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Rich BS, McCracken K, Nagel C, Allen L, Aldrink JH. The Shared Ovary: A Multidisciplinary Discussion With Pediatric and Adolescent Gynecology. J Pediatr Surg 2024; 59:1349-1354. [PMID: 38614951 DOI: 10.1016/j.jpedsurg.2024.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/04/2024] [Indexed: 04/15/2024]
Abstract
Pediatric and adolescent ovarian lesions are common and are frequently managed by both pediatric surgeons and pediatric and adolescent gynecologists. During the 2023 American Academy of Pediatric Section on Surgery meeting, an educational symposium was delivered focusing on various aspects of management of pediatric and adolescent benign and malignant masses, borderline lesions, and fertility options for children and adolescents undergoing cancer therapies. This article highlights the discussion during this symposium.
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Affiliation(s)
- Barrie S Rich
- Division of Pediatric Surgery, Northwell Health, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Kate McCracken
- Section of Pediatric and Adolescent Gynecology, Division of Gynecology, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Christa Nagel
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, The James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Lisa Allen
- Division of Pediatric Gynecology, Department of Obstetrics and Gynecology, Sick Kids Hospital, University of Toronto, Toronto, Canada
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
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Use and Accuracy of Intraoperative Frozen Section Analysis for Ovarian Masses in Children and Adolescents. J Pediatr Adolesc Gynecol 2023; 36:155-159. [PMID: 36209999 DOI: 10.1016/j.jpag.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/12/2022] [Accepted: 10/02/2022] [Indexed: 11/12/2022]
Abstract
STUDY OBJECTIVE Describe the current practice patterns and diagnostic accuracy of frozen section (FS) pathology for children and adolescents with ovarian masses DESIGN: Prospective cohort study from 2018 to 2021 SETTING: Eleven children's hospitals PARTICIPANTS: Females age 6-21 years undergoing surgical management of an ovarian mass INTERVENTIONS: Obtaining intraoperative FS pathology MAIN OUTCOME MEASURE: Diagnostic accuracy of FS pathology RESULTS: Of 691 patients who underwent surgical management of an ovarian mass, FS was performed in 27 (3.9%), of which 9 (33.3%) had a final malignant pathology. Among FS patients, 12 of 27 (44.4%) underwent ovary-sparing surgery, and 15 of 27 (55.5%) underwent oophorectomy with or without other procedures. FS results were disparate from final pathology in 7 of 27 (25.9%) cases. FS had a sensitivity of 44.4% and specificity of 94.4% for identifying malignancy, with a c-statistic of 0.69. Malignant diagnoses missed on FS included serous borderline tumor (n = 1), mucinous borderline tumor (n = 2), mucinous carcinoma (n = 1), and immature teratoma (n = 1). FS did not guide intervention in 10 of 27 (37.0%) patients: 9 with benign FS underwent oophorectomy, and 1 with malignant FS did not undergo oophorectomy. Of the 9 patients who underwent oophorectomy with benign FS, 5 (55.6%) had benign and 4 (44.4%) had malignant final pathology. CONCLUSIONS FSs are infrequently utilized for pediatric and adolescent ovarian masses and could be inaccurate for predicting malignancy and guiding operative decision-making. We recommend continued assessment and refinement of guidance before any standardization of use of FS to assist with intraoperative decision-making for surgical resection and staging in children and adolescents with ovarian masses.
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Wang H, Wang L, An S, Ma Q, Tu Y, Shang N, Pan Y. American college of radiology ovarian-adnexal reporting and data system ultrasound (O-RADS): Diagnostic performance and inter-reviewer agreement for ovarian masses in children. Front Pediatr 2023; 11:1091735. [PMID: 36969276 PMCID: PMC10030612 DOI: 10.3389/fped.2023.1091735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/20/2023] [Indexed: 03/29/2023] Open
Abstract
Objective To evaluate the diagnostic performance and inter-observer agreement of the American College of Radiology Ovarian-Adnexal Reporting and Data System Ultrasound (O-RADS) in the diagnosis of ovarian masses in children. Methods From June 2012 to December 2021, 163 ovarian masses in 159 patients with pathologic results were retrospectively analyzed. Each mass was classified into an O-RADS category according to the criteria. The diagnostic performance of O-RADS for detecting malignant ovarian masses was assessed using histopathology as the reference standard. Kappa (k) statistic was used to assess inter-observer agreement between a less-experienced and a well-experienced radiologist. Results Out of 163 ovarian masses, 18 (11.0%) were malignant and 145 (89.0%) were benign. The malignancy rates of O-RADS 5, O-RADS 4, and O-RADS 3 masses were 72.7%, 34.6%, and 4.8%, respectively. The area under the receiver operating characteristic curve was 0.944 (95% CI, 0.908-0.981). The optimal cutoff value for predicting malignant ovarian masses was > O-RADS 3 with a sensitivity, specificity, and accuracy of 94.4%, 86.2% and 86.2% respectively. The inter-observer agreement of the O-RADS category was good (k = 0.777). Conclusions O-RADS has a high diagnostic performance for children with ovarian masses. It provides an effective malignant risk classification for ovarian masses in children, which shows high consistency between radiologists with different levels of experience.
