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

Ovarian tumors in the pediatric population: An update

Research reveals that 1% of neoplasms in females under 17 years of age are ovarian neoplasms and though usually benign, malignant tumors may occur in the pediatric age group. This review considers various current concepts of these tumors including the epidemiology, risk factors, clinical presentations, diagnosis, differential diagnosis, and treatment options including the need to provide fertility-sparing surgery as well as their potential impacts on the psychological well-being of children and adolescents. We gathered data from the published articles ranging from studies, meta-analyses, retrospective studies, and reviews. We focused on the articles published in English between January 1, 2000, and August 31, 2023. Only a few articles published prior to 2000 were included for historical perspective.

[Ovarian masses in infants and children]

BACKGROUND

Abnormalities of the ovary are frequently seen on ultrasound examination, sometimes symptomatic, but are more commonly asymptomatic.

PURPOSE

Presentation of the most important entities of ovarian masses and their imaging features in infants and children. Discussion of criteria for differentiation between benign and potentially malignant masses.

MATERIALS AND METHODS

Review of current literature and presentation of image examples.

RESULTS

The most common lesions are ovarian cysts in infants, which usually do not require therapy. Because of the risk of torsion, surgery should be discussed for lesions with a size of 5 cm or more. Benign teratomas represent three-quarters of all solid tumors of the infantile ovary. Malignant masses are rare. The task of imaging is to assess the potential risk of malignancy, also using imaging scores.

CONCLUSIONS

Imaging plays a crucial role for therapeutic considerations. Depending on the potential risk, ovarian-sparing surgery is preferred to preserve fertility, as long as the oncologic risk is reasonable.

Congenital Hepatic Cyst in Patients With Patau Syndrome: A Rare Clinical Finding

Trisomy 13 (T13), frequently referred to as Patau syndrome, is a rare autosomal aneuploidy most commonly due to nondisjunction in meiosis. Frequently seen characteristics include cleft lip, cleft palate, cerebral defects, anophthalmia, and polydactyly among many more. We report a rare case of a newborn female with T13, demonstrating several known anomalies associated with the syndrome and an associated large congenital hepatic cyst, exhibiting a significant mass effect on vital organs. Based on a literature review conducted in August 2023, we found no previous documentation of a congenital hepatic cyst reported with T13.

Fetal Ovarian Cyst-A Scoping Review of the Data from the Last 10 Years

Abdominal cystic masses are diagnosed during the intrauterine period and have a relatively low incidence. Fetal ovarian cysts are the most common form diagnosed prenatally or immediately after birth. The pathophysiology of the development of these types of tumors is not fully elucidated, with ovarian hyperstimulation caused by maternal and placental hormones being the most accepted hypothesis. During intrauterine development, the diagnosis of fetal ovarian cysts is most often made accidentally during usual check-up ultrasounds corresponding to the first, second, and third trimesters of pregnancy. We conducted a scoping review with the aim to map the current knowledge regarding the treatment of fetal ovarian cysts diagnosed in the intrauterine period. Focusing on the articles published in the last 10 years in the specialized literature, we tried to identify a conceptualization regarding the surveillance and treatment of these anomalies.

Gynecological Examination in Children and Adolescents

Pediatric gynecological examination is one of the gynecological examinations that are quite simple, but many doctors are unable to do it properly because of the infrequentness of doing this examination. Consulting a child with gynecological complaints, endocrine problems, or sexual abuse often takes a long time and is thorough. However, evidence-based data on the problem of gynecological examinations in children and adolescents are inadequate because of the high bias in many studies. The purpose of this review is to seek from the literature regarding the correct procedures for gynecological examinations in children and adolescents, the order of examinations, and how to carry out a good examination so as not to leave a traumatic experience for children.

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.

Minimally Invasive Surgery for Congenital Abdominal Cystic Lesions in Newborns and Infants

BACKGROUND/AIM

In the variety of congenital abdominal cystic lesions (CACL) of different origin, ovarian cyst is the most common intra-abdominal pathology in female neonates. The prognosis and timing of treatment varies depending on the nature of CACL. This study aimed to assess the results of diagnostics and treatment of CACL.

PATIENTS AND METHODS

A retrospective analysis was performed of 39 cases of CACL, with the spectrum including ovarian, enteric, mesenteric and pancreatic origin. Outcome of minimally invasive surgery, open surgery or conservative approach was analyzed.

