Pediatric Ultrasound Scientific and Case Reports Session
An Infrequent Cause Of Adnexal Cystic Lesion In Infants: Intrauterine Ovarian Torsion And Diagnostic Sonographic Findings
Monday, April 8, 2024
7:47am – 7:54am
Location: 410
Authors: Nazli Akyel, Basaksehir Cam and Sakura City Hospital Tuba Banaz, University of Health Sciences-Basaksehir Cam and Sakura City Hospital
Objectives We aimed to demonstrate sonographically the little-known entity, intrauterine ovarian torsion (IUOT), as a cause of adnexal cystic mass in infants. We had a significant number of patients diagnosed with IUOT, and because the sonographic findings are highly diagnostic, this would be considerably useful in the management of infants with adnexal cystic masses. Methods Patients diagnosed with IUOT radiologically and surgically were retrospectively evaluated. Recorded ultrasound images, ultrasound reports, surgical notes, and pathological diagnoses were examined.The demographic characteristics of the patients were noted. Results Twenty-one infants diagnosed with IUOT were included in the study. Eleven of them (52.4%) had a lesion in the left ovary, while ten (47.6%) had a lesion in the right ovary. Thirteen patients underwent surgery (61.9%). Eight patients were followed up (38.1%), and the lesions disappeared in all of them during follow-up. In 13 operations, intraoperative evidence of autoamputation was found in 4 patients (37.7%). There was no prediction of autoamputation in any patient during preoperative imaging. The preliminary diagnosis was IUOT in fourteen patients. Six patients’ preliminary diagnoses were duplication cyst and/or mesenteric cyst. A complex cystic lesion with a solid component was described in one patient pre-operatively, and after surgery, the pathological diagnosis revealed serous cystadenofibroma within the autoamputated torsed ovary. The pathological diagnosis in all other 12 patients revealed hemorrhagic necrosis within the lesion, and dystrophic calcification was observed in the cyst wall without the presence of lining epithelium. Ultrasound examination was performed within the first week of the neonatal period in 10 patients (10/21), and out of these, 8 were patients with prenatal ovarian cyst follow-ups, while 2 were diagnosed during postnatal imaging. Eleven patients (11/21), aged between 1 month and 10 months (mean 3.6 months), underwent sonographic examination during the infantile period, with 3 of them having prenatal cyst history and 8 not having. 11 had a prenatal ovarian cyst history (11/21). Sonographic findings include; fluid-fluid level or layering debris, intracystic clot, thick echogenic wall, septations, wall calcification, and loss of distension. A layering debris was seen in 15 (71.4%) cases, intracystic clot in 8 (38%), thick echogenic wall in 16 (76.1%), septations in 12 (57.1%), wall calcification in 5 (23.8%), and loss of distension in 13 (61.9%). Except for one patient diagnosed with torsed cystadenofibroma postoperatively, no solid component was described in any of the patients. No vascularization was observed in any of the lesions in Doppler imaging.
Conclusions The IUOT has distinguishing sonographic findings such as layering debris, fluid-fluid level, and thick wall with no solid component. In addition to these findings, if a prenatal cyst history and shrinking during follow-up is observed, it greatly supports the diagnosis. Meanwhile, a normal ovary should not be seen in the ipsilateral adnexa. In newborns and especially in infants younger than 6 months, if there is fluid-fluid level or layering debris within the cystic lesion, and if prenatal cyst history is also included, the findings are pathognomonic. Depending on the degree of necrosis in the torsed ovary, features such as a fishnet appearance and hemorrhagic content can be observed. It is important that it does not contain any solid component or that the hemorrhagic component is not considered solid. Depending on the stage of necrosis, loss of distension also supports the diagnosis. Over time, the cyst wall thickens and becomes more echogenic, and in pathological specimens, dystrophic calcification in the cyst wall is common. During follow-up, it can completely disappear as it becomes completely calcified. In the management, surgical exploration and oophorectomy can be performed if it is totally necrosed. Additionally, it can be followed up until it disappears with calcification during close ultrasound imaging. However, autoamputated ovaries can lead to intestinal adhesions and related obstructions; therefore, excision is generally preferred.