- Email: [email protected]
Canadian National Physician Survey on Fertility Preservation for Prepubertal Female Oncology Patients
296
Poster Abstracts / J Pediatr Adolesc Gynecol 30 (2017) 275e298
improve, clinicians need to be familiar with the hormonal changes in this patient population.
45. Patterns of Follow Up Care 6 Months After LARC Insertion Among Adolescent Women Rosheen Grady MD, Caren Steinway MSW, MPH, Aletha Akers MD, MPH* The Children’s Hospital of Philadelphia, Philadelphia, PA
Background: Adolescents in the United States are at high risk of unintended pregnancy. Long-acting reversible contraception (LARC) is recommended as first-line for adolescents, yet these methods are underutilized in this population. Little is known about the clinical service utilization patterns of younger adolescents (age 14-17) following LARC insertion as existing studies have focused on older adolescent and young adult women. We compared patterns of follow up care among younger and older adolescent women during the first 6-months after insertion of a hormonal intrauterine system (IUS). We hypothesized that younger adolescents would make more calls and unscheduled clinic visits compared to older adolescents. Methods: We completed a retrospective chart review of patients recruited from a pediatric hospital who had completed participation in a randomized controlled trial examining pain control options during insertion of the 13.5 mg levonorgestrel IUS. All participants were females ages 14 - 22 years who had received the IUS at least 6 months prior to the chart review. Follow up care during the first 6-months was defined as: 1) the number of patient-initiated telephone calls, 2) the reason for each call, and 3) the number of clinic visits. Young adolescents were defined as those aged 14-17 years; older adolescents were those aged 18-22 years. This study was approved by the Institutional Review Board of the Children’s Hospital of Philadelphia. Results: Twenty-nine patients were included in the study; 11 (37.9%) were aged 14- 17 years old. The sample was 75.8% black, 13.8% white, and 10.3% other. Most (68.9%) were publicly insured. There were 10 patientinitiated calls during the 6-month follow-up; 6 (60.0%) were made by younger adolescents. Compared to older adolescents, younger adolescents were more likely to make follow up phone calls (45.4% vs 16.7%). The most common reason for patient-initiated phone calls in both groups was abdominal pain and cramping. All older adolescents complained about abdominal pain and/or cramping. Younger adolescents complained about a broader range of issues (bleeding, urinary complaints). Conclusions: Patterns of follow up care and the reasons for patientinitiated encounters differ between older and younger adolescent women following insertion of hormonal IUS. Anticipating the service demands of younger adolescent patients may decrease barriers to providing IUS care to this distinct population and improve the quality of care services.
46. Barriers to Exercise in Pregnancy Natalie Buckham MD, Sara Wilcox PhD, Alicia Dahl MS, Kerry Sims MD* Department of Obstetrics and Gynecology and Department of Exercise Science, University of South Carolina
Background and Significance: Greater than half of all women of reproductive age are overweight or obese. Obese or overweight teens are at higher risk of pregnancy complications compared with normal weight teens. Exercise during pregnancy can help minimize these risks by promoting healthy weight gain, thereby reducing risk of developing gestational diabetes, high blood pressure and cesarean delivery. Adequate physical activity needs to be recognized as a means to promote health and prevent chronic disease. We sought to examine patient knowledge regarding healthy weight gain and exercise during pregnancy. Methods: A total of 250 patients completed an online anonymous survey created in Survey Monkey. All respondents were 12 weeks gestation
with a singleton pregnancy. A total of 30 respondents were between the ages of 16-20; these adolescent surveys were analyzed. Open ended questions were imported into QSR NVIVO 11 software for analysis. Responses were coded to capture major themes of data. Results: A total of 33% of the adolescent respondents reported an adequate understanding of appropriate pregnancy weight gain, while 31% reported more than the recommended weight gain as appropriate. A total of 20 % conveyed an accurate understanding of current guidelines for physical activity in pregnancy. Adolescents listed walking (83%), stretching (17%), swimming (13%) and yoga (10%) as safe exercises during pregnancy and listed running (47%), weight training (33%), crunches (30%) and jumping (7%) as unsafe exercises during pregnancy. Adolescents listed benefits of exercise during pregnancy as improved labor (43%), general health benefits (30%) and