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Benign Tumors of the Benign Tumors of the Female Reproductive Tract Female Reproductive Tract

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(1)Benign Tumors of the Female Reproductive Tract 輔仁大學 實習醫師核心課程 新光吳火獅紀念醫院婦產科 黃莉文.

(2) Benign tumors of the Female Reproductive Tract  Pelvic. mass. A pelvic mass may be gynecologic in origin or it may arise from the urinary tract or bowel.  The gynecologic causes of a pelvic m ass may be uterine, adnexal, or more specifically ovarian. .

(3)

(4) Prepubertal Age Group - Differential Diagnosis Differential Diagnosis  < 5% of ovarian malignancies  Germ cell tumors make up 1/2 to 2/3  35% of all ovarian neoplasms occurri ng during childhood and adolescence were malignant  < 9y/o, 80% malignant .

(5) Prepubertal Age Group - Differential Diagnosis  . .  . Symptoms: abdominal or pelvic pain Pelvic mass very quickly becomes abdominal in location as it enlarges because of the small size of the pelvic cavity. Diagnosis is difficult because of the rarity of the condition (and therefore a low index of suspicion) Many symptoms are nonspecific Acute symptoms are more likely to be attributed to more common entities such as appendicitis..

(6) Prepubertal Age Group - Differential Diagnosis Abdominal palpation  bimanual rectoabdominal examination  Abdominal in location: can be confuse d with other abdominal masses  Acute pain: torsion. . The ovarian ligament becomes elongated as a result of the abdominal location, thu s creating a predisposition to torsion..

(7) Prepubertal Age Group - Diagnosis and Management Ultrasonography  Unilocular cysts are virtually always b enign and will regress in 3 to 6 month s do not require surgical management with oophorectomy or oophorocystect omy. .

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(9) Prepubertal Age Group - Diagnosis and Management .  . . Close observation recommended (discuss ri sk of ovarian torsion with the child's parent s.) Recurrence rates after cyst aspiration - 50 %. Attention: long-term effects on endocrine f unctioning, future fertility, preservation of ovarian tissue Premature surgical therapy - ovarian and tu bal adhesions that can affect future fertility ..

(10) Prepubertal Age Group - Diagnosis and Management Additional imaging : CT, MRI, Doppler flow studies.  Risk of a germ cell tumor is high, the finding of a solid component mandates surgical assessment. .

(11) Adolescent Age Group  Differential  Ovarian. Diagnosis. Masses  Uterine Masses  Inflammatory Masses  Pregnancy.

(12) Adolescent Age Group - Ovarian masses  .  . The risk of malignant neoplasms lower. Germ cell tumors - most common tumors o f the first decade of life but occur less freq uently during adolescence. Epithelial neoplasms - increasing frequency with age. Mature cystic teratoma - most frequent neo plastic tumor of children and adolescents, a ccounting for > 1/2 of ovarian neoplasms i n women < 20 y/o.

(13) Adolescent Age Group - Ovarian masses Neoplasia can arise in dysgenetic gon ads.  25% of dysgenetic gonads of patients with a Y - malignant.  Gonadectomy - recommended for pati ents with XY gonadal dysgenesis or it s mosaic variations. .

(14) Adolescent Age Group - Ovarian masses . Functional ovarian cysts Incidental finding on examination  Pain caused by torsion, leakage, or rupture. . . Endometriosis is less common during adolescence than in adulthood. . In series of adolescents referred with chronic pain, 50% to 65% have been found to have endometriosis..

(15) Adolescent Age Group - Ovarian masses Most adolescents with endometriosis do not have associated obstructive an omalies.  In young women, endometriosis may have an atypical appearance, with no npigmented or vesicular lesions, perit oneal windows, and puckering. .

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(17) Adolescent Age Group - Uterine Masses Uterine leiomyomas - not common  Obstructive uterovaginal anomalies oc cur during adolescence, at the time of menarche, or shortly thereafter.  The diagnosis is frequently neither su spected nor delayed, particularly whe n the patient is seen by a general sur geon. .

(18) Adolescent Age Group - Uterine Masses .  . Uterine anomalies - imperforate hymen, tra nsverse vaginal septa, vaginal agenesis wit h a normal uterus and functional endometri um, vaginal duplications with obstructing lo ngitudinal septa, and obstructed uterine ho rns. Cyclic pain, amenorrhea, vaginal discharge, or an abdominal, pelvic, or vaginal mass. Hematocolpos, hematometra.

(19) Obstructive Genital Anomalies.

(20)

(21) Hematocolpos.

(22) Bulging vaginal mass.

(23) Bulging vaginal mass.

