Vol.2, No.7, 402-404 (2013) Case Reports in Clinical Medicine
Copyright © 2013 SciRes. OPEN ACCESS
Comprehensive laparoscopic surgical staging of
ovarian dysgerminoma in a 10-year-old girlA
case report
Nisrin Anfinan*
Gynecology Oncology Unit, Department of Obstetric and Gynaecology, Faculty of Medicine, King Abdulaziz University, Je d d a h , KS A ;
*Corresponding Author: dr_nisreen2001@yahoo.com
Received 4 August 2013; revised 5 September 2013; accepted 20 September 2013
Copyright © 2013 Nisrin Anfinan. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Minimal access surgery to stage early ovarian
cancer (EOC) is still regarded as an investiga-
tion among many gynecologic oncologists. This
is a case of comprehensive laparoscopic surgi-
cal stage of an ovarian dysgerminoma in a 10-
year-old girl described. This patient was re-
ferred to the gynecology oncology unit status
post left salpingo-oophorectomy through a mid-
line incision when the histopathology showed
pure dysgerminoma. We then performed the
lap arosco pic stage including peritoneal washing;
resection of the left infundibulopelvic ligament;
systematic pelvic, common iliac, and infrarenal
bilateral paraaortic lymphadenectomy; and omen-
tectomy. The uterus and right adnexum were
spared to preserve future fertility. The final his-
topathology showed no metastatic disease (stage
ovarian dysgerminoma), and patient has no evi-
dence of recurrence after 52 months follow up.
Conclusion: This is the youngest patient report-
ed in the literature with a comprehensive laparo-
scopic surgical stage for ovarian neoplasm. A
full laparoscopic staging for ovarian cancer in a
10-year-old girl is safe and might be considered
as an alternative to the sta nder of care.
Keyw ords: Ovarian Dysgerminoma; Laparo scopy;
Comprehensive Surgical Staging; Child
In recent years, minimally invasive surgery (MIS) has
been widely used to establish a diagnosis, for staging
purposes, and evaluation of recurrent or metastatic dis-
ease in children [1,2]. The use of MIS techniques in
children is growing with the availability of smaller in-
struments and equipment more suitable for the pediatric
patients [3]. The main indications for use of MIS tech-
niques are diagnostic biopsies (mediastinal or lung tu-
mors, and retroperitoneal extrarenal masses), resection of
the primary tumor in patients with thoracic and abdomi-
nal neuroblastic tumors, and post-treatment of the resid-
ual mass in patients with lymphoma [4]. The role of MIS
for surgical staging of the early stage ovarian cancer is
feasible [5,6].
This is a case of comprehensive surgical restaging per-
formed in a 10-year-old girl affected by a pure ovarian
dysgerminoma apparently confined to one ovary.
A 10-year-old premenarchal girl was referred to our
gynecology oncology unit at King Abdulaziz University
Hospital in January 2011 after she had undergone a la-
parotomy through a midline incision performed by a ge-
neral gynecologist and left salpingo-oophorectomy was
done. At that time, histological analysis of a surgical
specimen revealed a pure dysgerminoma, but unfortu-
nately she was not staged. The options were discussed
with her parents who elected for her to undergo a restag-
ing proce dure.
Her medical history was unremarkable; physical ex-
amination revealed a well-healed incision that extended
from the midline up to the umbilicus. The patient’s
weight and height were 25 kg and 140 cm, respectively.
Laboratory tests performed revealed preserved renal
function and a normal hemoglobin level. The LDH was
elevated 4461 U/L, other tumor markers CA 125, CEA,
and α-FP were normal. She was prepared and admitted
for surgery, and the informed consent form was signed
*MD, ABOG. Scientific Chair of Professor Abdullah Hussain Ba-
salamah for Gynecological Cancer.
N. Anfinan / Case Reports in Clinical Medicine 2 (2013) 402-40 4
Copyright © 2013 SciRes. OPEN ACCESS
by her parents.
Considering the young age of the patient, we per-
formed comprehensive surgical staging via laparoscopy.
Intra-abdominal inspection revealed an adhesion of the
omentum over the left uterine cornua with no evidence of
disseminated disease in the pelvis and upper abdomen.
