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Benign Mullerian Papilloma
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Oral Abstracts / J Pediatr Adolesc Gynecol 27 (2014) e23ee30
of LNG-IUS in adolescents with developmental disability for menstrual suppression. Eliminating pre-operative ultrasound for girls with special needs reduces patient and family anxiety, time, and costs.
12. Discovery of Pelvic Mass During Evaluation of Precocious Puberty Kim Hoover MD*, Janeen Arbuckle MD, PhD University of Alabama at Birmingham, Birmingham, Alabama
Background: Common presenting signs of early puberty are thelarche, adrenarche, and menarche. Here we discuss the differential diagnosis, evaluation, and management of a child referred for evaluation of precocious puberty whose ultimate diagnosis was a rare uterine mass. Case: MA is a 4 year old Caucasian female referred by her primary care doctor secondary to concerns for early pubertal onset. Her family reported a one month history of vaginal spotting; no signs of adrenarche or thelarche were reported. The patient’s review of systems was negative for trauma, foul smelling discharge, incontinence/retention, constipation, or pain. On exam she was Tanner Stage I for breast, axillary and pubic hair development. Abdominal exam was soft, non-tender, and without adenopathy or obvious mass. The external pelvic exam appeared normal, without discharge or blood noted at introitus. The vagina appeared patent on a limited in-office exam. Given these physical exam findings, menarche was felt to be unlikely. A pelvic ultrasound and exam under anesthesia were therefore performed. The pelvic ultrasound was notable for fluid filled uterine cavity with concern for hydrometrocolpos and left hydronephrosis. Further imaging with CT characterized the fluid collection as a large intracavitary uterine mass measuring 5.5 x 6 x 6.8 cm with left iliac adenopathy and severe left hydronephrosis. Exam under anesthesia revealed a fixed mass indistinct from the uterus occupying the entirety of the left pelvis. Inflammatory changes on the vaginal walls were noted, creating mild agglutination. The cervix had a friable consistency and hysteroscopy was not possible due to obliteration of the endocervical canal. Biopsies of the endocervical canal and ectocervix returned Ewing’s Sarcoma. She is currently under care of Pediatric Oncology with plans for neoadjuvant chemotherapy, radiation, with follow up surgical excision. Comments: Though precocious puberty can present as menarche, it rarely occurs in the absence of thelarche and/or adrenarche. More common causes of vaginal spotting in a young child are vaginal/vulvar infection, dermatoses, foreign body, or vaginal trauma. One must also confirm that bleeding is truly from the vagina as urinary and gastrointestinal pathologies may present with findings misinterpreted as vaginal bleeding. The most common malignant soft tissue mass in childhood is rhadomyosarcoma. Though rhabdomyosarcomas are rare, accounting for 4-6% of all childhood malignancies, an extraosseous Ewing’s sarcoma is even rarer. Ewing’s sarcomas occur primarily in bone, with a median age of diagnosis of 15 years old, and an incidence of 3 per million per year. They are derived primarily from mesenchymal stem cells in bone marrow. Sites not derived from bone occur rarely. Those of female genital tract have been reported in older non-Caucasian females as young as 16 years of age. Our patient represents the youngest patient reported to date. New treatments for large soft tissue masses focus on chemotherapy and radiation, with possible subsequent excision. This case emphasizes the importance of an expedited and thorough physical exam to obtain a diagnosis and tailor treatment.