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Khaja A, Frazier L, Weil BR, Weldon CB, Laufer MR, Shim J. Interdisciplinary Management of Malignant Ovarian Tumors in the Pediatric and Adolescent Age Group. J Pediatr Adolesc Gynecol 2022; 35:260-264. [PMID: 34718078 DOI: 10.1016/j.jpag.2021.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/10/2021] [Accepted: 10/18/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Anam Khaja
- Division of Gynecology, Boston Children's Hospital, Boston, Massachusetts.
| | - Lindsay Frazier
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher B Weldon
- Department of Anesthesiology, Critical Care, and Pain Medicine, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc R Laufer
- Division of Gynecology, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Boston Children's Hospital, Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School. Boston, Massachusetts
| | - Jessica Shim
- Division of Gynecology, Boston Children's Hospital, Boston, Massachusetts; Division of Gynecology, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Watson L, Gavens E, Pachl M, Singh M, Soccorso G, McCarthy L, Arul GS. Controlled aspiration of large paediatric ovarian cystic tumours. J Pediatr Surg 2022; 57:711-714. [PMID: 34348845 DOI: 10.1016/j.jpedsurg.2021.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/18/2021] [Accepted: 06/29/2021] [Indexed: 01/27/2023]
Abstract
AIM Cystic ovarian masses in children may be physiological or neoplastic. It is mandatory that suspected neoplastic lesions are resected without tumour spillage. However, a large midline incision is cosmetically unappealing incision to young women. Here we describe our experience of using controlled drainage without spillage that allows a cosmetic pfannenstiel approach without compromising oncological principles. METHOD All girls treated with large ovarian cystic masses since 2008 in our centre were identified and data was collected prospectively. A small pfannenstiel incision was performed followed by peritoneal washings; tissue glue was used to stick an Opsite™ dressing to the cyst surface and fluid drained so there was no leakage back into the patient. Once aspirated the cyst was delivered and an ovarian preserving cystectomy was performed where possible. RESULTS Twenty-three girls (median age 14.5 years (8.1 to 16.5 years) were included. Pre-operative MRI scan showed a complex lesions with median volume of 1169 ml (range 252-7077 ml). At surgery 22/23 cysts were intact and removed without spillage. HISTOLOGY mature teratoma (11), serous cyst (3), mucinous cyst adenocarcinoma (2), mucinous cystadenoma (5), Sertoli-Leydig tumour, sclerosing stromal tumour. One girl with pre-operative rupture of a mucinous adenocarcinoma subsequently died. Ovarian sparing cystectomy was performed in 17/23 girls. All other patients are well without evidence of recurrence. CONCLUSION This is the largest series in children and adolescents using controlled drainage of cystic ovarian tumours. Though there were a range of diagnoses we have shown that these can be removed safely with a cosmetic pfannenstiel approach while following oncological principles.
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Affiliation(s)
- Lucy Watson
- Department of Paediatric Surgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, UK
| | - Elizabeth Gavens
- Department of Paediatric Surgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, UK
| | - Max Pachl
- Department of Paediatric Surgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, UK
| | - Mike Singh
- Department of Paediatric Surgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, UK
| | - Giampiero Soccorso
- Department of Paediatric Surgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, UK
| | - Liam McCarthy
- Department of Paediatric Surgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, UK
| | - G Suren Arul
- Department of Paediatric Surgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, UK.
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What Should Be the Topics of a Prospective Study on Ovarian Masses in Children?—Results of a Multicenter Retrospective Study and a Scoping Literature Review. Curr Oncol 2022; 29:1488-1500. [PMID: 35323325 PMCID: PMC8946882 DOI: 10.3390/curroncol29030125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/19/2022] [Accepted: 02/25/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose: to determine management problems of ovarian masses in girls in order to form a baseline for prospective randomized studies of the established topics and quality improvement of our management. Materials and Methods: We performed a national analysis of clinical aspects of ovarian masses in girls operated on in Poland, analyzed retrospectively medical files of all consecutive patients aged 0–18 who underwent surgeries for ovarian lesions between 2012 and 2017 at 17 pediatric surgical departments and complemented the analysis with a scoping review of a recent primary research related to ovarian masses in children. Results: The study group comprised 595 patients. Forty-four (7.39%) girls were diagnosed with malignant tumors. The overall preservation rate was 64.54%. The analysis revealed that positive tumor markers (OR = 10.3), lesions larger than 6 cm (OR = 4.17) and solid mass on ultrasound examination (OR = 5.34) are interdependent variables differentiating malignant tumors from non-malignant lesions (X42 = 79.1; p = 0.00000). Our scoping review revealed 10 major branches of research within the topic of ovarian masses in pediatric population. Conclusions: We have developed an overview of the field with the emphasis on the local environment. Our next step is a multi-institutional prospective study of a quality improvement project implementation based on the obtained knowledge.