weight maintenance (17%). They listed risks of exercise during pregnancy as preterm labor (27%), miscarriage (23%) and physical stress to the baby (13%). Adolescents listed their “bump or belly” (27%) as the most common physical barrier to exercise, followed by energy level (23%), and motivation (7%). They listed ways to improve exercise frequency as improved motivation (20%), having an exercise partner (20%) and increased energy levels (13%). Conclusion: These results indicate poor knowledge regarding appropriate pregnancy weight gain. An education gap exists for patients in identification of benefits and risks to exercise in pregnancy, and safe exercises in pregnancy. Our survey suggests prenatal education to increase patient knowledge concerning exercise during pregnancy, improve motivation and to engage supportive partners may help teens achieve appropriate levels of exercise during pregnancy. Healthy lifestyles may extend beyond pregnancy and perhaps help reduce the burden of obesity on the future health of women. Natalie L Buckham, MD Background Clinical Science Department of Obstetrics and Gynecology University of South Carolina, School of Medicine 418 Joshua St, Columbia, SC, 29205 Phone: 660-726-2532. Email: [email protected]
47. Canadian National Physician Survey on Fertility Preservation for Prepubertal Female Oncology Patients Bianca Stortini MD, FRCSC 1,2,3, Bryden Magee MD, FRCSC 2,3, Tania Dumont MD, FRCSC 1,2,3, Aaron Jackson MD, FRCSC*1,2,3 1 2 3
Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada The Ottawa Hospital, Ottawa, Ontario, Canada University of Ottawa, Ottawa, Ontario, Canada
Background: The increasing incidence of childhood cancers, coupled with improved overall survival rates has resulted in a growing cohort of reproductive aged survivors. Many cancer treatments are gonadotoxic and can lead to infertility and premature ovarian insufficiency (POI). The most established technique for fertility preservation (FP) is controlled ovarian hyperstimulation (COH) for the purpose of oocyte or embryo cryopreservation. However, COH poses 3 important issues: 1) possible delay in initiating treatment; 2) ovarian stimulation is impossible in pre-pubertal girls; and 3) discomfort with the transvaginal approach. For pre-pubertal girls, the only option for FP is ovarian tissue cryopreservation (OTC), but it remains an experimental technique. The objectives of this study are to 1) assess the need for improved discussion about, and access to FP options for pre-pubertal female oncology patients; and to 2) identify barriers to accessing FP. Method: A cross-sectional study using an internet-based survey was distributed to Canadian paediatric haematologist-oncologists (PHO) and paediatric and adolescent gynaecologists (PAG) in September 2016. Participants were identified via the C17 Council database (PHO) and the North American Society of Paediatric and Adolescent Gynaecology
Poster Abstracts / J Pediatr Adolesc Gynecol 30 (2017) 275e298
listserve (PAG). Descriptive statistics were used to analyze the data. The study was approved by the Ottawa Health Science Network Research Ethics Board and by the Children’s Hospital of Eastern Ontario Research Ethics Board. Results: Fourteen PHO, six PAG, one obstetrician-gynaecologist and one physician who follows paediatric cancer survivors completed the survey. The preliminary results are as follows. Most (19/22) providers were confident in their ability to identify patients at moderate/high risk of POI/ infertility and almost all (20/22) “usually” or “always” discuss the possible impacts of treatment on the future fertility. Poor prognosis, the need to initiate immediate therapy and that FP options in this population remain experimental were the main reasons for not discussing future fertility. Nine of 14 PHO “sometimes” or “usually” refer patients to a reproductive specialist prior to the initiation of therapy. The main reason (14/22) patients are not referred was a lack of time prior to starting treatment. All physicians saw benefit in OTC, in that re-implanted ovarian tissue may allow for future fertility. Concerns about OTC include a possible delay in cancer treatment, increased anxiety for patients/families and cost. However, the majority (16/22) of the providers felt that OTC should be considered medically necessary and should receive provincial funding. Conclusion: Physicians treating pre-pubertal female oncology patients often discuss the impact of treatment on future fertility and refer to reproductive specialists. The most common barrier to discussing future fertility and making early referrals is limited time prior to treatment. There is a clear interest for OTC to become an accessible FP technique for this population. The next step will be to establish OTC in our centre and advocate for provincial funding for this service.
