Opting for conservative management over surgery for neonatal ovarian cysts

OBJECTIVE

To explore the suitability of conservative management for neonatal ovarian cysts in newborns.

METHODS

A retrospective cohort study was conducted, involving infants diagnosed with neonatal abdominal/pelvic cysts at two separate medical institutions from January 2015 through July 2021. Data collection included clinical characteristics, imaging results, pathological findings, and postnatal outcomes. Statistical analyses were performed using the Student's t-test, Mann-Whitney U-test, and receiver operating characteristic (ROC) curve.

RESULTS

In total, 34 cases of neonatal abdominal/pelvic cystic masses were detected, with mean birth weight of 3401 ± 515 g. Of these, 22 patients underwent postnatal cystectomy/oophorectomy. Pathological assessments revealed 16 uncomplicated cysts, 5 complex cysts, and 1 ovarian cyst with torsion complications. Notably, the cysts' dimensions at the time of surgical intervention had significantly decreased from the initial measurements (p = 0.015). The ROC curve analysis presented an area under the curve of 0.642, indicating moderate accuracy in employing cyst size as a discriminative feature to differentiate complex from simple ovarian cysts. Additionally, a short-term follow-up of nonsurgical cases indicated a 100% resolution rate by 24 months of age (n = 9).

CONCLUSION

Given their predominantly benign nature, the majority of neonatal ovarian cysts seem to be amenable to conservative management. This approach remains justified for larger cysts with minimal torsion risk, as well as considering the observed reduction in cyst size at birth, which further supports the case against surgical intervention.

Torsion of paratubal cyst mimicking ovarian torsion: A rare case of difficult diagnosis

INTRODUCTION

Paratubal cysts are frequent lesions, and may be responsible for complications such as adnexal torsion, which is rare and difficult to diagnose. Management requires emergency surgery in an attempt to preserve the adnexa.

PRESENTATION OF CASE

We report a rare case of a young patient admitted with a Torsion of paratubal cyst mimicking ovarian torsion, the positive diagnosis was difficult.

DISCUSSION

Paratubal cysts are lesions that constitute around 10 % of adnexal masses, and may have their embryological origin in Wolfian remnants. Morgagni's hydatid is by far the most common form. Torsion of a para-tubal cyst may manifest as sudden, continuous, or rapidly worsening pain in the iliac fossa. Ultrasound should systematically seek to identify the ovaries outside the lesion. Isolated tubal torsion can only be treated surgically. Laparoscopy is the gold standard.

CONCLUSION

Paratubal cyst torsion is rare and very difficult to diagnose, but should be systematically considered in the case of an adolescent presenting with acute pelvic pain.

Ovarian Masses in Children and Adolescents: A Review of the Literature with Emphasis on the Diagnostic Approach

Most abdominal masses in the pediatric population derive from the ovaries. Ovarian masses can occur in all ages, although their incidence, clinical presentation and histological distribution vary among different age groups. Children and adolescents may develop non-neoplastic ovarian lesions, such as functional cysts, endometrioma, torsion, abscess and lymphangioma as well as neoplasms, which are divided into germ cell, epithelial, sex-cord stromal and miscellaneous tumors. Germ cell tumors account for the majority of ovarian neoplasms in the pediatric population, while adults most frequently present with epithelial tumors. Mature teratoma is the most common ovarian neoplasm in children and adolescents, whereas dysgerminoma constitutes the most frequent ovarian malignancy. Clinical manifestations generally include abdominal pain, palpable mass, nausea/vomiting and endocrine alterations, such as menstrual abnormalities, precocious puberty and virilization. During the investigation of pediatric ovarian masses, the most important objective is to evaluate the likelihood of malignancy since the management of benign and malignant lesions is fundamentally different. The presence of solid components, large size and heterogenous appearance on transabdominal ultrasonography, magnetic resonance imaging and computed tomography indicate an increased risk of malignancy. Useful tumor markers that raise concern for ovarian cancer in children and adolescents include alpha-fetoprotein, lactate dehydrogenase, beta subunit of human chorionic gonadotropin, cancer antigen 125 and inhibin. However, their serum levels can neither confirm nor exclude malignancy. Management of pediatric ovarian masses needs to be curative and, when feasible, function-preserving and minimally invasive. Children and adolescents with an ovarian mass should be treated in specialized centers to avoid unnecessary oophorectomies and ensure the best possible outcome.