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Xac MC, Jetelina KK, Jarin J, Wilson E. Benign, Borderline, and Malignant Pediatric Adnexal Masses: A 10-Year Review. J Pediatr Adolesc Gynecol 2021; 34:454-461. [PMID: 33453397 DOI: 10.1016/j.jpag.2021.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/30/2020] [Accepted: 01/01/2021] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE To investigate the incidence, clinical features, tumor markers, radiologic findings, types of surgeries, and histologies for adnexal masses in female pediatric and adolescent patients. DESIGN Retrospective chart review. SETTING Children's Health in Dallas and Plano, Texas from 2009 to 2018. PARTICIPANTS Female patients younger than 19 years old who underwent surgical management of an adnexal mass. INTERVENTIONS None. MAIN OUTCOME MEASURES Imaging characteristics, tumor markers, surgical procedures, and histopathology. RESULTS In total, 752 patients (mean age, 13.7 years) underwent 756 surgical procedures for 781 adnexal masses. Of these, 732/781 (93.7%) were benign, 7/781 (0.9%) were borderline, and 42/781 (5.4%) were malignant. Of all 781 masses, 520/781 (66.6%) were ovarian and 261/781 (33.4%) were paratubal or tubal. Benign masses were associated with Hispanic race, pain, simple or cystic characteristics on imaging, and negative tumor markers. Borderline and malignant masses were associated with white race, pain, mass or distension, larger size, and heterogeneous appearance on imaging. Borderline masses were associated with negative tumor markers. Malignant masses were associated with elevated alpha fetoprotein, beta human chorionic gonadotropin, cancer antigen 125, and lactate dehydrogenase. CONCLUSION Most adnexal masses in the pediatric and adolescent population are benign. Benign masses were significantly smaller, more likely to have negative tumor markers, and appear simple or cystic. There is little standardization with respect to preoperative tumor markers for adnexal masses. High-yield tumor markers for malignancy include alpha fetoprotein, beta human chorionic gonadotropin, cancer antigen 125, and lactate dehydrogenase. Low-yield tumor markers include inhibin A and B. Gynecologists performed more fertility-preserving surgeries including mini-laparotomies and fewer laparotomies for benign masses than pediatric surgeons.
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Affiliation(s)
- May C Xac
- University of Texas Southwestern Medical School, Dallas, Texas
| | - Katelyn K Jetelina
- Children's Health, Dallas, Plano, Texas; Department of Epidemiology, University of Texas Health Science Center, Human Genetics, and Environmental Sciences, Houston, Texas; Department of Data and Population Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jason Jarin
- Children's Health, Dallas, Plano, Texas; Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ellen Wilson
- Children's Health, Dallas, Plano, Texas; Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas.
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Billmire D, Dicken B, Rescorla F, Ross J, Piao J, Huang L, Krailo M, Pashankar F, Frazier L. Imaging Appearance of Nongerminoma Pediatric Ovarian Germ Cell Tumors Does Not Discriminate Benign from Malignant Histology. J Pediatr Adolesc Gynecol 2021; 34:383-386. [PMID: 33316416 PMCID: PMC8096645 DOI: 10.1016/j.jpag.2020.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 11/06/2020] [Accepted: 11/14/2020] [Indexed: 10/22/2022]
Abstract
STUDY OBJECTIVE Pediatric ovarian neoplasms with imaging appearance suggestive of teratoma are often presumed to have low risk of malignancy. We assessed the pre-operative imaging appearance of pediatric malignant ovarian germ cell tumors (MOGCT) and the presence of associated teratoma in a series of MOGCT. DESIGN Retrospective review of clinical and pathology data. SETTING Multicenter trial for extracranial malignant germ cell tumors in young female individuals by the Children's Oncology Group (COG study AGCT0132) that included yolk sac tumor, embryonal carcinoma and choriocarcinoma. PARTICIPANTS Female individuals 0-20 years of age at enrollment with ovarian primary nonseminomatous malignant germ cell tumors. INTERVENTIONS Review of data forms, including prospectively collected surgical checklist documenting imaging characteristics of the tumor, and review of pathology reports. MAIN OUTCOME MEASURES Description of imaging appearance and frequency of mixed histology with benign teratoma elements. RESULTS A total of 138 female individuals (11 months to 20 years of age) had primary ovarian tumors. Imaging appearance and pathology information were available for 133 patients. Among the 133 patients, tumor appearance was solid (10.5%), solid with calcification (3.0%), mixed cystic and solid (58.7%), mixed cystic and solid with calcification (24.8%), and unknown (3.0%). In all, 54% had elements of teratoma in addition to malignant histology. CONCLUSION Mixed cystic and solid appearance with or without calcification was seen in 83.5% of pediatric ovarian malignant germ cell tumors. Associated benign teratoma was common. The presence of a mixed cystic and solid appearance on preoperative imaging should not dissuade the surgeon from obtaining preoperative serum markers and undertaking complete surgical staging.
