He et al.

BMC Women’s Health (2022) 22:421

https://doi.org/10.1186/s12905-022-02013-4

CASE REPORT Open Access

Rethinking ovary preservation by adnexal

torsion reversal in adolescents: a case of delayed
diagnosis
Yue He, Chen Ji, Xiao‑Chang Shen, Ke‑Xin Zhang, Yu‑Mei Wu and Yan Wang*   

Abstract
Background: This article discusses the management of an adolescent woman with a delayed diagnosis of adnexal
torsion (AT) whose ovaries were successfully preserved.
Case presentation: The patient was a 14-year-old female teen admitted with the chief complaint of lower abdomi‑
nal pain for 3 days and worsening pain for 2 days. Magnetic resonance imaging suggested a high possibility of torsion
in the anterosuperior uterine mass and was accompanied by severe ovarian edema, bleeding, and enlargement.
Intraoperatively, the left fallopian tube was characterized by thickening and torsion and appeared blackish purple.
The left fallopian tube paraovarian cyst was about 20 cm in size, and the left adnexa was twisted 1080° along the left
infundibulopelvic ligament (suspensory ligament of the left ovary). The left ovary appeared blackish purple, with an
enlarged diameter of about 10 cm. At the request and with the informed consent of the patient’s parents, we pre‑
served the left ovary and removed the left fallopian tube. The results of the endocrine, ultrasound, and tumor marker
tests were normal 1 month after surgery. Follicles and blood flow signals seen in ultrasound examinations indirectly
proved the successful preservation of the left ovary in the follow-up.
Conclusions: Our attempt to preserve the ovaries in an adolescent with a delayed diagnosis of AT was successful.
Keywords: Ovary preservation, Delayed diagnosis, Adnexal torsion, Adolescent, Case report

Background < 20 years, and 46% of cases in adolescents only had tor-
Adnexal torsion (AT) is an anatomical translocation of sion of the ovary, without ovarian cysts [2]. The most
the ovaries and/or fallopian tubes along the axis of the common clinical presentation of AT is the sudden onset
infundibulopelvic ligament and the suspensory liga- of localized lower abdominal pain with or without nau-
ments of the ovaries, resulting in partial or total obstruc- sea and vomiting. Ultrasonography, computed tomogra-
tion of the blood supply to the ovary. It is ranked as the phy (CT), magnetic resonance imaging (MRI), and other
fifth most common acute abdomen in gynecological examinations have auxiliary significance in diagnosing
practice [1, 2]. AT can occur in women of any age, but AT.
it mostly occurs in women of childbearing age, followed With improvements in the understanding of AT, sev-
by children and adolescents, with 30% being girls aged eral studies have shown that recovery of ovarian function
is possible after torsion release, regardless of the visual
appearance of the AT [1, 3]. Therefore, once AT is sus-
*Correspondence: [email protected] pected, prompt diagnostic surgery should be performed
Department of Gynecological Oncology, Beijing Obstetrics and Gynecology
to release the torsion and preserve ovarian function and
Hospital, Capital Medical University. Beijing Maternal and Child Health Care fertility as much as possible. At present, there is a new
Hospital, Dongcheng District, 17 Qihelou Street, Beijing 100006, China understanding of the early diagnosis of AT and the choice

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He et al. BMC Women’s Health (2022) 22:421 Page 2 of 6