Ovarian Torsion and Its Remediation in a Three-Year-Old Girl

Ovarian torsion is a rare, emergent occurrence seen in the premenarchal population. If detected promptly, ovarian torsion can be treated via detorsion. We present a case of a three-year-old girl whose ovary spontaneously torsed and was corrected via ovarian detorsion. The patient presented with sudden-onset abdominal pain and emesis; a transabdominal ultrasound with Doppler was performed, which led to the diagnosis of ovarian torsion. The patient was directly taken into surgery for correction, after which she quickly recovered and was subsequently discharged. The choice of ovarian detorsion to protect fertility in pediatric patients is supported by this case and by the related literature. The key to safeguarding fertility in these patients lies in rapid detection, which remains a challenge in the pediatric population. By raising widespread awareness of the use of Doppler ultrasound as well as symptom presentation, the protection of fertility in cases of pediatric ovarian torsion can be improved.

The role of magnetic resonance imaging in acute abdominal pain in paediatric age group

Background

The purpose of this study is to evaluate the utility of magnetic resonance imaging in the assessment of acute atraumatic abdominal pain as the first line cross sectional modality in children, so as to prevent excessive radiation exposure from computed tomography scan and to review the magnetic resonance imaging features of common acute abdominal and pelvic conditions.

Results

30 patients (0–18 years) underwent rapid unenhanced magnetic resonance imaging. The results of our study indicated that for the diagnosis of causes for acute abdominal pain, magnetic resonance imaging had sensitivity of 92% (95% confidence interval 73.8–97.6%) and a specificity of 80% (95% confidence interval 28.4–99.5%). The positive predictive value was 95.8% (95% confidence interval 79.9–99.3%) and negative predictive value was 67% (95% confidence interval 33.1–89.0%) which had a highly significant statistical association (p < 0.001).

Conclusion

Unenhanced magnetic resonance imaging is an excellent option for the initial, detailed evaluation of acute abdominal emergencies in pediatric patients because it can diagnose the whole range of presenting abnormalities which include the causes of abdominal pain warranting surgical and nonsurgical management.

Added value of gadolinium-based contrast agents for magnetic resonance evaluation of adnexal torsion in girls

PURPOSE

Ultrasound is the first-line imaging modality to evaluate adnexa in girls with clinical suspicion of torsion. Patients with equivocal ultrasound findings can undergo MRI for better delineation of adnexal pathology. Here, we assess the utility of intravenous contrast in MRI evaluation of adnexal torsion in children.

METHODS

Two pediatric radiologists (R1, R2) retrospectively reviewed 198 pelvic MRI exams in 172 girls (median age 15 years). Each MRI was reviewed twice. The first review included pre-contrast images only. A second review, at least 1 month later, included both pre- and post-contrast images. Readers concluded if findings were suspicious for torsion or not. Readers' findings were compared to each other's and to surgical and MRI reports and clinical course.

RESULTS

198 MRI exams yielded 354 evaluable ovaries. Surgical and pathological reports were available for 47 patients. 11 patients had adnexal torsion. Both readers accurately diagnosed acutely torsed ovaries during pre- and post-contrast reviews (n = 4). However, readers disagreed on torsed paraovarian cysts (n = 4) and chronically/intermittently torsed ovaries (n = 3). In 21 non-torsed ovaries that had lesions, one or both readers concluded that there were pre-contrast features of torsion. In this set with ovarian lesions, contrast helped readers to correctly conclude no torsion (R1 = 8, R2 = 6) more commonly than to incorrectly conclude torsion (1 each), improving post-contrast specificity for each reader.

CONCLUSIONS

Post-contrast sequences did not provide additional benefit in evaluating acutely torsed ovaries but helped in excluding torsion in patients with adnexal lesions. Therefore, contrast administration should be individualized, potentially reserved only for those with abnormal ultrasound or pre-contrast images.

Pediatric Ovarian Torsion: Should You Go With the Flow?

OBJECTIVES

Ovarian torsion (OT) is an emergency that mandates early detection and surgical detorsion to avoid catastrophic consequences of further adnexal injury. Prompt ultrasound is critical for accurate diagnosis. Traditionally, evaluation of arterial and venous flow was used as a diagnostic tool for OT, but recent radiologic research has indicated that ovarian size and size discrepancy between sides is a better diagnostic criterion. This study seeks to determine whether ovarian size discrepancy or vascular flow to the ovary is more accurate in the diagnosis of OT in the pediatric emergency population and to better describe symptoms that distinguish OT from other abdominal and pelvic pathology.