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Affiliation(s)
- Deborah Billmire
- Division of Pediatric Surgery, Indiana University, Indianapolis, Indiana.
| | - Bryan Dicken
- Division of Pediatric Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Frederick Rescorla
- Division of Pediatric Surgery, Indiana University, Indianapolis, Indiana
| | - Jonathan Ross
- Department of Urology, Rush University, Chicago, Illinois
| | - Jin Piao
- Children's Oncology Group, Monrovia, California
| | - Li Huang
- Children's Oncology Group, Monrovia, California
| | - Mark Krailo
- Department of Research Preventive Medicine, University of Southern California, Monrovia, California
| | - Farzana Pashankar
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Lindsay Frazier
- Department of Pediatrics, Harvard University, Dana Farber Cancer Institute, Boston, Massachusetts
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Farràs Roca L, Alshehri ED, Goldberg HR, Amirabadi A, Kives S, Allen L, Navarro OM, Lam CZ. Diagnostic Performance of a Sonographic Volume and Solid Vascular Tissue Score (VSVTS) for Preoperative Risk Assessment of Pediatric and Adolescent Adnexal Masses. J Pediatr Adolesc Gynecol 2021; 34:377-382. [PMID: 33271292 DOI: 10.1016/j.jpag.2020.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/16/2020] [Accepted: 11/19/2020] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVE To evaluate the diagnostic performance of a Volume and Solid Vascular Tissue Score (VSVTS) for preoperative risk assessment of pediatric and adolescent adnexal masses. DESIGN A retrospective cohort study comprised of all female individuals who presented with an adnexal mass that was managed surgically between April 2011 and March 2016. SETTING The Hospital for Sick Children (Toronto, Ontario, Canada). PARTICIPANTS Female individuals 1-18 years of age who presented to a large tertiary pediatric hospital with an adnexal mass that was managed surgically. MAIN OUTCOME MEASURES Main 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. RESULTS A 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). CONCLUSIONS A 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.
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Affiliation(s)
- Lara Farràs Roca
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Ebtehaj D Alshehri
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Hanna R Goldberg
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Afsaneh Amirabadi
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sari Kives
- Section of Gynecology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Ontario, Canada
| | - Lisa Allen
- Section of Gynecology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Ontario, Canada
| | - Oscar M Navarro
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Z Lam
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.
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Pecorelli S, Tonegatti UG, Stern MV, Bulotta AL, Laffranchi F, Stegher C, Odicino F, Alberti D. Management of Large Pediatric and Adolescent Ovarian Neoplasms with a Leak-Proof Extracorporeal Drainage Technique: Our Experience Using a Hybrid Minimally Invasive Approach. J Pediatr Adolesc Gynecol 2021; 34:394-399. [PMID: 32828966 DOI: 10.1016/j.jpag.2020.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 08/05/2020] [Accepted: 08/07/2020] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVE In 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. DESIGN Case series study, describing interventions and outcomes. SETTING Department of pediatric surgery in a tertiary pediatric and adult university hospital. PARTICIPANTS Pediatric patients affected by large cystic ovarian mass. INTERVENTIONS Hybrid minimally invasive approach using leak-proof extracorporeal drainage. MAIN OUTCOME MEASURES Data on demographic characteristics, tumor marker values, and imaging findings were collected and analyzed. Outcome of surgical technique was evaluated and reported. RESULTS Between 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%). CONCLUSION After 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.
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Affiliation(s)
- Silvia Pecorelli
- Department of Pediatric Surgery, "Spedali Civili" Children's Hospital, Brescia, Italy.
| | - Uca Giacomo Tonegatti
- Department of Pediatric Surgery, "Spedali Civili" Children's Hospital, Brescia, Italy
| | - Maria Vittoria Stern
- Department of Pediatric Surgery, "Spedali Civili" Children's Hospital, Brescia, Italy
| | - Anna Lavinia Bulotta
- Department of Pediatric Surgery, "Spedali Civili" Children's Hospital, Brescia, Italy
| | | | - Claudia Stegher
- Department of Obstetrics and Gynecology, ASST Spedali Civili Brescia, Brescia, Italy
| | - Franco Odicino
- Department of Obstetrics and Gynecology, ASST Spedali Civili Brescia, Brescia, Italy
| | - Daniele Alberti
- Department of Pediatric Surgery, "Spedali Civili" Children's Hospital, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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Lawrence AE, Minneci PC, Deans KJ. Ovarian Masses and Torsion: New Approaches for Ovarian Salvage. Adv Pediatr 2020; 67:113-121. [PMID: 32591055 DOI: 10.1016/j.yapd.2020.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Amy E Lawrence
- Department of Pediatric Surgery, Center for Surgical Outcomes Research, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Peter C Minneci
- Department of Pediatric Surgery, Center for Surgical Outcomes Research, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Katherine J Deans
- Department of Pediatric Surgery, Center for Surgical Outcomes Research, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
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Takayasu H, Masumoto K, Tanaka N, Aiyoshi T, Sasaki T, Ono K, Chiba F, Urita Y, Shinkai T. A clinical review of ovarian tumors in children and adolescents. Pediatr Surg Int 2020; 36:701-709. [PMID: 32346848 DOI: 10.1007/s00383-020-04660-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE To determine the features which predict torsion and the pre-operative indicators of malignancy in cases of ovarian torsion in ovarian tumors (OTs) in children. METHODS The medical records of 35 pediatric patients who underwent surgery for OT, except for neonate cases, from 1997 to 2018 at our institution were reviewed retrospectively. RESULTS The pathological diagnosis was mature teratoma in 17, immature teratoma in 9, yolk sac tumor in 3, and others in 6. The preoperative diagnosis, which was made based on the imaging findings and the serum tumor marker values, matched with the pathological diagnosis in 29/35 (83%). Ovarian torsion occurred in 14/35 (40%). All but one case that presented with torsion had intermittent abdominal pain as the primary symptom. The preoperative white blood cell count was significantly higher in cases where ovary preservation was impossible than where it was possible (p = 0.01) among the cases presenting with torsion. CONCLUSION Preoperative imaging findings and the serum tumor marker values enabled us to make an accurate preoperative diagnosis. Patients with intermittent abdominal primary symptoms were more likely to have ovarian torsion than those without such symptoms, and leukocytosis may indicate irreversible ischemic changes in the affected ovary.
