Fetal ovarian cysts: prenatal diagnosis, management and postnatal outcome

Surgical management of ovarian masses in children and adolescents: experience of an academic institution in France

PURPOSE

Surgical management of ovarian masses in girls still challenging. The aim of the study is to report an 8-year experience in managing children with ovarian masses, and to demonstrate the advantages and the limitations of laparoscopy for such lesions.

METHODS

Data of girls aged less than 18 years operated because of an ovarian mass between January 2015 and February 2023 were retrospectively reviewed. Patients were divided into two groups: group A including children operated by laparoscopy, and Group B of patients who underwent open surgery.

RESULTS

Eighty-eight children were enrolled. Laparoscopy was performed in 56 patients (63.6%). Group A patients had smaller tumor size (53.6±38.5 vs. 122.2±75.4 mm, P<0.0001), shorter operative time (50.4±20.3 vs. 71.5±36.5 min, P = 0.004), reduced length of hospital stay (1.4±1.1 vs. 3±2.3 days, P<0.0001), and absence of postoperative complications. Only 3 cases (5.7%) of recurrence were seen exclusively within patients followed for benign tumors during a mean follow-up period of 4.6±3 years.

CONCLUSION

Laparoscopy should be done in benign ovarian lesions or/and if a torsion is seen. For tumors at high risk of malignancy, laparoscopy can be performed to establish a clear macroscopic diagnosis, for staging of the disease, and resection of small tumors. Conversion to open surgery is indicated in case of doubt.

Alpha-fetoprotein level in fetuses, infants, and children with ovarian masses: a literature review

Alpha-fetoprotein (AFP) is a serum protein highly produced during the fetal period. It is also known as a biomarker of various pathologies. Commonly, tumors requiring diagnosis and monitoring through AFP determination appear during the first year of life, with poorer outcomes when presenting in fetal life. Due to advancements in imaging technology, the detectability of ovarian masses in infants is higher. However, the use of AFP as a biomarker could improve diagnosis in cases when imaging and histological examinations are not sensitive enough to detect tumors. From the outcome of our investigation, it is possible to conclude that there is evidence of an association between increased AFP levels and ovarian masses. However, previous studies have presented contradictory and unverified results, with the authors emphasizing that future research is needed. In this article, an analysis of the available literature on AFP as a biomarker of ovarian masses in children was performed. Two types of literature were reviewed: guidance and published studies (clinical trials, reviews, and systematic reviews). We searched the Embase, PubMed, ScienceDirect, and Web of Science databases to collect essential data.

Managing Fetal Ovarian Cysts: Clinical Experience with a Rare Disorder

Background and Objectives: Fetal ovarian cysts (FOCs) are a very rare pathology that can be associated with maternal-fetal and neonatal complications. The aim of this study was to assess the influence of ultrasound characteristics on FOC evolution and therapeutic management. Materials and Methods: We included cases admitted to our perinatal tertiary center between August 2016 and December 2022 with a prenatal or postnatal ultrasound evaluation indicative of FOC. We retrospectively analyzed the pre- and postnatal medical records, sonographic findings, operation protocols, and pathology reports. Results: This study investigated 20 cases of FOCs, of which 17 (85%) were diagnosed prenatally and 3 (15%) postnatally. The mean size of prenatally diagnosed ovarian cysts was 34.64 ± 12.53 mm for simple ovarian cysts and 55.16 ± 21.01 mm for complex ovarian cysts (p = 0.01). The simple FOCs ≤ 4 cm underwent resorption (n = 7, 70%) or size reduction (n = 3, 30%) without complications. Only 1 simple FOC greater than 4 cm reduced its size during follow-up, while 2 cases (66.6%) were complicated with ovarian torsion. Complex ovarian cysts diagnosed prenatally underwent resorption in only 1 case (25%), reduced in size in 1 case (25%), and were complicated with ovarian torsion in 2 cases (50%). Moreover, 2 simple (66.6%) and 1 complex (33.3%) fetal ovarian cysts were postnatally diagnosed. All of these simple ovarian cysts had a maximum diameter of ≤4 cm, and all of them underwent size reduction. The complex ovarian cyst of 4 cm underwent resorption during follow-up. Conclusions: Symptomatic neonatal ovarian cysts, as well as those that grow in size during sonographic follow-up, are in danger of ovarian torsion and should be operated on. Complex cysts and large cysts (with >4 cm diameter) could be followed up unless they become symptomatic or increase in dimensions during serial ultrasounds.

