|Year : 2021 | Volume
| Issue : 2 | Page : 119-123
Abdominopelvic mass in adolescents and young adults: An audit in a tertiary care center
Pratibha Kumari1, Satya Kumari1, Jyotsna Rani1, Kavya Abhilashi1, Sangeeta Pankaj1, Vijayanand Choudhary2, Pravin Kumar3
1 Department of Gynecological Oncology, SCI, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
2 Department of Hematology (Pathology), Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
3 Department of General Surgery, JLNMCH, Bhagalpur, Bihar, India
|Date of Submission||29-Aug-2021|
|Date of Decision||01-Oct-2021|
|Date of Acceptance||03-Nov-2021|
|Date of Web Publication||6-Dec-2021|
Department of Gynecological Oncology, SCI, Indira Gandhi Institute of Medical Sciences, Patna - 800 014, Bihar
Source of Support: None, Conflict of Interest: None
Background: The present study aimed to review the clinicopathologic profile of adolescent and young adult patients of abdominopelvic lump.
Materials and Methods: The hospital records of the patients of age 10-29 years who underwent surgical intervention for suspected ovarian tumor at gynecological oncology department in a tertiary hospital were searched retrospectively for demographic characteristics, clinical findings, range of tumor markers, the surgical procedure patients underwent, and the histopathological findings of adnexal masses. The duration of the study was of 18 months (from August 2019 to February 2021).
Result: During this period, 27 patients of age 10–29 years with abdominopelvic mass were operated. Out of 27, 14 patients had malignant ovarian mass and 13 were of benign nature. However, 3 patients had tumor of nonovarian origin. In the study, immature teratoma ranked first among malignant tumor, while inflammatory pathology was dominant in the list of benign adnexal tumor. There was a fair correlation between tumor markers and histopathological characteristics of the tumors.
Conclusion: The study highlights the importance of early diagnosis and optimal management of adnexal masses in adolescents and young adult females for better outcomes. Fertility - sparing surgeries should be considered in indicated cases.
Keywords: Adnexal mass, adolescent, adolescents and young adults, ovarian tumors, tumor markers
|How to cite this article:|
Kumari P, Kumari S, Rani J, Abhilashi K, Pankaj S, Choudhary V, Kumar P. Abdominopelvic mass in adolescents and young adults: An audit in a tertiary care center. J Indira Gandhi Inst Med Sci 2021;7:119-23
|How to cite this URL:|
Kumari P, Kumari S, Rani J, Abhilashi K, Pankaj S, Choudhary V, Kumar P. Abdominopelvic mass in adolescents and young adults: An audit in a tertiary care center. J Indira Gandhi Inst Med Sci [serial online] 2021 [cited 2022 Jan 23];7:119-23. Available from: http://www.jigims.co.in/text.asp?2021/7/2/119/331753
| Introduction|| |
The term adolescents and young adults (AYAs) is difficult to define in patients with cancer and lacks universal consensus. The WHO defines adolescents as of 10–19 years age group, youth as 15–24 years, and young people as of 10–24 years. The United States Surveillance, Epidemiology, and End Results program report used the 15–29 years of age range for defining AYA, while Adolescent and Young Adult Oncology Progress Review Group (AYAO PRG) report (2006) and the European Network for Cancer Research in Children and Adolescents considered 15–39 years as its cutoff.
Abdominopelvic mass in AYA patients of adnexal origin has always been a challenging clinical situation for the attending gynecologist. The adnexal masses may arise from the ovary, Fallopian tube, or surrounding connective tissues and is a common gynecological problem with higher incidence in reproductive age group. The rate of incidence rises exponentially with age from 0.43/100,000 women at infancy to 152/100,000 at 35 years. Gynecological malignancies are not common within the pediatric and adolescent populations and they mostly originate from the ovary but sometimes also from the uterus, cervix, vagina, and vulva. The ovarian tumors in premenarchal girls are mostly benign; however, chances of being malignant tumors may exist. Malignant ovarian mass accounts for 0.9% of all childhood and adolescent malignancies. Germ cell tumor is the most common tumor accounting for 70% of ovarian tumors in this particular age group and only 3% of them are malignant. Teratomas are the most common germ cell tumor in AYA females. Epithelial tumors of ovary are uncommon among young and adolescent females and are found in <1% cases.
