Abstract

Objectives

Although adnexal masses are an essential reason for gynecological surgeries in adolescents, early diagnosis and treatment are essential for preserving fertility. This study aimed to analyze the clinical features, treatment management, and histopathological results of patients with adnexal masses in a tertiary care center in the middle and late adolescent age group.

Materials and Methods

Adolescent patients with adnexal masses were evaluated retrospectively between January 2015 and December 2019. Patients were classified as middle (15-17 years) and late (18-21 years) adolescents. Patients’ complaints, diagnoses, mass diameters and locations, treatment methods, surgery characteristics, and histopathological results were compared.

Results

A total of 141 patients in the middle adolescence (n=20) and late adolescence groups (n=121) were included in the study. Abdominal pain (70.9%), abdominal distension (11.3%), and menstrual disorders (7.1%) were the most common symptoms in the entire population. It was determined that 51.9% of the masses were benign neoplastic tumors, and 1.9% were malignant tumors. Surgery was not considered in 24.8% of the patients. Of the operated adolescents, 65% underwent laparoscopy, and 95.3% (n=101) underwent ovarian-preserving surgery. The most common histopathological diagnoses were benign serous cysts (18.9%), mature cystic teratoma (18.9%), and hemorrhagic cysts (17%). The laparoscopic surgery rate was significantly higher in the late adolescent group (p=0.024). The operated patients’ average mass size was significantly higher (p<0.001).

Conclusion

The malignancy rate is low in patients with early and late adolescent adnexal masses. In the management of these patients, minimally invasive methods and ovarian protective interventions are essential in preserving fertility.

Introduction

Adolescence is defined as a period that begins with rapid biological and physical development, as well as sexual and psychosocial maturation, and in which the individual gains independence and social productivity. Adolescence is the transition period from childhood to adulthood. It is divided into periods such as early adolescence (10-14 years), middle adolescence (15-17 years), and late adolescence (18-21 years) according to developmental characteristics and health care needs (1). Adnexal masses may originate from the genital system, urinary, gastrointestinal tract, or retroperitoneal, depending on functional, congenital, inflammatory, and neoplastic processes. Although adnexal masses are rare in adolescents, they are the most common cause of gynecological surgery. Its incidence has been reported as 2.6 per 100 thousand (2). When planning the treatment of patients with adnexal masses, many factors such as age, menarche status, physical development, and malignant potential of the mass should be considered. Preserving the integrity of the ovarian tissue and other genital structures is extremely important for fertilization.

With the widespread use of ultrasonography (USG) in clinical practice, the frequency of detection of adnexal masses has increased. Most of these masses are simple cysts or corpus luteum cysts with a low potential for malignancy. The rarity of adnexal masses in adolescents, the low index of suspicion, and non-specific complaints can make diagnosis difficult (3-6). More information is needed regarding the histopathological structure of the existing mass for early diagnosis and management of adnexal masses in adolescents to protect fertilization and physiological development.

This study analyzes the clinical characteristics, treatment management, and histopathological results of patients with adnexal masses in a tertiary care center in middle and late adolescence.

Materials and Methods

This retrospective observational study was started by the principles of the Declaration of Helsinki after receiving approval from the University of Health Sciences Türkiye, Kanuni Sultan Süleyman Training and Research Hospital, Clinical Trials Review Board and Ethics Committee (date: 02.01.2023, approval no.: KAEK/2022.12.242). The study included patients in the middle (15-17 years) and late (18-21 years) adolescent age group who were followed up for adnexal mass at the University of Health Sciences Türkiye, Kanuni Sultan Süleyman Training and Research Hospital between January 2015 and December 2019. Patients under 15 and over 21 were excluded from the study.

The patient’s age, symptoms, USG findings (adnexal mass size and side), laboratory findings (CA-125 level), treatment management, need for urgent surgery, the surgical procedure applied in operated patients, and histopathological results of the mass were recorded.

