Performance of grayscale combined with contrast-enhanced ultrasound in differentiating benign and malignant pediatric ovarian masses

OBJECTIVES

To evaluate grayscale US combined with contrast-enhanced ultrasound (CEUS) in the preoperative differentiation between benign and malignant ovarian masses in a pediatric population.

MATERIALS AND METHODS

This retrospective study enrolled patients who underwent grayscale US and CEUS before surgery because of ovarian masses between July 2018 and September 2023, with available histopathologic or follow-up results. Two senior radiologists summarized the grayscale US and CEUS characteristics of all ovarian masses, including percentage of solidity, ascites, vascularity, and enhanced vessel morphology. These characteristics were then independently reviewed by radiologists with different experience to assess interobserver agreement. Diagnostic performance was evaluated using the area under the receiver operating characteristic curve (AUC), while interobserver agreement was evaluated by intraclass correlation coefficient (ICC).

RESULTS

A total of 26 children (median age: 10.1 [7.5, 11.7] years; age range: 0-14 years; benign: 15 patients) were included. The main characteristics of malignant ovarian tumors were abundant blood flow and twisted blood vessels within the mass, enhanced portion of the mass over 50 percent (all p < 0.001). The grayscale US combined with CEUS showed better diagnostic performance than the grayscale US alone (AUC = 0.99 [95% CI: 0.95, 1.00] vs AUC = 0.70 [95% CI: 0.50, 0.90] p < 0.001). A statistically significant AUC before and after CEUS was also shown between two junior radiologists (0.75 vs 0.92 and 0.69 vs 0.86, respectively, both p < 0.05). ICC of CEUS was better than that of grayscale US among radiologists.

CONCLUSION

The combination of grayscale US and CEUS might improve the diagnostic accuracy in differentiating benign and malignant pediatric ovarian masses.

CLINICAL RELEVANCE STATEMENT

Grayscale ultrasound combined with contrast-enhanced ultrasound can improve the diagnostic performance in the preoperative differentiation of benign and malignant ovarian lesions in a pediatric population.

KEY POINTS

Correctly distinguishing benign from malignant ovarian masses in pediatric patients is critical for determining treatments. Grayscale combined with contrast-enhanced ultrasound (CEUS) differentiated benign and malignant pediatric ovarian masses better than grayscale US alone. Junior radiologists' diagnostic performances could be and were significantly improved with the application of CEUS.

Imaging appearance of ovarian dysgerminoma: A report of two cases

Ovarian dysgerminoma is a rare germ cell tumor accounting for 1%-2% of all malignant ovarian tumors and is generally associated with a good prognosis. The condition is more frequent in young women and can arise in dysgenetic gonads that contain gonadoblastomas. Imaging findings, particularly MRI, have a prominent role in the early and correct identification of ovarian dysgerminoma, the most common ovarian malignant germ cell tumor. On CT and MR images, ovarian dysgerminoma often appears as a large, solid mass. The edematous condition of characteristic fibrovascular septa can be well displayed by imaging, which can guide the radiologists to make an accurate diagnosis. This article describes 2 cases of patients with ovarian dysgerminoma who presented with pelvic pain. Imaging showed a right ovarian mass that was surgically and histologically confirmed.

Management strategy for children with ovarian immature teratoma: results from a tertiary pediatric oncology center

OBJECTIVES

We present an Egyptian study on pediatric ovarian immature teratomas (ITs), aiming to clarify our treatment strategy selection.

METHODS

A retrospective review of all children with pure ovarian ITs who were treated at our institution between 2008 and 2023. The analysis included clinical characteristics, tumor staging according to Children's Oncology Group (COG), grading based on the Norris system, management, and outcomes.

RESULTS

Thirty-two patients were included, with a median age of 9 years. All patients underwent primary surgery. Unilateral salpingo-oophorectomy was performed in 31 patients. Surgical staging was completed in all patients. Based on COG staging, there were 28 patients (87.5%) stage I, 1 (3%) stage II, and 3 (9.5%) stage III. According to Norris classification, 16 patients (50%) were classified as grade I, 9 (28%) grade II, and 7 (22%) grade III. All patients in stage I were treated using surgery-alone approach, whereas the remaining four (12.5%) received adjuvant chemotherapy. Five patients in stage I had gliomatosis peritonei (GP), and none of them underwent extensive surgery. At a median follow-up of 86 months, two patients had events. The first patient (stage III/grade I) developed IT relapse on the operative bed, and the second (stage I/grade I) had a metachronous IT on the contralateral ovary. Both patients were successfully managed with surgery followed by second-line chemotherapy. Five-year overall survival and event-free survival for all patients were 100% and 93.4%, respectively.

CONCLUSIONS

Surgery-alone strategy with close follow-up achieves excellent outcomes for localized ovarian ITs in children, irrespective of the Norris grading or the presence of GP. However, adjuvant chemotherapy is questionable for patients with incompletely resected or locally advanced tumors, and its role requires further evaluation through prospective multicentric studies with a larger sample size.

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.

