Ovarian tumors in children and adolescents: a series of 41 cases

The Shared Ovary: A Multidisciplinary Discussion With Pediatric and Adolescent Gynecology

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.

Aetiology and diagnostic utility of serum ascites albumin gradient in children with ascites

BACKGROUND

Ascites in children is multifactorial and serum ascites albumin gradient (SAAG) ≥1.1 helps differentiate portal hypertension (PHTN) related from non-PHTN ascites.

AIMS

We evaluated the aetiology and diagnostic accuracy of SAAG in children with ascites.

METHODS

Children with ascites were retrospectively evaluated. Etiological diagnosis was based on clinical presentation and investigations. All cases with ascitic fluid analysis and a definite diagnosis were included for calculating the utility of SAAG.

RESULTS

We enrolled 878 children (568[64.7%] boys). Majority were PHTN related (638[72.7%]) and secondary to acute viral hepatitis (98,15.4%), acute liver failure (185,29%), chronic liver disease (276,43.3%) and Budd-Chiari syndrome (79,12.4%). Other causes included tubercular (46,5.2%), pancreatic (32,3.6%), chylous (20,2.3%), biliary (12,1.4%), pseudoascites (16,1.8%), infections (46,5.2%), nephrotic (26,2.9%), malignancy (23,2.6%), cardiac (9,1.0%) and others (10,1%). SAAG (n = 305) correctly differentiated PHTN and non-PHTN ascites in 272 (89.2%) cases, with a high sensitivity (97%), specificity (93%) and diagnostic accuracy (95.8%). Reasons for inaccurate SAAG included mixed ascites (n = 9), different day serum and ascitic fluid albumin estimation (n = 5), serum albumin ≤1.1 g/dL (n = 2), chylous ascites (n = 3), hypergammaglobulinemia (n = 1), albumin infusions (n = 1) and unexplained (n = 12).

CONCLUSIONS

Nearly 27% children had non-PHTN related ascites. SAAG differentiates PHTN from non-PHTN ascites with a diagnostic accuracy of 95%.

Mature cystic teratoma overlapping with giant serous cystadenoma of the ovary: A case report

Ovarian lesions represent a diagnostic challenge for the radiologist and should be approached according to the patient's age, menstrual cycle, and imaging characteristics. These lesions can be cystic, mixed, or solid-predominant structures. Generally, the occurrence of benign lesions surpasses that of malignant ones at a ratio of 3:1. However, within infantile and juvenile age groups, this becomes an infrequent occurrence, making up only about 5% of ovarian tumor cases. This case report sheds light on a unique scenario involving a pediatric patient who harbored 2 benign tumors simultaneously: a mature cystic teratoma and a serous cystadenoma.

Pediatric, adolescent, and young adult breast and reproductive tumors

Tumors of the breast and reproductive organs that occur in children, adolescents, and young adults (AYA) have different biological features and can present special challenges. Although prognosis for these tumors is generally favorable, the long-term effects of treatment can be debilitating. Treatments are often multimodal and may include surgery as well as chemotherapy and/or radiation, which can cause considerable distress and anxiety related to loss of femininity or masculinity, concern over future fertility, or sexual dysfunction. Thus, tumors of the reproductive organs in pediatric/AYA patients require special consideration of the treatment effects beyond the intended oncologic outcome. Multidisciplinary teams should be involved in their care and address issues of fertility, sexual dysfunction, and psychosexual concerns before treatment begins. This review addresses histology, risk factors, prognosis, staging and treatment of gynecologic, breast and testicular cancers in pediatric and AYA patients.

Ovarian neoplasia in adolescence: a retrospective chart review of girls with neoplastic ovarian tumors in Saudi Arabia

Background

Ovarian neoplasia in children and adolescents is a rare tumor. The diagnosis and management of such tumors is often difficult and delayed due to non-specific symptoms and low suspicion. Surgical management that preserves fertility and ovarian function should be the goal.

