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Rich BS, McCracken K, Nagel C, Allen L, Aldrink JH. The Shared Ovary: A Multidisciplinary Discussion With Pediatric and Adolescent Gynecology. J Pediatr Surg 2024; 59:1349-1354. [PMID: 38614951 DOI: 10.1016/j.jpedsurg.2024.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/04/2024] [Indexed: 04/15/2024]
Abstract
Pediatric and adolescent ovarian lesions are common and are frequently managed by both pediatric surgeons and pediatric and adolescent gynecologists. During the 2023 American Academy of Pediatric Section on Surgery meeting, an educational symposium was delivered focusing on various aspects of management of pediatric and adolescent benign and malignant masses, borderline lesions, and fertility options for children and adolescents undergoing cancer therapies. This article highlights the discussion during this symposium.
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Affiliation(s)
- Barrie S Rich
- Division of Pediatric Surgery, Northwell Health, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Kate McCracken
- Section of Pediatric and Adolescent Gynecology, Division of Gynecology, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Christa Nagel
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, The James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Lisa Allen
- Division of Pediatric Gynecology, Department of Obstetrics and Gynecology, Sick Kids Hospital, University of Toronto, Toronto, Canada
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
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Behr GG, Morani AC, Artunduaga M, Desoky SM, Epelman M, Friedman J, Lala SV, Seekins J, Towbin AJ, Back SJ. Imaging of pediatric ovarian tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper. Pediatr Blood Cancer 2023; 70 Suppl 4:e29995. [PMID: 36184758 PMCID: PMC10642215 DOI: 10.1002/pbc.29995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 08/26/2022] [Indexed: 11/05/2022]
Abstract
Ovarian tumors in children are uncommon. Like those arising in the adult population, they may be broadly divided into germ cell, sex cord, and surface epithelium subtypes; however, germ cell tumors comprise the majority of lesions in children, whereas tumors of surface epithelial origin predominate in adults. Diagnostic workup, including the use of imaging, requires an approach that often differs from that required in an adult. This paper offers consensus recommendations for imaging of pediatric patients with a known or suspected primary ovarian malignancy at diagnosis and during follow-up.
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Affiliation(s)
- Gerald G Behr
- Department of Radiology, Memorial Sloan Kettering Cancer Center/Weill Cornell Medicine, New York, New York, USA
| | - Ajaykumar C Morani
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maddy Artunduaga
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Sarah M Desoky
- Department of Radiology, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Monica Epelman
- Department of Radiology, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Jonathan Friedman
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Shailee V Lala
- Department of Radiology, New York University Langone Health, New York, New York, USA
| | - Jayne Seekins
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, Stanford, California, USA
| | - Alexander J Towbin
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Susan J Back
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Hao J, Sun Z, Song G. Laparoscopy for Ovary-Sparing Tumorectomy in Children with Ovarian Tumors: A Clinical Retrospective Analysis. J Laparoendosc Adv Surg Tech A 2023; 33:296-302. [PMID: 36716193 DOI: 10.1089/lap.2022.0372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Objective: The aim of this study is to analyze the characteristics of pediatric ovarian tumors (OTs) and evaluate treatment strategies for ovary-sparing tumorectomy (OST). Materials and Methods: Medical records of children from October 2011 to December 2021 were reviewed. Data regarding clinical characteristics, pathological type, and management of OST were analyzed. Results: In total, 61 patients with OTs were screened. The median age was 14.8 ± 3.0 years. The median length and volume of borderline and malignant OTs were larger than those of benign OTs (P < .001 and P = .05, respectively). There was a significant difference in the median OT volume between torsion and nontorsion OTs (P = .04). The overall OST rate was 91.8% (67/73). A total of 53.4% (39/73) lesions were treated with laparoscopic OST. The OT volume was smaller in patients who underwent laparoscopy than in those who underwent laparotomy (P = .04). The probability of intraoperative tumor rupture or spillage was higher during laparoscopy than during laparotomy (P = .02). No significant differences were observed in OT recurrence. Seven patients had borderline and malignant tumors, 3 of whom had stage IA tumors and underwent OST. None of the patients experienced relapse. Conclusions: OT size is a useful reference factor for differential diagnosis and choosing laparoscopic surgery. Intraoperative tumor rupture and spillage of benign tumors during laparoscopy and laparotomy did not seem to be associated with recurrence, and laparoscopic OST was considered safe. Further prospective studies are required to confirm these conclusions.
