Original Article

Ovarian cysts and tumors in infancy and childhood

Madhumita Mukhopadhyay, Ram Mohan Shukla1, Biswanath Mukhopadhyay1,
Kartik C. Mandal1, Amit Ray1, Neha Sisodiya1, Mahadev Prasad Patra1
Department of Pathology, Post-Graduate Medical Education and Research, 1Pediatric Surgery, N R S Medical
College, Kolkata, India

Address for correspondence: Prof. Biswanath Mukhopadhyay, 7E, Dinobandhu Mukherjee Lane, Sibpur, Howrah - 711 102,
West Bengal, India. E-mail: mukhopadhyay_b@yahoo.in

ABSTRACT Access this article online

Website: www.jiaps.com
Aim: Review of the clinical presentation, types (histology), and stages of presentation and DOI: ***
overall outcome of ovarian tumors. Materials and Methods: This is a retrospective study. Quick Response Code:

Forty nine girls from 3days to 12 years were included in the study. Results: Fourteen girls
had benign and thirty three had malignant ovarian tumors. One girl had bilateral ovarian
non-Hodgkin lymphoma. Dysgerminoma (40%) was the commonest malignant tumor
followed by malignant teratoma (16.6%). Conclusion: Pain and abdominal lump are the
most common modes of presentation. Prognosis depends on the size of the tumor, stage
and histology of the tumor. Conservative surgery should be the aim. Multidisciplinary
management gives good prognosis.

KEY WORDS: Dysgerminoma, endodermal sinus tumor, germ cell tumors, Ovarian tumors

INTRODUCTION gonadotrophic hormone) was done in only 8 patients

Gynecological malignant conditions account for
approximately 3% of all types of cancer in children.[1]
The incidence of ovarian tumors in pediatric age group
account for only 1% of childhood malignancy.[2] Ovarian
cysts are from mature follicles and were previously
considered to be uncommon in the first year of life.[3]
The rarity of these conditions and controversies in the
management prompted us to report our experience.
MATERIALS AND METHODS
This is a retrospective study of 49 patients treated at the
authors Institutions over 10 years from January 2000 to
January 2010. Baseline investigations, ultrasonography
of the whole abdomen was done in all cases. CT scan
was not available in the initial part and has been
done in the last 20 patients. Tumor marker estimation
(serum alpha fetoprotein and beta human chorionic
of suspected teratoma.
Fourteen patients of benign ovarian tumors underwent
ovarian cystectomy. One patient of dermoid cyst who
had torsion, the cyst was gangrenous and could not
be saved. We could not save the ovary of the neonate
with the torsion (cyst was diagnosed antenatally)
but operated at the age of 15days. The cyst was
7cm 6cm. The second neonate with simple cyst and
Hirschsprungs disease, only the cyst was excised. Thirty
three patients of malignant ovarian tumors underwent
unilateral salpingo-oophorectomy. One with bilateral
ovarian tumors (non-Hodgkin lymphoma) underwent
bilateral salpingo-oophorectomy [Figure 1]. One patient
had multiple peritoneal deposits (malignant teratoma
intermediate) and two had hemorrhagic ascites. All
the specimens were sent for histopathological (HP)
examination. All patients with malignant tumors
received systemic combination chemotherapy.

Cite this article as: Citation will be included before issue gets online***
Source of Support: None, Conflict of Interest: No.

