Differential Diagnosis Fewer than 2% of ovarian malignancies occur in children and adolescents (22). Ovarian tumors account for approximately 1% of all malignant tumors in these age groups. Germ cell tumors make up one-half to two-thirds of ovarian neoplasms in individuals younger than 20 years of age. A review of studies conducted from 1940 until 1975 concluded that 35% of all ovarian neoplasms occurring during childhood and adolescence were malignant (23). In girls younger than 9 years of age, approximately 80% of the ovarian neoplasms were malignant. Germ cell tumors account for approximately 60% of ovarian neoplasms in children and adolescents compared with 20% of these tumors in adults (23). Epithelial neoplasms are rare in the prepubertal age group; thus, data usually are reported from referral centers. Some reports include only neoplastic masses, whereas others include nonneoplastic masses; some series combine data from prepubertal and adolescent girls. One community survey of ovarian masses revealed that the frequency of malignancy was much lower than previously reported; of all ovarian masses confirmed surgically in childhood and adolescence, only 6% of patients with ovarian enlargement had malignant neoplasms, and only 10% of neoplasms were malignant (24). Surgical decision making inﬂuences the statistics on incidence; the surgical excision of functional masses that would resolve in time inﬂates the percentage of benign masses. In one series, nonneoplastic masses in young women and girls younger than 20 years of age constituted two-thirds of the total (25). Even in girls younger than 10 years of age, 60% of the masses were nonneoplastic, and two-thirds of the neoplastic masses were benign. Authors of older case series were less aware of the benign and functional masses that are now found incidentally with routine sonographic images. Functional, follicular cysts can occur in fetuses, newborns, and prepubertal children (26). Rarely, they may be associated with sexual precocity.
Management of A plan for the management of pelvic masses in prepubertal age girls is shown in Figure 14.8. Prepubertal Pelvic Masses Unilocular cysts are virtually always benign, even in this age group, and will regress in
Figure 14.8 Management of pelvic masses in premenarchal and adolescent girls.
3 to 6 months; thus, they do not require surgical management with oophorectomy or oophorocystectomy. Close observation is recommended, and there is a risk of ovarian torsion that must be discussed with the child’s parents (27). Recurrence rates after cyst aspiration (either ultrasonographically guided or with laparoscopy) may be as high as 50%. Attention should be directed to long-term effects on endocrine function and future fertility; preservation of ovarian tissue is a priority for patients with benign tumors. Oophorectomy should be avoided if at all possible for benign masses (28). Premature surgical therapy for a functional ovarian mass can result in ovarian and tubal adhesions that can adversely affect future fertility. Solid masses, those larger than approximately 8 cm, and enlarging masses require surgical intervention, as the likelihood of neoplasm is high.