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Prevalence of malignant adnexal masses in pregnancy at gynecology and oncology department of Ghaem hospital from 2010 to 2014
Abstract
Introduction: The majority of adnexal tumors in pregnancy are benign. It is important to distinguish between benign and malignant ovarian tumors. Due to the sensitivity of pregnancy, especially malignant adnexal masses in pregnancy and the lack of accurate information from the prevalence of this malignancy, this study was performed with aim to evaluate the prevalence of adnexal masses in pregnancy. Method: This cohort study was performed on 53 pregnant women with adnexal mass who needed to surgery referred to gynecology oncology department of Mashhad Ghaem Hospital during 2010-2014. Evaluating variables included maternal age, gestational age, sonographic characteristics of tumor, clinical symptoms of patient, type of surgery, pathology status of tumor, performed chemotherapy and prognosis of mother and fetus. Data collection tool was a questionnaire. Data was analyzed by SPSS statistical software (version 16), and Mann-Whitney and Kruskal-Wallis tests. PResults: the prevalence of malignancy was 21% (11patients). The most frequent malignancy in adnexal masses and pregnancy was germ cell tumors. 55% of these tumors were in stage 3 and 4. Borderline tumors included 18% of malignant tumors. In this study, maternal mortality rate of 5.6% and maternal mortality rate of 3.8% was reported. Conclusion: Adnexal masses in pregnancy should be evaluated with more care and sensitivity and in cases of suspected or stable tumors, it is better to perform surgery in gynecologic oncology centers. © 2015, Mashhad University of Medical Sciences. All rights reserved.
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The diagnosis of a gynecological malignancy during pregnancy is rare but not uncommon. Cancer treatment during pregnancy is possible, but both maternal and fetal interests need to be respected. Different treatment plans may be justifiable and multidisciplinary treatment is advised. Clinical trials are virtually impossible, and current evidence is mainly based on small case series and expert opinion. Individualization of treatment is necessary and based on tumor type, stage, and gestational age at time of diagnosis. Termination of pregnancy is not necessary in most cases. Surgery and chemotherapy (second trimester and onwards) are possible types of treatment during pregnancy. Radiotherapy of the pelvic area is not compatible with an ongoing pregnancy. This article discusses the current recommendations for the management of gynecological malignancies (cervical, ovarian, and vulvar cancers) during pregnancy.
Our objective was to review the surgical management, surgical outcomes, and obstetric outcomes of adnexal masses in pregnancy.
A retrospective review was performed of pregnant women before 20 weeks of gestation who underwent laparoscopy or laparotomy for management of an adnexal mass during the period of January 2005 to June 2012 at a university-affiliated hospital.
Thirty-five pregnant women underwent surgical removal of adnexal masses during the 7.5-year study period: 21 (60.0%) underwent laparoscopic surgery, and 14 (40.0%) underwent laparotomy. The left upper quadrant entry technique was used in 20 women. Conversion to laparotomy was required in 2 women because of extensive pelvic adhesions. The mean gestational age at surgery was 15.2 ± 1.9 weeks. All women had undergone ovarian cystectomy. A malignant mass was found in 3 (8.6%) women. The laparoscopy group had a significantly less blood loss (67.4 ± 55.8 vs 153.6 ± 181.0 mL, P = .048) and shorter mean hospital stay (2.8 ± 1.0 vs 3.8 ± 1.1 days, P = .006) than the laparotomy group. One woman miscarried soon after surgery. There was no significant difference in obstetric outcomes between the laparoscopy and laparotomy groups.
Surgical management of adnexal masses during pregnancy appears to have favorable outcomes for the mother and the fetus.
The reported incidence of adnexal masses during pregnancy vary from 1 in 81 pregnancies to 1 in 8000 pregnancies. There is still a debate on management of incidental adnexal masses during the caesarean section concerning the risk of this additional procedure on postoperative morbidity and mortality. The aim of our study was to investigate the management of incidental adnexal masses which were observed during caesarean section in a tertiary health care centre.
The medical records of the patients who had incidental adnexal masses during caesarean section at Bakirkoy Dr. Sadi Konuk Teaching and Research Hospital, Department of Obstetrics and Gynecology from January 2006 to September 2011 were evaluated retrospectively. The data was processed with the SPSS 16.0 statistical software.
The number of total live births was 17341 and 6624 of them were done by caesarean section (31%). There were 38 cases of incidental adnexal masses which were discovered at caesarean section. The most common pathologic diagnosis of the masses were paraovarian-paratubal cysts with the rate of 23.7% (n=9). Cystectomy procedure during caesarean section did not alter the morbidity of the patient.
In conclusion for detecting adnexal masses during pregnancy follow-up of growth rate of adnexal mass will be a useful reference during the observation period if ideally all pregnant women have a first-trimester ultrasound examination with regular adnexa check-up.
