Pediatric Ovarian Tumors Video Podcast

Hi everyone, my name is Sophia Abdulha, and I'm Doctor Ponzi's current research fellow. So one of the shortcomings of audio podcasts is that we cannot show you any videos or pictures during the actual podcast. So for our latest podcast release, pediatric ovarian tumors to Doctor Frederick Roscola, we are trying something new. So in addition to our normal audio podcast, we'll also be releasing a video version of the podcast that will include intermittent videos and pictures that are. During the podcast. So every time you hear this sound, it means we're showing you an image or video during the podcast and you can look down at your device. This will only be available on the new state and Surgery app on iOS, but if you don't have it, don't worry, you can still access it on iTunes or our website GlobalcastMD.com and click on the podcast tab. Please leave your comments and suggestions, and we hope you enjoy. Stay Current is a multimedia publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. This chapter is created and edited by Todd Ponsky, Sophia Abdulhai, Abdulruf Lamoshi, and Rajavendra Rao and is recorded and produced at Akron Children's Hospital in Akron, Ohio. This is Todd Ponske from State Current in Pediatric Surgery, and today we are going to be talking about ovarian tumors. We actually have with us someone who is an absolute undisputed expert in the field, Dr. Fred Rescola, who is the surgeon in chief at Riley Hospital in Indianapolis, and he is the Anna Healey Professor of Surgery. He's also on the COG Germ Cell Committee. So as everyone knows, he is clearly the expert in germ cells, and when I saw Fred, I asked him if we could do. A germ cell audio chapter and he was very adamant about doing ovarian. And Fred, thank you for joining us and I really appreciate you being here and tell us why you wanted to talk about ovarian. Well, first, thanks for doing this, Todd. You know, I think ovarian is a great topic, one, it's pretty common, and I think most of us as pediatric surgeons see a lot of ovarian tumors. We see more of them than we see of like Wilms, neuroblastoma or other types of tumors, even though Among the ovarian tumors, most of them are not malignant. We're frequently asked to see a young girl or an adolescent with an ovarian mass, and so I think it's a very common thing. I think it's also something where it's very important for us as pediatric surgeons to emphasize ovarian preservation when we see things like torsion or tumors. Since so many are benign, we often can preserve the ovary and. There's evidence that we're doing better at that, but there's also some evidence that there are a lot of tumors that have been taken out in the last 20 years where we probably could have in retrospect, preserved some functional ovary and not done a complete oophorectomy. I love how you stated that right off the bat. So we're going to start and end with that, that if anything to take away, it's the movement towards ovarian preservation. So Fred, let's jump right into it. You get called about a 4-year-old girl. She has a 1 week history of abdominal pain and is noted to have a large, predominantly cystic mass extending from the pelvis into the upper abdomen, and she does have a 2 x 3 centimeter solid component. With calcifications, how do you even begin with workup and what are you thinking with this patient, and then what's your differential? Well, I think you know right off the bat from her history, it's about a one week history. You always want to be thinking about the potential of torsion with these. The tumors can tours, but if she's had about a week history, it's probably not an acute process. It's probably been going on for a while. So I think right off the bat for any ovarian tumor, you really need to check markers for certain, get an alpha fetoprotein. HCG is unlikely to be elevated in this age. We usually just check it anyway, but those would be the main markers we'd get at this age. And then I think you're looking at imaging, you know, we always think that ultrasound is a good first screening, but in reality, most of these children are going to end up with a CT scan. And so then in the scan you're really looking at, you were kind of mentioned that it's predominantly cystic. So I think when you look at the child, you know, one thing we're always trying to determine is what is the risk of malignancy from the imaging, and I think there's very good data that if it's predominantly cystic. Probably the chance of malignancy is probably 3 or 4%. If it's kind of a more heterogeneous, the malignancy rate might be more like 15 to 20%, and if it's solid, it's probably over 25% at least. So I think this girl is probably in a benign category. If the markers are normal, I think almost certainly she's benign. That's not 100%, and there's definitely some children that'll have malignancies. So I think it emphasized that when we do take her to the operating room, we have to sort of try to preserve the principles of an oncologic operation. But with a specific girl, I'd be thinking, you know, if her markers come back normal, I would definitely try to