Management of ovarian dermoid cysts in the pediatric and adolescent population

Approaches to the Diagnosis and Management of Paediatric Ovarian Tumours and Oncological Outcomes in a Single-centre Study. Evidence in Support Of IPSO Reccomendations

BACKGROUND

Approaches to paediatric ovarian tumours vary. Cross-sectional imaging is reliable but not always performed. Laparoscopic tumourectomy, although popular, is not recommended by International Paediatric Surgical Oncology Society (IPSO); tumour spillage remains the main concern. We aimed to investigate the reliability of preoperative evaluation and identify perioperative factors associated with adverse outcomes.

METHODS

Single-centre retrospective study (2015-2022) of clinical presentation, preoperative investigation, operative approaches and oncological outcomes in all females <18 years treated for ovarian tumours. Logistic regression was used to identify predictors of malignancy and of second disease events. Data are presented as median (IQR) or rates.

RESULTS

Sixty girls aged 12.5 (10-15) years with follow-up of 51 (30.5-76.3) months were included. Incidence of malignant and low malignant potential tumours was 19/60 (32%). Tumour size and consistency proved predictive of malignancy. Clinical assessement, tumour markers and cross-sectional imaging combined showed 75% sensitivity, 100% specificity and 7% misclassified malignancy rate. Second disease events (11/60, 18%) were associated with misclassified malignancy (2/11 vs. 1/49, p = 0.04) and positive margins (4/11 vs. 5/49, p = 0.02). Ovarian-sparing surgery did not influence second events (5/11 vs. 28/49, p = 0.48). There was no significant association between second events and laparoscopic tumourectomy (3/11 vs. 20/49, p = 0.40); spillage rate was however more frequent with laparoscopy (5/11 vs. 2/32, p = 0.008).

CONCLUSION

Misclassified malignancy, noted in 7% of patients undergoing optimal work-up, adversely impacted outcomes, highlighting the importance of oncological principles in both oophorectomy and ovarian-sparing surgery. Malignancy incidence and misclassification can be underestimated when tumours with malignant behaviour potential, such as immature teratomas and borderline tumours, are grouped as benign. There was no direct association between operative approaches and second events. Laparoscopy, however, failed to maintain oncological principles more frequently than open surgery and hence risks upstaging of paediatric ovarian pathology.

LEVEL OF EVIDENCE

III.

Ovarian Dermoid Cyst Trajectory in Premenarchal Girls

STUDY OBJECTIVE

Mature ovarian dermoid cysts (ODCs) are the most common benign ovarian tumors diagnosed in children. However, there is minimal data on management of ODCs in premenarchal patients. This study assesses characteristics associated with expectant (EM) vs surgical (SM) management in premenarchal patients and the growth rate of ODCs in EM patients at a single institution.

METHODS

Forty-four premenarchal patients, either post-surgical with pathologically-confirmed ODC or having radiologic findings consistent with ODCs, were included. Data collected included demographics, cyst characteristics, imaging findings, presence of symptoms, surgical procedure performed, and ovarian torsion occurrence.

RESULTS

Patient age at diagnosis was similar between groups (SM: 8.8 vs EM: 8.0, P = .55). At presentation, 36 patients (82%) underwent SM and 8 (18%) underwent EM. There was a significant difference in cyst size between groups (SM: 8.9 cm vs EM: 3.6 cm, P = .004). Of SM patients, 30% underwent oophorectomy vs cystectomy, with a significant difference in ODC size between procedures (11.8 cm vs 7.7 cm, P = .016). Of EM patients, 75% had at least one and 60% had three follow-up ultrasounds, with average follow-up timeframes of 3.7 and 27 months respectively. Average yearly ODC growth rate for the latter group was 0.8 cm.

CONCLUSION

The average yearly growth rate of ODCs in premenarchal patients within our institution was slower than in older cohorts, and both age and cyst size played significant roles in determining surgical procedure. Continued study on EM in premenarchal ODCs will help define parameters for recommending SM vs EM in this population.

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.

Malignant Transformation of Unknown Duration of an Ovarian Mature Cystic Teratoma Presenting as a Trocar Recurrence in a Young Patient: A Case Report and Literature Review

Although laparoscopic cystectomy is a safe and effective management strategy for ovarian mature cystic teratoma (MCT) in pediatric and adolescent patients, it has been challenged because of its association with a higher risk of intraoperative spillage leading to chemical peritonitis, adhesion formation, and iatrogenic implantation of malignant cells. Here, we report a rare case of a 23-year-old female patient with MCT tissue during laparoscopic ovarian cystectomy that remained in the peritoneum, possibly becoming malignant thereafter. Intraoperatively, the cyst's contents leaked into the abdominal cavity. The abdominal cavity was thoroughly cleaned before the operation was completed. Pathological examination revealed an MCT without malignant findings. The patient's postoperative course was uneventful. Although the excised tissue was benign, the patient presented with a mass at the trocar wound (upper suprapubic area) 2 years after initial surgery. Biopsy results indicated squamous cell carcinoma. Moreover, peritoneal and bladder invasions were diagnosed. She subsequently experienced symptoms of cancerous peritonitis. Achieving a complete cure through surgery alone was deemed difficult; however, successful neoadjuvant chemotherapy and tumor reduction surgery kept her alive up until the publication of this case report, 3 years since diagnosis with squamous cell carcinoma. This case indicates that malignant transformation of MCTs can occur at any age.

Mature Cystic Teratoma: An Integrated Review

Ovarian dermoid cysts, also called mature cystic teratomas (MCTs), account for 69% of ovarian germ cell tumors in young women. The tumors are formed by tissues derived from three germ layers, and sebaceous materials are most commonly seen. The origin of MCTs is widely considered to be the germ cell origin, which completes meiosis I. The clinical symptoms vary widely, but 20% of tumors could be asymptomatic. The diagnosis of MCTs is usually made without difficulty by ultrasound and confirmed by histopathology post-operatively. The imaging findings have a high diagnostic value. The typical characteristics present in the sonographic images, including a dermoid plug or Rokitansky nodule, are considered strong evidence for a teratoma. Although the malignant transformation of MCTs is rare, it can occur in some cases, especially in women of advanced age. The treatment of MCTs depends on the risk of malignancy, the age of the patient, and the patient's fertility reserve requirement. In this article, we review the epidemiology, clinical symptoms, diagnosis criteria, cellular origin, and treatment of mature cystic teratomas.

