# Ovarian Tumors Video Podcast — GCMD Library

<p>An interactive discussion between Dr. Ponsky and Dr. Rescorla about the management of ovarian tumors in pediatric patients. <p>Dr. Frederick Rescorla is surgeon-in-chief at Riley Children's Hospital, Anna Olivia Healey Professor of Pediatric Surgery at Indiana University School of Medicine, and COG germ cell committee member.</p> <p>Intro track is adapted from "I dunno" by grapes, featuring J Lang, Morusque.<br> Artist URL: ccmixter.org/files/grapes/16626<br> License: creativecommons.org/licenses/by/3.0/</p></p><p><a href="http://videolibrary.globalcastmd.com/ovarian-tumors-video-podcast"></a></p><p>INTRODUCTION</p><ul><li>Pediatric ovarian tumors are commonly seen by all pediatric surgeons. </li><li>The majority of ovarian tumors are not malignant.</li><li>Ovarian preservation is critical in these patients. </li><ul><li>The frequency of ovarian sparing operations are increasing, but there are still oophorectomies being performed that could have been treated with ovarian preserving procedures.</li></ul><li><a>Overview of Ovarian Tumors:</a></li><ul><li>In large scale studies, there is a 10% overall risk of malignancy.</li><li>Malignant tumors</li><ul><li>Germ cell</li><ul><li>This is the predominant type, occurring in 50-80% of cases.</li><li>Most common type is yolk sac tumor.</li><li>Also, embryonal, dysgerminomas and mixed tumors, like yolk saw with mature and immature teratomas.</li></ul><li>Sex chord stromal tumors</li><ul></ul></ul><li>Benign:</li><ul><li>Germ cell</li><ul><li>This also predominates in the benign category.</li><li>Mature teratoma</li><ul><li>Occurs in up to 50% of cases.</li></ul><li>Immature teratoma</li><ul><li>Occurs in 10-15% of cases.</li></ul></ul><li>Functional cysts</li><li>Cystadenoma</li></ul></ul></ul><p><a>CASE I: Ovarian cystic mass with some solid component</a></p><ul><li>Case I: A 4 year old girl presents with a 1-week history of abdominal pain and was found to have a large, predominantly cystic mass extending from her pelvis into her upper abdomen, with a 2 x 3 cm solid component with calcifications.</li><ul><li>History and Physical</li><ul><li>Always consider torsion in these patients, but this is less likely in a patient with a 1-week history of pain.</li><li>If you see pubic hair in this patient, consider a functional tumor, likely a sex chord stromal tumor.</li><ul><li>This will require an in depth hormonal evaluation of the products of sex chord stroll tumors, such as testosterone and its breakdown levels.</li></ul></ul><li>Workup</li><ul><li>Tumors Marker</li><ul><li>AFP must be checked. HCG is unlikely to be elevated in this age, but you should also check it.</li><li>Not all malignant tumors will have elevated markers, particularly if they are mixed tumors like embryonal.</li><li>Unless there is concern for torsion, it is worth waiting for the tumor markers (particularly AFP) before operating.</li></ul><li>Imaging</li><ul><li>Ultrasound is a good upfront screening tool, but the majority will end up requiring a CT scan to better evaluate the cyst.</li><li>Cyst characteristics will help determine the risk of malignancy.</li><ul><li>For a predominantly cystic mass, the risk of malignancy is 3-4%.</li><li>For a heterogenous mass, the risk of malignancy is 15-20%.</li><li>For a solid mass, the risk of malignancy is over 25%.</li></ul></ul></ul><li>Surgical approach</li><ul><li>If this patient’s tumor markers return normal, this is likely a benign tumor, but you will still need to preserve the principles of an oncologic operation.</li><li>An ovarian preserving procedure should be attempted for this patient.</li><li>An open operation will require a large midline incision given that this is a big cyst, and should avoid this.</li><li>Laparoscopy may be considered.</li><li>Dr. Rescorla performs this surgery using a small lower abdominal incision on the side that the tumor is arising from (described below) [1].</li></ul><li><a>Surgical technique</a></li><ul><li>Create a small lower abdominal incision, about 3-4 cm, on the side that the tumor is arising from.</li><li>Once the cystic component is identified, it is drained through a bag to avoid fluid spillage.</li><ul><li>Dry off the cystic component, and then use a surgical glue, such as Dermabon® or Indermil®, to glue a large plastic sheet directly onto the tumor.</li><li>The fluid is then drained through this bag, which prevents spillage of potentially malignant fluid.</li></ul><li>Once the fluid is drained, the tumor can often be delivered out of the abdomen.</li><li>Perform a partial oophorectomy, if it is possible.</li><li>If the tumor is very small, this technique may be difficult as you may not be able to find tumor. Consider laparoscopy in these cases.</li><li>Perform peritoneal washings.</li><ul><li>If there is fluid, send it for cytology.</li><li>If there is not fluid, rinse around some saline and then send it for cytology.</li></ul><li>Inspect the other ovary. Perform a contralateral biopsy if it looks abnormal.</li><li>Remove any omentum that is adhered to the tumor. </li><li>Inspect the abdominal cavity for any peritoneal implants. Biopsy anything suspicious.</li><li>Evaluate the retroperitoneal lymph nodes.