16 Journal of Indian Association of Pediatric Surgeons / Jan-Mar 2013 / Vol 18 / Issue 1

 Mukhopadhyay, et al.: Ovarian cysts and tumors

RESULTS differential diagnosis of young girls with abdominal

The age of presentation ranged from 3 days to 12 years
with majority of patients seen between the age of 9 to
12 years. The most common presentation were lower
abdominal pain (80%), palpable mobile abdominal
lump (73%), urinary symptoms in the form of increased
frequency (46%) and dysuria (73%). Lesions in the right
ovary were seen in 26 patients; on the left in 22 patients
and bilateral in 1 patient.
Interestingly, two patients were admitted with acute
pain abdomen and revealed twisted ovarian cyst at
laparotomy. One of them presented with acute retention
of urine and had twisted dermoid cyst of left ovary.
The youngest patient, aged 3 days was admitted with
peritonitis. She had perforation of transverse colon due
to Hirschsprungs disease and found to be having a
simple cyst in the left ovary [Figure 2]. Another neonate,
aged 6 days, presented to us as antenatally diagnosed
ovarian cyst in the left side of 6 cm diameter. The baby
was crying most of the time. Initially, the parents were
not willing for operation. They brought the baby back
at the age 15 days. The lower abdomen was tender
and distended. Laparotomy revealed twisted ovarian
cyst with gangrene of the ovary. The final outcome of
HP examination of ovarian tumors with their FIGO
staging, outcome of surgery and combination systemic
chemotherapy are given in Table 1. The follow up period
was 1 to 10 years.
DISCUSSION
Malignant ovarian tumors are rare, particularly in
patients under 5 years of age.[4] Solid ovarian tumors are
uncommon in pediatric population but when occurred,
they are a major source of anxiety for the patients and
their family. Ovarian tumors must be considered in the
pain, mass or other non-specific symptoms. In a large
study, Templeman et al, stated that malignant ovarian
tumors in children and adolescents are rare, accounting
for 0.9% of all malignancies in this age group.[5] Hassan
et al, confirmed that during the first two decade of life
ovarian tumors represent the most frequent tumors of
female genital tract.[6]
Two-third of malignant tumors in children are germ
cell tumors.[7] Most of the malignant germ cell tumors
are dysgerminoma,[8] in contrast to adult ovarian tumor
where 90% are epithelial cell origin and about 10%
are non-epithelial.[9] Ovarian lesions can present with
variable signs and symptoms, most often the clinical
presentation does not differentiate benign tumor from
a malignant tumor as found in our series. Abdominal
pain was the most common symptom encountered.
Ovarian masses often present with abdominal
complaints that can mimic other diseases, in particular,
appendicitis.[10] A mobile, palpable abdominal mass was
the most frequent physical finding. Bagolan etal,[11]
confirmed that patients with echogenic cysts with
fluid debris, retracting clot or septation should undergo
surgery because such findings were associated with
complications.
The treatment of anechoic cysts depends on their
size at diagnosis. Those that were less than 5 cm in
diameter were unlikely to cause problems. The cysts
that were larger than 5 cm in diameter often required
surgery for postnatal torsion or other complications
as reported in literature[11] Neonatal ovarian cysts are
rare. Neonates, influenced by maternal hormones, are
likely to have functional cysts.[12] In this report, three
cysts had undergone torsion and in none of these could
the ovary be preserved.[11] The incidence of ovarian
torsion is around 17% and is more common in patients
with ovarian cysts and mature cystic teratomas than

Table 1: Details of histology and the management done

Nature Histopathology Number FIGO staging Surgery Chemotherapy
Benign Simple follicular Cyst 02 Ovariectomy-01
Ovarian cystectomy-01
Benign Mature teratoma 12 Ovarian cystectomy
Benign Granulosa cell tumor 02 Ovarian cystectomy
Malignant: Dysgerminoma 13 Stage I- 4 patients. U/L salpingo-oophorectomy VAC-4
Stage II-6 patients. BEP-9
Immature teratoma 8 Stage I-5 patients U/L salpingo-oophorectomy VAC-5
Stage II-2 patients BEP-3
Mixed germ cell tumors 5 Stage I-2 patients U/L salpingo-oophorectomy VAC-2
Stage II-2 patients BEP-3
Stage III-1 patient
B/L Non-Hodgkin Lymphoma 1 Stage II B/L salpingo-oophorectomy COMP
Endodermal Sinus tumor 6 Stage II-2 patients U/L salpingo-oophorectomy VAC-2
Stage III-3 patients BEP-4
BEP: B-Bleomycin, E-Etoposide, P-Prednisolone; VAC: V-Vincristine, A-Actinomycin D, C-Cyclophosphamide; COMP: C-Cyclophosphamide, O-Oncovin,
M-Methotrexate, P-Prednisolone

Journal of Indian Association of Pediatric Surgeons / Jan-Mar 2013 / Vol 18 / Issue 1 17

