Epithelial ovarian tumors in children: some high yield points

Ovarian germ cell tumors are the most common neoplastic tumors of the ovary in children. Less common are tumors derived from the ovarian surface epithelium, accounting for 15% of ovarian neoplastic tumors. These epithelial tumors are rarely seen in premenarchal patients.

Ovarian epithelial tumors in children are either mucinous or serous. Each one of these two categories can be divided into a benign subgroup, malignant subgroup, or subgroup of tumors of low malignant potential, also known as borderline tumors (where the lack of invasion into the ovarian stroma is characteristic, despite varying levels of nuclear atypia). Thus a patient may have a mucinous cystadenoma, mucinous cystadenocarcinoma, or mucinous tumors of borderline malignancy.

The overall intraoperative management of this group of tumors is based on adult protocols. At minimum, thorough staging of the abdomen is required, with focus on careful examination of the contralateral ovary, as bilateral disease is common with these tumors.

Do we need an esophagram to evaluate a spontaneous pneumomediastinum in kids?

The paper was published in JPS a few days after the subject was brought up amongst our group.  Basically, what do we do with a kiddo who presents with a pneumomediastinum with no antecedent history of trauma or retching, and who is otherwise doing well with no fever or signs of mediastinitis.

In this paper, the authors retrospectively reviewed 27 patient with a spontaneous pneumomediastinum(SPM) who underwent an esophagram as part of their evaluation. The authors noted that none of the patient had a demonstrable injury to the esophagus. They concluded that an esophagram is not necessary for the evaluation of SPM. They felt the source of the air in this group of patients was alveolar disruption and not an esophageal injury.

Needles to say, a series of 27 patients is not sufficient to make a final conclusion on the subject. That being said, the series helps us support any decision we make regarding clinical follow up on a patient with a SPM, who is otherwise well with no other signs of esophageal injury such as dysphagia or pleural effusion on a CXR. 

What's the deal with the abdoimno-scrotal hydrocele?

As it's name implies, an abdomino-scrotal hydrocele is a hydrocele that extends into the peritoneal cavity. It is a rare variant that makes up 3% of pediatric hydroceles. A recent meta-analysis by Dout et al published in the Journal of Pediatric Surgery looked at a total of 116 cases of abdomino-scrotal hydroceles in an attempt to better define this entity in terms of natural history, management, and clinical implications.

The authors describe a wide variability in natural history reported; ranging form hydroceles that spontaneously resolved to ones that continued to grow. The management strategies were equally varied; ranging from a combined inguinal/laparoscopic approaches to a more simple scrotal approach.

What I found most useful in this study was the association between these hydroceles and testicular dysmorphism.  Based on this report, the incidence of dysmorphism was around 28%. This was felt to be related to the amount of pressure exerted by these hydroceles on the surrounding tissue, including the testicular vessels.

This is relevant because it suggests that there may be benefit to more urgent intervention for an abdomino-scrotal hydrocele compared to the garden-variety non-communicating hydrocele, which one may opt to observe for a period of time.