Review of a 25-Year Experience in the Management of Ovarian Masses in Neonates, Children and Adolescents: From Laparoscopy to Robotics and Indocyanine Green Fluorescence Technology

Background: Ovarian masses in pediatric populations are the most common abdominal masses in young girls. In neonates, the majority of masses are benign while in children and teen-agers the risk of malignancy exists. The aim of this study is to perform a 25-year experience retrospective analysis of clinical and therapeutic aspects of ovarian tumors in girls, in order to show how the development of minimally invasive technology has changed the management of this pathology. Methods: The records of patients under the age of 18 who were operated in three pediatric surgical units due to ovarian mass, in the last 25 years, were reviewed retrospectively. The study group comprised 147 patients operated between 1996 and 2021 with a diagnosis of ovarian masses. Data involved were demographical, surgical, follow-up and final diagnosis. We analyzed the type of surgical technique, intra-operative data (operative time, the use of different technologies), complications, length of stay and long-term follow-up. Based on these data, we assessed how the surgical approach to ovarian masses has changed in the last 25 years in newborns and young girls. Results: The patients ages ranged between 7 days and 15 years (median, 59 days). All the procedures were completed in laparoscopy or robotics without conversion in open surgery. One-hundred and eleven patients were neonates; they all had follicular cysts and they were all managed in laparoscopy using 1 or 3 trocars. In 80/111 patients (72%), a small part of ovarian parenchyma was saved; in 31/111 patients (28%), in which the ovarian parenchyma was not available, an ovariectomy was performed. Patients in which we saved a small part of ovary, at long term follow-up (minimum follow-up of 12 years) (29/80, 36%), developed a normal ovary at US control. Thirty-six were older patients. They had a histological diagnosis of benign (30) or malign (6) tumors. All the patients (8/36) with a pre-operative suspicion of ovarian malignancy received an ovariectomy and an adnexectomy using sealing devices. In the last 10 years in all the children, except neonates, we adopted sealing devices and, in the last 4 years, in 20 cases, we always adopted ICG fluorescence technology to check ovarian vascularization in case of torsion or to check lympho-nodes condition in case of malignancy. Conclusions: In neonatal ovarian cysts, surgical management remained unchanged and an ovarian sparing procedure is always indicated and the long-term follow-ups confirm this hypothesis. The principal innovation in this age period is the use of ICG fluorescence technology to check ovarian vascularization in case of torsion. In teenagers, the decision-making strategy is based on the tumoral markers and on the morphological aspects of the mass. Robotics cystectomy or ovariectomy now-days represents the safer and faster way to perform this. Sealing devices are essential tools for dissection and resection to avoid bleeding. ICG fluorescence technology in all ages is fundamental to check ovary vascularization after detorsion or to check lympho-node status in case of malignancy. All the suspected lesions have to be removed with an endo-bag.

The Role of Surgery in Antenatal Ovarian Torsion: Retrospective Evaluation of 28 Cases and Review of the Literature

STUDY OBJECTIVE

Antenatal ovarian torsion (AOT) is rare and requires differentiating from other congenital cystic masses of the abdomen and pelvis in neonates. In this study, it was aimed to evaluate the prenatal characteristics and postnatal outcomes of AOT. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Hospital records of patients (n = 28) with diagnosis of AOT between 2004 and 2020 were reviewed and their prenatal characteristics, postnatal examination, imaging, operative, and histopathological findings were evaluated.

RESULTS

There were 28 patients during the study period. In most of the patients (25/28; 89.3%) AOTs were detected prenatally. All were term babies with a mean birth weight of 3010 ± 466.6 g. Mean maternal age was 25.75 ± 3.65 years. Prenatal history was event-free in all and none had additional anomalies. Physical examination revealed mobile intra-abdominal cystic lesions in 16 (57.1%) patients. AOTs mimicked other pathologies as intestinal duplication cyst or mesenteric cyst (n = 7), complex ovarian cyst (n = 3), mature cystic teratoma (n = 3), simple renal cyst (n = 1), and ectopic kidney (n = 1) in 15 (53.6%) patients in postnatal ultrasonography. Elective laparoscopic surgery was performed in 26 (92.8%) patients. The other 2 patients required emergency open surgery because of acute symptoms. Ovaries were autoamputated in 17 (60.7%) patients. Histopathological examination revealed necrosis and dystrophic calcification in all specimens. There was neoplastic involvement in 2 patients (serous cystadenoma and gonadoblastoma). No complication occurred in the early follow-up period (mean: 73.9 ± 46.8 months).

CONCLUSION

AOTs can be detected easily during the antenatal period. Neoplastic involvement with AOTs is rare but possible. Although AOTs might mimic other cystic pathologies, it should be one of the first diagnoses to be considered, in the presence of a palpable intra-abdominal mass and complex cystic lesion in infant girls. It can be efficiently and safely managed using minimally invasive techniques.