</li><ul><li>Although CT imaging will give a good evaluation of these, it is still recommended to evaluate them intraoperatively.</li><li>This may be performed through the same incision by palpation, by moving your hands up to the aortic bifurcation, and then feeling for both iliac systems.</li><ul><li>Palpation is adequate to evaluate the lymph nodes, and visual inspection is not required.</li><li>If you cannot perform this, then closing the incision and performing a laparoscopic evaluation is an option.</li></ul><li>If a lymph node is enlarged, remove it.</li><ul><li>There is no role for lymph node dissection.</li><ul><li>This differs from adult management, because adults are largely dealing with epithelial tumors, and pediatric germ cell tumors are very chemo-responsive.</li></ul></ul></ul></ul><li><a>Ovarian Salvage Technique</a></li><ul><li>Evaluate for the blood supply coming into the ovary and the fallopian tube.</li><li>The tumor is usually off the top of the ovary. Lift up the tumor, and a white rim is usually seen going up on the tumor. This is likely the edge of the tumor and the normal ovary.</li><li>Remove the mass off the ovary using a combination of hold and cold scissors, and make sure to stay on the side of the normal ovary.</li><li>If there is bleeding, close the flat edges of the remaining ovary together.</li></ul></ul></ul><p><a>CASE 2: Ovarian cystic mass in an adolescent</a></p><ul><li>Case 2: A 13-year-old female presents with vague abdominal discomfort and she has noticed that her abdomen is getting bigger. Ultrasound and then CT A/P identify a large, completely cystic pelvic mass.</li><ul><li>Workup</li><ul><li>This is likely a benign cyst of the ovary, but given the size, recommend checking tumor markers to be sure.</li><li>If the tumors markers are normal, then the risk of malignancy is less than 1%.</li></ul><li>Operative approach</li><ul><li>The likelihood of malignancy is so low that you do not need to use oncologic precautions, and can perform this laparoscopically.</li><li>If the tumor returns as malignant, then the patient will require chemotherapy.</li><ul><li>Given that the risk of malignancy is so low, you should not subject all females to larger abdominal incisions to perform on oncologic resection in these cases. </li></ul></ul><li> Surgical Technique</li><ul><li>You can drain the cyst through one of your trocars.</li><li>Use scissors to perform a cystectomy.</li><li>Given that this is unlikely malignant, remove as much of the cyst to minimize its chances of recurring. It is okay to leave a portion of the cysts lining on the ovary. </li></ul></ul></ul><p><a>CASE 3: Adolescent with a solid ovarian mass</a></p><ul><li>Case 3: A 14-year-old female presents with a 3-month history of lower abdominal pain and she has noticed her abdomen is enlarging. On imaging, she was found to have a large solid pelvic mass. Tumors markers were checked and her AFP returned as 44,000.</li><ul><li>Preoperative Workup</li><ul><li>This is going to be malignant, given that it is large, solid and the AFP is elevated [2].</li><li>First decision that needs to be made is if this can be resected up front.</li><li>Imaging</li><ul><li>CT chest/abdomen/pelvis will help determine stage and evaluate if the patient is a candidate for an upfront resection.  </li><ul><li>CT is used to evaluate the retroperitoneal lymph nodes, contralateral ovary, and evidence of metastases.</li></ul><li>CT chest should be performed at the same time as the abdominal CT.</li><ul><li>Distant metastases do not require biopsy, and can be followed with imaging.</li></ul></ul></ul><li>Surgical considerations</li><ul><li>If the tumor is confined to the tumor, it is ideal to perform an upfront resection.</li><li>If there is evidence of disease outside of the ovary, the patient will get neoadjuvant chemotherapy.</li><li>If there is evidence of bilateral ovarian involvement, then consider neoadjuvant chemotherapy and delayed resection.</li></ul><li>Chemotherapy</li><ul><li>It is a platinum-based regimen, with bleomycin and etoposide.</li><li>There is no role for radiation therapy.</li></ul><li>Surgical approach</li><ul><li>If it is confined to the ovary, perform an open operation through a pfannenstiel incision.</li><ul><li>This is different than in adults, who perform midline incisions.</li></ul><li>There is no role for laparoscopy in these patients.</li><li>Perform a complete oophorectomy, making sure to leave the tumor intact.</li><ul><li>Performing a salpingooophorectomy is optional. There is no oncologic reason to remove the fallopian tube, so if it is not encased or adhered to the tumor, it is okay to preserve it.</li></ul><li>Evaluate the retroperitoneal lymph nodes and remove any enlarged lymph nodes.</li><li>Only perform omental and peritoneal biopsies if they are suspicious looking. If the omentum is adhered to the tumor, remove it with the tumor.</li><li>Perform peritoneal washings.</li><ul><li>Peritoneal washings are the main thing that can upstage her in the OR.</li><ul><li>Billmire et al. found that 5 patients were Stage 3 just based on peritoneal washings alone  [3].</li></ul><li>If the peritoneal washings are positive, then she will need chemotherapy.