CATTEDRA e U.O. DI CHIRURGIA PEDIATRICACATTEDRA e U.O. DI CHIRURGIA PEDIATRICA

U.O. DI CLINICA OSTETRICOU.O. DI CLINICA OSTETRICO--GINECOLOGICAGINECOLOGICA

UNIVERSITA’ DEGLI STUDI “G. D’ANNUNZIO” CHIETI UNIVERSITA’ DEGLI STUDI “G. D’ANNUNZIO” CHIETI -- PESCARAPESCARA

XXXVIII Congresso Nazionale S.I.C.P.Riunione del Gruppo di Studio di Chirurgia Oncologica

Firenze 27 Settembre 2007

XXXVIII Congresso Nazionale S.I.C.P.Riunione del Gruppo di Studio di Chirurgia Oncologica

Firenze 27 Settembre 2007

CelentanoCelentano C., Lelli Chiesa P., Lisi G.C., Lelli Chiesa P., Lisi G.

Lesioni cistiche dell’ovaioin epoca neonatale, prepubere, adolescenziale

Strategie terapeutiche:Esperienze ed opinioni a confronto

Lesioni cistiche dell’ovaioin epoca neonatale, prepubere, adolescenziale

Strategie terapeutiche:Esperienze ed opinioni a confronto

CISTI OVARICHE NEONATALI

OPZIONI TERAPEUTICHEOPZIONI TERAPEUTICHE

•• aspirazione prenataleaspirazione prenatale

•• aspirazione percutanea aspirazione percutanea postnatale postnatale

•• waitwait and and seesee

•• intervento chirurgicointervento chirurgicoLaparotomicoLaparotomico

LaparoscopicoLaparoscopico

aspirazioneaspirazione

fenestraturafenestratura

marsupializzazionemarsupializzazione

cistectomiacistectomia

ovariectomiaovariectomia

annessectomiaannessectomia

Cisti ovariche fetali

Aspirazione prenataleAspirazione prenatale

Brandt and Helmrath, 2005

“There are no good data to support

the effectiveness of prenatal aspiration

in preventing ovarian torsion, and concern by

many physicians exists regarding the risk of

the procedure to both fetus and mother.”

Cisti ovariche neonatali

Aspirazione percutanea Aspirazione percutanea postnatalepostnataleCONTRO

Rischi associati significativi (in caso di diagnosi non certa)

Risultati non superiori al wait and see*

Rischio torsione postnatale già basso

No nella cisti complex (emorragia – peritonite)

PRO

Mini invasiva

rischio torsione

morbidità

rischio recidiva

INDICAZIONI Cisti massive semplici sintomatiche

(insufficienza respiratoria o compressione cavale)

*“There are no good prospective data to confirm that aspiration is more effective than simple observation.” Brandt and Helmrath, 2005

CISTI OVARICHE NEONATALICISTI OVARICHE NEONATALI

Cisti semplici < 4Cisti semplici < 4--5 cm5 cm

asintomaticheasintomatichewaitwait and and seesee

Cisti semplici > 4Cisti semplici > 4--5 cm5 cmCisti che non regrediscono Cisti che non regrediscono

Cisti sintomatiche Cisti sintomatiche Cisti Cisti complexcomplex

managementmanagement

CONTROVERSOCONTROVERSO

Brandt and Helmrath, 2005

* Cisti ovarica di diametro > 5 cm stabile al monitoraggio US

CISTI OVARICHE NEONATALI ≥≥5 cm o 5 cm o complexcomplex(casistica 2000-2007)

17

8

semplici

9

complex

Wait and see

Intervento chirurgico 2*

Risoluzione6

CISTI OVARICHE NEONATALI

TRATTAMENTO CHIRURGICO

LAPAROTOMIA

9

LAPAROSCOPIA

2

1 Cisti complexDetorsione

Ovariectomia TU

1 cisti semplice

(Ø 5 cm)

Unroofing

8 Cisti complex 1 cisti semplice

(Ø 7 cm)

“Cistectomia”

(assenza tessuto ovarico residuo)

7 Ovariectomia

1 Cistectomia

11

“Expected cyst resolution is 50% by 1 month, 75% by 2 months, and 90% by 3 months of age.”

Strickland J., 2004

“…resolution of a cyst may take considerable time, even up to 10 months, particularly for larger cysts.”

Chiaramonte et al, 2001

waitwait and and seeseeFINO A QUANDO ?FINO A QUANDO ?

“Since the incidence of malignancy in neonatal cysts approaches zero, postnatal management for asymptomatic, simple cyst involves observation with regular ultrasound review.” Templeman C, Strickland J, 2004

TRATTAMENTO DI ATTESATRATTAMENTO DI ATTESA

PREREQUISITIPREREQUISITI

1. cisti sicuramente di origine ovarica

2. no chiara componente solida alla ecografia (per quanto debris e setti da

emorragia siano accettabili)

3. α-fetoproteine (?) e βHCG normali

4. paziente asintomatica

CISTI OVARICHE NEONATALI

Masse cistiche addominali neonatali

Diagnosi differenziale

• Duplicazione intestinale

• Cisti mesenterica

• Cisti omentale

• Cisti del coledoco

• Pseudocisti meconiale

• Linfangioma

• Cisti del dotto onfalomesenterico

• Cisti renali ed ureterali

• Cisti epatiche

• Cisti uracale

• Idrometrocolpo

• Mielomeningocele anteriore

“There is general consensus that

cysts larger than 5 cm in diameter may be

at increased risk of torsion.”Nyberg DA et al, 2002

30 sett e.g.

