2. Pelvic mass in Prepubertal Girls
Dr. Zohreh Yousefi
Professor OF Mashhad University of Medical Sciences
Gynecologist Oncologist

3. Origin of Pelvic mass gynecologic
non gynecologic
non gynecologic urinary tract
Gasterointestinal
Otheres

4. Wilms' tumor or nephroblastoma
cancer of the kidneys that typically occurs in children
Most nephroblastomas are unilateral
Typical symptoms are:
-large abdomen
-abdominal pain
-Fever
-nausea and vomiting
-blood in the urine
(20% high blood pressure in some cases)

5. rupture of Wilms' tumor and hemorrhage
risk of peritoneal dissemination of the tumor
metastasis it is usually to the lung
It is highly responsive to treatment
90% of patients surviving at least five years

6. Neuroblastoma
the second most common solid tumour in childhood
8% of the total number of children's cancers
Neuroblastoma is a cancer of specialised nerve cells called neural crest cells
In some children, the neuroblastoma can occur in nerve tissue along side the spinal cord in the neck , chest, abdomen or pelvis

7. Signs and symptoms
If the tumor is in the abdomen,
may be swollen and they may complain
of constipation or
have difficulty passing urine
blood pressure may also be high
diagnose neuroblastoma
blood, urine, or  bone marrow tests
x-rays; CT or MRI scans; and MIBG

8. The treatment of neuroblastoma depends on
the age of the child
the size
position of the tumour
the tumour biology
(including the MYCN status)
and whether the neuroblastoma has spread
Treatment
Surgery Chemotherapy

9. Appendicitis

10. Appendicitis is most common in teens and young adults in their early 20s
children younger than 4 years are at the highest risk for a rupture.
Up to 80 percent of appendicitis cases in this age group occurred with rupture
young children have fewer of the classic symptoms of nausea, vomiting and pain localized in the lower right portion of the abdomen than do teenagers and young adults
making the diagnosis easy to miss or delay

11. ultrasound and CT scan images can be helpful, but are not always conclusive,
even if they are available on an emergency basis
CT scans in particular expose young children to radiation
which should be avoided if possible
The only absolute way to diagnose the condition is surgery

12. Gynecologic causes of pelvic mass
Ovary
Uterian
Cervicovaginal

13. Müllerian duct abnormality
congenital entities that result from nondevelopment, defective vertical or lateral fusion, or resorption failure of the müllerian ducts
the majority are asymptomatic
when a müllerian duct becomes obstructed
may present with an abdominal mass and dysmenorrhea
If the patient is not treated in a timely fashion
the consequences
can be severe, extending even to infertility

14. ultrasonography initially to delineate any abnormalities in the genital tract
US cannot help identify the type of MDA
In contrast, MRI is a valuable technique for noninvasive evaluation of the female pelvic anatomy and
accurate MDA classification
If obstruction is present
surgical correction of the MDA may be required

15. Neonatal hematometrocolpos
Neonatal hematometrocolpos. (a) Transverse US scan shows a huge cystic mass (C) with a fluid-debris level (arrow)

16. Duplex uterus with an obstructed hemivagina in a 12-year-old girl
Transverse US scan shows a normal left uterus (arrow) and a dilated right uterus (U).

17. Neonatal uterus
Longitudinal US scan shows a prominent cervix (arrows) and a visible endometrium (arrowheads). Some fluid (F) is seen within the vagina

18. They are mimic tumor of ovary
Wolffian duct Remnant
Mullerian Dact Remnant
Wolffian duct Remnant
They are mimic tumor of ovary
They are small but may enlarge and infarct
These are incidental finding at laparotomy and
cause no difficult or symtom

19. The gynecologic causes of a pelvic mass
Neoplastic mass In younger girls
Cervico-vaginal rare

21. The gynecologic causes of a pelvic mass
Neoplastic mass
In girls younger than 9 years of age, approximately
80% ovarian tumors were found to be malignant
Fewer than 2% of ovarian malignancies
occur in children and adolescents
Non-epithelial tumors predominate

22. Germ cell tumors
½ -2/3 of ovarian neoplasms in younger than 20 years of age
Develop from primordial germ cells
Termed as malignant, though do not have high malignant potential

23. Germ cell tumors
Germinoma
Teratoma

24. Typically grow rapidly- 60% seen in first 2 decades of life
producing symptoms of distention and abdominal fullness
Torsion may occur, producing an acute abdomen
obvious malignancy with involvement of opposite ovary
( Dysgerminoma)
all have a tendency to spread to the paraaortic lymph node
isosexual precocity reported

25. Unilateral oophorectomy and lymphadenectomy
ultrasonographic appearance is very different
with heterogeneous and solid components
Karyotype
Unilateral oophorectomy and lymphadenectomy
followed by adjuvant chemotherapy
Follow up necessary

27. Juvenile Granulosa Cell Tumors
derive from granulosa cells
tend to be of low malignity
most of them have mixed components
both solid and liquid
Present as pelvic mass

28. Sex cord stromal tumours

29. Secrete estrogen and sometimes prolactin
precocious pseudopuberty , galactorrhea
measurement of anti-Müllerian hormone (AMH) and inhibin and carletenin