METHODS

This was a retrospective, cross-sectional study evaluating all female pediatric patients, aged 1 to 18 years, who underwent a pelvic ultrasound to evaluate for OT over a 2-year period in our pediatric emergency department. Patients suitable for inclusion were identified via Nuance mPowerTM, a search engine that provides clinical analytics based on radiology reports generated within our institution.

RESULTS

We reviewed the medical records of 193 female patients aged 1 to 18 years, all of whom had a pelvic ultrasound (with or without Doppler) to evaluate for OT during the study period. In comparing ovarian size on ultrasound, patients with OT had a significantly larger magnitude of difference in ovarian volume than patients without torsion (5.57× [interquartile range, 3-12.5] vs 1.56× [interquartile range, 1.24-2.25; P < 0.001]). Ovarian torsion was associated with a 33-fold increased risk of lack of arterial flow (relative risk, 33.33) and with a 9-fold increased risk of lack of venous flow (relative risk, 9.27), when compared with those patients without OT. Patients with OT were significantly more likely to have emesis and peritoneal signs on examination, as well as previous history of OT (P = 0.01, 0.02, and 0.002, respectively) than those without OT. All patients with OT reported abdominal pain.

CONCLUSIONS

We found that a large size discrepancy between ovaries is indicative of OT. Our data also suggest that presence of Doppler flow on ultrasound cannot be used to exclude OT but that lack of Doppler flow on ultrasound is a significant diagnostic marker. As previous studies have also found, clinical symptoms of OT are nonspecific and do not offer any certainty in differentiating OT from other pathologies.

Ovarian torsion: diagnosis, surgery, and fertility preservation in the pediatric population

Ovarian torsion is rare in the pediatric population. Delayed diagnosis can significantly impact fertility. The aim of this review is to highlight current knowledge regarding clinical presentation, diagnosis, surgical management, and follow-up in the pediatric population. Whilst the presentation is often very unspecific, most children will present with sudden severe unilateral pelvic pain associated with vomiting. A key diagnostic test is pelvic ultrasonography, which may help demonstrate an asymmetric enlarged ovary with peripherally displaced follicles. In the pediatric population, ovarian torsion may occur in a normal ovary. However, underlying lesions can be found in half of cases. Benign neoplasms (teratomas or cystic lesions) represent the commonest etiology, with the risk of malignancy being less than 2%. Surgical management should be focused on fertility preservation. This is achievable through ovarian detorsion ± ovarian cystectomy ± oophoropexy to avoid recurrence. Follow-up studies demonstrate excellent recovery rates of detorsed ovaries including those with ischemic appearances. What is Known: • Ovarian torsion is a rare diagnosis in the pediatric population. • Aspecific symptoms and differential diagnoses lead to missed or delayed diagnosis increasing the risk of oophoprectomy and further infertility. What is New: • Reviewing the latest knowledge about clinical presentation, diagnostic, surgical management, and follow-up of ovarian torsion in the pediatric population. • Adiponectin was negatively associated with diastolic blood pressure and HOMA-IR, and chemerin was negatively associated with glucose.

Ovarian Torsion: Presentation and Management in a Pediatric Patient

Background. Adnexal torsion is the fifth most common gynecologic emergency accounting for approximately 20 to 30% of ovarian surgeries in pediatric patients. Case. The patient is a ten-year-old female who presented to the emergency room for severe left lower quadrant abdominal pain. On presentation, she was hemodynamically stable with an acute abdomen. A transabdominal ultrasound showed a predominantly anechoic structure measuring up to 5.6 cm without definitive Doppler flow, concerning for a large cyst causing ovarian torsion. Gynecology was consulted, and the patient underwent a diagnostic laparoscopy, aspiration of the left ovarian cyst, and left ovarian detorsion. Pathology results were consistent with benign cystic contents. Conclusion. Appropriate diagnosis and timely surgical gynecological intervention allowed this pediatric patient to salvage and preserve ovarian function.