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Affiliation(s)
- Hajime Takayasu
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Kouji Masumoto
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Nao Tanaka
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tsubasa Aiyoshi
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Takato Sasaki
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Kentaro Ono
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Fumiko Chiba
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yasuhisa Urita
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Toko Shinkai
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
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Lawrence AE, Fallat ME, Hewitt G, Hertweck P, Onwuka A, Afrazi A, Bence C, Burns RC, Corkum KS, Dillon PA, Ehrlich PF, Fraser JD, Gonzalez DO, Grabowski JE, Kabre R, Lal DR, Landman MP, Leys CM, Mak GZ, Overman RE, Rademacher BL, Raiji MT, Sato TT, Scannell M, Sujka JA, Wright T, Minneci PC, Deans KJ, Aldrink JH. Understanding the Value of Tumor Markers in Pediatric Ovarian Neoplasms. J Pediatr Surg 2020; 55:122-125. [PMID: 31677824 PMCID: PMC7181461 DOI: 10.1016/j.jpedsurg.2019.09.062] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 09/29/2019] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this study was to determine the diagnostic accuracy of tumor markers for malignancy in girls with ovarian neoplasms. METHODS A retrospective review of girls 2-21 years who presented for surgical management of an ovarian neoplasm across 10 children's hospitals between 2010 and 2016 was performed. Patients who had at least one concerning feature on imaging and had tumor marker testing were included in the study. Sensitivity, specificity, and negative and positive predictive values (PPV) of tumor markers were calculated. RESULTS Our cohort included 401 patients; 22.4% had a malignancy. Testing for tumor markers was inconsistent. AFP had high specificity (98%) and low sensitivity (42%) with a PPV of 86%. The sensitivity, specificity, and PPV of beta-hCG was 44%, 76%, and 32%, respectively. LDH had high sensitivity (95%) and Inhibin A and Inhibin B had high specificity (97% and 92%, respectively). CONCLUSIONS Tumor marker testing is helpful in preoperative risk stratification of ovarian neoplasms for malignancy. Given the variety of potential tumor types, no single marker provides enough reliability, and therefore a panel of tumor marker testing is recommended if there is concern for malignancy. Prospective studies may help further elucidate the predictive value of tumor markers in a pediatric ovarian neoplasm population. TYPE OF STUDY Retrospective Cohort Review. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Amy E. Lawrence
- Center for Surgical Outcomes Research, Nationwide Children’s Hospital, Columbus, OH,Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | - Mary E. Fallat
- Hiram C. Polk, Jr; M.D. Department of Surgery, Division of Pediatric Surgery, University of Louisville School of Medicine, Louisville, KY
| | - Geri Hewitt
- Department of Surgery, Division of Pediatric and Adolescent Gynecology, The Ohio State University, Nationwide Children’s Hospital, Columbus, OH
| | - Paige Hertweck
- Hiram C. Polk, Jr; M.D. Department of Surgery, Division of Pediatric Surgery, University of Louisville School of Medicine, Louisville, KY,Department of Obstetrics and Gynecology, Louisville University School of Medicine, Louisville, KY
| | - Amanda Onwuka
- Center for Surgical Outcomes Research, Nationwide Children’s Hospital, Columbus, OH
| | - Amin Afrazi
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Christina Bence
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Robert C. Burns
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Kristine S. Corkum
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Patrick A. Dillon
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Peter F. Ehrlich
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Jason D. Fraser
- Division of Pediatric Surgery, Department of Surgery, Children’s Mercy Hospital, Kansas City, MO
| | - Dani O. Gonzalez
- Center for Surgical Outcomes Research, Nationwide Children’s Hospital, Columbus, OH,Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | - Julia E. Grabowski
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Rashmi Kabre
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Dave R. Lal
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Matthew P. Landman
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Charles M. Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Grace Z. Mak
- Section of Pediatric Surgery, Department of Surgery, The University of Chicago Medicine and Biologic Sciences, Chicago, IL
| | - R. Elliott Overman
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Brooks L. Rademacher
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Manish T. Raiji
- Section of Pediatric Surgery, Department of Surgery, The University of Chicago Medicine and Biologic Sciences, Chicago, IL
| | - Thomas T. Sato
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Madeline Scannell
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Joseph A. Sujka
- Division of Pediatric Surgery, Department of Surgery, Children’s Mercy Hospital, Kansas City, MO
| | - Tiffany Wright
- Hiram C. Polk, Jr; M.D. Department of Surgery, Division of Pediatric Surgery, University of Louisville School of Medicine, Louisville, KY
| | - Peter C. Minneci
- Center for Surgical Outcomes Research, Nationwide Children’s Hospital, Columbus, OH,Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | - Katherine J. Deans
- Center for Surgical Outcomes Research, Nationwide Children’s Hospital, Columbus, OH,Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | - Jennifer H. Aldrink
- Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
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van Heerden J, Tjalma W. The multidisciplinary approach to ovarian tumours in children and adolescents. Eur J Obstet Gynecol Reprod Biol 2019; 243:103-110. [DOI: 10.1016/j.ejogrb.2019.10.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/02/2019] [Accepted: 10/17/2019] [Indexed: 01/30/2023]
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Goldberg HR, Kives S, Allen L, Navarro OM, Lam CZ. Preoperative Risk Stratification of Adnexal Masses in the Pediatric and Adolescent Population: Evaluating the Decision Tree System. J Pediatr Adolesc Gynecol 2019; 32:633-638. [PMID: 31330247 DOI: 10.1016/j.jpag.2019.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/27/2019] [Accepted: 07/15/2019] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVE To 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). DESIGN A retrospective cohort study of patients who presented with adnexal masses and were surgically treated between April 2011 and March 2016. SETTING The Hospital for Sick Children (Toronto, Ontario, Canada). PARTICIPANTS Patients 1-18 years of age with adnexal masses who underwent surgical treatment. INTERVENTIONS AND MAIN OUTCOME MEASURES Main 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. RESULTS The 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). CONCLUSION Our 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.
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Affiliation(s)
- Hanna R Goldberg
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sari Kives
- Section of Gynecology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Allen
- Section of Gynecology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Oscar M Navarro
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Z Lam
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.
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Abstract
Ovarian neoplasms are rare in children. Although usually asymptomatic, they sometimes present with abdominal pain, abdominal distension or palpable mass. The distribution of neoplasms in the pediatric population is different from in adults; benign mature cystic teratoma is the most common ovarian tumor in children. Radiologists should be familiar with the variable sonographic, CT and MRI findings of ovarian neoplasms. Although the less frequently encountered ovarian malignancies cannot be reliably distinguished by imaging alone, it does play an important role in workup. This review discusses the imaging and relevant clinical manifestations of the more commonly encountered pediatric ovarian neoplasms.
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Madenci AL, Vandewalle RJ, Dieffenbach BV, Laufer MR, Boyd TK, Voss SD, Frazier AL, Billmire DF, Rescorla FJ, Weil BR, Weldon CB. Multicenter pre-operative assessment of pediatric ovarian malignancy. J Pediatr Surg 2019; 54:1921-1925. [PMID: 30867096 DOI: 10.1016/j.jpedsurg.2019.02.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 02/13/2019] [Accepted: 02/17/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE The purpose of this study was to develop a pre-operative risk assessment tool for childhood and adolescent ovarian malignancy, in order to guide operative management of pediatric ovarian masses. METHODS We conducted a retrospective analysis of patients <18 years old who underwent ovarian surgery at two quaternary care pediatric centers over 4 years (1/1/13-12/31/16). Probability of malignancy was estimated based on imaging characteristics (simple cyst, heterogeneous, or solid), maximal diameter, and tumor markers (α-fetoprotein, β-human chorionic gonadotropin). RESULTS Among 188 children with ovarian masses, 11% had malignancies. For simple cysts, there were no malignancies (0/24, 95% CI = 0-17%). Among solid lesions, 44% (15/34, 95% CI = 28-62%) were malignant. Among marker-elevated heterogeneous masses, 40% (2/5, 95% CI = 12-77%) were malignant. Conversely, small (≤10 cm) and large (>10 cm) marker-negative heterogeneous lesions had malignancy proportions of 0% (0/39, 95% CI = 0-11%) and 5% (2/40, 95% CI = 1-18%), respectively. CONCLUSIONS Given the malignancy estimates identified from these multi-institutional data, we recommend an attempt at ovarian-sparing resection for simple cysts or tumor marker-negative heterogeneous lesions ≤10 cm. Oophorectomy is recommended for solid masses or heterogeneous lesions with elevated markers. Finally, large (>10 cm) heterogeneous masses with non-elevated markers warrant a careful discussion of ovarian-sparing techniques. Complete surgical staging is mandatory regardless of operative procedure. TYPE OF STUDY Study of Diagnostic Test. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Arin L Madenci
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer Center and Harvard Medical School, Boston, MA; Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
| | - Robert J Vandewalle
- Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Bryan V Dieffenbach
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer Center and Harvard Medical School, Boston, MA; Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Marc R Laufer
- Division of Gynecology, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Theonia K Boyd
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Stephan D Voss
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - A Lindsay Frazier
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer Center and Harvard Medical School, Boston, MA
| | - Deborah F Billmire
- Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Frederick J Rescorla
- Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer Center and Harvard Medical School, Boston, MA
| | - Christopher B Weldon