of surgical approach. This article discusses the manage- anti-Mullerian hormone (AMH), 6.39 [0.24–11.78]
ment of an adolescent woman with a delayed diagnosis of ng/mL.
AT who had successful ovarian preservation. 4. Enhanced MRI: The left uterine horn was stretched
upward, the uterine fundus was approximately
4.3 × 3.0 × 5.1 cm in size, and a solid mass was
Case presentation seen in the anterosuperior uterus, approximately
The patient was a 14-year-old female teen admitted with 10.3 × 6.4 × 11.5 cm in size, showing iso-T1, a short
a chief complaint of lower abdominal pain for 3 days, T2 predominantly mixed signal, a flocculent long T2
which exacerbated for 2 days. Menarche had occurred signal, and a low signal on DWI, with small cystic foci
at 10 years of age, the patient had regular menstruation, scattered in the periphery, non-enhanced or mildly
and her last menstrual period was on January 10, 2022. heterogeneous, strengthening on enhanced MRI,
Three days before admission, she experienced sponta- and another larger cystic foci with long T1 and long
neous, dull pain in the lower abdomen after changing T2 signals that were connected with the above solid
posture. Ultrasonography conducted in another hospital mass, measuring approximately 19.2 × 9.9 × 14.2 cm,
showed a large cyst on the right side of the pelvis meas- with a thick and enhanced cystic wall on enhanced
uring 19.6 × 9.6 cm. Moderate to low echogenicity with MRI, and pelvic effusion. No abnormally enlarged
an area of about 11.5 × 6.3 cm was observed in the mid- lymph nodes were seen in the pelvis and bilateral
upper pelvic cavity; she sought medical attention at our inguinal regions. Diagnostic conclusions included
hospital. Two days before admission (the date of admis- a solid mass in the anterosuperior uterus and an
sion was January 10, 2022), she experienced increased enlarged left ovary; the right upper cystic mass was
abdominal pain with hypothermia and vomiting, but diz- considered a left ovarian cystic mass, and the possi-
ziness, headache, palpitations, and shortness of breath bility of torsion in the left ovary and its cystic mass
were absent. She did not undergo diagnosis or treatment was high and accompanied by severe ovarian edema,
for personal reasons and underwent consultation at our bleeding, enlargement, and pelvic effusion.
department for further pelvic examination. A gynecologi-
cal examination showed abdominal distension, a palpable The intraoperative condition (Fig. 1) was as follows:
mass, positive tenderness, and rebound tenderness. She small amounts of cool yellowish fluid were found in
denied any history of chronic diseases, drug allergies, the pelvis, the left fallopian tube was characterized by
surgery, or blood transfusions.
At the time of admission, her temperature, blood pres-
sure, and pulse rate were 37.7 °C, 140–145/80–90 mmHg,
and 80–90 beats/minute, respectively. On physical exam-
ination, abdominal distension, fixed lower abdominal
tenderness, rebound tenderness, and shifting dullness
were negative. Gynecological examination (anal examina-
tion) revealed a mass that could be palpated at the pel-
vis, positive and rebound tenderness, and smooth rectal
mucosa.
The ancillary examinations were as follows:

1. Routine blood test:white blood cells (WBC),

16.88 × ­109/L [4 × ­109–10 × ­109]; hemoglobin (HGB),
97 [110–150] g/L; and platelets (PLT), 227 × ­109/L
[100 × ­109–300 × ­109].
2. Tumor markers:human epididymis protein 4 (HE4),
40.44 [0–92] pmol/L; alpha fetoprotein (AFP), < 0.61
[0–7] ng/mL; carbohydrate antigen 199 (CA199), Fig. 1 Intraoperative condition. The left fallopian tube was thickened,
3.84 [0–39] U/mL; and CA125, 66.97 [0–35] U/mL. twisted, and blackish purple. The left fallopian tube paraovarian cyst
was about 20 cm in size (blue arrow), the left adnexa was twisted
3. Endocrine tests: follicle-stimulating hormone (FSH),
1080° along the left infundibulopelvic ligament–suspensory ligament
4.06 [1.50–9.10] IU/L; estrogen 2 (E2), 21.3 [52.80– of the left ovary (high tension), and the left ovary was blackish purple
214.20] pg/mL; progestogen (P), 0.289 [4.44–28.03] with an enlarged diameter of about 10 + cm (yellow arrow). The
ng/mL; luteinizing hormone (LH), 5.5 [0.50–16.90] color of the left ovary was slightly restored after reduction of the left
IU/L; testosterone (T), 2.52 [0.31–1.66] nmol/L; and adnexa, whereas the left fallopian tube remained blackish purple
He et al. BMC Women’s Health (2022) 22:421 Page 3 of 6

