Thirty-eight cases of paraovarian cysts in children and adolescents: a retrospective study

PURPOSE

Paraovarian cysts in children and adolescents can be challenging to accurately diagnose prior to surgery. Our objective is to outline the clinical characteristics of paraovarian cysts and enhance the precision of diagnosing paraovarian cysts in this age group.

METHODS

We retrospectively analyzed all patients with paraovarian cysts who underwent surgery in our department from 2013 to 2021. The review focused on demographic characteristics, clinical manifestations, intraoperative findings, and postoperative pathology of these patients.

RESULTS

This cohort was composed of 38 children with paraovarian cysts. The average diameter of the cysts was 4.8 cm (range 0.5-10 cm). Among the cases, 25 (65.8%) had adnexal torsion. Postoperative pathology showed that all cases were simple cysts with serous fluid. After the procedure, the patients were monitored for a period ranging from 12 to 108 months. B-ultrasound and physical examination did not reveal any significant abnormalities.

CONCLUSIONS

B-ultrasound can help diagnose paraovarian cysts by detecting slight deviation movement between the cyst and the uterus. The presence of adnexa torsion in children and adolescents with paraovarian cysts does not depend on BMI, but rather on the size of cysts. Laparoscopic cyst removal has proven to be an effective surgical approach with favorable outcomes.

Retrospective analysis of patients with surgically proven ovarian torsion, our experience

Aim

To study the patients who were admitted to our hospital with surgically proven ovarian torsion and were operated for the same and to study for whom detorsion was done.

Materials and Methods

A retrospective analysis of the medical records and surgical notes of 150 patients with surgically proven ovarian torsion over a 10-year period between January 2011 and January 2021 was carried out. Surgical notes included details like mode of the surgery (laparotomy or laparoscopy), type of surgery (oophorectomy, detorsion, detorsion with cystectomy), whether fixation was done or not, size of mass/ovary, laterality, appearance of the torted ovary, color of the ovary, and number of twists. Histopathologic reports of the patients who underwent oophorectomy or detorsion with cystectomy were also recorded.

Results

During the 10-year study period, 88 (58.7%) patients had undergone laparotomy and 62 (41.2%) patients had undergone laparoscopy. Detorsion with cystectomy was done in 96 (64%) cases, detorsion alone in 14 (9.3%) cases, and oophorectomy was done in 40 (26.6%) cases. There was no significant difference in terms of increase in postoperative complications.

Conclusion

Laparoscopic detorsion with cystectomy is the most common surgical procedure used for ovarian torsion at King Hussein Medical Center.

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.

Paraovarian cystoadenofibroma: an unusual finding in two adolescent twin sisters

BACKGROUND

The presence of a rare lesion for pediatric population, encountered in twins, as far as we know, is an exceptional event. The event made the management of a pathology, for which there are no guidelines in the pediatric field, even more delicate.

CASE REPORT

Two twin sisters came to our attention, a short time after each other, due to the presence of a voluminous abdominal mass. After complete resection, the histological diagnosis was that of a paraovarian cystoadenofibroma.

DISCUSSION

In pediatric surgery being minimally invasive is mandatory. However in selected cases the only objective, especially speaking of pediatric patients, ais to be radical and to protect the adnexal structures.

Standardizing the surgical management of benign ovarian tumors in children and adolescents: A best practice Delphi consensus statement

AIM

No widely agreed consensus protocols exist for the management of benign ovarian tumors (BOT) in children. This presents a substantial risk for suboptimal management. We aimed to generate multispecialty consensus guidance to standardize surgical management and provide a clear follow-up protocol for children with BOTs.

METHODS

Prospective two-round confidential e-Delphi consensus survey distributed among multispecialty expert panel; concluded by two semistructured videoconferences.

