Surgical indications in antenatally diagnosed ovarian cysts

Fetal ovarian cysts management and ovarian prognosis: a report of 82 cases

BACKGROUND/PURPOSE

Fetal ovarian cysts are frequently complicated by intracystic hemorrhage without associated clinical signs, which is often secondary to ovarian torsion leading to loss of the ovary. The aim of this study was to evaluate ovarian outcome and the place of prenatal management and surgery in the first few days of life in order to save the ovary.

METHODS

Between January 1987 and June 2006, 82 fetal ovarian cysts in 79 patients were managed and clinically and ultrasonographically followed up for several months (median, 11 months; range, 6 months to 10 years) in all of the cases where the ovary was not removed. The ultrasonographic results regarding the ovarian parenchyma were broken down into 3 categories: follicular ovary, homogeneous ovary, and undetected ovary.

RESULTS

Twenty-seven cysts remained simple throughout their evolution, and 55 were complicated by intracystic hemorrhage usually several weeks before birth. Overall, after disappearance of the cyst, a follicular ovary was detected in only 39% of the cases (32/82) and more often when the cyst was simple than when it presented an intracystic hemorrhage (85% vs 16.4%, chi(2), P < .0001).

CONCLUSIONS

A review of our series confirms the poor ovarian outcome linked to ultrasonographic signs of intracystic hemorrhage. Preventive action by puncture of "simple" cysts is still being studied. The presence of a bilateral cyst can, if pulmonary maturity has been reached, be an argument for inducement of premature birth with a view to performing conservative surgery. After birth, surgery in the first few days of life is only justified if the signs of intracystic hemorrhage appeared in the period very close to birth.

Fetal ovarian cysts diagnosed during prenatal ultrasound screening

OBJECTIVE

To discuss the follow-up and management of fetal ovarian cysts (FOCs) and review the current literature.

CASE REPORT

A 26-year-old, gravida 2, para 0, abortus 1, Rh-negative patient was diagnosed with bilateral FOCs during ultrasound examination at 32 weeks gestation. Fetal nuchal translucency measured at 12 weeks gestation was 1.2 mm, and a combined triple test for trisomy 21 suggested a 1/800 risk. She was regularly monitored at our antenatal outpatient clinic, and the course of her pregnancy was uncomplicated until 32 weeks gestation, when bilateral FOCs were diagnosed. Because of cephalopelvic disproportion, a cesarean section was performed at 39 weeks gestation and a 3,680-g Rh-positive female baby was delivered. The baby was admitted to the neonatal care unit and was monitored by pediatricians. Ultrasound examination in the second postpartum month revealed spontaneous regression of the bilateral ovarian cysts.

CONCLUSION

Although FOCs are not usually life-threatening, the risk of losing the ovaries due to torsion during the neonatal period and the resulting sexual development disorders and infertility are very disturbing.

Management of prenatal ovarian cysts

OBJECTIVES

The aim of the present study was to analyze the antenatal and postnatal outcome of fetal ovarian cysts in relation to their ultrasonographic pattern and size.

METHODS

Sixteen fetal ovarian cysts were diagnosed in 16 fetuses and followed with serial ultrasonograms in utero and after birth until spontaneous or surgical resolution.

RESULTS

Eleven fetal ovarian cysts were simple cysts at first prenatal scan but 3 of the 11 became complex cysts at last prenatal scan and required postnatal laparoscopic surgery. Seven of the 11 simple cysts (63%) disappeared on follow-up imaging by ultrasonograms or MRI during pregnancy or within 2 months after birth. The rate of spontaneous resolution of simple cysts was higher than that of complex cysts (40.0%). The mean maximum diameter of the ovarian cysts before delivery that were subsequently excised surgically at postnatal period (50+/-13.4 mm) was not different from that of ovarian cysts that resolved spontaneously (42.8+/-12.8 mm, P=0.2918).

CONCLUSION

In our study, cyst size did not predict the risk of ovarian loss. The opportunity of laparoscopic exploration versus conservative management needs to be investigated because some complex cysts resolved spontaneously in the postnatal period.

Antenatally diagnosed ovarian cyst with torsion managed laparoscopically

Ovarian cyst are the most common intra-abdominal cyst in female neonate. With the help of ultrasound one can make an antenatal diagnosis. We present one such neonate, she was managed by laparoscopic excision. We conclude that neonatal laparoscopy is technically feasible for management of such cysts.

Transumbilical management for neonatal ovarian cysts

BACKGROUND/PURPOSE

Since Tan and Bianchi (Br J Surg. 1986;73:399) reported umbilical incision as an access for pyloromyotomy in infantile hypertrophic pyloric stenosis, many pediatric surgeons have used this approach for a number of other procedures. Because of the long pedicle with good mobility and the frequent intraabdominal position of the neonatal ovarian cyst, we attempted to manage it via the transumbilical route.