do some type of ovarian preserving procedure for her. So let me back up and ask you, so give me a little overview of ovarian tumors. What's out there? What should we be looking out for? Yeah, it's great. You know, overall, when you look at the big studies, probably 10% at most are malignant of all the, you know, if you look at the big studies, maybe even a little bit less than that. Within the malignant group, germ cell in children predominates, probably at least greater than 50% in some series, maybe 80%. So a germ cell is by far the most common, and then there might be some sex cords, stromal tumors, a few borderline malignancies. So that's again only about 10% of the whole group in germ cell predominates in the benign category. The benign germ cell tumors dominate again. So things like mature teratoma is probably at least half of those girls, and then there's immature teratoma maybe for 10 to 15%. And then you're looking at functional cysts, cyst adenoma, a few other rare malignancies, so. In both malignant and benign germ cell type tumors predominate. OK, so that's a great overview, and I'm assuming when you look for these types of what can be a concerning tumor on evaluation on their exam, you can look for do they have any precocious puberty signs of there being more concerning. What would that tell you if you saw evidence of pubic hair in a 4 year old? I think you'd really be worried about a functional tumor, probably in the sex cord stromal category, and I think that would prompt a more in-depth hormonal evaluation for the byproducts of sex cord tumors, you know, testosterone levels and some of the breakdown product levels. So yeah, absolutely. OK, so back to this child, this 4 year old, so now you have this scan, you've checked the markers, they're pending because they're not going to come back right away. Do you wait for them to come back and then what is your workup plan and then how do you proceed? So we usually can get an alpha fetoprotein back within several hours, so we would probably wait for that if we could. I think it's probably worth doing that. That's the only one I'd wait for. If there was some reason I couldn't wait, if she was quite uncomfortable. I think the way you've described this with predominantly cystic, an area of calcification, no secondary characteristics, I think. I would probably go ahead and do the surgery. I think you can still do a totally perfect oncologic operation without spilling this girl, so I would, I'd be comfortable taking her to the operating room even if the markers weren't back. OK. And you know, you mentioned the imaging being suggestive, but you believe that it can accurately predict benign versus malignant. Well, I don't think it can accurately predict. I think it can put you in the right category most of the time. But I think if you look at the data from the malignant tumors, the big studies out of the Children's oncology group, a very high percentage have cystic components within it. Now we don't really know what percent is cystic from those, those studies. They don't have all that data, but I think there are definitely some girls who present with mixed tumors where there's a solid and cystic component that turn out to be malignant. Not all the girls have elevated markers, you know, if it's a mixed tumor with, let's say, embryonal carcinoma, you might not have elevated markers. So even though it's very, very, very uncommon. I still think it is worth it. I think one interesting thing I saw a few years ago in one of Dr. Deborah Belmeyer's papers was a group of stage 3 ovarian tumors, I think there were 20 of them, 5 of them were stage 3 only because their peritoneal fluid was positive for malignant cells. And if that had not been checked, they would have been considered stage 1 tumors, likely with a higher recurrence rate. So I really You know, these are pretty simple tests. They're not very hard to do. They don't hurt the child. It just takes a few extra minutes for us, and they're, I think it's a good principle to have kind of the standard operation in your mind all the time and for the most part to do that. OK, so this brings us to the next question. So this girl has her markers come back. They're both negative, and you're now heading to the operating room. Tell me your preoperative thoughts and tell me how you're going to approach this surgically. So my thought on her, since she's very big. And you know it'd probably take a big midline to get the thing out intact without any disruption. I really don't want to do that in her, you know, you could consider a laparoscopic approach. I would probably tend to do a little different approach where you make a small lower abdominal incision on the side that you think it's arising from and then I get into the abdomen, find the cystic component of the tumor, and then I just dry it all off and there's a technique where you. Use either Inderal or Duurbond to put it directly on the tumor. You have to wall off the area so you don't spill it, and then just take a big plastic sheet of, you know, bag and glue it onto the tumor. So you have a common interface where there's the tumor glue in