Functional ovarian lesions in children and adolescents: when to remove them

Ovarian tumors in the pediatric population: An update

Research reveals that 1% of neoplasms in females under 17 years of age are ovarian neoplasms and though usually benign, malignant tumors may occur in the pediatric age group. This review considers various current concepts of these tumors including the epidemiology, risk factors, clinical presentations, diagnosis, differential diagnosis, and treatment options including the need to provide fertility-sparing surgery as well as their potential impacts on the psychological well-being of children and adolescents. We gathered data from the published articles ranging from studies, meta-analyses, retrospective studies, and reviews. We focused on the articles published in English between January 1, 2000, and August 31, 2023. Only a few articles published prior to 2000 were included for historical perspective.

Postoperative outcomes of ovarian preserving surgery in premenopausal women with adnexal torsion

OBJECTIVE

We aimed to determine whether ovarian-preserving surgery for adnexal torsion helps preserve ovarian function without increasing the risk of postoperative complications.

METHODS

We retrospectively evaluated 71 women who were surgically diagnosed with adnexal torsion between January 2015 and December 2019 at Severance Hospital, Yonsei University College of Medicine (ovarian preservation group, 56; oophorectomy, 15). Serum anti-Müllerian hormone (AMH) levels measured within 6 months before surgery were compared to levels measured 6-24 months after surgery. Surgical findings and postoperative complications were compared between the groups.

RESULTS

There was a borderline significant difference in the decrease in serum AMH levels between the oophorectomy group and ovarian preservation group before and after surgery. There were no significant differences between the groups in terms of fever, infection, or duration of admission. Discoloration of the twisted ovary was found in 27.3% and 33.3% of the patients in the ovarian preservation and oophorectomy groups, respectively. There was no difference in the decrease in serum AMH levels between patients with and those without discoloration.

CONCLUSION

Ovarian-preserving surgery may not increase postoperative complications in patients with adnexal torsion, even if a twisted mass is suspected to be necrotic. Moreover, the ovarian reserve may not be affected by torsion if the ovary is preserved. Conservative ovarian surgery can be safely performed to preserve the reproductive potential of women with adnexal torsion and cystic masses.

Ovarian torsion in the pediatric population: predictive factors for ovarian-sparing surgery-an international retrospective multicenter study and a systematic review

STUDY OBJECTIVE

Ovarian torsion (OT) in pediatric age is a challenging condition to diagnose and treat. To date, there is still no clear consensus about its management. Our aim was to assess some possible associated factors that can help surgeons in decision-making.

DESIGN

We conducted a retrospective multicentric study of pediatric OT surgically treated between 2010 and 2020 in six Italian and German institutions, comparing our findings with a literature review of the last 10 years (2010-2020).

PARTICIPANTS

Patients aged 0-18 years with a diagnosis of OT intraoperatively confirmed and surgically treated at the involved institutions.

RESULTS

Ninety-seven patients with a mean age at diagnosis of 8.37 years were enrolled in the study. Severe abdominal pain was present in 82 patients (84.5%). Eighty children (82.5%) presented an enlarged ovary with an US diameter > 5 cm and only 32 (40%) of them underwent conservative surgery. A laparoscopic approach was performed in 60 cases (61.9%) although in 15 (15.5%) conversion to open surgery was deemed necessary. A functional cyst was present in 49 patients (50.5%) while 11 children (11.3%) suffered from OT on a normal ovary.

CONCLUSIONS

Our results showed that a post-menarchal age (p = .001), a pre-operative US ovarian size < 5 cm, (p = .001), the presence of severe abdominal pain (p = .002), a laparoscopic approach (p < .001), and the presence of a functional cyst (p = .002) were significantly associated with conservative surgery.

The protective effect of JZL184 on ovarian ischemia reperfusion injury and ovarian reserve in rats

AIM

Ovarian torsion is a gynecopathology that requires emergency surgery in women. However, ischemia reperfusion injury (IRI) occurs after treatment with detorsion. This study aimed to evaluate the effects of monoacylglycerol lipase inhibitor JZL184 on ovarian IRI and ovarian reserve.