</li></ul></ul><li>Cryopreservation</li><ul><li>This is currently not being done in young patients, but if chemotherapy is being given, then it should be considered.</li></ul></ul></ul><p><a>CASE 4: Ovarian torsion</a></p><ul><li>Case 4:  A 13-year-old female presents with 24 hours of right lower quadrant abdominal pain. An ultrasound and CT are obtained to evaluate for appendicitis, and there is a 6 cm ovary with heterogenous fluid. The radiologist cannot tell for sure if this is a hemorrhagic ovarian cyst with torsion, but they do see blood flow.</li><ul><li>Workup</li><ul><li>This patient requires an urgent operation.</li><li>Consider sending tumor markers, but they will not be back before you go to the OR.</li></ul><li>Surgical approach</li><ul><li>Detorse the ovary.</li><li>If there is a clear cystic component, then it is ok to decompress the ovarian cyst, and remove part of the cyst wall to prevent it from recurring.</li><li>If it is a mass, it is ok to detorse the ovary, close the abdomen and return at a later date once you have performed additional workup.</li><ul><li>Returning in 1 week or so will not make a difference oncologically.</li><li>This approach will also allow for the inflammation to decrease, and allow for a potential ovarian preserving operation.</li></ul></ul><li><a>Oophoropexy</a></li><ul><li>Some controversy about the benefits of this.</li><ul><li>Adults will often just perform detorsion without oophoropexy.</li></ul><li>Smorgick et al. found that premenarchal patients have a higher risk of torsion and an oophoropexy should be considered in these patients [4].</li><li>Technical options are stitching the ovary to the lateral side wall or shortening the utero-ovarian ligament.</li></ul><li>Followup</li><ul><li>Recommend a repeat ultrasound in 4-6 weeks to evaluate the ovarian function.</li></ul></ul></ul><p><a>SURVIVAL OUTCOMES</a></p><ul><li>Germ cell tumors</li><ul><li>For stage 1 (no evidence of malignancy outside of the ovary), the overall survival is 96%.</li><ul><li>Managing them with surgery alone without chemotherapy is an option.</li><li>There is a 50% relapse rate of those treated this way but salvage chemotherapy is successful in most patients [5].</li></ul><li>For stage 2 and 3 (with lymph node and peritoneal disease), survival is 97% with chemotherapy.</li><li>For stage 4 cancers (metastases), overall survival is 80%, but this is dependent on the patient's age.</li><ul><li>If less than 11 years of age, survival is 92%.</li><li>If greater than 11 years of age, survival is 60%.</li><ul><li>These patients are considered high-risk patients and require additional chemotherapy.</li></ul></ul></ul></ul><p><a>REFERENCES</a></p><p>[1] Ehrlich PF, Teitelbaum DH, Hirschl RB, Rescorla F. Excision of large cystic ovarian tumors: combining minimal invasive surgery techniques and cancer surgery—the best of both worlds. J Pediatr Surg. 2007;42(5):890-893. doi:10.1016/j.jpedsurg.2006.12.069</p><p>[2] Papic JC, Finnell SME, Slaven JE, Billmire DF, Rescorla FJ, Leys CM. Predictors of ovarian malignancy in children: Overcoming clinical barriers of ovarian preservation. J Pediatr Surg. 2014;49(1):144-148. doi:10.1016/j.jpedsurg.2013.09.068</p><p>[3] Billmire D, Vinocur C, Rescorla F, et al. Outcome and staging evaluation in malignant germ cell tumors of the ovary in children and adolescents: an intergroup study. J Pediatr Surg. 2004;39(3):424-429. doi:10.1016/j.jpedsurg.2003.11.027</p><p>[4]  Smorgick N, Melcer Y, Sarig-Meth T, Maymon R, Vaknin Z, Pansky M. High risk of recurrent torsion in premenarchal girls with torsion of normal adnexa. Fertil Steril. 2016;105(6):1561-1565.e3. doi:10.1016/j.fertnstert.2016.02.010</p><p>[5] Billmire DF, Cullen JW, Rescorla FJ, et al. Surveillance After Initial Surgery for Pediatric and Adolescent Girls With Stage I Ovarian Germ Cell Tumors: Report From the Children’s Oncology Group. J Clin Oncol. 2014;32(5):465-470. doi:10.1200/JCO.2013.51.1006</p>

Type: podcast · 34 min · posted 2020-12-30
Canonical: https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979

## Chapters
- [0:00](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=0) Introduction and Topic Selection
- [3:02](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=182) Case 1: Four-Year-Old with Mixed Cystic-Solid Mass
- [7:20](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=440) Surgical Technique for Ovarian Preservation
- [14:55](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=895) Case 2: Thirteen-Year-Old with Large Cystic Mass
- [19:20](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1160) Case 3: Malignant Solid Tumor
- [24:57](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1497) Ovarian Torsion Management
- [29:33](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1773) Survival Outcomes and Closing

## Statements
- "Ovarian tumors are more common in pediatric surgery than Wilms tumor or neuroblastoma, though most are not malignant" — Frederick Rescorla (epidemiological) [2:00](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=120)
- "Approximately 10% or less of pediatric ovarian tumors are malignant" — Frederick Rescorla (epidemiological) [5:03](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=303)