Krukenberg tumor in pregnancy is very rare and management of this condition is a dilemma for physicians. Moreover, the existence of a primary Krukenberg tumor is still in debate. Herein, we present a 29-year-old woman at 29 weeks of pregnancy, admitted with premature labor and revealed to have a signet ring cell ovarian tumor with an undetermined primary origin. A primary Krukenberg tumor or a Krukenberg tumor with an undetermined origin has not been previously reported in a pregnant patient. By virtue of the controversy, we are not eager to use the term ‘primary Krukenberg tumor’ for this case, although the possibility of the existence of this kind of tumor cannot be totally ignored.
Although uncommon, the incidence of cancer complicating pregnancy is increasing. Managing these pregnancies creates many diagnostic, therapeutic, and ethical dilemmas for the patient, her family, and the medical care team. Despite concerns for fetal well-being, maternal survival should be the first priority. Although surgery and chemotherapy may be used during pregnancy, radiation is generally contraindicated. For most nongynecologic cancers, termination of pregnancy does not improve maternal outcome. Iatrogenic prematurity is the most common pregnancy complication associated with malignancy in pregnancy because many of these infants are delivered early to facilitate maternal treatment. Overall, maternal cancer survival is generally good and does not differ from that of nonpregnant patients.
The aim of this study was to investigate the impact of the histological findings on the treatment of malignant ovarian tumors in pregnant women.
This is a retrospective study of 41 patients diagnosed and treated for ovarian malignancy during pregnancy between 1985 and 2010.
The median age of the study group was 30 years old, ranging from 20 to 41. Thirty-eight (92 %) patients were diagnosed with stage I, and one (2 %) with each of stages II, III, and IV. Twenty-five (61 %) patients had borderline malignancy, 8 (20 %) were diagnosed with epithelial ovarian cancer, 7 (17 %) with germ cell tumor, and one with sex cord stromal tumor. All patients received primary surgery; 7 (17 %) patients had cystectomy, 32 (78 %) had unilateral salpingo-oophorectomy, and 3 (7 %) underwent hysterectomy with bilateral salpingo-oophorectomy. Thirty-one (76 %) patients delivered live newborns; 21 had borderline tumor (84 %), 2 had ovarian cancers (25 %), and 8 had non-epithelial tumor (100 %). Six cases were terminated in order to perform the standard treatment for ovarian malignancy and 2 cases aborted spontaneously.
In pregnant women, ovarian cancer is exceptionally less frequent compared with non-pregnant women, i.e. age-matched, statistically-corrected controls based on the Japanese annual report [8/33 (24 %) vs. control (60 %); ovarian cancer/(ovarian cancer + borderline tumor), P = 0.001]. The pregnant women with ovarian cancer chose to prioritize treatment of ovarian cancer at the sacrifice of their babies while those with borderline tumor or non-epithelial tumor were able to successfully deliver live newborns.
Epithelial ovarian cancer (EOC) in pregnancy is a rare situation. Due to its low incidence with a consecutive lack of clinical trials many questions regarding indication of different treatment approaches are unanswered. This article discusses the current literature to elaborate recommendations for the management of EOC during pregnancy. A literature search of diagnostic approaches and treatment strategies for EOC complicated by pregnancy was performed. We reviewed the available information with emphasis on surgery as well as chemotherapeutical treatment options. EOC in pregnancy is often diagnosed at early stage and no data support that concurrent pregnancy influences the growth rate or propensity for spread of EOC. Radical cytoreduction of all visible tumour followed by subsequent systemic chemotherapy is the standard treatment of EOC in most non-pregnant women. In pregnant women, however, chemotherapy as well as radical surgery should be avoided in the first trimester because of teratogenesis and high abortion rates. Besides induced abortion followed by classic management of EOC, pregnancy preserving surgery, followed by chemotherapy in the second or third trimester, timely delivery as well as neo-adjuvant chemotherapy with subsequent completing surgery appear to be viable treatment options.
Since there is only very limited information regarding the optimal therapeutic approach to EOC during pregnancy, each case needs to be addressed individually. Treatment in specialised centres should be intended especially in this rare and challenging situation.
To outline and discuss the clinical features and outcomes of adnexal masses that were treated during cesarean delivery at a tertiary referral hospital located in Ankara, Turkey.
The operating room and pathology department databases for 2007-2012 were retrospectively reviewed for surgically managed adnexal masses during cesarean delivery. Clinicopathologic characteristics and maternal and neonatal outcomes were assessed.