36 x 35 mm

34 sett e.g.

59 x 50 mm

7 gg di vita

40 x 37 mm27 gg di vita

35 x 26 mm

67 gg di vita

18 x 13 mm

CISTI OVARICHE FETALI/NEONATALI

TORSIONETORSIONE27 – 78%40% ?

•• aderenze infiammatorieaderenze infiammatorie occlusione intestinaleocclusione intestinale

•• emorragia emorragia intracisticaintracistica

•• rottura della cistirottura della cisti

•• ostruzioni vie urinarieostruzioni vie urinarie

•• autoauto--amputazione della cistiamputazione della cisti

•• PeritonitePeritonite

•• (S.I.D.S.)(S.I.D.S.)

ascite

peritonite

“….Cysts with torsion sometimes adhere to the

bowel loops, which may lead to other complications such as

intestinal obstruction and/or rupture with peritonitis. For

these reasons we believe that surgical interventionshould be performed as early as possible if torsion is

suspected.” Kuroiwa M. et al, 2004

“In patients with presumed prenatal torsion who

subsequently have two ovaries on US, hemorrhage into the cyst,

rather than torsion may have been responsible for the initial

sonographic appearance. Alternatively, viable ovarian tissue may

have been prevent despite the torsion, allowing recovery of the

ovary with time.” Brandt and Helmrath, 2005

“Given the large number of cases that end in oophorectomy in some surgical series, it is not apparent that surgery offers any advantages over expectant management.”

“The decision to observe, rather than surgically treat neonatal cysts is supported by data that show that surgical intervention most often leads to oophorectomy, rather than an ovarian sparing procedure.”

Brandt and Helmrath, 2005

Nyberg DA et al, 2002

CISTI OVARICHE IN PAZIENTI PREPUBERI

TERAPIA

“Because of the present, albeit low risk of

malignancy , any ovarian cyst in the

prepubertal child that persist or is complexwarrants surgical resection.” Brandt and Helmrath, 2005

“The management will depend upon the diagnosis however: preservation of ovarian tissue should be the primary concern.” Templemann C, 2004

4 CISTI OVARICHE in età PREPUBERALE

Età media 5.2 a.; range 1.8-9.5 a.

TRATTAMENTO CHIRURGICO

LAPAROTOMIA

3 CASILAPAROSCOPIA

1 CASO

1 cisti US semplice con sottili setti interni (Ø 13 x 11 cm)

RMN:

Markers nella norma

DetensioneUnroofing

1 Cisti ovaricatorta (Ø 6 cm)

2 masse ovarichesolido-cistiche

(Ø 10 x 6 cm)

1 Ovariectomia

1 Salpingovariectomia

Ovariectomia

4 TERATOMI CISTICI OVARICI

3 MATURI - 1 IMMATURO (grado 1)

2nd lookovariectomia

“For the ovary the surgicalapproach had to be made through a transversal, subumbilical incision or a Pfannestiel incision.

The procedure included the excision of the tumour with the ovary (preserving the salpinx if possible), the inspection of the controlateral ovary, the biopsy of regional lymph-nodes (iliac), the biopsy of suspected areas and peritoneal fluid sampling forcytologic examination when it waspresent.”

“For the ovary the surgicalapproach had to be made through a transversal, subumbilical incision or a Pfannestiel incision.

The procedure included the excision of the tumour with the ovary (preserving the salpinx if possible), the inspection of the controlateral ovary, the biopsy of regional lymph-nodes (iliac), the biopsy of suspected areas and peritoneal fluid sampling forcytologic examination when it waspresent.”

Mature and immature teratomas: results of the first paediatric Italian study

Pediatr Surg Int (2007) 23: 315-322

Quint E.H., Smith Y.R.

Ovarian surgery in premenarchal girlsJ Pediatr Adolesc Gynecol 12: 27, 1999

“Torsion was the most common diagnosis in

our study group and was usually unsuspected.

Premenarchal ovarian surgery usually included

removal of the entire ovary. However, because

malignancies are uncommon in this population

(9.6%), a cystectomy should be considered

when appropriate and technically feasible.”

“Conservative management with untwisting the ovary and pexing both retained detorsed and controlateral ovaries especially in idiopathic torsions should be considered in cases of ovarian torsion in children.”

Celik A. et al

Long-term results of conservative management of adnexal torsion in children

J Pediat Surg 40: 704, 2005

Aziz D. et al

Ovarian torsion in children: is oophorectomy necessary?J Pediat Surg 39: 750, 2004

“…Detorsion is the procedure of choice for most cases

of ovarian torsion.”

Torsione cisti ovarica

OOFORECTOMIA

Appendicectomia? SI

Fissazione ovaio residuo? ???*

*“Because the long-term effect of oophoropexy on fertility is uncertain,

it may be reasonable to recommend controlateral oophoropexy only when a

normal appearing ovary has torsed, and this situation may be difficult to assess

at surgery.” Quint E.H., Smith Y.R., 1999

GRAZIE PER LA VOSTRA ATTENZIONE !