RESULTS

Twenty-eight neonates underwent surgery, while 11 were treated conservatively. Twenty patients were treated with a laparoscopic technique and eight with laparotomy combined with laparoscopy. Final diagnosis included: Fifteen cases of ovarian pathology (ovarian torsion in 11 cases), 12 treated laparoscopically and three with laparotomy, six enteric duplications (four laparoscopic and two laparotomic), three mesenteric cysts (one laparoscopic and two laparotomic), two pancreatic cysts (both laparoscopic only), two duodenal stenoses, including duodenal septum (both laparotomies with Heineke-Mikulicz plasty). No blood transfusion apart from two cases requiring re-laparotomy and no early complications were observed in any case; no death occurred.

CONCLUSION

With the strategy of management based on ultrasound and laboratory data, a laparoscopically assisted minimal access approach resulted in minimal risk of complications and complete recovery in all patients, leading to exclusion of oncological risk.

"Follow the Fallopian tube": A technique to improve sonographic identification of ovaries in children

Ovary detection is the first step in confirming ovarian lesions. The daughter cyst sign is widely used for this purpose; however, it is not always applicable. Recent improvements in image resolution allow Fallopian tube delineation, which can serve as a guide to identify the ovary. This anatomical approach ("follow the Fallopian tube" technique) comprises three steps: (1) confirm the uterus; (2) follow the Fallopian tube; and (3) find the ovary. Other applications of this approach include the differentiation between nonovarian and ovarian masses and ruling out ovarian torsion and an auto-amputated ovary.

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. (...).

Daughter cyst sign in liver hydatid cyst

Daughter cyst sign is one of the most characteristic imaging findings of liver hydatid cysts. It is schematically divided into two types according to the daughter cyst localization in regard to the hydatid cyst wall: endogenous daughter cysts and exogenous daughter cysts. The endogenous daughter cyst is presented by a small cyst that protrudes into the lumen of the cystic mass. The exogenous daughter cysts are enclosed in the laminated layer then gradually pushed outwards giving the hydatid a bumpy appearance that distorts the classic circular radiological image. Imaging findings could detect these daughter cysts and dictate some additional precautions during surgical procedures. This surgery is associated with a high recurrence rate essentially in case of exogenous daughter cysts. However, if we detect many exogenous daughter cysts, a radical treatment should be favored otherwise the post-operative recurrence will be certain.

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.

Neonatal ovarian cysts: ultrasound assessment and differential diagnosis

Ovarian cysts are the most common abdominal cysts in female fetuses and newborn girls. Ultrasonography is the imaging technique of choice for diagnosing ovarian cysts because it makes it possible to differentiate them from other cystic lesions. Although most neonatal ovarian cysts regress in the first few months after birth, complications can occur during gestation or after birth. The manifestations of ovarian cysts on ultrasonography will depend on the complications. The management is controversial, although the current trend favors watchful waiting. We describe the different presentations of neonatal ovarian cysts with their complications and their patterns of findings on ultrasonography. We also discuss the differential diagnosis with other cystic abdominal lesions, and finally we discuss the therapeutic management of neonatal ovarian cysts.

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.

Postnatal sonographic spectrum of prenatally detected abdominal and pelvic cysts

OBJECTIVE

The purpose of this article is to illustrate the sonographic findings of a spectrum of neonatal abdominal and pelvic cystic lesions.

CONCLUSION

Neonatal abdominal and pelvic cystic lesions can arise from many organs, and they have a broad differential diagnosis. Distinctive sonographic findings may be present and can help establish the correct cause and guide proper management.

microRNA biomarkers in cystic diseases

microRNAs (miRNAs) are small non-coding RNAs that regulate gene expression by targeting the 3’-untranslated region of multiple target genes. Pathogenesis results from defects in several gene sets; therefore, disease progression could be prevented using miRNAs targeting multiple genes. Moreover, recent studies suggest that miRNAs reflect the stage of the specific disease, such as carcinogenesis. Cystic diseases, including polycystic kidney disease, polycystic liver disease, pancreatic cystic disease, and ovarian cystic disease, have common processes of cyst formation in the specific organ. Specifically, epithelial cells initiate abnormal cell proliferation and apoptosis as a result of alterations to key genes. Cysts are caused by fluid accumulation in the lumen. However, the molecular mechanisms underlying cyst formation and progression remain unclear. This review aims to introduce the key miRNAs related to cyst formation, and we suggest that miRNAs could be useful biomarkers and potential therapeutic targets in several cystic diseases. [BMB Reports 2013; 46(7):338-345]

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.

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.

Cystic abdominal masses in children: a pictorial essay

Cystic abdominal masses in children are not an infrequently encountered condition of childhood. These lesions usually present with large size and mimick each other with similar presenting symptoms. Imaging examinations have an important role to determine the type of the cystic abdominal masses, which is crucial for management of patients and presurgical planning. In this pictorial essay, we summarized the imaging features of common cystic abdominal masses of children, including cystic lesions arising from liver, biliary ducts, kidney, pancreas, bowel, ovary, mesentery, and miscellaneous tissues.