- "Among malignant ovarian tumors in children, germ cell tumors predominate at greater than 50% and in some series up to 80%" — Frederick Rescorla (epidemiological) [5:15](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=315)
- "In benign ovarian tumors, mature teratoma comprises at least half of cases and immature teratoma accounts for 10-15%" — Frederick Rescorla (epidemiological) [5:35](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=335)
- "Predominantly cystic ovarian masses have approximately 3-4% malignancy risk" — Frederick Rescorla (clinical) [4:10](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=250)
- "Heterogeneous ovarian masses have 15-20% malignancy risk" — Frederick Rescorla (clinical) [4:25](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=265)
- "Solid ovarian masses have over 25% malignancy risk" — Frederick Rescorla (clinical) [4:35](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=275)
- "Alpha-fetoprotein (AFP) is the primary tumor marker for ovarian masses in young children; HCG is unlikely to be elevated in this age group" — Frederick Rescorla (clinical) [3:25](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=205)
- "In a COG study of stage 3 ovarian tumors, 5 out of 20 cases were stage 3 only because peritoneal fluid was positive for malignant cells" — Frederick Rescorla (clinical) [8:10](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=490)
- "The six-step oncologic operation for ovarian tumors includes: peritoneal washings, tumor removal, contralateral ovary inspection (biopsy only if abnormal), omental assessment (remove only if adherent), peritoneal cavity assessment, and retroperitoneal lymph node palpation" — Frederick Rescorla (guideline) [10:40](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=640)
- "Contralateral ovary biopsy is now recommended only if the ovary appears abnormal, not routinely" — Frederick Rescorla (guideline) [10:50](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=650)
- "Lymph node dissection is not required; only enlarged nodes should be sampled" — Frederick Rescorla (guideline) [11:10](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=670)
- "For large predominantly cystic masses with normal markers, the malignancy risk is much less than 1%" — Frederick Rescorla (clinical) [15:50](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=950)
- "Laparoscopic decompression and cystectomy is appropriate for large purely cystic masses with normal markers" — Frederick Rescorla (opinion) [16:10](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=970)
- "Stage 1 ovarian germ cell tumors (confined to ovary) have 96% overall survival" — Frederick Rescorla (clinical) [30:10](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1810)
- "Stage 1 ovarian germ cell tumors managed with observation alone have approximately 50% relapse rate but nearly 100% salvage rate with chemotherapy" — Frederick Rescorla (clinical) [30:25](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1825)
- "Stage 2 and 3 ovarian germ cell tumors treated with chemotherapy have 97% survival" — Frederick Rescorla (clinical) [30:55](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1855)
- "Stage 4 ovarian germ cell tumors have 80% overall survival, but this breaks down to 92% for patients under 11 years and 60% for patients over 11 years" — Frederick Rescorla (clinical) [31:10](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1870)
- "Chemotherapy for malignant ovarian germ cell tumors consists of platinum, etoposide, and bleomycin" — Frederick Rescorla (clinical) [24:16](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1456)
- "There is no role for radiation therapy in pediatric ovarian germ cell tumors" — Frederick Rescorla (guideline) [24:15](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1455)
- "For solid ovarian masses with elevated AFP, chest CT is required for staging in addition to abdominal imaging" — Frederick Rescorla (guideline) [20:53](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1253)
- "If malignant ovarian tumor is amenable to resection and confined to the ovary, upfront surgery is preferred to achieve potential stage 1 status and avoid chemotherapy" — Frederick Rescorla (opinion) [20:00](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1200)
- "Fallopian tube preservation during oophorectomy for malignancy is optional; it should be preserved if not adherent to tumor but can be removed if encased" — Frederick Rescorla (opinion) [21:42](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1302)
- "Omental biopsy is not required unless the omentum is adherent to the tumor or appears abnormal" — Frederick Rescorla (guideline) [23:37](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1417)
- "Ovarian cryopreservation is not currently standard practice before chemotherapy for pediatric ovarian tumors but may become more common in the future" — Frederick Rescorla (opinion) [24:32](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1472)
- "For ovarian torsion, detorsion alone is the standard approach; oophoropexy is recommended for pre-menarchal girls or patients with history of prior torsion of the same ovary" — Frederick Rescorla (guideline) [27:00](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1620)