Laparoscopy versus laparotomy for pediatric ovarian dermoids

BACKGROUND

With increased surgeon comfort using laparoscopy, we hypothesized resection of pediatric ovarian dermoids using laparoscopy would yield a shorter length of stay and no increase in morbidity or recurrence compared to laparotomy.

METHODS

A retrospective review was performed amongst eleven pediatric hospitals. Patients aged 2 to 21 who underwent resection of an ovarian dermoid from 2010 to 2020 were included. Patient characteristics, operative details, and outcomes by approach were evaluated using Chi-squared and Wilcoxon-Mann tests.

RESULTS

466 patients were included, with a median age of 14.4 and median follow-up of 4.0 months. 279 patients underwent laparoscopy (60%), 139 laparotomy (30%), and 48 laparoscopy converted to laparotomy (10%). There were no differences in rates of tumor spillage by approach (p = 0.15). 65% underwent ovarian-sparing surgery and 35% underwent oophorectomy. Length of stay was significantly shorter amongst patients who underwent laparoscopy (1 day versus 2 days for laparotomy and converted, p<0.0001). There were no differences in rates of suspected recurrence or reoperation (p = 0.19 and p = 0.57, respectively).

CONCLUSION

Patients who underwent laparoscopy experienced no differences in the rates of tumor spillage, recurrence, or reoperation and had a shorter length of stay compared to laparotomy. Laparoscopy is an acceptable approach for resection of pediatric ovarian dermoids.

Lessons from a large nationwide cohort of 350 children with ovarian mature teratoma: A study in favor of ovarian-sparing surgery

BACKGROUND

Ovarian mature teratoma (OMT) is a common ovarian tumor found in the pediatric population. In 10%-20% of cases, OMT occurs as multiple synchronous or metachronous lesions on ipsi- or contralateral ovaries. Ovarian-sparing surgery (OSS) is recommended to preserve fertility, but total oophorectomy (TO) is still performed.

DESIGN

This study reviews the clinical data of patients with OMT, and analyzes risk factors for second events. A national retrospective review of girls under 18 years of age with OMTs was performed. Data on clinical features, imaging, laboratory studies, surgical reports, second events and their management were retrieved.

RESULTS

Overall, 350 children were included. Eighteen patients (5%) presented with a synchronous bilateral form at diagnosis. Surgery was performed by laparotomy (85%) and laparoscopy (15%). OSS and TO were performed in 59% and 41% of cases, respectively. Perioperative tumor rupture occurred in 23 cases, independently of the surgical approach. Twenty-nine second events occurred (8.3%) in a median time of 30.5 months from diagnosis (ipsilateral: eight cases including one malignant tumor; contralateral: 18 cases; both ovaries: three cases). A large palpable mass, bilateral forms, at diagnosis and perioperative rupture had a statistical impact on the risk of second event, whereas the type of surgery or approach did not.

CONCLUSION

This study is a plea in favor of OSS as the first-choice treatment of OMT when possible. Close follow-up during the first 5 years is mandatory considering the risk of 8.3% of second events, especially in cases with risk factors.

Fast Leak-Proof, Intraumbilical, Single-Incision Laparoscopic Ovarian Cystectomy for Huge Ovarian Masses: "Hybrid Cystectomy and Reimplantation" Method

Background and Objectives: To introduce a new technique for fast leakage-proof, intraumbilical, single-incision laparoscopic ovarian cystectomy for huge ovarian masses (>10 cm) Materials and Methods: Seven consecutive, reproductive-aged women, including three adolescents, with huge ovarian masses (mature cystic teratoma, n = 4; endometrioma, n = 2; and mucinous cystadenoma, n = 1) who underwent transumbilical single-incision ovarian cystectomy with the new “hybrid cystectomy and reimplantation” method were included. The procedure was: (1) trans-umbilical single-incision laparoscopy; (2) inspection of the pelvic cavity and placing the mass in a laparoscopic endo-bag for cystic content leakage prevention; (3) in-bag resection using cold scissors and minimal cauterization of the cystectomy site; (4) in-bag tissue extraction; (5) rapid extracorporeal cystectomy with traction without electrocautery; (6) re-insertion of the retrieved ovarian cortex intracorporeally through the single port, and (7) intracorporeal suture of the retrieved tissue to the in situ ovary. Results: The mean patient age was 24.71 ± 6.56 (range 17–37) years and the mean maximal diameter of the masses was 17.71 ± 2.86 (range 13–22) cm. There was no case of unintended intracorporeal cyst rupture and no need for copious irrigation for washing and suctioning the leaked mass content. The mean total operating time was 76.42 ± 6.39 (range 65–85) min, the total volume of saline used for irrigation was 814.28 ± 331.35 (range 500–1500) mL, and the estimated blood loss was 107.14 ± 47.72 (range 50–200) mL. There were no perioperative complications. All patients except the two endometriosis patients had regular, normal menstruation. Conclusions: Our preliminary findings were encouraging in terms of the safety and efficiency of the new method. Future trials need to elucidate the benefits of this method in terms of fertility preservation.

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

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.

Ovarian Sparing Surgery in Mature Ovarian Teratomas in Children: A 20-Year Single-Center Experience

INTRODUCTION

 Despite its benign nature, possible bilateral presentation, and a very good prognosis, ovarian sparing tumorectomy (OST) in mature ovarian teratoma (MOT) is not commonly performed. Unilateral oophorectomy has physiological consequences, while bilateral is devastating. The aim of this study is promotion of OST in MOT among children.

MATERIALS AND METHODS

 We reviewed 120 patients operated for MOT between August 1999 and 2019.