METHODS

All patients were treated under intubation general anesthesia. Semicircular infraumbilical incision was made, and the abdomen was entered through a transverse fascial incision. The partially collapsed cyst after aspiration was exteriorized through the incision for cystectomy, partial deroofing, or adnexectomy.

RESULTS

From May 2000 to December 2006, 6 female newborns with ovarian cysts were treated via the transumbilical route. There were no complications from surgery. The operation time and duration of hospital stay were short. The cosmetic appearance after the procedure was good.

CONCLUSIONS

The initial result suggests that transumbilical management for neonatal ovarian cysts may be a good alternative procedure when laparoscopic equipment is unavailable or experienced technique is lacking.

Clinical experiences of fetal ovarian cyst: diagnosis and consequence

Ovarian cysts are the most frequent, prenatally diagnosed intra-abdominal cysts. Fetal ovarian cyst often presents complication such as torsion and seems to be an indication for surgical intervention. In this study, we reviewed pre- and post-natal medical records and ultrasonography of 17 fetuses that were diagnosed with ovarian cysts. In a total of 17 cases, postnatal surgery was performed in 7 infants. Of these cases, four cases of ovarian cyst torsion were confirmed. In the remaining 10 fetuses, one case regressed completely during pregnancy, and the other nine cases including two complex cysts resolve spontaneously after birth. Postnatal symptomatic cysts or cysts with a diameter greater than 5 cm that do not regress or enlarge should be treated, but uncomplicated asymptomatic cysts less than 5 cm in diameter should only be observed and reassessed by serial ultrasonography. If they regress spontaneously, no surgical intervention is necessary independent of their sonographic findings.

Cystic Colon Duplication as Differential Diagnosis to Ovarian Cyst

OBJECTIVE

We report the case of a female fetus with a single spherical anechoic cyst on the right side of the lower abdomen first diagnosed at 22 weeks of pregnancy.

METHODS

Serial ultrasound monitoring and needle aspiration of the cyst were performed.

RESULTS

The cyst grew during pregnancy up to 8 cm diameter. Needle aspiration was performed at 33 and 36 weeks. At 38 weeks labor was induced and a girl was delivered spontaneously. Postnatally the child showed abdominal distention, vomiting, and an obstruction of venous return of the right leg. To improve venous circulation, another needle aspiration of the cyst was performed. Laparoscopy revealed cystic colon duplication.

CONCLUSIONS

Prenatal differentiation of a single round anechoic cyst in the pelvis of a female fetus can be difficult. As a rare abnormality cystic colon duplication has to be considered.

Is Conservative Management of Prenatal and Neonatal Ovarian Cysts Justifiable?

OBJECTIVES

To evaluate conservative management of fetal and neonatal ovarian cysts.

METHODS

We followed the progress of 11 fetal and 2 neonatal ovarian cysts.

RESULTS

Ten fetal cysts were simple at recognition, but 8 silently became complex by birth, with ovarian loss in 6/11 cases (54%). In 2 cases where large simple cysts presented for the first time at birth, serious complications occurred, resulting in the death of 1 newborn.

CONCLUSIONS

If a fetal ovarian cyst is already complex before birth it can be managed conservatively, albeit with loss of the ipsilateral ovary in the majority of cases. As simple fetal ovarian cysts frequently become complex before birth, intervention may be justifiable to preserve the ovary. But any intervention also has the potential for complications, and may be ineffective. Intervention also requires accurate differentiation of ovarian cysts from other abdominal cysts.

Conservative Versus Surgical Treatment for Complex Neonatal Ovarian Cysts: Outcomes Study

OBJECTIVE

Prenatally diagnosed complex ovarian cysts are most often managed surgically in an attempt to save the ovary. Nevertheless, published surgical results disclose that most patients undergo oophorectomy or salpingo-oophorectomy. We assessed whether a surgical or conservative approach was more appropriate by comparing the long-term outcome of infants treated by both methods. A hypothesis for the cause of complex cysts is presented.

CONCLUSION

Clinical evidence questions the use of surgery for asymptomatic complex ovarian cysts. Histologic analysis suggests gonad maldevelopment as the origin of complex neonatal ovarian cysts.

Ovarian cysts in infants and children

The etiology of ovarian cysts varies with the developmental stage and hormonal milieu of the patient. In general, most ovarian cysts are functional in nature and usually resolve without treatment. Treatment is indicated if the diagnosis is in question, the cyst persists, or the patient is symptomatic. Laparoscopy has become the approach favored by most pediatric surgeons for the treatment of ovarian cysts. All surgical procedures for ovarian cysts should spare functional ovary as much as is technically possible. Simple cysts should be fenestrated. Complex or functional cysts should be excised, with preservation of the remaining ovary.

