1. Ovarian cysts and neoplasms in infant , children and adolescents
T Allameh MD
Associated professor of Ob& Gyn
fellowship of Gynecology oncology

2. Ovarian cysts in the fetus
Follicular ovarian cysts in fetuses and neonates are common and increase in advancing gestational age and diabetes mellitus, preeclampsia and rhesus isoimmunization
Diagnosis by sonography
* female sex
* non midline cystic structure
*Normal urinary tract
* Normal GI
simple cysts < 2cm are physiologic
Congenital hypothyroidism is associated with fetal ovarian cysts

4. Management and outcome
Spontaneous regression by 6 months of age

5. Ovarian cyst in neonate
Spontaneous regression by 4- 6 months age
Serial ultrasound at birth and every 4-6 weeks until the cysts resolves
Aspiration of simple cysts > 4-5 cm
Surgical intervention for complex cysts increasing in size symptomatic and persisting for more than 4-6 months
Malignancy ? Torsion ?

6. Surgical excision of cyst
Complex
Symptomatic
Increasing in size
Persisting for more than 4-6 months.

7. Outcome Spontaneous regression 50% resolves in first 3 months
30-40% torsion

8. Ovarian cysts in infants and prepubertal children
Physiologic cysts are uncommon
Some ovarian cysts are hormonally active and result in precocious pseudopuberty
Premature vaginal bleeding and ovarian enlargement ( McCune –Albright syndrome? )
Idiopathic precocious puberty ( ovarian cyst in response to GNRH)

10. Clinical manifestation
In early life the ovary in abdominal organ and more susceptible to torsion
Perforation, infarction and hemorrhage

11. Evaluation
Ultrasonography
Doppler ultrasound

12. Management
Observation 4-8 weeks or more in simple cyst and asymptomatic patients
Surgery is always indicated at the time of diagnosis of ovarian torsion ( oophoropexy?)

13. Ovarian cysts in adolescents
Clinical features
Simple or complex

14. Differential diagnosis
Obstructive genital lesions ( imperforate hymen , noncommunicating uterine horn )
Ovarian tumors ( benign cystic tratuma , serous or mucinous cyst adenoma )
Tubal condition ( paratubal cyst, EP, hydrosalpinx )
Uterine mass( myoma, pregnancy)
GI condition ( appendicular abscess )

15. Management Follicular cyst ( simple cyst <6cm can be observed )
In symptomatic patients laparoscopic cystectomy
Chorpus luteum cyst 5-12 cm observation is recommended
* will involute during the2 weeks to 3 months
* surgery is rarely needed

16. Ovarian neoplasms 1% of all tumors in children and adolescents
Fewer than 5% of ovarian malignancy occur in this group
35- 45% of ovarian cancers in children are germ cell tumors

17. Ovarian neoplasms
Any mass that not resolves spontaneously needs to be further evaluating (benign or malignant)
A persistent simple ovarian mass is most likely a mucinous or serous cyst adenoma
A persistent complex mass is most likely a germ cell tumor
The most common germ cell tumor in an adolescent is a teratoma
Teratoma can be benign ( mature teratuma) or malignant (immature teratoma)

18. Ovarian neoplasms
Ovarian cancer is the most common gynecologic malignancy in women <25y
Germ cell tumors make up one half to two third of ovarian neoplasm in girls up to 18 y( compare with 20% of ovarian tumors in adult)
Epithelial neoplasm are rare in the prepubertal age group

19. Clinical manifestation
Abdominal pain
Increasing abdominal girth, nausea and vomiting
Asymptomatic
Abdominal palpation
Rectal examination in the dorsal supine position (in any girl with non specific abdominal or pelvic complains )

20. Imaging Sonography ( simple ,complex, solid, bilateral ,free fluid )
Doppler sono
Age
Clinical manifestation
Tumor marker
A solid ovarian mass in childhood is always considered malignant until proven otherwise by histological examination

21. Differential diagnosis of solid tumors
Dysgerminomas
Neuroblastoma
Willms` tumor
Rhabdomyosarcoma
Lymphoma
Leukemia

22. Tumor marker
Alpha fetoprotein ( endodermal sinus tumor , mixed germ cell tumor and immature teratoma)
LDH ( dysgerminoma )
CA-125 (epithelial ovarian cancer)
hCG ( embryonal ovarian carcinomas, choriocarcinoma )
CEA ( epithelial or germ cell)
Inhibin and mullerian inhibiting substance (MIS)
Granulosa theca cell tumor
Thrombocytosis (suspicious for malignancy)

23. Treatment Surgical staging
Preservation of reproductive and sexual function
Excision of the lesion
Large ovarian cyst can be removed with preservation of the normal ovarian cortex
If malignancy is suspected , a unilateral salpingo oophorectomy and appropriate staging is performed
it is preferable to subject the patient to a second procedure after the final pathology