Characteristics and Risk Factors for Ischemic Ovary Torsion in Children

Identifying ischemic ovary as a complication of ovary torsion (OT) is a significant challenge in children. This study identified risk factors for ischemic OT among pediatric OT patients to prevent delayed treatment. This retrospective study included pediatric inpatients who underwent operation for OT over 20 years. We employed multivariable logistic regression to find the risk factors associated with ischemic OT. Among the 118 patients included in this study, 78 (66.1%) had ischemic OT. Patients with ischemic OT tended to be younger; had more frequent vomiting; and had elevated White blood cell (WBC), C-Reactive protein (CRP), and segments in comparison with non-ischemic OT patients. Multivariable regression showed increased odds of ischemic ovary torsion, associated with higher WBC (12.3 × 10³/mm³ vs. 8.7 × 10³/mm³, p < 0.001), CRP (50.4 mg/L vs. 8.4 mg/L, p < 0.001), and vomiting (55.1% vs. 25%, p = 0.002) than in non-ischemic patients. A receiver-operating characteristic (ROC) analysis indicated that patients with vomiting, leukocytosis, or CRP ≧ 40 mg/L were more likely to have ischemic OT (sensitivity, 92%; specificity, 54%; PPV, 79.6; NPV, 78.9%). Ischemic OT is common among pediatric OT patients. The presence of potential risk factors of vomiting, leukocytosis, and CRP more significant than 40 mg/L may assist clinicians in ensuring an expedited surgical treatment.

Computed Tomography Features of Adnexal Torsion: A Meta-Analysis

OBJECTIVES

We performed a meta-analysis of studies examining the computed tomography (CT) features of adnexal torsion (AT).

METHODS

We searched PubMed, Embase, Web of Science, and the Cochrane Library for studies involving the proportion of CT features in patients with AT and that used surgery as the reference test. Study quality was assessed using the Newcastle-Ottawa scale and the Agency for Healthcare Research and Quality tool.

RESULTS

Twelve articles involving 483 patients were included. The pooled proportion of right-sided adnexal lesion was 54% (95% confidence interval [CI]: 49%-56%). The pooled proportions of the ovarian lesion histopathological types were: benign germ cell tumors, 33% (95% CI: 28%-37%); benign cystic lesions, 26% (95% CI: 21%-30%); benign epithelial neoplasms, 24% (95% CI: 20%-29%); sex cord-stromal tumors, 4% (95% CI: 2%-6%); borderline neoplasms, 3% (95% CI: 1%-6%); and hemorrhagic cysts, 2% (95% CI: 0%-3%). The pooled proportions of CT features were: Adnexal enlargement, 99% (95% CI: 98%-99%); adnexal with mass, 98% (95% CI: 97%-100%); twisted pedicle, 81% (95% CI: 78%-83%); mass with thickened wall, 77% (95% CI: 73%-81%); tubal thickening, 73% (95% CI: 68%-77%); abnormal location of adnexa, 69% (95% CI: 63%-75%), pelvic ascites, 43% (95% CI: 38%-49%); pelvic fat infiltration, 41% (95% CI: 34%-48%); uterine deviation, 37% (95% CI: 31%-42%); and lack of enhancement, 20% (95% CI: 14%-25%).

CONCLUSION

Adnexal enlargement, adnexal mass, and twisted pedicle may be the most important CT features for diagnosing AT.

A Case of Torsion in an Otherwise-Normal Ovary with a Giant Hematosalpinx Larger than Enlarged Ovary: Utilization of Diagnostic Laparoscopy for the Accurate Diagnosis

We report a case of torsion in an otherwise-normal ovary with a giant hematosalpinx. A 23-year-old woman presented with complaints of abdominal pain and nausea. At initial visit, there was few abnormal findings of imaging tests, and we made a diagnosis of ovarian hemorrhage. Three days later, she came back with increased symptoms, and we detected the mass of a complex solid cystic structure with a unilocular cyst much larger than solid component. A diagnostic laparoscopy was performed immediately, and we could make a diagnosis of torsion in an otherwise-normal ovary with a giant hematosalpinx. We performed a salpingectomy and could preserve her ovary. This is the first case of torsion in an otherwise-normal ovary with a giant hematosalpinx which enlarged to a greater extent than the ovary.

