Fetal-neonatal ovarian cysts--their monitoring and management: retrospective evaluation of 20 cases and review of the literature

European Paediatric Surgeons' Association Consensus Statement on the Management of Neonatal Ovarian Simple Cysts

INTRODUCTION

 Neonatal ovarian simple cyst management from the pediatric surgical aspect is unclear on cyst size, follow-up, and preferred surgical approach. Therefore, this topic was selected for the 2022 Consensus Session meeting of the European Paediatric Surgeons' Association (EUPSA).

METHODS

 The literature was reviewed on a predefined set of questions relating to the management of the neonatal ovarian simple cysts by a panel of 7 EUPSA members, on current evidence-based opinion and practice outlined. Each question (1) outcomes of fetal interventions in neonates after birth and consensus on size/timing of intervention, (2) consensus on the type of interventions, and (3) complications in neonatal ovarian cysts and follow-up recommendations in nonoperated/operated cysts, was presented with available evidence to congress session participants. The management approach was agreed by participants and comments were accounted to formulate the consensus statement.

RESULTS

 There is still limited data on potential benefits and complications of prenatal ultrasound-guided aspiration; however, neonates after such procedures should be followed for 6 months. Neonates with simple ovarian cysts larger than 4 cm should be offered surgical interventions within the 2 weeks of life with complete laparoscopic cyst aspiration and fenestration with bipolar instruments being the preferred approach. Ultrasound follow-up after surgical intervention after 3 months and with the conservative approach after every 3 to 4 months until 1 year.

CONCLUSION

 A peer-reviewed consensus statement for the management of neonatal ovarian simple cyst was formulated based on current evidence and peer practice. The EUPSA recognizes that the statement can be useful for pediatric surgeons in decision making for this pathology.

Congenital and gynecological tumors: A review

Congenital tumors are rare, and malignant congenital tumors are uncommon. Benign tu,mors might be life-threatening, depending on the location and size of the tumor. Different factors affect congenital tumors, such as maternal and placental hormones and environmental factors such as drugs, radiation, and infection. Developing fetal imaging methods and continuous follow-up during pregnancy are important factors in congenital tumor prognosis. Ultrasound is the most common method used for fetal evaluation. The complementary evaluation method is MRI. Both methods are helpful and widely spread for the detection of congenital tumors. These imaging methods help the medical team make a suitable decision about therapy. Some of these tumors regressed spontaneously, and some need surgical treatments. Treatment of tumors has developed rapidly, and recently molecular-targeted drugs have been used.

A Case Series of Fetal-Neonatal Ovarian Cyst from a Tertiary Care Hospital

The occurrence of ovarian cyst in the neonate is rare and antenatally diagnosed by ultrasonography. This study aims to increase awareness about its occurrence and histological features. We performed a retrospective review on 10 cases of neonatal ovarian cyst (NOC) during 4 years (2016-2020) in a tertiary care center in South India. The neonates were diagnosed with abdominal cysts by the antenatal ultrasonogram in the third trimester. They were operated from day 5 to 35 days of age. There was no side predilection, and most of them were unilateral (9 out of 10 cases). Histopathological examination showed simple cysts (50%), serous cystadenomas (20%), cyst with no viable lining (20%), and follicular cyst (10%) and 90% of the cysts had torsion-induced changes. The pathologist and the clinician should be aware of the occurrence of serous histology in NOC cases.

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.

Vanishing enteric duplication cyst presenting with melaena

A toddler presented with melaena on a background of a possible enteric duplication cyst, diagnosed in the neonatal period which 'vanished'. What was later confirmed to be a small bowel duplication cyst was not seen on follow-up ultrasounds and thus the patient was managed expectantly until presentation as an emergency. Our case highlights the challenges faced in managing cystic abdominal structures in infancy and the potential consequences of expectant management. We discuss whether cross-sectional imaging or diagnostic laparoscopy should be advocated when duplications cysts are considered amongst the differentials of a lesion on ultrasound.

