When to operate on ovarian cysts in children?

Ovarian cysts are rare conditions in the pediatric age group. They are characterized by different clinical presentations and by the need to establish adequate type and timing of treatment in order to prevent complications, such as ovarian necrosis after torsion and infertility. The diagnostic approach should differentiate benign occasional findings, such as follicular cysts, from neoplastic lesions, and functional cysts which can occur either isolated or in the context of McCune-Albright syndrome. Our aim was to review all the patients affected by ovarian pathologies seen in our department in the past 5 years, in order to establish a protocol for the correct management of these conditions.

In the past 5 years we studied 133 patients diagnosed with ovarian lesion. We subdivided the patients into three groups according to age: group A (age <6 months: 66 cases); group B (pre-pubertal patients, age 7 months to 10 years: 10 cases); and group C (pubertal patients, age 11-14 years: 57 cases). We collected historical and clinical data and assigned specific cut-off values in order to perform statistical analysis (Fisher's exact test) comparing the three groups.

Ultrasound examination proved to be indispensable in the early detection of ovarian lesions and for identifying the correct treatment. Cyst size, and moreover appearance with ultrasound, were important considerations when selecting the most appropriate therapeutic approach. The larger lesions were found in group B, giving symptoms that required hospitalization (pelvic pain, nausea and vomiting) and leading to increased incidence of postoperative complications. Laparoscopic surgery appeared to be safe and effective for the treatment of ovarian pathologies.

The management of ovarian lesions in children must be based on a minimally invasive approach, based on the patient's age and ultrasound findings. Treatment should be conservative, with ovariectomy undertaken only when essential. In adolescents, only cysts larger than 6 cm that do not resolve with estro-progestinic therapy within 6 months should be surgically approached; in infants, any signs of cyst complications must be addressed surgically.