Ovarian torsion

Ovarian torsion is a rare problem in the pediatric age group that must be included in the differential diagnosis of any girl with abdominal pain or a pelvic or abdominal mass. Clinical presentation is nonspecific, and diagnosis is based on a high index of suspicion. Ultrasound scan remains the most useful investigation, but blood flow on Doppler examination does not exclude ovarian torsion. Current recommendations of treatment strongly support ovary conservation, and macroscopic appearance of the ovary is not a reliable indicator of the degree of necrosis and potential for ovary recovery. For children with ovarian torsion, laparoscopic detorsion should be performed with strong consideration of oophoropexy. An underlying ovary lesion such as mature teratoma or functional cyst is found in most cases; however, the risk of cancer in these patients is extremely low. If there is concern of a mass or underlying pathology, then follow-up ultrasound, resolution of edema and interval laparoscopic treatment may be required.

Renal failure as a result of mesenteric cyst

The authors report a rare case of renal failure secondary to abdominal cyst in a newborn girl. The clinical presentation was one of a largely distended abdomen coupled with anuria. The histopathologic and clinical findings suggest mesenteric cyst causing renal failure by mass effect.

The neonate with an abdominal mass

Abdominal masses in neonates reflect a wide spectrum of diseases,from lesions that can cause significant morbidity and mortality,to conditions readily corrected surgically, to entities which maybe safely observed. It is incumbent upon the infant's physician to determine the nature of the mass in a timely, safe, and cost-effective manner.

Neonatal Ovarian Cysts: Management with Reference to Magnetic Resonance Imaging

OBJECTIVE

Ultrasound (US) has been used as a tool to determine the indication for surgery for neonatal ovarian cysts. The purpose of this study was to investigate whether magnetic resonance imaging (MRI) contributes to optimal management.

METHODS

Between 1993 and 2001, US and MRI studies were simultaneously performed on 13 consecutive infants younger than 2 months of age with ovarian cysts. The US Patterns were classified as complex or simple. Signal intensity (SI) of the cysts on MRI was compared with that of the liver on T1-weighted images (T1WI) and with urine on T2-weighted images (T2WI). We assumed that high SI on T1WI and iso or low SI on T2WI indicated complications.

RESULTS

There were 10 complex and three simple cysts on US. Of the 10 complex cysts, two had no complications at surgery or resolved spontaneously. These two cysts showed low SI on T1WI. Eight complex cysts showed high SI on T1WI and all were haemorrhagic. The US diagnosis corresponded to the MRI findings in three simple cysts. The sensitivity of US for haemorrhage was 80%, and that of MRI was 100%.

CONCLUSIONS

We found that MRI was a more reliable diagnostic modality than US for diagnosing neonatal ovarian cysts.

Neonatal ovarian cysts

Foetal and neonatal ovarian cysts have previously been considered uncommon. With the development of sonography, however, the detection of cysts has increased. As ovarian cyst formation in the perinatal period is a self-limiting process, treatment options depend on the risk of complications and on the ability to differentiate these benign cysts from other pathology. The history of two neonates with an ovarian cyst detected antenatally with ultrasound techniques is described.

CONCLUSION

It is important that paediatricians have knowledge about the incidence, treatment and prognosis of foetal neonatal ovarian cysts.

Fetal ascites immediately after rupture of ovarian cysts

Ruptured fetal ovarian cysts are difficult to diagnose. We report on ultrasonograms recorded before and immediately after spontaneous rupture of fetal ovarian cysts followed by transient ascites. Ultrasound findings of transient ascites accompanied by rapid reduction in cyst size could aid in diagnosing rupture of fetal ovarian cysts.

Minimally invasive management of the prenatally torsed ovarian cyst

BACKGROUND

Fetal and neonatal ovarian cysts are detected frequently by ultrasonography. The presence of these lesions can result in adnexal torsion in utero with autoamputation. Historically, these have been removed at laparotomy.

METHODS

Retrospective chart review was performed at a single children's hospital from October 1996 to September 2001.

RESULTS

Six cases of torsion of ovarian cysts were removed laparoscopically. Five of the 6 patients had prenatal ultrasound diagnosis. The sixth had the cyst detected incidentally by magnetic resonance imaging (MRI) at 3 months of age. All cysts were complex by ultrasound criteria. All 6 procedures were performed via a 2-port laparoscopic approach. The average age at surgery was 3.7 months (range, 9 days to 7.5 months). There were no postoperative complications. Five patients were discharged on the day of surgery.

CONCLUSION

Laparoscopy offers a safe, effective, and cosmetic means of managing perinatal torsion of ovarian cysts.

Ovarian cysts in neonates, children and adolescents

PURPOSE OF REVIEW

This review is intended to increase the understanding of normal ovarian physiology in neonates, prepubescent girls and adolescents and to outline management guidelines for ovarian cysts at each age.

