Obstetrics & gynecology science

Korean Society of Obstetrics and Gynecology (대한산부인과학회)
권호 표지

Clinicopathologic Review of Uterine Adnexal Tumor Torsion

자궁부속기 종양 염전의 임상.병리학적 고찰

Ha, Jun-Young;Yang, Hoe-Saeng
하준영;양회생

  • Published : 20040200
⟨ Previous Next ⟩

Abstract

Objective : We analyzed the frequency, clinical symptom, physical exam, site and the degree of torsion, ultrasound findings, histological aspects and the relationship between the pregnancy of ovarian torsion in order to help the early detection of the disease and conservation of the ovary. Methods : Out of 510 operative cases of adnexal mass patients in Dongguk university hospital from March 1993 to March 2003, 50 histologically confirmed cases of ovarian torsion were selected and retrospectively analyzed. Results : Operative cases of adnexal mass were 510 including the 42 complicated by pregnancy and out of these, torsion occurred in 50 cases (10%) with 16 pregnancy complication. Clinical features of 50 torsion cases are as follows. The frequencies of uterine adnexal tumor torsion were reported by age, 36 cases (72%) in their twenties and thirties, with 21 (42%) nulliparous women at the highest. 42 (84%) had no previous operative history. On the clinical features and physical exam, in the order of frequency, 48 cases (96%) of lower abdominal pain were the highest, and 42 (84%) of GI symptoms, 11 (22%) of urogenital symptoms, and 4 cases (8%) of vaginal bleeding was noted. Under CBC study, 28 (56%) leukocytosis were reported. And on the ultrasound findings, 46 cases (90%) of tumor with hypertrophic wall were noted, septum existed in 12 cases (24%), and 40 (78%) represented internal shadow of the solid portion. The tumor size between 5 to 9 centimeters were the most with 30 cases (58%), and the sum of torsions with 360 and 720 degrees consisted of 40 (78%), occupying for the most of the cases. 27 (55%) of right side existed compared to the 22 (45%) of left. 42 had no previous transabdominal surgery. In the method of operation, 41 (82%) explorative surgeries and 9 cases (18%) of laparoscopic surgery was done, and 5 of these were conservative (12%). The necrosis was noted in 44 cases, and internal bleeding was present in 39 cases. Histologically, functional cyst consisted highest in numbers with 25 (49%), where benign neoplasm with 22, and one malignant neoplasm. About relationship with pregnancy, 9 cases (56%) of corpus luteal cyst were the most. Outcome of the pregnancy was 9 (56%) full term deliveries, 2 abortions (12%), and 1 (6%) preterm delivery. Conclusion : Ovarian torsion should be considered when women in between their twenties and thirties with abrupt onset of lower abdominal pain along with nausea and vomiting, leukocytosis, and 5 to 9 cm sized cystic mass with the wall hypertrophy present in ultrasound. Immediate and accurate diagnosis and treatment should follow.

