Jemds.comOriginal Article

STUDY OF OVARIAN LESIONS IN CHILDREN

K. Nagarjuna,1S. Srinivas2, K. Ramesh Reddy3,K. Lavanya4, Inugala Anusiri5

1Associate Professor, Department of Paediatric Surgery, Niloufer Hospital, Osmania Medical College, Hyderabad.

2Assistant Professor, Department of Paediatric Surgery, Niloufer Hospital, Osmania Medical College, Hyderabad.

3Professor & HOD, Department of Paediatric Surgery, Niloufer Hospital, Osmania Medical College, Hyderabad.

4Assistant Professor, Department of Paediatric Surgery, Niloufer Hospital, Osmania Medical College, Hyderabad.

5Post Graduate, Department of Paediatric Surgery, Niloufer Hospital, Osmania Medical College, Hyderabad.

ABSTRACT: AIM:Tostudyovarianlesionsinpaediatricpatients.

MATERIALSANDMETHODS:AllcasesofovarianlesionspresentingtoNilouferHospitalduringthestudyperiodspanning7yearswereincludedinthestudy.Allcaseswereclinicallyexaminedandevaluatedwithserummarkerslikeα-fetoproteinandβ-HCG,ultrasonographyofabdomenandpelvisandcontrastenhancedcomputedtomographyofabdomenandpelvis.Thecasesweremanagedeitherconservativelyorsurgicallydependingonthediagnosis.

RESULTS:Atotalof36casesofovarianlesionspresentedtoNilouferHospitalduringthestudyperiod.Theageofthepatientsrangedfromnewbornto14years.Themostcommonpresentingsymptomwasanabdominalorpelvicmass.Themostcommonultrasoundcharacterofthenon-neoplasticovarianlesionwascysticwhereasthatofaneoplasticovarianlesionwascomplexormixed.Nonneoplasticlesionswerepresentin22patients.Neoplasticlesionswereseenin14patients.

CONCLUSION:Physiologicalorfunctionalovariancystsarethecommonestovarianlesionsseeninthepaediatricagegroup.Ultrasonogramisaccurateandveryreliableindistinguishingneoplasticfromnon-neoplasticandmalignantfrombenignovarianlesions.Non-neoplasticlesionscanbemanagedconservativelyinabout40%ofcases.Neoplasticlesionsinchildrenrequirealessradicalapproachinordertopreserveovarianfunction.

HOW TO CITE THIS ARTICLE:K. Nagarjuna, S. Srinivas, K. Ramesh Reddy,K. Lavanya, InugalaAnusiri.“Study of Ovarian Lesions in Children”. Journal of Evolution of Medical and Dental Sciences 2015; Vol. 4, Issue 90, November 09; Page: 15534-15536,

DOI: 10.14260/jemds/2015/2225.

Journal of Evolution of Medical and Dental Sciences/ eISSN- 2278-4802, pISSN- 2278-4748/ Vol. 4/ Issue 90/ Nov.09, 2015 Page 1

Jemds.comOriginal Article

INTRODUCTION: Ovarianlesionsarerelativelyrareinpaediatricagegroup.1andthoserequiringhospitaladmissionsareevenmoreuncommon.Neverthelesstheselesionsneedtobeconsideredinthedifferentialdiagnosisinallgirlswithabdominalpain,abdominalmassorprecociouspuberty.2Ovarianlesionsinpaediatricsincludenon-neoplasticandneoplasticmasses.Non-neoplasticmassesincludefunctionalcystsandneoplasticlesionsincludebenignandmalignanttumorsoftheovary.Ovariantumorsmakeupto1%ofallchildhoodmalignancies.1Removalofovarymayhavesignificantimpactonfuturefertilityprospectsofayoungpatient.1Thiscannotbeavoidedinaneoplasticlesion,whichmaythreatenthechild’ssurvival.Paediatricovariantumorsdifferfromadultovariantumorsinpresentation,histologyandbiologicalbehaviourandmandateadifferenttherapeuticapproach.3

MATERIALSANDMETHODS:Theovarianlesionswerestudiedoveraperiodof7yearsatNilouferHospitalandInstituteofChildHealth.Specificdatacollectedforeachpatientincluded:

Financial or Other, Competing Interest: None.