Fetal Ovarian Cysts: Prenatal Diagnosis Using Ultrasound and MRI, Management and Postnatal Outcome—Our Centers Experience

The present study provides our clinical experience regarding the imaging diagnosis, management and postnatal outcome of neonates prenatally suspected of having developed ovarian cysts. This multicenter observational study included patients diagnosed prenatally with fetal ovarian cysts and follow-up in the postnatal period. Descriptive statistics were used to render the information regarding the prenatal imaging aspect of the fetal pelvic masses using ultrasound and/or MRI, prenatal surveillance and postnatal neonate’s immediate outcome, indications leading to surgery and pathologic aspect. The inclusion criteria were fulfilled by 21 patients. The mean gestational age at the time of initial diagnosis was 31.28 weeks of gestation (WG). Only five out of 21 cysts regressed completely during pregnancy without postnatal complications. In addition, 11 out of 21 infant’s required surgical treatment in the first two weeks after birth, mainly for ovarian torsion. Five out of 21 neonates were referred to postnatal follow-up clinically and by ultrasound, but three out of five cases required emergency surgical treatment for acute complications. Ultrasound plays a major role in the diagnostic of fetal ovarian cyst. From our experience, MRI does not bring supplementary data or change the management. Spontaneous resolution of fetal ovarian cysts is to be expected but the ovarian mass could lead to serious complications, if resolution does not occur in due time.

Diagnosis, Management, and Therapy of Fetal Ovarian Cysts Detected by Prenatal Ultrasonography: A Report of 36 Cases and Literature Review

BACKGROUND

Fetal ovarian cysts are the most frequently diagnosed intra-abdominal cysts; however, the evidence for perinatal management remains controversial.

METHODS

We retrospectively reviewed cases of fetal ovarian cysts diagnosed by prenatal ultrasonography at our institution between January 2010 and January 2020. The following were investigated: gestational age at diagnosis, cyst size, appearance, prenatal ultrasound findings, and postnatal outcomes. Prior to 2018, expectant management was applied in all cases; after 2018, in utero aspiration (IUA) of simple cysts ≥40 mm was performed.

RESULTS

We diagnosed 29 and seven simple and complex cysts, respectively. Fourteen patients had simple cysts with a maximum diameter <40 mm, and two of them progressed to complex cysts during follow-up; however, when the diameter was limited to <35 mm, no cases showed progression to complex cyst. Fifteen of the simple cysts were ≥40 mm; three progressed to complex cysts, and two of them were confirmed to be ovarian necrosis. In four patients who underwent IUA, the ovaries could be preserved.

CONCLUSIONS

IUA is a promising therapy for preserving ovaries with simple cysts ≥40 mm in diameter; however, the indications for fetal surgery and the appropriate timing of intervention require further study.

Natural history of fetal ovarian cysts in the prenatal and postnatal periods

PURPOSE

To determine the natural history of fetal ovarian cysts and to investigate whether the prognosis can be predicted by prenatal ultrasonography (US).

METHODS

This retrospective study includes cases of fetal ovarian cysts diagnosed by prenatal US over a 6-year period. Cases were divided into four subgroups of cysts (small and simple, small and complex, large and simple, large and complex) according to their size and echotexture. US examinations were repeated every 2 weeks from the time of diagnosis to treatment.

RESULTS

A total of 37 cases were included in the study. 32.4% of the cases regressed spontaneously in the prenatal period and 32.4% did so in the infantile period. Prenatal resolution occurred more frequently with small cysts than with large cysts (p = 0.03). Neonates with complex cysts required surgical treatment more often than neonates with simple cysts (p = 0.009). 27.0% of the cases underwent surgery due to ovarian torsion. The torsion rate of fetal ovarian cysts that progressed in the prenatal period was significantly higher than in the case of stable cysts (p = 0.001).

CONCLUSION

The size of the fetal ovarian cysts, their US appearance and the progression of the cysts during follow-up are the main determinants of the neonatal outcome.

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

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.

Fetal abdominal tumors and cysts

This article reviews the contemporary diagnosis and management of the most common abdominal neoplasms and cystic lesions diagnosed in the fetus. Fetal tumors discussed include teratomas (sacrococcygeal, cervical or mediastinal), mesoblastic nephroma, nephroblastoma (Wilms' tumor), neuroblastoma, and hepatoblastoma. Fetal abdominal cystic lesions discussed include ovarian cyst, choledochal cyst, intestinal duplication cyst, mesenteric cyst, simple hepatic cyst, and meconium pseudocyst. We discuss the rare indications for fetal intervention or fetal surgery and other perinatal management, including prenatal interventions and fetal surgery for sacrococcygeal teratoma. The lesions reviewed are detected by widespread use of screening ultrasonography during pregnancy. Work-up for these abnormalities may include fetal MRI which enhances the diagnostic accuracy of abdominal tumors and cystic lesions and can aid in characterization of the lesion in relationship to surrounding anatomic structures. Accurate prenatal diagnosis of such lesions permits recommendations for optimal location and timing of delivery, and inclusion of appropriate caregivers and expertise to facilitate postnatal management. Perinatal management of the fetus with a neoplasm requires consideration of the optimal timing and mode of delivery, and pediatric oncology and surgical specialty care. The majority of tumors diagnosed antenatally have good prognosis with current multimodality treatment.

