Ovarian Tumors In Patients Under 20 Years Old Biology Essay

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Over the period of 2 years 30 patients with ovarian tumors of less than 20 years age were studied. Patient with more then 20 years of age were excluded.

All the patients received as out patient department accept 4 cases, were admitted through emergency. All the patients were investigated for complete blood picture, ESR, Random Blood Sugar, Urine detailed report, Urea, Creatinine, Serum Electrolyte, LFT, Ultrasound and X.Ray Chest. In some patients IVP, CT scan and Serological markers eg: CA-125 were done.

RESULTS:

Out of 30 patients only 5 (16.66%) had malignant tumors and 25 (83.33%) had benign ovarian tumors.

Of the benign ovarian tumors mature teratoma were 10(40%), serous cyst adenoma were 5(20%), mucinous cyst adenoma were 3 (12%), endometriotric cysts were 3 (12%), corpusluteal cysts were 3 (12%), pare-ovarian cyst was 1 (4%). Of the malignant variants immature teratoma was 3 (60%), dysgerminoma was 1 (20%) and endodermal sinus tumor was 1 (20%).

Most of patients had benign ovarian tumors e-g germ cell tumors . Almost in all of the patient's diagnosis was confirmed by laparotomy and histopathology. No complication was encountered peroperatively and post operatively.

CONCLUSION:

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Patients, less then 20 years of age, had mainly benign ovarian tumors, and were germ cell tumors. For benign tumors adhesion prevention strategies should be used. Surgical intervention should as much as possible be directed towards preservation of ovarian tissue.

KEY WORDS: Ovarian Tumors, under 20 Years, management.

INTRODUCTION:

Ovarian tumors during the first two decades of life represent the most frequent tumor of female genital tract1. The ovarian tumors account for approximately 1% of all tumors in children and adolescents. Less than 5% of ovarian malignancies occur in this age group. 30% of all ovarian neoplasm occurring during childhood and adolescence are malignant 2. Types of ovarian tumor specific to child and adolescence patients includes germ cell and granulose cell tumor3. Benign neoplasm are the most common ovarian masses under 20 years of aged 3,4,5. Commonest benign ovarian tumors are mature cystic teratoma (dermoid cystic) and follow by cystadenoma5,6. Among the malignant ovarian tumors, dysgerminoma and endodermal sinus tumor are more common in this age group6,7,8,9. Exact incidence in Pakistan is not known but it is the 4th common cancer among female of Pakistan10. About 15% of the patients with malignant ovarian tumors are a symptomatic at the time of diagnosis11. Tumors markers are extremely useful in the D/D, follow the patient's response to therapy and monitor for recurrence of diseases 6,7,8,9. Knowledge of features of the disease which relate accurately to prognosis and survival could be helpful in management. This study was under taken to evaluate the type of tumor and management in women less then 20 years of age.

PATIENTS AND METHODS:

This study was carried out in the department of Gynae Unit-2 Sheikh Zaid Women Hospital, Chandka Medical College Larkana from December 2007 to December 2009.

30 patients of ovarian tumor either benign or malignant included in this study. Each patient was evaluated with detailed history and thorough physical, systemic and local examination. Investigation included blood complete picture, Random Blood Sugar, liver function test, blood urea and creatinine were done. Serological markers e-g CA-125, was done in 5 patients, it was not significantly high. Ultrasound was used to detect the ovarian tumors in almost all the cases to see the site and size of tumor. Diagnostic laparoscopy was not done in any of these patients. X-Ray Chest was done in every case preoperatively, no abnormality was detected. IVP was done in 4 patients in whom pre-surgical suspicious of malignant ovarian tumors were made on chemical and U/S basis and was found normal. Planning of management was made on fertility of patients and stage of tumor. The management options were surgery and chemotherapy. Type of surgery was decided when abdomen was opened. In suspected benign tumors where adjacent structures were not involved or no vascularization or adhesion, in those cases conservative surgery was done. In malignant tumors ascitic fluid sent for cytology and debulking surgery was done. Finding were noted on check list. Figo classification was use to stage the tumor. In cases of malignant tumors patients were sent for chemotherapy post operatively.

RESULTS:

Thirty patients were analyzed from December 2007 to December 2009. Of these 30 cases only 5 (16.66%) had malignant ovarian tumors and 25 (83.33%) had benign ovarian tumors.(table 1) Of the benign ovarian tumors, mature teratoma were 10(40%), serous cyst adenoma were 5(20%), mucinous cyst adenoma were 3 (12%), endometriotric cysts were 3 (12%), corpusluteal cysts were 3 (12%), pare-ovarian cyst was 1 (4%). Of the malignant variants immature teratoma were 3 (60%), dysgerminoma was 1 (20%) and endodermal sinus tumor was 1 (20%). (Table 2)

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Pain in abdomen, distention of abdomen, retention of urine and menstrual disturbances were the commonest presenting symptoms(Table 3).