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.

Giant Ovarian Serous Cystadenoma in an Infant: Report of a Rare Case

The incidence of abdominal cysts in infants is 1 in 500 to 1 in 1,000 live births. Among the ovarian cysts in infants, serous cystadenoma is extremely rare with only few reported cases in the literature. Here, we report a case of a giant neonatal ovarian serous cystadenoma treated with laparoscopic cystectomy and confirmed by histopathological examination.

A 27-year-old delivered a female baby with uneventful caesarean section at full term. The antenatal ultrasonography (USG) in third trimester had showed an abdominal cyst in the left side of the abdomen. Postnatal USG was suggestive of omental cyst. A contrast-enhanced computed tomography scan of the neonate showed a large cyst occupying the entire abdomen. On laparoscopic evaluation, a cystic mass filled with 500 mL of clear yellow fluid was seen in the left pelvic fossa. Left ovary could not be visualized separately. The right ovary, fallopian tubes, and uterus were normal. The entire cyst was removed and sent for histopathological examination. On gross examination, a unilocular cyst measuring 10×8×6.5 cm with a wall thickness of 0.2 cm was noted. On microscopic examination, the histomorphological features were consistent with serous cystadenoma of the ovary. There is a paucity of literature regarding pathological diagnosis of such cases and hence we report one such case.

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.

Symptomatic Persistent Fetal Ovarian Cysts

ABSTRACT

Vomiting in young infants is a common presentation to the pediatric emergency department with a broad differential diagnosis. We present 2 cases seen in our emergency department of infant females with symptomatic complex ovarian cysts who presented with vomiting. The first case study describes a patient with a prenatally diagnosed ovarian cyst that was being followed with serial ultrasounds by general surgery. The second case study describes a patient with reportedly normal prenatal ultrasounds with a subsequent diagnosis of a large complex ovarian cyst. These cases were selected to review pertinent imaging findings, discuss management decisions, and expand the differential of vomiting in the young female infants.

Surgical Management of Adnexal Masses in the Pediatric and Adolescent Age Group: Our Experience

CONTEXT

Adnexal masses in girls represent a wide pathological spectrum. We performed a retrospective analysis of clinical and diagnostic aspects of adnexal masses in girls.

AIMS

To analyze the clinical characteristics and surgical management of adnexal masses in children and adolescents.

SETTINGS AND DESIGN

Retrospective observational analysis from 2000 to 2020.

SUBJECTS AND METHODS

This analysis was performed on 28 children under the age of 17 years with adnexal masses who were managed by us at tertiary care centers of Delhi-NCR. Patients were analyzed based on their age at the time of admission, their presenting complaints, clinical and radiological findings, tumor markers, management, and follow-up.

RESULTS

The age ranged between newborn and 17 years. Abdominal pain, nausea with vomiting, and abdominal lump was the most common presenting complaints. Pelvic ultrasound with or without color Doppler done in all patients and computed tomography, magnetic resonance imaging was performed in seven patients preoperatively. Adnexal masses were unilateral in 26 (92.85%) patients and bilateral in 2 (7.15%) patients. Five babies had antenatal diagnosis of ovarian cysts. Serum alpha fetoprotein (AFP) and beta-human chorionic gonadotropin (b-HCG) were normal in all 19 tested patients. Cancer antigen 125 (CA-125) was raised in three ovarian tumors out of 9 tested patients. Laparoscopy was performed in 23 out of 28 patients (30 ovaries). Ovarian cyst torsion was present in 50% patients. Ovarian cystectomy was done in 10 (33.3%) patients. Six (20%) ovaries were saved by detorsion of the ovary and deroofing of the cyst with or without ovarian biopsy. Oophorectomy was done in five (16.7%) patients. Salpingo-oopherectomy had to be done in seven (23.3%) patients. Histopathology revealed functional nonneoplastic lesions in 18 cases (66.7%), benign neoplastic lesions in 8 cases (29.6%), and malignant neoplastic lesion in 1 case (3.7%).