Guidelines of the Italian Society of Videosurgery in Infancy (SIVI) for the minimally invasive treatment of fetal and neonatal ovarian cysts

In the last three decades, fetal ovarian cysts were diagnosed more frequently, due to technological improvement and the increasing use of prenatal screening ultrasound. Nonetheless, treatment uncertainties are still present, either prenatally or postnatally. Recently, significant innovations on diagnosis and treatment have been proposed and a more conservative, minimally invasive approach may be offered to the Pediatrician or the Surgeon who face with this condition during prenatal or neonatal age. (...).

Prenatal evaluation and postnatal outcomes of fetal ovarian cysts

To evaluate the natural history and outcome of cases of fetal ovarian cyst under conservative prenatal treatment. A retrospective cohort study included patients diagnosed with fetal ovarian cysts was conducted between January 2008 to December 2016. Data including clinical data, sonographic feature and postnatal outcomes were obtained. One hundred and two cases were included for statistical analysis. The rate of spontaneous resolution was significantly higher among cases with simple than complex cysts (70/92 or 76.1% vs 2/10 or 20%, P < .01) and for cysts <4 cm than cysts ≥4 cm (50/56 or 89.3% vs 22/46 or 47.8%, P < .01). Ovarian torsion was confirmed in 5/102 (4.9%) cases; neither prenatal characteristics of cysts (complex: 2/10 or 20% vs simple: 3/92 or 3.3%, P = .07), nor their size (≥40 mm: 4/46 or 8.7% vs < 40 mm: 1/56 or 1.8%, P = .17) was predictive for ovarian torsion. 25/102 (24.5%) of cysts change in size or sonographic characteristics prenatally. Half of the complex cysts at the last prenatal scan are not ovarian in origin. 98/102 neonates (96.1%) were able to preserve both ovaries. Spontaneous resolution of ovarian cysts is predicted by cyst size and characteristics, whereas likelihood of torsion cannot be predicted.

Huge fetal ovarian cyst

Most fetal ovarian cysts increase in size during the late stages of pregnancy. Early treatment of a huge neonatal cyst may reduce the risk of gastrointestinal obstruction.

Prenatal Diagnosis of a Cyst of the Canal of Nuck Associated With an Ovarian Cyst and Acute Polyhydramnios

In the female, the canal of Nuck is a tubular fold of parietal peritoneum that travels along with the round ligament through the inguinal canal to its attachment on the labia majora. The canal of Nuck is analogous to the processus vaginalis in the male. In embryonic development, this pathway typically obliterates early in life; however, in some cases, it may partially or completely fail to close. This failure to obliterate can lead to complications ranging from a cyst of the canal of Nuck (also known as a female hydrocele) to herniation and incarceration of abdominal and pelvic organs. There is little information available in the medical literature concerning this rare condition; therefore, it is important for sonographers, physicians, and surgeons to be familiar with this developmental abnormality. This report represents the first prenatal case of a cyst of the canal of Nuck, along with the unique combination of a large left fetal ovarian cyst and acute polyhydramnios. The embryology, incidence, differential diagnosis, management, and treatment of these female conditions are discussed.

Differences in Origin and Outcome of Intra-Abdominal Cysts in Male and Female Fetuses

OBJECTIVE

To investigate the origin and outcome in a cohort of male and female fetuses with intra-abdominal cysts, in order to provide recommendations on management and to improve prenatal counselling.

METHODS

From 2002 to 2016, intra-abdominal cysts were detected by ultrasound in 158 fetuses. Cases with an umbilical vein varix were excluded. Fetal, neonatal, and maternal characteristics were retrieved from electronic patient files.

RESULTS

In female fetuses (n = 114), intra-abdominal cysts were diagnosed at a later gestational age compared with male fetuses (n = 44) (median 32.0 vs. 21.5 weeks, p < 0.001). The maximum prenatal cyst diameter was larger in female fetuses (median 35 vs. 17 mm, p < 0.001). Associated anomalies were less frequent in females (n = 15, 13.2%) compared with males (n = 15, 34.1%). In females (n = 114), most cysts were of ovarian origin (n = 81, 71.1%). Surgery was performed in 30 (26.3%) female and 15 (34.1%) male neonates (p = 0.33). Anorectal malformations were present in 6 cases and often not recognized prenatally.

CONCLUSIONS

The differences in the origin of intra-abdominal cysts between male and female fetuses, resulting in differences in prenatal presentation and postnatal outcome should be taken into account in prenatal counseling within a multidisciplinary team. Evaluation of the fetal perianal muscular complex is indicated.

Case 246: MR Imaging of a Complex Cystic Mass in a Newborn Girl

History A 6-day-old female neonate presented to the outpatient pediatric surgery clinic for evaluation of a possible prenatal abdominal mass. The neonate was delivered at term via cesarean section due to macrosomia, with a reported birth weight of 11 lb 8.7 oz (5.23 kg). The patient's postnatal course was remarkable for resolving neonatal hyperbilirubinemia. A physical examination was remarkable for a palpable mass in the abdomen. Maternal risk factors included class II obesity, type 2 diabetes, and metabolic syndrome. Prenatal images obtained at an outside institution were not available at this time. Ultrasonography (US) of the abdomen and pelvis was performed 6 days after birth. Follow-up US at 29 days of life revealed no substantial change in the appearance of the findings. This patient remained asymptomatic, and gadolinium-enhanced (Magnevist; Bayer Pharma, Berlin, Germany) magnetic resonance (MR) imaging of the abdomen and pelvis was performed at 84 days of life. The mass was excised surgically at 89 days of life, and the patient had an uncomplicated postoperative course.

