Evolution in the Management of Pediatric and Adolescent Ovarian Torsion as a Result of Quality Improvement Measures

Study Objective

The aim of this study was to document the change in ovarian conservation rate after ovarian torsion as a result of continuous quality improvement (CQI) measures, and to determine factors that contribute to this outcome.

Management of Large Ovarian Neoplasms in Pediatric and Adolescent Females

The overwhelming majority of ovarian cysts in pediatric and adolescent girls are physiologic; however, large simple and complex ovarian lesions often require surgical intervention due to the increased risk of neoplasia. In this review article, we discuss the preoperative evaluation and intraoperative management of large ovarian neoplasms. We review the current literature regarding long term ovarian function and fertility, rates of recurrence and residual disease, and novel surgical approaches. Managing large ovarian neoplasms in the pediatric and adolescent population requires careful preoperative and intraoperative care to optimally resect neoplasia while maximizing fertility and minimizing pain.     

Rate of Oophorectomy for Benign Indications in a Children's Hospital: Influence of a Gynecologist

Study Objective

To compare the rates of oophorectomy performed by pediatric surgeons for benign indications before and after the addition of a gynecologist to the surgical staff of a children's hospital.

Management of Large Pediatric and Adolescent Ovarian Neoplasms with a Leak-Proof Extracorporeal Drainage Technique: Our Experience Using a Hybrid Minimally Invasive Approach

Study ObjectiveIn a pediatric setting, laparoscopic management of large cystic ovarian neoplasms with low malignancy probability is not suitable, because of the mass size; nevertheless, an effort should be made to be as minimally invasive as possible, without violating the principles of oncologic surgery. We describe our experience in managing these neoplasms with leak-proof extracorporeal drainage through mini laparotomy, followed by cyst excision or oophorectomy.DesignCase series study, describing interventions and outcomes.SettingDepartment of pediatric surgery in a tertiary pediatric and adult university hospital.ParticipantsPediatric patients affected by large cystic ovarian mass.InterventionsHybrid minimally invasive approach using leak-proof extracorporeal drainage.Main Outcome MeasuresData on demographic characteristics, tumor marker values, and imaging findings were collected and analyzed. Outcome of surgical technique was evaluated and reported.ResultsBetween 2011 and 2018, 17 patients (mean age, 10.2 years; range, 2-14 years) affected by large cystic ovarian mass, were eligible for this technique. All patients had negative preoperative tumor markers. Of the seventeen subjects, 13/17 girls (76%) underwent pelvic magnetic resonance imaging. No sign of lymphadenopathy or metastasis was found. Surgery was successful in all patients, with ovarian preservation in 5/17 cases (29.4%). Mean surgical time was 98 minutes; no intra-abdominal leakage of neoplasm content or postoperative complications occurred. Mature cystic teratoma was the most frequent histopathological diagnosis (71%).ConclusionAfter a thorough patient selection, the management of large cystic ovarian neoplasms with leak-proof extracorporeal drainage performed through a mini laparotomy is a feasible and safe approach, with excellent cosmetic results. When achievable, ovarian-sparing surgery has to be considered.     

Preoperative Risk Stratification of Adnexal Masses in the Pediatric and Adolescent Population: Evaluating the Decision Tree System

Study ObjectiveTo evaluate the diagnostic performance of the Decision Tree System (DTS) rules 2 and 3 for surgically managed adnexal masses in the North American population and to compare it with the risk stratification criteria used at The Hospital for Sick Children (≥8 cm and complex/solid).DesignA retrospective cohort study of patients who presented with adnexal masses and were surgically treated between April 2011 and March 2016.SettingThe Hospital for Sick Children (Toronto, Ontario, Canada).ParticipantsPatients 1-18 years of age with adnexal masses who underwent surgical treatment.Interventions and Main Outcome MeasuresMain outcome measures included diagnostic performance (preoperative sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV] for malignancy) of the DTS rules 2 and 3 and ≥8 cm and complex/solid criteria.ResultsThe malignancy rate was 10.4%. The DTS rules 2 and 3 had a sensitivity of 84% (95% confidence interval [CI], 79-90), specificity of 77% (95% CI, 71-83), PPV of 30% (95% CI, 17-42), and NPV of 98% (95% CI, 94-100). The 8 cm or larger and complex/solid criteria had a sensitivity of 89% (95% CI, 85-94), specificity of 71% (95% CI, 64-77), PPV of 27% (95% CI, 16-38), and NPV of 98% (95% CI, 96-100).ConclusionOur study showed that DTS rules 2 and 3 had similar diagnostic performance as the 8 cm or larger and complex/solid criteria in the same population, with a very high NPV and a low PPV. Future prospective investigations should be conducted to further assess how DTS components can be incorporated into future algorithms for the management of adnexal masses in the pediatric population.     