Juvenile Granulosa Cell Tumor Mimicking HAIR-AN in a 4-year-old: A Case Report

Predominantly androgen secreting juvenile granulosa cell tumors (JGCT) are uncommon and few reports have been published. We present a case of a JGCT that presented with signs of prepubertal hyperandrogenism and insulin resistance to highlight the possible interaction between hyperandrogenemia and hyperinsulinism. A 4-year-old girl presented with acanthosis nigricans and hyperinsulinism, mimicking the hyperandrogenism, insulin resistance and acanthosis nigricans syndrome at an age much younger than is typical for this diagnosis. Laboratory studies revealed elevated insulin, inhibin A and B, and total testosterone. All laboratory results normalized after unilateral salpingo-oophorectomy. The final diagnosis was Stage 1A JGCT. This case highlights the importance of including ovarian tumors in the differential diagnosis when considering causes of virilization and insulin resistance. This case also suggests a potential relationship between excess testosterone secretion and hyperinsulinemia and strengthens evidence that hyperandrogenemia may promote hyperinsulinism in ovarian disease.

Diagnostic Conundrum of a Sertoli Cell Tumor in a 2-Year-Old Girl with Peripheral Precocious Puberty and a Café-au-Lait Macule: A Case Report

INTRODUCTION

Ovarian Sertoli cell tumors represent a subset of sex cord stromal tumors and are exceedingly rare in prepubertal children. Here, we report a girl with vaginal bleeding due to a Sertoli cell tumor who was originally thought to have McCune-Albright syndrome (MAS).

CASE PRESENTATION

A previously healthy girl presented at age 2 years 6 months with breast development and vaginal bleeding. On exam, she had Tanner 4 breasts, Tanner 1 pubic hair, estrogenized vaginal mucosa, and a café-au-lait macule. Laboratory studies revealed an elevated estradiol with suppressed gonadotropins and negative tumor markers. Her bone age was advanced by more than 3 years. Pelvic ultrasound (US) revealed an enlarged uterus and a slightly larger left compared to right ovary. She was started on tamoxifen for presumed MAS. A repeat pelvic US 1 month later showed a heterogenous mass in the left ovary which was subsequently resected. Pathology revealed a Sertoli cell tumor, lipid-rich variant. Germline sequencing revealed a pathogenic STK11 variant, diagnostic for Peutz-Jeghers syndrome (PJS).

CONCLUSION

The findings in our patient were strikingly similar to those encountered in MAS. To our knowledge, our patient is the youngest ever reported to present with precocious puberty due to a Sertoli cell tumor in the setting of PJS.

Diagnostic Performance of Magnetic Resonance Imaging for Pediatric Ovarian Neoplasms: A Multi-Institutional Review

STUDY OBJECTIVE

To assess the diagnostic performance of MRI to predict ovarian malignancy alone and compared with other diagnostic studies.

METHODS

A retrospective analysis was conducted of patients aged 2-21 years who underwent ovarian mass resection between 2009 and 2021 at 11 pediatric hospitals. Sociodemographic information, clinical and imaging findings, tumor markers, and operative and pathology details were collected. Diagnostic performance for detecting malignancy was assessed by calculating sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for MRI with other diagnostic modalities.

RESULTS

One thousand and fifty-three patients, with a median age of 14.6 years, underwent resection of an ovarian mass; 10% (110/1053) had malignant disease on pathology, and 13% (136/1053) underwent preoperative MRI. MRI sensitivity, specificity, PPV, and NPV were 60%, 94%, 60%, and 94%. Ultrasound sensitivity, specificity, PPV, and NPV were 31%, 99%, 73%, and 95%. Tumor marker sensitivity, specificity, PPV, and NPV were 90%, 46%, 22%, and 96%. MRI and ultrasound concordance was 88%, with sensitivity, specificity, PPV, and NPV of 33%, 99%, 75%, and 94%. MRI sensitivity in ultrasound-discordant cases was 100%. MRI and tumor marker concordance was 88% with sensitivity, specificity, PPV, and NPV of 100%, 86%, 64%, and 100%. MRI specificity in tumor marker-discordant cases was 100%.

CONCLUSION

Diagnostic modalities used to assess ovarian neoplasms in pediatric patients typically agree. In cases of disagreement, MRI is more sensitive for malignancy than ultrasound and more specific than tumor markers. Selective use of MRI with preoperative ultrasound and tumor markers may be beneficial when the risk of malignancy is uncertain.

CONCISE ABSTRACT

This retrospective review of 1053 patients aged 2-21 years who underwent ovarian mass resection between 2009 and 2021 at 11 pediatric hospitals found that ultrasound, tumor markers, and MRI tend to agree on benign vs malignant, but in cases of disagreement, MRI is more sensitive for malignancy than ultrasound.

Gynecologic Adnexal Tumors and Tumor-Like Lesions in Children and Adolescents: Experience at a Cancer Center

Introduction. Tumors and tumor-like lesions of the uterine adnexa in children and adolescents are uncommon but may carry devastating consequences. Methods. We conducted an observational retrospective cohort study, to describe patients aged 0 to 19 years diagnosed with tumors and tumor-like lesions of the uterine adnexa at our institution between 2000 and 2018. Results. Eighty-nine patients with 105 adnexal lesions were included. Thirty-seven (42%) patients presented with benign tumors, 13 (15%) with borderline tumors, 25 (28%) with malignant tumors and 14 (16%) with tumor-like lesions. Germ cell tumors (n = 45|43%) were the most frequent, followed by epithelial tumors (n = 30|29%). No significant differences were found in the age distribution of the lesions by malignant potential or histologic group. Most patients (n = 80|90%) were treated primarily with conservative surgery, including cystectomy (n = 25|28%) and unilateral oophorectomy/adnexectomy (n = 54|61%). Thirty-four (38%) underwent surgical staging (partial omentectomy and peritoneal biopsies). Twenty (23%) patients with borderline and malignant tumors were submitted to chemotherapy. Four (5%) patients with borderline or malignant tumors relapsed, one of whom died from disease. Conclusion. Gynecological lesions in children and adolescents encompass a wide range of rare histological tumor subtypes, requiring evaluation by experienced pathologists. Most tumors were diagnosed at early stages, with low relapse and mortality rates. Conservative management, with fertility sparing surgery and limited use of adjuvant chemotherapy, is of utmost importance.

