Management - Ovarian Masses in Adolescent Girls

In practice, the clinician is confronted by two very different situations: (1) a pelvic mass or an endocrine syndrome is discovered and complementary investigations are required for better definition of the nature of the tumor, and (2) acute abdominal pain and vomiting signal an emergency situation, with the danger of adnexal torsion, and surgery is indicated without further delay.

Ovarian Mass Discovered on Subacute Pain or an Endocrine Syndrome
Once pregnancy and PID have been eliminated, the initial diagnosis is based on the association of plain abdominal radiographs and ultrasonography, which (1) confirms the presence of the mass (differential diagnosis with pseudo-masses such as fecalomas, obstructed bladder, pregnancy, urinary disorder or ascites); (2) identifies its location in the upper intervesico-rectal space, thus excluding pelvic tumors of the other spaces and directing attention to the genital apparatus; (3) analyzes its structure: fluid, solid or mixed, and (4) assesses tumor spread.

In most cases, these simple investigations will suggest the diagnosis of an ovarian cyst or teratoma. Viewed in an overall context of suspected leukemia or a lymphoma, they will be sufficient to identify a tissue mass localized in an ovary.

Diagnosis may sometimes be more difficult: a complex cyst with a pseudo-solid appearance or teratomas with a marked calcified component. Here tumor marker measurement, sectional imaging and above all MRI come into their own. MRI is more specific in the analysis of the various components and provides indispensable information on the relationships and spread of the mass.

Adnexal Torsion
Torsion is the most common complication of ovarian masses, with a frequency ranging from 3 to 33%. When the ovarian mass manifests with acute pain, torsion is highly probable, ranging from 42% to 80%, depending on the series.

Several publications have suggested that ovarian tumors with torsion are usually benign. A possible explanation is that the rapid growth of a malignant tumor leads to peritumoral inflammation and the formation of adherences. The size of the mass does not appear to be significantly correlated with the presence or absence of torsion. Although torsion has not been shown to correlate with cyst size, larger cysts, and thus heavier ovaries, appear to be less prone to torsion. Moreover, in several publications of acute ovarian torsion, the frequency of associated tumors varies from 32% to 84%.

The clinical symptoms of tumoral adnexal torsion are in no way specific.

Usually, acute subumbilical abdominal pain is associated with vomiting. The diagnosis can be difficult and the differential diagnosis may include appendicitis, kidney stone, PID, ectopic pregnancy and ruptured ovarian cyst.

Ultrasonography reveals an echogenic pelvic mass that is usually complex (solid and cystic) and the homolateral ovary is not visualized. Effusion in Douglas' pouch is generally a late manifestation. If there are abnormal calcifications on ultrasound study or on the plain radiograph, a teratoma may be suspected. Lack of blood flow on Doppler ultrasonography suggests arterial obstruction. CT scan may be useful but treatment must not be delayed too long just to obtain complementary imaging or biological tests (tumor markers).