the bag, and then you can protect the wound and, and basically just place a knife directly through this common interface and suck out all the fluid, and you often can remove a liter or two of fluid. And once you get that out, you might, it might not be completely empty, but often you can deliver the tumor out of the abdominal cavity at that point and then proceed to inspect it. If it's amenable to a partial oophorectomy, you can do a partial oophorectomy right at that time. I do still believe, so I'm just kind of talking about the tumor removal. I still think it's very important to do peritoneal washings, you know, on this girl, I probably would do it right away when I get in the belly, just, you know, see if there's any fluid. If there is, suck it out and send it for cytology. If there's not, put some saline in, rinse it around for a little bit, and then aspirate that. Later in the operation, I would look at the other ovary. We used to recommend a contralateral biopsy. Now we only recommend a biopsy if it looks abnormal. So look at the other ovary. See if the omentum's adherent to the tumor. If the omentum is adherent to the tumor, take it out. If it's not, you can leave it alone and then assess the peritoneal cavity, see if there's any spread peritoneal implants, and then in this case, probably at the very end, look at the retroperitoneal lymph nodes. Now, most likely you're gonna have a pretty good idea of the retroperitoneal lymph nodes from the CT scan, but. We still like people to look, and the only requirement is if you see a node that's enlarged to simply remove that lymph node. No rule for lymph node dissection, just a simple lymph node removal for sampling, and that's all. So it's sort of 6 steps total counting removal of the tumor and. So we try to go through those 6 steps every single time. All right, so I have a bunch of questions and a couple comments. Number 1, if you make that, by the way, I do it the same way with that bag. There's actually a great surgeon, Coca Gonzalez, who's down at Clinica las Condes in Santiago, Chile, who gave me a great picture of what that looks like. So I'll post that with her permission of what that. Looks like gluing the bag to the tumor, but I love that approach as well, and I have questions for you about it. Specifically, I want to start with the last thing you said. How do you explore the retroperitoneal lymph nodes through a tiny incision like that, or do you close it and put a laparoscope in? Well, I think that's definitely an option, and in reality you can probably inspect the peritoneal cavity better with a laparoscope than through a small incision. You know, usually the incisions for these would be maybe 3 to 4 centimeters in length. If I can put a retractor in and feel up to the aortic bifurcation up and feel both iliac systems and up above the bifurcation a little bit, I'll probably be satisfied with that, with palpating, right, just palpating, right. Great. And you know one thing we've done is we've closed that incision almost completely and then put a trochar into the end of the incision and look. That's a great technique. I have a question for you about that as well. So I know a lot of people love. Approaching these laparoscopically, I think what you just described is sometimes even less invasive than putting 3 or 4 trochars in. But I have only successfully been able to do that, Fred, and I'm curious your approach when they are really big, that when you make that incision, it's right there. That tumor is right there. You don't have to go looking for it. Otherwise, I would need a laparoscope to help push the ovary up to that tiny incision. Do you agree with that, or. So I think if they really have to be really, really big to do that technique, and I think if they're smaller, I think the laparoscope is the best way to go and then make your decision intraoperatively based on what you see. Now when you get the ovary out, you've glued the bag, you've aspirated out the fluid, you deliver the ovary, and you mentioned doing an ovarian salvage resection of the tumor. Do you score the outside and sort of nucleate it out? How do you do that? Yeah, I think in general that's basically what I do, you know, you'll look for the blood supply coming into the ovary. You look for where the fallopian tube is. Usually the tumor is kind of off the top, so to speak. And so you usually end up lifting the tumor up and then kind of scoring where I think the normal ovary will be. Usually there's a little white rim going up on the tumor. And I think you have to score it. You can use hot and cold scissors and just start to cut away, trying to stay out of the cystic component, and you know you just often end up with a very flat ovary that's a little thicker by the blood supply, but it's often very thin on the periphery. But I think that's OK. That's, that's ovarian tissue, and that's what you need to preserve. Sometimes I'll get a little bleeding and sometimes I'll close it up. I'll put a few stitches to close the two flat edges together, but I think you can also just leave it open. So to clarify, the tumor is inside the ovary. It's the ovaries is