Original Report
Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio Might Predict Pediatric Ovarian Torsion: A Single-Institution Experience and Review of the Literature

https://doi.org/10.1016/j.jpag.2020.12.003Get rights and content

Abstract

Study Objective

To determine clinical and laboratory characteristics of ovarian torsion (OT; n = 28) compared with a non-OT control (OC; n = 64) group.

Design

Retrospective single-center review performed between January 2006 and December 2016.

Setting

Academic department of pediatric surgery.

Participants and Interventions

Postoperative diagnosis of pediatric ovarian pathology (International Classification of Diseases, 10th Revision code N83) in 88 patients who underwent 92 surgeries for suspected OT, aged from 3 days to 17.8 years.

Main Outcome Measures

Predictive value for OT according to biometric, procedural, and laboratory parameters at the time of admission.

Results

Compared with OC, OT in patients aged older than 1 year was associated with elevated values regarding white blood cell count, neutrophils, neutrophil to lymphocyte ratio (NLR; all P < .001), platelet to lymphocyte ratio (PLR; P = .003), platelets (P = .011), and a trend toward raised C-reactive protein (P = .054), whereas lymphocytes and lymphocyte to C-reactive protein ratio (both P < .001) were decreased. Using receiver operating characteristic analysis for differentiating OC from OT, besides lymphocytes and NLR (both area under the curve > 0.9), PLR elicited strongest discriminatory accuracy (area under the curve = 0.946 ± 0.037; P < .001; sensitivity 82%; specificity 90%). At binary logistic regression analysis PLR (P = .018) was independently predictive of OT. OT was suspected on ultrasound imaging in 15/18 (83%), showed a right-sided dominance in 13/18 (72%), and was associated with younger age (P = .003). No differences regarding laboratory or procedural parameters in patients aged younger than 1 year were discerned.

Conclusion

Blood count indices such as PLR, NLR, and lymphocyte to C-reactive protein ratio might be helpful in identification of inflammatory processes as induced by ischemia in OT. Together with ultrasound and clinical features, these parameters constitute potential predictors of OT in girls aged older than 1 year.

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.

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      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.

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    The authors indicate no conflicts of interest.

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