Adnexal masses occurred in 151 women (0.3% of all cesarean deliveries). Most (54.9%) masses were incidentally discovered during cesarean delivery. The mean mass size was 5.3±3.7cm (range, 3-30cm). The majority (96.7%) of the women underwent excision of the mass and ovarian repair. Most masses were benign, with dermoid cysts constituting the most common diagnosis (23.8%). Rare tumors such as thecoma, hyperreactio luteinalis, hemangioma, and benign Brenner tumor were also encountered. Three (2.0%) women were postoperatively diagnosed with ovarian cancer. Preterm delivery and neonatal intensive care unit admission rates were 15.9% and 11.9%, respectively. There were no serious neonatal morbidities and no neonatal mortality.
Adnexal masses encountered during cesarean delivery generally have a favorable prognosis in terms of maternal and fetal outcome.
The diagnosis of an incidental adnexal lesion during pregnancy has become more common after the widespread use of routine ultrasonography (US). The aim of this study was to examine the diagnostic approach, management strategy and the pathological findings in cases of adnexal lesions that were diagnosed and treated during pregnancy in our department.
This was a 15-year retrospective study. Cases of adnexal lesions detected during routine prenatal care by US or while performing cesarean section, between January 1996 and December 2010 at Aretaieion Hospital of the National University of Athens, were analyzed.
In this study period 39 cases of adnexal lesions were diagnosed during pregnancy or cesarean section. The age of the women was between 21 and 40 years (mean age 32.4). Surgical excision of the lesions was decided in 32 cases and conservative treatment was followed in the remaining seven cases. Surgical removal of the lesions was performed during cesarean section in 13 cases of term gestations and in four cases of preterm gestations in which pregnancy termination was considered necessary. Laparotomy during the antepartum period led to excision of adnexal lesions in 15 cases. Histology revealed benign ovarian lesions in 25 cases (78.1%), borderline ovarian tumors in two cases (6.3%), malignant ovarian tumors in four cases (12.5%) and adenocarcinoma of the appendix in one case (3.1%) presenting as an ovarian mass.
The management of cases diagnosed with adnexal lesions during pregnancy remains controversial. According to the literature, the estimated risk of malignancy for adnexal masses during pregnancy is low (2-3%) and complications of these lesions are extremely rare. These data suggest that adnexal masses could be managed conservatively if possible with US follow-up. On the other hand, the results of this study showed a higher incidence of malignancy among adnexal lesions that were surgically treated (15.6%).
Surgical intervention and histological examination in cases suspicious for malignancy at US and clinical findings remain the treatment of choice even during pregnancy.
Abstract Objective: To determine if persistent ovarian masses in pregnancy are associated with increased adverse outcomes. Methods: This is a retrospective cohort of 126 pregnant women with a persistent ovarian mass measuring 5cm or greater who delivered at two university hospitals between 2001 and 2009. Maternal outcomes included gestational age at diagnosis, delivery and surgery as well as miscarriage, preterm birth (PTB), ovarian torsion and hospital admission for pain. Neonatal outcomes included birth weight, RDS, IVH, death and sepsis. Results: 1225 ovarian masses were identified (4.9%) in 24,868 patients. A persistent ovarian mass was found in 0.7%. Average gestational age at diagnosis was 17.8 weeks. Miscarriage rate was 3.3%. Average gestational age at delivery was 37.9weeks. 8.5% had ovarian torsion, 10.3% had admission for pain, and 9.3% had preterm births. The mean Cesarean delivery rate was 46.3%. The average neonatal weight was 3,273 grams. There was 1 neonatal death in this cohort. The rate of RDS was 2.8%, IVH 0.9%, and Neonatal sepsis 1.9%. The most common surgical pathologic diagnosis was dermoids (37.6%). No overt malignancies were seen. Conclusion: A persistent ovarian mass in pregnancy does not confer an increased risk of adverse pregnancy outcomes.
To investigate risks of torsion and malignancy by adnexal mass size during pregnancy.
Retrospective review of medical records.
General university hospital and healthcare center.
Four hundred and seventy women who underwent surgery for adnexal masses during pregnancy between 2002 and 2009.
Rate of torsion and malignancy according to mass size classified into four groups: <6, 6-10, 10-15 and ≥15 cm.
Torsion was encountered in 55 patients (11.7%) and malignancy was confirmed in 20 (4.3%). A mass size of 6-10 cm had a significantly higher risk of torsion than a mass <6 cm (odds ratio 2.68, 95% confidence interval 1.33-5.40, p=0.006). Masses ≥15 cm had an approximately 12-fold higher risk of malignancy compared with masses <6 cm (odds ratio 12.36, 95% confidence interval 2.90-52.67, p=0.001). However, for masses of 10-15 cm, the risks of both torsion and malignancy were not higher than those of masses <6 cm.
Risks of torsion and malignancy are not directly proportional to increasing mass size in pregnant women. Physicians should be aware of a high risk of malignancy in women with an adnexal mass of over 15 cm. However, if a mass is smaller, the size should not be considered as a single independent factor in a decision for surgery.