wrapped around it, so you need to open up the ovary to get the tumor nucleated out. Exactly. Well, that's great. So and then you go back in, you find the other ovary, you feel for the retroperitoneal nodes, which, to be honest, I have not routinely done that through that small incision. So I will start doing that now, and the peritoneal. Washings. Great, that's fantastic. Anything else that we need to think about with this patient, either pre-op, intra-op, post-op, before we move on to my next scenario? I think we've pretty well covered it. OK, so next kid. So now you've got a 13-year-old, and this, I think, is a very common scenario for all of us. A 13-year-old comes in. She's had some very vague abdominal discomfort, but she noticed that her belly was getting bigger. They got an ultrasound and then a CT scan, of course they did it all, and they call you that she's got a really big, completely cystic, volleyball sized pelvic mass. Now what? Yes, I think this is a pretty common scenario. It's Primarily, most likely just a benign cyst of the ovary. We typically, based on the size, would probably check markers just to be certain, but the markers are not undoubtedly be negative. Then I think you have to get it out, you know, we did a study at our place where if they're this big and if the markers were normal and they were just predominantly cystic, the risk of malignancy was much less than 1%. So I think you could pretty much say this is not malignant. And I don't, I don't think it makes much difference how you decompress the cyst. I think it's not wrong to put a scope in and decompress it with a trochar, aspirate it all, and then do a partial oophorectomy, which you could definitely do a laparoscopy, and you're, you're basically doing a cystectomy. So I think you could easily do that that way, and I think. It'd be almost unheard of for that to be malignant, you know, I mean, there probably at some point it'll be some child that'll have a malignancy, but then they just have to go get chemotherapy. I don't think you can subject all these girls to really big incisions when it's very common and the chance of malignancy is so low. OK, so you know Mack Harmon jokes around with me that I do these podcasts completely selfishly so I can. Learn more about questions I have and that it is absolutely partially true. So let me ask you questions about that. What I think I'm hearing you say is that the difference between the first case and the second case, again, the first case was a younger patient that had a mixed tumor. It was mostly cystic with a small solid component, and this one that really looks like a benign teratoma that has all cystic is that you don't necessarily have to worry as much about the oncologic precautions of the bag, and you could do this one laparoscopically. That's correct. Now, as I talk about this second case, I'm really thinking this is a benign cyst. You know, I don't think there were any calcifications or anything to make us think it's a teratoma, so I think it's probably going to be a benign cyst. It might be a purely cystic teratoma, but even in that case, I think you're probably fine. Yes. OK. And I would love for people to comment in this audio chapter below if they disagree with anything that's being said today, because we'd love to hear everyone's opinions on this and how it's managed in different parts of the world. So if you were to do this laparoscopically, you decompress it, would you decompress it, and what's your technique? Do you go in with an energy device and start lifting the ovary and peeling it off? Of the tumor that's inside. Yeah, so are we talking about the second case, the second case. So it's purely cystic, purely cystic, and there's no calcifications, right? Yeah, so I think in this case you can just use a scissors and cut the cyst off the ovary. You're probably going to leave the back wall of it on. There's going to be a lining of the cyst that will be on the ovary. I probably wouldn't worry a lot about that. You know, sometimes these get so big that the ovary is sort of flattened out on it, and I think in some of those cases. It's pretty hard to do a partial oophorectomy laparoscopically, so I think, and again, you're not really worried about this being cancer, so I think it doesn't make a lot of difference. I think you just, you know, you wanna get the cyst out. Minimize the chance of it recurring, and I think you want to do it minimally invasive. I don't think she merits a big incision. Yeah, I don't know if you have videos of that. I'd love to see. I know the video that I've seen of Marcella Bayez, she scores the outside of the ovary and sort of goes around and around and around as she shells it out and just lifts it out from inside the ovary. All right, next case. So now you have A girl who has a 3 month history of lower abdominal pain and her belly, her lower abdomen has grown in size, has swelled, and on imaging she's got a predominantly solid mass. It's filling the pelvis. You check the tumor markers and the AFP in this, I didn't say her age, let's say she is a teenager, so she's out of the neonatal period. She's got an AFP of 44,000. What