(24) Bulging vaginal mass.

(25) Cruciate/Circular Incision.

(26) Uterine anomalies.

(27) Adolescent Age Group - Inflammatory Masses   . Adolescents have the highest rates of PID An adolescent who has pelvic pain may be found to have an inflammatory mass. The diagnosis is primarily clinical, based on the presence of lower abdominal, pelvic, an d adnexal tenderness; cervical motion tend erness; a mucopurulent discharge; elevate d temperature, white blood cell count, or s edimentation rate.

(28) Adolescent Age Group - Inflammatory Masses Associated with the risks STD  Inflammatory masses may consist of .  Tuboovarian. complex  Tuboovarian abscess  Pyosalpinx  Hydrosalpinx.

(29) Adolescent Age Group - Inflammatory Masses.

(30) Adolescent Age Group - Pregnancy    . Pregnancy should always be considered Adolescents more likely to deny the possibil ity of pregnancy. Ectopic pregnancies may cause pelvic pain and an adnexal mass. Quantitative measurements of b-hCG, ecto pic pregnancies are being discovered befor e rupture, allowing conservative managem ent with laparoscopic surgery or medical th erapy with methotrexate..

(31) Adolescent Age Group - Diagnosis A history and pelvic examination  Anxiety associated with a first pelvic e xamination  Issues of confidentiality related to qu estions of sexual activity.  Always include a pregnancy test (rega rdless of stated sexual activity)  CBC/DC.  Tumor markers (AFP, hCG…) .

(32) Adolescent Age Group - Diagnosis Ultrasonography.  TVS provide more detail than Abd son ography  TVS may not be well tolerated by adol escents  CT or MRI .

(33) Adolescent Age Group - Management Laparoscopy  Acute PID to confirm the diagnosis  Persisted symptoms in patient with the clinical diagnosis of PID or TOA  The surgical management of inflammatory masses is rarely necessary in adolescents, except ruptured TOA or failure of medical management with broad-spectrum antibiotics .

(34) Reproductive Age Group  Differential  Uterine. Diagnosis. Masses  Ovarian Masses  Nonneoplastic Ovarian Masses  Other Benign Masses  Neoplastic Masses  Other Adnexal Masses.

(35) Reproductive Age Group - Uterine Masses Uterine leiomyomas - most common b enign uterine tumors.  Usually diagnosed on physical examin ation.  Incidence: 20% (reproductive age)  40% to 50% of women older than 35 years of age. .

(36) Types of fibroids.

(37) Reproductive Age Group - Uterine Masses Malignant degeneration < 0.5%  Leiomyosarcoma -rare malignant neo plasm composed of cells that have sm ooth muscle differentiation.  Most diagnoses are determined (post operatively) after microscopic examin ation. .

(38) Reproductive Age Group - Uterine Masses . Symptoms Menorrhagia  Chronic pelvic pain  Acute pain  Urinary symptoms: Frequency, Partial ur eteral obstruction, complete urethral obs truction  Infertility .

(39) Reproductive Age Group - Uterine Masses . Symptoms Rectosigmoid compression, with constipa tion or intestinal obstruction  Prolapse of a pedunculated submucous t umor  Venous stasis of the lower extremities an d possible thrombophlebitis secondary to pelvic compression  Polycythemia  Ascites .

(40) Reproductive Age Group - Uterine Masses Management of Leiomyomas  Nonsurgical Management . Intervention is reserved for specific indic ations and symptoms.  Periodic examinations  GnRH agonists .

(41) Reproductive Age Group - Uterine Masses GnRH agonists  40% to 60% decrease in uterine volu me  Hypoestrogenism: reversible bone los s and symptoms: hot flashes.  limited to short-term use  Regrowth of leiomyomas within a few months after stopping therapy in abo ut 1/2 women treated.

(42) Reproductive Age Group - Uterine Masses  . .  .  . Indications for GnRH agonist: 1.Preservation of fertility in women with large leiomyomas b efore attempting conception, or preoperative treatment befo re myomectomy 2.Treatment of anemia to allow recovery of normal hemoglo bin levels before surgical management, minimizing the need for transfusion or allowing autologous blood donation 3.Treatment of women approaching menopause in an effort to avoid surgery 4.Preoperative treatment of large leiomyomas to make vagin al hysterectomy, hysteroscopic resection or ablation, or lapar oscopic destruction more feasible 5.Treatment of women with medical contraindications to sur gery 6.Treatment of women with personal or medical indications f or delaying surgery..