thickening and torsion and appeared blackish purple, the

left fallopian tube paraovarian cyst was about 20 cm in
size, the left adnexa twisted 1080° along the left infundib-
ulopelvic ligament (suspensory ligament of the left ovary)
(high tension), and the left ovary was blackish purple with
an enlarged diameter of about 10 cm. The color of the left
ovary was slightly restored after the reduction of the left
adnexa, and there was no obvious cyst in the ovary, while
the left fallopian tube remained blackish purple.
The patient’s parents informed us that the patient was
young and had a strong willingness to preserve her ova-
ries and that she could be followed-up closely. They were
informed with the following details: there was a possibil-
ity of re-torsion if the ovaries were preserved; the blood
supply to the ovaries was poor; surgery might be needed
if necrosis occurred; the left fallopian tube was twisted
and hypertrophied, had poor blood supply, and had lost
its normal form and function; and re-torsion, hydrosal-
pinx, and ectopic pregnancy may occur if the left fallo-
pian tube was preserved. Based on the latest consensus,
left ovary preservation was considered, but the recom-
mendation was to resect the left fallopian tube. The
patient’s family expressed their understanding. At the Fig. 2 Postoperative condition. The left ovary was preserved (blue
arrow), and the left fallopian tube was removed (yellow arrow), and at
request and with the informed consent of the patient’s
the same time, blood clot cleaning of the left ovary was performed
parents, we preserved the left ovary, removed the left fal-
lopian tube, and performed blood clot cleaning of the left
ovary (Fig. 2). For further treatment according to the spe-
cific postoperative conditions and pathology, we did not ovary was 5 cm in the maximum longitude size, with une-
perform a frozen section because there was no evidence ven echo. Multiple cysts (13 cysts/plane) were seen, and
of malignancy observable by the naked eye. the diameter of the larger cysts was 0.7 cm. Blood flow
On day 1 after surgery, she had a transient temperature signals could be seen in Color Doppler Flow Imaging
increase of 39 °C, which later spontaneously decreased to (CDFI) ovary, Resistance Index (RI) = 0.77, Pulse Index
normal, with good gas expulsion and defecation. (PI) = 1.97 (yellow arrow). The follicles and blood flow
Reexamination results were as follows: (1) coagulation: signals revealed by ultrasound, indirectly proved the suc-
fibrinogen (FIB), 6.7 [1.8–4] g/L; activated partial throm- cessful preservation of the left ovary.
boplastin time (APTT), 28.4 [23.3–32.5] s; thrombin
time (TT), 14.3 [14–21]s; international normalized ratio Discussion
(INR), 1.030 [0.8–4]; and D-dimer (D-D), 5.13 [0–0.55] Management of AT
mg/L. (2) Routine blood tests showed the following: In recent years, early diagnosis and standardized man-
WBC, 10.35 × ­109/L [4 × ­109–10 × ­109]; HGB, 95 [110– agement of AT have received attention from Chinese
150] g/L; and PLT, 365 × ­109/L [100 × ­109–300 × ­109]. and overseas experts. Surgical exploration is considered
A postoperative pathology test suggested a left fal- the standard method to confirm the diagnosis of AT. The
lopian tube paraovarian cyst with fibrocystic wall-like incidence of AT in women aged 1–20 years was 5/100,000
tissue in the left ovary, extensive congestion, and hemor- in a US study [2], and the results of a Korean study were
rhage, and no apparent lining epithelium, consistent with consistent with that of the US findings [3]. Studies have
torsional pathological changes. reported [2, 4] that the incidence of malignant prepu-
One month after surgery, the results of the endocrine, bertal adolescent ovarian cysts is 0.5–4%, and the inci-
ultrasound, and tumor marker tests were normal, and dence of malignancy in children with ovarian cysts and
menstruation was normal. The results of the endocrine AT is only 1.8%. The American College of Obstetricians
tests were as follows: FSH, 7.35 [1.50–9.10] IU/L; E2, and Gynecologists (ACOG) [2] and the Chinese Medical
35.7 [52.80–214.20] pg/mL; P, 0.223 [4.44–28.03] ng/mL; Doctors’ Association [5] developed an expert consensus
LH, 17.0 [0.50–16.90] IU/L; T, 1.680 [0.31–1.66] nmol/L; for AT in American and Chinese women in 2019 and
and AMH, 4.14 [0.24–11.78] ng/mL. Ultrasound:The left 2020, respectively. Both consensuses provide detailed
He et al. BMC Women’s Health (2022) 22:421 Page 4 of 6