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.

Landscape of somatic mutated genes and inherited susceptibility genes in gynecological cancer

Traditionally, gynecological cancers have been classified based on histology. Since remarkable advancements in next-generation sequencing technology have enabled the exploration of somatic mutations in various cancer types, comprehensive sequencing efforts have revealed the genomic landscapes of some common forms of human cancer. The genomic features of various gynecological malignancies have been reported by several studies of large-scale genomic cohorts, including The Cancer Genome Atlas. Although recent comprehensive genomic profiling tests, which can detect hundreds of genetic mutations at a time from cancer tissues or blood samples, have been increasingly used as diagnostic clinical biomarkers and in therapeutic management decisions, germline pathogenic variants associated with hereditary cancers can also be detected using this test. Gynecological cancers are closely related to genetic factors, with approximately 5% of endometrial cancer cases and 20% of ovarian cancer cases being caused by germline pathogenic variants. Hereditary breast and ovarian cancer syndrome and Lynch syndrome are the two major cancer susceptibility syndromes among gynecological cancers. In addition, several other hereditary syndromes have been reported to be associated with gynecological cancers. In this review, we highlight the genes for somatic mutation and germline pathogenic variants commonly seen in gynecological cancers. We first describe the relationship between clinicopathological attributes and somatic mutated genes. Subsequently, we discuss the characteristics and clinical management of inherited cancer syndromes resulting from pathogenic germline variants in gynecological malignancies.

Clinical Characteristics of Gynecologic Problems During Childhood in the Korean Population

BACKGROUND

This study analyzed common gynecologic problems among Korean patients younger than ten years.

METHODS

We performed a retrospective analysis of medical records of patients younger than ten years who visited the Pediatric and Adolescent Gynecology Clinic at Samsung Medical Center between 1995 and 2020.

RESULTS

Among the 6,605 patients who visited the Pediatric and Adolescent Gynecology Clinic, data from 642 patients younger than ten years were analyzed in this study. The most common chief complaint was genital anomalies, followed by increased vaginal discharge and abnormal findings on clinical examinations. The most common disease entity was agglutination of the labia minora, which was commonly discovered incidentally during routine screenings. Vulvovaginitis, the second most common disease, was identified by symptoms of vaginal discharge, pruritus, and vaginal spotting. Neoplasm, issues with vaginal bleeding, and "other causes" were additional categories of gynecologic problems. 245 patients (38.2%) were referred from primary care sources, 175 patients (27.4%) sought care directly at the clinic, 169 patients (26.3%) were referrals from the institution's pediatric department, and the remainder were referrals from other departments.

CONCLUSION

This study provides information about the gynecologic problems most frequently encountered in pediatric patients. The study provides helpful insight for primary care physicians into the proper management and timing of referrals for these gynecologic problems of pediatric patients.

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 Masses: The Value of Acoustic Shadowing on Ultrasound Examination

Adnexal lesions are a common finding in women and pose a clinical challenge since ovarian cancer is a highly lethal disease. However, most adnexal masses are benign, benefiting from a more conservative approach. In preoperative assessment, transvaginal ultrasound plays a key role in evaluating morphologic features that correlate with the risk of malignancy. The acoustic shadow is the loss of echo behind sound-absorbing components, such as calcifications or fibrous tissues, which are predominantly found in benign lesions. However, recognizing the acoustic shadow is a difficult skill to master, and its usefulness may be underappreciated.

Manifestations of Ovarian Cancer in Relation to Other Pelvic Diseases by MRI

Imaging plays a pivotal role in the diagnostic approach of women with suspected ovarian cancer. MRI is widely used for preoperative characterization and risk stratification of adnexal masses. While epithelial ovarian cancer (EOC) has typical findings on MRI; there are several benign and malignant pelvic conditions that may mimic its appearance on imaging. Knowledge of the origin and imaging characteristics of a pelvic mass will help radiologists diagnose ovarian cancer promptly and accurately. Finally, in special subgroups, including adolescents and gravid population, the prevalence of various ovarian tumors differs from that of the general population and there are conditions which uniquely manifest during these periods of life.

Therapeutic Management and Prognostic Factors for Ovarian Malignant Tumours in Adolescents: A Comprehensive Review of Current Guidelines

Background: Ovarian malignant tumours are rarely diagnosed in adolescents but may have a significant impact on their survival, future fertility and quality of life. The management of such cases is rather complex and requires expertise and careful planning according to scarce existing evidence and recommendations. Objective: The aim of this study was to review and compare recommendations from published guidelines regarding the diagnosis, prognosis and treatment of malignant ovarian tumours in adolescents. Evidence acquisition: A comparative descriptive/narrative review of guidelines issued by L’Observatoire des Tumeurs Malignes Rares Gynécologiques, the British Society for Paediatric & Adolescent Gynaecology, the European Society for Medical Oncology, the European Society of Gynecological Oncology-European Society for Paediatric Oncology and the European Cooperative Study Group for Pediatric Rare Tumors was conducted. Results: All guidelines recommend a thorough diagnostic work-up, consisting of both imaging tests and serum tumour marker measurement, as well as the use of immunohistochemical methods to confirm the diagnosis and complete surgical staging prior to constructing the treatment plan. There is a lack of recommendations regarding the assessment of prognostic factors, with only one guideline providing detailed information. Treatment strategies, as suggested by the majority of guidelines and with only a few discrepancies between them, should include both surgery and adjuvant therapies, mainly chemotherapy, with great emphasis on fertility preservation when it is considered oncologically safe and on the significance of regular and long-term follow-up. Conclusions: There is a significant degree of agreement among recommendations of existing guidelines. The reported differences, although limited, highlight the need for the adoption of an international consensus in order to further improve the management of adolescent ovarian cancer.

