A diagnosis and treatment algorithm for adnexal masses in female children and adolescents.

Adnexal masses in children and adolescents can present with non-specific symptoms and signs, often resulting in diagnostic delay. Ultrasonography remains the primary imaging modality for initial evaluation; however, distinguishing benign from malignant lesions is difficult. In addition, tumor markers offer limited specificity. Diagnostic strategies therefore vary significantly by age and pubertal status, highlighting the need for a risk-based assessment system that integrates age, imaging features, and laboratory findings to balance timely intervention with avoidance of overtreatment. Notably, functional ovarian cysts are extremely rare in premenarchal girls. When an adnexal mass is detected in this age group, a more proactive diagnostic approach is warranted, with careful evaluation for neoplastic etiologies. Adnexal masses in children and adolescents frequently are discovered incidentally during routine investigation for unrelated concerns. Pelvic pain, reported in approximately 70% of cases, is the most common presenting symptom and typically manifests as persistent abdominal or pelvic discomfort or a dull ache. 9 Pain is often related to mass enlargement, local compression, or traction. Acute and severe abdominal pain raises concern for complications such as torsion, rupture, and hemorrhage. Malignant masses are more likely to present with a palpable mass, abdominal distension, and cachexia compared with benign masses. Ultrasonography findings such as massive ovarian edema, the presence of an adnexal mass, vortex sign, reduced or absent ovarian blood flow, and pelvic fluid accumulation may suggest adnexal torsion. 10 Among these, the ovarian crescent sign—visualization of residual normal ovarian tissue compressed by an adjacent mass—is considered the most critical imaging feature. Incorporation of this sign into the diagnostic assessment, together with associated ovarian edema, can facilitate rapid recognition of ovarian torsion even in the setting of an otherwise benign-appearing tumor. 11 Nevertheless, it must be remembered that ovarian or adnexal torsion can occur in the absence of ultrasound findings, and a history of acute onset of pain, nausea, and dizziness may be the only clues, often combined with only a marginally increased ovarian size. Some imaging characteristics give important clues to assist in diagnosing benign from malignant adnexal masses. These include a diameter ≥5–8 cm, cystic-solid lesions, papillary protrusions, thick septa with blood vessels, abdominal or pelvic ascites, and evidence of metastatic disease. Among these features, the presence of a solid component has been identified as the most statistically significant predictor of malignancy. 12 Tumor markers may provide additional diagnostic clues. GCTs are often associated with elevated levels of alpha-fetoprotein (AFP), β-human chorionic gonadotropin (β-hCG), and lactate dehydrogenase (LDH). Epithelial tumors may present with elevated levels of common cancer antigen 125 (CA125), whereas SCST is often accompanied by abnormally elevated levels of estradiol or testosterone. 13 However, the primary clinical value of tumor markers lies in high negative predictive value (94.4%), which is useful for excluding malignancy. In contrast, the positive predictive value remains relatively low (17.1%), limiting their utility in confirming malignant disease. 13

A wide range of adnexal masses, ranging from physiological cysts and embryological remnants to neoplastic lesions, occurs in female children and adolescents. The neoplastic lesions are classified according to the cell lines from which the lesions originate. According to their biological behavior, histopathological characteristics, and clinical prognosis of these neoplastic lesions, they are classified as benign, borderline, or malignant tumors. In general, they are mainly classified as germ cell tumors (GCTs), epithelial tumors, and sex cord stromal tumors (SCSTs). 1 GCT accounts for 60%–70% of ovarian tumors in children and adolescents and represents the most common type in this age group. GCT includes teratoma, dysgerminoma, endodermal sinus tumor, embryonal carcinoma, and primary choriocarcinoma. Epithelial tumors account for about 17% of cases, among which borderline ovarian tumors (BOTs) represent 20%–30% of epithelial ovarian tumors in children, most commonly occurring between 15 and 19 years of age. 2 Granulosa cell tumors are the most common subtype of SCST. Juvenile granulosa cell tumors account for approximately 5% of cases, predominantly affect adolescents, and are associated with a relatively high malignant potential. Based on the biological behavior, histopathological features, and clinical prognosis, adnexal tumors are further classified as benign, borderline, and malignant. BOTs are extremely rare in children and adolescents. 3 The main pathological subtypes include borderline serous cystadenoma and borderline mucocele, with an incidence of 2%–4%. 4 Overall, malignant tumors account for 3%–8% of ovarian tumors in this population. 4 The pathological types and clinical characteristics of malignant ovarian tumors in children and adolescents differ markedly from those in adults, with malignant ovarian germ cell tumors (MOGCTs) accounting for the majority. 5 The age of onset shows a bimodal distribution, with the first peak occurring in children younger than 7 years and the second peak in adolescence aged 14–18 years. Common pathological types include immature teratoma, yolk sac tumor, and GCT. Interstitial tumors of the sex cord are another important category of adnexal malignancies in young girls. Physiological or functional ovarian cysts are common in adolescent women and are usually secondary to pituitary gonadotropin stimulation, such as follicular cysts and corpus luteum cysts, accounting for 30%–50% of cases. 6 Endometriosis is often difficult to diagnose in its early stages because of atypical clinical symptoms. Ovarian endometriomas can occasionally occur in adolescence and are almost invariably found in association with obstructive Müllerian anomalies. About two-thirds of adolescent girls with chronic pelvic pain or dysmenorrhea have laparoscopic evidence of endometriosis. 7 Rare conditions such as McCune-Albright syndrome are also associated with a predisposition to functional ovarian cysts. Non-ovarian adnexal lesions include para-tubal and para-ovarian cysts, which arise from congenital remnants of accessory and mesonephric ducts, and have an incidence of about 4%. 8 Other tubal diseases, including ectopic pregnancy and pelvic abscess, should also be considered in sexually active adolescent populations. Müllerian anomalies, including accessory uterine cavities and rudimentary uterine horns, although related to the uterus, can be mistaken for adnexal lesions; thus, careful assessment is necessary.