Adnexal masses were classified as non-neoplastic, neoplastic benign, and neoplastic malignant according to histopathological results and analyzed between groups. Study data were accessed retrospectively through the hospital information system and patient files. The patients were divided into mid-adolescent and late-adolescent, according to age range, and the study data were compared between the groups. Patients with adolescent adnexal masses were also analyzed by classifying them into expectant and surgery groups according to the need for surgery.

The sample size was not determined in this retrospective descriptive study in which we evaluated adnexal masses in early and late adolescents. All patients who met the inclusion criteria during the five years were included in the study.

Statistical Analysis

SPSS 26.0 program (SPSS Inc., Chicago, USA) was used to analyze the data. Data are expressed as mean, standard deviation, number of patients, and percentage. The conformity of the variables to the normal distribution was evaluated analytically (Shapiro-Wilks test) and visually (histogram). Independent samples t-test was used to analyze quantitative data with normal distribution among the groups, and the Mann-Whitney U test was used to analyze quantitative variables that did not show normal distribution. The Pearson chi-square and Fisher’s exact tests were used to evaluate qualitative data. The statistical significance level was accepted as p<0.05.

Results

A total of 141 patients were included in the study: 20 (14.1%) in the middle adolescence group and 121 (85.9%) in the late adolescence group. The mean age of the entire population was 19.5±1.7 (15-21) years. While 24.8% (n=35) of the patients were followed up without surgery, surgery was performed in 75.2% (n=106). Laparoscopy was performed in 65.1% (n=69) of the operated patients, and laparotomy was performed in 34.9% (n=37). The rate of laparoscopic surgery in the late adolescence group was significantly higher than in the early adolescence group (p=0.024). While the average diameter of adnexal masses in the entire population was 5.8±2.5 (range, 2-14) cm and the average carbohydrate antigen (CA)-125 level was 21±14.6 (range, 4-90) U/mL, no significant difference was detected between the groups (p=0.880 and p=0.578, respectively). The most common complaints in adolescents with adnexal masses were abdominal pain (70.9%), abdominal swelling/palpable mass (11.3%), and menstrual irregularity (7.1%) and swelling (70.9%) (Table 1).

In patients with adnexal masses who underwent surgery, 51.9% (n=55) had benign neoplastic tumors, 46.2% (n=49) had non-neoplastic tumors, and 1.9% (n=2) had malignant tumors. One of the patients with malignant tumors was 17 years old (anaplastic large cell lymphoma), and the other was 20 years old (dysgerminoma). Both patients had abdominal pain, and a mass was detected on the left side. Unilateral salpingo-oophorectomy was performed in both patients. No significant difference in mass characteristics was observed between the groups (p=0.069). Although the rate of emergency surgery in the late adolescent group was higher than in the mid-adolescent group, no significant difference was detected (63.3% vs. 36.7%, p=0.052). The most frequently performed surgical operations were cystectomy (57.5%), detorsion (26.4%), and cyst aspiration (10.4%). The operations performed were similar between the groups (p=0.189) (Tables 2 and 3).

When patients with adnexal masses were classified according to whether they had undergone surgery, their diameter was significantly higher in the surgery group (6.3±2.6 vs. 4.2±1.4 cm, p<0.001). Additionally, the complaint of abdominal pain was found to be significantly higher in patients who underwent surgery (84% vs. 31.4%, p<0.001) (Table 4).

Discussion

This study investigated patients with adnexal masses in the middle and late adolescence age group. It found that the majority of adnexal masses were benign neoplastic tumors (such as benign serous cysts and mature cystic teratoma) and non-neoplastic tumors (hemorrhagic cysts), and the rate of malignant tumors was low. It was determined that laparoscopic surgery was performed at a significantly higher rate in the late adolescent age group. In addition, ovarian-sparing surgery was performed at a rate as high as 95% in all adolescents.