Sex Cord-Stromal Tumors of the Ovary

Ovarian sex cord-stromal tumors (OSCSTs) are a rare group of ovarian neoplasms that can be benign or malignant. They are classified into pure sex cord tumors, pure stromal tumors, and mixed SCST. The most common malignant OSCSTs are adult granulosa cell tumors. In contrast to the more common ovarian epithelial malignancies, OSCSTs present in younger patients, often at early stages, with better prognoses. Imaging features are variable, and pathology is required for diagnosis. However, certain tumors demonstrate characteristic imaging appearances that can be useful in narrowing the differential diagnosis.

Ovarian Teratomas in Children and Adolescents: Our Own Experience and Review of Literature

Background: Ovarian teratomas are the most common type of ovarian mass during childhood and adolescence. There is no clear guidance for the management of the ovarian teratomas in children and adolescents. It is necessary, however, to understand the feature of these tumours and the indications for operating on them, and to put subjective criteria for the management in elective or emergency presentations. Methods: Medical records of patients between the age of 12 and 20 years old that underwent surgery for ovarian teratomas at the Department of Obstetrics and Gynaecology in University Hospital of Ioannina, between January 2000 and August 2022, were reviewed. A medical database was searched between January 2000 and August 2022 with the following keywords: ovarian teratoma, paediatrics and adolescents. Results: We present the results of forty patients, with a mean age of 11.8 years of age. All patients had surgery, where three out of four underwent oophorectomy and only one out of four underwent ovary-sparing operation; similar results were found in the literature. Conclusion: Ovary-sparing treatment is more common recently compared with the past, such as MIS compared with laparotomy. Better-organised and -planned prospective multi-centre studies are necessary to gain a deeper knowledge of the physiology and prognostic factors of teratomas in children.

Review of a 25-Year Experience in the Management of Ovarian Masses in Neonates, Children and Adolescents: From Laparoscopy to Robotics and Indocyanine Green Fluorescence Technology

Background: Ovarian masses in pediatric populations are the most common abdominal masses in young girls. In neonates, the majority of masses are benign while in children and teen-agers the risk of malignancy exists. The aim of this study is to perform a 25-year experience retrospective analysis of clinical and therapeutic aspects of ovarian tumors in girls, in order to show how the development of minimally invasive technology has changed the management of this pathology. Methods: The records of patients under the age of 18 who were operated in three pediatric surgical units due to ovarian mass, in the last 25 years, were reviewed retrospectively. The study group comprised 147 patients operated between 1996 and 2021 with a diagnosis of ovarian masses. Data involved were demographical, surgical, follow-up and final diagnosis. We analyzed the type of surgical technique, intra-operative data (operative time, the use of different technologies), complications, length of stay and long-term follow-up. Based on these data, we assessed how the surgical approach to ovarian masses has changed in the last 25 years in newborns and young girls. Results: The patients ages ranged between 7 days and 15 years (median, 59 days). All the procedures were completed in laparoscopy or robotics without conversion in open surgery. One-hundred and eleven patients were neonates; they all had follicular cysts and they were all managed in laparoscopy using 1 or 3 trocars. In 80/111 patients (72%), a small part of ovarian parenchyma was saved; in 31/111 patients (28%), in which the ovarian parenchyma was not available, an ovariectomy was performed. Patients in which we saved a small part of ovary, at long term follow-up (minimum follow-up of 12 years) (29/80, 36%), developed a normal ovary at US control. Thirty-six were older patients. They had a histological diagnosis of benign (30) or malign (6) tumors. All the patients (8/36) with a pre-operative suspicion of ovarian malignancy received an ovariectomy and an adnexectomy using sealing devices. In the last 10 years in all the children, except neonates, we adopted sealing devices and, in the last 4 years, in 20 cases, we always adopted ICG fluorescence technology to check ovarian vascularization in case of torsion or to check lympho-nodes condition in case of malignancy. Conclusions: In neonatal ovarian cysts, surgical management remained unchanged and an ovarian sparing procedure is always indicated and the long-term follow-ups confirm this hypothesis. The principal innovation in this age period is the use of ICG fluorescence technology to check ovarian vascularization in case of torsion. In teenagers, the decision-making strategy is based on the tumoral markers and on the morphological aspects of the mass. Robotics cystectomy or ovariectomy now-days represents the safer and faster way to perform this. Sealing devices are essential tools for dissection and resection to avoid bleeding. ICG fluorescence technology in all ages is fundamental to check ovary vascularization after detorsion or to check lympho-node status in case of malignancy. All the suspected lesions have to be removed with an endo-bag.

