive cytology must be apparent to allot a case to stage IV; parenchymal liver metastasis qualifies as stage IV disease

Treatment Functional cysts: Most are small and resolve on their own, and observation for several menstrual cycles is appropriate. *For cysts that are growing, persistent, or symptomatic, or if malignancy is suspected: cystectomy is indicated.

Surgery is the initial modality of treatment for stage I-IVA epithelial ovarian cancer Only a small percentage of women with epithelial ovarian cancer can be treated with surgery alone, which includes patients with stage IA (grade 1) and stage IB (grade 1) serous, mucinous, endometrioid, and Brenner tumors Clear-cell carcinomas are associated with a significantly worse prognosis in stage I; all patients with this histologic subtype should be considered for chemotherapy Women at any stage of epithelial ovarian cancer should be considered for clinical trials if available

References Pediatrics in Review Vol. 31 No. 11 November 1, 2010 pp. 477 -482 (doi: 10.1542/pir.31-11-477) www.emedicine.com www.uptodate.com