Clinical signs and symptoms vary in adolescents with adnexal masses. Clinical symptoms such as abdominal pain or pelvic pain, a mass in the abdomen or pelvic area, menstrual irregularities, and nausea/vomiting may be observed. Sometimes, it can be diagnosed incidentally without causing any complaints. Additionally, since ovarian pathologies are rarely encountered in adolescents, non-specific symptoms such as acute abdominal pain may suggest more common pathologies such as acute appendicitis. For this reason, it may be difficult to diagnose patients. In the literature, the most common presenting complaint of adolescents with adnexal masses has been reported as abdominal pain (56-87%) (7, 8). Other frequently reported symptoms are abdominal swelling-palpable mass (6.7-10.2%), menstrual disorders (3-10.2%), and nausea/vomiting (3.4-4.7%) (7-9). In our study, consistent with the literature, the most common symptoms in the patients were abdominal pain (70%), abdominal swelling/palpable mass (11.3%), and menstrual disorders (7.1%). In addition, in this study, a significantly higher rate of abdominal pain complaints was detected in patients who underwent surgery compared to the observed patients.

Adnexal masses are rare in the adolescent age group. Due to irregular menstruation and frequent anovulation, most of these masses are non-neoplastic ovarian cysts, including follicular cysts, corpus luteum, and theca lutein cysts. Although spontaneous resolution is often observed, surgical treatment is required in approximately 25% of cases due to persistence (10). USG is often sufficient for the diagnosis of follicular cysts. Benign neoplasms are more common than malignant neoplasms. The most common types of benign neoplasms include mature teratomas, mucinous and serous cystadenomas, and endometriomas (11). Sükür et al. (9) reported that 67% of adolescent adnexal masses were non-neoplastic tumors, and 20.3% were benign neoplastic tumors. The authors stated that the most common non-neoplastic tumors are follicular cysts and corpus luteum cysts, while benign neoplastic tumors are frequently detected as mature teratoma and cystadenoma. Kang et al. (8) reported that adnexal masses were more common on the right side; 53% were benign neoplastic, 35% were non-neoplastic, and 7 were malignant tumors. The authors stated that among non-neoplastic tumors, corpus luteum cysts are more frequently detected in the middle adolescence age group, and endometriosis is more frequently detected in the late adolescence age group. In addition, they emphasized that mature cystic teratoma in benign neoplastic tumors is detected more frequently in both middle and late adolescence. In our study, consistent with the literature, more than half of the adnexal masses (51.9%) were detected as benign neoplastic tumors and were localized on the right side. While follicular cysts were most frequently detected among non-neoplastic tumors, benign serous cysts and mature cystic teratoma were most frequently detected among benign neoplastic tumors.

Malignant ovarian tumors constitute only 0.9% of all childhood and adolescence malignancies (12). Unlike adults, approximately 80% of malignant ovarian tumors are germ cell tumors. Although USG images of germ cell tumors vary, they can be distinguished from dermoid cysts due to the teeth, hair, and fatty tissues found within them. The second most common neoplastic tumors seen in adolescents are epithelial neoplasms, and their incidence increases with increasing age (13, 14). The two most common types are serous and mucinous tumors. Kang et al. (8) reported that 7.8% of adnexal masses in children and adolescents were detected as malignant tumors (non-epithelial ovarian malignant neoplasms and borderline malignant tumors). Studies from tertiary centers in Türkiye reported that malignant tumors were detected in 0.9-11.8% of patients with adolescent adnexal masses (7, 9, 15). In our study, consistent with the literature, malignant tumors were detected in 1.9% (n=2) of patients with adolescent adnexal masses (dysgerminoma and anaplastic large cell lymphoma).

