Imaging
Numerous techniques are available and play a fundamental role not only in establishing a positive diagnosis and orienting the etiology, but also in surveillance and the assessment of spread.

The plain abdominal radiograph may reveal a mass syndrome. It shows tonal differences (fat), intratumoral calcification or ossification, the skeleton and surrounding soft tissues.

Ultrasonography by an abdominal approach with a full bladder indicates the nature of the mass (fluid, solid, homogeneous or otherwise), its size and borders, its location and relations with adjacent organs and any possible repercussions on the upper urinary tract. Doppler ultrasonography may help to identify the structure of a mass. Certain signs may be useful in evaluating the probable benign or malignant nature of the ovarian mass. These signs have a varying predictive value, which is increased when several elements are found together (poorly defined borders, a thick irregular wall, thick rigid septations with angulated junctions, growths, mainly solid component, size, local spread). The contribution of ultrasonography, and especially Doppler ultrasonography, in pediatric practice is nevertheless limited by the impossibility of endovaginal investigation.

Sectional Imaging: Computed tomography (CT) or magnetic resonance imaging (MRI) help to locate the mass and above all to identify its nature. MRI is particularly valuable for characterizing the various fluid and tissue structures.

Various modalities identify tissue structure, blood (hemorrhagic complication of a cyst, adnexal torsion), mucus, fat, and the more or less complex association of various components (dermoid cyst, teratoma, endometriosis).

If the tumor is solid, MRI provides arguments as to its malignant or benign nature and its potential in affirming malignancy is considered to be about 86% in the adult. MRI is indispensable at the present time in assessing the spread of malignant tumors.

Laboratory Studies
Laboratory studies are necessary in the first instance and are useful to differentiate other pelvic conditions such as pregnancy and pelvic inflammatory disease (PID). First, a pregnancy test should be routinely performed to exclude an ectopic pregnancy. Leukocytosis, elevated erythrocyte sedimentation rate and C-reactive protein are highly predictive of inflammatory processes such as appendicitis or PID, and screening for sexually transmitted diseases must be done. In this case, medical treatment with broad-spectrum intravenous antibiotics is usually sufficient.

Hormonal Investigations
Endocrine manifestations are due to abnormal secretion of steroid hormones by the tumor: estrogens, androgens or both. Clinical features depend on the abnormal hormonal secretion. Excessive production of sex steroids (estrogens or androgens or both) with suppressed pituitary gonadotropin level (LH and FSH) are in favor of gonad production. High steroid levels are not suppressed by the dexamethasone test and this response can differentiate ovarian origin and adrenal hypersecretion.

Serum Tumor Markers
Some ovarian neoplasms secrete protein or hormone markers that can be assayed in either peripheral blood samples or the ovarian cyst fluid. These substances are not specific markers for ovarian origin but are specific of tissue function. They are less useful in the diagnosis of ovarian mass than for the detection of possible recurrences in the follow-up after initial treatment. The main helpful markers are carcinoembryonic antigen (CEA) in epithelial and germ cell tumors; α-fetoprotein (αFP), which is produced by mixed germ cell tumors and immature teratomas, and human chorionic gonadotropin (hCG), which is elevated in choriocarcinoma and embryonic ovarian carcinomas. Cancer antigen 125 (CA 125) is a protein expressed on the cell membrane of normal ovarian tissue. It is a sensitive but not specific marker for non-mucinous epithelial ovarian cancer. Elevated serum CA 125 is typically associated with ovarian malignancies but it can also be found in association with other intraperitoneal processes such as endometriosis, hydronephrosis, PID and other epithelial gastrointestinal cancers. The value of the serum tumor marker CA 125 to date has been in monitoring response to chemotherapy in patients with ovarian cancer and in detecting recurrent disease. Inhibin B is a glycoprotein secreted by ovarian granulosa cells. Elevated serum inhibin concentration was reported in granulosa cell tumors and in some mucinous carcinomas. In the postnatal period, granulosa cells also secrete another glycoprotein, müllerian inhibiting substance (MIS). Very elevated serum levels of MIS were found in a woman with an ovarian sex cord tumor (

table 1).

Surgery
The recent literature shows that in pediatric practice conventional surgery still holds a considerable place, although the present trend is toward increasing use of laparoscopy. As in other fields, the most appropriate approach may well be video-assisted surgery, as the two techniques are complementary.

Open surgery allows precise intervention on the adnexae while respecting the imperatives of oncological surgery. However, when extensive abdominal investigation (up to the diaphragm) is required, the necessarily wide approach leaves, at the very least, non-negligible esthetic sequelae.

Laparoscopy allows complete exploration of the peritoneal cavity and acquisition of biopsy samples if required -  especially of the supramesocolic region -  and peritoneal washings for cytological study. Inversely, intervention on the adnexae is less precise than with conventional surgery, even in experienced hands: immobilization of the ovary and fallopian tube and their isolation from neighboring structures to prevent fluid or cell leakage are of lesser quality.

Even if this argument may be moderated by the rarity of malignant tumors, it must always be borne in mind when dealing with an ovarian mass; at least one case of peritoneal dissemination after laparoscopic treatment of a teratoma has been published. The most reasonable attitude is probably to associate these two techniques in the wider context of video-assisted surgery.

The first stage consists of laparoscopy using the ‘open’ technique, which avoids the risks of blind performance of pneumoperitoneum. The peritoneal cavity can be completely explored and the ovarian mass assessed (size, surface, connections between the ovarian parenchyma and the tumor), and a functional mass can be treated and an adnexa untwisted if necessary.

When all the clinical, radiological, biological and endoscopic criteria of benignity are met and the organic mass is small in size, tumoral excision (tumorectomy but not adnexectomy) can be envisaged, either within the abdomen by laparoscopy or outside the abdominal cavity after externalization of the adnexa by a short incision at the level of an iliac fossa.

In all other cases, ovarian surgery is carried out by a wide pelvic approach such as the Pfannenstiel technique. Extensive laparotomy is now very infrequent.