Isolated torsion of a fallopian tube: an uncommon cause of abdominal pain in an 11-year-old

This report describes a rare case of isolated fallopian tube torsion (IFTT) in a premenarchal 11-year-old girl. The patient presented with subacute abdominal pain, associated with nausea and vomiting. Sonographic findings revealed left tube enlargement with free intraperitoneal fluid. Doppler mapping was not unequivocal. During exploratory laparoscopy, a large pelvic necrotic mass was found to be a twisted left fallopian tube. After detorsion, salpingectomy was performed and the patient recovered promptly, showing no complications 3 months post operation. IFTT should be considered as a differential diagnosis of lower abdominal pain in adolescent girls with normal-appearing ovaries on ultrasound. Conservative management for fertility preservation is the ideal approach. Therefore, avoiding delay in laparoscopy is crucial.

Can contrast enhanced ultrasound (CEUS) be useful in the diagnosis of ovarian torsion in pediatric females? A preliminary monocentric experience

PURPOSE

To describe contrast enhanced ultrasound (CEUS) characteristics of ovarian torsion in pediatric females, assessing the potential diagnostic advantages of method as well as its limitations.

MATERIALS AND METHODS

A retrospective study design was used. Between January 2018 and December 2020 we analyzed all pediatric females who underwent explorative surgery with a suspected diagnosis of ovarian torsion, and who were previously evaluated by conventional ultrasound (US), color-Doppler ultrasound (CDUS) and CEUS.

RESULTS

We examined twenty pediatric females with a median age of 12 years. US identified 9/20 ovarian complex masses against 13/20 by CEUS. At US abdominal free fluid was shown in 13/20 patients and in 18/20 cases with CEUS. In our case series the evaluation of contrast enhancement at CEUS in the detection of ovarian torsions revealed a sensitivity of 94.1%, a specificity of 100% and an overall accuracy of 95%.

CONCLUSION

Although there is a known ultrasound semeiotics suggestive of ovarian torsion, it is not always possible to obtain a diagnosis of certainty with conventional US even with CDUS. The study reports that complementation with CEUS showed excellent agreement with surgery obtaining a diagnosis in almost all the pediatric females examined.

Clinical and CT features of ovarian torsion in infants, children and adolescents

OBJECTIVE

To investigate the clinical features and computed tomography (CT) findings of pediatric ovarian torsion.

METHODS

A retrospective analysis of the clinical and CT data of 61 newborns, infants, children, and adolescents with ovarian torsion confirmed by histopathology was performed.

RESULTS

Clinical features included abdominal mass, abdominal pain, nausea and vomiting, and fever. The tumor marker α-fetoprotein was increased in five cases. Ovarian enlargement was found in 26 cases, and follicles were detected in the peripheral region of the ovary in 21 cases. Twenty-one cases presented as solid mixed-density masses on CT images. A total of 30 cases of ovarian torsion were associated with a benign ovarian mass. Among 27 cases of cystic or predominantly cystic masses, the mass had a thickened wall in 26 cases and showed an uneven density in 23 cases. Among all 61 patients, a torsed pedicle was detected in 47 cases. A torsed ovary or mass exhibited mild contrast enhancement in seven cases. Uterine deviation toward the involved side, blurred fat space around lesions, and pelvic free fluid were also found.

CONCLUSION

Pediatric ovarian torsion presents a relatively characteristic CT appearance. Correct diagnosis can be established based on clinical and imaging features.

A Case Report of Pediatric Ovarian Torsion: The Importance of Diagnostic Laparoscopy

Introduction

Pediatric ovarian torsion is a relatively rare occurrence with chances of significant morbidity and possible mortality if not treated emergently.

Case Report

In this report, we review a case of pediatric ovarian torsion in a nine-year-old that was difficult to diagnose on initial presentation to the hospital due to various factors, which inevitably led to delayed resolution.

Conclusion

We discuss the diagnosis of pediatric ovarian torsion including risk factors, symptoms, imaging modalities, and surgical diagnostics. To improve diagnosis and shorten time to treatment, this case supports the use of laparoscopy for diagnosis of ovarian torsion if indicated by clinical suspicion and supplemental imaging studies.

