With the introduction of prenatal and postnatal ultrasound, awareness of ovarian cysts in newborns has gradually increased and accumulated. Substantial ovarian tumors in newborns are actually very rare, and cysts of ovarian origin are often ovarian cysts. The incidence of fetal ovarian cysts detected by prenatal ultrasound has been reported to be 1:2500; 98% of newborns and small infants have small ovarian cysts detectable by ultrasound, of which more than 20% are more than 9 mm in diameter. These findings enrich the knowledge of the natural course of ovarian cysts and also pose new challenges for the diagnosis and treatment of ovarian cysts in newborns and small infants.
1. Etiology
Infants are in a period of hormonal activity in the body and high levels of gonadotropin-releasing hormone (GnRH), FSH and LH are associated with stimulation of follicle formation of cysts. The physiological environment of the fetus is rich in pituitary gonadotropins (FSH and LH), placental HCG and estrogen, all of which influence follicular development. At birth, HCG and E2 levels decrease rapidly, leaving only the fetal pituitary gonadotropins LH and FSH to stimulate and maintain the ovarian follicles. Neonatal hypothalamus and pituitary sensitivity to negative feedback is maintained for only 4-6 months, at which point most stimulation ceases and ovarian cysts begin to recede. Most ovarian simple cysts regress spontaneously within 1-6 months after birth.
2.Pathology
Pathology is the most definitive way to clarify the nature of ovarian cysts in newborns. Most cysts are follicular cysts. Ovarian cysts that are torsional and necrotic may be seen only as necrotic, fibrous tissue, and no ovarian follicles or parenchymal ovarian components can be found. Parenchymal tumors of the ovary in newborns are very rare, but should not be ignored. In a study of 257 ovarian cysts diagnosed prenatally, 170 underwent postnatal surgery and three cystadenomas and two teratomas were found. Other authors have reported the presence of germ cell tumors, plasmacytic cystadenomas, benign teratomas and endodermal sinus tumors. Even the presence of ovarian cancer has been reported in fetal autopsies. Juvenile granulosa cell tumor, also reported in 3 cases, occurred in infants of 7 months of age.
3. Clinical presentation
Fetal ovarian cysts can cause excessive amniotic fluid, pulmonary dysplasia or obstructed labor when they are huge, resulting in dual impact on the mother and fetus, requiring fetal surgical intervention when necessary, which is required during pregnancy to ensure the safety of the mother and baby. Most children with neonatal ovarian cysts are born without abnormalities. If the cyst is large, there are more obvious clinical manifestations, such as a bulging abdomen and a soft, fluctuating asymptomatic mass to palpation, usually without intestinal obstruction. Most children are asymptomatic and are detected by prenatal or postnatal ultrasound. Those found in prenatal ultrasound are mostly around 28 weeks of gestation.
4.Diagnosis
Ultrasound is fast, safe and economical, and can examine both mother and fetus. The diagnostic criteria of ultrasound are.
(1) Cystic masses in the lower and lateral abdomen.
(2) normal urinary and gastrointestinal structures. Some of the conditions that can be differentiated are cystic intestinal duplication, lymphangioma, mesenteric cyst, common bile duct cyst, large omental cyst, intestinal cystic meconium peritonitis, umbilical ureteral cyst, renal cyst, hydronephrosis, enlarged bladder, duodenal atresia, antral spinal bulge, hepatic cyst, and even the need to differentiate from uterovaginal fluid.
Nussbaum in 1988 proposed a method to differentiate between simple and complex cysts: simple cysts are homogeneous anechoic areas with inconspicuous or thin and homogeneous masses, whereas complex cysts present with fluid-solid debris planes with coagulated clots and compartments and strong echogenicity of the cyst wall. Complex cysts often occur as a result of cyst torsion and intracystic hemorrhage.
