Outpatient minilaparotomy ovarian cystectomy for benign teratomas in teenagers

Benign, Borderline, and Malignant Pediatric Adnexal Masses: A 10-Year Review

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.

Postoperative Outcomes among Pediatric and Adolescent Patients Undergoing Minilaparotomy vs Laparoscopy in the Management of Adnexal Lesions

STUDY OBJECTIVE

To compare institutional experience in postoperative recovery in children and adolescents who undergo laparoscopy vs minilaparotomy in the management of benign adnexal cystic lesions.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care children's hospital.

PARTICIPANTS

Patients ages 6-21 years who underwent surgical management for benign adnexal lesions.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Comparison of surgery times, size of lesions, pain scores, and patient length of stay after minilaparotomy vs laparoscopy.

RESULTS

Forty-four patients were identified. Of those, 59% (n = 26) had a laparoscopic procedure and 41% (n = 18) underwent minilaparotomy. Patients who underwent minilaparotomy were more likely to have a larger adnexal mass than those in the laparoscopy group with a median size of 15.5 cm vs 6.0 cm, respectively (P < .001). Postoperative length of stay and recovery were comparable in both groups.

CONCLUSION

Minilaparotomy offers a minimally invasive option for the management of benign adnexal lesions in the pediatric and adolescent age group with recovery comparable to that of laparoscopy. The minilaparotomy approach should be considered when laparoscopy is limited.

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. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We used a retrospective chart review of patients ages 5-21 years who underwent surgical management by pediatric surgeons for benign adnexal indications at a tertiary care children's hospital. Patient characteristics and clinical outcomes were recorded. Rates of oophorectomy for patients managed before the addition of a gynecologist (1998-2004) were compared with those managed after a gynecologist joined the surgical staff (2005-2013). Logistic regression analysis was conducted to compare the likelihood of oophorectomy before and after the addition of a gynecologist to the surgical staff.

RESULTS

One hundred sixty-five cases were included in the final analysis. Pediatric surgeons were 8 times more likely to perform an oophorectomy for benign indications before the addition of a gynecologist to the surgical staff (odds ratio, 8.3; 95% confidence interval, 3.76-18.16). Oophorectomy was performed in 45% (25/56) of cases from 1998 to 2004 compared with 11% (12/109) of cases from 2005 to 2013. Younger age (P = .009), ischemic-appearing adnexa (P < .0001), presence of torsion (P = .017), and mature teratoma (P = .041) were associated with higher likelihood of oophorectomy.

CONCLUSION

There was a higher rate of ovarian preservation for benign indications performed by pediatric surgeons after the addition of a gynecologist to the surgical staff. Younger patients, those with a mature teratoma, and ovarian torsion continue to be at higher risk for oophorectomy.

Pediatric germ cell tumors

Pediatric germ cell tumors represent a diverse group of tumors that present from in utero through adolescence at many nongonadal locations, from the neck to the sacrococcygeal region. Surgical resection remains the central element of management, and accurate surgical staging is essential to properly ascertain the correct risk-based treatment. The management for all benign tumors (mature and immature teratomas) and select completely resectable malignant tumors is surgery alone. Modern-day chemotherapy is extremely effective in infants and children with unresectable and metastatic disease and these children have a very high survival rate. The use of neoadjuvant chemotherapy allows vital organ preservation and there is no role for resection of vital structures at the time of initial presentation.

Ovarian germ cell tumors in children. Management, survival and ovarian prognosis. A report of 75 cases

BACKGROUND/PURPOSE

The aims of this study were to evaluate survival and ovarian prognosis in patients treated for ovarian germ cell tumor (OGCT) and to propose a decision-making protocol.

METHODS

Charts of girls operated on for OGCT from 1976 up to 2009 were reviewed retrospectively. Tumor characteristics were assessed by tumor markers, imaging, and pathology.