RESULTS

 Ovariectomy was performed in 15 patients (14 between 1999 and 2009 and 1 after 2010). In 105 girls, OST was possible including 32 with ovarian torsion. The approach was laparoscopy in 30 girls (11 conversions) and laparotomy in 94. Intra-abdominal spillage occurred in 30% of laparoscopic dissections. Postoperative morbidity was not associated with surgical approach (p = 0.613) or presence of adnexal torsion (p = 0,608). Follow-up was from 4 months to 9 years (median = 4 years) with access to 90% of patients. Bilateral lesions were observed in six (synchronous in five and metachronous in one) patients. Recurrence appeared in three patients operated via laparotomy and OST (after 12, 46, and 74 months). In one girl, asynchronous contralateral MOT was found 5 years after unilateral oophorectomy. Ovarian regeneration after torsion was observed in sonography in 84.4% of the patients. None of the patients experienced chemical peritonitis or malignant tumor transformation.

CONCLUSION

 OST is safe and effective and should be the first-line procedure in children. Laparoscopy and laparotomy constitute a complementary approach to MOT. Ultrasound follow-up is necessary to monitor recurrence, contralateral disease, and ovarian regeneration.

Massive, benign, cystic ovarian tumors: A technical modification for minimally invasive resection

The majority of large, cystic ovarian tumors presenting in children are benign and amenable to ovarian sparing surgery (OSS). Laparoscopy is impractical in these cases and when attempted has been associated with a high rate of intraperitoneal fluid spill. We present a modified technique for controlled cyst decompression that allows delivery of the ovary through minilaparotomy and subsequent OSS. Criteria that must be met for the procedure to be undertaken are discussed.

Short- and Long-Term Complications of Intraoperative Benign Ovarian Cyst Spillage: A Systematic Review and Meta-analysis

OBJECTIVE

To review short- and long-term complications associated with intraoperative rupture of benign ovarian cysts.

DATA SOURCES

The Cochrane Central Register of Controlled Trials, BIOSIS, Medline (Ovid), Web of Science, ClinicalTrials.gov, and Google Scholar were searched using the following terms and their combinations: "spillage," "rupture," "leakage," "ovarian cyst," "teratoma," "dermoid," "operative," "surgery," "outcome."

METHODS OF STUDY SELECTION

Randomized controlled and observational studies evaluating the operative outcomes of surgical treatment of ovarian cysts with intraoperative spillage compared with those of surgical treatment of ovarian cysts without spillage were included. A systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed.

TABULATION, INTEGRATION, AND RESULTS

A total of 28 studies were included in the qualitative analysis and 12 in the quantitative analysis. Ovarian cyst diameter was not found to be associated with the risk for spillage (relative risk [RR] 0.75; 95% confidence interval [CI], -0.33 to 1.82). Intraoperative benign ovarian cyst rupture was not associated with adverse short- and long-term outcomes such as reoperation (RR 1.16; 95% CI, 0.39-3.48), infertility (RR 0.73; 95% CI, 0.15-3.63), transient fever (RR 3.22; 95% CI, 0.83-12.51), and readmission (RR 1.00; 95% CI, 0.33-2.98). However, intraoperative spillage was found to be associated with increased risk for benign recurrence (RR 3.1; 95% CI, 1.05-9.14). A subgroup analysis of the studies that included only dermoid cysts showed an association between intraoperative cyst rupture and postoperative chemical peritonitis (RR 9.36; 95% CI, 1.20-73.28).

CONCLUSION

Intraoperative ovarian cyst spillage of a benign cyst is associated with limited adverse clinical outcomes. Although the surgical approach (minimally invasive vs open) should not be affected by the concern regarding an intraoperative cyst rupture, maximal efforts should be made to prevent intra-abdominal spillage.

Homemade Glove Retrieval Bag in Laparoscopic Complete Excision of Benign Ovarian Teratoma with Ovarian Tissue Preservation in Children: A Case Series

STUDY OBJECTIVE

To present our experience of laparoscopic resection of pediatric benign ovarian teratomas with gonadal preservation, using a homemade glove retrieval bag. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Review of all girls with benign ovarian teratomas who were managed with laparoscopic ovarian-sparing surgery (OSS) at our hospital between January 2013 and December 2018.

RESULTS

Eleven patients were included for analysis with a mean age of 6.1 years. Ten patients received elective surgery, whereas 1 patient received emergency surgery because of ovarian torsion. Main indication for OSS was the existence of a dissection plane between tumor margins and healthy ovarian tissue. Postoperative outcome and follow-up were uneventful with a median follow-up of 30.1 months (range; 12-60 months).

CONCLUSION

Laparoscopic OSS can be safely performed for these tumors. Laparoscopic magnification with energy devices are excellent tools in such procedures. The homemade glove bag can be used to retrieve the tumor effectively in countries with limited resources.

What recent primary studies tell us about ovarian teratomas in children: a scoping review

Our knowledge of ovarian teratomas in children is still far from complete, and much remains to be discovered. Here, we conduct a scoping review of the primary research related to ovarian teratomas in pediatric age. To our knowledge, there is no published synthesis of the literature surrounding ovarian teratomas in children using scoping review methodology. We identified 24 studies from 11 countries; 18 studies were retrospective, 3 were prospective, and 3 were experimental. There were 6 studies concerning mature teratomas, 5 concerning immature teratomas, and 13 that included both tumor types. Overall, 9 out of all the studies concerned more than 50 patients. We revealed 7 major branches of research within the topic of ovarian teratoma in pediatric population: recurrence rate/relapse and follow-up strategy, malignant potential, prognostic factors, use of sparing surgery, differences between the use of laparoscopy and laparotomy, use of chemotherapy, and additional examinations to test the character of the lesion (immature vs. mature). This scoping review has revealed a number of knowledge gaps in the evidence base for pediatric ovarian teratomas. Overall, this topic has not been extensively explored, and more research dedicated exclusively to this tumor and patient population is required.

Diagnosis and treatment of the intra-abdominal gonad in the pediatric population: Testes, ovaries, dysgenetic gonads, streaks, and ovotestes

BACKGROUND/PURPOSE

Pediatric surgical specialists are often confronted with the difficult task of identifying, diagnosing and managing intra-abdominal gonads in children. Ranging from the intra-abdominal cryptorchid testis to normal or pathologic ovaries and gonads in disorders of sexual development, all intra-abdominal gonads in the pediatric population pose different diagnosis and management challenges. Understanding the hormonal and fertility potential of the gonad and knowing its potential cancer risk is essential when deciding how to manage these patients. In addition, the ideal surgical management for each one of these patients is often debated.