Unenhanced MRI of the Abdomen and Pelvis in the Comprehensive Evaluation of Acute Atraumatic Abdominal Pain in Children

OBJECTIVE. The purpose of this study is to show the utility of rapid unenhanced MRI in the comprehensive assessment of acute atraumatic abdominal pain in children, including appendicitis and alternate diagnoses, and to review the MRI features of common acute abdominal and pelvic conditions in a large, single-institution cohort. CONCLUSION. Rapid unenhanced MRI is an excellent option for the initial, comprehensive evaluation of acute abdominal emergencies in pediatric patients because it can diagnose the full range of presenting abnormalities, including causes of abdominal pain warranting surgical and nonsurgical management.

[Top ten pediatric radiological emergencies]

Pediatric emergencies encompass a wide range of different findings. These include injuries to the child's body due to high-energy trauma or abuse, unclear limitations of consciousness and primarily unspecific abdominal or thoracic pain as well as swallowing or inhalation of foreign bodies. Detailed knowledge of the various imaging methods and the correct application are important. This article gives an overview of the significance of imaging techniques for emergency diagnostics in childhood and adolescence.

Added value of MRI for the diagnosis of adnexal torsion in children and adolescents after inconclusive ultrasound examination

PURPOSE

The purpose of this study was to assess the performance of magnetic resonance imaging (MRI) in children and adolescents with suspected adnexal torsion (AT) after inconclusive initial ultrasound examination.

MATERIALS AND METHODS

Twenty-eight girls with a mean age of 12±4 (SD) years (range: 1 month to 18years) were included. All had clinically suspected AT and inconclusive initial ultrasound findings followed by pelvic MRI as a second-line imaging modality. The final diagnosis was obtained by surgery or follow-up. Two radiologists blinded to the clinical, ultrasound and surgical data, retrospectively and independently reviewed MRI examinations. Clinical and MRI features associated with AT were searched for using univariate analyses.

RESULT

Among the 28 patients, 10/28 patients (36%) had AT and 22/28 (79%) had an ovarian or tubal mass. AT was associated with an age<13years (OR: 10.7; 95% CI: 1.3-148.2) (P=0.022) and a whirlpool sign at MRI (OR: 61.0; median unbiased estimate, 7.2) (P<0.0001). When a mass was present, the best quantitative MRI criteria for AT were mass volume and ovary-corrected volume≥30cm³ (κ=0.72 and 0.61, respectively), mass axis length≥5cm (κ=0.90), and mass surface area≥14 cm² (κ=0.58), with moderate to almost perfect interobserver agreement. The overall sensitivity, specificity and accuracy of MRI for the diagnosis of AT were 100% (10/10; 95% CI: 69-100), 94% (17/18; 95% CI: 73-100) and 96% (27/28; 95% CI: 82-100) respectively, with perfect interobserver agreement (κ=1).

CONCLUSION

In pediatric patients with suspected AT and inconclusive initial ultrasound examination, a strategy including MRI as a second-line imaging modality should be considered if MRI does not delay a potential surgery.

Ovarian torsion and laparoscopy in the paediatric and adolescent population

A 9-year-old girl attended the emergency department with right-sided abdominal pain and vomiting. Due to history and following examination, an ultrasound was requested which demonstrated a large complex midline mass. The most likely diagnosis was ovarian torsion, for which the patient underwent laparoscopy, detorsion and ovarian cystectomy. Histology revealed a mature cystic teratoma. Although less common than in the adult population, it is important to consider ovarian torsion in children and adolescents. Presentation is usually with pain accompanied by vomiting and fever, although these symptoms are not always present. Current management is organ-sparing, with laparoscopy±cystectomy. We discuss the adaptations for this procedure with regard to the paediatric and adolescent population. Differences in the anatomy and physiology must lead to consideration for alterations in surgical technique and positioning to ensure the safest and best quality care for these young patients.

Ovarian torsion: developing a machine-learned algorithm for diagnosis

BACKGROUND

Ovarian torsion is a common concern in girls presenting to emergency care with pelvic or abdominal pain. The diagnosis is challenging to make accurately and quickly, relying on a combination of physical exam, history and radiologic evaluation. Failure to establish the diagnosis in a timely fashion can result in irreversible ovarian ischemia with implications for future fertility. Ultrasound is the mainstay of evaluation for ovarian torsion in the pediatric population. However, even with a high index of suspicion, imaging features are not pathognomonic.

OBJECTIVE

We sought to develop an algorithm to aid radiologists in diagnosing ovarian torsion using machine learning from sonographic features and to evaluate the frequency of each sonographic element.