Besides different radoimaging modalities such as ultrasonography, computed tomography, and magnetic resonance imaging, estimation of panel of tumor markers such as CA-125, alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (beta-HCG), lactate dehydrogenase (LDH), and serum inhibin can help in differentiating benign from malignant ovarian tumors and also in predicting the histological nature of tumor. However, negative tumor markers do not exclude the risk of malignancy because the markers are seen to be positive in only 54% of cases.
The present study reviewed the clinicopathologic profile of adolescent and young adult patients of abdominopelvic mass who underwent surgical intervention for suspected ovarian tumor at gynecological oncology department in a tertiary hospital, Bihar. The study aimed to see the trend of histopathology of adnexal mass in young girls and also to evaluate the diagnostic accuracy of tumor markers to establish the diagnosis of malignancy.
| Materials and Methods|| |
This retrospective audit was conducted after obtaining approval from the institutional ethical committee. In this study, we collected data of the 27 patients of abdominopelvic lump who were adolescent or in early adulthood (of 10–29 years of age) and underwent surgical intervention for suspected ovarian tumor during August 2019–February 2021 at the gynecological oncology department, SCI, IGIMS, Bihar. The reason of selecting 29 years as cutoff age in the study is because in the Indian population, this represents the young adult years, often a time of transition. During this phase of life, concerns such as going to college, building a career, or starting a family or relationship are often higher in the priority list other than health.
The clinical presentation, intraoperative details, and histopathological findings of these patients were obtained from hospital medical records and the operating theater registers. These patients are being followed up to observe for progression-free survival and overall survival. Due to COVID pandemic, telephonic and telemedicine consultation was conducted to obtain the clinical details of patients following their discharge from hospital to minimize the risk of coronavirus exposure.
| Results|| |
20/34 (74%) of females belonged to the reproductive age group, i.e. 20–30 years of age. The rest of the patients were of 10–20 years. About 48.14% (13/27) of patients were nulliparous and 22.22% (6/27) had two or more children [Table 1]. All patients underwent laparotomy and in 24 cases out of 27, ovary was found as a culprit. Among nonovarian tumors, one case each of paraovarian cyst, uterine leiomyoma, and of desmoid fibromatosis was found. Seventy-five percent of ovarian masses were unilateral [Table 2].
|Table 1: Demographic and clinical characteristics of the adolescents and young adults patients presenting with abdominopelvic mass|
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The diagnostic accuracy of various tumor markers was studied and correlated with final histopathological findings. In this study, The CA-125 levels in ovarian cancer ranged from 09 to 1800 IU/mL1 with a mean value of 271 ± 396 ng/mL [Table 3]. The mean value of carcinoembryonic antigen and CA 19–9 was 5.3 ± 7.4 ng/mL and 151 ± 336 U/mL, respectively. Serum AFP ranged from 1.2 to 6131 ng/mL and LDH as 115–874 ng/mL confirming the high rates of sensitivity and specificity associated with these tumor markers in germ cell tumor of the ovary [Table 3]. Out of 24 ovarian masses, 14 were malignant. Eight (57.14%) out of 14 patients with malignant ovarian tumors underwent interval debulking surgery, whereas upfront surgery was performed in six patients (42.85%). Radical surgery was performed in 6 out of 14 cases of carcinoma ovary, whereas 8 patients underwent complete staging and fertility-sparing surgery. Adjuvant chemotherapy was given in indicated cases. Among patients with benign ovarian pathology, 6 underwent cystectomy and 4 patients had unilateral salpingo-oophorectomy due to nonsalvageable ovary [Table 4].
|Table 3: Distribution of tumor markers in patients included in the study|
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|Table 4: Clinical stage and surgical management of malignant ovarian masses|
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Postoperative histopathologic evaluation of 27 operated patients revealed as 40.74% of benign ovarian pathology. 33.3% had immature cystic teratoma and epithelial tumor was found in 7.4% of the patients. Out of 24 patients with ovarian masses, 1 (4.1%) had serous cystadenocarcinoma and 1 (4.1%) had malignant mucinous tumor. There were 12 patients (50%) with malignant germ cell tumors, among which 9 (37.5%) were immature teratoma, 2 (8.3%) were cases of yolk sac tumors, and 1 (4.1%) was dysgerminoma [Table 5]. About 11 patients (78.3%) had advanced carcinoma of the ovary belonging to StageIIIc. On post-treatment follow-up, all patients with benign pathology including 10 ovarian and 3 of nonovarian origin were doing well without any evidence of recurrence. All cases of ca ovary received adjuvant chemotherapy. Out of 14 ovarian malignancies, one patient with dysgerminoma presented with recurrence and received chemotherapy. Two patients succumbed to death were cases of high-grade immature teratoma in Stage IIIc.