METHODS

Descriptive literature review.

RESULTS/CONCLUSION

Herein, we reviewed gonadal formation, common etiologies, diagnosis and management of intra-abdominal testes, pathologic ovaries and gonads in disorders of sexual development. Fertility potential and cancer risk for each were also reviewed and how both affect surgical management of the gonad.

TYPE OF STUDY/LEVEL OF EVIDENCE

Review Article, Level V.

Approaches to the management of pediatric ovarian masses in the 21st century: Systematic review and meta-analysis

BACKGROUND

Laparoscopy is increasingly being adopted for the treatment of ovarian pathologies in adults. However, its implementation for the management of pediatric ovarian masses varies and the evidence, to date, has not been comprehensively analyzed. This review aims to compare laparoscopic and open surgical management of pediatric ovarian masses.

METHODS

We searched PubMed, Cochrane Library and Google Scholar from the year 2000 till April 2017. Studies selected for this included those on epidemiological trends of pediatric ovarian lesions, assessing outcomes of laparoscopic management and comparison of laparoscopic and open surgical techniques for pediatric ovarian masses. A meta-analysis comparing outcomes of both modalities was performed using standard methodology.

RESULTS

A total of 44 studies met the inclusion criteria of which 15 were on histological types of ovarian lesions, 24 assessed laparoscopic management only and five compared laparoscopy with open surgery for pediatric ovarian masses. Nonneoplastic lesions were the most common ranging from 36.5% to 73.7%, with cystic lesions being the most prevalent. Neoplastic lesions ranged between 26.3% and 63.5%, with germ cell tumors being the most common, while malignancy ranged between 3.5% and 10.8%. Laparoscopic management was generally advocated for managing benign lesions with a cautious approach for suspicion of malignant lesions. In comparison to open surgery, laparoscopic surgery had shorter operating time (MD = -33.24 min, 95% CI = -34.29 to -32.19, p < 0.0001), less intraop bleeding (MD = - 61.46 ml, 95% CI = -62.69 to -60.24, p < 0.0001), and reduced length of hospital stay (MD = -2.78 days, 95% CI= -2.82 to -2.74, p<0.0001). Complication rates were equivocal between the two approaches. Spillage rates could not be assessed.

CONCLUSION

Limited evidence suggests that laparoscopic approach to presumptively benign ovarian masses have better outcomes when compared to open surgery with regards to operating time, blood loss and hospital stay. However, complication rates were similar between the two approaches. Studies with rigorous scientific methods are needed for a definitive recommendation, especially in resource limiting settings. However malignant lesions should still be managed with an open surgical approach to avoid upstaging of disease status.

LEVEL OF EVIDENCE

II.

Pediatric ovarian tumors, a challenge for pediatrician and gynecologist: Three case reports (CARE compliant)

RATIONALE

Ovarian or adnexal tumors are very rare in patients below the age of 18 years, most of them being functional cysts, only 10% being malignant. We report 3 cases of ovarian tumors with the aim of revealing the particularities regarding the diagnosis and management of benign and malignant ovarian tumors in pediatric patients.

PATIENT CONCERNS

The 1st case, a 9-year-old girl presented for diffuse abdominal pain, distended abdomen and rapid increase in abdominal volume. The 2nd case describes a 13-year-old female patient admitted for acute abdominal pain and nausea, and the 3rd one was an 18-year-old female teenager who presented for distended abdomen, intermittent diffuse abdominal pain and rapid increase in abdomen volume.

DIAGNOSES

The abdominal ultrasound revealed in all 3 patients suggestive signs for ovarian tumors.

INTERVENTIONS

The 1st patient underwent laparotomy with adnexectomy, and the histopathological exam showed the diagnosis of dysgerminoma. The 2nd patient underwent laparoscopy with adnexectomy, and the histopathological exam revealed a borderline tumor. The 3rd patient benefited by a laparotomy with left ovariectomy, and the histopathological exam pointed out a mature teratoma.

OUTCOMES

The outcome was favorable in all 3 cases, but the patients with dysgerminoma and mature teratoma were further referred to the oncologist for proper assessment.

LESSONS

Laparoscopy may represent the first choice for uncomplicated ovarian masses. The diagnosis and the therapeutic plan must be based on symptoms, pelvic ultrasound, the time of menarche and the potential serum markers.

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.

Single-port laparoscopic-assisted resection for a large abdominal cystic lymphangioma: a case report

Background

We report the case of a young woman with a large abdominal cystic lymphangioma that was successfully resected using single-port laparoscopic-assisted cystectomy. This avoided the need for a large surgical incision, as would result during conventional laparotomy.

Case presentation

A 17-year-old young woman was admitted to our hospital complaining of abdominal pain that had persisted for 3 days. Computed tomography revealed a 10 × 10 × 10-cm low-density area in the mid-abdomen, and magnetic resonance imaging showed a large abdominal cystic lesion. A mesenteric cyst was suspected, and single-port laparoscopic-assisted resection was performed. The cyst fluid was aspirated using a tissue adhesive, a suction tube with negative pressure, and a 16-gage over-the-needle catheter and syringe. The tumor size was reduced without any spillage of cyst fluid into the abdominal cavity. Then, the shrunken cystic tumor was successfully removed via the small wound and resected outside the abdomen. Pathological findings revealed an abdominal cystic lymphangioma derived from the greater omentum.

Conclusions

Our procedure was easy to perform and required no special materials. Therefore, it could be applied to various cases, such as for abdominal cystic diseases.

Intraoperative Rupture of Ovarian Dermoid Cysts in the Pediatric and Adolescent Population: Should This Change Your Surgical Management?

STUDY OBJECTIVE

(1) To determine the incidence of chemical peritonitis after cystectomy for ovarian dermoid cysts with intraoperative cyst rupture in the pediatric and adolescent population; and (2) to examine the intraoperative and postoperative outcomes of cystectomies performed for ovarian dermoid cysts using laparoscopy and laparotomy, especially those with intraoperative cyst rupture.

DESIGN

A retrospective cohort study of female patients who underwent ovarian cystectomy with proven ovarian dermoid pathology between July 2007 and July 2015.

SETTING

Texas Children's Hospital, Houston, Texas.

