Assessment of the usefulness of ultrasound screening in fetal ovarian cysts

OBJECTIVES: The aim of the study was to assess the usefulness of ultrasound in management and prognosis in fetal ovarian cysts. MATERIAL AND METHODS: The study included 38 fetuses with cyst in abdominal cavity, who, between 1995 and 2006, underwent an ultrasound examination in our unit at the Polish Mother's Memorial Hospital in Lodz, The Department for Diagnosis and Prevention of Birth Defects. RESULTS: In all 38 fetuses with cyst in abdominal cavity we have diagnosed 27 (74%) cases of ovarian cyst. In 14 (74%) fetuses cysts regressed spontaneously, including all cysts < or = 40mm (n = 7). In 3 cases with cysts > 40mm needle aspiration has been successfully performed, without any further complications. Surgical neonatal treatment has been performed in 5 cases in prenatal cysts > 40mm without prenatal aspiration. In 3 cases cysts > 40mm regressed spontaneously. Ovarian cysts in 22 (87%) cases were an isolated malformation; in 5 (19%) cases other malformations were present CONCLUSIONS: 1. Fetal ovarian cysts < or = 40mm required only ultrasound assessment and, in majority of cases, revealed the tendency to spontaneous regression. 2. Cysts > 40mm in maximal diameter have signaled complications more often and required surgical procedure after birth. 3. In utero, aspiration of fetal ovarian cyst > 40mm may lead to cyst regression, making the surgery after birth unnecessary.     

Ultrasonographic criteria for the conservative management of antenatally diagnosed fetal ovarian cysts

Routine antenatal ultrasonography at regular intervals will detect fetal ovarian cysts. Before the era of ultrasound, the attending physician was unaware of the presence of these cysts. It is therefore imperative that a protocol for the management of asymptomatic, antenatally diagnosed ovarian cysts be developed. The vast majority of these cysts are benign and functional; laparotomy during the neonatal period is not only unnecessary but may be harmful. In a prospective study undertaken at Tygerberg Hospital, Parowvallei, South Africa, six ultrasound criteria were drawn up for the safe, conservative management of these neonates. Adherence to these criteria enabled us to manage five of seven neonates conservatively. Laparotomy in one neonate showed a benign functional ovarian cyst. Retrospectively, this case should have been managed conservatively. In the remaining neonate a laparotomy for an acute abdomen demonstrated torsion of an ovarian cyst, emphasizing the necessity for adequate follow-up.     

Fetal and neonatal ovarian cysts: what's their real meaning?

PURPOSE OF INVESTIGATION: The management of fetal ovarian cysts is still controversial despite the improvement in prenatal diagnosis with ultrasonography. Some studies suggest an aggressive management, while others opt for a conservative one. The prognosis of the majority of congenital ovarian cysts is good since they have a benign origin. Sometimes, however, complications such as torsion or rupture can occur which often require surgical intervention after delivery. In this paper we report our experience and a brief review of the literature. METHODS: The authors report on 32 pregnant women in whom ultrasonography revealed the presence of an echo-rare or echo-free area in the fetal abdomen suggestive of an ovarian cyst. All women were followed-up during pregnancy with serial ultrasound examinations. Postnatal ultrasound controls confirmed the prenatal diagnosis in all cases. The diameters of the cysts ranged from 2.7 to 7.5 cm. RESULTS: In the 16 cases (50%) in which the cyst diameter was below 4 cm, periodic ultrasound examinations revealed a tendency towards spontaneous regression of the cysts. In the other 16 cases (50%) in which the cyst diameter exceeded 4 cm, cystectomy was necessary due to subsequent complications (torsion in 6 cases, 37.5%, and intracystic hemorrhage in the other 10, 62.5%). CONCLUSION: The most appropriate clinical approach in the management of benign feto-neonatal ovarian cysts is to adopt a wait-and-see policy, assessing the course of the condition by means of periodic ultrasound monitoring. Only when tumefactions measure more than 4 cm in diameter with attendant complications is surgical therapy indicated. Without complications, however, aspiration of the cystic contents is possible even in ovarian cysts exceeding 4 cm in diameter.     