summary norms and guidelines on AT regarding clinical of AT more accurate and prompt [11]. However, it is
presentation, differential diagnosis, treatment, and fol- unknown whether the reduced ovary is congested, edem-
low-up. Two expert consensuses emphasize that age is a atous, or even necrotic due to ischemia, which will have
critical factor for selecting torsional reduction or adnexal more serious consequences if there is secondary infec-
resection and that premenopausal patients should tion or rejection.
undergo routine AT reduction with preservation of the Another concern is that the preserved ovaries still have
affected adnexa, even if the ovary is purplish black and the potential for future re-torsion. In addition, whether
necrosis is suspected when observed intraoperatively by or not to perform ovarian fixation still needs to be deter-
the naked eye. In some cases, the ovary’s color does not mined in a study with a large sample size. In our patient,
return to normal immediately after reduction but takes we unfortunately removed a unilateral fallopian tube that
36 h to do so after torsion release [2]. Adnexal resection was edematous, severely deformed, and possibly severely
should be considered for postmenopausal patients whose impaired in function; however, fortunately, the ovary was
ovarian function has severely reduced and whose adnexal preserved. We observed normal ovarian structures and
masses have a relatively high chance of malignancy. ovulation under ultrasonography during the follow-up
The guidelines of the Royal College of Obstetri- monitoring, indirectly proving the feasibility that even
cians and Gynecologists suggest that in premenopau- purplish-black ovaries should be preserved. Moreover,
sal women, adnexal masses > 7 cm in diameter have an we realized that based on the pathological findings, it was
increased risk of rupture and therefore require elective not difficult to guess that this young patient could have
surgical management [6]. Moreover, the mean diameter had a comorbid paraovarian cyst that had twisted after
of the adnexa (encapsulated mass) was 6.2 cm higher in activity, resulting in ovarian congestion, edema, and even
patients with AT than the mean diameter (4.2 cm) of the ischemic necrosis, but the ovary itself did not have any
adnexa (including the mass) in those without torsion lesion. The function of the twisted ovary could be pre-
[OR 95% CI 2.88 (1.15–7.21)]; hence, the diameter of the served if we performed reduction alone, but postopera-
adnexa (including the mass) being > 6 cm was considered tive clot absorption would increase the risk of fever or
the surgery threshold [6]. even infection, and the enlarged appendage would lead to
re-torsion. The follow-up results proved that this method
Concerns regarding preserved ovaries after ovarian torsion could increase the success of ovary preservation while
Most scholars view that the intraoperative finding of a partially retaining the function of the left ovary. In the lit-
darkened ovary means that it is necrotic, AT reduction erature, the overall incidence of recurrence of AT (rAT)
increases the incidence of thromboembolic events, and in female teens was reported to be low, approximately
surgical treatment is mostly performed by resection of 2–12% [8]. A study reported [12] that three risk factors
the affected adnexa, which has led to many unnecessary are associated with AT: enlarged adnexa, preservation of
adnexal resections. The reported incidence of pulmonary the ovaries in the previous surgery, and in vitro fertiliza-
embolism after AT was only 0.2%, and AT reduction did tion (IVF) treatment. Cohort studies have shown that the
not increase the incidence of thromboembolic events incidence of adnexal re-torsion without the combination
[7]. The intraoperative coloration of the ovaries under of these high-risk factors, with one, two, or three high-
the naked eye is also not a reliable basis for determin- risk factors, was 44.4, 67.9, 82.9, and 100%, respectively.
ing whether the ovary is necrotic [8, 9]. Several studies Women who are at high risk for these factors should be
have shown that an ovary that was found to be severely closely monitored, especially if they require IVF, and, if
ischemic during surgery can return to normal function necessary, laparoscopic exploration should be performed.
after reduction [10]. However, in clinical practice, when In our patient, the adnexal cyst was seen intraopera-
we see the black and purple appendages after torsion and tively to be a paraovarian cyst and was large enough to
the infundibulopelvic ligament is filled with a purplish cause overall torsion of the left adnexa, and the ovary was
blood clot, any doctor may find it difficult to reduce and edematous, congested, and even necrotic due to progres-
preserve the appendage. Although the risk of thrombosis sive ischemia. We did not see a solid mass during intra-
is very low, it will seriously endanger the lives of young operative dissection of the ovary; hence, we removed
women if it occurs. Further validation is required to see the left ovarian necrosis and clots, and a drainage tube
if the ovarian function is retained after preservation. was inserted into the pelvis, which reduced the probabil-
The only thing that can help determine the recovery of ity of postoperative infection and fever, reduced the size
the ovaries is their size and ovulation under ultrasound of the ovary, and reduced the likelihood of recurrence
monitoring—absent Doppler flow is a sign of ovarian of adnexal re-torsion. If the female teen had undergone
necrosis. Clinical correlation between ultrasonography early detection and treatment of the paraovarian cyst,
findings and the patient’s symptoms makes the diagnosis she might not have been in such a passive situation, with
He et al. BMC Women’s Health (2022) 22:421 Page 5 of 6

