1.Intervention of ovarian tumor should be done and not done
Fetal ovarian cysts can cause excessive amniotic fluid, pulmonary dysplasia or obstructed labor when they are huge, and some scholars suggest that aspiration and decompression treatment should be performed prenatally. Since most neonatal ovarian torsion occurs prenatally, prenatal intervention to prevent torsion has some justification. Therefore, many scholars suggest that prenatal cyst aspiration is appropriate when the diameter of the cyst is greater than 4 cm. The phenomenon of antepartum bilateral ovarian torsion with self-interruption is also evidence in favor of intervention for fetal ovarian cysts. However, other studies have shown that recurrence of cysts after prenatal aspiration is more common and can occur even as early as 1 week after aspiration. Aspiration also carries a risk of intracapsular hemorrhage, as well as inadvertent penetration of intestinal duplication malformations or other non-ovarian tissues, which can also be damaging to the mother. Therefore, there is no unanimous opinion on whether to intervene prenatally.
Ovarian cysts in neonates and infants are occasionally neoplastic, but the majority are benign. The majority of ovarian cysts detected by ultrasound in the neonatal period are small, asymptomatic lesions. Clinical observations suggest that almost all neonatal simple cysts can disappear on their own when maternal and placental hormone levels decline, therefore, simple asymptomatic ovarian cysts less than 4-5 cm in diameter are usually not urgently removed surgically. The management of larger simple cysts (>4-5 cm in diameter) and complex cysts is still controversial. One is that surgical intervention should be performed for large or complex cysts in newborns to reduce ovarian torsion and other complications and to have the advantage of preserving ovarian tissue. Surgical intervention can be either percutaneous or translaparoscopic aspiration, laparoscopic debulking or resection, or open surgery. Another viewpoint advocates a conservative approach to ovarian cysts, with serial ultrasound follow-up for observation in the following cases.
(i) the cyst is clearly of ovarian origin.
(ii) Debris and segregation due to hemorrhage are visible on ultrasound, but there is a definite absence of parenchymal components.
(iii) Normal AFP and β-HCG.
④The child is asymptomatic.
In conclusion, simple and complex cysts can be observed, but must be followed closely. If symptoms progress and the cyst persists, surgical intervention is appropriate, which requires preservation of as much ovarian tissue as possible. All newborns with symptomatic ovarian cysts require surgical intervention. Although ovarian torsion often occurs in the fetal period and the torsioned ovary loses viability, surgery is unlikely to save the torsioned ovary in the management of complex cysts of the newborn ovary, although complications such as bleeding, rupture leading to peritonitis, intestinal obstruction, and wandering masses can be avoided.
As with neonatal ovarian cysts, most prepubertal ovarian cysts originate from the follicle and resolve spontaneously. Indications for the selection of cysts in this age group for observation and follow-up include.
(i) The cyst originates from the ovary.
(ii) The cyst is non-complex.
③ normal serum AFP and β-HCG.
④ No clinical symptoms.
The indications for surgery were.
① persistence of cysts.
(ii) concern about the possibility of malignancy.
(iii) clinical symptoms (including those induced by hormonally active cysts).
There is debate about the size of the cyst and the risk of torsion. Since larger ovarian cysts have been observed to resolve spontaneously, cyst size is no longer an absolute indication for surgical intervention. Prepubertal ovarian cysts should shrink after 2 to 3 weeks. If the cyst has shrunk at 2 to 3 weeks of follow-up, monthly ultrasonography is recommended until the cyst has completely disappeared. If the cysts do not shrink or persist for 1 to 6 months, surgical intervention should be considered. Because ovarian tumors can occur at this age, complex ovarian cysts are not suitable for observation and surgical removal is appropriate. If persistent simple cysts require surgical intervention, cystectomy with preservation of the ovaries is preferred. Cystotomy should be considered only when a true simple cyst is clearly identified. Hormonally active cysts and benign cystic teratomas (with normal AFP and β-HCG) should also be selected for ovary-preserving tumor resection.
The goal of treatment of ovarian cysts in adolescence is to relieve symptoms, eliminate risk, and maximize preservation of ovarian tissue. In functional simple ovarian cysts, only follow-up observation is required in most cases as most ovarian cysts resolve on their own. The duration of follow-up observation is not clearly defined and has been set at 2 to 3 months or 2 to 3 menstrual cycles, while others suggest a longer period of observation in asymptomatic cases. Hormone-suppressing drugs such as oral contraceptive pills (OCP) have no effect on adolescent ovarian cysts and are not recommended.
Indications for surgery for these functional simple cysts are.
(i) the appearance of significant symptoms and (ii) the absence of regression on serial ultrasound follow-up. Surgery is also advocated for larger cysts to prevent ovarian torsion. The surgical options available are aspiration, aperture or cystectomy. In adolescent girls with persistent or symptomatic functional ovarian cysts, most scholars advocate laparoscopic exploration and cyst debulking or resection. The recurrence rate of ovarian cyst debulking is 5% to 8%, but more ovarian tissue can be preserved than with resection. Complex ovarian cysts are most often caused by internal bleeding from a functional cyst, and once such a cyst ruptures, it will cause a considerable amount of intra-abdominal bleeding. If the presentation on ultrasound is consistent with a complex functional cyst, serial ultrasound follow-up is feasible. However, when the cyst does not resolve after 2-3 menstrual cycles or is accompanied by significant symptoms, there is an indication for surgical intervention. Complex cysts in adolescence should also be considered as dermatomal cysts or other tumors and serum AFP and β-HCG should also be checked before determining the treatment plan. if there is abnormal elevation, it suggests the possibility of ovarian malignancy and should be removed for surgery. If the serum AFP and β-HCG are normal, the likelihood of malignancy is low and surgery with preservation of ovarian tissue can be considered. Most surgeons prefer laparoscopic surgery to remove complex cysts, but in cases of very large cysts or elevated plasma AFP and β-HCG suggestive of malignant teratoma, an open surgical approach (e.g., suprapubic skin incision) is advisable, not only to obtain better exposure but also to reduce the risk of tumor rupture.
Pediatric ovarian malignancies of any age, once diagnosed, require standard radical ovarian tumor surgery. The recommended scope of surgical resection includes ipsilateral oophorectomy + ipsilateral adnexal resection + greater omental resection. Intraoperative collection of pelvic and ascitic fluid, centrifugation for tumor cells, and lavage of the abdominal cavity to collect pelvic and ascitic fluid if necessary are required to understand the stage of the tumor. Follow-up chemotherapy and/radiotherapy are decided according to the pathology and staging of the tumor. In recent years, it has been suggested that for malignant ovarian tumors, the affected ovary should be preserved if possible to protect the reproductive function of the child. However, the consequent increased risk of tumor recurrence requires close follow-up. For malignant ovarian tumors, “secondary exploration” is necessary 6 months after surgery to understand the status of the ovary, whether there are any implants or tumor metastases in the abdominal cavity, pelvis, rectum-uterine space, anterior rectum wall, or liver surface of the child. malignant tumor, and the survival rate and quality of survival of children with malignant tumor.