Objective

This study aimed to review the clinical presentation, tumor characteristics, and management of Saudi Arabian adolescents.

Methods

A retrospective chart review was conducted on adolescent girls aged 19 or less admitted to tow referral hospital in Riyadh, Saudi Arabia, diagnosed with adnexal mass over an 8 years’ period; patients who were older than 19 were excluded.

The data collected from patients’ charts included age, presenting symptoms, radiologic findings, type of surgery, specialist who performed the surgery, and histopathology of the tumors.

We classified patients according to age using the three WHO developmental stages: early adolescence (10–13 years old), middle adolescence (14–16 years old), and late adolescence (16–17 years old).

The statistical study used SPSS version 18.0 to determine the data’s frequency, distributions, and means (SPSS Inc., Chicago, IL).

Results

We analyzed 164 patients, between 10 and 19 years old, admitted to two hospitals between 2009 and 2017. We found that 85% of these patients underwent surgery for adnexal mass removal, and 90.2% were symptomatic or emergency cases. The majority of our patients were post-menarche (96.95%), and were between the ages of 14 and 19. The most common surgical procedure for tumor removal was laparoscopic cystectomy (74.4%).

An adnexal mass with a solid component on ultrasound is the most commonly found indicator of malignancy. The majority of tumors were benign (32.3%). Germ cell tumors were the most common (68.7%) malignant tumor, and yolk sac tumors were the most common subgroup of germ cell tumors. When managed by a gynecologist, surgical intervention can be a successful method of preserving fertility.

Conclusions

Our results confirm that the majority of neoplastic ovarian tumors in children and adolescents are benign, and surgical intervention can be used to maintain fertility, especially when managed by a gynecologist. This is one of the largest reported series and the first from our area.

Ultrasonographic diagnosis and surgical outcomes of adnexal masses in children and adolescents

This study aimed to evaluate the incidence, clinical diagnosis, surgical treatment, and histopathological findings of adnexal masses in children and adolescents. This retrospective study included patients aged < 20 years who were diagnosed with adnexal masses between January 2005 and December 2018 at the Konkuk University Medical Center. Adnexal masses were diagnosed in 406 patients. The mean age of patients was 17.3 years at the time of diagnosis. The primary presenting symptoms and signs were abdominal pain (81.4%), mass per abdomen (13.7%), dysmenorrhea (3.4%), incidental finding (2%), and abdominal distention (0.5%). In total, 204 patients underwent surgery for adnexal masses, and 202 patients were observed without surgery. Histopathological examination revealed 110 benign neoplasms, 72 non-neoplastic lesions, 3 ectopic pregnancies, 3 tubo-ovarian abscesses, 7 borderline malignant tumors, and 9 non-epithelial ovarian malignant tumors. Abdominal pain was the most common reason for hospital visits and surgery in adolescents and young women with adnexal masses. The ultrasonographic diagnosis was consistent with the histopathological diagnosis. In recent years, the use of minimally invasive surgery such as laparoscopy and robotic, has increased in young patients with adnexal masses.

Clinical and Computed Tomographic Features of Ovarian Lesions in Infants, Children, and Adolescents: A Series of 222 Cases

STUDY OBJECTIVE

To investigate the clinical and computed tomography (CT) characteristics of ovarian lesions in infants, children, and adolescents.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective analysis of the clinical and CT data was performed in 222 patients who were 20 years or younger with ovarian lesions. Patients' age, medical history, symptoms, tumor marker levels, and CT imaging findings were recorded.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Identification of the clinical and CT features of ovarian lesions in infants, children, and adolescents.