Outcome of fetal ovarian cysts diagnosed on prenatal ultrasound examination: systematic review and meta-analysis

OBJECTIVE

To explore the outcome of fetuses with a prenatal diagnosis of ovarian cyst.

METHODS

The electronic databases MEDLINE and EMBASE were searched using keywords and word variants for 'ovarian cysts', 'ultrasound' and 'outcome'. The following outcomes in fetuses with a prenatal diagnosis of ovarian cyst were explored: resolution of the cyst, change of ultrasound pattern of the cyst, occurrence of ovarian torsion and intracystic hemorrhage, need for postnatal surgery, need for oophorectomy, accuracy of prenatal ultrasound examination in correctly identifying ovarian cyst, type of ovarian cyst at histopathological analysis and intrauterine treatment. Meta-analyses using individual data random-effects logistic regression and meta-analyses of proportions were performed. Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale.

RESULTS

Thirty-four studies (954 fetuses) were included. In 53.8% (95% CI, 46.0-61.5%) of cases for which resolution of the cyst was evaluated (784 fetuses), the cyst regressed either during pregnancy or after birth. The likelihood of resolution was significantly lower in complex vs simple cysts (odds ratio (OR), 0.15 (95% CI, 0.10-0.23)) and in cysts measuring ≥ 40 mm vs < 40 mm (OR, 0.03 (95% CI, 0.01-0.06)). Change in ultrasound pattern of the cyst was associated with an increased risk of ovarian loss (surgical removal or autoamputation) (pooled proportion, 57.7% (95% CI, 42.9-71.8%)). The risk of ovarian torsion was significantly higher for cysts measuring ≥ 40 mm compared with < 40 mm (OR, 30.8 (95% CI, 8.6-110.0)). The likelihood of having postnatal surgery was higher in patients with cysts ≥ 40 mm compared with < 40 mm (OR, 64.4 (95% CI, 23.6-175.0)) and in complex compared with simple cysts, irrespective of cyst size (OR, 14.6 (95% CI, 8.5-24.8)). In cases undergoing prenatal aspiration of the cyst, rate of recurrence was 37.9% (95% CI, 14.8-64.3%), ovarian torsion and intracystic hemorrhage were diagnosed after birth in 10.8% (95% CI, 4.4-19.7%) and 12.8% (95% CI, 3.8-26.0%), respectively, and 21.8% (95% CI, 0.9-40.0%) had surgery after birth.

CONCLUSION

Size and ultrasound appearance are the major determinants of perinatal outcome in fetuses with ovarian cysts. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Outcome of fetal gastro-intestinal cysts: a systematic review and meta-analysis

OBJECTIVES

To explore the outcome of fetal gastrointestinal (GI) cysts and to ascertain the detection rate of prenatal ultrasound in identifying these anomalies.

METHODS

Medline and Embase databases were searched. The outcomes explored were: resolution of the cyst, additional GI anomalies detected only at birth, clinical symptoms, need for surgery, post-surgical complications and diagnostic accuracy. Meta-analyses of proportions and hierarchical summary receiver operating characteristics (HSROC) model were used to analyse the data.

RESULTS

Ten studies were included; 27.0% (95% CI 2.6-64.4) of the cysts resolved either pre or post-natally. Additional GI anomalies were detected in 6.0% (95% CI 1.1-14.7). Clinical symptoms occurred in 31.1% (95% CI 14.9-50.2), while 50.6% (95% CI 10.0-90.8) had surgery. Post-surgical complications occurred in 6.1% (95% CI 0.2-19.6). Overall detection rate of prenatal ultrasound in correctly identifying GI cysts was good (sensitivity: 94.5%, 95% CI: 39.1-99.8; specificity: 97.7%, 95% CI 89.9-99.5).

CONCLUSION

GI cysts are usually benign. Clinical symptoms occur in approximately one third of children. About one third of the cysts resolves, while the rate of complications after surgery is low. Prenatal ultrasound has an overall good diagnostic accuracy in identifying these anomalies. © 2016 John Wiley & Sons, Ltd.