Various methods are used to diagnose adnexal masses and determine treatment. Most masses are detected using USG, the first-line imaging test (10, 16). USG is a valuable diagnostic tool in distinguishing adnexal masses due to its easy accessibility, cost-effectiveness, and high diagnostic accuracy. USG findings can also provide helpful information about whether the patient needs surgery or conservative treatment (17). In addition, USG can enable continuous imaging and follow-up of relatively small ovarian masses without surgical treatment (18). The literature has stated that most simple cysts, whose size is 5-7 cm on USG, decrease in size or improve during follow-up (19). Kang et al. (8) reported that patients with adnexal masses who underwent surgery (50%) had larger tumors than those who were followed up without surgery (50%), neoplastic features were detected on USG, and in addition, the USG diagnosis was consistent with the histopathological diagnosis.

In addition to USG, computed tomography (CT) or magnetic resonance imaging (MRI) can also help diagnose malignant ovarian tumors. Additional information, such as the nature of the adnexal mass and metastatic involvement of pelvic and para-aortic lymph nodes, can be determined by CT or MRI. In our study, USG was used as the first method in diagnosis in all patients with adnexal masses. Computed tomography or MRI are auxiliary imaging methods when malignancy is suspected. Surgery was not performed in 24.8% of the patients, and they were followed up. Consistent with the literature, the mass sizes of the patients in the surgery group were significantly higher than in the follow-up group. Although many tumor markers such as human α-fetoprotein , β-hCG, CA-125, CA-19-9, and carcinoembryonic antigen are used in the follow-up of malignant ovarian tumors, their levels have been reported to be expected in approximately 50% of malignant tumors (20). In their same study, Kang et al. (8) reported that serum tumor markers were at normal levels in 44% of patients with adnexal masses. Therefore, normal serum tumor marker levels cannot exclude malignancy. In our study, CA-125 levels were analyzed as a tumor marker. Consistent with the literature, the CA-125 level was average in one of the patients with malignant neoplasm (middle adolescent group, diagnosed with anaplastic large cell lymphoma). In contrast, the CA-125 level was high in the other group (late adolescent group diagnosed with dysgerminoma). No significant difference was detected between middle and late adolescence age groups.

The standard treatment for benign ovarian tumors that are not considered malignant is ovarian-sparing surgery (21). A conservative approach should be applied as much as possible in order to preserve fertilization. Cystectomy and detorsion of the torsioned mass are usually performed using minimally invasive surgical methods (laparoscopic or robotic surgery). Ovarian-sparing surgery has been reported to have a low recurrence rate and high clinical success (22). Kang et al. (8) reported that 87% of patients with adnexal masses underwent ovarian-sparing surgery, and no patient required laparotomy. Pekcan et al. (15) reported that 94% of adolescents with adnexal masses underwent laparoscopy, and 1% of the patients underwent laparotomy. Dağdeviren et al. (7) reported that 67% of the patients underwent laparoscopy, and 28% underwent laparotomy after laparoscopy. The authors also emphasized that torsion was detected in 1/3 of the patients, and successful treatment was achieved with detorsion except for one of the patients. In our study, laparoscopy was performed in 65% of the patients who underwent surgery, while no patients underwent laparotomy after laparoscopy. Ovarian-sparing surgery was performed in 95.3% (101/106) of the operated patients. The fact that the pediatric surgery clinic decides on laparoscopy or laparotomy in some patients in the middle adolescence age group is influential in determining the lower rates of laparoscopic surgery in patients in the middle adolescence age group compared to the literature. However, our ovarian-preserving surgery rates were found to be similar to the literature.

Study Limitations

The study has some limitations. First, it is a single-center and retrospective study. Second, tumor markers other than CA-125 in adolescents with adnexal masses were not analyzed. Third, it could not be determined to what extent auxiliary methods such as CT and MRI, which were used in diagnosing all patients other than USG, were used in the diagnosis.

Conclusion

In conclusion, patients with adnexal masses in the early and late adolescence age group often experience abdominal pain, abdominal distension, and menstrual disorders. Most of these patients have benign neoplastic tumors and non-neoplastic tumors, but malignant tumors are rare. Recognizing rare adnexal masses in adolescent patients, monitoring them with conservative treatment when appropriate, and planning ovarian-preserving surgeries with minimally invasive methods when necessary are essential in preserving fertility.