METHODS

Forty-eight female Wistar albino rats were divided into six groups. Group 1: Sham, Group 2: Ischemia, Group 3: ischemia/reperfusion (IR), Group 4: IR + JZL184 4 mg/kg, Group 5: IR + JZL184 16 mg/kg, Group 6: IR + vehicle (dimethyl sulfoxide). Three hours of ischemia followed by 3 h of reperfusion. Two different doses of JZL184 (4 and 16 mg/kg) were administered intraperitoneally in Group 4 and 5, 30 min before reperfusion. Ovarian IRI and ovarian reserve were evaluated in serum and tissue by using histopathological and biochemical parameters.

RESULTS

Treatment with JZL184 was associated with a significant increase in ovarian 2-arachidonoylglycerol and improved serum anti-Mullerian hormone, İnhibin B, primordial follicle count, and ovarian histopathological damage score (p < 0.05). JZL184 treatment significantly decreased the level of malondialdehyde, and increased superoxide dismutase enzyme activity and glutathione (GSH) levels (p < 0.05). The increased phosphorile nuclear factor-κB (Phospho-NF-κB-p65), tumor necrosis factor alpha (TNF-α), interleukin-1beta (IL-1β), transforming growth factor beta 1 (TGF-β1), and TUNEL assay immunopositivity scores in ovarian I/R injury were decreased after treatment with JZL184 (p < 0.05).

CONCLUSIONS

JZL184 showed significant ameliorative effects on ovarian IRI and ovarian reserve caused by IR through acting as an antioxidant, anti-inflammatory, and antiapoptotic agent. Thus, JZL184 may be a novel therapeutic agent for ovarian IRI.

Age-Specific Frequencies and Characteristics of Ovarian Cysts in Children and Adolescents

OBJECTIVE

The aim of the present study was to document ovarian cyst frequency and characteristics as well as distribution of these parameters with respect to age in children and adolescents.

METHODS

We retrospectively analyzed the medical records of 1009 girls between the ages of 5-18 years who presented to our pediatric emergency department (PED) with pelvic pain and therefore underwent pelvic ultrasound examination between June 2011 and May 2014.

RESULTS

In total, 132 of 1009 girls (13.1%) were identified as having ovarian cysts ≥1 cm in diameter. The frequency of ovarian cysts was found to be 1.8% (6/337) in children aged 5-9 years and 18.8% (126/672) in those aged 10-18 years. All the cysts detected in children aged 5-9 years were small (<3 cm) and simple with age-specific frequencies ranging between 1.5-2.7%. With the onset of adolescence, ovarian cyst frequency started to increase with age and ranged between 3.8-31.3% throughout adolescence. Age of peak ovarian cyst frequency was 15 years with a rate of 31.3%. Large ovarian cysts (>5 cm) were identified in 19 adolescents (15.1%) with most occurring during middle adolescence. Of the 19 adolescents, five were found to have cyst-related significant ovarian pathologies including cystadenoma (n=3) and ovarian torsion (n=2).

CONCLUSION

In children aged 5-9 years, ovarian cysts were infrequent and small (<3 cm). Peak ovarian cyst frequency was detected at the age of 15 years. All patients diagnosed with cyst-related significant ovarian pathologies were adolescents having a cyst >5 cm in diameter with a complex appearance in most.

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.

The approach to chronic pelvic pain in the adolescent

Adolescents present to outpatient and acute care settings commonly for evaluation and treatment of chronic pelvic pain (CPP). Primary care providers, gynecologists, pediatric and general surgeons, emergency department providers, and other specialists should be familiar with both gynecologic and nongynecologic causes of CPP so as to avoid delayed diagnoses and potential adverse sequelae. Treatment may include medications, surgery, physical therapy, trigger-point injections, psychological counseling, and complementary/alternative medicine. Additional challenges arise in caring for this patient population because of issues of confidentiality, embarrassment surrounding the history or examination, and combined parent-child decision making.

Treatment of ovarian lesions in children and adolescents: a retrospective study of 130 cases

In this study, we analyze the management of ovarian masses in a total of 130 children surgically treated for 137 ovarian lesions (7 bilateral). The most frequent symptoms were chronic (52.3%) and acute (25.4%) abdominal pain. Histological examination revealed 64 (46.7%) functional lesions, 59 (43.1%) benign neoplasms, 5 (3.7%) malignant ones, and 7 (6.6%) torsed normal ovaries. Ovarian torsion occurred in 36 cases (26.27%). A conservative treatment was performed in 81 (59.1%) girls: 61 (75.3%) treated in nonemergency and 20 (24.7%) in emergency surgery; laparoscopic approach in 35 cases (43.2%); and open surgery in 46 (56.8%). The remaining 56 (40.9%) ovarian masses underwent nonconservative surgery: 40 cases (71.4%) nonemergency and 16 (28.6%) emergency; laparoscopy in 20 patients (35.7%); and open surgery in 36 (64.3%). Fertility preservation should be a goal in the surgical treatment. The management of ovarian torsion should include adnexal detorsion and recovery of the ovarian tissue. In case of benign neoplasms, laparoscopic tumorectomy should be the gold standard; in early stage malignant tumors, fertility-sparing surgery with accurate staging is preferred.