Management of fetal teratomas

Fetal teratomas are the most common tumors diagnosed prenatally. The majority of these tumors are benign and cured by complete resection of the mass during the neonatal period. Prenatal diagnosis has improved the perinatal management of these lesions and especially for the teratomas that might benefit from fetal intervention. A comprehensive prenatal evaluation including conventional ultrasounds, Doppler, echocardiography and fetal MRI, is essential for an effective counseling and perinatal management. Antenatal counseling helps the parents to better understand the natural history, fetal intervention, and perinatal management of these tumors, which differ dramatically depending on their size and location. Fetal surgical debulking improves survival in cases of sacrococcygeal teratoma with cardiac decompensation. Additionally, the use of an EXIT procedure reduces the morbidity and mortality if a complicated delivery in cases of cervical and mediastinal teratomas. Here, we offer an overview of all fetal teratomas and their recommended management, with emphasis on in utero treatment options.

Prenatal diagnosis of cloacal malformation

Persistent cloaca malformation is the most severe type of anorectal and urogenital malformation. Decisions concerning the surgical treatment for this condition are taken during the first hours of life and may determine the quality of life of these patients. Thus, prenatal diagnosis becomes important for a prompt and efficient management of the fetus and newborn, and accurate counseling of the parents regarding its consequences and the future of the baby. Careful evaluation by ultrasonography, and further in-depth analysis with MRI, allow prenatal detection of characteristic findings, which can lead to diagnose or at least suspect this condition. We reviewed our experience and the literature in order to highlight the most important clues that can guide the physician in the differential diagnosis.

Ovarian Cyst Aspiration in the Neonate: Minimally Invasive Surgery

STUDY OBJECTIVE

To review our experience with laparoscopic aspirations and minimally invasive surgeries for neonatal ovarian cysts and report the outcome of their follow-up.

DESIGN

Twenty-one neonates diagnosed as having ovarian cysts were retrospectively reviewed at our hospital from 2006 through 2013.

RESULTS

Of 21 neonates, 8 showed simple cysts and 13 showed complex cysts in their ultrasound scan. Laparoscopic aspiration was performed for all neonates with simple cysts. Torsion was found in 7 of 13 neonates with complex cysts. Three neonates underwent detorsion, while 2 neonates underwent oophorectomy. Two neonates already showed autoligation, showing a cystic mass, which was removed. The remaining 6 neonates with a complex cyst underwent only aspiration because no torsion was found. Of 14 neonates who underwent only aspiration, 11 showed no cyst, while 3 neonates, having a cyst with a size of less than 2 cm, underwent follow-up. Of 3 neonates who underwent detorsion, 1 showed an ovary without cyst, while 2 showed neither cyst nor ovary.

CONCLUSION

Laparoscopically, neonatal ovarian cysts may be diagnosed and aspirated simultaneously, simply, and safely.

Management of fetal ovarian cyst using in utero aspiration

Objective: To study the clinical outcome of fetal ovarian cysts managed with in utero aspiration.

Methods: All cases of fetal ovarian cysts diagnosed from 2002 to 2013 were reviewed. In utero aspiration was performed for patients with simple cysts larger than 4 cm before term gestation.

Results: There were 21 cases of fetal ovarian cysts. Four patients (19%) were diagnosed with complex cysts at the time of referral. Among the 17 cases of simple cysts, in utero aspiration was performed in seven patients. There were no complications after the therapy and none of them developed complex cysts. An ovarian cyst was confirmed by cyst fluid that contained high levels of estradiol, progesterone and testosterone. For two patients with simple cysts who met the indications for in utero aspiration but did not receive therapy, one developed a complex cyst. Among the eight patients with simple cysts who did not fulfill the indications for aspiration, seven of them had cysts that regressed spontaneously, and one developed complex cysts during pregnancy.

Conclusion: Torsion of fetal ovarian cysts was common with expectant management. Management of fetal ovarian cysts larger than 4 cm using in utero aspiration may avoid torsion, which could otherwise lead to ovarian loss.

Ovary and testicle and everything in between: lesions and imaging in the newborn

Assessment of the neonatal reproductive tract requires an understanding of embryology, awareness of common clinical presentations, and familiarity with normal newborn variation. This review of the neonatal reproductive tract emphasizes the use of sonography in the evaluation of developmental, acquired, and neoplastic conditions in male and female newborns. Anchored in embryologic origins, the discussion also includes descriptions of findings that may be encountered in prenatal imaging. Comments on clinical correlation are included to guide appropriate triaging of these complex cases. Imaging pearls and pitfalls are incorporated into this review, including the recognized effects of maternal hormones in female infants.

The clinical relevance of fetal MRI in the diagnosis of Type IV cystic sacrococcygeal teratoma--a review

The introduction of fetal magnetic resonance imaging (MRI) has improved the prenatal evaluation of uterine, placental and fetal anatomy. However, its utilization has mostly been restricted to fetal central nervous system anomalies. We review how adjunct fetal MRI was performed and diagnosis of cystic type IV sacrococcygeal teratoma was made. We also discuss the clinical relevance of fetal MRI in differentiating this lesion from other selected abdominal/pelvic cystic malformations and lesions.