RESULTS

A total of 136 patients had abdominal pain, and 73 patients had palpable abdominal mass. The β-HCG was elevated in 4 and AFP was elevated in 16 of the 222 cases. A total of 235 lesions were found in 222 cases, including 75 non-neoplastic and 160 neoplastic lesions. Ovarian cyst exhibited homogeneous low density. The torsion of a normal-sized ovary demonstrated mild or no enhancement. The torsion associated with an ovarian mass demonstrated a thickened, hyperdense wall. Mature teratoma presented as a cystic mass, with bulk fat and coarse calcification. Immature teratoma appeared as a solid mass with foci of fat and fine calcification. Yolk sac tumor was shown as cystic-solid mass with intense enhancement of solid component. Wall and septation of benign epithelial tumors were relatively uniform in thickness; mural nodule was detected in borderline tumor; and malignant epithelial tumor was predominantly a solid mass with intense enhancement.

CONCLUSION

Ovarian cyst is the most common non-neoplastic lesion. Torsion of a normal-sized ovary was the second most common non-neoplastic lesion, almost always causing abdominal pain. Germ cell tumor has the highest incidence among neoplastic lesions. Fat and calcification are highly specific for germ cell tumor. The elevation of AFP and HCG levels in serum indicates germ cell tumor. Ovarian epithelial tumor is usually large, benign, and predominantly cystic. The combination of clinical and imaging features is helpful for correct diagnosis.

Imaging in pediatric ovarian tumors

The spectrum of ovarian tumors in the pediatric population differs significantly from that in adults. Germ cell tumors are the predominant class of ovarian tumors in children, whereas epithelial tumors are the most common in adults. Ultrasonography is the modality of choice for the initial evaluation of pediatric ovarian tumors. Determining the diagnosis based on imaging may prove difficult, and combining the imaging findings with the clinical scenario is very helpful in reaching a differential diagnosis during clinical practice. We will discuss the spectrum of ovarian neoplasms in the pediatric population and describe their clinical, pathologic, and imaging characteristics. A few unique entities related to ovarian tumors, such as growing teratoma syndrome, anti-N-methyl-D-aspartate receptor encephalitis, and hereditary ovarian tumor syndromes, are also discussed. In addition, we will review several entities that may mimic ovarian neoplasms as well as their distinct imaging features.

Effect of Surgical Specialty on Management of Adnexal Masses in Children and Adolescents: An 8-Year Single-Center Review

STUDY OBJECTIVE

Children with adnexal masses might be managed by pediatric surgeons, urologists or gynecologists, with the potential for different management strategies between specialties. In this study we compared ovarian conservation rates and surgical approach for adnexal masses in children and adolescents managed either by pediatric surgeons/urologists or gynecologists at a tertiary care institution.

DESIGN

Retrospective cohort review.

SETTING

Tertiary pediatric and adult university hospital.

PARTICIPANTS

Patients younger than 18 years of age with an adnexal mass managed surgically with removal of histologically confirmed ovarian or fallopian tube tissue from 2008 to 2015.

INTERVENTIONS

Laparoscopic or open procedure for adnexal mass.

MAIN OUTCOME MEASURES

The primary outcome was rate of ovarian conservation relative to surgical specialty. The secondary outcome was surgical approach relative to surgical specialty.

RESULTS

Forty-eight patients underwent surgery for adnexal masses; 26 (54%) under pediatric surgery/urology and 22 (46%) under gynecology care. Laparoscopy was performed in 5 (19%) pediatric and 19 (86%) gynecology cases (P = .000006). Of 24 patients older than 12 years of age with a benign tumor, 10 (42%) underwent procedures resulting in loss of an ovary with or without fallopian tube; 8 of these (80%) were under pediatric care. Of the remaining 14 (58%) who underwent ovarian conserving surgery, 12 (80%) were under gynecology care (P = .0027).

CONCLUSION

Patients with a benign tumor were significantly more likely to undergo ovary-preserving surgery under gynecology care than under pediatric surgery/urology care. A multidisciplinary team approach involving gynecology and pediatric surgical specialties would be valuable in assessing the merits of ablative or conservative surgery in each case.