Laparoscopic management of ovarian cysts during pregnancy

OBJECTIVE: To evaluate the results of laparoscopic surgery in the management of ovarian cysts in pregnant patients. PATIENTS AND METHODS: Retrospective study including 26 pregnant patients who underwent the laparoscopic management of ovarian cysts. The indications for surgery were persistent adnexal mass, abnormal ovarian cysts revealed by ultrasound examination, suspicion of cyst complications. The technique used, the immediate postoperative results and obstetrical outcomes were studied. RESULTS: Twelve patients were operated during the first trimester of pregnancy, 13 in the second, and one in the third trimester. A 12 mmHg CO2 pneumoperitoneum was created, using a Veress needle in 22 cases, and an open technique in 4 cases. Trocar sites were decided according to the uterine size and to the cyst situation. A cystectomy was performed in 11 cases, an adnexectomy in 7 cases, an oophorectomy in one case, a cyst aspiration with a biopsy of the cyst wall in 6 cases and an ovarian torsion removal in one case. A conversion to laparotomy was necessary in 3 cases. There were no immediate postoperative complications and obstetrical outcomes were good in all cases. DISCUSSION AND CONCLUSION: In pregnant patients, laparoscopic management of adnexal masses appears to be safe for both mother and child.     

Basal ovarian cysts and clomiphene citrate ovulation induction cycles

OBJECTIVE: To evaluate the effect of simple basal ovarian cysts in patients undergoing infertility treatment with clomiphene citrate. To evaluate the effect of clomiphene citrate on pretreatment simple ovarian cysts. METHODS: Prospective cohort trial of 84 infertility patients undergoing ovulation induction with clomiphene citrate. Patients with basal ovarian cysts of 10 mm or greater (n = 42) were compared with patients without ovarian cysts (n = 42). The main outcome measure was ovulation determined by menstrual cycle day 21 progesterone level. Each patients with an ovarian cyst was also evaluated for persistence or resolution of the cyst in association with ovulation and cyst size. Pretreatment and posttreatment transvaginal ultrasound examinations were performed on all patients. RESULTS: Demographic data were similar among the groups. The mean ovarian cyst size was 17.4 +/- 5.8 mm. Patients in the ovarian cyst group were significantly less likely to ovulate (80.9% versus 97.6%, P < .05), but did not differ in pregnancy rate compared with patients without baseline ovarian cysts (4.8% versus 11.9%, P = .43). Persistent ovarian cysts occurred in 36.7% of the patients. The initial size of the cyst did not predict cyst persistence. CONCLUSION: According to these data, basal ovarian cysts significantly reduce ovulatory events in patients treated with clomiphene citrate. LEVEL OF EVIDENCE: II-2.     

Peritonitis caused by a ruptured, infected mesenteric cyst initially interpreted as an ovarian cyst. A case report

BACKGROUND: Mesenteric cysts are rare intraabdominal lesions of childhood that may vary in presentation from an asymptomatic mass to an acute abdomen. CASE: We encountered a rare case of peritonitis caused by a ruptured, infected mesenteric cyst of the mesocolon in a female child that had been initially interpreted as a ruptured ovarian cyst. CONCLUSION: When confronted with a large unilocular or septated echolucent mass in the lower abdomen in female children, gynecologists should consider a mesenteric cyst in the differential diagnosis.     

Prenatal diagnosis and management of fetal ovarian cysts

Congenital ovarian cysts are a pathological condition which can be diagnosed in utero by ultrasound. We report 14 consecutive diagnoses of fetal ovarian cysts, obtained in the second and third trimesters of pregnancy. Congenital ovarian cysts have almost invariably a good prognosis, and no change in the standard obstetrical management is required. However, the evolution of the disease in utero is extremely variable. The cyst may increase in size, decrease or even disappear, or undergo complications such as torsion and rupture, which may carry some risks to the fetus. When a fetal ovarian cyst is detected, serial ultrasound examinations should be performed. If one of the above complications is suspected, the option of prompt caesarean section should be considered.     

Treatment of an antenatally diagnosed fetal ovarian cyst by needle aspiration during the neonatal period

Summary An ultrasound scan revealed an ovarian cyst in the fetal lower abdomen at 29 weeks of gestation. Repeated examinations demonstrated that the cyst increased in size to 6.5 cm×6.1 cm×5.0 cm at 33 weeks of gestation, and the cyst showed no complications between 29 weeks of gestation and early infancy. The female infant was vaginally delivered at 41 weeks of gestation without any complications. Transabdominal needle aspiration of the cyst fluid was performed on the 14th day after birth. The concentrations of estrone, estradiol, estriol, and progesterone in the cyst fluid were almost the same as those in the infant’s serum, while the concentration of pregnenolone was six times that in the infant’s serum. Cytology of the cyst fluid was negative. The cyst thus seems to have been a non-functioning simple cyst of ovarian origin. Follow-up until the baby was one year old showed no recurrence of the cyst.     