MAIN RESULTS

Consensus was generated on these core outcome sets: preoperative/intraoperative management; follow-up; adolescent gynecology referral. (1) Children with BOTs should receive the same management as other patients with potentially neoplastic lesions: Preoperative discussion at a pediatric oncology multidisciplinary meeting to risk stratify tumors, and management by health professionals with expertise in ovarian-sparing surgery and laparoscopy. (2) Ovarian-sparing surgery for BOTs should be performed wherever possible to maximize fertility preservation. (3) Ovarian masses detected during emergency laparoscopy/laparotomy should be left in situ wherever feasible and investigated appropriately (imaging/tumor markers) before resection. (4) Follow-up should be undertaken for all patients after BOT resection. Patients should be offered referral to adolescent gynecology to discuss fertility implications.

CONCLUSION

This best practice Delphi consensus statement emphasizes the importance of managing children with BOTs through a well-defined oncological MDT strategy, in order to optimize risk stratification and allow fertility preservation by ovarian-sparing surgery wherever possible.

High risk and low prevalence diseases: Ovarian torsion

INTRODUCTION

Ovarian torsion is a rare, frequently misdiagnosed condition that carries with it a high rate of morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of ovarian torsion, including presentation, evaluation, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Ovarian torsion is one of the most common gynecological surgical emergencies and occurs with complete or partial rotation of the ovary along the supporting ligaments, obstructing vascular flow. Several risk factors include the presence of an ovarian mass or cyst. The most common population affected includes reproductive aged women, though cases also occur in premenarchal females, pregnant women, and postmenopausal women. Abdominal or pelvic pain is common but is not always sudden in onset or severe. Nausea and vomiting occur in 70%. Ultrasound can assist with diagnosis, but a normal ultrasound examination cannot exclude the diagnosis. Computed tomography with intravenous contrast can assist with diagnosis. Treatment includes emergent gynecologic consultation for surgical detorsion, along with symptomatic therapy in the ED.

CONCLUSIONS

An understanding of ovarian torsion can assist emergency clinicians in diagnosing and managing this disease.

Ultrasonographic diagnosis and surgical outcomes of adnexal masses in children and adolescents

This study aimed to evaluate the incidence, clinical diagnosis, surgical treatment, and histopathological findings of adnexal masses in children and adolescents. This retrospective study included patients aged < 20 years who were diagnosed with adnexal masses between January 2005 and December 2018 at the Konkuk University Medical Center. Adnexal masses were diagnosed in 406 patients. The mean age of patients was 17.3 years at the time of diagnosis. The primary presenting symptoms and signs were abdominal pain (81.4%), mass per abdomen (13.7%), dysmenorrhea (3.4%), incidental finding (2%), and abdominal distention (0.5%). In total, 204 patients underwent surgery for adnexal masses, and 202 patients were observed without surgery. Histopathological examination revealed 110 benign neoplasms, 72 non-neoplastic lesions, 3 ectopic pregnancies, 3 tubo-ovarian abscesses, 7 borderline malignant tumors, and 9 non-epithelial ovarian malignant tumors. Abdominal pain was the most common reason for hospital visits and surgery in adolescents and young women with adnexal masses. The ultrasonographic diagnosis was consistent with the histopathological diagnosis. In recent years, the use of minimally invasive surgery such as laparoscopy and robotic, has increased in young patients with adnexal masses.

World Federation for Ultrasound in Medicine Review Paper: Incidental Findings during Obstetrical Ultrasound

Although the prevalence of incidental findings revealed during an obstetric ultrasound examination is low, the findings may include adnexal and cervical masses, uterine or urinary congenital malformations, free fluid in the pouch of Douglas or tortuous vessels (varices). Adnexal masses are the most common finding and vary in imaging characteristics. They are mainly unilateral, cystic masses with a low risk of malignancy that are treated conservatively. The International Ovarian Tumor Analysis scoring models may be helpful in differentiating benign from malignant masses. For those masses >5 cm, follow-up is recommended, and resection could be considered to avoid risk of torsion, rupture and hemorrhage, which may compromise pregnancy outcome. Uterine masses such as fibroids are commonly diagnosed early in the first trimester and should be followed up during pregnancy to evaluate any changes. Transabdominal and transvaginal ultrasound is the first-line test for the diagnosis of such incidentalomas; however, magnetic resonance ultrasound may have a useful role in excluding malignancy potential. As a result of their low frequency and the lack of good evidence, there are no specific guidelines on the management of incidentalomas detected at obstetric scans. Their management should follow the related general guidelines for ovarian, cervical and uterine masses, with individualized management depending on the pregnancy status.