The right adnexum and uterus were carefully examined
and appeared normal. Peritoneal washing was performed
before starting the procedure. The procedure consisted of
systematic bilateral pelvic (including external iliac, in-
ternal iliac, and obturator), bilateral common iliac, and
infrarenal bilateral paraaortic lymph node dissection
(Figure 1); omentectomy; and obtaining peritoneal bi-
opsy specimens. The staging procedure was successfully
completed in 249 minutes with an estimated blood loss
of 200 mL, using a 10-mm umbilical trocar, 3 suprapubic
5-mm ancillary trocars, and one 3-mm ancillary trocar
placed in the left hypochondrium at the level of the mid-
clavicular line. Abdominal drainage was placed and re-
moved the next day. The decrease in the patient’s hemo-
globin (Hb) level was 1 g/dL (Hb before 11 g/Dl-Hb
after 10 g/dL), and the postoperative hospital stay was
not complicated. The postoperative period was unevent-
ful, and the girl was discharged from the hospital 2 days
after the surgery. All other surgical specimens including
total of 24 pelvic and para aortic lymph nodes and the
peritoneal washing revealed no evidence of neoplastic
lesions, so the final diagnosis was a pure ovarian dys-
germinoma at Ia stage (FIG O classification) .
Follow-up visits with physical examination and eval-
uation of tumor markers were planned 1 month and 3
months after the surgery and then every 3 months. Her
lactate dehydrogenase level soon returned to the normal
range with no evidence of recurrence after 52 months
follow up.
Figure 1. Laparoscopic view of the retroperitoneal space after
complete para-aortic lymphadenctomy (A) inferior vena cava;
(B) inferior mesenteric artery; (C) aorta.
Ovarian germ cell tumors are rare neoplasms, repre-
senting about 3% to 5% of all ovarian malignancies.
Dysgerminomas are commonly diagnosed in the 2nd and
3rd decades of life, approximately 85% - 90% are con-
fined to one ovary [7].
As for other ovarian tumors, the in itial management of
a dysgerminoma is surgery, and the traditional approach
to this condition is staging. Comprehensiv e surgical stag -
ing allows to identify patients with a more advanced
stage disease that should receive adjuvant chemotherapy.
For unstaged IA ovarian dysgerminoma, the management
is still controversial. Vicus reported 4 cases of relapsed
patients with unstaged IA ovarian dysgerminoma [8],
Kasenda also reported 2 cases of recurrence with appar-
ent IA, surgically unstaged patients. The authors con-
cluded that comprehensive initial surgical staging is man-
datory to minimize treatment burden [9].
Traditionally surg ical staging performed through a ge-
nerous midline laparoto my incision. However, the role of
MIS for early stage ovarian cancer is feasible [5,6],
opening new perspectives for the management of ovarian
germ cell malignant tumors. Laparoscopy now allows
performance of all procedures required by International
Federation of Gynecology and Obstetrics (FIGO) guide-
lines for surgical staging of ovarian malignancies (i.e.,
complete removal of ovarian neoplasm, pelvic and pa-
raaortic lymph nodes, and omentum).
Uccella et al. reported the first case of comprehensive
laparoscopic surgical staging of an ovarian dysgermi-
noma in a 13-year-old girl [10]. For a 20-cm pelvic mass
rising from the right adnexum, she underwent laparo-
scopic right salpingo-oophorectomy. Pathologic findings
were consistent with a diagnosis of pure dysgerminoma.
Laparoscopic staging included peritoneal washing; re-
section of the right infundibulopelvic ligament; system-
atic pelvic, common iliac, and infrarenal paraaortic lym-
phadenectomy; appendectomy; and infracolic omentec-
tomy. The uterus and left adnexum were spared to pre-
serve future fertility [10].
Our report of performing comprehensive surgical re-
staging of an apparent early-stage ovarian dysgerminoma
via laparoscopy in a 10-year-old ch ild is of great interest
for a number of reasons. This type of neoplasm is largely
curable [11], and its chemosensitiv ity has been proven to
be preserved also in cases of recurrent disease. In addi-
tion, the postoperative recovery is much faster when the
operation is performed laparoscopically compared with
via laparotomy. Our patients were able to go home next
day with less pain which is certainly much less psycho-
logical and physical consequences of having another
major abdominal incision. In addition, the lower rate of
postoperative adhesions after laparoscopic procedures
(when compared with laparotomy) is of utmost impor-
N. Anfinan / Case Reports in Clinical Medicine 2 (2013) 402-40 4
Copyright © 2013 SciRes. OPEN ACCESS
tance in these patients, because it is well known that ad-
hesions can be responsible for infertility [12]. In addition ,
she was spared the unnecessary adjuvant chemotherapy
considering negative staging after the second su rgery.
Written informed consent was obtained from her par-
ents for publication of this case report and acco mpanying
This is the youngest patient reported in the literature
with a comprehensive laparoscopic surgical stage for
ovarian neoplasm. A full laparoscopic stage for ovarian
cancer in 10 year old girl is safe and might be considered
as an alternative to the stander of care.
I would like to thank professor Khalid Sait, my team, the anesthesia
department and t h e o p e rating room staff for the their help and assistant.
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