Giant Paratubal Serous Cystadenoma in an Adolescent Female: Case Report and Literature Review

BackgroundParaovarian/paratubal cysts constitute 5-20% of all adnexal lesions and typically originate from the paramesonephric or Müllerian duct. The primary epithelial tumors arising from paraovarian cysts account for 25% of the cases, but giant cystadenomas of paraovarian origin are extremely uncommon during childhood and adolescence with very few cases reported in the literature.CaseWe present the case of a 15-year-old female that presented with a bulky mass in the abdomen and pelvis. An initial clinical and radiological examination indicated an ovarian cyst measuring ∼25 × 20 cm. However, explorative laparotomy revealed a giant paratubal cyst that was successfully treated with complete excision using fertility-sparing surgery. Histopathological examination was consistent with a serous cystadenoma. The postoperative course was uneventful and the girl was discharged on the seventh postoperative day. At the follow-up of 6 months, the patient was doing well.     

Fine needle aspiration cytology of the ovary: is it reliable?

PURPOSE OF INVESTIGATION: The purpose of this study was to evaluate the cytologic findings from the fluid of ovarian cysts in comparison with the histologic diagnosis. METHODS: Over a four-year period all women with single ovarian cysts and no evidence of malignancy from ultrasound examination and tumour marker levels were included in the study. Prior to removal of the cyst, fluid was aspirated from the cyst and prepared for cytologic examination. Subsequently the ovarian cyst wall and biopsy from the ovary were sent for histologic examination. The cytologic findings were compared to the histologic diagnosis. RESULTS: The material of the study was 120 ovarian specimens from 107 women. Twenty-four (20%) of the specimens submitted for cytology were non diagnostic and a comparison between cytologic and histologic findings was possible in 96 cases. The sensitivity and the specificity of fine needle aspiration (FNA) cytology of the ovary was 25% and 97%, respectively. CONCLUSIONS: FNA cytology of the ovary is an accurate method for predicting benign ovarian histologic findings in carefully selected populations.     

Primary hypothyroidism presenting as multiple ovarian cysts in an adult woman: A case report

A 21-year-old woman was referred because of abdominal pain. On physical examination, her abdomen was distended up to the umbilical region. Ultrasound and computer tomography of the abdomen revealed bilateral multiple ovarian cysts. Laboratory studies revealed increased liver function, total cholesterol and creatine phosphokinase. Further clinical investigations determined that the patient suffered from primary hypothyroidism due to autoimmune thyroiditis. The cysts resolved spontaneously after the simple replacement of a thyroid hormone. Some reports have been published of primary hypothyroidism presenting as ovarian cysts and precocious puberty in prepubertal girls. However, the case presented herein indicates that an ovarian tumor as a result of hypothyroidism may also occur in adult females. To avoid inadvertent surgery to remove an ovarian tumor, it is essential that a patient with multiple ovarian cysts and hypothyroidism be properly managed, as the simple replacement of a thyroid hormone could resolve the ovarian cysts.     

Prenatal diagnosis of a large subchorionic placental cyst with intracystic hematomas. A case report

A large intrauterine cyst containing a heterogenous mass was found by ultrasound in the placenta of a 35-year-old gravida 2 para 1 woman. The cyst, measuring 10.9 x 10.1 cm with a heterogenous mass shadow, was attached near the placental cord insertion site. The woman delivered a healthy female baby weighing 3,330 g by cesarean section without complication. A histopathological examination revealed that the lesion was a subchorionic cyst and contained an internal hematoma. Large subchorionic cysts are extremely rare, and secondary hemorrhage within the cyst has not been reported. In this article, we report the case of a woman with a large subchorionic cyst complicated by an intracystic hematoma and review its clinical significance.     