Fine-needle aspiration cytology of juvenile granulosa cell tumour: A case report with summary of prior published cases

Juvenile granulosa cell tumours (JGCT) are uncommon tumours of the ovary and can present diagnostic difficulty both on histology and cytology because of its rarity. Here we present the fine-needle aspiration cytology (FNAC) findings of a 4 year-old girl who came with a large abdominal mass and bleeding per vaginum. FNAC from the mass showed features suggestive of granulosa cell tumour (GCT) and which was later confirmed on histology to be of juvenile type. Only two cases of cytological findings of JGCT have been described earlier, both of which were recurrent cases and at metastatic sites. The main cytological feature in our case was presence of thick colloid like fluid containing apparent bubbles along with small clusters of uniform cells with eosinophilic cytoplasm and fine vacuolation. The presence of these secretions corresponding to the macrofollicles on histology has not been reported earlier.

Non-Hodgkin Lymphoma Imaging Spectrum in Children, Adolescents, and Young Adults

In children, adolescents, and young adults (CAYA), non-Hodgkin lymphoma (NHL) is characterized by various age-related dissimilarities in tumor aggressiveness, prevailing pathologic subtypes, and imaging features, as well as potentially different treatment outcomes. Understanding the imaging spectrum of NHL in CAYA with particular attention to children and adolescents is critical for radiologists to support the clinical decision making by the treating physicians and other health care practitioners. The authors discuss the currently performed imaging modalities including radiography, US, CT, MRI, and PET in the diagnosis, staging, and assessment of the treatment response. Familiarity with diagnostic imaging challenges during image acquisition, processing, and interpretation is required when managing patients with NHL. The authors describe potentially problematic and life-threatening scenarios that require prompt management. Moreover, the authors address the unprecedented urge to understand the imaging patterns of possible treatment-related complications of the therapeutic agents used in NHL clinical trials and in practice. Online supplemental material is available for this article. ^©RSNA, 2022.

Promising Therapeutic Impact of a Selective Estrogen Receptor Downregulator, Fulvestrant, as Demonstrated In Vitro upon Low-Grade Serous Ovarian Carcinoma Cell Lines

Few studies have reported hormonal agent use in the treatment of low-grade serous ovarian carcinomas (LGSOCs), which are chemoresistant. Considering the need for novel effective therapies, we investigated the hormone receptor expression and hormonal inhibition efficacy in LGSOCs. Using immunohistochemistry, we assessed the estrogen receptor (ER) expression status in 33 cases of histologically confirmed serous ovarian tumors, including 10, 11, and 12 cases of LGSOCs, serous borderline tumors (SBTs), and serous cystadenomas (SCAs), respectively. The genetic background reported in our previous study was used in the current study. MPSC1 cells, which were established from LGSOCs, were used in cell proliferation assays. We observed a higher ER expression in LGSOCs and SBTs than in SCAs (70%, 81%, and 50%, respectively). Thus, LGSOCs and SBTs exhibit higher ER expression than SCAs. Moreover, the PIK3CA mutation positively correlated with ER expression in LGSOCs (p = 0.0113). MPSC1 cells showed low ER expression on Western blotting. MPSC1 cell proliferation was significantly inhibited by fulvestrant (a selective ER downregulator). The activation of ER and PI3K/AKT signaling pathways may play an important role in LGSOC carcinogenesis. ER downregulation with fulvestrant or combination therapy with PI3K inhibitors is a possible novel treatment for patients with LGSOCs.

Progression of Cystadenoma to Mucinous Borderline Ovarian Tumor in Young Females: Case Series and Literature Review

STUDY OBJECTIVE

To study the progression of benign ovarian lesions to mucinous borderline ovarian tumors (mBOTs); analyze the clinicopathologic features, diagnosis, and management of mBOTs in pediatric and adolescent girls; and provide a review of the literature on mBOTs in this population.

DESIGN

Retrospective chart review of female adolescents younger than 18 years diagnosed with mBOTs between July 2017 and February 2021.

SETTING

Yale New Haven Hospital, New Haven, Connecticut; and Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut.

PARTICIPANTS

Three female patients diagnosed with mBOTs between ages 12 and 17 years.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Clinical presentation, preoperative characteristics, surgical technique, histology, tumor stage, treatment, progression, outcome, and rate of recurrence.

RESULTS

Three adolescent patients were identified to have mBOTs. All three patients presented with a chief complaint of abdominal pain. One of the 3 patients was premenarchal at presentation. Two of the 3 patients were initially diagnosed with a mucinous cystadenoma and had recurrences of an ovarian cyst in the same ovary within 5 and 17 months, respectively. Pathology of the recurrent cyst was consistent with mBOT. Two of the 3 patients initially underwent cystectomy, and all ultimately had a unilateral salpingo-oophorectomy. Subsequent surveillance over 2 to 4 years found no evidence of disease recurrence.

CONCLUSION

mBOTs are rare in the pediatric and adolescent population and could arise from benign ovarian tumors.

Assessment of the performance of the O-RADS MRI score for the evaluation of adnexal masses, with technical notes

Objective

To assess the performance of the Ovarian-Adnexal Reporting and Data System Magnetic Resonance Imaging (O-RADS MRI) score in the evaluation of adnexal masses and to provide technical notes about its current MRI parameters and concepts.

Materials and Methods

This was a prospective study of 226 patients with 287 adnexal masses (190 submitted to surgery or biopsy and 97 followed for at least one year). We calculated the sensitivity, specificity, positive predictive value, and negative predictive value for the O-RADS MRI score, using ≥ 4 as the cutoff for malignancy. We performed a technical analysis of the main updates to the score, announced in September 2020 by the American College of Radiology, in comparison with the original (2013) version.