the left fallopian tube necrotic and severely twisted, lead- scientific knowledge should be imparted so that girls will
ing to its removal and the left ovarian function being not be embarrassed if they develop abdominal pain and
severely affected. Therefore, we recommend performing discomfort and will instead seek timely medical attention.
laparoscopic exploration in female teens who are found
to have adnexal cysts, if the adnexal diameter (including Possible surgical method of ovarian torsion
the mass) is > 6 cm, and persists for 3 months (excluding Regarding the choice of surgical approach in the consen-
physiological ones), or if it is accompanied by discom- sus, laparoscopic exploratory surgery was suggested to be
fort such as dull pain in the lower abdomen with adnexal used as the first choice. However, the ovary and cyst will
cysts persistence. Although the incidence is extremely increase dramatically after adnexal mass necrosis and
low, it indirectly suggests that paraovarian cysts should torsion. Often, the adnexal mass is about 20 cm in diam-
not be ignored. Periovarian cysts and surgery should be eter, and the thickening of the infundibulopelvic is often
recommended if there is intraoperative or imaging evi- accompanied by thrombosis, which might cause signifi-
dence of persistent and enlarged masses. cant difficulties for laparoscopic surgery. The surround-
The following reasons are summarized in the case of ing structures cannot be seen clearly, and it is easy to
our adolescent female teen who successfully preserved cause collateral damage. Whether laparoscopic surgery
her ovaries: (1) The time to torsion was about 72 h, and has absolute advantages over small-incision open sur-
we found that the AT was quickly treated surgically to gery needs to be examined, but laparoscopic surgery is
give adequate time for the recovery of the torsioned a good option if used only as an experimental procedure
adnexa. The longer the interval between the onset of AT to provide an opportunity for adnexal reduction. Even
and surgical treatment, the greater the likelihood of ovar- if adnexal masses with diameters > 10 cm have a higher
ian damage. Therefore, emergency surgical intervention chance of intraoperative spillage, this does not implicate
is required once AT is diagnosed. The time between the an a priori need for proceeding with open surgery, par-
disruption of the adnexal blood supply and irreversible ticularly when the risk of malignancy is low. The presence
ovarian damage is unclear; however, some studies have of ascites and the size of the lesion associated with a high
suggested that ovarian function may still be restored level of CA 125 affected the correct assessment of the
beyond 72 h of AT, but most believe that ovarian func- risk of malignancy, exposing the patient to overtreatment
tion begins to decline dramatically after 48–72 h [9]. [13]. Considering the confirmed advantage in operative
Early and rapid surgical intervention can better protect time and intraoperative blood loss [14], current evidence
ovarian function and fertility. (2) The patient was young suggests performing laparoscopic ovarian detorsion;
in good physical condition, had an abundant blood sup- although this procedure is acceptable, we must keep in
ply to the ovaries, and recovered quickly. (3) The patient’s mind that ischemia/reperfusion (I/R) injury can extend
family cooperated, and the patient received follow-up and worsen ischemic and necrotic damage [15].
and a second surgery, giving the surgeon confidence and Our patient underwent emergency surgery, and the
creating a chance to preserve the ovary successfully. (4) preoperative investigation of the adnexal mass revealed
We administered anti-inflammatory and anti-thrombotic that the size of the mass reached the level of the umbili-
treatment before and after the surgery to prevent infec- cus, the mass was huge, and the patient was considered
tion and thromboembolism. to have a true cyst present with an unknown multi-com-
Currently, there are no guidelines on the prevention of partment-like nature; hence, a longitudinal small-incision
AT for female teens in the expert AT consensus. For ado- open surgery was performed. However, in retrospect, it
lescent women who have had their menarche before aged may have been feasible if laparoscopic exploration had
< 20 years, parents and schools often neglect gynecologi- been performed at that time, the left fallopian tube was
cal examinations during routine physical examinations resected after reduction, and the left ovary was pre-
because they have not yet started becoming sexually served. Ovarian function can be observed after waiting
active, and because there are more activities and sports at 6–8 weeks to decide on the follow-up treatment.
this age. Cysts also grow gradually with age; hence, they
are often detected only when they are huge and affect Conclusions
patients’ lives or when they are found to have reached We experienced several cases of ovarian cyst torsion in
an acute stage such as torsion or rupture. The symp- adolescent women in the last year. After the reduction in
toms are also atypical and are easily missed and misdi- adolescents and children, the symptoms are not typical,
agnosed. Therefore, prevention is more important than and many patients are found to have purplish-black ova-
the treatment of children and female teens, and it is rec- ries. Some of these affected girls lose unilateral adnexa,
ommended to increase gynecological ultrasound screen- which is deplorable. Our attempt to preserve the ova-
ings every year. Moreover, physiological health-related ries in adolescents with delayed diagnosis of AT was
He et al. BMC Women’s Health (2022) 22:421 Page 6 of 6