- "A study in Fertility and Sterility Journal demonstrated that pre-menarchal girls have higher risk of ovarian torsion" — Frederick Rescorla (clinical) [27:00](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1620)
- "For torsed ovary with suspected teratoma, detorsion followed by delayed definitive surgery after imaging and marker evaluation is preferred over acute oophorectomy" — Frederick Rescorla (opinion) [28:31](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1711)
- "Black, torsed ovaries should not be removed; detorsion should be performed" — Frederick Rescorla (opinion) [32:25](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1945)
- "Ovarian preservation should be performed for all cystic or mixed cystic-solid masses; complete oophorectomy is reserved only for solid malignant tumors" — Frederick Rescorla (guideline) [32:44](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1964)
- "Pediatric surgeons have improved ovarian preservation rates over the past 20 years, but retrospective analysis shows many tumors were removed where functional ovary could have been preserved" — Frederick Rescorla (opinion) [2:20](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=140)
- "Partial oophorectomy technique involves scoring the ovarian capsule around the tumor and enucleating the mass, often leaving a thin rim of ovarian tissue" — Frederick Rescorla (clinical) [13:34](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=814)
- "The glued bag technique for tumor decompression involves using Indermil or Durban to glue a plastic bag directly onto the tumor surface, creating a sealed interface for aspiration" — Frederick Rescorla (clinical) [9:20](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=560)
- "Pediatric ovarian germ cell tumors are very chemo-responsive, unlike adult epithelial ovarian carcinomas" — Frederick Rescorla (clinical) [23:20](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1400)
- "Modern CT scans are highly effective at detecting retroperitoneal lymph node involvement and distant metastases in ovarian tumors" — Frederick Rescorla (clinical) [22:30](https://library.globalcastmd.com/watch/ovarian-tumors-video-podcast-1979?t=1350)

## Transcript
 Hi everyone, my name is Sophia Abdullahi and I'm Dr. Ponce'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 with Dr. Frederick Raskorla, 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 discussed 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 Current 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 Abdullahi, Abdulruf Lamoshi and Rajavendra Rao and is recorded and produced at Akron Children's Hospital in Akron, Ohio. This is Todd Ponsky from State Current and Pediatric Surgery. And today we're going to be talking about ovarian tumors. We actually have with us someone who is an absolute undisputed expert in the field, Dr. Fred Raskorla, who is the surgeon in chief at Riley Hospital in Indianapolis. And he is the Anna Healy 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 ovarian. 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 four-year-old girl. She has a one-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 two-by-three-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? Great. Well, I think 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 torse. But if you said 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 a certain, get an alpha phenoprotein. And 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 get up with a CT scan. And so then in the scan, you're really looking at, you were going to mention 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 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 aren't normal, I think almost certainly she's benign. That's not 100%. And there's definitely some children that will have malignancies. I think it emphasized that when we do take her to the operating, we have to sort of try to preserve the principles of an oncologic operation. But with this 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, that's great. You know, overall, when you look at the big studies, probably 10% at most are malignant of all. 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 germ cells by far the most common. And then there might be some sex cord 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 cyst, cyst adenoma, a few other rare malignancies. So in both malignant and benign, germ cell type tumors predominate. Okay. So that's a great overview. And, you know, I'm assuming, you know, 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 four-year-old? Yeah, 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. Okay. So back to this child, this four-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'd be comfortable taking her to the operation even if the markers weren't back. Okay. 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 that. Now, we don't really know what percent is cystic. From 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 Billmar's papers was a group of stage 3 ovarian tumors. I think there were 20 of them. Five 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 in there. 