Almost in all of the patient's diagnosis was confirmed by laprotomy and histopathology. Theraepeutic laproscopic aspiration of cyst was done in one patient who was a diagnosed case of simple ovarian cyst on the basis of U/s. Otherwise laprotomy was done in all the cases. Most of the patients had benign ovarian tumor as evaluated intraoperatively and treated by conservative surgery. Unilateral cystectomy was done in 4 (16%) and bilateral cystectomy was done in 2 (8%) patients. In all these cases ovarian tissue was conserved and reconstructed. Unilateral oopherectomy and cystectomy was done in 6 (24%) patients. Drainage of endometriotic cyst and reconstruction of ovaries was done in 1 (4%) patient. Unilateral salpingo/oopherectomy with wedge resection of other ovary was done in 1 (4%) patient. Total abdominal hysterectiomy was done in 2 (40%) patients as primary procedure in the young lady with bilateral ovarian involvement, ruptured capsule and moderate ascites. Debulking surgery (TAH with BSO + Omentectomy + Appendiectomy) was done in 3 (60%) cases (Table 4). Operative findings were noted on tick list. Frozen section facility is not yet available in our hospital. So surgery was decided at the time of laprotomy and then further management was decided on histopathological report. All of the patients with benign ovarian tumor were advised for 6 months follow-up and only 20 patients came for regular follow-up and further evaluation. Patients with malignant ovarian tumors sent for chemotherapy. 2 patients died due to recurrence of malignancy of endodermal sinus tumor and Dysgerminoma. 2 patients were in good condition after receiving 3 pulses of chemotherapy and 1 patient did not returned. Mortality rate was difficult to assess because of non co-operation of the patients for follow-up. Patients are mostly irregular due to lack of knowledge and poverty.

Second look operation could not be done in any of the patients with malignant disease. Two of the patients who had regular follow up did not show any residual disease on u/s.

No complication was reported in any case

DISCUSSION:

In our series study was done in the women under 20 years of age. Total no of patients with ovarian tumors under 20 years of age were 30. In our series almost all the patients were admitted through OPD accept 4 cases were admitted through emergency with acute abdominal pain and retention of urine. The presenting symptoms in most of the patients were pain in abdomen, pelvic pain, distension of abdomen and menstrual disturbances. In Lind fort's series pain was the main presenting complaint followed by abdominal distension and torsion8 In a review of 81 cases from Lind forte's 35% of cases were malignant. Huffman12 reported that 30% of 999 tumors and Breen and Maxson 27% of 1309 tumors in children and adolescents were malignant.13, 14 in another series from Nepal malignancy rates have varied from 15-35%. In our study 16.66% of cases were malignant. Like international data germ cell tumors and sex cord stromal tumors were preponderate in adolescents.13, 15 In this study (83.33%) ovarian tumors were benign and (16.66%) were malignant This is similar to the data from western countries where 75-80% of ovarian tumors are benign.16 Also study carried in India by Pilli et al 17 had approximately similar results which showed that 75.2% ovarian tumors were benign. However this figure was only 59.2% in study carried in Pakistan by Ahmad et al.18 Doppler U/S has been found to be helpful in suspicious of malignancy but not used in our study. Of the various treatment modalties available for ovarian tumor. Only surgery with complete removal of tumor burden can be considered as potential curative. Gentle tissue handling, meticulous hemostasis and adhesion prevention strategies were adopted for fertility preservation. Post operative morbidity and mortality is quite insignificant after surgery in our study.

CONCLUSION:

In women less than 20 years of age benign germ cell tumors are common, which are easily managed by surgical measures usually without complication. Malignant germ cell tumors common in this age group mostly diagnosed in advanced age. Early diagnosis is key factor to improve the prognosis and need a proper screening programme in this age group. Ovarian tumors under 20 years of age were mainly found in un-married and nulliparous women's. So that conservative surgery by retained the uterus and contralateral ovary should be preferred. It is desirable to embark upon a second surgery if final pathology reveals a malignancy rather then proceed with radical surgery.

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Ovarian Tumors in less than 20 years of age (n=30).

TABLE-I

Types of Tumor in less than 20 years of age.

S.No

Types of Tumor

No. of Cases

%

1

2

3

Benign

Borderline

Malignant

25

0

5

83.33%

--

16.66%

TABLE II

Histopathological typing of ovarian tumors

S.No

Types of Surgery

No. of Cases

%

1

2

3

4

5

6

7

8

9

Mature Teratoma

Serous cyst adenoma

Mucinous cyst adenoma

Endometriotic cyst

Corpus luted cyst

Para ovarian cyst

Immature Teratoma

Dysgerminoma

Endodermel Sinus Tumors

10

5

3

3

3

1

3

1

1

40%

20%

12%

12%

12%

4%

60%

20%

20%

TABLE III

Clinical presentation of patients under 20 years of age.

S.No

Symptoms

No. of Cases

%

1

2

3

4

5

6

7

Pain in abdomen

Abdominal distension

Pain+abdominal distension

Menstrual problems e.g scanty menses irregular bleeding P/V

Dysmenorrhea

Amenorrhea

Pain in lower abdomen+retentinof urine

Pain+abdominal distendions+Gl upset+fever.

6

5

4

2

2

2

1

4

4

33.33%

16.66%

13.33%

6.66%

6.66%

6.66%

3.33%

13.33 %

13.33%

TABLE IV

Operative procedures performed.

S.No

Types of Surgery

No. of Cases

%

1

Cystectomy

4

16%

2

Cystectomy+Oopherectomy

6

24%

3

Salpingo-Oopherectomy

10

40%

4

Bilateral cystectomy

2

8%

5

Drainage of Endometriotic Cyst + Reconstruction of ovaries.

1

4%

6

Therepeutic laproscopic drainage of cyst

1

4%

7

Salpingo - Oopherectomy with wedge resection of other ovary.

1

4%

8

Debalking Surgery TAH with BSO + Omentectomy + Appendeicectomy.

3

60%

9

TAH with BSO

2

40%