aggressive, malignant neoplasms. It is important to be aware of this entity in order to appropriately counsel patients and their families and to make an accurate diagnosis and treatment plan. Case: A 2 year old female presented with intermittent episodes of vaginal bleeding that varied from heavy to light spotting. She had no significant medical or family history. Her physical exam was unremarkable, and she was noted to have Tanner stage I normal external female genitalia. Vaginoscopy was then performed and revealed a tan-pink colored pedunculated mass with frond-like projections filling the vaginal apex. A biopsy was obtained with pathology consistent with a benign mullerian papilloma. Pathology was then reviewed at another facility which confirmed the diagnosis. The patient then returned to the operating room where she underwent vaginoscopy which identified the lesion as originating from the anterior portion of the cervix (Fig. 1). It was completely resected and final pathology again confirmed the diagnosis. The patient has had no further episodes of vaginal bleeding and is doing well to date. She will return to for follow-up vaginoscopy six months following resection to assess healing and for evidence of recurrence. Comments: Vaginal bleeding in a prepubertal girl is often a distressing symptom. When it is paired with the findings of a vaginal mass it is important to know the differential diagnosis in order to provide adequate counseling to the patient’s family. The histologic assessment of the specimen is critical and must be distinguished from the more common embryonal rhabdomyosarcoma. Unlike the malignant sarcoma, a benign mullerian papilloma is treated with local excision alone. There have been forty reported cases in the literature to date; therefore, it is important to familiarize oneself with this rare entity. Six have been documented to recur, and two had malignant transformation. The two malignancies were both in women, ages 49 and 52, who were known to have had longstanding recurrent papillomas. There has not been a consensus regarding long term surveillance of these patients. It has been suggested to repeat vaginoscopy at six months and then if symptoms of abnormal vaginal bleeding recur. This is currently the plan for this patient, but it is important to consider the most appropriate follow-up of these patients in order to identify recurrences but to avoid unnecessary procedures and overtreatment.
Fig. 1. Pedunculated cervical lesion.Ă
13. Benign Mullerian Papilloma Laura L. Kruger MD 1, Ashlyn Savage MD 2, Lesley Breech MD*1 1 Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio 2 Medical University of South Carolina, Charleston, South Carolina
Background: Benign mullerian papilloma is a rare childhood tumor of the female reproductive tract that typically presents with vaginal bleeding in a prepubertal girl. The findings of a vaginal or cervical mass in these patients along with some of the histopathologic features can mimic more
14. Case Series: Endoloop for Hemostatic Control of Hemorrhagic Ovarian Cysts Katherine McCracken MD, S. Paige Hertweck MD, Meredith Loveless MD* Kosair Children’s Gynecology Specialists, Kosair Children’s Hospital, Louisville, KY
Background: Corpus luteal cysts are functional cysts that occur frequently in the post-menarchal population1, 2, and can be associated
Oral Abstracts / J Pediatr Adolesc Gynecol 27 (2014) e23ee30
of LNG-IUS in adolescents with developmental disability for menstrual suppression. Eliminating pre-operative ultrasound for girls with special needs reduces patient and family anxiety, time, and costs.
12. Discovery of Pelvic Mass During Evaluation of Precocious Puberty Kim Hoover MD*, Janeen Arbuckle MD, PhD University of Alabama at Birmingham, Birmingham, Alabama
Background: Common presenting signs of early puberty are thelarche, adrenarche, and menarche. Here we discuss the differential diagnosis, evaluation, and management of a child referred for evaluation of precocious puberty whose ultimate diagnosis was a rare uterine mass. Case: MA is a 4 year old Caucasian female referred by her primary care doctor secondary to concerns for early pubertal onset. Her family reported a one month history of vaginal spotting; no signs of adrenarche or thelarche were reported. The patient’s review of systems was negative for trauma, foul smelling discharge, incontinence/retention, constipation, or pain. On exam she was Tanner Stage I for breast, axillary and pubic hair development. Abdominal exam was soft, non-tender, and without adenopathy or obvious mass. The external pelvic exam appeared normal, without discharge or blood noted at introitus. The vagina appeared patent on a limited in-office exam. Given these physical exam findings, menarche was felt to be unlikely. A pelvic ultrasound and exam under anesthesia were therefore performed. The pelvic ultrasound was notable for fluid filled uterine cavity with concern for hydrometrocolpos and left hydronephrosis. Further imaging with CT characterized the fluid collection as a large intracavitary uterine mass measuring 5.5 x 6 x 6.8 cm with left iliac adenopathy and severe left hydronephrosis. Exam