Diagnostic Considerations
Important considerations
In all cases in which reproductive-aged women (even at the extremes) present with abdominopelvic complaints, a pregnancy test should be ordered to help exclude the possibility of pregnancy. Occasionally, patients with other tumors, such as carcinoma of the pancreas or other GI tumors, have an elevated bhCG level in the absence of pregnancy.
Pelvic and rectal examinations should not be deferred in reproductive-aged patients who present with vague abdominal complaints. Pelvic masses are not palpable upon abdominal examination until they reach 8-10 cm and are pushed up out of the pelvis. Failure to perform pelvic and rectal examinations may delay diagnosis of pelvic masses such as ectopic pregnancies and malignant tumors. This can have grave consequences both for patients and physicians.
The widespread use of ultrasonography in obstetrics has led to more frequent diagnosis of adnexal masses during pregnancy. Pregnancy is not a contraindication to proceeding with a workup of an abdominal mass. However, surgical intervention should be delayed until 16-18 weeks of gestation to decrease risks to the fetus in the embryonic stage of development.
Special concerns
Ovarian tumors occur or can be found during pregnancy. Because only 2% of masses in pregnant women are malignant, these masses can be followed expectantly if diagnosed in the first trimester because most masses resolve spontaneously. Tumors that persist into the second trimester, especially if complex or larger than 6 cm, should be managed surgically.
Approximately 10% of GCTs occur in pregnant patients. These masses do not resolve with expectant management, and surgical therapy should be carried out as follows:
-
The optimal time for abdominal exploration is approximately 16-18 weeks of gestation. The incidence of fetal loss, preterm labor, and maternal morbidity appears to be lower at this gestational age. A high vertical incision should be employed because the adnexa are out of the pelvis at this point in pregnancy. Because most tumors are stage Ia (see Staging), a unilateral salpingo-oophorectomy is sufficient treatment for most patients. In cases in which spread outside of the ovary already has occurred, treatment recommendations become unclear. Total abdominal hysterectomy and bilateral salpingo-oophorectomy, with removal of the fetus and placenta in toto, is another option to be considered. Some patients have been treated with unilateral salpingo-oophorectomy, resection of all visible tumor, and adjuvant chemotherapy.
-
The decision to begin chemotherapy during pregnancy rests with the patient and physician because all chemotherapy agents are potential teratogens. Reports of chemotherapeutic agent use in the second and third trimester for other ovarian tumors exist, but caution should be taken because little is known about the long-term effects on the developing fetus. Delaying adjunct therapy until after delivery is not well studied but could be considered because many of these tumors exhibit indolent growth.
A higher propensity for torsion exists in pregnant patients because the adnexa become abdominal structures early in the second trimester. In pregnant patients presenting with acute abdominal pain and a palpable mass, sonographic evaluation of the adnexa can help confirm the presence of an adnexal mass.
Other conditions in the differential diagnosis
Other conditions to consider in the differential diagnosis for any pelvic mass can include, but is not limited to, those listed below.
Gastrointestinal
Consider the following:
-
Fecal impaction
-
Low-lying cecum
-
Bowel/omental adhesions
-
Colon cancer
-
Metastatic gastrointestinal carcinoma
Genitourinary
Consider the following:
-
Endometriosis
-
Ovarian torsion
-
Hydrosalpinx/pyosalpinx
-
Pelvic abscess
-
Uterine fibroids
-
Uterine anomalies
-
Embryologic remnants
-
Bladder distention/urinary retention
-
Pelvic kidney
-
Urachal cyst
Other
Also consider the following:
-
Retroperitoneal mass
-
Peritoneal cyst
-
Benign lesions of the uterine corpus
The differential diagnosis for patients presenting with endocrine manifestations includes, but is not limited to, the following:
-
Pregnancy
-
True precocious puberty
-
Exogenous hormone administration
-
Polycystic ovary syndrome
-
Adrenal tumors
Differential Diagnoses
-
Appendicitis
-
Colonic Obstruction
-
Ectopic Pregnancy
-
Microfollicular pattern of an adult granulosa cell tumor at 100X magnification. Inset is characteristic Call-Exner bodies and nuclear grooves (400X). Image courtesy of James B. Farnum, MD, TriHealth Department of Pathology.
-
Less well-differentiated diffuse pattern of adult granulosa cell tumor. Monotonous pattern can be confused with low-grade stromal sarcoma (200X). Inset is high-power magnification demonstrating nuclear grooves and nuclear atypia. Image courtesy of James B. Farnum, MD, TriHealth Department of Pathology.
-
Juvenile granulosa cell tumor. Multiple follicles in various shapes and sizes (200X). Inset shows nuclei that are rounded, hyperchromatic, lacking grooves and showing atypia, and are abnormal mitotic figures (400X). Image courtesy of James B. Farnum, MD, TriHealth Department of Pathology.
-
Gyriform pattern of adult granulosa cell tumor. Undulating single-file rows of granulosa cells (200X). Image courtesy of James B. Farnum, MD, TriHealth Department of Pathology.
-
Theca cell tumor. Typical thecoma with lipid-rich cytoplasm, pale nuclei, and intervening hyaline bands (200X). Image courtesy of James B. Farnum, MD, TriHealth Department of Pathology.
-
Luteinized thecoma. Vacuolated theca cells with an abundant fibromatous stroma (200X). Image courtesy of James B. Farnum, MD, TriHealth Department of Pathology.