목적 : 자궁부속기 종양 염전의 조기 진단 및 난소기능 보존을 위해, 염전의 발생빈도, 임상 양상, 이학적 소견, 염전의 위치 및 정도, 임신과의 관계, 초음파 소견, 병리조직학적 소견을 분석하고자 한다. 연구 방법 : 1993년 3월부터 2003년 3월까지 동국대학병원 산부인과에서 자궁부속기 종양으로 진단되어 수술한 510예 중 수술소견 및 병리조직학적 소견 상, 염전이 확인된 50예를 대상으로 후향적으로 분석하였다. 결과 : 자궁부속기 종양으로 수술한 경우는 임신이 동반된 42예를 포함하여 510예였고 이중 염전이 발생 한 경우는 임신이 동반된 16예 (38%)를 포함하여 50예 (10%)였다. 염전이 발생한 50예에 대한 임상적 양상은 다음과 같다. 연령별 발생빈도는 20-30대군 (20-39세)으로 36예 (72%)였고, 미산부에서 21예 (42%)로 가장 높았다. 기왕 수술병력과의 관계에서 수술병력이 없는 경우가 42예 (84%)였다. 빈도별 증상으로 하복부 동통 48예 (96%), 소화기계 증상 42예 (84%), 비뇨기계 증상 11예 (22%), 질 출혈 4예 (8%)였고, 일반혈액 검사 상 백혈구 증가의 경우는 28예 (56%)였다. 초음파 소견상 종양벽의 비대는 46예 (90%)에서 관찰되었고, 고형질 내부음영 40예 (78%), 격막의 존재가 12예 (24%)였다. 수술적 소견으로 염전체의 크기는 5-9 cm이 30예 (58%)로 가장 많았고, 염전의 정도는 360$^{\circ}$와 720$^{\circ}$ 회전 된 염전체가 40예 (78%)였다. 발생 위치는 우측 27예 (55%), 좌측 22예 (45%)였다. 수술방법으로는 개복수술이 41예 (82%), 복강경수술 9예 (18%)였다. 전체 수술 중, 보존적 종양 절제술의 경우는 5예 (12%)였다. 병리조직 소견상 괴사 소견 44예 (86%), 내부출혈 소견 39예 (76%)였다. 조직학적으로는 기능성 낭종 25예 (49%), 양성 신생물은 22예 (43%)였다. 악성 신생물은 1예 (2%)가 있었다. 임신 중 염전체의 종류로는 황체낭종 9예 (56%)로 가장 많았으며, 염전체의 수술 후 임신의 예후는 만삭분만이 9예 (56%), 유산이 2예 (12%), 조산 분만이 1예 (6%)였다. 결론 : 오심, 구토를 동반한 급성 하복부 동통을 보이는 20-30대 가임기 여성에서 백혈구의 증가가 있고, 초음파 상 자궁부속기에 종양벽 두께의 증가를 보이는 5-9 cm 크기의 낭성 종양이 발견되면 염전을 고려하여, 적절하고 신속한 진단 및 치료를 시행해야 한다.