(43) Reproductive Age Group - Uterine Masses Indications for surgery :      . Abnormal uterine bleeding - anemia, unresponsive to hormonal management Chronic pain with severe dysmenorrhea, dyspareu nia, or lower abdominal pressure or pain Acute pain, as in torsion of a pedunculated leiomy oma, or prolapsing submucosal fibroid Urinary symptoms or signs such as hydronephrosis after complete evaluation Infertility, with leiomyomas as the only abnormal fi nding Markedly enlarged uterine size with compression s ymptoms or discomfort..

(44) Reproductive Age Group - Uterine Masses  Indications. for surgery because o f the inability to exclude uterine s arcoma:  Rapid enlargement of the uteru s during premenopausal years  or any increase in uterine size i n a postmenopausal woman.

(45) Reproductive Age Group - Uterine Masses . . . Hysterectomy has long been viewed as the definitive management of symptomatic uter ine leiomyomas. Myomectomy is an alternative to hysterecto my for patients who desire childbearing, w ho are young, or who prefer that the uteru s be retained. Recent studies suggest that t he morbidity of abdominal myomectomy an d hysterectomy are similar Laparoscopic myomectomy minimizes the si ze of the abdominal incision, although seve ral small incisions are required..

(46) Reproductive Age Group - Uterine Masses .  . . Vaginal myomectomy is indicated in the cas e of a prolapsed pedunculated submucous f ibroid. Hysteroscopic resection of small submucou s leiomyomas The recurrence risk for leiomyomas has be en reported to be as high as 50% after my omectomy, with up to 1/3 requiring repeat surgery. Endometrial ablation can decrease bleeding for women with primary intramural fibroid.

(47) hysteroscopy.

(48) Reproductive Age Group - Uterine Masses . Nonextirpative approaches: . . . Myolysis - use of lasers to coagulate or needle electrodes to deliver an electrical current to indi vidual leiomyomas Uterine artery embolization - have serious cons equences, including infection, massive bleeding , and necrosis requiring emergency surgery. Stil l consider investigational.. Long-term safety and efficacy have not yet been demonstrated..

(49) Reproductive Age Group - Ovarian Masses   . . During the reproductive years, the most co mmon ovarian masses are benign. About 2/3 ovarian tumors are encountered during the reproductive years. Most ovarian tumors (80% to 85%) are be nign, and 2/3 of these occur in women bet ween 20 and 44 y/o. The chance that a primary ovarian tumor is malignant in a patient < 45 y/o is less than 1 in 15..

(50) Reproductive Age Group - Ovarian Masses Pelvic findings in patients with benign and malignant tumors differ.  Benign - unilateral, cystic, mobile, an d smooth  Malignant -bilateral, solid, fixed, irreg ular, and associated with ascites, culde-sac nodules, and a rapid rate of gr owth .

(51)

(52) Reproductive Age Group - Nonneoplastic Ovarian Masses Nonneoplastic Ovarian Masses  Functional ovarian cysts include . follicular cysts  corpus luteum cysts  theca lutein cysts . . All are benign and usually do not caus e symptoms or require surgical mana gement..

(53) Reproductive Age Group - Nonneoplastic Ovarian Masses . Follicular cyst the most common functional cyst  cystic follicle can be defined as follicular cyst when diameter > 3 cm.  found incidental to pelvic examination  usually resolve in 4 to 8 weeks, seldom rupture causing pain and peritoneal signs .

(54) Reproductive Age Group - Nonneoplastic Ovarian Masses . Corpus luteum cysts less common than follicular cysts.  may rupture, leading to a hemoperitone um and requiring surgical management.  High risk - anticoagulant therapy.  Rupture - more often on the right side a nd during intercourse.  Most ruptures on cycle days 20 to 26. .

(55) Reproductive Age Group - Nonneoplastic Ovarian Masses . . . Combination monophasic oral contraceptive therapy has been reported to markedly red uce the risk of functional ovarian cysts. It appears that, in comparison with previou sly available higher-dose pills, the effect of cyst suppression with current low-dose oral contraceptives is attenuated. Most studies have suggested that the use o f triphasic oral contraceptives is not associa ted with an appreciable increased risk of fu nctional ovarian cysts..

(56) Reproductive Age Group - Ovarian Masses Other Benign Masses  Women with endometriosis may devel op ovarian endometriomas (“chocolat e” cysts), which can enlarge to 6 to 8 cm in size.  A mass that does not resolve with obs ervation may be an endometrioma. .

(57) ovarian endometriomas (“choco late” cysts).

(58) Endometrioma.

(59) Endometrioma – “chocolate” content.