Fetal ovarian cyst mimicking a CSF pseudocyst in the setting of shunt failure

Fetal ovarian cysts are common congenital lesions encountered in the neonatal population. These cysts are typically benign and rarely require any invasive intervention. Abdominal pseudocyst formation as a result of a ventriculoperitoneal shunt is a relatively infrequent occurrence and is similarly an uncommon cause of shunt failure. The authors present the case of a 4-month-old girl with shunted hydrocephalus who presented with shunt failure from a suspected abdominal pseudocyst that was found to be a fetal ovarian cyst.

Fetal ovarian cyst: 2- and 3-dimensional ultrasound as a new diagnostic method to rule out ovarian torsion

Owing to the improvement in obstetric ultrasound imaging, prenatal diagnosis of ovarian masses has increased considerably. Fetal ovarian cysts can be suspected when an ultrasound scan shows intra-abdominal structures in female fetuses in the presence of normal bowel and urinary structures. The most common complication is the adnexal torsion, causing partial or complete strangulation of blood supply via ovarian vessels, leading ovarian ischemia, or necrosis. Current information regarding the treatment of fetal ovarian cysts is based on personal experiences and some case series. The management is controversial, characterized by dissimilar approaches, such as “wait and see”, prenatal or postnatal aspiration, or neonatal surgery. In more than half of the cases, spontaneous regression occurs in the prenatal or postnatal period, probably due to the small size and simple aspect. Large cysts may cause both local effects (adnexal torsion, ovarian autoamputation), and distant effects (intestinal and urinary obstruction, adhesion with adjacent organs, abdominal and thoracic mass effect, pulmonary hypoplasia, hemoperitoneum, ascites, polyhyramniosis). In the absence of accurate guidelines for management, we must start with the development of more accurate methods for diagnosing associated complications such as torsion. This case report describes the role of three-dimensional (3-D) ultrasonography as potential diagnostic method for ruling out adnexal torsion when an ovarian cyst is present.

Postnatal Outcome in Cases of Prenatally Diagnosed Fetal Ovarian Cysts under Conservative Prenatal Management

Aim: To evaluate the outcome of cases of prenatally diagnosed fetal ovarian cyst under conservative prenatal management. Methods: This retrospective cohort study included patients diagnosed between January 2005 and August 2013. They were managed expectantly during pregnancy and followed up until spontaneous regression of the cyst or postnatal surgery. The outcomes of fetal ovarian cysts were compared combined appearance as being simple or complex at prenatal scan and maximum size of cysts ≥40 or <40 mm. Results: There were 33 study cases. Prenatally 3/33 cases (9%) had spontaneous cyst regression during pregnancy. 14 cysts (42%) were treated surgically, of which torsion was confirmed in 4 (29%). Another 14/33 cases (42%) regressed spontaneously under conservative management after birth. The ovaries could be preserved in 28 patients (85%). The incidence of torsion between complex cysts and simple cysts was not statistically different. The incidence of torsion between patients with cyst size ≥40 and <40 mm was similar. Conclusions: The ovaries could be preserved in approximately 85% of patients under conservative management. The present study could not reveal the significance of prenatal ultrasonographic findings of fetal ovarian cyst for predicting the outcome of patients' ovaries.

Management of neonatal ovarian cysts and its effect on ovarian preservation

BACKGROUND/PURPOSE

Management of asymptomatic neonatal ovarian cysts varies. Some surgeons advocate initial observation, while others recommend immediate operation depending on cyst size and complexity. This study aims to compare outcomes of initial observation versus primary surgery, focusing on incidence of postnatal torsion and ovarian preservation.

METHODS

A retrospective study (1997-2012) of neonates with an ovarian mass was performed. Data on cyst size, ultrasound characteristics, clinical course, complications, and pathology were extracted.

RESULTS

Thirty-seven neonates with asymptomatic ovarian cysts were identified (N=25 observed, N=12 primary surgery). Overall, 12/25 (48%) observed had successful cyst regression, including 3/8 (38%) cysts ≥50mm and 6/15 (40%) complex. 13/25 patients (52%) underwent surgery for failure of cyst regression (11/13) or concern for interval torsion (2/13). Postnatal torsion occurred in 1/25 observation patients (4%), or 1/8 (13%) with cysts≥50mm. Overall rate of ovarian preservation between groups was not statistically different [6/8 (75%) observed versus 8/9 (89%) primary surgery; P=0.577]. Pathology found viable ovarian tissue in all oophorectomy specimens (N=3).

CONCLUSIONS

Postnatal torsion is rare. A period of observation spares half of neonates from an operation, without decreasing ovarian salvage. Initial management should consist of observation, regardless of size or complex characteristics. If operative intervention is necessary, ovary preserving techniques should be utilized.

Prenatal diagnosis and management of a massive fetal ovarian hemorrhagic cyst torsion with secondary fetal anemia

We report the case of one of the largest prenatally detected fetal hemorrhagic cyst with ovarian torsion and fetal anemia leading to subsequent cesarean section delivery and further unilateral oophorectomy of the neonate. Usually, fetal ovarian cysts tend to resolve spontaneously within the first months after birth. There is no need of surgical treatment for such simple cysts. Routine sonographic examinations are obligatory, because in some cases complications such as massive hemorrhage, cyst rupture, or ovarian torsion with following infarction can occur. With the occurrence of these complex cyst signs by sonographic investigation, subsequent intervention should be considered by an interdisciplinary team.