RECENT FINDINGS

Ultrasound has increased the level of understanding regarding the development of ovarian cysts. With ultrasound, ovarian cysts are recognized as a consequence of follicular growth and atresia that can be a normal developmental occurrence at all ages. Clinical experience has taught us that ovarian cysts are common, frequently regress without treatment and are seldom associated with malignancy. New management schemes are developing which rely on increased recognition of torsion and prompt intervention to untwist the adnexa and leave it in situ. In addition, new operative techniques are being developed that are less invasive and morbid, as well as being more conservative of ovarian tissue.

SUMMARY

With the understanding of normal ovarian follicular growth in girls prior to full maturity, the normal development of ovarian cysts can be appreciated. Conservative therapies with observation can often replace surgical management. When treatment is necessary, knowledge of less invasive and morbid techniques can improve ovarian preservation rates.

Bilateral ovarian autoamputation in an infant

A case of bilateral ovarian autoamputation in an asymptomatic infant is presented. Cystic lesions were detected within the abdomen of the fetus during antenatal ultrasound scan (USS). USS performed shortly after birth showed a single lesion thought to be a duplication cyst, but at laparotomy 2 free floating cysts representing the ovaries were discovered. A review of the natural history of neonatal ovarian cysts and the management is given.

Exteriorization-aspiration minilaparotomy for treatment of neonatal ovarian cysts

INTRODUCTION

Recent literature indicates that laparoscopic techniques are considered the most appropriate approach for management of neonatal ovarian cysts (NOC). However, laparoscopic equipment may be unavailable in most centers, has high costs, and demands a long learning curve, especially in newborns.

METHODS

A minilaparotomy with exteriorization-aspiration ("catch and suck") approach was used in 14 female newborns with antenatally diagnosed ovarian cysts. Average operating time was 25 minutes (range 15-45 min.). Postoperative course was uneventful in all cases; no intra- or postoperative complications were recorded. Length of stay was 48 hours in all patients.

CONCLUSIONS

Minilaparotomy with cyst aspiration and subsequent removal may prove a reliable and safe technique in the treatment of NOC: operating time and length of stay are not significantly longer than laparoscopic approach, making this procedure a valid alternative.

The management of fetal ovarian cysts

BACKGROUND/PURPOSE

Ovarian torsion causing the loss of an ovary represents the most common complication of fetal ovarian cysts and occurs more frequently before than after birth. Thus, treatment of fetal simple ovarian cysts should be performed antenatally; however, criteria for prenatal decompression still need to be evaluated. Previous experience of the authors showed that large simple cysts have a poor outcome, whereas preliminary attempts of their "in utero" aspiration were all successful and uneventful. The authors evaluated the outcome of fetal simple ovarian cysts after prenatal aspiration and considered criteria for this procedure. The outcome of cysts showing a prenatal ultrasound pattern of torsion also was studied.

METHODS

This prospective study includes 73 ovarian cysts (48 simple, 25 showing torsion) diagnosed in 72 fetuses from June 1992 to June 1999, and followed up until spontaneous resolution or surgery. Prenatal aspiration was performed in the case of simple cysts >/=5 cm in diameter. The outcome of these cysts was compared with that of similar cysts not aspirated in the authors previous study (X(2). Cysts with an US pattern of torsion persisting at birth were operated on. The outcome of simple cysts less than 5 cm and cysts with a prenatal ultrasound appearance of torsion also was evaluated.

RESULTS

Prenatal decompression was performed without any complications in 14 cases: 12 (86%; 95% CI: 0.68 to 1.00) regressed subsequently; 2 (14%; 95% CI: 0.00 to 0.32) showed torsion postnatally. This outcome is significantly better than that of similar cysts not aspirated in the authors' previous study(10) (P =.0002). Among the 34 simple cysts less than 5 cm, 26 (76%; 95% CI: 0.62 to 0.90) resolved spontaneously; 8 (24%; 95% CI: 0.10 to 0.38) had complications, 7 of which showing torsion (diameter at evidence of torsion, 4.4 cm [median]; range, 3.3 to 5.2 cm). Among the 34 cysts showing torsion (25 with initial US pattern of torsion + 9 subsequently complicated simple cysts), 24 (71%; 95% CI: 0.56 to 0.86) required oophorectomy; 9 (26%; 95% CI: 0.11 to 0.41) spontaneously disappeared at ultrasound, one of which required surgery for intestinal obstruction secondary to adhesion of a necrotic ovary; one patient (3%; 95% CI: 0.00 to 0.09) was lost to follow-up.

CONCLUSIONS

Prenatal aspiration of ovarian cysts appears effective and safe: a "cutoff" of 4 cm should be investigated. Cysts with ultrasound pattern of torsion persisting postnatally require surgery; options for their management, when sonographically disappearing and asymptomatic, need to be investigated.