Submission20-10-2015, Peer Review 21-10-2015,

Acceptance 29-10-2015, Published 07-11-2015.

Corresponding Author:

Dr.K.Nagarjuna,

D. No. 4-7-12/53, Ravindra Nagar,

Nacharam, Hyderabad-500076.

E-mail:

DOI:10.14260/jemds/2015/2225.

Age at presentation. Presenting symptoms and signs.

RADIOLOGICAL INVESTIGATIONS:Ultrasonogram,radio-graphofabdomenandpelvis,contrastenhancedCTofabdomenandpelvis,

MRI of abdomen and pelvis Serum markers:

  • αfetoprotein,β-HCG
  • Operativereports
  • Pathologyreports.

RESULTS:Asystematicsearchidentified36patientswithovarianlesionsovera7yearperiod.Theageatpresentationrangedfromnewbornto14years.17patientswerebetween8yearsand14yearsofage,9patientswerebetween1and8yearsofage.3patientswereunder1yearofage.7patientspresentedintheneonatalperiod.Neoplasticlesionswerenotfoundinneonatesandinfants.Bothneoplasticandnon-neoplasticlesionspredominatedinthe1to14yearsagegroup.Benignneoplasmspredominatedinthe5to10yearsageandmalignantneoplasmswereequallydistributedinallagegroupsabove1yearofage.

Themostcommonpresentingcomplaintwasabdominalorpelvicmasswhichwaspresentin24cases.Secondmostcommonpresentingsymptomwaspainabdomenwhichwaspresentin12patients.5patientsweredetectedinantenatalultrasoundexamination.4patientspresentedwithvomiting.2patientswerediagnosedincidentallyonultrasoundexamination,whichwasdoneforsomeotherindication.2casesweredetectedonroutinephysicalexaminationand1patientpresentedwithabdominaldistension.

Endocrinemanifestationsassociatedwithovarianlesionswerefoundin1patientwhohadafollicularcyst.

Massabdomenwasthecommonestsymptominbothneoplasticandnon-neoplasticlesions.Acutepainabdomenwithfeverandvomitingwasthecommonestpresentationoftorsionofovary4casesofovariantorsionwereseen,outofwhich3occurredinnon-neoplasticovariancystsand1occurredinamaturecysticteratoma.

Ultrasoundexaminationrevealedacysticlesionin18cases,solidlesionin5casesandcomplexlesionin13cases.Thesizeofthelesionswaslessthan5cmin10cases,5to10cmin17casesandmorethan10cmin9cases.Themostcommonultrasoundcharacterofthenon-neoplasticovarianlesionwascysticwhereasthatofaneoplasticovarianlesionwascomplexormixed.Majorityofthenon-neoplasticovarianlesionsmeasuredbetween5to10cminsizeandneoplasticlesionsweremorethan10cminsize.

Leftovarianpathologywasfoundin19cases(53%)andrightovarianpathologywasfoundin17cases(47%).

Nonneoplasticlesionswerepresentin22patients.Outofthese22cases17hadfollicularcysts,2hadlutealcystsand3hadovariancystwithtorsion.

Neoplasticlesionswereseenin14patients,ofwhich8werebenignand6weremalignant.

Germcelltumorsarethemostcommonneoplasticlesionsaccountingfor92.8%ofalltumors.Therewere7casesofmaturecysticteratoma,2casesofdysgerminoma,3casesofyolksactumor,1caseofmalignantteratomaand1caseofepithelialtumor.Benignserouscystadenomawasseenin1patient.

Therewere6caseswithmalignantovarianneoplasms.αfetoproteinwaselevatedin3caseswithyolksactumorsandonecasewithmalignantteratoma.Omentectomy,retroperitoneallymphnodedissectionandbiopsyofcontralateralovarywasavoidedinchildrenwithouttheirgrossinvolvement.Onlysuspiciouslymphnodesanddoubtfulareasweresentforbiopsy.Asceticfluidwassentforanalysis,unilateralsalpingo-oopherectomywasperformedinallthesechildren.Chemotherapywasgiveninovariantumorsthathasspreadbeyondtheconfinesoftheovary.