Results

We found that an O-RADS MRI score of 4 or 5 was associated with malignancy of an adnexal mass, with a sensitivity of 91.11% (95% CI: 83.23-96.08), specificity of 94.92% (95% CI: 90.86-97.54), positive predictive value of 89.13% (95% CI: 81.71-93.77), negative predictive value of 95.90% (95% CI: 92.34-97.84), and overall accuracy of 93.73% (95% CI: 90.27-96.24).

Conclusion

Our findings support the use of the O-RADS MRI score for evaluating adnexal masses, especially those considered indeterminate on ultrasound. The updates made recently to the O-RADS MRI score facilitate its interpretation and will allow its more widespread use, with no loss of diagnostic accuracy.

Appearances Are Deceptive: Two Case Reports in Teenagers on the Conservative Laparoscopic Surgery for Adnexal Torsion with Apparent Infarction

Introduction. Torsion of the ovary, tube, or both is estimated to be responsible for 2-7% of all gynaecological emergencies. Oophorectomy is commonly performed for adnexal torsion with a possible negative impact on fertility in women of reproductive age. Case Presentations. We report two cases of teenage girls presented with adnexal torsion describing their laparoscopy features. Detorsion without additional surgical intervention could save their ovaries. Discussion. Detorsion is a more conservative surgical approach that should be considered in all younger women with ovarian torsion.

Case report: Primary ovarian Burkitt's lymphoma: A puzzling scenario in pediatric population

Burkitt's lymphoma (BL) is defined as a highly invasive B-cell lymphoma, usually characterized by an excellent prognosis, more than 90% of children and adolescents being cured with highly dose-intensive multiagent chemotherapy. Primary ovarian localization without involvement of other organs is a rare manifestation of BL, especially in pediatric population. Symptoms at diagnosis are similar to other ovarian lesions and differential diagnosis may be challenging for clinicians. A 12-year-old girl was referred to our institution for abdominal pain and palpable mass observed by the pediatrician. Diagnostic work-up demonstrated a large mass arising from the right ovary, causing compression on abdominal aorta, inferior vena cava, ureters and bowel, with a second smaller lesion on the left ovary. At surgery, a 15 cm-large, ruptured mass arising from the right ovary was found, associated with a second lesion originating from the left ovary (8 cm) and multiple nodules of the greater omentum. Right salpingo-oophorectomy was performed, incisional biopsies were taken from the left ovary and omental nodules and peritoneal fluid samples were collected for cytology. Pathology revealed a Burkitt lymphoma and the patient underwent chemotherapy according to AIEOP LNH-97 Protocol, group R3 with Rituximab. Preoperative diagnosis of primary ovarian lymphoma is extremely difficult. Surgical exploration is often necessary in patients presenting with acute abdominal or pelvic pain; when the suspicion of primary ovarian lymphoma arises intraoperatively, every effort should be made to minimize invasive procedure in order to enhance post-operative recovery.

Bilateral ovarian fibromas in a 15-year-old primary amenorrhea patient: a case report

A 15-year-old female with primary amenorrhea, obesity, and insulin resistance, was admitted for further examination due to large pelvic masses found during a transabdominal ultrasound, which was performed while assessing the amenorrhea. The magnetic resonance imaging showed bilateral, multifocal fibrosing tumors, originating from both ovaries. A laparotomy was performed, during which the right ovary masses were enucleated and the left adnexectomy was performed. A histological examination of the tissue material revealed bilateral ovarian fibromas with calcification and ossification. The genetic examination confirmed the diagnosis of Gorlin syndrome. The patient recovered well, and on the first follow-up 1 month after surgery, already experienced her first spontaneous menstrual bleeding.

Ovarian teratoma in a teenager causing ureterohydronephrosis: Case report and literature review

RATIONALE

Teratomas are solid tumors that may occur in both gonadal and extragonadal locations, depending on the age of the child. Benign cystic teratomas are relatively common tumors among women of reproductive age, but they can occur at any age. The clinical presentation is not specific. They can be found incidentally when patients are investigated for other conditions or they can present as emergencies when the ovarian teratoma is torsioned or ruptured.

PATIENT CONCERNS

We present the case of a 17-year-old adolescent girl that was seen in our emergency department on several occasions for recurrent episodes of abdominal pain ongoing for 6 months.

DIAGNOSIS

An ultrasonography (US) was performed as an outpatient and a left ovarian mass was found along with right ureterohydronephrosis (UHN). Further assessment of the mass was done by abdominal and pelvic CT and tumoral markers. CT appearance was more suggestive of a teratoma.

INTERVENTIONS

She underwent laparotomy with complete excision of the tumor.

OUTCOME

The patient had an uneventful recovery. A renal US follow up showed reduction of the dilatation, demonstrating that the condition was secondary to tumor compression.

LESSONS

In a teenager with nonspecific symptoms, a high suspicion index for tumors is mandatory. An early diagnosis and management avoid complications like UHN.

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

STUDY OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Ovarian carcinoma in children with constitutional mutation of SMARCA4: single-family report and literature review

Ovarian carcinoma is an extremely rare malignancy in children, often developing on the underlying inherited background. Female carriers of pathogenic germline mutations of SMARCA4 are at risk of an aggressive type of undifferentiated ovarian cancer called small cell carcinoma of the ovary, hypercalcemic type (SCCOHT). Regardless of age of the patient, stage of the disease, and oncological treatment, the prognosis for SCCOHT is poor. Therefore, early intervention with risk-reducing surgeries is recommended for these patients. In this study, we report genetic testing of a family with two children carrying pathogenic germline mutations of SMARCA4 and summarize the course of SCCOHT in all pediatric patients reported in the literature with constitutional defects identified within the SMARCA4 locus.

