Ovarian lesions and tumors in infants and older children

Abstract

Objectives: Ovarian lesions are rare but frequent in children. Patients could present with abdominal pain, but ovarian lesions could also be incidentally found on ultrasound. Awareness is required in cases with acute, severe lower abdominal pain, as ovarian torsion could be the cause. Other lesions can be cysts or benign or malignant ovarian tumors. Thus, the aim of this paper is to review typical ovarian lesions according to age, imaging and laboratory findings, and surgical management.

Methods: We retrospectively analysed the patient charts of 39 patients aged 10.4 ± 6.1 years (from 3 months to 18 years) with ovarian lesions treated in our institution between 01/2009 and 08/2020. All clinical and pathological findings of infants and children operated on for ovarian lesions were included.

Results: Ovarian lesions in children younger than 2 years of age were typically ovarian cysts, and ovarian tumors were not observed in this age group. In older children over 10 years of age, tumors were more common - with mostly teratoma or other germ cell tumors, followed by epithelial tumors. Moreover, acute or chronic ovarian torsion was observed in all age groups. In general, ovarian tumors were much larger in size than ovarian cysts or twisted ovaries and eventually showed tumor marker expression of AFP or ß-HCG. Simple ovarian cysts or twisted ovaries were smaller in size. Surgery for all ovarian lesions should aim to preserve healthy ovarian tissue by performing partial ovariectomy.

Conclusions: In adolescent girls with acute abdominal pain, immediate laparoscopy should be performed to rule out ovarian torsion. Careful imaging evaluation and the assessment of tumor markers should be performed in painless ovarian lesions to indicate an adequate surgical ovarian-sparing approach.

Keywords: laparoscopy; ovarian cyst; ovarian torsion; ovarian tumors; surgery.

Figure 1:

Graph of number of patients (percentage) with tumorous lesions in patients with ovarian mass according to age group. No occurrence of a tumorous lesions in patients with ovarian mass was observed in the age group younger than 2 years. An increasing portion of ovarian tumors were observed in the age groups from 2 to 10 years, and in females older than 10 years (n=39; p<0.025 by Chi-square test).

Figure 2a–c:

Sonography (a) and MRI (b) findings showed a cystic mass in a 6 week old infant with hemorrhagic solid mass and fibrous septation of the cystic mass typically suggesting ovarian necrosis. Intraoperative situs (c) revealed an old (intrauterine) ovarian torsion with a necrotic ovary.

Figure 3a/b:

Graph ovarian volume of ovarian cysts and torsed ovaries (a) showed an increased volume in ovary torsion. Graph average ovarian mass volume showing that tumorous ovarian lesions (b) showed a much higher volume when compared to ovarian cysts or ovaries with torsions.

Figure 4:

Intra-OP picture of ovarian torsion with vital ovary. Laparoscopic detorsion is warranted to preserve the ovary timely.

Figure 5a/b:

MRI scan showed a big monocystic tumor which fills nearly the whole abdominal cavity (a sagittal; b lateral). After complete resection, histological examination revealed a serous cystadenoma of the ovary.

Figure 6a–c:

MRI scan (a) showed a big cystic-solid tumor of the ovary suggesting ovarian teratoma. AFP values were normal. Ex-situ photograph of the opened resected tumor showed the typical appearance of mucous and hairy contents of a mature teratoma (b). Intra-OP picture showed partial resection of the ovarian mass, preserving healthy ovarian tissue (c).