13casesofnon-neoplasticlesionsweremanagedbysurgicalinterventionand9weremanagedconservatively.Conservativemanagementwasgiventopatientswithlesionssmallerthan5cminsize,simplecyst,asymptomaticcyst,cystsdecreasinginsizeonfollowupscan,unequivocalovarianorigin,αfetoproteinandβ-HCGwithinnormallimits.

DISCUSSION:Ovarianlesionsarerareinchildhood.4andasaresultoperationsfortheselesionsareuncommon.InNilouferHospitalmorethan3000paediatricsurgeriesareperformedperyearandoftheseonly36casesofovarianlesionswereoperatedinstudyperiodof7years.Thisaccountstoanaverageofabout5surgeriesforovarianlesionsperyearor0.1%ofallpaediatricsurgerycases.AccordingtoCassetalseries.5fromHouston,Texaswhichperformsmorethan4200paediatricsurgeriesperyear,therewereonly7ovariansurgeriesperyearwhichrepresentabout0.2%ofoverallpaediatricsurgerycases.BreenandMaxon.6inareviewof613casesfrom10repotsfounda36%frequencyofnon-neoplasticlesionsand64%ofneoplasticlesions.Freudetal.2inareviewof34girlspresentedanincidenceof53%fornon-neoplasticand47%forneoplasticlesions.Desilvaetalreported67.2%incidenceofnon-neoplasticlesionsand32.8%incidenceofneoplasticlesions.Inourseriesnon-neoplasticlesionswereseenin61.11%ofcasesandneoplasticin38.89%ofcases.Physiologicalandfunctionalovarianlesionsarethemostcommonnon-neoplasticlesions.Thesemayoccurduetofailureofafollicularruptureorbecausethecorpusluteumfailstoregress.Thesearethecommonestlesionsfoundinourseries.

Ovariantumorsarenotcommoninchildrenandaremostlybenigninnature.7Mostpaediatricovarianneoplasmsareofgermcelloriginfollowedbysexcordstromalandepithelialtumors.InDesilvaetal.8series72.7%ofneoplasmswereofgermcellorigin.Freudetalseriesdocumented69%incidenceofgermcelltumors,19%incidenceofstromaland6%incidenceofepithelialtumors.Inourstudytheincidenceofgermcelltumorsis92.8%andepithelialtumorsis7.2%therewerenomalignantepithelialorstromaltumorsinourstudy.InDesilvaetalseries,84%ofallgermcelltumorswerematurecysticteratoma.

Inourstudy53.8%ofallgermcelltumorswerematurecysticteratoma.InDesilvaetalstudymalignanttumorswererareandfoundonlyin13.6%ofcasesandtherewasonlyonemalignantepithelialtumor.Inourstudymalignantneoplasmsoftheovarywereofgermcelloriginandfortunatelytheyaccountforonly16.6%ofalllesionsoftheovary.Αfetoproteinisasensitivemarkerformalignantgermcelltumorslikeyolksactumorandmalignantteratoma.Thistumormarkerisusefulinthediagnosisandfollowupofthesecasespostoperatively.

Analysisofclinicalfeaturescouldnotdistinguishbetweenneoplasticandnon-neoplasticovarianlesions.Mostcommonpresentingcomplaintinpaediatricovarianlesionisabdomenorpelvicmass.Ovarianlesionsmaypresentwithprecociouspuberty,uniquetopre-menarchealgirlswithhormonallyactiveovarianlesions.Thismaybecausedbysecretionofhormonebythelesion.Itcanalsobeseeninhormonallyinactivelesions,thisisduetothemasseffectofthelesioncausingexcessivesecretion.Lessthan10%ofprecociouspubertyinfemalesisassociatedwithovarianlesions.Desilvaetalseriesreportedtwochildrenwithnon-neoplasticovarianlesionandonechildwithgermcelltumorspresentingwithprecociouspuberty.

