1. Basic patient information
During the 7-year period, 212 patients were surgically evaluated for ovarian lesions with symptoms of abdominal pain. At the surgical evaluation, the median age of the patients was 14.5±3.6 years; 155 patients (73.1%, 155/212) had regular menstruation, 20 patients (9.4%, 20/212) had irregular menstruation, and 37 patients (17.5%, 37/212) had not yet begun menstruating.
126 (59.4%, 126/212) patients presented with an abrupt onset of abdominal pain. In addition to pain, subjects presented with other symptoms and objective findings. The incidence rates of symptom of vomiting, nausea, fever, diarrhea, frequent urination, and abnormal vaginal bleeding were 26.9%, 6.6%, 3.3%, 0.9%, 1.8%, respectively. One patient presented with clinical characteristics of precocious puberty. No patients presented with abnormal skin pigmentations or other known syndrome markers at physical examination.
Pelvic abdominal ultrasound was the priority imaging modality used in all the patients (n 100%, 212/212) to characterize the ovarian disease as simple, complex, or solid lesions. US examination showed an adnexal mass in all our patients: simple ovarian masses in 188 (88.7%), complex ovarian masses in 20 (9.4%), and solid lesions in 4. An additional abdominal Computed Tomography scan(CT)or Magic resonance imaging༈MRI༉was performed for 39 patients (18.4%) to exclude suspected malignant pathologies.
Serum levels of the tumor markers CA-125, CA-199, α-fetoprotein, and β-human chorionic gonadotropin were detected in 105 cases. The tumor markers were abnormally elevated in 26 patients, and AFP, CA125, CA199 and β-HCG were abnormal in 6, 12, 7 and 1 patients, respectively.
2. Comparison of the clinical information between the EMS and ELS groups
The patients were divided into two groups, namely, the emergency surgery (EMS, n=96) group and the elective surgery (ELS, n=116) group. In the EMS group, pain often presented as acute pain. Compared with the ELS group, the proportion of patients with emergency onset, persistent pain, duration less than 3 months was significantly higher in the EMS group (p<0.05). There were significantly more patients without menarche in the EMS group than in the ELS group (p<0.05). The average tumor size in the ELS group was larger than that in the EMS group (p<0.05) (Table 1).
Table 1
Comparison of patient characteristics in the EMS and ELS groups
|
EMS (n=96)
|
ELS (n=116)
|
Sum (n=212)
|
P value
|
Age (years)
|
14.2±3.9
|
14.9±3.2
|
14.5±3.6
|
0.071
|
Onset of pain
|
|
|
|
0.045
|
Emergency onset
|
64(66.7%)
|
62(53.5%)
|
126(59.4%)
|
|
Non-emergency onset
|
32(33.3%)
|
54(46.5%)
|
86(40.6%)
|
|
Duration of pain
|
|
|
|
0.000
|
≤3 months
|
81(84.4%)
|
45(37.8%)
|
126(59.4%)
|
|
>3 months
|
15(15.6%)
|
71(61.2%)
|
86(40.6%)
|
|
Frequency and intensity
|
|
|
|
0.000
|
Persistent、intense
|
88(91.7%)
|
49(42.2%)
|
137(64.6%)
|
|
intermittent
|
8(8.3%)
|
67(57.8%)
|
75(35.4%)
|
|
Location
|
|
|
|
0.143
|
right or left quadrant
|
58(60.4%)
|
49(42.2%)
|
107(50.5%)
|
|
not accurate and/or referred pain
|
38(39.6%)
|
67(57.8%)
|
105(49.5%)
|
|
Ultrasound
|
|
|
|
0.886
|
simple
|
84(87.5%)
|
104(89.7%)
|
188(88.7%)
|
|
complex
|
10(10.4%)
|
10(8.6%)
|
20(9.4%)
|
|
solid
|
2(2.1%)
|
2(1.7%)
|
4(1.9%)
|
|
Menstruation
|
|
|
|
0.022
|
menarche
|
74(77.1%)
|
103(88.8%)
|
177(83.5%)
|
|
no menarche
|
22(22.9%)
|
13(༈11.2%)
|
35(16.5%)
|
|
Surgical approach
|
|
|
|
0.263
|
laparoscopy
|
84(87.5%)
|
95(81.9%)
|
179(84.4%)
|
|
laparotomy
|
12(12.5%)
|
21(18.1%)
|
33(15.6%)
|
|
Tumor size (unilateral)
|
8.2±3.2
|
8.8±5.1
|
8.5±5.9
|
0.001
|
Side of the tumor
|
|
|
|
0.161
|
left side
|
40(41.7%)
|
49(42.2%)
|
89(42.0%)
|
|
right side
|
54(56.3%)
|
58(50.0%)
|
112(52.8%)
|
|
bilateral side
|
2(2.0%)
|
9(7.8%)
|
11(5.2%)
|
|
3. The surgical procedure and pathological results of the EMS and ELS groups.
Among the 212 patients, 179(84.5%, 179/212)underwent laparoscopic surgery with an average tumor size of 7.7±3.4cm, and there were no intraoperative or postoperative complications. The average tumor size of 33 patients༈ 15.6%, 33/212༉who underwent laparotomic surgery was 12.9±5.6 cm. The mean tumor size of patients undergoing laparotomic surgery was significantly higher than that of patients undergoing laparoscopic surgery༈P=0.000༉. A total of 81.1% (172/212) of the subjects had performed adnexal conservative surgery, and 78.8% (167/212) of these patients had an adnexal mass removed. In the EMS group, the proportion of unilateral adnexectomy was 20.5%༈25/96༉, significantly higher than that in the ELS group༈20.5% vs 5.2%, P=0.000༉. Nine patients with suspected malignant tumors underwent lateral adnexectomy and biopsy at the suspected site (Table 2).