PARTICIPANTS

One hundred forty-four patients between the ages of 1 and 21 years who underwent an ovarian cystectomy with proven benign ovarian dermoid histology on the basis of pathology reports.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Occurrence of spill of cyst contents, chemical peritonitis, postoperative complications, and hospital readmissions.

RESULTS

One hundred forty-four female patients underwent cystectomy (38 laparotomy and 106 laparoscopy) resulting in benign ovarian dermoid histology. Their mean age was 12.4 ± 4.1 years (range, 1-21), mean cyst size was 9.2 ± 6.4 cm (range, 1-30 cm), no patients had elevated tumor markers, 42 (29.1%) presented with torsion, 73 (50.7%) had cyst fluid spill, and there were no cases of chemical peritonitis. Few significant differences were found between cases performed via laparoscopy and laparotomy and those with and without intraoperative cyst rupture resulting in spill of contents. Laparotomy cases were found to have larger mean cyst size (P < .001), estimated blood loss (P = .003), and presence of bilateral cysts (P = .017) compared with laparoscopic cases. Cyst fluid spill occurred in more laparoscopic cases ([67/106] 63.2% vs [6/38] 15.8%; P < .001), and risk increased with cyst size greater than 5 cm (P < .001). In the laparoscopy group, cyst size greater than 5 cm was more likely to present with torsion (P < .001). There was no significant difference in the repeat cystectomy rate between the laparoscopy and laparotomy groups even with cyst rupture (P = .394). Only 5 cases presented to the emergency room postoperatively and 2 were admitted postoperatively for umbilical port site dehiscence and pyelonephritis.

CONCLUSION

Laparoscopic cystectomy of ovarian dermoid cysts is associated with greater intraoperative cyst rupture. However, cyst rupture is rarely associated with complications, therefore minimally invasive surgical management of ovarian dermoid cysts is a reasonable surgical approach.

Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses

Adnexal masses (ie, masses of the ovary, fallopian tube, or surrounding tissues) commonly are encountered by obstetrician-gynecologists and often present diagnostic and management dilemmas. Most adnexal masses are detected incidentally on physical examination or at the time of pelvic imaging. Less commonly, a mass may present with symptoms of acute or intermittent pain. Management decisions often are influenced by the age and family history of the patient. Although most adnexal masses are benign, the main goal of the diagnostic evaluation is to exclude malignancy. The purpose of this document is to provide guidelines for the evaluation and management of adnexal masses in adolescents, pregnant women, and nonpregnant women and to outline criteria for the identification of adnexal masses that are likely to be malignant and may warrant referral to or consultation with a gynecologic oncologist.

Surgical Management of Benign Adnexal Masses in the Pediatric/Adolescent Population: An 11-Year Review

STUDY OBJECTIVE

The purpose of this study was to compare ovarian conservation rates and surgical approach in benign adnexal surgeries performed by surgeons vs gynecologists at a tertiary care institution.

DESIGN

A retrospective cohort review.

SETTING

Children's and adult tertiary care university-based hospital.

PARTICIPANTS

Patients 21 years of age and younger who underwent surgery for an adnexal mass from January 2003 through December 2013.

INTERVENTIONS

Patient age, demographic characteristics, menarchal status, clinical symptoms, radiologic imaging, timing of surgery, surgeon specialty, mode of surgery, rate of ovarian conservation, and pathology were recorded. Patients were excluded if they had a uterine anomaly or pathology-proven malignancy.

MAIN OUTCOME MEASURES

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

RESULTS

Of 310 potential cases, 194 met inclusion criteria. Gynecologists were more likely than surgeons to conserve the ovary (80% vs 63%; odds ratio, 2.28; 95% confidence interval, 1.16-4.48). After adjusting for age, body mass index, mass size, and urgency of surgery, the difference was attenuated (adjusted odds ratio, 1.84; 95% confidence interval, 0.88-3.84). Surgeons and gynecologists performed minimally invasive surgery at similar rates (62% vs 50%; P = .11). A patient was more likely to receive surgery by a gynecologist if she was older (P < .001) and postmenarchal (P = .005).

CONCLUSION

Results of our study suggest that gynecologists are more likely to perform ovarian-conserving surgery. However, our sample size precluded precise estimates in our multivariable model. Educational efforts among all pediatric and gynecologic surgeons should emphasize ovarian conservation and fertility preservation whenever possible.

Ovarian-Sparing Surgery in Pediatric Benign Ovarian Tumors

STUDY OBJECTIVE

To evaluate outcomes of children after ovarian-sparing surgery (OSS) for non-neoplastic and benign neoplastic ovarian lesions.

DESIGN

Retrospective cohort study from January 2003 to January 2012.

SETTING

Single, high-volume, tertiary care hospital.

PARTICIPANTS

Children 18 years of age and younger.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Postoperative complications and tumor recurrence after OSS.

RESULTS

One hundred nine patients underwent OSS with a median age of 13.3 years (interquartile range [IQR], 11.4-15.1 years). Eighty-two patients were treated laparoscopically with 4 conversions to an open procedure. Postoperative complications included surgical site infections in 7 patients (6%). Pathology most commonly revealed functional ovarian cysts (n = 57) and mature teratomas (n = 37). Ninety-four patients (86%) were followed for a median of 10.4 months (IQR, 0.72-30.8 months). Fifty-five patients (60%) had subsequent imaging surveillance a median of 7.6 months postoperatively (IQR, 3.9-13 months). Ten patients (10%) developed a second ipsilateral lesion within a median time of 11 months (IQR, 7.7-24 months), of whom 5 girls had repeated surgery for mass enlargement or persistent abdominal pain at a median time of 10.5 months (IQR, 8.0-12.65 months). Fifty-eight patients (63%) began or resumed menses at their most recent follow-up. Three girls became pregnant after OSS at a median follow-up of 5 years (range, 2.4-6.7 years).

CONCLUSION

Benign ovarian lesions in children can be treated successfully with OSS with low recurrence and repeat surgery rates.