The Recurrence Rate of Ovarian Dermoid Cysts in Pediatric and Adolescent Girls

Study ObjectiveTo assess the rate of recurrence of ovarian dermoid cysts in pediatric and adolescent girls at the Hospital for Sick Children.DesignA retrospective chart review of all dermoid cysts surgically managed at the hospital for Sick Children from January 2003 to June 2012.SettingThe Hospital for Sick Children, Toronto, Canada.Participants66 adolescent and pediatric patients <18 years old treated with ovarian cystectomy of their dermoid cysts by either laparoscopy (n = 40) or laparotomy (n = 26).Main Outcome MeasuresTotal dermoid cyst recurrence, recurrence after laparoscopy versus laparotomy, follow-up imaging completed and ultrasonographic identification of other ovarian cysts in follow-up. Data was assessed with Fisher exact test where appropriate (P < .05).ResultsThe mean age of patients at time of surgery was 12.9 years (range 2.5-18.1). 25/66 (38%) of patients received no follow-up, 6/66 (9%) were followed by a single ultrasonography and 35/66 (53%) were followed with annual ultrasonography for up to 5 years. 35 patients completed their initial ultrasonography where 19/35 (54%) patients had new ovarian cysts diagnosed including: 6 functional/hemorrhagic, 3 dermoid, and 10 unspecified cysts. All new dermoids were suspected at first follow-up ultrasonography (6/35), but 3 required a second follow-up ultrasonography for confirmation. Overall, 7/66 (11%) patients had recurrent or persistent dermoid cysts of which 2 (3%) required repeat surgery. There was no significant impact on the type of surgery and dermoid recurrence.ConclusionThe incidence of recurrent dermoid cysts in a pediatric and adolescent population following ovarian cystectomy is 10.6% where only 3% will recur and require further surgical management.     

Diagnostic Performance of a Sonographic Volume and Solid Vascular Tissue Score (VSVTS) for Preoperative Risk Assessment of Pediatric and Adolescent Adnexal Masses

Study ObjectiveTo evaluate the diagnostic performance of a Volume and Solid Vascular Tissue Score (VSVTS) for preoperative risk assessment of pediatric and adolescent adnexal masses.DesignA retrospective cohort study comprised of all female individuals who presented with an adnexal mass that was managed surgically between April 2011 and March 2016.SettingThe Hospital for Sick Children (Toronto, Ontario, Canada).ParticipantsFemale individuals 1–18 years of age who presented to a large tertiary pediatric hospital with an adnexal mass that was managed surgically.Main Outcome MeasuresMain outcome measures included diagnostic performance of the VSVTS for malignancy via sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), negative likelihood ratio (LR?), and receiver operating characteristic area-under-the-curve (AUC) analysis.ResultsA total of 179 masses in 169 subjects were included. The malignancy rate was 10.6%. The AUC for the VSTVS was 0.919. A VSTVS cut-off value of 4 achieved a sensitivity of 79% (95% CI 0.54-0.93), specificity of 88% (95% CI 0.82-0.93), PPV of 0.44 (95% CI 0.33-0.56), NPV of 0.97 (95% CI 0.94-0.99), LR+ of 6.77 (95% CI 4.18-10.97), and LR? of 0.24 (95% CI 0.10-0.57).ConclusionsA sonographic scoring system based on the volume and presence of solid vascular tissue improves PPV for preoperative risk stratification of adnexal masses in the pediatric and adolescent population compared to existing ultrasound-only approaches. Further prospective research is needed to determine how best to incorporate components of such scoring systems into clinical management algorithms.     