48. Vulvar Lesions in an 8-Year-Old Girl: Cutaneous Manifestations of Multisystem Langerhans Cell Histiocytosis Elisa M. Jorgensen MD, Peter P. Chen MD, PhD, Julia A. Cron MD* Yale University School of Medicine, New Haven, CT, USA
Background: Langerhans cell histiocytosis (LCH) is a rare localized or systemic disease characterized by proliferation of myeloid-derived dendritic cells. Vulvar lesions may be the herald symptom of LCH and may
Tanner Stage at Time of Gonadectomy
297
mimic other cutaneous lesions. Prognosis varies widely based on the extent and spread of disease. Case: An 8-year-old girl with a 4-month history of vulvar lesions resistant to topical steroids was referred by her pediatrician. Vulvar biopsy was diagnostic for LCH. Imaging studies revealed a left hip lesion consistent with LCH. The patient was subsequently treated for multisystem LCH with vinblastine and prednisone. Comments: Though rare, LCH may be diagnosed by gynecologists and should be included in the differential diagnosis for vulvar lesions, particularly in children. LCH may mimic other vulvar cutaneous lesions, some of which may be acquired via sexual contact, including molluscum contagiosum and condylomata acuminate. We recommend having a low threshold for performing biopsy of vulvar lesions. Timely diagnosis of LCH is important in order to complete further workup for systemic disease and initiate treatment.
49. Gonadal Pathology in a Case Series of Patients With 45X/46XY Mosaic Turner Syndrome Vrunda Patel MD, Christina Buchanan IV MS, Veronica Gomez-Lobo* Children’s National Medical Center, Washington D.C.
Background: While Turner syndrome classically presents with a 45X karyotype, 8-12% of individuals with Turner syndrome have 45X/46XY mosaicism or partial Y chromosome material present1. Turner mosaic karyotype has also been classified as a form of partial gonadal dysgenesis presenting with a female phenotype. Existence of Y chromosome material in Turner patients has been associated with a 10-43% risk of gonadoblastoma, which can progress to malignant germ cell neoplasms24 . Due to this risk, a gonadectomy is recommended for mosaic Turner patients. However, there is controversy surrounding the ideal time for this procedure to be performed. There have been six reported cases of gonadoblastoma in mosaic Turner patients under the age of three (9 months-2.8 years) suggesting that malignancy can present early in childhood1-2,5-8 . This study aims to describe the gonadal pathology following gonadectomy for mosaic Turner patients at a single institution. Case: A retrospective chart review was performed of eight patients with Turner’s mosaicism at Children’s National Medical Center. Six out of eight patients underwent gonadectomy.
Patient
Age
Age at Gonadectomy
Radiological Imaging
1
15
10
I
2
3
2
I
3 4
20 11
14 8
Not available Not available
5
21
16
I
6
20
16
III-Breast IV-Pubic hair
Not available
7
13
Deferred
I
8
15
Deferred
I
1. Small uterus, immature in appearance. 2. Ovaries not identified. 1. Uterus is prepubertal in size. 2. Ovaries not identified.
1. An indeterminate 2 mm x 9 mm hypoechoic streak like area is seen in the expected region of the right ovary. 2. A small heterogeneous structure with hypoechoic foci, measuring 7 mm x 4 mm x 5 mm, is identified in the expected region of the left ovary. Normal sonographic appearance of the uterus. Neither ovary is clearly delineated by ultrasound. Not available Normal pre-pubertal uterus with an asymmetrically small right ovary Not available
Pathology Fibrous streak gonads with focal involuted gonadoblastoma
Bilateral ovarian gonadoblastoma Streak ovaries bilaterally Streak ovary with diminutive fallopian tube bilaterally Streak ovary with ectopic adrenal cortical tissue Streak gonads with bilateral steroid-hilar cell hyperplasia and € llerian and Wolffian immature Mu internal ducts N/A N/A
Poster Abstracts / J Pediatr Adolesc Gynecol 30 (2017) 275e298
improve, clinicians need to be familiar with the hormonal changes in this patient population.