An Uncommon Case of Adolescent Ovarian Teratoma Incarcerated in Inguinal Hernia

Mature cystic teratoma is the most frequent benign ovarian neoplastic lesion in adolescents and is generally composed of fully differentiated tissue arising from multipotential three germinal layers. It accounts for approximately 50% of benign ovarian tumors in childhood. Rarely, a bilateral, synchronous, or metachronous presentation can be observed, supporting a conservative approach as the first surgical approach. We report a case of an ovarian mature cystic incarcerated in indirect inguinal hernia in a 15-year-old girl undergoing ovary-sparing surgery. To our knowledge this is the first case of such lesion incarcerated in an inguinal hernia reported in literature.

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

STUDY OBJECTIVE

We investigated whether rupture increased the recurrence rate of pediatric ovarian neoplasms.

DESIGN

20-year single-institution retrospective study.

SETTING

Tertiary, free-standing, university children's hospital.

PARTICIPANTS

All girls with ovarian neoplasms treated during between 1991 and 2011.

MAIN OUTCOME MEASURE

Tumor recurrence.

RESULTS

Fifty-nine tumors in 53 patients were managed, including 51/59 (86%) benign and 8/59 (14%) malignant. Laparotomy was employed in 44/59 (75%), laparoscopy in 8/59 (14%), and laparoscopy converted to laparotomy in 7/59 (12%). Total and partial oophorectomy (cystectomy) was used for 15/51 (29%) and 36/51 (71%) of benign tumors, respectively. All malignant tumors underwent total oophorectomy. Accidental rupture or intentional tumor puncture occurred in 26/56 cases (46%), 23/51 benign and 3/5 malignant. Rupture was associated with increasing cyst size on univariate and multivariate analyses (p = 0.002 and p = 0.004, respectively). There were 5 recurrences (9%) in 4 patients, including 4 benign (3 mature teratomas, 1 mucinous cystadenoma), and 1 malignant yolk sac tumor. Recurrence occurred in 2/30 (7%) without rupture and 3/26 (12%) with rupture, p = 0.66. Follow-up was available for 50/53 patients (94%), with a median of 23.8 months [range 0.2-189 months]. All recurrences were salvaged by surgery.

CONCLUSIONS

In this limited study, intra-operative rupture did not increase the recurrence rate or worsen the prognosis of pediatric ovarian neoplasms.

Ovarian Mature Cystic Teratoma: Challenges of Surgical Management

Although ovarian mature cystic teratomas are the commonest adnexal masses occurring in premenopausal women, there are many challenges faced by gynecologists on deciding upon the best surgical management. There is uncertainty, lack of consensus, and variation in surgical practices. This paper critically analyzes various surgical approaches and techniques used to treat these cysts in an attempt to outline a unified guidance. MEDLINE and EMBASE databases were searched in January 2015 with no date limit using the key words “ovarian teratoma” and “ovarian dermoid.” The search was limited to articles in English language, humans, and female. The two authors conducted the search independently. The laparoscopic approach is generally considered to be the gold standard for the management. Oophorectomy should be the standard operation except in younger women with a single small cyst. The risk of chemical peritonitis after contents spillage is extremely rare and can certainly be overcome with thorough peritoneal lavage using warmed fluid. There is a place for surveillance in some selected cases.

The recurrence rate of ovarian dermoid cysts in pediatric and adolescent girls

STUDY OBJECTIVE

To assess the rate of recurrence of ovarian dermoid cysts in pediatric and adolescent girls at the Hospital for Sick Children.

DESIGN

A retrospective chart review of all dermoid cysts surgically managed at the hospital for Sick Children from January 2003 to June 2012.

SETTING

The Hospital for Sick Children, Toronto, Canada.

PARTICIPANTS

66 adolescent and pediatric patients <18 years old treated with ovarian cystectomy of their dermoid cysts by either laparoscopy (n = 40) or laparotomy (n = 26).

MAIN OUTCOME MEASURES

Total dermoid cyst recurrence, recurrence after laparoscopy versus laparotomy, follow-up imaging completed and ultrasonographic identification of other ovarian cysts in follow-up. Data was assessed with Fisher exact test where appropriate (P < .05).

RESULTS

The mean age of patients at time of surgery was 12.9 years (range 2.5-18.1). 25/66 (38%) of patients received no follow-up, 6/66 (9%) were followed by a single ultrasonography and 35/66 (53%) were followed with annual ultrasonography for up to 5 years. 35 patients completed their initial ultrasonography where 19/35 (54%) patients had new ovarian cysts diagnosed including: 6 functional/hemorrhagic, 3 dermoid, and 10 unspecified cysts. All new dermoids were suspected at first follow-up ultrasonography (6/35), but 3 required a second follow-up ultrasonography for confirmation. Overall, 7/66 (11%) patients had recurrent or persistent dermoid cysts of which 2 (3%) required repeat surgery. There was no significant impact on the type of surgery and dermoid recurrence.

CONCLUSION

The incidence of recurrent dermoid cysts in a pediatric and adolescent population following ovarian cystectomy is 10.6% where only 3% will recur and require further surgical management.

Laparoendoscopic single-site ovarian cystectomy and concomitant appendectomy in an adolescent

BACKGROUND

Laparoendoscopic single-site surgery (LESS) is emerging as an alternative technique to conventional laparoscopy for the treatment of common surgical diseases.

CASE

We report a case of a 13-year-old female with self-limited abdominal pain. Imaging studies showed a right ovarian mass with features of a dermoid cyst and an appendicolith within the appendix without signs of acute appendicitis. She underwent concomitant LESS ovarian cystectomy and appendectomy without any complications.

SUMMARY AND CONCLUSION

LESS is feasible with standard laparoscopic instruments. It is a safe technique with excellent cosmetic results and minimal postoperative pain.

Single-incision laparoscopic resection of ovarian masses in children: a preliminary report

PURPOSE

Ovarian masses in the pediatric population are commonly resected with a three or four port laparoscopic approach. Single-incision laparoscopic (SIL) resection is an alternative approach. However, there is limited experience with this modality in ovarian mass resection.

METHODS

We reviewed SIL ovarian mass resections performed by our group from 2010 to 2012. We evaluated patient demographics, surgery statistics, and hospital course.