under anesthesia revealed a fixed mass indistinct from the uterus occupying the entirety of the left pelvis. Inflammatory changes on the vaginal walls were noted, creating mild agglutination. The cervix had a friable consistency and hysteroscopy was not possible due to obliteration of the endocervical canal. Biopsies of the endocervical canal and ectocervix returned Ewing’s Sarcoma. She is currently under care of Pediatric Oncology with plans for neoadjuvant chemotherapy, radiation, with follow up surgical excision. Comments: Though precocious puberty can present as menarche, it rarely occurs in the absence of thelarche and/or adrenarche. More common causes of vaginal spotting in a young child are vaginal/vulvar infection, dermatoses, foreign body, or vaginal trauma. One must also confirm that bleeding is truly from the vagina as urinary and gastrointestinal pathologies may present with findings misinterpreted as vaginal bleeding. The most common malignant soft tissue mass in childhood is rhadomyosarcoma. Though rhabdomyosarcomas are rare, accounting for 4-6% of all childhood malignancies, an extraosseous Ewing’s sarcoma is even rarer. Ewing’s sarcomas occur primarily in bone, with a median age of diagnosis of 15 years old, and an incidence of 3 per million per year. They are derived primarily from mesenchymal stem cells in bone marrow. Sites not derived from bone occur rarely. Those of female genital tract have been reported in older non-Caucasian females as young as 16 years of age. Our patient represents the youngest patient reported to date. New treatments for large soft tissue masses focus on chemotherapy and radiation, with possible subsequent excision. This case emphasizes the importance of an expedited and thorough physical exam to obtain a diagnosis and tailor treatment.
aggressive, malignant neoplasms. It is important to be aware of this entity in order to appropriately counsel patients and their families and to make an accurate diagnosis and treatment plan. Case: A 2 year old female presented with intermittent episodes of vaginal bleeding that varied from heavy to light spotting. She had no significant medical or family history. Her physical exam was unremarkable, and she was noted to have Tanner stage I normal external female genitalia. Vaginoscopy was then performed and revealed a tan-pink colored pedunculated mass with frond-like projections filling the vaginal apex. A biopsy was obtained with pathology consistent with a benign mullerian papilloma. Pathology was then reviewed at another facility which confirmed the diagnosis. The patient then returned to the operating room where she underwent vaginoscopy which identified the lesion as originating from the anterior portion of the cervix (Fig. 1). It was completely resected and final pathology again confirmed the diagnosis. The patient has had no further episodes of vaginal bleeding and is doing well to date. She will return to for follow-up vaginoscopy six months following resection to assess healing and for evidence of recurrence. Comments: Vaginal bleeding in a prepubertal girl is often a distressing symptom. When it is paired with the findings of a vaginal mass it is important to know the differential diagnosis in order to provide adequate counseling to the patient’s family. The histologic assessment of the specimen is critical and must be distinguished from the more common embryonal rhabdomyosarcoma. Unlike the malignant sarcoma, a benign mullerian papilloma is treated with local excision alone. There have been forty reported cases in the literature to date; therefore, it is important to familiarize oneself with this rare entity. Six have been documented to recur, and two had malignant transformation. The two malignancies were both in women, ages 49 and 52, who were known to have had longstanding recurrent papillomas. There has not been a consensus regarding long term surveillance of these patients. It has been suggested to repeat vaginoscopy at six months and then if symptoms of abnormal vaginal bleeding recur. This is currently the plan for this patient, but it is important to consider the most appropriate follow-up of these patients in order to identify recurrences but to avoid unnecessary procedures and overtreatment.
Fig. 1. Pedunculated cervical lesion.Ă
13. Benign Mullerian Papilloma Laura L. Kruger MD 1, Ashlyn Savage MD 2, Lesley Breech MD*1 1 Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio 2 Medical University of South Carolina, Charleston, South Carolina
Background: Benign mullerian papilloma is a rare childhood tumor of the female reproductive tract that typically presents with vaginal bleeding in a prepubertal girl. The findings of a vaginal or cervical mass in these patients along with some of the histopathologic features can mimic more
14. Case Series: Endoloop for Hemostatic Control of Hemorrhagic Ovarian Cysts Katherine McCracken MD, S. Paige Hertweck MD, Meredith Loveless MD* Kosair Children’s Gynecology Specialists, Kosair Children’s Hospital, Louisville, KY
Background: Corpus luteal cysts are functional cysts that occur frequently in the post-menarchal population1, 2, and can be associated