CONCLUSIONS

Adnexal masses in children are generally benign. AFP, b-HCG, and CA-125 in ovarian torsion are within normal limits. Urgent surgery is required if torsion is established. The ovary should be preserved wherever possible.

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.

Ovarian torsion in utero diagnosed at 37 weeks of pregnancy: A case report

Background

Fetal ovarian masses are common abdominal anomalies in female fetuses, often diagnosed in the third trimester. Most masses are benign and tend to resolve spontaneously within a few months after birth, but larger masses may present complications such as torsion.

Case

A 21-year-old primagravid woman was noted to have a complex avascular solid mass in the fetal left pelvis, which was consistent with complex fetal left ovarian torsion. The patient underwent induction of labor at 39 weeks for possible intervention. The infant underwent surgery at 5 weeks of age and a torsed, necrotic ovary was discovered.

Conclusion

The diagnosis of ovarian torsion in utero is rare, and prenatal and postnatal guidelines are needed on frequency of monitoring, timing of delivery, and postnatal follow-up.

•

Diagnosis of ovarian torsion antenatal is rare.

•

Counseling is a balance of the risk-benefit of timing of delivery and surgical intervention.

•

How long an ovary has been torsed is unpredictable, aggressive management may not be optimal.

•

Multidisciplinary planning is beneficial for postnatal counseling and management.

•

More research is necessary for optimal timing of delivery in cases of in-utero ovarian torsion.

Surgically treated ovarian lesions in preadolescent girls

INTRODUCTION

The purpose of this study was to investigate the epidemiology and characteristics of surgically treated ovarian lesions in preadolescent girls.

MATERIAL AND METHODS

This was a retrospective cohort study including all 0- to 11-year-old girls operated at a single center from 1999 to 2016 for ovarian cysts, neoplasms or torsions. Patient charts were reviewed for symptoms, preoperative radiological imaging, operative details and histopathology.

RESULTS

We identified 78 girls, resulting in a population-based incidence of 4.2/100 000. Infants (n = 44) presented with benign cysts (42/44, 95%, one bilateral), a benign neoplasm (1/44, 2%) and a torsion without other pathology (1/44, 2%). Torsion was found in 25/29 (86%) ovaries with complex cysts and in 3/15 (21%) ovaries with simple cysts in preoperative imaging (P < 0.001). Most infants were symptomless. Lesions in 1- to 11-year-old girls (n = 34) included benign neoplasms (n = 21/34, 62%), malignant neoplasms (n = 5/34, 15%), a cyst with torsion (n = 1/34, 3%) and torsions without other pathology (n = 7/34, 21%). Torsion was more common in benign (17/21, 81%) than in malignant neoplasms (1/5, 20%) (P < 0.020). Ovarian diameter did not differ between ovaries with or without torsion (P = 0.238) or between benign and malignant neoplasms (P = 0.293). The duration of symptoms in lesions with or without torsion was similar.

CONCLUSIONS

The majority of surgically treated ovarian lesions in preadolescent are benign lesions with torsion. Surgery should be ovary-preserving and performed without delay.

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.

Premature Ovarian Insufficiency: An Adolescent Series

STUDY OBJECTIVE

To study the presentation and causes of premature ovarian insufficiency (POI) in adolescents.

DESIGN

Retrospective notes review.

SETTING

Tertiary referral outpatient clinic for pediatric and adolescent gynecology.

PARTICIPANTS

Adolescents with POI.

INTERVENTIONS

Standard POI evaluation.

MAIN OUTCOME MEASURES

Age and clinical symptoms at presentation, causative factors for POI, if identified.

RESULTS

We identified 22 girls with POI, with a mean age of 15.6 years. Eight of them presented with delayed puberty, 3 with primary amenorrhea, and the remainder presented with either irregular bleeding (n = 9) or secondary amenorrhea (n = 2). For those who presented with delayed puberty, only 3 were found to have a sex chromosome abnormality. A clear cause for the POI was identified in 3 further cases.