Ultrasound and alternative multimodality imaging of intra-abdominal and pelvic cystic masses in the newborn

Introduction: Ultrasound is used commonly to detect and diagnose intra-abdominal and pelvic cystic masses in the newborn as it is easily available, relatively low cost, and non-invasive. Discussion: The diagnosis can be made or narrowed down by determining the location, size, sonographic features, organ involvement, and internal vascularity. The differential diagnoses include hydronephrosis, multicystic dysplastic kidney, adrenal haemorrhage, cystic teratomas, ovarian cysts, enteric cysts, meconium cysts, and liver haemangiomas. With the appropriate radiological knowledge, the ultrasound practitioner can help obtain an accurate diagnosis. Conclusion: This pictorial essay will familiarise the reader with the different common causes of intra-abdominal and pelvic masses detected on ultrasound through a wide range of conditions. The role of ultrasound in the evaluation of these conditions will be discussed and alternative imaging correlates will be offered.

Multimodality imaging review for suspected ovarian torsion cases in children

OBJECTIVES

Ovarian torsion (OT), although rare, can be described as a complete or partial twist of the ovary with impairment of blood flow. Although occurring at any age, it is more common in children and during pregnancy. Presenting symptoms are non-specific but include either persistent or intermittent acute abdominal pain, making early diagnosis difficult. Delayed diagnosis is associated with an increased need for oophorectomy. The aim of this literature review is to establish the safest and most efficacious imaging strategy for OT by comparing and contrasting evidence for current imaging modalities found in the literature.

KEY FINDINGS

Characteristically, OT can be identified through a combination of findings some of which includes an enlarged ovary, multiple follicles at the periphery and a "whirlpool" sign. Currently, ultrasound is the preferred primary imaging modality; although computed tomography (CT) and magnetic resonance imaging (MRI) may also be used when findings are equivocal; with MRI being the safer option.

CONCLUSION

Ultimately, while it is true that ovarian torsion is not a common cause of acute abdominal pain in children, it should always be considered in the differential diagnosis. Prior to selecting an imaging modality; the clinical presentation, age group, possible radiation dose and availability of the modality needs to be considered to ensure the appropriate imaging strategy.

IMPLICATIONS FOR PRACTICE

With new tools such as scoring systems, B-flow imaging (BFI), diffusion-weighted imaging (DWI) and susceptibility-weighted imaging (SWI) currently being explored for possible use in the future, early diagnosis of OT may be attainable. Thus, reducing the likelihood of adverse complications and consequently the need for oophorectomy.

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.

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.

Physiologic Ovarian Cysts versus Other Ovarian and Adnexal Pathologic Changes in the Preadolescent and Adolescent Population: US and Surgical Follow-up

Background Ovarian and adnexal cysts are frequently encountered at US examinations performed in preadolescent and adolescent patients, yet there are few published studies regarding the outcomes of cysts in this population. Purpose To identify characteristics at US that help to distinguish physiologic ovarian cysts from nonphysiologic entities. Materials and Methods Female patients who underwent pelvic US with or without Doppler from January 2009 through December 2013 were identified by using a centralized imaging database. Patients older than 7 years and younger than 18 years with ovarian or adnexal cysts at least 2.5 cm were included. Demographic characteristics, date of surgery, surgical notes, and pathologic reports were extracted from the electronic medical record. Initial and follow-up dates of US, cyst size and complexity, imaging diagnosis, and change on subsequent US images were recorded. Statistical analysis was performed with the Wilcoxon rank sum and Kruskal-Wallis tests for continuous variables and the Fisher exact test for categorical variables. Results Of 754 patients who met inclusion criteria (age, 8-18 years; mean age, 14.6 years ± 1.9 [standard deviation]; mean cyst size, 5 cm ± 3.3), 409 patients underwent complete follow-up that included resolution at imaging (n = 250) or surgery (n = 159). In the patients with complete imaging follow-up, mean time to US documentation of resolution was 194 days ± 321; 59.6% (149 of 250) patients had nonsimple cyst characteristics. One-hundred fifty-nine patients underwent surgical intervention (mean cyst size, 8.5 cm ± 5.3), and 69.8% (111 of 159) of the cysts had simple characteristics. Of the 159 cysts, 100 (62.8%) were defined in the pathologic report as paratubal cysts. Of 409 patients, no malignancies were encountered in this study population with surgical or imaging resolution. Conclusion No malignancies were encountered in the study population and the majority of cysts resolved at follow-up imaging. Large size, persistence, and separability from the ovary were most helpful for identification of nonphysiologic paratubal cysts. © RSNA, 2019.