RESULTS

Six patients were identified with mean age of 14 years. Imaging studies showed cystic masses ranging 4-6 cm in five patients, and 20 cm in one patient. One patient presented with recurrent teratoma. Pathology revealed four benign teratomas, one benign cyst, and one serous cystadenoma. Average operating time was 75 min. All patients had an ovarian-preserving resection. Three patients had cyst spillage, including the one who presented with recurrence (this was the only patient with a subsequent recurrence). Hospital stay averaged 37 h. Narcotic use averaged 9.9 mg of morphine daily. All patients had excellent cosmetic results, and no postoperative complications.

CONCLUSIONS

Ovarian cystic mass excision using the SIL approach carries a higher risk of tumor spillage. Although the incidence of malignancy is low, they cannot be conclusively excluded with our current preoperative evaluations. At this time, we recommend SIL resection only for simple cysts with low malignant potential; however, further experience with this procedure will likely improve the risk of tumor spillage in the future.

Surgical technique to prevent spillage of cyst fluid during operation for cystic ovarian tumors

We describe a new technique to prevent spillage of cyst fluid in patients undergoing surgery for cystic ovarian tumors. The cyst is first covered with a sterilized surgical sheet applied with quick-drying glue and is then punctured. This technique completely prevents spillage of cyst fluid into abdominal cavity.

Ovary-sparing surgery for teratomas in children

AIM

To share our experience in ovary-sparing surgery for teratomas in children.

PATIENTS AND METHODS

The medical records of nine patients (mean age of 11.2 years, r 6-15 years) who had undergone ovary-sparing surgery for teratoma were analyzed retrospectively. Mean duration for follow-up was 29.5 months (r 15-75 months).

RESULTS

Five patients suffered from chronic abdominal pain; two had acute colicky abdominal pain. In two patients, there was no presenting clinical symptom. Two patients were operated on emergency basis due to symptoms related with acute abdomen. On the other hand, seven were operated electively. Ultrasonography was performed in all patients. Additionally, MRI and tumor markers were performed in all but two. Main radiologic findings consisted of heterogenous cystic and solid ovarian masses predictive of teratoma. The definitive diagnosis in emergency cases were as follows: perforated appendicitis plus teratoma [1]; torsion of the ovarian mass with teratoma [1]. The final diagnosis in electively treated seven patients were: unilateral ovarian teratoma [4], bilateral ovarian teratoma [1], bilateral teratoma plus appendiceal inflammatory mass [1], unilateral teratoma and contralateral corpus hemorrhagicum cyst [1]. The operations were performed by open conventional surgery in six and laparoscopy in three patients. The procedures were ovary-sparing surgery in 12 ovaries, appendectomy in 2 patients and detorsion of ovary in 1 patient. The main indication for ovary-sparing surgery was the "existence of a perfect dissection plane between the tumor margins and healthy ovarian tissue". The remaining ovarian tissue was evaluated macroscopically for residual lesions. Frozen section was performed in three suspected patients and the ovarian margins were free of any tumor cell. The pathologic diagnosis was: mature cystic teratoma in 10, immature teratoma in 1 and corpus hemorrhagicum cyst in 1. The postoperative outcome and follow-up was uneventful.

CONCLUSION

Heterogenous ovary mass containing solid and cystic portions with echogenic areas on ultrasound imaging is highly suggestive of ovarian teratomas. Emergent surgical intervention is indicated if there is any suspicion of ovarian torsion. Otherwise, MRI is performed for further radiological evaluation. Based on radiologic findings, ovary-sparing surgery can be safely performed if the preoperative diagnosis is teratoma and there is always a plane of dissection between the normal ovary and cyst wall.

Access to conservative surgical therapy for adolescents with benign ovarian masses

OBJECTIVE

To perform a population-based analysis to determine possible factors associated with use of laparoscopy and ovarian-conserving cystectomy.

METHODS

Women and girls aged 18 years or younger with benign ovarian masses who underwent surgery from 2000 to 2010 and were recorded in a commercial database were analyzed. Patients were classified based on the surgical approach (open compared with laparoscopy) and procedure (oophorectomy compared with cystectomy). Use of laparoscopy and performance of cystectomy were characterized using multivariable logistic regression models accounting for patient, surgeon, and hospital characteristics.

RESULTS

A total of 2,126 patients, including 1,425 (67.0%) who underwent laparotomy and 701 (33.0%) who had laparoscopy, were identified. Laparoscopy increased from 32.1% in 2000 to 57.9% by 2010. In a multivariable model, African American women and girls (odds ratio [OR] 0.49, 95% confidence interval [CI] 0.37-0.65) and patients in the Northeast (OR 0.65, 95% CI 0.46-0.94) were less likely to undergo laparoscopy, whereas treatment at a high-volume hospital (OR 1.35, 95% CI 1.04-1.75) was associated with use of laparoscopy. Cystectomy was performed in 57.1% in 2000 and increased to 61.4% in 2010. The only significant predictors of cystectomy were age and the specialty of the treating physician; patients aged 13-16 years (OR 1.34, 95% CI 1.03-1.75) were more likely to undergo cystectomy than were younger patients, whereas patients treated by surgeons (OR 0.51, 95% CI 0.38-0.68) were less likely to undergo cystectomy than were those treated by gynecologists.

CONCLUSION

The treatment of adolescents with benign ovarian masses is highly variable. In addition to patient characteristics, both physician and hospital factors strongly influenced treatment.

LEVEL OF EVIDENCE

II.

Laparoscopic management of a large torted ovarian cyst in an adolescent virgin: a case report

We report a case of a torted mature cystic teratoma in a 23-year-old, sexually inactive, virgin female which necessitated immediate laparoscopy. The patient and her family stressed that the integrity of the hymen must be maintained at any cost, for cultural reasons. We opted out of our routine intravaginal preparation for laparoscopic surgery to honor the patient’s request to maintain the integrity of the hymen. Left salpingo-oophorectomy was accomplished, and the specimen was removed using a large nephrectomy endobag. Here, we describe techniques that are useful for this procedure, including the use of gauze attached to ovum forceps to manipulate the uterus through the rectum, and a review of the literature.