Prenatal diagnosis of fetal ovarian cyst: case report and review of the literature

Foetal ovarian cysts are the most frequently encountered intra-abdominal cystic masses diagnosed prenatally. The aetiology of foetal ovarian cysts is still unknown, but hormonal stimulation is generally considered to be responsible for the disease. The diagnosis is made by the exclusion of other cystic lesions confined to the foetal abdomen. In this article we report antenatally-detected foetal ovarian cyst with a review of the available literature. Antenatal ultrasonography (USG) revealed an abdominal cystic mass 41×33 mm in diameter in a 33-week gestation female foetus. The normal anatomy of other foetal abdominal organs suggested that an ovarian cyst was the most likely diagnosis. In the antenatal follow-up period, the cyst diameter increased with time. After delivery, USG scan confirmed the antenatal findings. Due to abdominal distension and respiratory distress, ovarian cystectomy was performed on the second postnatal day. The histopathological evaluation of the surgical material reported a serous cystadenoma of the ovary with non-malignant properties.

Torsion of the gonad in the pediatric population: spectrum of histologic findings with focus on aspects specific to neonates and infants

Histopathologic findings of gonadal torsion in neonates and infants (GTNI) are poorly defined in the literature. We describe herein the histopathologic spectrum of GT with emphasis on the pediatric population and on features specific for NI (≤1 year of age). Twenty-four cases of GTNI (6 females/18 males), 33 cases of GT in an older pediatric population (OPP) (19 females/14 males), and 43 cases of GT in adults (35 females/8 males) were found in our pathology files between 2003 and 2011. Our findings disclosed 2 categories of GT: 1) the group of NI, and 2) that of OPP and adults who share a similar presentation as acute hemorrhagic necrosis of the gonad. Although findings in NI were rather uniform, a few differences were demonstrated between the 2 genders. All GTNI revealed calcifications, fibrosis, siderophages, and extensive necrosis. However, prominent necrotizing palisaded granulomatas were seen in most (4 of 6) cases of ovarian torsion but not in the testicular counterpart. Furthermore, complete gonad regression was encountered exclusively in neonatal testicular torsion cases. In conclusion, 1) pathologic findings in GT are distinctly different between NI and OPP, the latter being more comparable to adults, presenting with acute hemorrhagic necrosis; 2) the distinctive findings in GTNI of both genders include calcifications, siderophages, and fibrosis, in addition to background necrosis; 3) of particular note, complete gonadal regression is seen only in the testis in GTNI; and 4) necrotizing palisaded granulomatas are unique to the ovarian subgroup and are often extensive, obscuring the nature of the process.

A tale of 2 torsions: ovarian torsion in infants and toddlers

Abdominal pain is a common chief complaint in both the emergency department and the primary care setting. Although most patients are ultimately diagnosed with benign self-limited conditions, the differential diagnosis in infants and toddlers does include ovarian torsion. In this article, we present 2 cases involving female infants younger than 18 months who were found to have ovarian torsion during evaluation in our pediatric emergency department. We discuss the clinical presentation, risk factors, diagnosis, management, and potential long-term complications of ovarian torsion, with special attention to the younger population.

Daughter cyst sign

The daughter cyst sign is a specific indicator of an uncomplicated ovarian cyst and pathologically represents a stimulated ovarian follicle. This finding must be differentiated from an ectopic pregnancy in a patient who has the potential to become pregnant. We report an uncomplicated ovarian cyst in a 3-year-old female with McCune-Albright syndrome and precocious puberty mimicking an ectopic pregnancy.

Fetal MR in the evaluation of pulmonary and digestive system pathology

BACKGROUND

Prenatal awareness of an anomaly ensures better management of the pregnant patient, enables medical teams and parents to prepare for the delivery, and is very useful for making decisions about postnatal treatment. Congenital malformations of the thorax, abdomen, and gastrointestinal tract are common. As various organs can be affected, accurate location and morphological characterization are important for accurate diagnosis.

METHODS

Magnetic resonance imaging (MRI) enables excellent discrimination among tissues, making it a useful adjunct to ultrasonography (US) in the study of fetal morphology and pathology.

RESULTS

MRI is most useful when US has detected or suspected anomalies, and more anomalies are detected when MRI and US findings are assessed together.

CONCLUSION

We describe the normal appearance of fetal thoracic, abdominal, and gastrointestinal structures on MRI, and we discuss the most common anomalies involving these structures and the role of MRI in their study.

TEACHING POINTS

• To learn about the normal anatomy of the fetal chest, abdomen, and GI tract on MRI. • To recognize the MR appearance of congenital anomalies of the lungs and the digestive system. • To understand the value of MRI when compared to US in assessing fetal anomalies.