Ovarian masses in pediatric patients: a multicenter study of 98 surgical cases in Tunisia

Ovarian masses requiring surgical intervention are uncommon in the pediatric population. Our aim is to report results of a multicentric Tunisian study concerning the clinical practice and the management of pediatric ovarian masses and to identify the factors that are associated with ovarian preservation. Between January 2000 and December 2015, 98 pediatric patients (<14 years) were surgically treated for ovarian masses at the five pediatric surgery departments in Tunisia. Ninety-eight patients were included in this study. The mean age of the patients at time of surgery was 8.46 ± 4.87 years. Sixty-three ovarian masses (64.3%) were non-neoplastic lesions, 24 (24.5%) were benign tumors, and 11 (11.2%) were malignant neoplasms. Conservative surgery (ovarian-preserving surgery) was successfully performed in 72.4% of the benign lesions, whereas only three patients (27.3%) with malignant tumors underwent ovary-sparing tumor resection (p < .001). The mean diameter of the tumors in the patients who underwent oophorectomy was significantly larger than that in the patients who underwent conservative surgery (7.8 ± 3.9 cm vs. 5.7 ± 2.9 cm, respectively, p = .001). In our study, the risk factors for oophorectomy were a malignant pathology and large tumor size. In accordance with the Gynecologic Cancer Intergroup consensus, we recommend that surgical management of ovarian masses in children should be based on ovarian-preserving surgery.

Ovarian torsion in children: Development of a predictive score

The aim of this study was to identify clinical signs and symptoms of ovarian torsion (OT) in children and to develop a simple predictive score.A chart review of patients with acute adnexal pathologies treated at the University Children's Hospital Basel, Switzerland, between March 2006 and June 2015 was performed. Medical records were screened for demographic and clinical data. These included clinical symptoms, laboratory studies, imaging, and type of treatment. The diagnosis OT was defined as intraoperative visualization of the torsed ovary around its pedicle at least 360 degrees. Variables predictive for OT were identified and the following score for the likelihood of having OT was developed: age (points = number of years) minus 3 points (if vomitus = "yes") and plus 1 point (if "pain duration >12 hours").A total of 80 patients with acute adnexal pathologies were identified. OT was recorded in 17 (21%) cases and ovarian cysts (OC) only in 63 (79%) cases. Patients who presented with OT were significantly younger than patients with OC only (P = .001). Correspondingly, 11 (65%) of the patients with OT had no menarche compared to 3 (5%) patients with OC only (P = .001). Vomiting (P = .001), a shorter pain duration (P = .01), and an elevated C-reactive protein (CRP) (P = .01) were observed significantly more often in patients with OT. The sensitivity of a positive OT score was 0.81 and increased to 1.00 if restricted to girls between 2 to 12 years of age.The presence of vomiting, short duration of abdominal pain, and elevated CRP level have a predictive value for the diagnosis of OT. In these patients, an exploratory laparoscopy should be conducted without delay. The presented OT score appears to be a helpful tool in diagnosing OT in children.