 Mukhopadhyay, et al.: Ovarian cysts and tumors
those with malignant tumors.[5] All surgical procedures
for ovarian cysts should spare functional ovary as
much as is technically possible. Simple cyst may be
fenestrated or excised with preservation of the ovary.[13]
Laparoscopy has become the approach favored by
most pediatric surgeons for the treatment of ovarian
cysts.[13] We started doing laparoscopy late and have
done laparoscopic ovarian cystectomy in three benign
ovarian cysts.
We have treated 49 patients of whom 14 patients had
benign (12 dermoid cysts, 2 patients with granulosa cell
tumors), 33 malignant ovarian tumors and two neonates
with simple cyst. As per FIGO classification, we had 12
patients with Stage I (39%), 13 patients with Stage II
(42%) and 7 patients with Stage III tumors (19 %). We
treated one patient of bilateral Non-Hodgkin lymphoma
of ovaries (stage II). Dysgerminoma was the most
common malignant tumor (40%) in our study followed
by malignant teratoma (16.6%). Dysgerminomas have
a uniform microscopic appearance consisting of large,
round cells that have vesicular nuclei and clear to
eosinophilic cytoplasm [Figure 3]. These cells resemble
Figure 1: Removed right and left ovaries in Non-Hodgkins lymphoma
Figure 3: Photomicrograph of dysgerminoma
18 Journal of Indian Association of Pediatric Surgeons / Jan-Mar 2013 / Vol 18 / Issue 1
primordial germ cells. Lymphoid infiltrates may be
present. 18/31 (58%) presented to us in stage II and
stage III conditions; though fortunately none of them
had features of distant metastasis (such as liver and
lung metastasis), but 2 patients were having ascites
and one patient of malignant teratoma intermediate
had peritoneal seedlings.
Ovarian malignant tumors are a heterogeneous group
including yolk sac tumor [Figure 4], choriocarcinoma,
immature and mature teratoma; careful evaluation
is important to avoid missing malignant elements in
this lesion.[14] Present policy is conservative surgery
to preserve fertility, even in patients with advanced
disease.[15]
All our patients underwent conservative surgery in the
form of ovarian cystectomy and unilateral salpingo-
oophorectomy sparing uterus and contralateral ovary
and bilateral salpingo-oophorectomy in one patient.
All patients with malignant ovarian tumors received
systemic chemotherapy in the form of vincristine,
actinomycin D and cyclophosphamide (VAC) regimen
Figure 2: Showing perforation of transverse colon and left ovarian cyst
Figure 4: Photomicrograph of yolk sac tumor
 Mukhopadhyay, et al.: Ovarian cysts and tumors
(8 cases) up to 1988 and then all were given bleomycin,
etoposide and cyclophosphamide (BEP) regimen
(22cases) and COMP regimen in bilateral NHL in 1 case.
Out of 14 patients of benign ovarian tumors, only
one patient had re-operation for adhesive intestinal
obstruction. We had two newborn babies with ovarian
cyst and both the neonates are doing well. The patient of
non-Hodgkin's lymphoma (bilateral) was doing well for
seven years but then lost to follow up. Primary ovarian
lymphoma is very rare and only isolated case reports
are available.[16] We treated two patients of granulosa
cell tumors. Granulosa cell tumors of the ovary are
prepubertal in 5% of the patients and often present
with virilization, abdominal lump, pain abdomen and
menstrual irregularities.[17] They are characterized by
the presence of small cyst like spaces called Call-Exner
bodies [Figure 5]. There was 90% survival in Stage I
tumors but the result was not satisfactory in stage II
(70%) and stage III tumors (40%).
CONCLUSION
Ovarian tumors are uncommon in girls below the age
of 12 years. Pain and abdominal lump are the most
common modes of presentation. Dysgerminoma is
the most common malignant ovarian tumor in our
Figure 5: Photomicrograph of granulosa cell tumor with callexner
bodies
Journal of Indian Association of Pediatric Surgeons / Jan-Mar 2013 / Vol 18 / Issue 1
experience. Prognosis depends on the size of the tumor,
stage and histology of the tumor. Conservative surgery
should be the aim. Multidisciplinary management gives
good prognosis.
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