RESULTS

Charts were available in 71 children presenting 75 OGCT. Tumors were benign in 58 cases and malignant in 17 cases. The average of the largest diameter of benign OGCT was significantly lower than that of malignant OGCT (76.5 +/- 49 mm versus 169 +/- 54 mm, P < .0001). Ovarian-sparing tumorectomy was carried out in 27 benign OGCT; 23 (85%) preserved ovaries were follicular. Malignant OGCTs were managed according to the protocols of the French Society for Pediatric Oncology. Bilateral oophorectomy had to be performed in 2 children. One patient presented a recurrence and 1 died.

CONCLUSIONS

In our series, both benign and malignant OGCTs have a good prognosis. A 75-mm cutoff size is proposed as an important criterion to preoperatively differentiate between benign and malignant tumors. In benign OGCT, ovarian-sparing tumorectomy leads to preserve ovaries in approximately 85% of cases, and in malignant OGCT, high survival rate has been obtained.

Spontaneous rupture of benign ovarian cystic teratoma in a premenarcheal girl

BACKGROUND

Spontaneous rupture of benign cystic ovarian teratoma is an unusual occurrence.

CASE

A 9-year-old girl presented with acute onset of abdominal pain. Under a radiological diagnosis of cystic ovarian teratoma, she underwent laparoscopic cystectomy, preserving as much ovarian tissue as possible. Direct observation of a defect on the tumor surface and the presence of keratinized squamous cells in the ascites were important clues for intraperitoneal rupture. Pathologically, the defect was surrounded by inflamed tissues adjacent to the gastric mucosa, suggesting that autolysis of the wall by proteolytic enzymes induced the spontaneous rupture.

SUMMARY AND CONCLUSION

We present the youngest and first premenarcheal case of spontaneous rupture of cystic ovarian teratoma. Early diagnosis and minimally invasive surgical procedure are essential to preserve future fertility.

Laparoscopic resection of benign ovarian tumours in children with gonadal preservation

PURPOSE

Ovarian tumours are often regarded as an indication for open oophorectomy, especially following torsion. We wish to report our results of laparoscopic ovarian cystectomy with ovarian preservation.

METHODS

Retrospective review of clinical records of patients who where managed with laparoscopic ovarian cystectomy with ovarian preservation.

RESULTS

Twelve records were identified over a 3-year period. The average age was 11.8 years (9-15). Presentation was of a mass in nine patients and torsion in three patients. Average size of the mass was 8.2 cm (5-18). Two patients had bilateral lesions. All patients were noted to have normal tumour markers. Successful cystectomy with ovarian preservation was accomplished in all cases using 3-port laparoscopy. The bilateral lesions were addressed at the same surgery with no increased length of stay or morbidity. In the three patients with acute torsion, an initial laparoscopic detorsion was performed with delayed laparoscopic cystectomy and ovarian preservation 7-10 days later. There was one complication of a minor umbilical port site infection. Histology was of a mature teratoma in ten cases and simple cyst in two. Six patients underwent routine ultrasonographic follow-up at 2-5 months at which time the involved ovary assumed a size and shape and blood flow comparable to the contra-lateral ovary in five patients. In one patient the affected side was smaller, 8.6 ml compared to 10 ml on the contra-lateral ovary. The remaining patients have been followed up clinically and remain asymptomatic.

CONCLUSION

Laparoscopic cystectomy with ovarian preservation can be successfully applied to benign ovarian tumours. Acute ovarian torsion is not a contraindication to this technique where a two stage procedure still enables us to offer ovarian preservation.

Ovarian germ cell tumors in children: a clinical study of 66 patients

BACKGROUND

Ovarian germ cell tumors are rare in childhood. The aim of this study is to review clinical presentation, management, and outcome in a two-center series of girls with ovarian germ cell tumor.

PROCEDURE

The records of 66 patients (median age 9 years) with histologically proven ovarian germ cell tumor (either benign or malignant), treated over a 44-year-span, were reviewed.