Pelvic pain in the middle of the night: use of MRI for evaluation of pediatric female pathology in the emergent setting

Acute pelvic pain in pediatric female patients is a common cause of emergency room visits. Imaging plays a crucial role in the clinical evaluation of these patients. Pelvic pain in female children can result from various pathologies. Ultrasound is the preferred first line imaging study; however, magnetic resonance imaging (MRI) is a helpful adjunct after hours, as it is available 24/7 in many institutions. Advantages of MRI include superior delineation of anatomy and higher tissue contrast resolution, particularly of the small pelvic structures. Given the lack of ionizing radiation, there is increasing use of MRI in children and adolescents, specifically in an emergent setting. In this pictorial review, we discuss pelvic MRI techniques and illustrate imaging findings of common etiologies of pelvic pain, emphasizing the advantages of MRI as an adjunct imaging modality.

Oophoropexy for ovarian torsion: a new easier technique

Background

Oophoropexy for ovarian torsion is easy to be done by many tools either suturing to the lateral pelvic wall, plication of the ovarian ligament or even fixation to the back of the uterus, but it is little bit difficult to do it for pregnant women with less manipulation.

Objective

We propose that using trocar site closure needle can be easier and faster technique to do this. To assess the feasibility of using the trocar site closure needle to do oophoropexy in ovarian torsion and its possible applicability.

Patients

Seven patients presented with ovarian torsion; four of them were pregnant at 7, 15, 19 and 20 weeks of gestation, two patients with ovarian hyperstimulation in IVF cycles and one adolescent patient with hemorrhagic cyst. They were diagnosed by clinical presentation and ultrasound with Doppler analysis, and confirmed by laparoscopy where they underwent detorsion and fixation of the ovary using the trocar site closure needle.

Results

Follow up of all the cases after one week showed improvement of the symptoms and normal Doppler flow of the target ovary then after three weeks by ultrasonography which revealed normal Doppler flow in the previously torsioned ovary. Two pregnant women underwent cesarean delivery where the operated ovary was observed during the delivery and was normal in shape and freely mobile with no adhesions.

Conclusion

We propose that this technique is easier, faster and more comfortable especially in ovarian torsion in pregnant women and torsion in hyperstimulated ovaries.

Electronic supplementary material

The online version of this article (doi:10.1186/s10397-017-1001-9) contains supplementary material, which is available to authorized users.

A review of ovary torsion

Ovarian torsion is a rare but emergency condition in women. Early diagnosis is necessary to preserve the function of the ovaries and tubes and prevent severe morbidity. Ovarian torsion refers to complete or partial rotation of the adnexal supporting organ with ischemia. It can affect females of all ages. Ovarian torsion occurs in around 2%-15% of patients who have surgical treatment of adnexal masses. The main risk in ovarian torsion is an ovarian mass. The most common symptom of ovarian torsion is acute onset of pelvic pain, followed by nausea and vomiting. Pelvic ultrasonography can provide information on ovarian cysts. Once ovarian torsion is suspected, surgery or detorsion is the mainstay of diagnosis and treatment.

Update on the surgical management of ovarian neoplasms in children and adolescents: analysis on 32 cases

This study analyzes updated clinical, diagnostic, and surgical directions for the treatment of ovarian neoplasms in children and adolescents, comparing them with a retrospective analysis of 32 cases treated in two Pediatric Surgery University Institutions. From January 2005 to December 2015, 32 pediatric patients were surgically treated for 32 ovarian tumors: 28 (87.5%) benign and 4 (12.5%) malignant neoplastic lesions. Median age at surgery was 11.2 years (12.8 years in patients with benign neoplasms, 7.25 years in patients with malignant ones). All patients with malignant and 25% of patients with benign ovarian lesions had elevated serum level of tumors markers. The surgical approach was laparotomic in 62.5% and laparoscopic in 37.5%; 81.2% surgeries were performed in elective surgery and 18.8% in emergency. Intraoperative frozen section analysis was performed in 18.75% of patients. The most frequent surgery (96.8%) was unilateral oophorectomy. After a median follow-up of 76 months (range 6-132 months), 31/32 patients are alive and disease-free. In case of malignant tumors, fertility-sparing surgery with accurate staging must be performed. Laparoscopic multiport is the gold standard approach for benign pediatric ovarian neoplasms, but the use of laparoscopy in full respect of oncological principles also for early stage malignant tumors is currently increased.