5. Evolution
The evolution of ovarian cysts is reflected by the changes in the prenatal and postnatal periods. 44-70% of prenatal diagnoses of simple ovarian cysts transform into postnatal complex cysts, mostly due to torsion. Some authors have suggested a correlation between the size of prenatal cysts and eventual loss of ovarian components, but most consider it irrelevant. Simple cysts regress spontaneously in the postpartum period in 82% of cases, Sakala et al. suggest that 50% regress in the first month after birth, 75% in about 2 months after birth and 90% in 3 months after birth. The remaining simple cysts are surgically aspirated or excised after observation due to non-resolution. For complex cysts, one study found a regression rate of 58-77% within 1 year, but most still underwent surgery for necrosis or torsion. Complex cysts are found to regress in about 16-25% of cases during follow-up and follicular and viable ovarian tissue is detected. Those children with cysts that regress but no viable ovarian tissue is found are highly suspected of ovarian torsion, necrosis and finally spontaneous resorption.
6. Treatment
The treatment of ovarian cysts in neonates is controversial. For simple cysts, if the cyst is larger than 4-5 cm in diameter, most scholars still advocate surgery or puncture and aspiration (including intrauterine puncture and aspiration), although some scholars advocate close ultrasound follow-up observation for such cysts as well. The indications for observation are as follows.
(1) The cyst is clearly from the ovary.
(2) Debris and segregation due to hemorrhage visible on ultrasound, but there is really no parenchymal component.
(3) Normal AFP and β-HCG.
(4) The child is asymptomatic.
For complex cysts, an increasing number of scholars still advocate observation, and those children whose cysts do not disappear during follow-up may be considered for surgical treatment. However, some authors emphasize the need to remove complex cysts to exclude the possibility of malignancy. Overall, both simple and complex cysts can be observed, but must be followed closely. If symptoms progress and the cyst persists, surgical intervention is indicated, 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 tortured ovary loses viability, surgery may prevent complications such as bleeding, rupture leading to peritonitis, intestinal obstruction, and wandering masses, although it is not possible to save the torsion side of the ovary in the management of complex cysts of the newborn ovary.
(1) Intrauterine puncture and aspiration
To avoid torsion of simple cysts in the uterine cavity, some authors have proposed intrauterine decompression protocols. bagolan in 2002 reported 14 cases of intrauterine ovarian cyst puncture aspiration without 1 complication and 2 cases of torsion even after puncture, with an overall ovarian preservation rate of 86%, which is significantly higher than the previously reported ovarian preservation rate with conservative treatment (44-70% of torsion). They recommended that intrauterine aspiration techniques be performed for ovarian cysts >= 4 cm, or cysts that are growing rapidly, or cysts that are wandering in the abdominal cavity.
(2) Postnatal cyst aspiration by puncture
Advocates of postnatal puncture and aspiration believe that this will preserve the maximum amount of ovarian tissue and avoid cyst-induced torsion. Moreover, many surgeries for ovarian cysts actually end up with removal of the ovary, and not many cystectomies or cyst openings are actually performed to preserve the ovary, which is a great pity as it is tantamount to losing the ovarian tissue that could have been preserved. Kessler, on the other hand, reported the experience of 17 cases of ovarian cyst aspiration, 67% of which preserved ovarian tissue without complications, and 3 cases of recurrence, which were re-aspirated with good results. One author reported the complications caused by mistaking intestinal-derived cysts for ovarian cysts and giving puncture aspirations, which is worthy of consideration.
(3) Surgical resection
Most large or complex cysts can be removed laparoscopically or by caesarean section. Generally speaking, cysts with a maximum diameter of more than 5 cm can be called large cysts. Although the goal of surgery is to preserve ovarian tissue, often the entire cyst is removed because no ovarian tissue is found in the cyst skin. If the entire cyst cannot be safely and completely debulked, a cystotomy may be used. Alternatively, the procedure can also rule out the possibility of neoplastic organisms at the same time. Sometimes saline can be injected between the ovary and the cyst to find the demarcation between the two so that they can be easily separated.
7. Complications
Complications observed on follow-up include missed malignancy, cyst torsion, ovarian necrosis, causing adhesive bowel obstruction, etc. Complications of cyst aspiration include misdiagnosis and the possibility of injury to surrounding organs. Complications of surgical resection include loss of normal ovarian tissue and adhesive intestinal obstruction.
8. Prognosis
There are no previous studies on the long-term fertility of the population with ovarian cysts in the neonatal and infantile periods.