To further improve the diagnosis and management of adnexal tumors in children and adolescents, future efforts should focus on three key areas. First, continued development of non-invasive diagnostic tools is needed to improve preoperative risk stratification while reducing unnecessary surgical interventions. Second, the establishment of standardized clinical pathways may help unify evaluation and treatment strategies and ensure consistent, high-quality care. Third, multidisciplinary collaboration Multi-Disciplinary Team (MDT) involving pediatric and adolescent gynecology, pediatric surgery, oncology, radiology, and reproductive medicine is essential to deliver individualized management from diagnosis to prioritize fertility preservation to long-term health outcomes.

Early diagnosis and timely surgical intervention for adnexal torsion are critical to preserving ovarian function in children and adolescents. Asymmetry in ovarian volume is often the first ultrasonographic feature suggestive of torsion. 11 A retrospective cohort study confirmed that mass size greater than 5 cm, acute onset pain, and persistent or recurrent pain were significantly associated with an increased risk of torsion. In this context, earlier and more liberal use of diagnostic laparoscopy may improve ovarian salvage rates. 14 Adnexal torsion requires prompt surgical detorsion to preserve ovarian function. Following detorsion, ovarian tissue should be preserved whenever possible to minimize the risk of long-term loss of ovarian function. Even if a potential ovarian tumor cannot be definitely evaluated or treated during the initial detorsion surgery, reassessment can be safely deferred until 6–8 weeks later, after resolution of ovarian edema. If a persistent mass is identified at that time, a second-stage surgical procedure can be performed to remove the lesion. 15 In the diagnosis and management of adnexal torsion in children and adolescents, ovarian preservation should remain the central principle. Early recognition, timely intervention, and laparoscopic detorsion are preferred whenever feasible. Even with the suspicion of a tumor, a staged surgical strategy should be considered to prioritize ovarian preservation. There is ample evidence that this conservative approach to ovarian torsion—irrespective of duration of symptoms, color, or size of the adnexal torsion—that over 90% of detorted ovaries will demonstrate a return to function. The risk of ovarian torsion with a malignancy is reported to be <2%. There is no evidence that there is any increased risk of thromboembolic events or infection with this approach. For benign ovarian tumors and cysts persisting for over 3 months or gradually increasing to over 5 cm, minimally invasive surgical resection of the lesion by ovarian cystectomy is the standard approach. By preserving the ovarian cortex or outer layer, which contains all the follicles, this allows for preservation of ovarian function. This approach can be used even for quite large cysts of 10 cm or more. 15 For patients where an ovarian cystectomy has been performed but pathology reports a borderline ovarian tumor, this surgical approach of preserving the ovary to preserve fertility is feasible for young patients, and long-term follow-up and management should then be offered due to a low risk of recurrence of the borderline tumor. 16 17 MOGCTs, which are commonly seen in children and adolescents, usually have an early onset and are often unilateral. In the surgical management of MOGCT, surgery that preserves fertility function is usually chosen, with unilateral adnexal resection, along with exploration of the lymph nodes on that side during surgery to allow staging. For young patients with MOGCT undergoing initial surgical treatment, if no ovarian metastasis is identified during intraoperative examination, then omentectomy, lymph node dissection, and biopsy of a normal appearing contralateral ovary are not necessary. 18 Even for advanced MOGCT, fertility preserving surgery combined with postoperative adjuvant chemotherapy can effectively protect the reproductive function of patients. 19 During surgery, the use of energy-based instruments should be minimized to reduce inadvertent damage to normal ovarian tissue. 20 Generally, gynecologists are more alert to ovarian tissue preservation for girls, adolescents, and women. We have drawn a diagnostic and treatment algorithm diagram for adnexal masses in female children and adolescents, hoping to provide a clearer explanation of the diagnosis and treatment process for adnexal masses (for details, please refer to figure 1 ).