45. Patterns of Follow Up Care 6 Months After LARC Insertion Among Adolescent Women Rosheen Grady MD, Caren Steinway MSW, MPH, Aletha Akers MD, MPH* The Children’s Hospital of Philadelphia, Philadelphia, PA
Background: Adolescents in the United States are at high risk of unintended pregnancy. Long-acting reversible contraception (LARC) is recommended as first-line for adolescents, yet these methods are underutilized in this population. Little is known about the clinical service utilization patterns of younger adolescents (age 14-17) following LARC insertion as existing studies have focused on older adolescent and young adult women. We compared patterns of follow up care among younger and older adolescent women during the first 6-months after insertion of a hormonal intrauterine system (IUS). We hypothesized that younger adolescents would make more calls and unscheduled clinic visits compared to older adolescents. Methods: We completed a retrospective chart review of patients recruited from a pediatric hospital who had completed participation in a randomized controlled trial examining pain control options during insertion of the 13.5 mg levonorgestrel IUS. All participants were females ages 14 - 22 years who had received the IUS at least 6 months prior to the chart review. Follow up care during the first 6-months was defined as: 1) the number of patient-initiated telephone calls, 2) the reason for each call, and 3) the number of clinic visits. Young adolescents were defined as those aged 14-17 years; older adolescents were those aged 18-22 years. This study was approved by the Institutional Review Board of the Children’s Hospital of Philadelphia. Results: Twenty-nine patients were included in the study; 11 (37.9%) were aged 14- 17 years old. The sample was 75.8% black, 13.8% white, and 10.3% other. Most (68.9%) were publicly insured. There were 10 patientinitiated calls during the 6-month follow-up; 6 (60.0%) were made by younger adolescents. Compared to older adolescents, younger adolescents were more likely to make follow up phone calls (45.4% vs 16.7%). The most common reason for patient-initiated phone calls in both groups was abdominal pain and cramping. All older adolescents complained about abdominal pain and/or cramping. Younger adolescents complained about a broader range of issues (bleeding, urinary complaints). Conclusions: Patterns of follow up care and the reasons for patientinitiated encounters differ between older and younger adolescent women following insertion of hormonal IUS. Anticipating the service demands of younger adolescent patients may decrease barriers to providing IUS care to this distinct population and improve the quality of care services.
46. Barriers to Exercise in Pregnancy Natalie Buckham MD, Sara Wilcox PhD, Alicia Dahl MS, Kerry Sims MD* Department of Obstetrics and Gynecology and Department of Exercise Science, University of South Carolina
Background and Significance: Greater than half of all women of reproductive age are overweight or obese. Obese or overweight teens are at higher risk of pregnancy complications compared with normal weight teens. Exercise during pregnancy can help minimize these risks by promoting healthy weight gain, thereby reducing risk of developing gestational diabetes, high blood pressure and cesarean delivery. Adequate physical activity needs to be recognized as a means to promote health and prevent chronic disease. We sought to examine patient knowledge regarding healthy weight gain and exercise during pregnancy. Methods: A total of 250 patients completed an online anonymous survey created in Survey Monkey. All respondents were 12 weeks gestation
with a singleton pregnancy. A total of 30 respondents were between the ages of 16-20; these adolescent surveys were analyzed. Open ended questions were imported into QSR NVIVO 11 software for analysis. Responses were coded to capture major themes of data. Results: A total of 33% of the adolescent respondents reported an adequate understanding of appropriate pregnancy weight gain, while 31% reported more than the recommended weight gain as appropriate. A total of 20 % conveyed an accurate understanding of current guidelines for physical activity in pregnancy. Adolescents listed walking (83%), stretching (17%), swimming (13%) and yoga (10%) as safe exercises during pregnancy and listed running (47%), weight training (33%), crunches (30%) and jumping (7%) as unsafe exercises during pregnancy. Adolescents listed benefits of exercise during pregnancy as improved labor (43%), general health benefits (30%) and weight maintenance (17%). They listed risks of exercise during pregnancy as preterm labor (27%), miscarriage (23%) and physical stress to the