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer Center and Harvard Medical School, Boston, MA
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Management of Ovarian Tumors and Adnexal Torsion in Children; How to Save? JOURNAL OF CONTEMPORARY MEDICINE 2019. [DOI: 10.16899/jcm.577708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
PURPOSE OF REVIEW This review highlights progress in the management of pediatric ovarian neoplasms. Recent research has identified disparities in the management of patients with benign ovarian neoplasms based on a variety of factors. However, the long-term effects of unilateral oophorectomy have prompted an emphasis on ovary-sparing surgery (OSS) for benign masses. One of the challenges still facing providers is the preoperative differentiation between benign and malignant masses. RECENT FINDINGS Recent studies highlight the variability in practice patterns surrounding the management of benign ovarian neoplasms. Progress continues to be made in identifying reliable factors that can be used to inform preoperative risk stratification of patients who present with ovarian neoplasms. These factors include imaging characteristics, symptoms and tumor markers. In addition, the safety of OSS with regard to recurrence and upstaging in appropriate settings continues to be demonstrated. SUMMARY This review highlights the importance of multidisciplinary collaboration in the treatment of ovarian neoplasms given the varied surgical approach by specialty. Multiple retrospective studies have identified factors that can be used for preoperative risk stratification and selection of patients for OSS. Prospective studies evaluating the accuracy of these factors for preoperative risk stratification are needed.
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Ovarian masses in the child and adolescent: An American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee systematic review. J Pediatr Surg 2019; 54:369-377. [PMID: 30220452 DOI: 10.1016/j.jpedsurg.2018.08.058] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 08/13/2018] [Accepted: 08/29/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND The treatment of ovarian masses in pediatric patients should balance appropriate surgical management with the preservation of future reproductive capability. Preoperative estimation of malignant potential is essential to planning an optimal surgical strategy. METHODS The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee drafted three consensus-based questions regarding the evaluation and treatment of ovarian masses in pediatric patients. A search of PubMed, the Cochrane Library, and Web of Science was performed and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to identify articles for review. RESULTS Preoperative tumor markers, ultrasound malignancy indices, and the presence or absence of the ovarian crescent sign on imaging can help estimate malignant potential prior to surgical resection. Frozen section also plays a role in operative strategy. Surgical staging is useful for directing chemotherapy and for prognostication. Both unilateral oophorectomy and cystectomy have been used successfully for germ cell and borderline ovarian tumors, although cystectomy may be associated with higher rates of local recurrence. CONCLUSIONS Malignant potential of ovarian masses can be estimated preoperatively, and fertility-sparing techniques may be appropriate depending on the type of tumor. This review provides recommendations based on a critical evaluation of recent literature. TYPE OF STUDY Systematic review of level 1-4 studies. LEVEL OF EVIDENCE Level 1-4 (mainly 3-4).
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Depoers C, Martin FA, Nyangoh Timoh K, Morcet J, Proisy M, Henno S, Lavoue V, Arnaud AP. A Preoperative Scoring System for Adnexal Mass in Children and Adolescents to Preserve Their Future Fertility. J Pediatr Adolesc Gynecol 2019; 32:57-63. [PMID: 30205159 DOI: 10.1016/j.jpag.2018.08.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 08/28/2018] [Accepted: 08/30/2018] [Indexed: 12/17/2022]
Abstract
STUDY OBJECTIVE To develop a predictive score for ovarian malignancy to avoid unnecessary adnexectomy in cases of adnexal mass in pediatric and adolescent girls. DESIGN A population-based retrospective study on girls who underwent surgery for an ovarian mass with normal levels of human chorionic gonadotrophin and alpha fetoprotein between 1996 and 2016. SETTING Rennes University Hospital, Rennes, France. PARTICIPANTS Eighty-one patients who received surgery for ovarian tumor. MAIN OUTCOME MEASURES The main outcome measure was the rate of malignant and borderline tumor. A preoperative scoring system was constructed after multivariate analysis. RESULTS The rate of malignant ovarian tumor was 6/81 (7%), borderline tumor was 7/81 (9%) (ie, outcome measure: 16%), and benign tumor was 84%. In a univariate analysis, the characteristics significantly associated with malignancy were early puberty, palpable mass, size and content of the tumor, and positive epithelial tumor markers (carcinoma antigen 125, carcinoembryonic antigen, and carcinoma antigen 19-9). The predictive malignancy score was on the basis of 2 variables obtained after multivariate analysis: tumor size and cystic content. The score defined 3 groups at risk for malignancy: low risk, middle-risk, and high-risk. The sensitivity for detecting malignancy was 1.3% (95% confidence interval [CI], 0.1-18.4), 26.2% (95% CI, 11.6-49.0), and 53.1% (95% CI, 29.1-75.8), respectively. CONCLUSION We set up a simple predictive score of malignancy on the basis of objective criteria to help decision-making on whether or not ovarian-sparing surgery is feasible in case of children and adolescents with ovarian tumors and normal human chorionic gonadotrophin and alpha fetoprotein levels while ensuring oncologic safety.
