Contributed by
ZAS
stefanie devriendt, and dirk vervloessem.
History
Newborn infant, female, born at 39 weeks. Prenatal diagnosis of a voluminous cyst in the right flank, 4.4 x 2.8 x 4.7 cm. After birth, clinical examination was unremarkable, no abdominal pain was found. Sonography was performed at 3 days old and showed a large cystic mass with echogenic wall and a marked fluid-debris level. The cyst was found in the left flank and measured 4.9 cm at the largest diameter. It was found anterior of the psoas muscle, at the level of the left kidney. The caudal border was close to the left ovary, but with compression the distance between both enlarged. The left ovary showed some small ovarian cysts; the right ovary was not found. No free fluid was seen. Normal appearance of other intra-abdominal organs.
Images (Click any image to enlarge)
Question
What is the diagnosis?
Your answer
Please log in to see your results.
Correct answer
Prenatal ovarian torsion
Discussion
Prenatal ovarian torsion (POT) is a clinical entity that is not very well known or often misunderstood. In the literature, ovarian cysts are often either categorized as simple or complex -depending on their radiological features- and described as small or large (>4cm). The diagnosis of POT is often missed because of a lack of knowledge on the specific characteristics of this entity. The combination of a prenatal diagnosis of a cyst in a female, which shows a fluid-debris level after birth together with an absent ovary is a pathognomonic sign of prenatal ovarian torsion. Oftentimes, the cyst will have an echogenic wall and sometimes contains septations. Ultrasound is the preferred imaging modality to confirm the diagnosis of POT. MRI can give additional information on the aspect of the cyst, but is most of the time unnecessary. The location of these cysts can vary on follow-up imaging because due to torsion, the cyst can become autoamputated and move freely in the abdominal cavity. This was also the case in this neonate, where the position of the cyst changed from the right pelvis to the left flank. The diagnosis of complex cysts in neonates can cause a lot of worry in parents and healthcare providers, leading to additional (unnecessary) testing. This child underwent a laparoscopic exploration at 3 months old, where an absent right ovary was seen, an autoamputated cyst was found in the left flank, adherent to the omentum. The left ovary showed a few smaller cysts.
Additional images
References
- A Nussbaum, R Sanders, D Hartman, D Dudgeon, T. Parmley . Neonatal ovarian cysts: sonographic-pathologic correlation Radiology, 168 (1988), pp. 817-821
- S Devriendt, S Heyman, P Leyman, C Meeussen, D Vervloessem. Prenatal Ovarian Torsion: diagnosis and management in the newborn. Journal of Pediatric Surgery Open, 6 (2024), 100117