successful in this case and further confirmed the validity 5. Gynecological Oncology (Group) Professional Committee of micro
noninvasive medicine professional committee of Chinese Medical
of the current consensus on AT in the United States and Association, Diagnosis and treatment branch of female reproductive tract
China. We hope that in future guidelines and consen- diseases of China eugenics Association. Chinese expert consensus on
sus improvement, scientific education on physiological the treatment of adnexal torsion (2020 Edition). J Pract Obstet Gynecol.
2020;36(11):822–6.
anatomy and physiological hygiene of adolescents can be 6. Management of Suspected Ovarian Masses in Premenopausal Women.
increased and the risk management-related issues such as 2011. https://​www.​rcog.​org.​uk/​globa​lasse​ts/​docum​ents/​guide​lines/​gtg_​
preventive measures and response to the onset of infec- 62.​pdf. Accessed: 11 Nov 2011.
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tion and thrombosis should be given attention during Variations in the management of adolescent adnexal torsion at a single
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8. Kives S, Gascon S, Dubuc E, Van Eyk N. No.341-diagnosis and manage‑
Abbreviations ment of adnexal torsion in children, adolescents, and adults. J Obstet
AFP: Alpha fetoprotein; AMH: Anti-Mullerian hormone; AT: Adnexal torsion; CA Gynaecol Can. 2017;39(2):82–90.
125: Carbohydrate antigen 125; CT: Computed tomography; D-D: D-Dimer; 9. Lu BC, Li YH, Wang LH, Huang Y, Wang Y. Clinical characteristics of ovarian
E2: Estrogen 2; FSH: Follicle-stimulating hormone; FIB: Fibrinogen; HGB: torsion and high-risk factor analysis for ovarian necrosis. Int J Clin Exp
Hemoglobin; LH: Luteinizing hormone; MRI: Magnetic resonance imaging; P: Med. 2018;11(10):11112–9.
Progestogen; PLT: Platelets; T: Testosterone; WBC: White blood cell. 10. Adeyemi-Fowode O, McCracken KA, Todd NJ. Adnexal torsion. J Pediatr
Adolesc Gynecol. 2018;31(4):333–8.
Acknowledgements 11. Carugno J, Naem A, Ibrahim C, Ehinger N, Moore J, Garzon S, et al. Is color
We are grateful to all the reviewers and editors who provided comments that Doppler ultrasonography reliable in diagnosing adnexal torsion? A large
substantially improved the manuscript. cohort analysis. Mini Invasiv Ther Allied Technol. 2022;31(5):620–7.
12. Meyer R, Meller N, Mohr-Sasson A, Abu-Bandora E, Cohen A, Tamir M,
Authors’ contributions et al. Prediction score for recurrent adnexal torsion in women with a
Conceptualization: H.Y., W.Y.; Project administration: H.Y., W.Y.; Resources: J.C., previous adnexal torsion. Int J Gynaecol Obstet. 2021;155(3):411–6.
S.X.C., Z.K.X.; Supervision: W.Y.M. and W.Y.; Writing-original draft: H.Y.; Writing - 13. Stabile G, Zinicola G, Romano F, Laganà AS, Pozzolo CD, Ricci G. Pelvic
review & editing: W.Y. All authors have read and approved the final manuscript, mass, ascites, hydrothorax: a malignant or benign condition? Meigs
and ensure that this is the case. syndrome with high levels of CA 125. Menopause Rev. 2021;20(2):103–7.
14. Casarin J, Laganà AS, Uccella S, Cromi A, Pinelli C, Gisone B, et al. Surgical
Funding treatment of large adnexal masses: a retrospective analysis of 330 con‑
Supported by Beijing Obstetrics and Gynecology Hospital, Capital Medical secutive cases. Minim Invasiv Ther. 2019;29(6):1365–2931.
University, Beijing Maternal and Child Health Care Hospital ‘Excellent Youth’ 15. Laganà AS, Sofo V, Salmeri FM, Palmara VI, Triolo O, Terzić MM, et al. Oxida‑
Plan Special Funds (No.YQRC201806). tive stress during ovarian torsion in pediatric and adolescent patients:
changing the perspective of the disease. Int J Ferti Ster. 2016;9(4):416–23.
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Ethics approval and consent to participate
Not applicable.

Consent for publication

We have written assent from the patient and the parents to publish the case.

Competing interests
No potential conflict of interest relevant to this article was reported.

Received: 5 April 2022 Accepted: 16 October 2022

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