Adnexal mass evaluation in the emergency department

Female patients who have stable vital signs presenting to the emergency department with abdominopelvic pain and an adnexal mass can be extremely difficult to manage. However, by performing a rapid problem-oriented history and physical with emphasis on the age of patient, menstrual history, and pelvic exam, a detailed differential diagnosis can be compiled. With the addition of a complete blood count and HCG, if appropriate, and a CA-125 for your consultant, additional information can be obtained while a ultrasound examination is being performed. With the above information, consultation and disposition should be readily accomplished.

Minimally invasive laparotomy for treatment of neonatal ovarian cysts

BACKGROUND/PURPOSE

The optimal management of neonatal simple ovarian cysts greater than 4 cm is not known. The authors describe a safe, simple, definitive surgical technique.

METHODS

We report 5 cases of simple ovarian cysts greater than 4 cm treated at the authors' institution between 1998 and 1999. All initial ultrasound findings were consistent with simple ovarian cysts greater than 4 cm. All patients underwent minimally invasive laparotomy. Length of operation ranged between 28 and 49 minutes. There were no intraoperative nor postoperative complications. The operation did not delay discharge. All patients were taking enteral nutrition and required no analgesia by postoperative day 1. No patient had recurrence of the ovarian cysts when screened by ultrasound scan at 4 months of age.

CONCLUSION

Minimally invasive laparotomy provides a safe, definitive treatment for neonatal ovarian cysts greater than 4 cm. J Pediatr Surg 36:868-869.

Surgery for ovarian masses in infants, children, and adolescents: 102 consecutive patients treated in a 15-year period

BACKGROUND/PURPOSE

Ovarian pathology, although rare in children, must be included in the differential diagnosis of all girls who present with abdominal pain, an abdominal mass, or precocious puberty.

METHODS

To improve clinical appreciation of these lesions, the authors reviewed the presentation, evaluation, and outcome of all patients with ovarian pathology surgically treated at their institution since 1985.

RESULTS

One hundred two girls (aged 9.8 +/- 5.5 years; range, 2 days to 20 years) underwent 106 separate ovarian operations (43 salpingo-oophorectomies, 21 oophorectomies, 33 ovarian cystectomies, and 9 ovarian biopsies). Of those presenting with acute abdominal pain (n = 59), 25 (42%) had ovarian torsion (14 associated with a mature teratoma), and only 1 (2%) had a malignant tumor. In contrast, of those presenting with an abdominal mass (n = 23), 6 (26%) had malignancies. There was no age difference between those with benign disease (9.9 +/- 5.6 years; n = 96) and those with malignant tumors (8.6 +/- 3.9 years, n = 10). Nine children had 10 operations for presumed malignant tumors (3 dysgerminomas, 2 immature teratomas with foci of yolk sac tumor, 2 juvenile granulosa cell tumors, 1 yolk sac tumor, and 1 Sertoli-Leydig cell tumor). These patients all had unilateral salpingo-oophorectomy, 4 had chemotherapy, and all are now disease free at 8.4 +/- 4.1 years follow-up.

CONCLUSION

Ovarian pathology remains a rare indication for surgery in girls less than 20 years of age. Because most of these lesions are benign, ovarian-preserving operations should be performed whenever feasible.

Fetal ovarian cysts: a report of three cases managed by intrauterine aspiration

Small follicular or functional theca-lutein cysts are a common finding in fetal and neonatal ovaries. After delivery, decrease of hormonal stimulation may lead to spontaneous resolution of the cyst. A high rate of complication has been underlined by recent studies, the most common being ovarian torsion with subsequent loss of the ovary. Because torsion may happen with any size of cyst, however large or small, we suggest in utero decompression even in small fetal ovarian cysts (< 5 cm). We report here three cases of such cysts managed by intrauterine aspiration with good outcome and no further need for neonatal surgery. In all cases cytology of the cyst aspirate demonstrated numbers of granulosa cells and fluid biochemistry showed a high amount of estradiol, progesterone, and testosterone that confirmed the etiology as ovarian. Despite the small size of the cysts, no technical difficulties were encountered and no maternal or fetal morbidity occurred. Prenatal management of fetal ovarian cysts remains controversial, however, and our limited experience needs to be assessed on a larger number of cases.

Laparoscopic management of neonatal ovarian cysts

A laparoscopic approach was used in four infants with antenatally diagnosed ovarian cysts requiring surgical intervention. Operating time ranged from 60 to 90 minutes, there were no intraoperative or postoperative complications, and all infants were discharged within 23 hours after surgery. If performed by experienced practitioners, microendoscopy is an alternative to laparotomy in neonates requiring surgical intervention for ovarian cysts.