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. Okay. 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, I would probably take a big bid line 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 Indermil or Durban 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 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, 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, in 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 and 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 is 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 could 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 six steps total, counting removal of the tumor. And so we try to go through those six steps every single time. All right. So I have a bunch of questions and a couple comments. Number one, 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 Condas 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. And, you know, usually the incisions for these would be maybe three to four centimeters in length. If I can put a retractor in and feel up to the aortic bifurcation 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 trocar in to 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 three or four trocars in. But I have only successfully been able to do that, Fred, and I'm curious your approach, when they're really big. That when you make that incision, it's right there. That tumor's 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? Yeah. 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 or section of the tumor. Do you score the outside and sort of enucleate 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'll look for where the fallopian tube is. Usually, the tumor is kind of off the top, so to speak. And so usually, I 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 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 okay. 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. The ovary's wrapped around it, so you need to open up the ovary to get the tumor enucleated out? Exactly. Well, that's great. 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. Right. 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 Lee pretty well covered it. Okay. 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? Yeah. So I think, you know, 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 undoubtedly negative. Then I think you have to get it out. You know, we did a study in our place where if they were 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 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 trocar aspirate all out and then do a partial refractory, which you could definitely do a laparoscopy. You're basically just doing a cystectomy. So I think you could easily do that. And I think it would be almost unheard of for that to be malignant. You know, I mean, there probably at some point would be some child that would 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. Okay. Okay. So, you know, Mac Harmon jokes around with me that I do these podcasts completely selfishly so I can learn more about questions I have. And that 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, small, solid component. And this one that is 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. Okay. 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 a 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 line 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 leufectomy 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 want to 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 Biles, 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 three-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's 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. At this point, I think you want to decide, is this something that can be resected up front? Because if it could be a stage one tumor, so if it's confined to the ovary, the washings are negative, the nodes are negative, the nodes are negative, the nodes are 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 oophrectomy. I think if you get in there and, 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 oophrectomy. We want the tumor out intact. Through a fan and steel? Yes. Yeah. Okay. The adults do midline in a lot of these women, but we still do a lower transverse fan and steel 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. Okay. 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? Okay. 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. Okay. So you go in through your fan and steel, you find the tumor. And do you do a salpingo ufrectomy? 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 if 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, it's not quite as easy as you think sometimes. I mean, 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. Okay. 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 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 one thing. If it otherwise looked like a stage one tumor, peritoneal 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 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 Guinon surgeons. Correct. Okay. I think part of it is that 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 serotomas and germ cell tumors, so it's a little bit different type of tumor. Yep. Okay. 