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.

Characteristics and management of adnexal masses in a canadian pediatric and adolescent population.

OBJECTIVE: To determine whether there were differences in presentation, imaging, and tumour markers between pediatric and adolescent gynaecology patients with adnexal masses managed expectantly and those managed surgically. METHODS: We conducted a retrospective review of patients who presented to the pediatric and adolescent gynaecology service with adnexal masses between January 2003 and January 2006 at Toronto's Hospital for Sick Children. We used t tests, chi-square, and Pearson correlation tests for analysis. RESULTS: We identified 114 patients with an adnexal mass. Fifty-nine percent had surgery (laparotomy 41.8%, laparoscopy 58.2%) and 41% were managed conservatively. The mean age of patients was 12.7 years (range 7 days to 18 years) and there was no difference in age between management groups (P = 0.59). The most common presenting symptom was abdominal pain (72.8%). Increased abdominal girth was found only in the surgical group (P < 0.01). Size of the mass was the only feature on imaging that differed between groups (11.1 cm surgical vs. 5.3 cm observed, P < 0.001). CT scans were performed in 35 patients, 94.3% of whom had surgery (P < 0.001). Tumour markers were drawn in 41.2% of patients, more often in surgical patients (P < 0.001), and 27% were abnormal, all in the surgical group. Surgical approaches included cystectomy, oophorectomy, or detorsion. Twelve percent of surgeries were for malignancies, representing 7.0% of all adnexal masses, and malignant masses were larger than benign masses (16.1 cm vs. 10.5 cm, P < 0.05). In cases that required only expectant management with serial ultrasound, both simple and complex masses resolved, with or without hormonal suppression. CONCLUSION: Larger masses and masses associated with increased abdominal girth or abnormal tumour markers were more likely to be managed by surgical intervention. Surgically managed patients had more investigations. Forty-one percent of masses in patients referred to pediatric and adolescent gynaecology specialists resolved with expectant management.

Ovarian epithelial tumors of low malignant potential: a case series of 5 adolescent patients.

Epithelial ovarian neoplasms are uncommon in pediatric and adolescent patients, accounting for approximately 20% to 30% of ovarian tumors in adolescent females and women younger than 25. Tumors of low malignant potential (LMP) account for a significant proportion of epithelial neoplasms in this patient population. This case series describes 5 adolescent patients, with a mean age of 14.4 +/- 2.4 years, diagnosed with ovarian tumors of LMP at one institution. Between November 2001 and January 2006, 5 patients were diagnosed with ovarian tumors of LMP of 126 patients who had surgery for adnexal masses. All patients underwent initial surgery via laparotomy. Two patients underwent ovarian cystectomy, and 3 had at least a unilateral salpingo-oophorectomy. One patient had stage IIIc disease, whereas the other 4 patients, not all completely staged, had presumed stage I disease. Three patients developed recurrent ovarian masses on follow-up. Two had recurrent LMP tumors (one bilateral) and one was a benign mucinous cystadenoma. This case series of 5 adolescent patients with ovarian tumors of LMP highlights the importance of considering epithelial neoplasms in any pediatric or adolescent patient with a pelvic mass and supports conservative management, with staging and fertility-sparing surgery; however, appropriate follow-up is essential, as evidenced by 3 of 5 patients exhibiting recurrent ovarian masses.

Management of ovarian dermoid cysts in the pediatric and adolescent population.

STUDY OBJECTIVE: To evaluate the surgical approach used in the management of ovarian dermoid cysts in the pediatric and adolescent population. DESIGN: A descriptive retrospective chart review of all cases of ovarian dermoid cyst excision between January 2001 and January 2006. SETTING: The Hospital for Sick Children, Toronto, Canada. PARTICIPANTS: Forty-one female children and adolescents who underwent operative management of an ovarian dermoid cyst. MAIN OUTCOME MEASURES: Surgical approach (laparoscopy vs laparotomy), intraoperative cyst rupture, length of hospital stay, and postoperative complications. RESULTS: The mean age was 12.5 years. All cysts were unilateral. Twenty-three patients (56%) underwent laparoscopic cystectomy, 14 (34%) underwent cystectomy via laparotomy, and 4 (10%) oophorectomies were performed via laparotomy. Cyst size was significantly larger in the laparotomy group compared to the laparoscopy group (mean diameter 14.4 cm vs 7.1 cm, respectively, P < .001). A significantly higher rate of cyst rupture was experienced during laparoscopic cystectomy (100%), compared to excision via laparotomy (27.7%, P < .001). Length of hospital stay was significantly shorter in the laparoscopy group compared to the laparotomy group (median of 0 vs 3 days, respectively, P < .001). A single case in the laparoscopy group sustained a bladder injury and developed postoperative necrotizing fasciitis resulting in a prolonged hospitalization and recovery. There were no operative or postoperative complications related to cyst content spillage, regardless of the surgical approach. CONCLUSION: Laparoscopic cystectomy is a safe and effective method of managing ovarian dermoid cysts in the pediatric and adolescent patient population.

Group A Streptococcus vulvovaginitis in breastfeeding women.