Keywords

References

  1. Graif M, Itzchak Y. Sonographic evaluation of ovarian torsion in childhood and adolescence. AJR 1988; 150: 647-9 https://doi.org/10.2214/ajr.150.3.647
  2. Hibbard LT. Adnexal torsion. Am J Obstet Gynecol 1985; 152: 456-61
  3. Lomano JM, Trelford JD, Ullery JC. Torsion of the uterine adnexa causing an acute abdomen. Obstet Gynecol 1970; 35: 221-5
  4. Lee CH, Raman SA, Sivanesaratnam V. Torsion of ovarian tumors: a clinicopathological study. Int J Gynecol Obstet 1989; 28: 21-5 https://doi.org/10.1016/0020-7292(89)90539-0
  5. Kisterner RW. Gynecology. Principles and Practice. 4th ed. Year book Medical Publishers, INS Chicago 1986: 304-6
  6. Koren Z, Bichanco S. Torsion of pregnant fallopian tube. J Obstet Gynecol Br Commomw 1967; 74: 603
  7. Koren Z, Bichanco S. Torsion of pregnant fallopian tube. J Obstet Gynecol Br Commomw 1967; 74: 603
  8. Lee CH, Raman S. Clinicopathological study Int. J Obstet Gynecol 1989; 28: 21-5 https://doi.org/10.1016/0020-7292(89)90539-0
  9. Katz VL, Watson WJ, Hansen WF, Washington JL. Massive ovarian tumor complicating pregnancy. A case report. J Reprod Med 1993; 45: 907-9
  10. Morice P, Louis-Sylvestre C, Chapron C, Dubuisson JB. Laparoscopy for adnexal torsion in pregnant women. J Reprod Med 1997; 42: 435-9
  11. Bider D, Mashiach S, Dulitizky M, Kokia E, Lipitz S, Ben-Rafael Z. Clinical, surgical and pathologic findings of adnexal torsion in pregnant and non-pregnant women. Surg Gynecol Obstet 1991; 173: 363-6
  12. James DF, Barber HR, Graber EA. Torsion of Normal Uterine Adnexa on Children Report of Three Cases. Obstet Gynecol 1970; 35: 226-30
  13. Burnett LS. Gynecologic causes of the acute abdomen. Surg Clin North Am 1988; 68: 385-98
  14. Hicken NE, Rasmussen LP. Intraperitoneal hemorrhage caused by strangulation and rupture of normal ovary in 8-year old girl, J Pedit 1941; 18: 652
  15. Kruger E, Heller DS. Adnexal torsion: A clinicopathological review of 31 cases. J Reprod Med 1999; 44: 71-5
  16. Graif M, Shalev J, Strauss S, Engelberg S, Mashiach S, Itzchak Y. Torsion of the ovary. sonographic features. AJR 1984; 143: 1331-4 https://doi.org/10.2214/ajr.143.6.1331
  17. Warner MA, Fleischer AC, Edell SL, Theme GA, Bundy AL, Kurtz AB, et al. Uterine Adnexal Torsion: Sonographic findings. Radiology 1985; 154: 773-5
  18. Nichols DH, Julian PJ. Torsion of the adnexa. Clin Obstet Gynecol 1985; 28: 375-80 https://doi.org/10.1097/00003081-198528020-00015
  19. 양희동, 박현직, 하충식, 황선제, 곽정상. 자궁부속기 염전의 임상병리학적 고찰. 대한산부회지 1993; 36: 1470-4
  20. Peterson WF, Prevost EC, Edmonds FT, Hundly JM, Morris FK. Benign cystic teratoma of the ovary. A clinico-statistical srudy of 1,007 cases with a review of the literature, Am J Obstet Gynecol 1955; 70: 368-82
  21. Jones HW, Weuts AC, Burret C. Novak's textbook of Gynecology 11th edition Williams & Wilkins 1988: 835
  22. 김현승, 선우재근, 김민관, 장경택, 배동한. 난소종양의 염전에 관한 임상적 연구. 대한산부회지 1997; 40: 1044-8
  23. Farrell TP, Boal DK, Teele RL, Ballantine TV. Acute torsion on normal uterine adnexa in children Sonographic Demonstration. 1982; 139: 1223
  24. Kelberg MR, Randall JH. Torsion of adnexal tumors and its relation to surgical emergency Am J Obstet Gynecol 1985; 52: 464
  25. Kohl GC. Torsion of uterine tube following Pomeroy sterilization. Obstet and Gynecol 1956; 7: 396
  26. Rosado WM Jr, Trambert MA, Gosnik BB, Pretorius DH. Adnexal torsion: diagnosis by using Doppler sonography. AJR Am J Roentgenolo 1992; 159: 1251-3 https://doi.org/10.2214/ajr.159.6.1442394
  27. Lee EJ, Kwon HC, Joo HJ, Suh JH, Fleischer AC. Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle. J Ultrasound Med 1998; 17: 83-9
  28. Koonings PP, Grimes DA. Adnexal torsion in postmenopausal women. Obstet Gynecol 1989; 73: 11-2
  29. diZerega GS, Rodgers K. The Peritoneum 1992; 22
  30. Bayer AI Wiskind AK. Adnexal torsion: Can the adnexa be saved? Am J Obstet Gynecol 1994; 171: 1506-10 https://doi.org/10.1016/0002-9378(94)90393-X
  31. McHutchison LL, Koonings PP, Ballard CA, d'Ablaing G 3rd. Preservation of ovarian tissue in adnexal torsion with fluorescein. Am J Obstet Gynecol 1993; 168: 1386-8 https://doi.org/10.1016/S0002-9378(11)90769-8
  32. Pryor RA, Wiczyk HP, O'Shea DL. Adnexal infarction after conservative surgical management of torsion of a hyperstimulated ovary. Fertil Steril 1995; 63: 1344-6
  33. Taskin O, Birincioglu M, Aydin A, Buhur A. The effects of twisted ischemic adnexa managed by detorsion on ovarian viability and histology; an ischemia-reperfusion rodent model. Hum Reprod 1998; 13: 2823-7 https://doi.org/10.1093/humrep/13.10.2823
  34. Peter A, Argenta, Thomas J. Yeagley, Gary Ott, Steven J. Sondheimer. Torsion of the Uterine Adnexa: Pathologic Correlations and Current Management Trends. J Reprod Med 2000; 45: 831-6
  35. Benjamin Caspi, Roni Levi, Zvi Appelman, David Rabinerson, Gil Goldman, Zion Hagay. Conservative management of ovairan cystic teratoma during pregnancy and labor. Am J Obstet Gynecol 2000; 182: 503-5 https://doi.org/10.1067/mob.2000.103768
  36. Nesson MJ, Cavalieri R, Graham D, Sanders RC. Cysts in pregnancy discovered by sonography. J Clin Ultrasound 1986; 14: 509-12 https://doi.org/10.1002/jcu.1870140703