Original ReportNeutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio Might Predict Pediatric Ovarian Torsion: A Single-Institution Experience and Review of the Literature
Introduction
Pediatric ovarian torsion (OT) is an emergency condition with an incidence ranging from 4.9/100000 to 20-30/100000.1 OT is defined as total or partial rotation of the ovarian pedicle around its vascular axis with consecutive compromise of venous, lymphatic, and arterial drainage and supply, resulting in hemorrhagic infarction and necrosis.2 Regarding underlying mechanism of OT, an association of sudden intra-abdominal pressure changes, tubal spasms, hypermobile elongated fallopian tubes and ligaments, together with enhanced hormonal activity in the premenarcheal and perinatal period is under discussion.3 OT mandates early surgical intervention for prevention of adnexal tissue damage with major implications on fertility.3 However, diagnosis of OT remains challenging because of its overall unspecific clinical presentation.1 To date, no specific diagnostic marker of predictive value for OT has been elucidated. Associated features of OT are leukocytosis, fever, abdominal pain, nausea, and vomiting.3 Although constituting a current hallmark in diagnosis of OT, evaluation of ovarian perfusion status using ultrasound (US) has its limitations because of a considerably elevated false negative rate.4,5 Addressing the issue of more sensitive predictors of OT, several complete blood count (CBC) parameters, including their ratios, have been recently investigated in adult cohorts, with neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) being among the most promising candidates.6
The aim of this study was to determine the diagnostic value of inflammatory markers in pediatric OT with emphasis on the role of NLR and PLR, which has not previously been investigated in children. This also accounts for the lymphocyte to C-reactive protein (CRP) ratio (LCR), which has been recently identified as a potential indicator for intestinal ischemia in adults with incarcerated abdominal wall hernias,7 with possible implications on ovarian ischemia secondary to OT in our series. Furthermore, we wanted to assess potential differences regarding clinical, biometrical, and procedural characteristics.
Section snippets
Materials and Methods
In a retrospective, single-center review, we identified 118 consecutive surgical cases on 114 patients aged from 3 days up to 17.8 years with a diagnosis of pediatric ovarian pathology (International Classification of Diseases, 10th Revision code N83). Exclusion criteria were associated appendicitis (n = 5), because of the known influence of appendicitis on NLR and PLR,8 malignant ovarian tumors (n = 2), mesothelic cysts (n = 8), and mature teratoma (n = 11), resulting in 92 surgeries on 88
Results
Because of the bimodal age distribution pattern of OT as depicted in Figure 1B, data from children who underwent surgery for benign ovarian pathology were categorized into 2 groups. The first group was aged older than 1 year (n = 76), the second group was aged younger than 1 year (n = 16). OT in patients aged older than 1 year was observed in 18 cases, whereas OC was observed in 58 cases (torsion rate, 0.24). Table 1 depicts main biometric, procedural, and ovarian characteristics.
A synopsis of
Discussion
Our results revealed significant associations of altered clinical and laboratory parameters in a state of OT in a pediatric cohort. The main finding of our study comprises the possible confirmation of clinically suspected OT according to laboratory indices such as PLR, NLR, and LCR, reflective of an immune response induced by ovarian ischemia. Moreover, PLR was also identified as an independent predictor for OT.
Acknowledgments
M.N. is currently receiving a research fellowship from the Ruhr-Universität Bochum (grant number: K133-19). The funding source had no involvement in study design, data collection, analysis, interpretation, writing of the report, nor the decision to submit the article for publication.
References (43)
Ovarian torsion
Semin Pediatr Surg
(2005)- et al.
Cannot exclude torsion-a 15-year review
J Pediatr Surg
(2009) - et al.
Novel serum inflammatory markers in patients with adnexal mass who had surgery for ovarian torsion
Fertil Steril
(2006) - et al.
Association between admission neutrophil to lymphocyte ratio and outcomes in patients with acute coronary syndrome
Am J Cardiol
(2008) - et al.
Predictive values of neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and other prognostic factors in pediatric idiopathic sudden sensorineural hearing loss
Int J Pediatr Otorhinolaryngol
(2019) - et al.
Blood count values and ratios for predicting sleep apnea in obese children
Int J Pediatr Otorhinolaryngol
(2017) - et al.
Platelets, inflammation and atherosclerosis
J Thromb Haemost
(2007) - et al.
Current trends in the surgical treatment of pediatric ovarian torsion: we can do better
J Pediatr Surg
(2015) - et al.
Surgery for ovarian masses in infants, children, and adolescents: 102 consecutive patients treated in a 15-year period
J Pediatr Surg
(2001) - et al.
The management of fetal ovarian cysts
J Pediatr Surg
(2002)
Update on the management of ovarian torsion in children and adolescents
World J Pediatr
Sonographic evaluation of ovarian torsion in childhood and adolescence
Am J Roentgenol
Sonographic findings of ovarian torsion in children
Pediatr Radiol
Evaluation of complete blood count parameters to predict ovarian torsion in women with adnexal mass
Gynecol Obstet Reprod Med
Lymphocyte–C-reactive protein ratio: a putative predictive factor for intestinal ischemia in strangulated abdominal wall hernias
Hernia
The correlation between complete blood count parameters and appendix diameter for the diagnosis of acute appendicitis
Healthcare (Basel)
Platelet to lymphocyte percentage ratio is associated with brachial-ankle pulse wave velocity in hemodialysis
Medicine (Baltimore)
New scoring system to create a prognostic criteria in colorectal carcinoma based on serum elevation of c-reactive protein and decrease in lymphocyte in peripheral blood
J Med Invest
Understanding diagnostic tests 3: receiver operating characteristic curves
Acta Paediatr
Neutrophil to lymphocyte ratio in the diagnosis of adnexal torsion
Int J Clin Exp Med
Early neutrophilia is associated with volume of ischemic tissue in acute stroke
Stroke
Cited by (10)
The role of neutrophil-to-lymphocyte ratio as a predictor of testicular torsion in children
2022, Journal of Pediatric UrologyCitation Excerpt :In the last few years, Neutrophil-to-lymphocyte ratio (NLR) has been postulated as an inflammatory marker in several diseases in children [5–7]. Recently it has been reported to be helpful in identification of inflammatory processes induced by ischemia such as ovarian torsion [8], although there are no studies so far examining this issue in pediatric patients with clinical and ultrasound suspicion of TT. The aim of this study is to analyze the possible role of the NLR as a predictor of TT in children and adolescents in order to facilitate prompt management of this condition.
Risk factors and predictive values of ovarian torsion necrosis in children
2024, Journal of Clinical Pediatric SurgeryOvarian torsion in the pediatric population: predictive factors for ovarian-sparing surgery—an international retrospective multicenter study and a systematic review
2023, Archives of Gynecology and ObstetricsAnalysis of risk factors and prediction method of ovarian torsion with ischemic necrosis in children with ovarian tumors
2023, Cancer Research and ClinicDirect bilirubin to lymphocyte ratio can discriminate acute appendicitis and ovarian torsion: a comparative study
2023, European Review for Medical and Pharmacological SciencesAdnexal Torsion in Adolescents – a Retrospective Analysis from a Tertiary Centre in Latvia
2023, Central European Journal of Paediatrics
The authors indicate no conflicts of interest.