RESULTS

Pain and an abdominal mass were the most frequent symptoms. The tumors were right-sided in 35, left-sided in 28, and bilateral in 3. Most patients (52) were stage I, 4 were stage II, 6 stage III, and 1, with liver metastases, stage IV. Sixteen patients had an emergency operation for tumor torsion. Unilateral salpingo-oophorectomy was the most frequently performed procedure (n = 46), and ovarian-sparing tumorectomy was performed in 9 patients (one bilaterally). Histologically, teratomas were found most frequently (mature: 45, immature: 9), followed by mixed tumors (n = 7), yolk sac tumors (n = 3), dysgerminoma (n = 2), gonadoblastoma (n = 2), and embryonal carcinoma (n = 1). Surgical removal of the tumor with or without the ovary and/or adnex was the sole treatment in 55 patients, chemotherapy was administered in 10 and radiotherapy + chemotherapy in one. Intra-operative spillage of tumoral fluid occurred in six; this did not influence outcome in five. Recurrence was observed in three patients. Two patients, with malignant disease, died. The 64 survivors are now between 8 months and 44 years after treatment.

CONCLUSIONS

With a recurrence rate of 4.5% and a mortality rate of 3%, this series confirms the excellent prognosis for girls with ovarian germ cell tumor (GCT).

Outcome and staging evaluation in malignant germ cell tumors of the ovary in children and adolescents: an intergroup study

PURPOSE

The aim of this study was to perform an evaluation of outcome and the role of surgical staging components in malignant germ cell tumors (GCT) of the ovary in children and adolescents.

METHODS

From 1990 to 1996, 2 intergroup trials for malignant GCT were undertaken by Pediatric Oncology Group (POG) and Children's Cancer Study Group (CCG). Stage I-II patients were treated with surgical resection and 4 cycles of standard dose cisplatin (100 mg/m2/cycle), etoposide, and bleomycin (PEB) chemotherapy. Stage III-IV patients were treated with surgical resection and randomly assigned to chemotherapy with PEB or high-dose cisplatin (200 mg/m2/cycle) with etoposide and bleomycin (HDPEB). Patients unresectable at diagnosis had second-look operation after 4 cycles of chemotherapy if residual tumor was seen on imaging studies. IRB approval of the protocols was obtained at each participating institution. An analysis of outcome data, operative notes, and pathology reports in girls with ovarian primary site was done for this report.

RESULTS

There were 131 patients with ovarian primary tumors of 515 entered on these studies. Mean age was 11.9 years (range, 1.4 to 20 years). Six-year survival rate was stage, I 95.1%; stage II, 93.8%; stage III, 98.3%; stage IV, 93.3%. In only 3 of 131 patients were surgical guidelines followed completely. Surgical omissions resulting in protocol noncompliance resulted from failure to biopsy bilateral nodes (97%), no omentectomy (36%), no peritoneal cytology (21%), no contralateral ovary biopsy (59%). More aggressive procedure than recommended by guidelines included total hysterectomy and bilateral salpingo-oophorectomy in 6 patients and retroperitoneal node dissection in 10 patients. Correlation of gross operative findings with pathology results was carried out for ascites, lymph nodes, implants, omentum, and contralateral ovary.

CONCLUSIONS

Pediatric ovarian malignant GCT (stages I-IV) have excellent survival with conservative surgical resection and platinum-based chemotherapy. Survival appears to have been unaffected by deviations from surgical guidelines. New surgical guidelines are proposed based on correlation of gross findings, histology, and outcome in these intergroup trials.

Managing mature cystic teratomas of the ovary

Mature cystic teratomas (MCT), commonly called dermoid cysts, are the most common benign germ cell tumors of the ovary in women of reproductive age. Future fertility is of major concern among these women; therefore, the surgical management must focus on preserving ovarian tissue and minimizing adhesion formation. Patients requiring surgery should be appropriately counseled about the risks and benefits of laparoscopy and laparotomy, the risks of intraoperative MCT spillage and adhesion formation. In addition, the risks of recurrence and malignant transformation should be discussed. The parents of children with MCTs have the same concerns as older women and a similar discussion should take place. The goal of this article is to review these issues and provide the physician with the information to counsel their patients preoperatively.