Ovarian masses in the newborn

Prenatal sonography uncovers many fetal ovarian masses that previously would have gone unrecognized. This challenges clinicians to learn the natural history of these asymptomatic lesions so as to provide the best care postnatally. Spontaneous resolution of simple ovarian cysts is expected by about 6 months of age, which is attributed to predicted changes in the postnatal hormonal milieu. After birth, levels of human chorionic gonadotropin (HCG) and estrogen plummet. Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) rise until about 3 months of age and then fall as the "gonadostat" matures. Although symptomatic cysts demand intervention, simple asymptomatic cysts less than 5 cm in diameter should be left alone but reassessed sonographically. If simple cysts are larger than 5 cm in diameter the risk of torsion may be significant, and intervention often is advocated. However, the risk of torsion versus the likelihood of resolution is not well established. The therapeutic goal for a clinician managing a newborn with a simple ovarian cyst is to maximize ovarian salvage. Aspiration alone may be a reasonable option. The laparascopic approach to the neonatal ovarian cyst provides a view of both ovaries and allows aspiration, unroofing, cystectomy, or ovariectomy. The sonographically complex cyst usually represents adnexal torsion but could be a neoplasm and warrants intervention because the morbidity from untreated neonatal adnexal torsion can be significant beyond loss of the ovary (eg, hemorrhage, peritonitis, intestinal obstruction, or a wandering tumor).

"Daughter cyst" sign: a sonographic finding of ovarian cyst in neonates, infants, and young children

OBJECTIVE

The purpose of this study was to assess the value of the "daughter cyst" sign, a sonographic finding of neonatal ovarian cysts, in differentiating ovarian cysts from other cystic masses in neonates, infants, and young children.

SUBJECTS AND METHODS

In a prospective study, 23 neonates, infants, and young children (age range, 1 day to 36 months) with a lower abdominal cystic mass underwent sonography. We defined the daughter cyst sign as the presence of a small cyst along the wall of a cystic mass. The diagnosis of ovarian cyst was made when this sign was present. Detailed pathologic correlation was available in four ovarian cysts. The size, wall thickness, and contents of the cysts were also evaluated.

RESULTS

The 23 cystic lesions included ovarian cyst (n = 11), lymphangioma (n = 3), enteric duplication cyst (n = 3), enteric cyst (n = 1), meconium pseudocyst (n = 2), hydrometrocolpos (n = 2), and urachal cyst (n = 1). The daughter cyst sign was seen in nine (82%) of 11 ovarian cysts but in none of the other cystic lesions. Sensitivity, specificity, and positive predictive value of the daughter cyst sign for differentiating ovarian cysts from other cystic lesions were 82%, 100%, and 100%, respectively. The daughter cyst corresponded to an ovarian follicle on pathologic examination.

CONCLUSION

The daughter cyst sign is a specific sonographic finding for an ovarian cyst and may be useful in differentiating uncomplicated ovarian cysts from other cystic masses in neonates, infants, and young children.

Pediatric germ cell tumors

Malignant germ cell tumors are relatively uncommon, accounting for approximately 3% of all childhood malignancies. Occurring with an incidence of approximately 4 per million among children less than 15 years of age, they account for approximately 225 new cases per year in the United States. Germ cell tumors occur in both gonadal and extragonadal sites, with extragonadal and testicular tumors predominating in children less than 3 years of age and with the gonads being the main location of tumors during and after puberty. They occur more frequently in girls than boys. Germ cell tumors are interesting for several reasons: (1) abnormal migration of primordial germ cells account for many of the childhood germ cell tumors; (2) markers exist to allow evaluation of the extent of resection and the development of recurrence for many of the tumors; and (3) the introduction of platinum-based chemotherapy has markedly improved the survival rate for germ cell tumors, as well as the salvage rate for recurrent or metastatic disease.

Pediatric germ cell tumors

Germ cell tumors are relatively rare tumors in childhood which often present with very large tumors in both gonadal and extragonadal locations. Extragonadal tumors are more common in neonates and infants, whereas gonadal sites predominate in childhood and adolescence. Management consists of surgical resection for localized disease, chemotherapy for residual or metastatic disease, and neoadjuvant chemotherapy and delayed surgical excision for unresectable lesions. The survival for children with germ cell tumors has improved significantly over the past 2 decades with the development of platinum-based chemotherapy. Mature and immature teratomas at any site, and completely resected (Stage I) malignant gonadal and extragonadal tumors, are treated with surgical excision and observation. Malignant lesions with microscopic residual, lymph node disease, or metastatic disease receive platinum-based chemotherapy. Current survival for low-stage (Stages I and II) gonadal sites approaches 100% and survival for higher stage (Stages III and IV) gonadal sites is approximately 95%. Survival for extragonadal lesions is approximately 90% for Stages I and II and 75% for Stages III and IV.

Ovarian surgery in premenarchal girls

STUDY OBJECTIVE

This study was undertaken to assess the indications, procedures, and pathology in premenarchal girls undergoing ovarian surgery.

DESIGN

Retrospective chart review.

SETTING

University of Michigan Medical Center 1980-1996.