Preoperative risk stratification of children with ovarian tumors

BACKGROUND

The appropriate operative approach to pediatric patients with ovarian tumors must balance real risk of malignancy with maximal preservation of reproductive potential. We evaluate preoperative risk of malignancy in order to more precisely guide treatment, so as to err on the side of ovarian preservation if at all possible.

METHODS

We retrospectively reviewed the records of all patients undergoing surgical intervention for ovarian tumors at a single institution. The primary endpoint was ovarian malignancy.

RESULTS

Of 502 patients who underwent surgery for ovarian tumors, 44 (8.8%) had malignancies. Malignancy rate (95% confidence interval) was low for cystic lesions <9cm (0.0%, 0.0-2.9%) and for tumor marker-negative heterogeneous lesions <9cm (2.3%, 0.4-12.1%). High-risk profiles for malignancy included tumor marker-positive heterogeneous lesions (66.7%, 35.4-87.9%) and solid tumors ≥9cm (69.2%, 16.2-40.3%). Intermediate risk tumors included cystic tumors ≥9cm (6.8%, 3.5-20.7%), tumor marker-negative heterogeneous lesions ≥9cm (31.2%, 18.0-48.6%), and solid tumors <9cm (11.1%, 4.4-25.3%).

CONCLUSIONS

We developed a decision strategy to help determine who may and may not require an ovarian-sparing approach, which warrants prospective application and validation. Ultimately, the decision to pursue an oncologic surgery with oophorectomy and staging (as opposed to fertility-preserving surgery) should be made after individualized discussion involving the surgeon, patient, and family.

Magnetic resonance imaging of acquired disorders of the pediatric female pelvis other than neoplasm

Transabdominal US remains the primary screening imaging modality of the pediatric female pelvis. However, MRI has become an invaluable adjunct to US in recent years. MRI offers superb soft-tissue contrast resolution that allows for detailed evaluation, particularly of the ovaries and their associated pathology. MRI can yield diagnostic information that is similar to or even better than that of US, especially in nonsexually active girls in whom transvaginal US would be contraindicated. MRI is generally a second-line examination and is preferred over CT because it does not involve the use of ionizing radiation. MRI might be underutilized in this population, particularly in differentiating surgical from nonsurgical conditions. This article reviews the relevant anatomy and discusses imaging of acquired conditions that involve the pediatric female genital tract, illustrating associated pathology with case examples.

Management of Large Ovarian Neoplasms in Pediatric and Adolescent Females

The overwhelming majority of ovarian cysts in pediatric and adolescent girls are physiologic; however, large simple and complex ovarian lesions often require surgical intervention due to the increased risk of neoplasia. In this review article, we discuss the preoperative evaluation and intraoperative management of large ovarian neoplasms. We review the current literature regarding long term ovarian function and fertility, rates of recurrence and residual disease, and novel surgical approaches. Managing large ovarian neoplasms in the pediatric and adolescent population requires careful preoperative and intraoperative care to optimally resect neoplasia while maximizing fertility and minimizing pain.

Fertility after oophorectomy due to torsion

Objectives:

To investigate the prevalence of infertility in patients who underwent salpingo-oophorectomy due to adnexal torsion (AT).

Methods:

All adult women admitted to the Teaching Institution of the University of Dammam, Dammam, Saudi Arabia who underwent surgery due to AT between January 2001 and 2010 were included. Complete data was collected from the time of admission to the follow up. The data was entered into the database and analyzed.

Results:

The data of 26 patients was available for analysis. The mean age (±standard deviation) at presentation was 22.19±4.4 years, and average age at follow up was 34.81±5.75 years. The average delay in presentation was 37.76±47 hours, and the surgery was performed at 45.07±48.57 hours. The right side was involved in 13 (53.8%) of the cases. Fourteen (53.9%) women presented with infertility. Eleven (78.57%) were treated for infertility, and 5 (45.5%) conceived. Patients who were younger at the time of torsion fared better with regard to pregnancy (p<0.03, 95% confidence interval:-6.85; <0.58).

Conclusion:

Patients who undergo salpingo-oophorectomy for AT have an increased risk of infertility and should be warned of this impending complication.