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. Okay. That's great. Okay. So if she does have positive peritoneal washings or peritoneal studying, she would need chemotherapy. Is there a role for radiation? No, it's pretty much just chemotherapy. It's a platinum-based, platinum etoboside and bleomycin. Okay. Yeah, it's pretty straightforward, very effective chemotherapy. And so there's no role of doing some cryopreservation of the other ovary? Okay. So that's a really good question. Right now, we are not doing that. But I think in children who get chemotherapy, that's going to be something that we'll probably be asked to do at some point. But I think right now, especially if there's no chemotherapy, definitely no cryopreservation. If you're going to save the other ovary, that's fine. But I think in the near future, with administration of chemotherapy, there'll be more frequent considerations of that. Okay. 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-old, 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. 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 tors. They can't tell you if there's torsion or not. They can tell you that they actually see blood flow, but they can't tell you if it's torsion or not. How do you manage that patient? And do you open up the cyst, or is that risky? Yeah. 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 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 might be unclear whether it's simply a torsion 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. And I think then the situation would most likely 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, fenestrate it or do something, and detorse the ovary. If you think it is a tumor or a mass, let's say, you don't really know if it's a million or benign, I think it's fine to detorse it. And 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 detorsion. There's some controversy about uforopexy. I think most of the adults simply do detorsions only. There's a recent study out of the Fertility and Sterility Journal demonstrating that pre-menarcal girls have a higher risk of torsion. And their recommendation was that if it's a pre-menarcal girl or if somebody's had a torsion of that same ovary before, to go ahead and do an uforopexy at that time. So that's kind of what we do. Okay. And how do you do your uforopexy? Do you stitch it to the lateral sidewall? 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 if it would actually work. I think it, I mean, 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 told that if you stitch it to the sidewall, it could alter the angle of the tube and could alter fertility. But it's easy to do. It makes sense to me. Have you done the ligament shortening? I have. I've clipped it. That was taught to me by one of the gyne-onc surgeons in Washington, D.C. And I've always found it much easier to just pexy. 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 tors, 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. 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 detorce it, give her some time to calm down, reimage it, 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 at our institution, you can still do an ovary and preserving operation at that time. Okay. 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 four to six week post-op range and see them back in a post-op visit with an ultrasound, make sure everything looks okay. 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. Okay. 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 embrionals. There'll be some dysgerminomas. 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 one, so no evidence and malignancy outside the ovary, the overall survival is 96%. And I think one way to manage them is without surgery, just observation. 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 that whole group of stage one, 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 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. Okay. 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 four, 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 four tumor, you're high risk. If you're under 11 and you have a stage four tumor, or if you have stage two or three, 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 going to get some more 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 two and three and the younger stage fours with just straightforward platinum, metoposide, 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. Okay. 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. Okay. 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. Right. I think that's the critical point. Well, Dr. Rescorla, 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 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 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 in Surgery app. Please send questions or comments to us at staycurrentpodcast at gmail.com. We'll see you next time.

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