PARTICIPANTS

Premenarchal girls, who underwent ovarian surgery.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

All available charts (n = 52) had information extracted concerning age at time of surgery, presenting symptoms, preoperative and postoperative diagnosis, procedure, and pathology report.

RESULTS

Of the 52 patients, 50% were less than 1 year old, 31% were between 1 and 8 years old, and 19% were between 8 and 12 years old. Presenting complaints in 31 patients included structural and or endocrinologic abnormalities, and the other 21 patients presented with abdominal or systemic complaints. The most common preoperative diagnosis was an abdominal/pelvic mass (n = 24). The postoperative diagnoses revealed 18 torsions and 16 ovarian masses without torsion, 8 chromosomal abnormalities, 5 hernias, and 5 malignancies. Procedures included 37 salpingo-oophorectomies (28 unilateral and 9 bilateral), 7 oophorectomies, and 7 cystectomies. One patient underwent a staging procedure. Pathology reports confirmed hemorrhagic infarctions (n = 19), dysgenic gonads (n = 8), simple cysts (n = 7), teratomas (n = 6), theca lutein cysts (n = 4), fibroma (n = 1), stromal tumor (n = 1), mucinous cystadenoma (n = 1), granulosa cell tumor (n = 1), uterine neuroblastoma (n = 1), mixed germ cell neoplasm (n = 1), metastatic Wilms' tumor (n = 1), and gonadoblastoma (n = 1).

CONCLUSIONS

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.

Surgical indications for neonatal ovarian cysts

Ante- or neonatal ovarian cysts can be often diagnosed by routine ultrasonography. Small simple ovarian cysts, which can be followed with serial ultrasonography, usually resolve spontaneously. Large simple cysts and complicated cysts should undergo surgical treatment to reduce the potential for serious complications. Seventeen ovarian cysts were experienced between 1983 and 1997. Sixteen cases underwent surgical treatment at less than 1 month of age according to our protocols. In this report, we reviewed these cases for clinical presentation, ultrasound data, management, intraoperative findings, complications, and outcome. At operation, nine of them showed torsion, and seven of them showed necrotic changes. Only five of them was considered to fall into torsion by preoperative ultrasonography. In five cases whose blood flow could not improve after reduction of torsion, salpingo-oophorectomy was performed. We consider that small simple ovarian cysts under 4 cm in diameter can be observed carefully with serial ultrasonography. But, not only complicated ovarian cysts and simple cysts over 5 cm in diameter, but smaller cysts showing no decrease in size should be considered for surgical indication to rescue the ovarian tissue.

Ovarian cysts in children and adolescents: their occurrence, behavior, and management

STUDY OBJECTIVE

To evaluate the characteristics and symptoms of ovarian cysts, their connection with the methods of treatment, and the effectiveness of the therapy.

METHODS

A retrospective analysis of data on girls with ovarian cysts was performed at a university clinic. Participants included 119 girls in whom 144 ovarian cysts were found by ultrasound examination performed either routinely or for a specific purpose. One group of patients received gestogen to facilitate resolution of the cyst and as treatment of menstrual disorder. Others received clomiphene citrate exclusively as therapy for menstrual irregularity. Aside from this, patients were treated by surgical intervention, or only follow-up sonography was performed. The site, number, size, and type of the cysts were examined. The indications for ultrasonography and the effectiveness of the treatment were analyzed.

RESULTS

The ovarian cysts were mostly unilateral, unilocular, and simple, with the size varying between 3 cm and 5 cm in diameter in 90 cases, more than 5 cm in 41 cases, and less than 3 cm in 13 cases. A number of cysts were found incidentally on ultrasound. Girls were scanned most often because of irregular bleeding (80 cases). Hormonal treatment was given in 105 cases, whereas in 35 cases only follow-up sonography was performed. Cysts resolved spontaneously in 4.5 weeks on average, or in 3 weeks after hormonal treatment. Surgical therapy was necessary for nine patients. The indication for surgery was the detection of complex cysts indicative of dermoid type, size of the cysts, severe pelvic pain, or failure of the cyst to resolve or decrease in size spontaneously or in response to treatment as determined by follow-up sonography. All of the cysts were benign on pathological evaluation.

CONCLUSION

Most ovarian cysts in girls could be managed conservatively, even the larger ones greater than 5 cm in diameter. Only exceptional cases required surgical therapy. Hormonal treatment shortened the duration of the cysts somewhat, but not significantly, and thus was useful mainly in the treatment of concomitant menstrual disorders.

Ovarian cysts in the pediatric population

With the widespread availability and use of pelvic sonography, the rate at which ovarian cysts are detected in the pediatric population has increased, and such cysts are an important problem encountered in pediatric surgical practice. Rational management should take into account key factors such as symptoms, patient age, menarchal status, cysts size, and character, as well as associated medical conditions. The purpose of this review is to discuss the incidence and pathophysiology of ovarian cysts in children. A management strategy is presented based on the above-mentioned key factors.

