[size=20px]An otherwise healthy and normal appearing 11 year-old girl presents with sudden lower abdominal pain. She is tender in the LLQ to palpation. US shows an 8 cm complex cyst on the left ovary with a small amount of free fluid in the pelvis. There is decreased flow to the left ovary. The cyst shows septations with a 3 cm solid component. Tumor markers are pending. At laparoscopy, there is torsion of the left ovary and a few small lesions on the liver capsule. There are no peritoneal or omental implants. Peritoneal fluid is sent for cytology and the liver lesions are biopsied. After detorsion of the left ovary, what is the most appropriate step in management?

 

A Close and await lab and biopsy results

 

B Obtain a frozen section of the ovarian mass

 

C Ovarian sparing cystectomy

 

D Oophorectomy

 

E Send liver biopsies for frozen section​[/size]

D

C

D

A

[size=20px]An otherwise healthy and normal appearing 11 year-old girl presents with sudden lower abdominal pain. She is tender in the LLQ to palpation. US shows an 8 cm complex cyst on the left ovary with a small amount of free fluid in the pelvis. There is decreased flow to the left ovary. The cyst shows septations with a 3 cm solid component. Tumor markers are pending. At laparoscopy, there is torsion of the left ovary and a few small lesions on the liver capsule. There are no peritoneal or omental implants. Peritoneal fluid is sent for cytology and the liver lesions are biopsied. After detorsion of the left ovary, what is the most appropriate step in management?

 

A Close and await lab and biopsy results

 

B Obtain a frozen section of the ovarian mass

 

C Ovarian sparing cystectomy

 

D Oophorectomy

 

E Send liver biopsies for frozen section​[/size]

 

D

A

Close and awsit lab and biopsy

D

D

A

correct answer

A Close and await lab and biopsy results

​

Ovarian masses in children are relatively rare with an annual incidence of 2.2-2.6 cases per 100,000 pediatric patients. The rate of malignancy ranges from 4-27%. The most common malignant neoplasms are germ cell tumors, sex cord stromal tumors, and epithelial ovarian tumors.

 

Imaging characteristics concerning for malignancy include:

 

Size > 8 cm

Presence of free fluid

Solid components

Papillary projections

Ill-defined borders

Complex components

Extension into surrounding structures

Lymphadenopathy

Metastatic disease

Tumor markers are also important in predicting malignancy risk of ovarian masses and helps in the preoperative planning.

 

Listed below are the negative predictive values of normal tumor marker values.

 

AFP 88%

 

LDH 92%

 

CEA 78%

 

CA 125 87%

 

Beta-HCG 85%

 

Inhibin A 80%

 

Inhibin B 79%

 

 

Tumor markers are most helpful when obtained as a panel during the preoperative work-up of an ovarian mass. In this situation, the patient required an urgent operation due to ovarian torsion and tumor marker levels were not back prior surgery. In addition to concerning features on ultrasound to suggest a possible malignancy, she was found to have some lesions on her liver. After careful inspection of the entire abdomen, collection of fluid for cytology, and biopsy of the liver lesions the most appropriate management is detorsion of the ovary and wait for tumor marker levels and biopsy results to guide further management.

 

If tumor markers are all normal and the liver lesions are benign, this patient could still be offered an ovarian sparing operation as the most likely diagnosis would be a teratoma. On the other hand, if tumor markers return elevated and/or the liver lesions are positive for malignancy then an appropriate oncologic operation is required. Obtaining frozen sections of the liver lesions is unlikely to change the management in this acute setting as it is difficult to obtain a definitive diagnosis even with pathologists experienced in gynecologic oncology. Also, the most likely finding on frozen section is gliomatosis, which will not influence the management of this patient. Finally, detorsion is safe as risk of re-torsion is minimal as long as definitive management is within the next 1-2 weeks.