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Affiliation(s)
- Jing Hao
- Department of Gynaecology, Weihai Municipal Hospital, Shandong, China
| | - Zhihuan Sun
- Department of Pediatric Surgery, Weihai Municipal Hospital, Shandong, China
| | - Guoxin Song
- Department of Pediatric Surgery, Weihai Municipal Hospital, Shandong, China
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Zhou J, Ye M, Jiang W, Zhu X. Quantification and influencing factors of perioperative hidden blood loss in patients undergoing laparoscopic ovarian cystectomy for benign ovarian tumours. J OBSTET GYNAECOL 2022; 42:3181-3186. [PMID: 35950341 DOI: 10.1080/01443615.2022.2109133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
This retrospective, monocentric study quantified hidden blood loss (HBL) and investigated its influencing factors in benign ovarian tumour patients undergoing laparoscopic ovarian cystectomy. Data from 153 patients who underwent laparoscopic ovarian cystectomy were retrospectively reviewed. HBL was calculated using the formula derived from 'Nadler' and 'Cross'. Pearson correlation was carried out to measure the association between HBL and potential risk factors. The average HBL was 280.22 ± 168.42 mL, accounting for 84.13 ± 19.20% of total blood loss (TBL) (347.48 ± 179.05 mL), which was a change of almost fourteen-fold relative to median visible blood loss [20.00 mL (10.00 mL, 57.5 mL)]. Surgical time, number of excisional tumours and preoperative albumin values were risk factors for HBL. HBL represents a large proportion more than 80% of TBL in patients undergoing laparoscopic ovarian cystectomy. Collectively, HBL is helpful for estimating intraoperative blood loss and better guidance of haemostatic agents, which reduces postoperative complications and expedites postoperative recovery. Additionally, the estimation of HBL also contributes to the summary, reflection and improvement of surgical technique.IMPACT STATEMENTWhat is already known on this subject? There has been a growing number of surgical patients with perioperative anaemia, which appears to be inconsistent with measured levels of visible intraoperative blood loss and postoperative drainage. This substantial but easily underestimated blood loss is known as hidden blood loss. To date, no published articles have evaluated HBL and its related risk factors in benign ovarian tumour patients undergoing laparoscopic ovarian cystectomy.What the results of this study add? HBL accounts for a large amount of TBL in laparoscopy for benign ovarian tumours. Surgical time, number of excisional tumours and preoperative albumin values are risk factors for HBL.What the implications are of these findings for clinical practice and/or further research? The management of HBL is important for the administration of perioperative blooding loss. In this context, HBL can be applied to estimate intraoperative blood loss and be better guidance of haemostatic agents to reduce postoperative complications and hasten postoperative rehabilitation. Additionally, the estimation of HBL also contributes to the summary, reflection and improvement of surgical technique.
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Affiliation(s)
- Junhan Zhou
- Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Miaomiao Ye
- Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wenxiao Jiang
- Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xueqiong Zhu
- Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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AlDakhil L, Aljuhaimi A, AlKhattabi M, Alobaid S, Mattar RE, Alobaid A. Ovarian neoplasia in adolescence: a retrospective chart review of girls with neoplastic ovarian tumors in Saudi Arabia. J Ovarian Res 2022; 15:105. [PMID: 36114569 PMCID: PMC9482250 DOI: 10.1186/s13048-022-01033-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 08/19/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Farràs Roca L, Alshehri ED, Goldberg HR, Amirabadi A, Kives S, Allen L, Navarro OM, Lam CZ. Diagnostic Performance of a Sonographic Volume and Solid Vascular Tissue Score (VSVTS) for Preoperative Risk Assessment of Pediatric and Adolescent Adnexal Masses. J Pediatr Adolesc Gynecol 2021; 34:377-382. [PMID: 33271292 DOI: 10.1016/j.jpag.2020.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/16/2020] [Accepted: 11/19/2020] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVE To evaluate the diagnostic performance of a Volume and Solid Vascular Tissue Score (VSVTS) for preoperative risk assessment of pediatric and adolescent adnexal masses. DESIGN A retrospective cohort study comprised of all female individuals who presented with an adnexal mass that was managed surgically between April 2011 and March 2016. SETTING The Hospital for Sick Children (Toronto, Ontario, Canada). PARTICIPANTS Female individuals 1-18 years of age who presented to a large tertiary pediatric hospital with an adnexal mass that was managed surgically. MAIN OUTCOME MEASURES Main outcome measures included diagnostic performance of the VSVTS for malignancy via sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), negative likelihood ratio (LR-), and receiver operating characteristic area-under-the-curve (AUC) analysis. RESULTS A total of 179 masses in 169 subjects were included. The malignancy rate was 10.6%. The AUC for the VSTVS was 0.919. A VSTVS cut-off value of 4 achieved a sensitivity of 79% (95% CI 0.54-0.93), specificity of 88% (95% CI 0.82-0.93), PPV of 0.44 (95% CI 0.33-0.56), NPV of 0.97 (95% CI 0.94-0.99), LR+ of 6.77 (95% CI 4.18-10.97), and LR- of 0.24 (95% CI 0.10-0.57). CONCLUSIONS A sonographic scoring system based on the volume and presence of solid vascular tissue improves PPV for preoperative risk stratification of adnexal masses in the pediatric and adolescent population compared to existing ultrasound-only approaches. Further prospective research is needed to determine how best to incorporate components of such scoring systems into clinical management algorithms.