MATERIALS AND METHODS

All pediatric patients treated for ovarian torsion at a quaternary pediatric hospital over an 11-year period were identified by both an internal radiology database and hospital-based International Statistical Classification of Diseases and Related Health Problems (ICD) code review. Inclusion criteria were surgical confirmation of ovarian torsion and available imaging. Patients were excluded if the diagnosis could not be confirmed, no imaging was available for review, the ovary was not identified by imaging, or torsion involved other adnexal structures but spared the ovary. Data collection included: patient age; laterality of torsion; bilateral ovarian volumes; torsed ovarian position, i.e. whether medialized with respect to the mid-uterine line; presence or absence of Doppler signal within the torsed ovary; visualization of peripheral follicles; and presence of a mass or cyst, and free peritoneal fluid. Subsequently, we evaluated a non-torsed control cohort from April 2015 to May 2016. This cohort consisted of sequential girls and young adults presenting to the emergency department with abdominopelvic symptoms concerning for ovarian torsion but who were ultimately diagnosed otherwise. These features were then fed into supervised machine learning systems to identify and develop viable decision algorithms. We divided data into training and validation sets and assessed algorithm performance using sub-sets of the validation set.

RESULTS

We identified 119 torsion-confirmed cases and 331 torsion-absent cases. Of the torsion-confirmed cases, significant imaging differences were evident for girls younger than 1 year; these girls were then excluded from analysis, and 99 pediatric patients older than 1 year were included in our study. Among these 99, all variables demonstrated statistically significant differences between the torsion-confirmed and torsion-absent groups with P-values <0.005. Using any single variable to identify torsion provided only modest detection performance, with areas under the curve (AUC) for medialization, peripheral follicles, and absence of Doppler flow of 0.76±0.16, 0.66±0.14 and 0.82±0.14, respectively. The best decision tree using a combination of variables yielded an AUC of 0.96±0.07 and required knowledge of the presence of intra-ovarian flow, peripheral follicles, the volume of both ovaries, and the presence of cysts or masses.

CONCLUSION

Based on the largest series of pediatric ovarian torsion in the literature to date, we quantified sonographic features and used machine learning to create an algorithm to identify the presence of ovarian torsion - an algorithm that performs better than simple approaches relying on single features. Although complex combinations using multiple-interaction models provide slightly better performance, a clinically pragmatic decision tree can be employed to detect torsion, providing sensitivity levels of 95±14% and specificity of 92±2%.

Cost Comparison of Ultrasound Versus MRI to Diagnose Adolescent Female Patients Presenting with Acute Abdominal/Pelvic Pain Using Time-Driven Activity-Based Costing

RATIONALE AND OBJECTIVES

To compare the cost of ultrasound (US) versus magnetic resonance imaging (MRI) using time-driven activity-based costing in adolescent female patients with suspected appendicitis.

MATERIALS AND METHODS

Process maps were created using data from electronic medical record review and patient shadowing for adolescent female patients undergoing US or noncontrast MRI exams of the abdomen and pelvis for suspected appendicitis. Capacity cost rates for all personnel, equipment, facilities, and supplies in each exam pathway were established from institutional accounting data. The cost of each process step was determined by multiplying step-specific capacity cost rates by the mean time required to complete the step. Total pathway costs for US and MRI were computed by summing the costs of all steps through each pathway, and a direct cost comparison was made between the two modalities.

RESULTS

Process maps for US and MRI pathways were generated from 231 and 52 patient encounters, respectively. Patients undergoing US exams followed one of six pathways depending on exam order (abdomen versus pelvis performed first) and whether additional time was needed for bladder filling. Mean total US pathway time was 91 minutes longer than for MRI (US = 166 minutes; MRI = 75 minutes). Total MRI pathway cost was $209.97 compared to a mean US cost of $258.33 (range = $163.21-$293.24).

CONCLUSION

MRI can be a faster and less costly alternative to US for evaluating suspected appendicitis in adolescent female patients. While precise costs will vary by institution, MRI may be a viable and at times preferable alternative to US in this patient population.

Non-visualization of the ovaries on pediatric transabdominal ultrasound with a non-distended bladder: Can adnexal torsion be excluded?

BACKGROUND

The pediatric reproductive organs are optimally imaged with a full bladder. The filling of the bladder, however, often leads to significant delay in diagnosis and can subject the patient to invasive bladder catheterization. As the key imaging feature in ovarian torsion is unilateral ovarian enlargement, we suspected that a torsed ovary is large enough to be visualized even if the bladder is not well distended.