(60) Reproductive Age Group - Ovarian Masses . . . In one study, 257 volunteers were examine d with ultrasonography; 22% were found t o have polycystic ovaries. The finding of bilateral generously sized ov aries on examination or polycystic ovaries o n ultrasonographic examination should pro mpt evaluation for the full-blown syndrome which includes hyperandrogenism and chro nic anovulation as well as polycystic ovaries . Therapy for PCOS is medical and generally not surgical..

(61) Polycystic Ovaries.

(62) Reproductive Age Group - Neoplastic Ovarian Masses . More than 80% of benign cystic terat omas (dermoid cysts) occur during th e reproductive years, although dermoi d cysts have a wider age distribution t han other ovarian germ cell tumors..

(63) Reproductive Age Group - Neoplastic Ovarian Masses Benign cystic teratomas have an admi xture of elements.  comprising more than a single cell typ e derived from more than one germ la yer, usually all 3.  Cells differentiate along various germ l ines, essentially recapitulating any tiss ue of the body. Examples include hair, teeth, fat, skin, muscle, and endocrine tissue .

(64) Reproductive Age Group - Neoplastic Ovarian Masses Malignant transformation: < 2%  Bilateral: 10%  Torsion: 15%, it occurs more frequently than with ovarian tumors because the high-fat content allowing them to float within the abdominal and pelvic cavity.  As a result, frequently is anterior in location. .

(65) Reproductive Age Group - Neoplastic Ovarian Masses . .  . Cystectomy is almost always possible, even if it appears that only a small amount of ov arian tissue remains. Preserving a small amount of ovarian corte x in a young patient with a benign lesion is preferable Laparoscopic cystectomy is often possible, Intraoperative spill of tumor contents is rar ely a cause of complications..

(66) KUB.

(67) Sonography.

(68) Mature Teratoma / Dermoid Cyst.

(69) Torsion.

(70) Laparoscopic Surgery.

(71) Spill of contents.

(72) Reproductive Age Group - Neoplastic Ovarian Masses  serous  The. cystadenomas. risk of epithelial tumors increas es with age  5% to 10% have borderline malign ant potential  20% to 25% are malignant  often multilocular, sometimes with papillary components..

(73) Reproductive Age Group - Neoplastic Ovarian Masses  . . Surface epithelial cells secrete serous fluid, resulting in a watery cyst content. Psammoma bodies are areas of fine calcific granulation, may be scattered within the tu mor and are visible on radiograph. Frozen section is necessary to distinguish b etween benign, borderline, and malignant s erous tumors, because gross examination a lone cannot make this distinction..

(74) Serous Cystadenoma.

(75) Serous Cystadenoma.

(76) Serous Cystadenoma. Psammoma bodies.

(77) Reproductive Age Group - Neoplastic Ovarian Masses  Mucinous  may. ovarian tumors. grow to large dimensions  lobulated, smooth surface, mult ilocular  Bilateral in up to 10% of cases  Five to ten percent of mucinous ovarian tumors are malignant..

(78) Reproductive Age Group - Neoplastic Ovarian Masses Mucoid material is present within the cystic loculations  may be difficult to distinguish histolog ically from metastatic gastrointestinal malignancies .

(79)

(80)

(81) Reproductive Age Group - Neoplastic Ovarian Masses . Other benign ovarian tumors include f ibromas (a focus of stromal cells), Bre nner tumors (which appear grossly si milar to fibromas and which are frequ ently found incidentally), and mixed f orms of tumors such as the cystadeno fibroma..

(82) Fibroma Meig’s Syndrome • defined as the triad of beni gn ovarian tumor with ascite s and pleural effusion that re solves after resection of the t umor. •40% of ovarian fibromas ar e associated with ascites and pleural effusion.

(83) Brenner Tumor.

(84)

(85) Postmenopausal Age Group Differential Diagnosis of Ovarian Masses    . During the postmenopausal years, the ovaries become smaller. Before menopause, the dimensions are approximately 3.5 × 2 × 1.5 cm. In early menopause, the ovaries are approximately 2 × 1.5 × 0.5 cm. In late menopause, they are even smaller: 1.5 × 0.75 × 0.5 cm..

(86) Postmenopausal Age Group . . Barber has described the postmenopausal palpable ovary (PMPO) syndrome, suggesting that any ovary that is palpable on examination beyond the menopause is abnormal and deserves evaluation Ovarian cancer is predominantly a disease of postmenopausal women; the incidence increases with age, and the average patient age is about 56 to 60 years.

(87)

(88) References Novak's Gynecology: Jonath an S. Berek, 2002 by Lippin cott Williams & Wilkins. 13/ e  Atlas of Human Anatomy, S tudent Edition, 3rd Edition By Frank H. Netter, MD .

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