Newborn Infants with Ovarian Cysts & Prenatal Diagnosis of Ovarian Cysts

Prenatal diagnosis of ovarian cysts has become common. Cysts are typically categorized and simple or complex. The incidence is thought to be approximately 1 in 2,635 pregnancies. (Kirkin). Simple cysts are defined as those with completely anechoic walls. Complex cysts show debris within the cyst, echogenic material within the cyst, or possibly clot).

Simple Cyst

Management is typically non-operative with serial ultrasound follow-up. Cysts over 5cm in diameter are candidates for surgery. The justification is an attempt to prevent torsion of the cyst.

Complex Cysts

Complex cysts have typically been managed with surgical removal. The reasoning behind surgical removal has been recently questioned (Enriquez G, Duran C, et al). The author make a compelling argument that complex cysts are a form of ovarian dysgenesis. The argument is bolstered by histologic findings of “No mature ovarian tissue” as well as findings of ” vestiges of germinal epithelium, consisting of a single layer of cuboidal …cells.” Most of the cysts in their study involuted between 3 and 15 months of age.

Ovarian Salvage

In a review by Brandt M et al (1991) oophorectomy was performed on 85% of simple and complex ovarian cysts. While cyst removal with ovarian sparing is is now considered ideal, many infants still undergo oophorectomy. Often this is because no viable ovary is found at surgery. The findings of the Enriquez study help explain why no viable ovary is often found at exploration.

While most pediatric surgeons have never diagnosed acute ovarian torsion in an infant, the reported findings include abdominal pain, vomiting, low grade temp. These findings are non-specific and unlikely to be helpful. Ultrasound is notoriously unreliable for diagnosing torsion. (Servaes)

Conclusions

Many papers offer guidance on simple and complex cysts, but none of the data is particularly good. Surgical and conservative approaches have different risks. There is no right or wrong answers, but most pediatric surgeons follow simple cysts <5cm for at least 6 months. The risk of torsion during that period is considered to be acceptably low, but not zero. Most surgeons recommend removal of complex cysts, especially if not getting smaller. Observation is deemed acceptable in the literature. Ovarian salvage is ideal, but often not feasible, especially in complex cysts. Ovarian dysgenesis may explain some of the low salvage rates.

Differential Diagnosis in Neonates
GI anomalies
Enteric duplications cysts
Omental cysts
Mesenteric cysts
Ovarian tumors (very rare)
includes cystic adenoma (2 cases), teratoma

Kirkin P, Jouppila P. Perinatal aspects of pregnancy complicated by fetal ovarian cyst. J Perinat Med 1985; 13:245-251)

Enriquez G, Duran C, Toran N, et al. Conservative versus surgical treatment for complex neonatal ovarian cysts: Outcomes Study. AJR: 185, Aug 2005; p501-508

Servaes S, Zurakowski D, Laufer MR, Feins N, Chow JS. Sonographic findings of ovarian torsion in children
Pediatr Radiol. 2007;37(5):446.