Fetal ovarian cyst decompression to prevent torsion

BACKGROUND/PURPOSE

Neonates who have ovarian torsion caused by an ovarian cyst often lose their ovary because the torsion and infarction occurred antenatally. Because ultrasound scan has been so effective in diagnosing ovarian cysts in utero, we have a better understanding of their natural history and can select appropriate cases for cyst decompression in utero to prevent torsion. The authors reviewed experience with seven fetuses who had fetal ovarian cyst.

METHODS

During a 26-month period, seven patients were referred for the evaluation of fetal ovarian cyst. The mean gestational age at presentation was 31.9 +/- 3.6 weeks (+/-SD; range, 27 to 37 weeks). There was no history of maternal risk factors such as diabetes mellitus or fetal risk factors such as hyperthyroidism or placentomegally. All seven cases involved isolated unilateral cysts without associated anomalies or chromosomal abnormalities. Mean initial cyst diameter was 3.4 +/- 1.7 cm (+/-SD; range, 1 to 6.1). Indications used for ovarian cyst decompression included anechoic cysts with a diameter > or =4 cm, a cyst "wandering" about the abdomen on serial sonograms, or demonstrating rapid enlargement (>1 cm/wk).

RESULTS

All but one cyst progressed in size during observation. One fetal ovarian cyst (diameter, 2 cm) subsequently regressed spontaneously and another (diameter, 2.1 cm) stabilized during prenatal ultrasound surveillance. One "cyst" observed with a diameter of 3.5 cm proved to be a persistent cloaca. Four fetal ovarian cysts met criteria for decompression. Because of fetal position, decompression could not be performed in one. One cyst (seen before defining criteria for decompression) with a diameter of 5 cm was observed only and underwent torsion. Two cysts (diameters, 6.1 cm and 4 cm) were decompressed in utero under local anesthesia with ultrasound guidance, of 95 mL and 35 mL, respectively. High cyst fluid progesterone (12,041 and 1,990 ng/dL, respectively) and testosterone (1,298 and 2,900 ng/dL, respectively) confirmed the etiology of the cyst as ovarian. Neither cyst recurred, and postnatal ultrasound scan confirmed resolution. There was no maternal or fetal morbidity or mortality and only the patient observed before development of criteria for decompression lost her ovary because of torsion.

CONCLUSIONS

Fetal ovarian cysts tend to present as isolated unilateral lesions in normal fetuses in the third trimester. Spontaneous regression of fetal ovarian cysts may occur. Fetal ovarian cyst decompression, in select cases, may preserve ovaries at risk for torsion.

Neonatal ovarian cysts: pathogenesis, diagnosis and management

This review discusses problems concerning the neonatal ovary. Neonatal ovarian cysts may undergo torsion and amputation. We discuss the pathogenesis, diagnosis, and management of these conditions.

Autoamputation of ovarian cyst in an infant

A right ovarian cyst was detected in a 34-week-gestation fetus on antenatal ultrasound scan (USS). Postnatal USS confirmed the presence of the cyst and showed it to be 4.6 cm in diameter. The cyst failed to resolve after a period of conservative management, and therefore surgical removal was performed. During the operation a free autoamputated right ovarian cysts was found. The complication had not been detected preoperatively in spite of regular USS follow-up.

Ovarian cysts: a clinical dilemma

The rapid development of ultrasound technology and its routine application during gynecological examinations has led to the more frequent detection of ovarian cysts. Such cysts can be diagnosed at any age or stage of a woman's life, and detected as early as the fetal stage or as late as the postmenopause. Ovarian cysts in female fetuses are usually detected during screening in pregnancy and followed after delivery as neonates. A few months are usually sufficient for spontaneous regression, although symptomatic cysts should be promptly operated. In fertile women, most cases present benign functional cysts which disappear after menstruation or can be managed easily with the combined oral contraceptive pill. When pregnancy is complicated with an adnexal mass, the second trimester is the preferable time of action in cases when operation is demanded. Transvaginal sonography plays an important role, not only in the detection of ovarian cysts but also in the diagnosis of malignancy. Large cysts, multiloculi, septa, papillae and increased blood flow are all suspected signs of neoplasia. The incidence of ovarian cancer increases with age and is predominantly a disease of peri- and postmenopausal women with an average patient age of 50-59 years. Vaginal sonography has been established as the examination of choice in screening and follow-up of patients, with complementary color Doppler studies and determination of serial serum levels of CA-125. If a malignant cyst is suspected, at any age, explorative laparotomy should be performed promptly. Sonographic or computerized tomographic scanner aspiration procedures, as well as laparoscopic surgery, should be reserved for diagnostic or therapeutic purposes in low-risk cancer patients.(ABSTRACT TRUNCATED AT 250 WORDS)