do you do with this one now? So now you've got a solid tumor. Yeah, so I think this is definitely going to be malignant. It's big. It's solid, and the AFP is elevated. So this is malignant for sure. And at this point I think you want to decide, you know, is this something that can be resected up front and because if it could be a stage 1 tumor, so if it's confined to the ovary, the washings are negative, the nodes are negative, there's no is a metastatic disease. She would be a potential candidate for surgery alone. So that's the real critical thing is to, you know, could she be a surgery alone patient? If you find evidence on imaging that the disease is outside the ovary, she will definitely get chemotherapy. I think if possible, it would be best to take out the primary initially, you know, I say in the perfect world, go take out the primary tumor as long as you can do it with a unilateral oophorectomy. I think if you get in there and um or if there's something on imaging that makes you think it's bilateral or if you think you can't get it out then I think neoadjuvant chemotherapy and a delayed resection is fine, but I think when you first look at it, that's kind of your question in your mind. Is this confined to the ovary or not? If it is confined to the ovary, then I think we should approach it. I think I would do an open operation. I don't think there's any role for laparoscopy. You have to do a complete oophorectomy. We want the tumor out intact through a fan and steel. Yes, yeah. OK. The adults do midline in a lot of these women, but we still do a lower transverse fanosteel type of incision and We feel we can do it all through that incision. I'm sorry, preoperative workup. Other than you have the markers, is there anything else you need to do different or not really? Well, she's going to need a chest CT no matter what, OK, so she'll need a chest CT for determination of her stage. So you might as well just get that right off the bat with the abdominal CT. Just get a chest CT. You'll have it all done, and I think it helps you kind of know the whole picture a little bit as a surgeon. In case something changes when you're in the operating room, I think it's at least good to know, is she a potential stage one candidate or is she not? OK, that's perfect. Now I'm sorry, and just to clarify again, if you see Mets. You still may take out the primary or you would just go in and get tissue. I think if it's amenable to resection, I would still take it out. OK, so you go in through your fan and steel, you find the tumor, and do you do a salpingo oophorectomy? So I think that's optional. I think if the fallopian tube is not Encased with tumor, if you can peel it off, I would peel it off and preserve it. If it was really adherent or some difficulty in the operating room or the tumor seemed to be around it, I wouldn't worry about it. But I think there's no reason oncologically that you have to take out the fallopian tube. So in general, I would leave it if I could. And so does the ovary just peel off the fallopian tube in the fimbria? Well, that's not quite as easy as you think sometimes, I mean. That's right. You've been there before, so I think sometimes you get a little bleeding once in a while, and I think if it gets too bad, I would just take it out. It's not essential. OK. And postoperatively, let's say that the washings were positive. I'm trying to think of things that you might find that would upstage her. Um, other than mets, right, so if it looks on preoperative imaging that there's no evidence of disease outside the ovary, you know, the CAT scans are so good right now they're going to pick up the retroperitoneal lymph nodes for the most part. They're going to pick up distant metastases. The things that you as the surgeon are going to determine, I think it's really peritoneal washings, and that would be the, the one thing if it, if it otherwise looked like a stage one tumor, perineal washings are probably the main thing that could bumper to a higher stage. It's unlikely that you're going to find enlarged lymph nodes if you didn't see them on the CT scan. We'd like you to look anyway, but it's pretty unlikely that you're going to find that. That's great. And this is just by palpation, not a retroperitoneal lymph node dissection, correct? Yeah, just palpation, absolutely. And just to point out, that's a big variance that I have noticed at the hospitals I've been at between us and the gynoc surgeons, correct? OK. I think part of it is that, you know, we are primarily dealing with germ cell tumors which are very chemo responsive tumors. They're not carcinomas. I think they deal with a little bit different type of tumor for the most part. They're dealing with epithelial tumors. We're dealing with teratomas and germ cell tumors, so it's a little bit different type of tumor. Yep, OK. So you do washings, you palpate the lymph nodes. Do you do omental biopsies and diaphragm biopsies and peritoneal biopsies? We don't do anything unless it's abnormal. So if you see something abnormal in the peritoneum or the diaphragm, then I think you should biopsy it. In terms of the omentum, if the