Ultrasound diagnosis and evaluation of fetal tumors

Fetal tumors represent a rare and heterogeneous group of abnormalities. A significant proportion of them can now be diagnosed by using modern high resolution ultrasonic equipment. During 15 years there were 57 fetal tumours detected prenatally. Hygroma colli is the most frequent fetal tumor. It should be emphasized that cystic hygroma generally carries poor prognosis, and after an early diagnosis, termination of pregnancy is most logical approach. Contrary to the general opinion our own experience showed that there are cases in which prognosis could be much better as illustrated with our 4 cases. All of the treated fetuses, after surgical resection, had normal development and are now on the age of 5, 4, 3 and 2 years of life. An ovarian cyst can be suspected if a fluid-filled structure is visualized next to a fetal kidney and female external genitalia are recognizable. The ultrasound finding suggestive of an ovarian cyst is that of a pelvic cystic or complex mass in a female fetus with normal kidneys and urinary bladder and a normal gastrointestinal tract. In most cases, the normal course of fetal ovarian cyst is a spontaneous intrauterine or postnatal involution. Prenatal diagnosis improves neonatal outcome by allowing an appropriate choice of the optimal time, mode and place of delivery in order to avoid accidental and unexpected intrapartum and postnatal complications. The management of a fetus affected by an ovarian cyst depends on the size and on the echo-pattern of the cyst. It remains unclear whether in utero puncture of the cyst and evacuation of its content should be justified in cases of particularly large ovarian cyst. In our opinion intrauterine procedure can be attempted in the presence of large cyst fulfilling the fetal abdomen. We have treated actively two cases of large ovarian cysts by ultrasonically guided puncture before delivery and both fetuses underwent surgery later without complications. If properly performed puncture of the cyst seems to be a low risk procedure in comparison to potential problems that cyst may cause to the fetus or by causing dystocia. Sacrococcygeal teratoma represents the most frequent tumor in the fetuses and newborns. Prenatal diagnosis is usually simple and based on the visualization of tumor of variable size and internal structure. Tumors may appear as completely cystic, mixed or predominantly solid with obvious calcifications. Cystic and calcified tumors are most likely to be benign. Obstetrical management of sacrococcygeal teratoma depends on numerous parameters which include size and texture of the tumor, and gestational age.(ABSTRACT TRUNCATED AT 400 WORDS)     

Multiloculated peritoneal inclusion cyst treated successfully with laparoscopic surgery

Background: Multiloculated peritoneal inclusion cysts or benign cystic mesotheliomas are most commonly found in women of reproductive years; the disease involves the abdomen, pelvis and retroperitoneum. Case: A 33-year-old, para 3-0-0-3, Thai woman presented to the hospital upon an incidental finding of left ovarian cyst and a mild pelvic pain for three months. Her pelvic examination revealed left ovarian cyst. Transvaginal ultrasonogram demonstrated a multiloculated cyst size 61×40×55 mm³ adherent to the normal left ovary. Laparoscopic surgery was performed. There was a multiloculated cyst 6 cm in diameter in the left pelvic cavity. The cyst was excised and the histopathology revealed inclusion cysts. She was well at discharge and throughout the four-week and six-month follow-up periods. Conclusion: Although multiloculated peritoneal inclusion cyst is uncommon, it should be included in the differential diagnosis of adnexal masses. Surgical excision remains the current recommended treatment for symptomatic disease. Surgical excision by laparoscopy might be an alternative method for successful management.     

Ovarian cysts in postmenopausal tamoxifen-treated breast cancer patients with endometrial thickening detected by transvaginal sonography

OBJECTIVE: To investigate the frequency of ovarian cysts in tamoxifen-treated postmenopausal breast cancer patients with endometrial thickening detected by transvaginal sonography. METHODS: Medical records and transvaginal sonographies of 38 postmenopausal women treated for breast cancer with adjuvant tamoxifen therapy who had undergone endometrial sampling due to abnormal endometrial thickness were reviewed retrospectively. RESULTS: During the study period five of 38 tamoxifen-treated postmenopausal patients (13.2%) had ovarian cysts. The mean tamoxifen treatment interval of the patients with an ovarian cyst was 22.4 +/- 18.4 months (p = 0.17). The mean endometrial thickness of the patients with an ovarian cyst was 12.6 +/- 5.9 mm (p = 0.17). Endometrial biopsy detected six cases of abnormal endometria, including endometrial carcinoma (n = 1), endometrial polyp (n = 1) and simple endometrial hyperplasia without atypia (n = 4). Three patients with ovarian cysts underwent laparatomy revealing simple cysts on histopathological examination. Two patients with ovarian cysts declined laparatomy and are currently under follow-up. CONCLUSION: Ovarian cysts a common side-effect of tamoxifen treatment in postmenopausal tamoxifen-treated breast cancer patients. Transvaginal sonography should be performed to detect any concomitant endometrial pathology.     

Concurrent maternal and fetal ovarian cysts

Due to improvements in ultrasonography, the detection of fetal abdominal masses has increased. We describe a case of co-existing maternal and fetal ovarian cysts in a 37-year-old primiparous woman. The fetal ovarian cyst was first identified in the third trimester and reached a maximum diameter of 9?cm. The maternal cysts were present from 20 weeks onwards; with a maximum diameter of 8?cm. Histological examination showed the maternal lesions were benign dermoid cysts. The fetal lesion resolved spontaneously by 5 months. This case illustrates that fetal and maternal ovarian cysts may co-exist and could potentially have a similar hormonal etiology.     