| Discussion|| |
Adnexal tumors occurring in AYA females are mostly of benign nature through ovarian malignancies are also not uncommon. Management of these tumors at this age group is quite challenging as the major concerns are confirmation of clinical diagnosis, nature of tumor, should be surgically intervened or not, extent of surgery in terms of ovary sparing or radical, route of surgery, feasibility of fertility-sparing surgery or risk of total surgery, and the fertility outcome in future.,, These patients often need a tailored approach and management to be decided according to the distinctive histological type of tumor, ovarian function, and fertility issues., Recently, efforts are being made to promote fertility-sparing surgery in the appropriate setting.,, Hence, such cases necessitate for a modified program of care starting from initial diagnosis to cure and follow-up for AYA females affected by gynecological malignancy.
Most of the studies from India related to ovarian cancer are conducted in premenopausal and postmenopausal women. When it comes to ovarian cancer in AYAs, literature is sparse. The attending gynecologist faces a diagnostic dilemma as there is a range of different histological classifications of ovarian tumors occurring in cases of adolescents and young females. Sometimes, Koch's abdomen may present masquerading ovarian malignancy due to the presence of adnexal mass, ascites, and raised CA-125. Henceforth, such cases demand meticulous history taking and clinical examination in adjunct to radiological imaging and estimation of a panel of tumor markers. In few AYA patients, preoperative FNAC or core biopsy from suspicious adnexal mass may be required not to miss the malignant pathology and for planning of appropriate surgical intervention accordingly. There may be a risk of repeat surgery in future owing to inadequate surgical staging, suboptimal surgical debulking, or due to recurrence of tumor. Hence, intraoperative frozen section and histopathological analysis of tumor have a great role while dealing with adnexal mass in AYA females.
Besides these clinical dilemmas, other issues exist including financial constraints, pressure of family planning in future, and propensity for loss to follow-up which affect the management and outcome of disease in such cases. Epithelial ovarian tumors need complete surgical staging and radical surgery, whereas germ cell tumors respond well to chemotherapy, so ovary-sparing surgery can be performed in early stage.
The 5-year survival rate reaches to 80%–90% if effective treatment is provided in early stage of ovarian cancer. Therefore, finding efficient early diagnostic markers is very crucial for the treatment and prognosis of malignant ovarian tumors. The tumor markers play an important role in predicting malignancy preoperatively, the response of a tumor to chemotherapy, and also the recurrence of tumor in patients after receiving the treatment.
One of the hurdles for tumor marker testing is the erratic unpredictable different cell lines progressing to ovarian malignancy in AYA groups and consequently leading to elevation of different tumor markers depending on the histology of tumor. Henceforth, combined estimation of multiple tumor markers can have higher sensitivity and efficacy for diagnosing malignant tumor and reduces the chances of misdiagnosis.
Our study supports other evidences in favor that an array of tumor markers of CA 19-9, LDH, AFP, and beta-HCG are seen superior in giving effective results than using a single biomarker in preoperative evaluation and planning of surgical management of adnexal masses.,, The study showed that preoperative testing with a panel of tumor markers carries a high potential to predict malignancy in ovarian masses occurring in AYA and can be used to stratify the risk of ovarian neoplasm. In the study, estimating the serum value of CA-125 and LDH in these patients had good sensitivity but relatively less specificity for diagnosing the adnexal mass as a malignant one. They were found elevated in benign inflammatory pathology also. CA-125 was elevated in a total of 17 patients and 5 of them were found to have benign tumors (3 cases of endometriosis and two of inflammatory TO mass). AFP and beta-HCG are often seen elevated in germ cell tumor, particularly with immature teratoma, hence making it a useful marker in young-aged patients.
| Conclusions|| |
The study tried to highlight the clinical presentation, histological pattern, potential of malignancy, and the role of tumor marker in AYA females with adnexal mass. In the present analysis, it was found that in young adults, adnexal mass of ovarian origin was the most common, and incidence of malignancy was significant. A panel of tumor markers showed a moderate correlation in diagnosing different types of ovarian malignancies. Preoperative diagnosis and predicting histological correlation may help in deciding the management and extent of surgery and henceforth may alleviate the concern of patients and surgeons to an extent. A collaborative approach and intensive team of gynecological and medical oncologists, anesthetists, and pathologists are paramount and need of the hour to save this highly productive group of the existing population.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]