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Affiliation(s)
- Lara Farràs Roca
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Ebtehaj D Alshehri
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Hanna R Goldberg
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Afsaneh Amirabadi
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sari Kives
- Section of Gynecology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Ontario, Canada
| | - Lisa Allen
- Section of Gynecology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Ontario, Canada
| | - Oscar M Navarro
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Z Lam
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.
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Lawrence AE, Minneci PC, Deans KJ. Ovarian Masses and Torsion: New Approaches for Ovarian Salvage. Adv Pediatr 2020; 67:113-121. [PMID: 32591055 DOI: 10.1016/j.yapd.2020.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Amy E Lawrence
- Department of Pediatric Surgery, Center for Surgical Outcomes Research, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Peter C Minneci
- Department of Pediatric Surgery, Center for Surgical Outcomes Research, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Katherine J Deans
- Department of Pediatric Surgery, Center for Surgical Outcomes Research, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
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Hanafy AK, Mujtaba B, Yedururi S, Jensen CT, Sanchez R, Austin MT, Morani AC. Imaging in pediatric ovarian tumors. Abdom Radiol (NY) 2020; 45:520-536. [PMID: 31745573 DOI: 10.1007/s00261-019-02316-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Abdelrahman K Hanafy
- Diagnostic Radiology, The University of Texas Health Science Centre at San Antonio, San Antonio, TX, 78229, USA
| | - Bilal Mujtaba
- Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holocombe Blvd, Houston, TX, 77030, USA
| | - Sireesha Yedururi
- Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holocombe Blvd, Houston, TX, 77030, USA
| | - Corey T Jensen
- Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holocombe Blvd, Houston, TX, 77030, USA
| | - Ramon Sanchez
- Radiology, Children's National Health System, 111 Michigan Avenue NW, Washington, DC, 20010, USA
| | - Mary T Austin
- Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holocombe Blvd, Houston, TX, 77030, USA
| | - Ajaykumar C Morani
- Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holocombe Blvd, Houston, TX, 77030, USA.
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Ovarian masses in the child and adolescent: An American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee systematic review. J Pediatr Surg 2019; 54:369-377. [PMID: 30220452 DOI: 10.1016/j.jpedsurg.2018.08.058] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 08/13/2018] [Accepted: 08/29/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND The treatment of ovarian masses in pediatric patients should balance appropriate surgical management with the preservation of future reproductive capability. Preoperative estimation of malignant potential is essential to planning an optimal surgical strategy. METHODS The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee drafted three consensus-based questions regarding the evaluation and treatment of ovarian masses in pediatric patients. A search of PubMed, the Cochrane Library, and Web of Science was performed and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to identify articles for review. RESULTS Preoperative tumor markers, ultrasound malignancy indices, and the presence or absence of the ovarian crescent sign on imaging can help estimate malignant potential prior to surgical resection. Frozen section also plays a role in operative strategy. Surgical staging is useful for directing chemotherapy and for prognostication. Both unilateral oophorectomy and cystectomy have been used successfully for germ cell and borderline ovarian tumors, although cystectomy may be associated with higher rates of local recurrence. CONCLUSIONS Malignant potential of ovarian masses can be estimated preoperatively, and fertility-sparing techniques may be appropriate depending on the type of tumor. This review provides recommendations based on a critical evaluation of recent literature. TYPE OF STUDY Systematic review of level 1-4 studies. LEVEL OF EVIDENCE Level 1-4 (mainly 3-4).
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Management of benign ovarian lesions in girls: a trend toward fewer oophorectomies. Curr Opin Obstet Gynecol 2017; 29:289-294. [DOI: 10.1097/gco.0000000000000400] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Spinelli C, Strambi S, Liloia C, Bertocchini A, Messineo A. Update on the surgical management of ovarian neoplasms in children and adolescents: analysis on 32 cases. Gynecol Endocrinol 2016; 32:787-791. [PMID: 27250513 DOI: 10.1080/09513590.2016.1190819] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Claudio Spinelli
- a Chair of Pediatric Surgery, Adolescent and Young Adult Endocrine Surgery Division, Department of Surgical, Medical, Molecular Pathology and of the Critical Area, Universita degli Studi di Pisa , Pisa , Italy and
| | - Silvia Strambi
- a Chair of Pediatric Surgery, Adolescent and Young Adult Endocrine Surgery Division, Department of Surgical, Medical, Molecular Pathology and of the Critical Area, Universita degli Studi di Pisa , Pisa , Italy and
| | - Concetta Liloia
- a Chair of Pediatric Surgery, Adolescent and Young Adult Endocrine Surgery Division, Department of Surgical, Medical, Molecular Pathology and of the Critical Area, Universita degli Studi di Pisa , Pisa , Italy and
| | - Alessia Bertocchini
- b Department of Pediatric Surgery , Universita degli Studi di Firenze , Firenze , Italy
| | - Antonio Messineo
- b Department of Pediatric Surgery , Universita degli Studi di Firenze , Firenze , Italy
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