CONCLUSION

Although POI in adolescents traditionally is associated with primary amenorrhea and delayed puberty, a proportion of girls will present with irregular bleeding that might be mistaken for expected menstrual disturbances of puberty, thus delaying the diagnosis. We identified a clear cause for POI in 6 cases. Although there were no familial cases of POI, it remains a possibility that genetic reasons might be involved in the pathogenesis.

Ovarian lesions among pediatric patients: A tertiary center experience (1997-2016)

Introduction

Ovarian lesions are not commonly seen in pediatric females; however, there are some reported cases among different pediatric age groups. Ovarian lesions can show, clinically, in many diverse presentations, and the treatment chosen may be conservative or surgical, accordingly. In this study, we aim to find ovarian lesions commonly operated on and their histopathological and clinical characteristics among pediatric patients at tertiary center in Riyadh, Saudi Arabia.

Material and methods

A retrospective review of medical records of all pediatric patients (aged 14 or younger) who underwent surgical removal of ovarian lesions from January 1997 to August 2016 at King Abdulaziz Medical City, Riyadh, Saudi Arabia was conducted.

Results

Records for a total of 14 girls with a mean age of 5.7 ± 5.1 years were reviewed. The most common clinical presentation was acute abdominal pain (n = 5, 35.7%). There were four patients without any complaints who were diagnosed incidentally (28.6%). More than half of the patients underwent laparoscopy (n = 8, 57.1%) and cystectomy procedures were performed on 50% of the patients (n = 7). Simple ovarian cysts (n = 5) were the most common ovarian lesions followed by mature cystic teratomas (n = 3) with 35.7% and 21.4%, respectively. Furthermore, simple ovarian cysts were more common among infants. There was only one death reported and she had been diagnosed with a mixed germ cell tumor.

Conclusion

The majority of ovarian lesions in the studied pediatric patients were benign. The most common lesions were simple ovarian cysts. Abdominal pain was the most common presenting symptom.

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.

Evaluation and Treatment Results of Ovarian Cysts in Childhood and Adolescence: A Multicenter, Retrospective Study of 100 Patients

STUDY OBJECTIVE

To investigate the characteristics of children with ovarian cysts and evaluate treatment strategies.

DESIGN

Retrospective study.

SETTING

Eight pediatric endocrinology clinics, Turkey.

PARTICIPANTS

A total of 100 children and adolescents with ovarian cysts.

INTERVENTIONS

Patient data collected via retrospective chart review. Patients were stratified according to age into 4 groups (newborns, 1-12 months, 1-8 years, and 8-18 years).

MAIN OUTCOME MEASURES

Special emphasis was given to torsion and tumor cases, concomitant diseases, treatment modalities, and problems during follow-up.

RESULTS

Most newborns and infants were asymptomatic with the cysts being discovered incidentally; in girls ages 1-8, symptoms were common, including breast budding (47.1%, 16 of 34) and vaginal bleeding (29.4%, 10 of 34). Girls older than 8 years mostly presented with abdominal pain (31.6%, 12 of 38) and menstrual irregularity (21.1%, 8 of 38). Most of our patients were diagnosed with a simple ovarian cyst, but 9 patients were found to have ovarian tumors. Ovarian torsion was detected in 7 patients; 5 with large and 2 with small cysts (<20 mm). Two patients had central precocious puberty (CPP) at presentation and 5 patients developed CPP during follow-up. The surgical intervention rate was high (38%, 38 of 100), but was associated with earlier treatment year, and this association remained significant after adjusting for confounders (P = .035).

CONCLUSION

Most girls have simple cysts, which have a favorable prognosis without intervention; however, there might be coexisting pathologies or complications such as tumors, torsion, and CPP; hence these patients should be evaluated accordingly and treated with a multidisciplinary approach.

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.