omentum is not attached to the tumor and if it on palpation is normal, we simply leave it alone. But if it would be adherent to the tumor, I would just take it with the tumor. Yep, OK, that's great. OK, so if she does have positive peritoneal washings or peritoneal studying, she would need chemotherapy. Is a role for radiation? No, it's pretty much just chemotherapy. It's a platinum-based platinum etoposide, and bleomycin. OK, yeah, it's pretty straightforward, very effective chemotherapy. And so there's no role of doing some cryopreservation of the other ovary. So that's a, that's a really good question. Right now we are not doing that, but I think, I think in children who get chemotherapy that's going to be something that we'll probably have to do at some point. But I think right now, you know, especially if there's no chemotherapy, definitely no cryopreservative, if you're going to save the other ovary, that's fine. But I think in the near future with the administration of chemotherapy there's there will be more frequent considerations of that. OK, let me take you through the most common debate that we have in our group, and I'm really curious on how you deal with this. So a 13-year-old, I keep saying 13-year-olds, so let's just keep picking that 13-year-old comes in with a 24 hour onset of acute abdominal pain in the right lower quadrant. They think it's appendicitis. They get a CAT scan or an ultrasound and they see a 6 centimeter ovary that has heterogeneous sort of fluid in there. It could be blood. They just can't quite tell. It looks mostly fluid, but it could be blood. So it looks like it could just be a hemorrhagic ovarian cyst that torsed. They can't tell you if there is torsion or not. They can tell you that they actually see blood flow, but they can't tell you if it's torsed or not. How do you manage that patient and do you open up the cyst or is that risky? That's a debate here too, so I think it's a pretty common problem, and you know you're going to probably be stuck going in on her relatively urgently. You're, you can send markers, but you're likely not going to have them back before you are in the operating room. So I think you're going to be in the operating room with this girl. You're probably going to find a torsion, and it's might be unclear whether it's simply a torched ovary that's hemorrhagic and big or whether there's a tumor with it. I think if you see a clear cystic component. I think it is fine to decompress it. I think then the situation most likely to be some type of ovarian cyst that's led to torsion, and I would go ahead and decompress the cyst, probably take out part of the cyst wall, penetrate it, or do something, and detourse the ovary. If you think it is a tumor or a mass, let's say you don't really know if what type of it's a malignant or benign, I think it's fine to detorse it. And you know your options then are whether you try to take it out. I think it's fine to leave it in and go back at a delayed time, you know, get all the data underhand. Again, if you think there's no tumor, it's really detortion. There's some controversy about oophoropexy. I think most of the adults simply do detortions only. There's a recent study out of the Fertility and Sterility Journal demonstrating that pre-medical girls have a higher risk of torsion. And their recommendation was that if it's a premal girl or if somebody's had a torsion of that same ovary before to go ahead and do an oophoropexy at that time. So that's kind of what we do. OK. That's, and, and how do you do your oophoropexy? Do you stitch it to the lateral side wall? So I usually do that. Some people talk about shortening the ligament. Putting a few stitches in. I've looked at that and thought about it if it would actually work. I think, I mean, it obviously it must work, but I have generally sutured it to the lateral wall. All right, and I've gone back and forth. I was, I was told that if you stitch it to the side wall, it could alter the angle of the tube and could alter fertility, but it's easy to do. It makes sense to me, so. Have you done the ligament shortening? I have. I've clipped it. That was taught to me by one of the gynong surgeons in Washington DC, and I've always found it much easier to just PEI. So I've gone back and forth, and I rarely do it. I do it if the ovary looks, you know, if it's a solid thing or it looks normal to me. If it's a normal looking ovary that torched, then I PEXy it. So, but you mentioned something. You mentioned that if they tell you there's a solid component to it, you may consider just doing an oophorectomy. So the real situation is that you have a mature teratoma that torses. So if you have it that's torsed, if you're trying to do it acutely, you're going to be stuck to an oophorectomy for sure, I think. I mean it's going to be hard to do it. You're not going to be able to do it. So I think in that very select group, you know, quite frankly, a week is not going to make any difference to her oncologically. So if you did torse it. Give her some time to calm down, reimage it, get, get some good imaging when this is resolved, see what it looks like, check the