Althoughovariantorsionisararediagnosis,itmustbeconsideredinallgirlswhopresentwithlowerabdominalpain,pelvicmass,nausea,vomitingandfever.960%ofovariantorsionhaveunderlyingovarianpathology.Mostofthelesionsarebenign.Malignantlesionsoftheovaryhavealowerrateoftorsionduetotheirtendencyoflocalinvasion.Theriskoftorsioncorrelateswiththesizeoftheovarianlesionandlengthofthepedicle.9Inourstudy3ofthe4ovariantorsionsoccurredinnon-neoplasticovariancystsandonecaseofneoplasticlesion(Maturecysticteratoma)presentedwithtorsion.

Abdominalsonographyremainsthemostreliablediagnostictoolintheassessmentofovarianmasses.InFreudetalseriestheappearanceandsizeoftheovarianlesionwasusefulinpatientmanagement.

InDesilvaetalseriescystsmeasuringover5cmweresignificantandweremanagedsurgically.Lesionsmeasuringmorethan10cmwithsolidorcomplexappearancewerelikelytobeneoplastic,inhisseriesthecommonestcauseofcomplexcystwasnon-neoplasticlesionorhaemorrhageintocorpuslutealorfollicularcyst.Inourstudythecommonestappearanceofnon-neoplasticovarianlesioniscystic.Majorityofnon-neoplasticovarianlesionswerebetween5to10cmandneoplasticlesionswereover10cminsize.Inourseriesmalignantlesionswerepredominantlysolidandbenignlesionswerepredominantlycomplex.

Conservativemanagementfornon-neoplasticlesionsisveryimportanttopreservetheovariantissueandfuturefertility.Evenunilateraloophorectomycanimpairresidualovarianfunctionandappeartoincreasetheriskoftrisomy21inoffspring.InDesilvaetalseriessurgicalinterventionwasdonein30%ofchildrenwithnon-neoplasticovarianlesions.Inourseriessurgerywasperformedin59%ofcasesofnon-neoplasticovarianlesions.

CONCLUSIONS:Physiologicalorfunctionalovariancystsarethecommonestovarianlesionsseeninthepaediatricagegroup.Commonestpresentingcomplaintofpaediatricovarianlesionisabdominalorpelvicmass.Ultrasonogramisaccurateandveryreliableindistinguishingneoplasticfromnon-neoplasticandmalignantfrombenignlesions.Non-neoplasticlesionscanbemanagedconservativelyinabout40%ofcases.Neoplasticlesionsinchildrenrequirealessradicalapproachinordertopreserveovarianfunction.

BIBLIOGRAPHY:

  1. Mark F. Brown et al. Ovarian Masses in Children, A review of 91 cases of malignant & benign masses. Journal of Paediatric Surgery. 1993 July; 28: p. 930-932.
  2. E. Freud et al. Ovarian masses in children. Clinical Paediatrics.1999, October; 38: p. 573-577.
  3. Daniel Von Allmen et al. Malignant lesions of the ovary in childhood. Seminars in Paediatric Surgery. 2005, May; 14: p.100-105.
  4. Andrea Hayes-Jordan et al. Surgical management of the incidentally identified ovarian mass. Seminars in Paediatric Surgery. 2005, May; 14: p. 106–110.
  5. Cass DL et al. Surgery for ovarian masses in infants, children and adolescents: 102 Consecutive patients treated in a 15 year period. J Paediatric Sur. 2001; 36: p. 693-699.
  6. Breen et al. Ovarian tumors in children and adolescents. Clinical obstetrics gynaecology. 1977; 20: p. 607-623.
  7. Claire L. Templeman et al. Benign Ovarian Masses. Seminars in Paediatric Surgery. 2005, May; 14: p. 93-99.
  8. K.S.H. De Silva et al. Ovarian Lesions in Children and adolescence–A 11 years Review. Journal of Paediatric Endocrinology and Metabolism. 2004; 17: p. 951-957.
  9. Darrell L. et al. Ovarian torsion. Seminars in Paediatric Surgery. 2005, May; 14: p. 86-92.

Journal of Evolution of Medical and Dental Sciences/ eISSN- 2278-4802, pISSN- 2278-4748/ Vol. 4/ Issue 90/ Nov.09, 2015 Page 1

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Fig. 1: Contrast enhanced CT

Showing Right Ovarian Cyst

Fig. 2: Intra Operative Picture Showing

Left Sided Ovarian Cyst in a Neonate

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