baby (13%). Adolescents listed their “bump or belly” (27%) as the most common physical barrier to exercise, followed by energy level (23%), and motivation (7%). They listed ways to improve exercise frequency as improved motivation (20%), having an exercise partner (20%) and increased energy levels (13%). Conclusion: These results indicate poor knowledge regarding appropriate pregnancy weight gain. An education gap exists for patients in identification of benefits and risks to exercise in pregnancy, and safe exercises in pregnancy. Our survey suggests prenatal education to increase patient knowledge concerning exercise during pregnancy, improve motivation and to engage supportive partners may help teens achieve appropriate levels of exercise during pregnancy. Healthy lifestyles may extend beyond pregnancy and perhaps help reduce the burden of obesity on the future health of women. Natalie L Buckham, MD Background Clinical Science Department of Obstetrics and Gynecology University of South Carolina, School of Medicine 418 Joshua St, Columbia, SC, 29205 Phone: 660-726-2532. Email: [email protected]
47. Canadian National Physician Survey on Fertility Preservation for Prepubertal Female Oncology Patients Bianca Stortini MD, FRCSC 1,2,3, Bryden Magee MD, FRCSC 2,3, Tania Dumont MD, FRCSC 1,2,3, Aaron Jackson MD, FRCSC*1,2,3 1 2 3
Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada The Ottawa Hospital, Ottawa, Ontario, Canada University of Ottawa, Ottawa, Ontario, Canada
Background: The increasing incidence of childhood cancers, coupled with improved overall survival rates has resulted in a growing cohort of reproductive aged survivors. Many cancer treatments are gonadotoxic and can lead to infertility and premature ovarian insufficiency (POI). The most established technique for fertility preservation (FP) is controlled ovarian hyperstimulation (COH) for the purpose of oocyte or embryo cryopreservation. However, COH poses 3 important issues: 1) possible delay in initiating treatment; 2) ovarian stimulation is impossible in pre-pubertal girls; and 3) discomfort with the transvaginal approach. For pre-pubertal girls, the only option for FP is ovarian tissue cryopreservation (OTC), but it remains an experimental technique. The objectives of this study are to 1) assess the need for improved discussion about, and access to FP options for pre-pubertal female oncology patients; and to 2) identify barriers to accessing FP. Method: A cross-sectional study using an internet-based survey was distributed to Canadian paediatric haematologist-oncologists (PHO) and paediatric and adolescent gynaecologists (PAG) in September 2016. Participants were identified via the C17 Council database (PHO) and the North American Society of Paediatric and Adolescent Gynaecology
Poster Abstracts / J Pediatr Adolesc Gynecol 30 (2017) 275e298
listserve (PAG). Descriptive statistics were used to analyze the data. The study was approved by the Ottawa Health Science Network Research Ethics Board and by the Children’s Hospital of Eastern Ontario Research Ethics Board. Results: Fourteen PHO, six PAG, one obstetrician-gynaecologist and one physician who follows paediatric cancer survivors completed the survey. The preliminary results are as follows. Most (19/22) providers were confident in their ability to identify patients at moderate/high risk of POI/ infertility and almost all (20/22) “usually” or “always” discuss the possible impacts of treatment on the future fertility. Poor prognosis, the need to initiate immediate therapy and that FP options in this population remain experimental were the main reasons for not discussing future fertility. Nine of 14 PHO “sometimes” or “usually” refer patients to a reproductive specialist prior to the initiation of therapy. The main reason (14/22) patients are not referred was a lack of time prior to starting treatment. All physicians saw benefit in OTC, in that re-implanted ovarian tissue may allow for future fertility. Concerns about OTC include a possible delay in cancer treatment, increased anxiety for patients/families and cost. However, the majority (16/22) of the providers felt that OTC should be considered medically necessary and should receive provincial funding. Conclusion: Physicians treating pre-pubertal female oncology patients often discuss the impact of treatment on future fertility and refer to reproductive specialists. The most common barrier to discussing future fertility and making early referrals is limited time prior to treatment. There is a clear interest for OTC to become an accessible FP technique for this population. The next step will be to establish OTC in our centre and advocate for provincial funding for this service.