Testicular epidermoid cysts in children: sonographic characteristics with pathological correlation

BACKGROUND

Testicular epidermoid cyst is a rare benign tumor in children. Although this entity is widely described in adults in literature, there are no large series describing the pathological and radiological findings in children. Knowledge of the sonographic features seen in children may alter surgical treatment.

OBJECTIVE

To describe the specific US characteristics of testicular epidermoid cyst in children and to correlate these findings with pathology.

MATERIALS AND METHODS

All children with pathologically proven epidermoid cyst and preoperative sonograms diagnosed at a single children's hospital between 1978 and 2008 were included. For each child, the medical records, preoperative US and pathological specimens were reviewed and correlated.

RESULTS

Eleven patients (ages 1-17 years old) met our criteria. Nine cysts had characteristic target or onion ring appearances, the youngest patient had a simple cyst-like lesion, one cyst had a heterogeneous appearance, and more than 80% of the cysts presented daughter cysts attached along the periphery of the main cyst.

CONCLUSION

In addition to the commonly described findings of the epidermoid cyst (the target and onion ring appearances), simple cysts and the presence of daughter lesions are newly described findings that point to the diagnosis of this benign entity in children.

Ultrassonografia pélvica em crianças e adolescentes

O conhecimento das mudanças que ocorrem no útero e ovários durante a puberdade é fundamental ao investigar alterações da pelve feminina em crianças e adolescentes. O exame ultrassonográfico nestas pacientes é rotineiramente realizado por via abdominal usando o líquido da bexiga como uma janela ultrassônica, embora possa ser algumas vezes realizado pela via vaginal em adolescentes sexualmente ativas. As principais indicações para ultrassonografia pélvica em crianças e adolescentes são a puberdade precoce ou atrasada, dor ou massas pélvicas, genitália ambígua, sangramento vaginal em crianças e amenorreia primária. Neste artigo relatamos a técnica do exame, além de descrever os achados mais freqüentes.

Radiological findings of tailgut cyst in a fetus

Tailgut cyst, or retrorectal cystic hamartoma, is a rare congenital lesion found in the presacral space. The lesion has not been adequately reported in the literature. In this article, we describe a case of tailgut cyst that was demonstrated as a large cystic lesion within a fetal pelvis using ultrasonography and magnetic resonance imaging.

Adnexal masses in infancy and childhood

The presentation of adnexal masses in childhood differs from that in adult women. Children may present with poorly localized symptoms or precocious puberty. Ovarian cysts occur throughout development; ovarian tumors are less frequent but occur in all age groups. Congenital malformations may present with signs or symptoms of an adnexal mass. Occasionally adnexal findings may suggest the presence of an underlying syndrome. Assessment of the patient's developmental, hormonal, and pubertal status is necessary to ensure an accurate diagnosis. Treatment options must consider risks to ovarian function and future fertility.

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.

Ultrasonography of intra-abdominal cystic lesions in the newborn

Intra-abdominal cystic lesions are increasingly recognized in the newborn because of the advent of routine antenatal ultrasonography. As these lesions are often asymptomatic or non-specific in clinical presentation in the newborn, imaging by ultrasonography has an important role in diagnosis. We present a pictorial review of the commonly encountered intra-abdominal cystic lesions in the newborn, with emphasis on ultrasonographic features that can aid differentiation between the various lesions.

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.

US of the pediatric female pelvis: a clinical perspective

When investigating pelvic pathologic conditions in female pediatric patients, one needs to be aware of the developmental changes that take place around puberty. The prepubertal uterus is thin, with a fundus equal in size to the cervix. Owing to the hormonal stimulation of puberty, the uterus enlarges and the fundus becomes prominent. The ovaries are demonstrated with ultrasonography (US) at all ages. Ovarian volume increases after 6 years of age. Microcystic follicles are normally seen throughout childhood. US is the modality of choice for imaging the pediatric female pelvis. The main indications for pelvic US in the pediatric age group are pubertal precocity or pubertal delay, pelvic pain or pelvic masses, and ambiguous genitalia. Vaginal bleeding in the prepubertal child can be due to a vaginal foreign body, vaginal rhabdomyosarcoma, or precocious puberty. Common causes of primary amenorrhea in teenagers include gonadal dysgenesis (Turner syndrome) and müllerian (uterovaginal) anomalies. Pelvic pain or pelvic masses in pediatric patients can be due to ovarian torsion, hemorrhagic ovarian cyst, pelvic inflammatory disease, or ectopic pregnancy.