Imaging Findings of Fetal-Neonatal Ovarian Cysts Complicated With Ovarian Torsion and Autoamputation

OBJECTIVE

Large nonresolving neonatal ovarian cysts may be a risk factor for complications such as torsion, mass effect, rupture, intracystic hemorrhage, and autoamputation. Torsed cysts and autoamputated cysts can cause a diagnostic dilemma. The objective of our study was to correlate the imaging findings of intrauterine ovarian torsion and autoamputated ovaries with their pathologic findings.

MATERIALS AND METHODS

We retrospectively analyzed the pre- and postnatal medical records, sonographic findings, operation notes, and pathologic reports of 15 patients with ovarian torsion. All patients had complex cysts noted on postnatal sonographic examination. A complex heterogeneous ovarian cyst was defined by the presence of a fluid-debris level indicating hemorrhage within the cyst, a retracting clot, septations with or without internal echoes, calcification, and a solid component.

RESULTS

On ultrasound examination, four cysts had solid components, and 11 were heterogeneous and had a fluid-debris level. Calcifications were seen in two patients. The mean patient age at the time of surgery was 3.9 months. Exploratory laparotomy was performed on all patients. Torsed ovaries were identified in five patients. Ten patients had ovaries that were floating free in the peritoneal cavity at the time of surgery. Histopathologic evaluation revealed that 11 of the cysts consisted of extensive hemorrhagic, necrotic autolytic tissue with dystrophic calcification. None of the cysts contained any ovarian tissue.

CONCLUSION

A complex heterogeneous ovarian cyst with a fluid-debris level indicating hemorrhage is a significant sonographic hallmark for the diagnosis of ovarian torsion. A calcified abdominal mass, with or without wandering, can be an autoamputated ovary.

Conservative management of a large neonatal ovarian cyst: a case report

We describe a case of a large simple neonatal ovarian cyst, which was managed successfully using "wait and watch" approach and serial ultrasound monitoring. A cystic lesion arising from right ovary was noted in antenatal ultrasound (USG) which was followed up with postnatal USG which revealed a large simple ovarian cyst without any complications. Patient was kept on expectant management with close clinical and USG monitoring. Cyst resolved spontaneously at 10 wk of age. A brief review of literature for likely aetio-pathogenesis and management is also presented.

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.

Recurrent fetal complex ovarian cysts with rupture followed by simple cyst in the neonatal period with no adverse sequelae

Fetal ovarian cysts are the most frequent type of abdominal tumors in female fetuses with prenatal detection rate of more than 30%. The etiology of fetal ovarian cysts is unclear, but hormonal stimulation as well as presence of maternal diabetes, hypothyroidism, Rh iso-immune hemolytic disease and toxemia has been generally considered responsible for the disease. Complications of fetal ovarian cysts include compression of other viscera, cyst rupture, hemorrhage and, most frequently, ovarian torsion with consequent loss of the ovary. Management is controversial with several options described in the literature, including watchful expectancy, antenatal aspiration of simple cysts to prevent torsion and ovarian loss and finally, resection of all complex cysts in the neonatal period. To date, no case report has described recurrent complex cysts with rupture in the fetal period and recurrence of simple cyst in neonatal period. By presenting this case, we wanted to show that surgical intervention in case of prenatally diagnosed fetal ovarian cyst should be considered postnatally and only in symptomatic or complicated cases.

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.

Non-surgical management of the auto-amputated adnexa in the neonate: a report on two cases

BACKGROUND

Prenatal ovarian torsion is a rare but significant gynecologic abnormality. Current literature has yet to establish standard management in the case of auto-amputated adnexa secondary to ovarian torsion in the neonate.

CASES

We report 2 cases of abdominal masses that were diagnosed in the antenatal period and were clinically consistent with auto-amputated adnexa followed with serial ultrasonography until resolution.

SUMMARY AND CONCLUSION

To our knowledge this is the first report in the literature to document resolution of 2 pelvic masses due to auto-amputated adnexa with expectant management. This suggests expectant management is an appropriate alternative to surgical management in carefully selected cases.

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.