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Affiliation(s)
| | - Flore-Anne Martin
- Service de gynécologie, Univ Rennes, CHU Rennes, Rennes, France; Service de chirurgie pédiatrique, Univ Rennes, CHU Rennes, Rennes, France
| | | | - Jeff Morcet
- Centre d'investigation clinique, Univ Rennes, CHU Rennes, INSERM, Rennes, France
| | - Maia Proisy
- Service de radiologie pédiatrique, Univ Rennes, CHU Rennes, Rennes, France
| | - Sebastien Henno
- Service d'anatomie pathologique, Univ Rennes, CHU Rennes, Rennes, France
| | - Vincent Lavoue
- Service de gynécologie, Univ Rennes, CHU Rennes, Inserm, Rennes, France
| | - Alexis Pierre Arnaud
- Service de chirurgie pédiatrique, Univ Rennes, CHU Rennes, Inra, Inserm, Institut NUMECAN - UMR_A 1341, UMR_S 1241, Rennes, France.
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Case series: Five pediatric germ cell/sex cord stroma tumors. Ann Med Surg (Lond) 2018; 37:11-20. [PMID: 30581564 PMCID: PMC6287085 DOI: 10.1016/j.amsu.2018.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/05/2018] [Accepted: 11/12/2018] [Indexed: 11/30/2022] Open
Abstract
This report consists of five pediatric tumors of ovarian cell lineage. These unusual, interesting tumors challenge both surgeon and oncologist. Some appear malignant, seemingly require chemotherapy, but behave with benignity. Some are easily resected; others demand the utmost skill. Complexity perplexes; elucidation is by selection – ignoring some things, attending to others. Case studies illustrate – for good or ill – the process whereby clinical conundrums are resolved.
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Ovarian conservation in management of pediatric gynecology malignancies. Curr Opin Obstet Gynecol 2018; 30:316-325. [DOI: 10.1097/gco.0000000000000484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Aldrink JH, Gonzalez DO, Sales SP, Deans KJ, Besner GE, Hewitt GD. Using quality improvement methodology to improve ovarian salvage for benign ovarian masses. J Pediatr Surg 2017; 53:S0022-3468(17)30638-3. [PMID: 29106919 DOI: 10.1016/j.jpedsurg.2017.10.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 10/05/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE Most ovarian masses in children are benign and potentially amenable to ovarian salvage surgery (OSS). Despite the common use of OSS among pediatric and adolescent gynecologists (PAG) in recognition of reproductive and hormonal health advantages, this technique is not commonly performed by pediatric surgeons. The aim of this quality improvement (QI) initiative was to improve our institutional rate of OSS for benign ovarian masses. METHODS Baseline data were obtained retrospectively from surgical procedures performed for benign ovarian masses between January 2012 and February 2016. Designed interventions to improve the rate of OSS included the development of an ovarian mass algorithm, standardization of radiologic templates, multidisciplinary analyses of ovarian procedures, and implementation of a training model for performing OSS. Procedures performed for benign ovarian masses from March 2016 to February 2017 comprised the process stage. RESULTS Our institutional baseline OSS rate was 28.8%. After implementation of the institutional algorithm, a single oophorectomy was performed for a benign mass, increasing the OSS rate to 96%. There have been no missed ovarian malignancies. CONCLUSIONS Utilizing preoperative risk assessment, QI methodology and multidisciplinary collaboration resulted in improved OSS rates for benign ovarian masses with no evidence of missed ovarian malignancies. LEVEL OF EVIDENCE Level II. This is a prospective comparative study, with comparison to a retrospective cohort. This is a quality improvement initiative without randomization.
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Affiliation(s)
- Jennifer H Aldrink
- Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH.
| | - Dani O Gonzalez
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH
| | - Stephen P Sales
- Department of Quality Improvement, Nationwide Children's Hospital, Columbus, OH
| | - Katherine J Deans
- Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH; Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH
| | - Gail E Besner
- Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Geri D Hewitt
- Department of Surgery, Division of Obstetrics and Gynecology, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
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Management of benign ovarian lesions in girls: a trend toward fewer oophorectomies. Curr Opin Obstet Gynecol 2017; 29:289-294. [DOI: 10.1097/gco.0000000000000400] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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