Magnetic resonance imaging of pediatric pelvic masses

Both benign and malignant pelvic masses are encountered in the pediatric population. Although ultrasonography remains the modality of choice for initial evaluation of a pediatric pelvic mass, in selected cases magnetic resonance (MR) imaging can add important diagnostic information. MR imaging has several advantages over ultrasonography and computed tomography, including superior contrast resolution and an ability to characterize abnormalities based on unique tissue characteristics. MR evaluation assists in lesion characterization, presurgical planning, and staging when a malignancy is suspected. MR imaging also offers a nonionizing imaging modality for long-term follow-up of patients undergoing therapy for malignant pelvic masses.

Laparoscopy in elective and emergency management of ovarian pathology in children and adolescents

INTRODUCTION

Ovaries are one of the most common locations of tumor masses in children. Some of them require surgery due to the risk of malignancy or necrosis. This organ seems to be ideal for the laparoscopic approach.

AIM

To evaluate the usefulness of laparoscopy in surgery of lesions located in the ovaries in patients under 18 years of age and assess the risk of changes in the ovaries in girls with acute abdominal symptoms.

MATERIAL AND METHODS

Retrospective evaluation of hospital records of the period 1996-2012 from a single hospital was performed. 105 laparoscopic procedures of ovarian pathology in patients aged 0-18 (mean: 13.5) years were reviewed. The overall sample was divided into groups depending on the indication and mode of surgery. Group I: elective or emergency surgery, imaging findings of ovarian cysts bigger than 5 cm or causing pain. Group II: elective surgery, the ovarian tumor visible in imaging (solid mass or mixed). Group III: treatment for acute abdomen, without visible ovarian pathology in the preoperative imaging studies. Group IV: elective treatment of other indications, incidental finding.

RESULTS

There were no deaths or major complications. There were no conversions. Average length of hospital stay after surgery was 2.5 days. The risk of appendicitis in patients referred for surgery due to ovarian cysts visualized in ultrasound, in the factual absence of ovarian pathology (false positive ultrasound), in the presented material was 5.2%. The risk of lesions in the ovaries in patients operated on due to acute abdominal pain, with no findings in the pre-operative ultrasound (false negative ultrasound), in the presented material was 7.4%. The risk of coexistence of changes in the ovaries with appendicitis found during the procedure due to acute abdominal pain in the study group was 6%.

CONCLUSIONS

The laparoscopic treatment for ovarian masses is safe and efficient. The risk of wrong preoperative diagnosis (ovary mass vs. appendicitis) is in any direction between 5 and 8%, which is a number large enough to be taken into consideration when surgical training and legislation is concerned.

Adnexal torsion in children and adolescents: new trends to conservative surgical approach -- our experience and review of literature

The purpose of this study is to discuss the surgical treatment for ovarian torsion in children and adolescents with a focus on the procedures of adnexal conservation surgery and its frequency in the literature of the last 10 years. We retrospectively reviewed the medical charts of 127 operative ovarian lesions including 30 ovarian torsions (23.6%) treated in two pediatric centers over a 10-year period. Age at presentation, presenting symptoms, diagnostic studies, surgical procedure and pathological findings were analyzed. Mean age was 13.7 years. Conservative surgery has been performed in 46.7% of the cases and laparoscopic approach in 40%. Ovarian torsion occurred in 56.7% on ovaries with functional lesion, in 23.3% on normal adnexa and in 20% on ovaries with benign neoplasm. The article includes a literature review (2000-2010) and a statistical analysis which shows a slow increase in conservative surgery from 28 to 45%. Laparoscopic surgery accounts for 23.5%. Literature review shows 40.5% normal adnexa, 33.2% non-neoplastic lesions, 25.3% benign neoplasms and 1% malignant neoplasms. The surgical treatment of children and adolescents presenting adnexal torsion should be practiced as an emergency and it should be more conservative as possible in order to maximize the future reproductive potential.