青少年卵巢肿瘤的临床病理分析

目的:探讨青少年卵巢肿瘤的临床病理特点。方法:回顾性分析67例20岁以下的青少年卵巢肿瘤患者的临床表现、诊断、病理和治疗。结果:临床症状以腹痛、腹部包块为主,肿瘤扭转率高。良性肿瘤41例,交界性3例,恶性23例;组织学类型以生殖细胞肿瘤最多。恶性肿瘤中65.2%为FIGOI期。除8例恶性患者进行了肿瘤细胞减灭术外,其余59例均进行了保留生育功能的手术。15例恶性肿瘤患者术后化疗。单因素分析显示仅化疗方案影响生存期,BEP优于VAC。结论:青少年卵巢肿瘤的临床病理特点与成人不同,首选保留生育功能的手术,BEP是恶性患者的一线化疗方案。     

Pediatric Ovarian Torsion and its Recurrence: A Multicenter Study

Study Objective

To report results of a retrospective multicentric Italian survey concerning the management of pediatric ovarian torsion (OT) and its recurrence.

Ovarian Tissue Collection for Cryopreservation in Pediatric Age: Laparoscopic Technical Tips

As the number of young girls subjected to chemo and radiotherapy is steadily increasing it is our duty to try to preserve their future fertility and ovarian function. A possibility is to collect ovarian samples, cryopreserve them and reimplant the tissue when the treatments are over. We report our 11 year experience with the use of laparoscopy to collect ovarian tissue samples. In particular we focus on the details of the surgical technique. The procedure was performed in 54 patients affected by malignancies or pathologies requiring chemo or radiotherapy, with good results. Cryopreservation seems to be a good option to preserve future fertility although it is still an experimental method.     

Laparoendoscopic Single-Site Ovarian Cystectomy and Concomitant Appendectomy in an Adolescent

BackgroundLaparoendoscopic single-site surgery (LESS) is emerging as an alternative technique to conventional laparoscopy for the treatment of common surgical diseases.CaseWe report a case of a 13-year-old female with self-limited abdominal pain. Imaging studies showed a right ovarian mass with features of a dermoid cyst and an appendicolith within the appendix without signs of acute appendicitis. She underwent concomitant LESS ovarian cystectomy and appendectomy without any complications.Summary and ConclusionLESS is feasible with standard laparoscopic instruments. It is a safe technique with excellent cosmetic results and minimal postoperative pain.     

Ovarian Torsion in an Adolescent with Beckwith-Wiedemann Syndrome and Unilateral Tubo-ovarian Hyperplasia

BackgroundBeckwith-Wiedemann syndrome (BWS) is the most common pediatric overgrowth syndrome. BWS has a broad phenotypic presentation along with an increased propensity to develop various embryonal tumors. There are very few reported cases of gonadal hyperplasia in BWS patients in the existing literature.CaseWe describe a 13-year-old girl with BWS who presented with an episode of abdominal pain and was found to have torsion and necrosis of a markedly hyperplastic right ovary and fallopian tube. We present a brief literature review on ovarian hyperplasia in BWS patients for which we used an online search of the databases PubMed, Embase, Ovid Medline, and Cochrane.Results and ConclusionThrough an extensive literature search, we only found 3 previous reports of ovarian hyperplasia in BWS patients, all in postmortem specimens. Our case highlights a potentially important aspect of visceral organ hyperplasia in patients with BWS that could remain indolent until adolescence and might present as an abrupt-onset abdominopelvic catastrophe.     

153例月经正常女性卵巢超声测量值分析

目的:研究月经正常的育龄女性其卵巢体积和卵泡数目的超声测量值的范围。方法:153例研究对象按年龄分为3组(第1组13～20岁,第2组21～30岁,第3组31～40岁),于月经周期早卵泡期进行经直肠或阴道B超检查并记录分析其卵巢体积和卵泡数目。结果:平均卵巢体积4.94±2.32cm3,80%的卵巢体积在2.47～7.75cm3;单侧卵巢卵泡数目的中位数为6个,80%的单侧卵泡数目在3～10个;双侧卵巢总卵泡数目的中位数为13个,80%的总卵泡数目在7～20个。卵巢体积在21～30岁组与31～40岁组之间差异有高度统计学意义(P<0.01);卵泡数目在31～40岁组与另外两组之间差异均有统计学意义(P<0.05)。相关分析显示卵泡数目与年龄呈负相关(r=-0.25,P<0.01)。结论:检测的13～40岁月经正常的女性平均卵巢体积、平均卵泡数目的正常值,能为相关疾病的诊治提供参考。     