Leak-proof puncture of ovarian cysts: instant mounting of plastic bag using cyanoacrylate adhesive

BACKGROUND: Reliable leak-proof aspiration of cyst contents is required for treatment of large ovarian cysts by minilaparotomy. TECHNIQUE: Through a small abdominal wound a transparent plastic bag was instantly mounted onto the cyst surface using an ethyl-2-cyanoacrylate adhesive. A 1-2-cm-wide cut was made in the consolidated cyst wall through the inside of the bag and the contents directly aspirated. The fluid was trapped inside the bag without leaking into the abdominal cavity. This method can also be applied to relatively small cysts by holding the cyst just beneath the wound. EXPERIENCE: We used this method in 30 patients with unilateral ovarian cysts and in one patient with an ovarian cyst associated with an ipsilateral paraovarian cyst. All patients were successfully treated without spillage, although in one case a large mucinous ovarian cyst ruptured before surgery. CONCLUSION: Minilaparotomy using the instant adhesive is cost-effective, safe, reliable, and easily implemented. This procedure is also applicable to relatively small cysts and is a viable alternative to laparoscopic surgery for treatment of dermoid cysts showing considerable calcification.     

The value of ultrasound visualization of the ovaries during the routine 11-14 weeks nuchal translucency scan

OBJECTIVE: To investigate the feasibility and possible value of routine screening for ovarian pathology in asymptomatic pregnant women at 11-14 weeks' gestation. STUDY DESIGN: A policy of routine ovarian visualization was implemented in 2925 pregnant women attending for a nuchal translucency scan at 11-14 weeks' gestation. In all cases, an attempt was made to visualize the ovaries on transabdominal ultrasound scan. Simple cysts were defined as unilocular cysts with regular internal walls and no solid components, which contained clear anechoic fluid. All other cysts were classified as complex. Simple cysts<5 cm in diameter were all managed expectantly with no further follow-up. All women with large simple cysts>or=5 cm in diameter or complex cysts had further detailed follow-up scans. Surgical intervention during pregnancy was offered to women with clinical symptoms suggestive of cyst complications or those with ultrasound features suggestive of malignancy. All other women were managed expectantly until after delivery. RESULTS: Adnexal cysts were found in 728/2925 (24.9%) pregnant women. 400/728 (55%) women had simple cysts<5 cm in diameter, whilst 328/728 (45%) women had large simple or complex cysts requiring follow-up. On subsequent scans, cysts resolved spontaneously in 278/328 (84.8%) women. A total of 33/728 (4.5%) women with ultrasound evidence of adnexal cyst underwent surgery. In one woman the intervention was required because of pain, one woman had suspected cancer on ultrasound scan and the remaining 31/33 (94%) of operations were performed at patients' requests. All the cysts were found to be benign on histological examination. The overall intervention rate was 1.1/100 screened pregnant women or 4.5/100 cysts detected on ultrasound scan. CONCLUSION: Asymptomatic adnexal cysts detected in the first trimester of pregnancy are unlikely to be malignant or to cause clinical symptoms antenatally. The policy of routine ultrasound visualization of the ovaries in pregnancy cannot be justified.     

Asymptomatic postmenopausal simple ovarian cyst

High-resolution transvaginal ultrasound frequently reveals incidental, simple ovarian cysts in asymptomatic postmenopausal women. Traditionally oophorectomy has been recommended for these women. However, evidence is emerging that most postmenopausal simple ovarian cysts are benign, allowing conservative management. Furthermore, many of these cysts will resolve spontaneously. Cancer antigen 125 (CA-125) and color Doppler may help differentiate benign from malignant cysts. When oophorectomy is favored, the laparoscopic approach may be considered, depending on the clinical situation. Nonoperative management of simple ovarian cysts in asymptomatic women is reasonable; regular follow-up with sonography should be performed. Because sonography is an operator-dependent test, it is imperative that the sonographer have expertise in ovarian imaging. Monitoring of CA-125 levels may be useful. Indications for removal during follow-up are increasing size, development of solid components, abnormal Doppler flow, CA-125 elevation, patient desire for removal of the cyst, and noncompliance with sonographic follow-up. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader will be able to estimate the prevalence of benign simple ovarian cysts in a postmenopausal population of women, to describe the natural history of a simple ovarian cyst, and outline the features consistent with a benign ovarian cyst on ultrasound.