Pediatric and adolescent gynecology through a global lens

Girls and adolescents, aged 0-19 years make up almost 30% of the world's female population yet their specific healthcare needs often slip between the gaps of pediatrics and adult women's health. Pediatric and adolescent gynecology is the clinical field that endeavors to address the reproductive health needs of this age group. The environment and psychosocial well-being, social determinants of health, have direct bearing on reproductive health, affecting menstrual cycles, menstrual hygiene, and risks for unintended pregnancy and sexually transmitted infections. This narrative review will highlight common gynecologic conditions of adolescents, especially where diagnosis and management are distinct from adult women. It will also present preventive health strategies to improve reproductive health through vaccination, improved access to hygiene supplies and contraception.

Contrast-enhanced ultrasound of the small organs in children

In pediatric and adult populations, intravenous contrast-enhanced ultrasound (CEUS) remains off-label for imaging of organs other than the liver and heart. This limited scope inhibits potential benefits of the new modality from a more widespread utilization. Yet, CEUS is potentially useful for imaging small organs such as the thyroid gland, lymph nodes, testes, ovaries and uterus, with all having locations and vasculature favorable for this type of examination. In the adult population, the utility of CEUS has been demonstrated in a growing number of studies for the evaluation of these small organs. The aim of this article is to present a review of pediatric CEUS of the thyroid gland, lymph nodes, testes, ovaries and uterus as well as to draw from the adult literature indications for possible applications in children.

Retrospective Analysis of Pure Ovarian Immature Teratoma in Patients Aged 15-39 Years: A Turkish Multicenter Study

Purpose: To evaluate the clinicopathological characteristics and surgical outcomes in patients with pure ovarian immature teratomas (POITs). Materials and Methods: In this multicenter study, a retrospective review was made of the databases of six Gynecology Oncology Departments in Turkey to identify patients with POITs who had undergone surgery between 1993 and 2019. Results: Evaluation was made of 48 patients with a median age at diagnosis of 22.5 years (range, 15-37 years). In 40 (83%) patients, stage I was determined and in eight patients, an advanced stage (IIIB, IIIC, and IVB) was determined. Tumors were found to be grade I in 17 (35.4%) cases, grade II in 12 (25%), and grade III in 19 (39.6%). Fertility-sparing surgery was applied to 42 (87.5%) patients and radical surgery to 6 (12.5%). The median follow-up was 60 months (range, 3-246 months). Recurrence was seen in seven patients, all with grade III tumors. In the final pathological examination of recurrent tumors, mature teratoma was reported in five patients, and immature teratoma in one patient. Salvage surgery was not performed in one patient as the tumor was unresectable and so a regimen of bleomycin, etoposide, and cisplatin (BEP) was administered. Conclusion: POITs are rare tumors seen at a young age, and benign or malignant relapse can be seen in these tumors. In this cohort, the malignant recurrence rate was 4.1%, and the benign recurrence rate was 10.4%. All the recurrences were in grade III tumors. Benign recurrences can be treated with surgery alone and the malignant group should be treated with surgery followed by chemotherapy.

Mature Ovarian Cystic Teratoma Mimicking a Bladder Diverticulum in a 16-year-old Female

A 16-year-old female was incidentally found to have an abnormal pelvic ultrasound while undergoing evaluation for mild scoliosis. A large, thick-walled, lobular, fluid-filled structure was found at midline in the pelvis that initially resembled bladder diverticula due to its anatomical position and sonographic appearance. Voiding cystourethrogram and computed tomography later revealed a large cystic mass originating from the right ovary. This report outlines a case of a mature cystic teratoma convincingly mimicking bladder anomaly on sonography.

Adolescent ovarian thecoma presenting as progressive hyperandrogenism: case report and review of the literature

Hyperandrogenism is frequent and under investigated in adolescent girls. A 15-year-6-month-old French girl presented with oligomenorrhea and slowly progressing virilization 2 years post-menarche. Medical history revealed prenatal pesticide exposure through maternal professional activity and recurrent premature thelarche. Severe hirsutism, mild facial acne and clitoromegaly were noted. Serum androgens (testosterone: 94 ng/dL, 4-androstenedione: 8.23 ng/mL) were high and non-classic 21-hydroxylase deficiency was excluded. Pelvic ultrasonography showed a left ovarian mass, confirmed by computed tomography scan. Tumor markers were negative. Laparoscopic surgery was performed. The pathological diagnosis was benign luteinized thecoma. Postoperatively, the menstrual cycle and serum androgens became normal and hirsutism slowly improved. Hyperandrogenism 2 years after menarche should be systematically investigated, even if slowly progressive, since it may be a symptom of a rare virilizing ovarian tumor, like thecoma.

Pure dysgerminoma of the ovary: CT and MRI features with pathological correlation in 13 tumors

Background

To investigate the spectrum of CT and MRI findings of dysgerminoma of the ovary.

Methods

CT and MRI imaging of 12 patients with 13 histologically proven dysgerminomas of the ovary were retrospectively reviewed. Patients^, ages ranged from 6 ~ 27 years (mean, 17.2 years). Two observers evaluated the following CT and MRI features of the tumor by consensus: (i) location, shape, and size; (ii) attenuation, T2 signal intensity, and ADC value; (iii) patterns of contrast enhancement; (iv) presence of fibrovascular septa; (v) presence of necrosis, hemorrhage, and calcification; (vi) presence of “ovarian vascular pedicle” sign. We also noted the extent or stage of the tumors.