OBJECTIVE

The purpose of this study was to retrospectively investigate if clinically suspected adnexal torsion can be excluded based on non-visualization of the ovaries on transabdominal ultrasound (US) with a non-distended bladder in pediatric patients.

MATERIALS AND METHODS

This retrospective study comprised 349 girls (1-19 years old) between Jan. 1, 2013, and July 30, 2018. Three hundred and forty-one of the girls were referred to transabdominal US to assess for adnexal torsion and/or appendicitis, and the ovaries were initially not visualized on US. Their bladders were subsequently filled and rescanned with a distended bladder showing the ovaries. Ovarian volumes and time between US scans were documented. The ratio of the volume of the larger ovary to the smaller one was calculated. Nine girls had surgically proven adnexal torsion and a preoperative transabdominal US with a non-distended bladder. There was an overlap of one girl between the two groups. The negative predictive value (NPV), positive predictive value (PPV), and sensitivity and specificity for exclusion of adnexal torsion based on non-visualization of the ovaries on US with a non-distended bladder were calculated.

RESULTS

One of the girls (1/341) who had a US study done with a non-distended bladder in which the ovaries were not visualized had a positive diagnosis of adnexal torsion. In eight of the nine girls who had surgically proven adnexal torsion, the torted ovary was identified with a non-distended bladder. The NPV and PPV for exclusion of adnexal torsion with a non-distended bladder was 1.0 and 0.8, respectively. The specificity and sensitivity were 99.4% and 88.9%, respectively. The mean and median time difference between the initial scan and the scan after bladder filling was 105.1 min (standard deviation [SD] -65.8) and 89.0 min (interquartile range [IQR]- 59.0, 130.5), respectively.

CONCLUSION

Non-visualization of the ovaries with a non-distended bladder on transabdominal US study can help exclude clinically suspected adnexal torsion, alleviating the need for bladder filling and prolonging the wait time in the emergency department. Inclusion of non-visualization of the ovaries as one of the features in a predictive score for adnexal torsion should be considered.

Ovarian Torsion in Premenarchal Girls

STUDY OBJECTIVE

To investigate characteristics that differentiate premenarchal girls with ovarian torsion (OT) from those without OT at the time of surgery.

DESIGN

Retrospective chart review of 36 premenarchal girls who underwent 42 surgeries for either OT (n = 33) or a nontorsed ovarian mass (n = 9) from 2006 to 2017.

SETTING

Large, tertiary care academic institution.

PARTICIPANTS

We included patients aged 0-12 years with International Classification of Diseases, Ninth Revision codes for torsion of the ovary, adnexa, ovarian pedicle, or fallopian tube. Controls had International Classification of Diseases, Ninth Revision codes for ovarian mass or cyst, who also underwent surgery and did not have OT.

INTERVENTIONS

Records were reviewed for patient characteristics including laboratory and imaging studies, surgical intervention, and pathologic diagnosis. Fischer exact test and the nonparametric Mann-Whitney U test were used for statistical analysis.

MAIN OUTCOME MEASURES

Characteristics predictive of OT in premenarchal girls.

RESULTS

Twenty-nine premenarchal patients were diagnosed with 33 episodes of OT. Nine patients underwent surgery for ovarian masses but did not have OT. All patients with OT reported abdominal pain (compared with 55.6% without OT; P < .001) and most had nausea and/or emesis (81.8% vs 33.3%; P < .009). Ultrasound findings of ovarian enlargement and decreased Doppler flow were significant in the OT group (P < .083, P < .009). There were 2 cases of malignancy in each group.

CONCLUSION

Patients with OT had significantly more nausea, emesis, and abdominal pain compared with those without OT. Additionally, 2 of 4 malignancies were found in patients with OT, indicating that malignancy should still be considered with large, complex masses.

Adnexal Torsion

Adnexal torsion is an uncommon gynecologic disorder caused by the partial or complete rotation of the ovary and/or the fallopian tube on its vascular support. Delay in treatment can impact fertility adversely. The objective of this report is to provide clinical recommendations based on the latest evidence. Specifically we discuss epidemiology, clinical presentation, diagnostic approach and management of adnexal torsion in adolescents.