Ovarian tumors in children and adolescents: a series of 41 cases

OBJECTIVE

Pictorial review with a detailed semiological analysis of ovarian tumors in children and adolescents to provide a relevant diagnostic approach.

PATIENTS AND METHODS

Retrospective study (2001-2011) of 41 patients under the age of 15 who underwent surgery for an ovarian mass with a definite pathological diagnosis.

RESULTS

Sixty-two percent of the lesions were benign, 33% were malignant and 5% were borderline. Germ cell tumors were most frequent (77.5%), followed by sex cord stromal tumors (12.5%) and epithelial tumors (7.5%). Malignant tumors were more frequent in children between 0 and 2 years old. On imaging, calcifications and fat were specific for germ cell tumors; the presence of a mural nodule was predictive of a mature teratoma (P<0.001). Predictive factors for malignancy were clinical, including abdominal distension (P<0.01) or a palpable mass (P=0.05), biological, including increased hCG and/or AFP levels (P<0.001) and radiological, including tumors larger than 12 cm (P<0.05), tumoral hypervascularity (P<0.01) and voluminous ascites (P<0.01).

CONCLUSION

This semiological analysis confirms the role of imaging in diagnosing the etiology of ovarian lesions in children and adolescents and emphasizes the importance identifying tumoral hypervascularity, which, in addition to classic criteria, is highly predictive of malignancy.

Magnetic resonance imaging of pediatric pelvic masses

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

Preoperative risk stratification of adnexal masses: can we predict the optimal surgical management?

STUDY OBJECTIVE

To characterize preoperative risk stratification with aim of identifying the accurate surgical approach of benign and malignant adnexal masses in pediatric patients.

DESIGN

A retrospective chart review of all cases of adnexal masses surgically managed between January 2001 and December 2006.

SETTING

The Hospital for Sick Children, Toronto, Canada.

PARTICIPANTS

129 cases of 126 pediatric and adolescent patients who underwent operative management of their adnexal masses.

MAIN OUTCOME MEASURES

Ultrasonographic characteristics (cyst size and character), surgical approach (laparoscopy vs laparotomy) and method of cyst removal (cystectomy vs oophorectomy). Data was assessed with a Fisher Exact test where appropriate (P < .05).

RESULTS

Malignancies were more frequently treated by laparotomy (n = 14, 98.6%, P < .001), and benign cases by laparoscopy (n = 78, 97%, P < .001). On ultrasonography, malignant masses were more often complex (n = 16, 100%, P = .006) and ≥8 cm (n = 16, 100%, P < .001) than benign masses (≥8 cm n = 60, 53%, complex n = 76, 67%). Combining ultrasonographic measurements of ≥8 cm and complexity identified 100% of malignant masses (n = 16) and 36% of benign masses (n = 41, P < .001, PPV = 37.1, NPV = 100%). Additional imaging including CT/MRI was ordered by pediatric surgeons (n = 17, 77%) more often than pediatric gynecologists (n = 44, 41%, P = .002). Furthermore, pediatric surgeons managed adnexal masses by oophorectomy (n = 12, 55%) more often as compared to pediatric gynecologists (n = 19, 18%, P < .001).

CONCLUSION

Using preoperative characteristics of complexity and ≥8 cm reduces the number of benign masses treated with laparotomy while ensuring malignant masses are managed with an open approach.

US of the pediatric female pelvis

This review presents the normal and pathologic development of the gonads and genitourinary tract and addresses the role of ultrasonography in the diagnosis and management of gynecologic disorders of the pediatric pelvis, including ambiguous genitalia, prepubertal bleeding, primary amenorrhea, pelvic mass, and pelvic pain.

Daughter cyst sign

The daughter cyst sign is a specific indicator of an uncomplicated ovarian cyst and pathologically represents a stimulated ovarian follicle. This finding must be differentiated from an ectopic pregnancy in a patient who has the potential to become pregnant. We report an uncomplicated ovarian cyst in a 3-year-old female with McCune-Albright syndrome and precocious puberty mimicking an ectopic pregnancy.