30. Treatment -unilateral oophorectomy -cystectomy and surgical staging
careful examination of the contralateral ovary
Postoperative follow-up consists of
ultrasonography
and tumor marker for several years
-Good prognosis

31. decreases of frequency functional cysts in early childhood
NON NEOPLASTIC MASS
Ovarian Cysts
more common in the neonatal and adolescent periods ( 3 and 8 years )
decreases of frequency functional cysts in early childhood
then increases as puberty

32. The Various Etiologies of Ovarian Cysts in Prepubertal Girls
Derived degenerated follicular cysts
ovarian gonadotropin stimulation
failure of follicular apoptosis
interaction with other hormonal secretion

33. Small cysts are more frequent than large cysts
Small cysts asymptomatic discovered incidentally on ultrasonography
elongated ovarian ligament of the abdominal
location of tumor a predisposition to torsion

34. symptomatic cases: ( Abdomino -Pelvic pain) acute or sub acute
non-specific signs (nausea, vomiting, urinary disorders)
Precocious development may be
transient onset breast development
increasing during ovarian cyst formation

35. Benign Teratoma
Dermoid cysts
most frequent neoplasms in childhood
mean age of diagnosis being 10 years
heterogeneous appearance in ultrasonography
a solid cystic component containing ectodermal tissue (skin, hair, dentin)
calcifications are also clearly visible
on plain radiographs

37. Treatment
Preferable method
in dermoid cyst in a young woman
shell it out from the ovarian stroma
and preserving functioning tissue

38. Autonomous Cyst
McCune-Albright Syndrome is a sporadic disorder
in small girls between 2 and 5 years
( early childhood)
recurrent ovarian cysts
diffuse anomalies

39. skin pigmentation skin spots café-au-lait
polyostotic fibrous dysplasia characterizes the McCune-Albright syndrome
symptoms bone and cutaneous signs
detected several years later
confirm the diagnosis by molecular studies
( mutations of Gs proteins )

40. The best known type of precocious pseudopuberty
metrorrhagia
and rapid breast development
premature thelarche
Central precocious puberty
(elevated estradiol)
Very low LH and FSH levels

41. Unilocular cysts <50mm may be followed conservatively
Treatment
Unilocular cysts <50mm may be followed conservatively
This is a gonado-independent form of puberty
usual puberty inhibiting treatments are ineffective
Only aromatase inhibitors seem to have a certain efficacy

42. Management of ovarian cysts with endocrine syndrome
hormonal investigations are necessary
ultrasound-guided percutaneous aspiration
Recurrence
or surgically by laparaoscopy in
the individual case.

44. Diagnostic Arguments of Ovarian Cysts in Prepubertal Girls
Limitation of pelvic capacity in prepubertal child
pelvic mass very quickly becomes abdominal location
Examination abdominal palpation
bimanual rectoabdominal
investigate the condition of the contralateral ovary

45. Transrectal ultrasonography
For girl who had not intercourse
No alternative imaging modality
has demonstrated sufficient superiority
to USG to justify its routine use

46. Ultrasonographic signs of malignancy
Adnexal pelvic mass with
area of complexity
-Irregular border
-solid patterns within
the mass
-Dense multiple septae
color Doppler
hypervascularized tumor

47. Transvaginal Ultrasonography
Ultrasonographic signs of malignancy
Adnexal pelvic mass with area of complexity
Irregular border
solid patterns within the mass
Dense multiple septae

48. Tumor Markers
a useful diagnostic aid in
difficult to analyze by ultrasonography
and in surveillance after tumor removal
αFP in endodermal sinus tumor and embryonic carcinomas and immature teratomas.
(β-HCG) in choriocarcinomas and dysgerminoma
CA-125 levels either in peripheral blood or in the cyst fluid after aspiration
LDH in dysgerminomas

49. Will regress in 3 to 6 months Close observation is recommended
Management
clinical signs
sonographic appearance
volume of the mass
finally its persistence
Unilocular cysts are virtually always benign
Will regress in 3 to 6 months
Close observation is recommended
surgical therapy for a functional ovarian mass
can result adhesions and adversely affect future fertility

50. larger than approximately 8 cm
surgical treatment is required
complicated cyst
hemorrhage
ovarian torsion
Solid masses
larger than approximately 8 cm

51. Torsion of a normal ovary in a 10-year-old girl with severe acute pelvic pain
Transverse US scan shows a markedly enlarged right ovary with peripheral follicles (arrows)

54. Management of adnexal torsion
Detorsion!
Only procedure which should be performed
Estimation of the degree of necrosis during surgery → inaccurate
Color, size, and edema → not reflect the true damage to ovarian tissue
Ischemic-hemorrhagic, black bluish appearance
result of venous and lymphatic stasis rather than gangrene
Any additional procedure should be avoided
Ovarian cystectomy of the black-bluish ischemic should be avoided
handling of the edematous friable and ischemic adnexa is risky
additional damage to the ovary
a high percentage of functional cysts

55. Management of adnexal torsion
Suspicous adnexal torsion
Emergency detorsion, only!
Adnexectomy avoided
Ovarian function is preserved in % of cases
Edema associated torsion
Interval cystectomy
Recurrence
Rare
Repeat torsion → ovarian fixation

56. Thank you for your attention !