48. Vulvar Lesions in an 8-Year-Old Girl: Cutaneous Manifestations of Multisystem Langerhans Cell Histiocytosis Elisa M. Jorgensen MD, Peter P. Chen MD, PhD, Julia A. Cron MD* Yale University School of Medicine, New Haven, CT, USA
Background: Langerhans cell histiocytosis (LCH) is a rare localized or systemic disease characterized by proliferation of myeloid-derived dendritic cells. Vulvar lesions may be the herald symptom of LCH and may
Tanner Stage at Time of Gonadectomy
297
mimic other cutaneous lesions. Prognosis varies widely based on the extent and spread of disease. Case: An 8-year-old girl with a 4-month history of vulvar lesions resistant to topical steroids was referred by her pediatrician. Vulvar biopsy was diagnostic for LCH. Imaging studies revealed a left hip lesion consistent with LCH. The patient was subsequently treated for multisystem LCH with vinblastine and prednisone. Comments: Though rare, LCH may be diagnosed by gynecologists and should be included in the differential diagnosis for vulvar lesions, particularly in children. LCH may mimic other vulvar cutaneous lesions, some of which may be acquired via sexual contact, including molluscum contagiosum and condylomata acuminate. We recommend having a low threshold for performing biopsy of vulvar lesions. Timely diagnosis of LCH is important in order to complete further workup for systemic disease and initiate treatment.
49. Gonadal Pathology in a Case Series of Patients With 45X/46XY Mosaic Turner Syndrome Vrunda Patel MD, Christina Buchanan IV MS, Veronica Gomez-Lobo* Children’s National Medical Center, Washington D.C.
Background: While Turner syndrome classically presents with a 45X karyotype, 8-12% of individuals with Turner syndrome have 45X/46XY mosaicism or partial Y chromosome material present1. Turner mosaic karyotype has also been classified as a form of partial gonadal dysgenesis presenting with a female phenotype. Existence of Y chromosome material in Turner patients has been associated with a 10-43% risk of gonadoblastoma, which can progress to malignant germ cell neoplasms24 . Due to this risk, a gonadectomy is recommended for mosaic Turner patients. However, there is controversy surrounding the ideal time for this procedure to be performed. There have been six reported cases of gonadoblastoma in mosaic Turner patients under the age of three (9 months-2.8 years) suggesting that malignancy can present early in childhood1-2,5-8 . This study aims to describe the gonadal pathology following gonadectomy for mosaic Turner patients at a single institution. Case: A retrospective chart review was performed of eight patients with Turner’s mosaicism at Children’s National Medical Center. Six out of eight patients underwent gonadectomy.
Patient
Age
Age at Gonadectomy
Radiological Imaging
1
15
10
I
2
3
2
I
3 4
20 11
14 8
Not available Not available
5
21
16
I
6
20
16
III-Breast IV-Pubic hair
Not available
7
13
Deferred
I
8
15
Deferred
I
1. Small uterus, immature in appearance. 2. Ovaries not identified. 1. Uterus is prepubertal in size. 2. Ovaries not identified.
1. An indeterminate 2 mm x 9 mm hypoechoic streak like area is seen in the expected region of the right ovary. 2. A small heterogeneous structure with hypoechoic foci, measuring 7 mm x 4 mm x 5 mm, is identified in the expected region of the left ovary. Normal sonographic appearance of the uterus. Neither ovary is clearly delineated by ultrasound. Not available Normal pre-pubertal uterus with an asymmetrically small right ovary Not available
Pathology Fibrous streak gonads with focal involuted gonadoblastoma
Bilateral ovarian gonadoblastoma Streak ovaries bilaterally Streak ovary with diminutive fallopian tube bilaterally Streak ovary with ectopic adrenal cortical tissue Streak gonads with bilateral steroid-hilar cell hyperplasia and € llerian and Wolffian immature Mu internal ducts N/A N/A