Uterine leiomyoma causing menometrorrhagia with a concomitant mature teratoma in a 15-year-old child: a case report and review of the literature

Uterine leiomyoma is the most common uterine tumor in adult females but is rare in the pediatric population with only 10 previous cases reported. We describe the unique case of a 15-year-old girl who presented with abdominal pain and menometrorrhagia and was found to have a uterine leiomyoma as well as a mature ovarian teratoma that required surgical resection. We review diagnostic imaging and optimal management for the 2 gynecologic masses in this teenage girl.

Laparoscopic treatment of ovarian cysts in adolescents and young adults

STUDY OBJECTIVE

To investigate the laparoscopic management of ovarian cysts in adolescents and young adults.

DESIGN

A retrospective chart review study.

SETTING

Zekai Tahir Burak Women's Health Research and Education Hospital.

PARTICIPANTS

A total of 282 females aged 25 years or younger underwent laparoscopic surgery for a presumed benign ovarian cyst. Patients were grouped as adolescents (ages 12-19, n = 79) or young adults (ages 20-25, n = 203).

MAIN OUTCOME MEASURES

Surgical approach, operative findings and the correlation of intraoperative diagnosis with the definitive pathological reports.

RESULTS

The mean age of the patients was 21.2 years. At laparoscopic surgery, 89 patients (31.6%) had endometriomas, 47 (16.7%) had dermoid cysts, and 37 (13.1%) had paraovarian cysts. Ninety-seven patients (34.4%) had simple ovarian cysts. Pathological reports revealed that young adults were more likely to have endometriomas (34.0% vs 7.6%, P < 0.01), but dermoid cysts and simple ovarian cysts were more frequent (20.3% vs 15.3%, P < 0.01 and 60.7% vs 40.9%, P < 0.01, respectively).in adolescents. Eleven of the cases (3.9%) were found to have mucinous cystadenomas and fourteen (5.0%) to have serous cystadenomas. Four cysts were malignant (1.4%). Cystectomy was performed in 205 cases (72.7%), fenestration of cyst wall was performed in 53 cases (18.8%), and aspiration was applied in 22 cases (7.8%). The types of operation were not significantly different among adolescents and young adults (P > 0.05). The operative diagnosis was highly correlated with the final pathological reports (kappa value= 0.901, P < 0.001). There were no operative and postoperative complications in our series.

CONCLUSION

With a careful preoperative screening, the laparoscopic surgery of ovarian cyst is an efficient and safe treatment for adolescents and young adults.

Ovarian-sparing surgery for ovarian teratoma in children

BACKGROUND

Ovarian teratoma (OT) is the most common ovarian neoplasm in children. Oophorectomy has been the standard treatment but may impair fertility. The aim of this study was to investigate the feasibility and outcome of ovarian-sparing surgery (OSS) for OT.

PROCEDURE

We retrospectively studied all children treated for OT at a pediatric teaching hospital in Paris, France, between March 1992 and July 2006. OSS was performed when deemed technically feasible in patients who had no lymphadenopathy by preoperative imaging or surgical exploration, normal tumor marker levels, and calcifications on radiographs.

RESULTS

We identified 30 patients, including 29 with unilateral OT and 1 with synchronous bilateral OT. Emergent surgery was performed in five patients, among whom four had ovarian torsion requiring oophorectomy and one underwent OSS. Of the 26 OTs in the 25 remaining patients, 10 were managed with OSS and 16 with oophorectomy. Subsequently, ultrasound monitoring detected OT development in the contralateral ovary in 4 (14%) patients, after a median of 3 years (range, 1-14 years); OSS was performed in all four cases. The patient with bilateral synchronous OT, managed by OSS initially, underwent unilateral oophorectomy 3 years later for a recurrence. Overall OSS was performed for 15 (42%) OTs.

CONCLUSIONS

Our results suggest recommendations for preserving fertility whenever possible without compromising the oncological prognosis. In particular, OSS should be reserved for patients who meet all criteria for localized mature teratoma. Long-term follow-up is crucial.

Ovarian dermoid cyst super-infected with methicillin-sensitive Staphylococcus aureus leading to the misdiagnosis of appendicitis in an adolescent

BACKGROUND

Mature cystic teratomas (dermoid cysts) are the most common ovarian tumor in adolescents. Super-infection of a dermoid cyst is a rare event usually associated with a concomitant infection.

CASE

A 14-year-old female was transferred to our institution with five days of fevers and abdominal pain. CT of the abdomen/pelvis was read as acute appendicitis with a 7.6 cm right adnexal dermoid cyst. The patient was treated for appendicitis but later found to have an infected dermoid cyst primarily infected with methicillin-sensitive staphylococcus aureus, which led the misdiagnosis of appendicitis.

SUMMARY AND CONCLUSION

Super-infection of an ovarian dermoid cyst is an extremely rare event. We recommend that previously described evaluation, surgical management, and ovarian conservation be employed in all cases of ovarian dermoid cysts.

Ovarian pathology for the pediatric urologist

OBJECTIVES

To report the breadth of ovarian conditions that pediatric urologists may encounter through diverse referral patterns.

METHODS

Two regional pediatric centers reviewed cases from 2000 to 2010, yielding 13 females with gonad-related conditions.

RESULTS

Six of 13 patients (46%) were referred for a presumed urological condition that was later discovered to be of ovarian origin or were already known to the urology clinic for a congenital urological anomaly. Six patients had tumor markers drawn, all of which were normal. Median age was 11.2 years. The most common presenting symptoms were pain (6/13), emesis (5/13), and precocious puberty (2/13). Median mass diameter was 7.5 cm with 2 patients having masses greater than 20 cm. Histologic diagnosis was mature teratoma (4/13), streak gonad (3/13), and hemorrhagic cyst (2/13). Two patients had potentially malignant tumors (immature teratoma and juvenile granulosa cell tumor).

CONCLUSIONS

At our centers, an ovarian condition is encountered an average of 1.3 times per year. As management of pediatric ovarian cysts and masses is controversial, pediatric urologists should be familiar with the diagnosis and treatment of such conditions.

Mucinous cystadenoma arising 3 years after ovarian-sparing surgery for mature teratoma in a child

We report the case of a 15-year-old girl diagnosed with mucinous cystadenoma 3 years after ovarian-sparing surgery for a mature teratoma located in the same ovary. Ovarian teratoma is the most common ovarian neoplasm in children, whereas mucinous cystadenoma is extremely rare during childhood.