卵巢囊肿与多囊卵巢皮质中卵泡密度分析及其冷冻保存

目的:探索来自卵巢囊肿及多囊卵巢综合征(polycystic ovary syndrome,PCOS)卵巢皮质中卵泡的分布特征,并观察冷冻对卵巢组织形态学的影响。方法:收集23例卵巢囊肿(卵巢囊肿组)及8例PCOS(PCOS组)的卵巢皮质,分析卵巢皮质中的卵泡密度;同时冷冻部分组织,观察冷冻前后各级卵泡的分布及形态学改变。结果:PCOS组中的卵泡密度明显高于卵巢囊肿组,但各卵泡囊肿组间的卵泡密度差异无显著性。冷冻后各组中卵泡分布以及形态正常的始基与初级卵泡比例,与冷冻前比较差异无显著性;而冷冻前后PCOS组织中初级卵泡比例显著高于卵巢囊肿组,形态正常的始基卵泡比例明显低于卵巢囊肿组。结论:卵巢囊肿与PCOS患者的卵巢皮质可作为人卵巢组织冷冻保存的标本来源。     

青少年卵巢混合性生殖细胞肿瘤一例并文献复习

卵巢恶性生殖细胞肿瘤（malignant ovarian germ cell tumor,MOGCT）来源于胚胎原始生殖细胞,好发于儿童、青少年和年轻女性,多涉及保留生育功能问题。报告1例15岁的卵巢混合性生殖细胞肿瘤病例,患者运动后突发左下腹痛,经腹彩色超声示盆腔中低回声包块,经腹腔镜探查术发现左侧卵巢巨大肿物破裂,引起腹腔内大出血。行左侧附件切除术,术后查血清甲胎蛋白（alpha fetoprotein,AFP）、糖类抗原19-9(carbohydrate antigen 19-9,CA19-9)和人绒毛膜促性腺激素（human chorionic gonadotropin,hCG）升高。病理结果示混合性生殖细胞肿瘤,以胚胎癌为主,可见绒毛膜癌成分及少许卵黄囊瘤、畸胎瘤成分。术后第11天正电子发射体层成像（positron emission tomography,PET）/CT显示无残留病灶,行平阳霉素+依托泊苷+顺铂（BEP）方案化疗4个周期,AFP、h CG于第2个周期后降至正常。至2022年2月患者月经恢复,随访至2022年5月无复发迹象。     

The Relationship between Intraoperative Rupture and Recurrence of Pediatric Ovarian Neoplasms: Preliminary Observations

Study ObjectiveWe investigated whether rupture increased the recurrence rate of pediatric ovarian neoplasms.Design20-year single-institution retrospective study.SettingTertiary, free-standing, university children's hospital.ParticipantsAll girls with ovarian neoplasms treated during between 1991 and 2011.Main Outcome MeasureTumor recurrence.ResultsFifty-nine tumors in 53 patients were managed, including 51/59 (86%) benign and 8/59 (14%) malignant. Laparotomy was employed in 44/59 (75%), laparoscopy in 8/59 (14%), and laparoscopy converted to laparotomy in 7/59 (12%). Total and partial oophorectomy (cystectomy) was used for 15/51 (29%) and 36/51 (71%) of benign tumors, respectively. All malignant tumors underwent total oophorectomy. Accidental rupture or intentional tumor puncture occurred in 26/56 cases (46%), 23/51 benign and 3/5 malignant. Rupture was associated with increasing cyst size on univariate and multivariate analyses (p = 0.002 and p = 0.004, respectively). There were 5 recurrences (9%) in 4 patients, including 4 benign (3 mature teratomas, 1 mucinous cystadenoma), and 1 malignant yolk sac tumor. Recurrence occurred in 2/30 (7%) without rupture and 3/26 (12%) with rupture, p = 0.66. Follow-up was available for 50/53 patients (94%), with a median of 23.8 months [range 0.2-189 months]. All recurrences were salvaged by surgery.ConclusionsIn this limited study, intra-operative rupture did not increase the recurrence rate or worsen the prognosis of pediatric ovarian neoplasms.     

Interdisciplinary Management of Malignant Ovarian Tumors in the Pediatric and Adolescent Age Group

Malignant ovarian neoplasms are uncommon in the pediatric and adolescent population. Imaging and tumor markers help to guide the preoperative risk/benefit analysis for planned surgical management, which is the mainstay of therapy. An interdisciplinary approach should be taken in the management of this vulnerable population from diagnosis through post-treatment surveillance. In this review, the initial evaluation, risk stratification, and management of various types of malignant ovarian masses will be addressed, with a special focus on how to optimize an interdisciplinary approach to ovarian masses.