Pediatric and adolescent gynecology: Treatment perspectives in minimally invasive surgery

Minimally invasive surgery (MIS) is widely utilized across multiple surgical disciplines, including gynecology. To date, laparoscopy is considered a common surgical modality in children and adolescents to treat gynecological conditions. Robotic surgical devices were developed to circumvent the limitations of laparoscopy and have expanded the surgical armamentarium with better magnification, dexterity enhanced articulating instruments with 5-7 degrees of freedom, and ability to scale motion thus eliminating physiologic tremor. There are well-documented advantages of MIS over laparotomy, including decreased post-operative pain, shorter recovery times, and better cosmetic results. Indications for MIS in pediatric gynecology are reported in this review and technical considerations are described to highlight new treatment perspectives in children and adolescents, which have already been described in the literature regarding adult patients.

A Preoperative Scoring System for Adnexal Mass in Children and Adolescents to Preserve Their Future Fertility

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.

Review of Laparoscopic Management of Mature Cystic Teratoma of Ovaries in Children

Ovarian cystic mature teratomas (OCMTs) are the most frequent ovarian tumors in childhood. This review aimed to determine the feasibility and safety of laparoscopic management of OCMT. Literature was searched for terms “mature,” “ovarian,” “teratomas,” and “laparoscopy.” Primary endpoints were age at surgery, laparoscopic and surgical technique, intraoperative complications, postoperative morbidity, and associated pathology. Literature search revealed 11 articles published between 1998 and 2014 that met the inclusion criteria. There were 105 (n = 95 unilateral; n = 10 bilateral) patients for this analysis, with mean age at surgery being 13 years. Four laparoscopic approaches were opted: gasless transumbilical laparoendoscopic single-site (LESS) surgery (n = 19), gasless multiport surgery (n = 24), single-incision laparoscopic surgery (SILS) (n = 3), and pneumoperitoneum multiport laparoscopy (n = 59). The 10 patients with bilateral OCMT underwent ovary-sparing surgery: LESS-assisted extracorporeal bilateral cystectomy in which tumors were punctured by a balloon catheter (n = 2), intracorporeal cystectomy for gasless multiport laparoscopy (n = 5) with use of endobags to prevent spillage, and transperitoneal multiport laparoscopy (n = 3). OCMT was associated with ipsilateral and unilateral ovarian torsion in five and bilateral ovarian torsion in one patient with bilateral OCMT. In four patients with unilateral OCMT, salpingo-oophorectomy was performed. Intraoperative complications were laceration of utero-ovarian ligament and bladder injury during a suprapubic port placement. The mean follow-up was 31.9 months. Patients with unilateral or bilateral OCMT can be offered ovarian-sparing surgery laparoscopically with one of the following techniques: LESS, SILS or multiport laparoscopy with pneumoperitoneal or gasless. Long-term follow-up of these techniques has shown no recurrence with low postoperative morbidity and low intraoperative complications.

Borderline Ovarian Tumor in the Pediatric and Adolescent Population: A Case Series and Literature Review

STUDY OBJECTIVE

To determine the diagnosis, management, and outcome for children and adolescents with borderline ovarian tumor (BOT), and to provide a review of the literature on BOT in children and adolescents.

DESIGN

A retrospective cohort study of female adolescents younger than age 21 years diagnosed with BOT between January 2001 and May 2016.

SETTING

Texas Children's Hospital, Houston, Texas.

PARTICIPANTS

Fourteen patients (ages 12 to 18 years) diagnosed with BOT.

MAIN OUTCOME MEASURES

Clinical presentation, preoperative characteristics, surgical technique, cancer stage, histology, treatment, and recurrence.