markers, and then go back in. I think when you go back in, this probably happened like a few times in our institution, you can still do an ovarian preserving operation at that time. OK. So you don't, if you have a torsion without a mass. Do you serially follow them with ultrasound to make sure it's getting smaller? So actually we do. We usually get an ultrasound in the 4 to 6 week post-op range and see them back in a post-op visit with an ultrasound, make sure everything looks OK. And I don't know if it's critical to do that. I think the families are a little reassured to know, is there some ovarian tissue over there or not? And again, I can't say that it's necessary, but we do do that. OK, yeah, we do the same. So what is the survival for ovarian tumors? Great. So we're looking just at the malignant tumors. So probably this is going to be a germ cell tumor question that I'm answering here. So in the category of germ cell tumors, the most common one is Yolk sac tumor, but then there'll be some embryonals. There'll be some dysterminoas. There'll be a lot of mixed tumors where you might have yolk sac with mature teratoma, yolk sac with immature teratoma. But if you take that group of girls, those children who are stage 1, so nove is a malignancy outside the ovary, the overall survival is 96%. And I think one way to manage this is without surgery, just observation. There's a, there's a fairly significant relapse rate, about 50% relapse rate in the stage one treated without chemotherapy, but the salvage rate of those ones that relapse is nearly 100%. In our last study, one girl did die, so of that whole group of stage 1, 50% received no chemotherapy at all, which is very important for things like long term. You know, avoiding the long term effects of chemotherapy. So I think if you can avoid chemotherapy, it's, it's critical. And in this tumor, since the salvage rate is so good with chemotherapy, we can afford to have a fairly high relapse rate. So that's the picture for stage one, about 96% survival. In our last study of yolk sac. I just want to make sure yolk sac tumors. Yeah, but all of these will be mixed tumors. In stage two, the survival is actually 97%, and that's the survival for stage two and three. So that's with chemo. Yes, that's all with chemo. OK, excellent survival. It's a very salvageable tumor, and these are kids with lymph node peritoneal disease and things like that. Now, the metastatic group has done worse. So if you take stage 4, the overall survival is about 80%, but it really breaks down by your age. So if you're less than 11 years of age, it's about 92% survival, and if you're over 11, it's 60%. And that has really driven the germ cell committee to sort of say, if you're over 11 and have a stage 4 tumor, you're high risk. If you're under 11, you have a stage 4 tumor or if you have stage 2 or 3, you're kind of intermediate risk. We'll give you chemotherapy, but you're not really high risk and the high risk ones, you know, are gonna get some more, uh, additional chemotherapy. It's more of a group where we don't really have the optimal therapy in hand, but we think we have the optimal therapy for those that are stage 2 and 3 and the younger stage 4s with just straightforward platinum, metopocyte and bleomycin. Do you biopsy all of the met sites? So no, if They have clearly metastatic disease. We do not biopsy them. We'll follow them with imaging, but we don't biopsy them. OK. And I promised that we were going to end with what we started with. I just want to reinforce this, Fred. If you go in on a torsion case and it's torsed and it is a black ovary, do you take it out? No. OK. And if Fred, you have a patient that has a completely cystic or cystic with some small solid component, do you take out the ovary? No, we would do an ovarian preserving procedure and I think that is the sort of change over time that is something that I want to emphasize and I think you wanted to emphasize. is that these ovaries do not need to come out unless it's a solid tumor. I think that's the critical point. Well, Dr. Roscola, I knew we were all eagerly awaiting. You were one of the ones that we have been dying to do a podcast with. I think a lot of people have requested that, and I know how busy you are, so I can't tell you how much I appreciate you taking the time to clarify all of this stuff for us. This has been incredibly helpful for me and I'm sure will be for the rest of the audience. Well, thank you, Todd. I think it's, this is just a great venue to get this information out, and I think it's so critical for us as pediatric surgeons to really You know, emphasize and improve our ovarian preservation rates. It's come up with several of our national meetings over the last few years. So I think it's an important concept, and I think what you've done with this podcast, hopefully we'll get that word out as well. I hope so too. We hope you enjoyed this episode of Stay Current in Pediatric Surgery. You can listen, watch, or read all content by downloading the Stay Current and Surgery app. Please send questions or comments to us at staycurrent podcast@gmail.com. We'll see you next time.