Results

75% lesions arised in the right ovary. Bilateral ovaries were involved in one case. Tumors displayed as a purely or predominantly solid mass (mean size, 17.0 ± 7.8 cm). Ten tumors were shaped multilobulated. The mean ADC value of lesions was 0.830 ± 0.154 × 10^− 3 mm²/s. Characteristic fibrovascular septa were observed in all lesions. Among them, classic septa were present in 69% lesions. They were thin, hypointense on T2WI with a linear intense enhancement indicating the blood vessels in septa. Due to the stromal edema, fibrovascular septa may become thick even amorphous in shape, hyperintense on T2WI and even low attenuation on CT with a slight enhancement except for a bright blood vessel on the edge. Massive necrosis was observed only in one lesion. Calcification was present in 3 of the 5 tumors on CT. “Ovarian vascular pedicle” sign was present in 12 lesions. Lymphadenopathy, retroperitoneal spread, and distant metastases combined with an implantation in Douglas’ cul-de-sac were present in one patient respectively.

Conclusion

On CT and MR images, ovarian dysgerminoma often appears as a large solid mass. The edematous condition of characteristic fibrovascular septa can be well displayed by imaging which then can guide the radiologists to make an accurate diagnosis. Calcifications often occur in the tumor. Nonspecific low ADC value and “ovarian vascular pedicle” sign may narrow the differential diagnosis.

A clinical review of ovarian tumors in children and adolescents

PURPOSE

To determine the features which predict torsion and the pre-operative indicators of malignancy in cases of ovarian torsion in ovarian tumors (OTs) in children.

METHODS

The medical records of 35 pediatric patients who underwent surgery for OT, except for neonate cases, from 1997 to 2018 at our institution were reviewed retrospectively.

RESULTS

The pathological diagnosis was mature teratoma in 17, immature teratoma in 9, yolk sac tumor in 3, and others in 6. The preoperative diagnosis, which was made based on the imaging findings and the serum tumor marker values, matched with the pathological diagnosis in 29/35 (83%). Ovarian torsion occurred in 14/35 (40%). All but one case that presented with torsion had intermittent abdominal pain as the primary symptom. The preoperative white blood cell count was significantly higher in cases where ovary preservation was impossible than where it was possible (p = 0.01) among the cases presenting with torsion.

CONCLUSION

Preoperative imaging findings and the serum tumor marker values enabled us to make an accurate preoperative diagnosis. Patients with intermittent abdominal primary symptoms were more likely to have ovarian torsion than those without such symptoms, and leukocytosis may indicate irreversible ischemic changes in the affected ovary.

Imaging in pediatric ovarian tumors

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

Pediatric and adolescent gynecology: Treatment perspectives in minimally invasive surgery

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

MR imaging in discriminating between benign and malignant paediatric ovarian masses: a systematic review

OBJECTIVES

The use of magnetic resonance (MR) imaging in differentiation between benign and malignant adnexal masses in children and adolescents might be of great value in the diagnostic workup of sonographically indeterminate masses, since preserving fertility is of particular importance in this population. This systematic review evaluates the diagnostic value of MR imaging in children with an ovarian mass.

METHODS

The review was made according to the PRISMA Statement. PubMed and EMBASE were systematically searched for studies on the use of MR imaging in differential diagnosis of ovarian masses in both adult women and children from 2008 to 2018.

RESULTS

Sixteen paediatric and 18 adult studies were included. In the included studies, MR imaging has shown good diagnostic performance in differentiating between benign and malignant ovarian masses. MR imaging techniques including diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) imaging seem to further improve the diagnostic performance.

CONCLUSION

The addition of DWI with apparent diffusion coefficient (ADC) values measured in enhancing components of solid lesions and DCE imaging may further increase the good diagnostic performance of MR imaging in the pre-operative differentiation between benign and malignant ovarian masses by increasing specificity. Prospective age-specific studies are needed to confirm the high diagnostic performance of MR imaging in children and adolescents with a sonographically indeterminate ovarian mass.

KEY POINTS

• MR imaging, based on several morphological features, is of good diagnostic performance in differentiating between benign and malignant ovarian masses. Sensitivity and specificity varied between 84.8 to 100% and 20.0 to 98.4%, respectively. • MR imaging techniques like diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) imaging seem to improve the diagnostic performance. • Specific studies in children and adolescents with ovarian masses are required to confirm the suggested increased diagnostic performance of DWI and DCE in this population.

Ultrasonographic and multimodal imaging of pediatric genital female diseases

Ultrasonography is the first-line imaging modality in the evaluation of the female pelvis in childhood and adolescence, because it is easy to perform, non-invasive and it does not require sedation. The transabdominal approach is preferred in children and adolescents, after filling the bladder to move away the bowel loops from the pelvis. The probe frequency must be adapted to age, thickness of tissues and depth of the structures under examination. High-frequency (4-12 MHz) linear or convex probes are used in newborns; high-frequency linear probes (4-12 MHz) in toddler, convex 5-7.5 MHz probes in girls and convex 3.5-5 MHz probes in teenagers. In this article, the main pathological conditions of the genital female tract in pediatric age are examined, such as congenital anomalies, disorders of sex development, ovarian cysts, ovarian tumors, adnexal torsion, primary amenorrhea, precocious puberty and pelvic inflammatory disease.