Table2 Surgical procedure of the patients
|
EMS (n=96)
|
ELS (n=116)
|
Sum (n=212)
|
Cystectomy
|
62
|
105
|
167
|
Laparoscopic
|
59
|
95
|
154
|
Laparotomic
|
3
|
10
|
13
|
Adnexectomy
|
25
|
6
|
31
|
Laparoscopic
|
20
|
0
|
20
|
Laparotomic
|
5
|
6
|
11
|
Laparotomic adnexectomy± greater omentum resection +biopsy
|
4
|
5
|
9
|
Laparoscopic tubal fenestration
|
2
|
0
|
2
|
Laparoscopic salpingectomy
|
3
|
0
|
3
|
Pathologic examination demonstrated adnexal mass with abdominal pain being mature cystic teratoma (34.0%,72/212), simple cyst(19.8%,42/212), mucinous or serous cystadenoma (9.4%,20/212), corpus luteum cyst (9.4%,20/212), para-ovarian cyst (8.5%,18/212), endometriosis cyst (8.0%,17/212), malignant germ cell tumor (3.3%,7/212) and sexual cord stromal cell tumor (2.4%,5/212) (Table 3). Among the 14 patients with complex lesions suspected malignancy indicated by preoperative ultrasound, 6 were confirmed to be malignant germ cell tumors and 3 were sex cord stromal tumors.
Table 3
Pathological results of adnexal mass in the two groups
|
EMS (n=96)
|
ELS (n=116)
|
Sum (n=212)
|
Simple cyst
|
21
|
21
|
42
|
Para-ovarian cyst
|
12
|
6
|
18
|
Mature cystic teratoma
|
24
|
48
|
72
|
Endometriosis cyst
|
6
|
11
|
17
|
Enlarged ovary
|
4
|
1
|
5
|
Corpus luteum cyst
|
14
|
6
|
20
|
Malignant germ cell tumor
|
3
|
4
|
7
|
Mucinous/Serous cystadenoma
|
4*
|
16
|
20
|
Sexual cord stromal cell tumor
|
3
|
2#
|
5
|
Inflammation
|
0
|
1
|
1
|
Tubal torsion
|
3
|
0
|
3
|
Ectopic pregnancy
|
2
|
0
|
2
|
*one case of borderline mucinous cystadenoma |
#one case of foam fibroma |
There were 7 cases of malignant germ cell tumors, including 3 cases of endodermal sinus tumors, 1 case of mixed germ cell tumors (endodermal sinus tumor complicated with immature teratoma tumor), 2 cases of immature teratoma, and 1 case of dysgeminoma. The postoperative treatment of the seven cases was supplemented with 3-6 cycles of PEB/PEV chemotherapy. There were 5 cases of sex cord stromal cell tumors, including 2 cases of juvenile granulosa cell tumors, 1 case of malignant steroid cell tumors, and 1 case of moderately differentiated Sertoli-Leydig cell tumors. Juvenile granulosa tumors and malignant steroid cell tumors were treated with adjuvant chemotherapy after the operation.
4. Clinicopathological characteristics of adnexal mass with acute complications
Of the 96 patients, 78(81.3%)had adnexal torsion, including adnexal mass,enlarged ovaries, and fallopian tubes,16 (16.7%) had mass rupture, and 2 (2.08%) had ectopic pregnancy. Among the 78 patients with adnexal torsion, 72 patients had adnexal mass. The average diameter of adnexal mass was 8.7±3.1cm, of which 97.2% patients were larger than 5cm. The average torsion degree was 653.2±419. Torsion occurred on the right side in 43 cases and 33 cases on the left. Cysts were bilateral and torsion occurred on one side in 2 cases. The most common pathologic types were mature teratoma and simple cyst, accounting for 29% and 26%, respectively,followed by para-ovarian cyst, serous/mucinous cystadenoma, and endometriosis cyst. Three patients presented with ovarian enlargement and torsion, 3 with fallopian tube torsion, 3 with malignant germ cell tumor, and 2 with sex cord stromal tumor. Of the 78 patients with torsion, 49 underwent ovary-preserving surgery, and 24 underwent adnexectomy. 23 patients (29.5%) underwent adnexectomy due to necrosis. 3 patients underwent salpingectomy for tubal torsion
(Table 4)
Table 4
Surgical method for patients with adnexal torsion
|
Number of patients
|
Adnexectomy
|
24
|
mature cystic teratoma
|
6
|
serous/mucinous cystadenoma
|
1
|
simple cyst
|
9
|
para-ovarian cyst
|
5
|
corpus luteum cyst
|
0
|
enlarged ovary
|
2
|
sexual cord stromal cell tumor
|
1
|
Cystectomy
|
49
|
mature cystic teratoma
|
17
|
serous/mucinous cystadenoma
|
3
|
simple cyst
|
11
|
Para-ovairan cyst
|
7
|
corpus luteum cyst
|
5
|
endometriosis cyst
|
3
|
enlarged ovary
|
1
|
sexual cord stromal cell tumor
|
0
|
malignant germ cell tumor
|
2
|
Salphingectomy
|
3
|
tubal torsion
|
3
|
Adnexectomy ± greater omentum resection +biopsy
|
2
|
granulosa cell tumor
|
1
|
immature teratoma
|
1
|