RESULTS

Median age at diagnosis was 15.5 years, with most postmenarchal. Abdominal mass/pain were the most common presenting symptoms. Median tumor size was 16.6 cm (range, 4-32 cm). Preoperative cancer antigen 125 (CA 125) was elevated in 54% (7/13) of cases. All patients had fertility-preserving surgery, either cystectomy (CY) or unilateral salpingo-oophorectomy (USO): 5 via laparoscopy (LSC) and 9 via laparotomy. Most were stage I with 5 serous and 9 mucinous BOT histology. No one received adjuvant chemotherapy. Two patients had recurrence. One had ipsilateral recurrence 2 months after LSC CY for FIGO stage IC1 mucinous BOT. The second had contralateral recurrence 15 months after laparotomy, right USO for FIGO stage IIIC serous BOT treated with LSC CY, then a second recurrence treated with USO after oocyte cryopreservation for fertility preservation. All patients were alive at last follow-up, 1 with disease.

CONCLUSIONS

BOT in children and adolescents can be treated conservatively with fertility-preserving techniques and surveillance with good outcome. The role of adjuvant therapy is not known.

Evaluation and Treatment Results of Ovarian Cysts in Childhood and Adolescence: A Multicenter, Retrospective Study of 100 Patients

STUDY OBJECTIVE

To investigate the characteristics of children with ovarian cysts and evaluate treatment strategies.

DESIGN

Retrospective study.

SETTING

Eight pediatric endocrinology clinics, Turkey.

PARTICIPANTS

A total of 100 children and adolescents with ovarian cysts.

INTERVENTIONS

Patient data collected via retrospective chart review. Patients were stratified according to age into 4 groups (newborns, 1-12 months, 1-8 years, and 8-18 years).

MAIN OUTCOME MEASURES

Special emphasis was given to torsion and tumor cases, concomitant diseases, treatment modalities, and problems during follow-up.

RESULTS

Most newborns and infants were asymptomatic with the cysts being discovered incidentally; in girls ages 1-8, symptoms were common, including breast budding (47.1%, 16 of 34) and vaginal bleeding (29.4%, 10 of 34). Girls older than 8 years mostly presented with abdominal pain (31.6%, 12 of 38) and menstrual irregularity (21.1%, 8 of 38). Most of our patients were diagnosed with a simple ovarian cyst, but 9 patients were found to have ovarian tumors. Ovarian torsion was detected in 7 patients; 5 with large and 2 with small cysts (<20 mm). Two patients had central precocious puberty (CPP) at presentation and 5 patients developed CPP during follow-up. The surgical intervention rate was high (38%, 38 of 100), but was associated with earlier treatment year, and this association remained significant after adjusting for confounders (P = .035).

CONCLUSION

Most girls have simple cysts, which have a favorable prognosis without intervention; however, there might be coexisting pathologies or complications such as tumors, torsion, and CPP; hence these patients should be evaluated accordingly and treated with a multidisciplinary approach.

Update on the surgical management of ovarian neoplasms in children and adolescents: analysis on 32 cases

This study analyzes updated clinical, diagnostic, and surgical directions for the treatment of ovarian neoplasms in children and adolescents, comparing them with a retrospective analysis of 32 cases treated in two Pediatric Surgery University Institutions. From January 2005 to December 2015, 32 pediatric patients were surgically treated for 32 ovarian tumors: 28 (87.5%) benign and 4 (12.5%) malignant neoplastic lesions. Median age at surgery was 11.2 years (12.8 years in patients with benign neoplasms, 7.25 years in patients with malignant ones). All patients with malignant and 25% of patients with benign ovarian lesions had elevated serum level of tumors markers. The surgical approach was laparotomic in 62.5% and laparoscopic in 37.5%; 81.2% surgeries were performed in elective surgery and 18.8% in emergency. Intraoperative frozen section analysis was performed in 18.75% of patients. The most frequent surgery (96.8%) was unilateral oophorectomy. After a median follow-up of 76 months (range 6-132 months), 31/32 patients are alive and disease-free. In case of malignant tumors, fertility-sparing surgery with accurate staging must be performed. Laparoscopic multiport is the gold standard approach for benign pediatric ovarian neoplasms, but the use of laparoscopy in full respect of oncological principles also for early stage malignant tumors is currently increased.