Group A beta-hemolytic streptococcus-associated vulvovaginitis is uncommon in adult women. Clinicians should include group A beta-hemolytic streptococcus as a possible cause of vulvovaginal symptoms in breastfeeding women. Along with appropriate antibiotic therapy, vaginal estrogen therapy may be considered to diminish susceptibility to recurrent infection in women with vaginal atrophy.

Simple vaginal mold for use in the postoperative care of patients with a transverse vaginal septum.

Severe vaginal stenosis is a potentially disabling complication of transverse vaginal septum resection due to the constriction of the resulting circular scar. We describe a vaginal mold that can be easily created by an occupational therapist, and used as a long-term stent of the vagina in young girls.

Vaginal laceration from a high-pressure water jet in a prepubescent girl.

OBJECTIVE: To document an unusual case of water douche injury in a prepubescent girl. DESIGN: Case report. RESULTS: After sitting atop a high-pressure water jet in a public fountain, a 9-year-old girl experienced pain and vaginal bleeding. She sustained a laceration high in her vaginal vault with an estimated total blood loss of 750 mL. Examination and vaginal packing were done under general anesthesia resulting in cessation of bleeding. CONCLUSIONS: High-pressure water douche is recognized as producing serious vaginal injury in adult women but is not well reported as a cause of genital trauma in the pediatric population. Although not well documented, the prepubescent vagina is capable of receiving significant trauma due to highly pressurized water. Initial trauma management should be implemented with subsequent repair of the laceration, if possible. The prepubescent genital anatomy must be taken into account during examination and postoperative care.

Regulation of the metastasis suppressor gene MKK4 in ovarian cancer.

OBJECTIVES: MKK4 is a metastasis suppressor that is downregulated in some ovarian cancers. We sought to investigate whether promoter methylation, loss of heterozygosity, or changes in phosphorylation are involved in MKK4 dysregulation during ovarian carcinogenesis. METHODS: Bisulfite sequencing was used to determine MKK4 promoter methylation. PCR analysis of tumor/normal DNA was performed to determine LOH at the MKK4 locus. Normal human ovarian surface epithelium (HOSE) and SKOV-3 cells were serum starved and treated with EGF, TGFbeta, or wortmannin. Western blotting was performed using antibodies that detect total and phosphorylated MKK4. RESULTS: No MKK4 promoter hypermethylation was detected in 21 ovarian cancers. LOH was detected at the MKK4 intragenic marker D17S969 in 35% of cases and at D17S1303 in 20%. MKK4 protein was detected in 97% of ovarian tumors. The inactivated phosphoserine 80 (ser-80) form comprised 62% of phosphorylated MKK4 protein in ovarian tumors. Treatment of HOSE or SKOV-3 cells with EGF induced a 1.7- to 4.2-fold increase in phosphorylation of ser-80 MKK4 without altering total MKK4 protein. TGFbeta increased MKK4 ser-80 phosphorylation by 5.4-fold above baseline. The PI3K/Akt pathway inhibitor wortmannin decreased the amount of ser-80 MKK4 by 50%, and inhibited EGF stimulation of MKK4 ser-80 phosphorylation by 60%. CONCLUSIONS: LOH of MKK4 occurs in some ovarian cancers, but without loss of MKK4 protein. MKK4 expression does not appear to be downregulated by promoter methylation. Peptide growth factors induce MKK4 ser-80 phosphorylation, which downregulates its activity. PI3K/Akt pathway inhibitors can partially block ser-80 phosphorylation and this may have therapeutic implications.

Endodermal sinus tumor of the infant vagina treated exclusively with chemotherapy.

Endodermal sinus tumor (EST) of the vagina is a rare malignancy usually diagnosed before 3 years of age. Historically, the approach to therapy has included radical surgical resection, with adjuvant irradiation, and chemotherapy. An infant presented with vaginal bleeding, imaging evidence of a vaginal mass and an elevated alpha-fetoprotein level. Examination under anesthesia with vaginal biopsies confirmed the diagnosis of an EST (yolk sac) tumor of the vagina. After 5 cycles of chemotherapy, the alpha-fetoprotein had normalized and repeat vaginal biopsies for suspected residual disease was negative for malignancy. To allow preservation of sexual and reproductive function, chemotherapy as a sole modality of treatment for EST should be considered.

The impact of hormone replacement therapy on the detection and stage of breast cancer.

HYPOTHESIS: Patients who receive hormone replacement therapy (HRT) and subsequently develop breast cancer are more likely to be diagnosed by palpation than mammography and have a higher stage of cancer at initial diagnosis. DESIGN: Retrospective case series. SETTING: University hospital. PATIENTS: Two hundred ninety-two patients with breast cancer who were postmenopausal. INTERVENTIONS: Clinical examination, mammography, and definitive therapy. MAIN OUTCOME MEASURES: Hormone replacement therapy use, mode of cancer detection, tumor size, nodal status, stage, and survival. RESULTS: Patients receiving HRT prior to diagnosis had significantly more incidences of mammographically detected tumors, ductal carcinoma in situ, T1 lesions, negative nodes, and better survival rates than nonusers. CONCLUSIONS: A history of HRT use had only beneficial and no discernible adverse effects on breast cancer detection and outcomes. These effects of HRT seem to be due to the development of less aggressive tumors rather than earlier detection.