SRP Discussion
Case Takeaways
Adnexal Pathology in Teen Girls
Case study of a 15-year-old girl presenting with a large abdominal mass and associated symptoms. The patient, who had been experiencing worsening left lower quadrant pain and bloating for 3 mos, was transferred to the hospital after a severe episode of abdominal pain and non-bilious vomiting. Despite the significant size of the mass, the patient was hemodynamically stable, and the abdomen was distended but not tender. The discussion highlighted the importance of early diagnosis and management of such cases, with emphasis on the need for further imaging and tumor marker testing.
Abdominal Cystic Mass Evaluation
The team discussed a patient with a large abdominal cystic mass that was initially evaluated with ultrasound, which showed a mainly cystic lesion compressing the bladder and potentially involving both ovaries. They determined that MRI would be the best imaging modality for further evaluation due to the size and complexity of the mass, as MRI can better differentiate between functional and neoplastic masses and aid in surgical planning for ovarian preservation. The discussion concluded with an invitation for others to share their approach to managing this patient after the ultrasound findings.
Ovarian Lesion Imaging Discussion
The team discussed imaging findings of bilateral ovarian lesions, with one expert explaining that a T2 fat sat sequence showed a large cystic lesion on the left and a fat-containing lesion on the right, both appearing as teratomas. They noted that while T1 post-Gad sequences showed no enhancement in the fat-containing portions, there was enhancement in a solid component of the left ovarian lesion. When asked about distinguishing between serous and mucinous fluid in the large cystic lesion, the expert explained that while CT might help with this distinction, MRI was less reliable due to artifacts, though mucinous content might appear slightly brighter on T1 sequences.
Abdominal Cyst Surgical Evaluation
The surgical team discussed a large abdominal cyst in a young patient, focusing on imaging evaluation and surgical approach. They confirmed that despite the large size, they could effectively assess for retroperitoneal adenopathy and other potential malignant indicators through imaging, though liver lesions might be harder to detect because of respiratory artifacts. During surgery, the team performed a decompression procedure using a plastic sheet and Derma bond to control fluid spillage, revealing a 720-degree torsion of the pedicle, with surprisingly viable tissue despite chronic torsion.
Ovarian Cyst Removal Surgery Discussion
The complex ovarian surgery involved a large left ovarian cyst and a smaller right ovarian cyst. The surgical team successfully preserved the right ovary by removing the cyst and draining fluid, while removing the left ovary because of extensive disease. The pathologist presented findings from both specimens, noting the right cyst was 3 cm with a fibrous lining and hair, while the larger left cyst weighed 936 g and contained sebaceous debris. The discussion concluded with questions about intraoperative ultrasound strategies for identifying ovarian tissue and the possibility of malignancy, with the team agreeing that ultrasound could be useful in cases where ovarian tissue is not clearly visible.
Benign Teratoma Pathology Review
The pathologist presented findings from a surgical specimen, describing a large mass with intact surfaces except for a drainage site, containing a 7-cm nodule with sebaceous debris and hair. Histology revealed three areas of mature teratoma, including skin, cartilage, and glial tissue, along with a mucinous cyst adenofibroma lined by non-stratified mucinous epithelium. Cytopathology samples from the peritoneal lavage and mass fluid were both reported as benign and negative for malignancy, showing reactive mesothelial cells and mixed inflammation.
Teratoma Diagnosis and Management
The discussion focused on the diagnosis and management of mature and immature teratomas in the ovaries. The speakers explained that mature teratomas, which are common in pediatric patients, can be cured with surgery alone if they lack immature elements, while immature teratomas may require adjuvant therapy depending on the grade of immaturity. They emphasized that bilateral disease occurs in about 10-15% of cases and can lead to a 15% risk of recurrence up to 14 yr later. The speakers also discussed the importance of follow-up care, particularly for patients with negative tumor markers, and highlighted the need to involve a gynecologic oncologist in cases requiring bilateral oophorectomy.