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1 All authors: Department of Diagnostic Radiology, Keimyung University School of Medicine, Dongsan Medical Center, 194, Dongsan-dong, Jung-Ku, Taegu, 700-310, Korea
Received July 12, 1999;
accepted after revision September 8, 1999.
Address correspondence to H. Lee.
Abstract
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SUBJECTS AND METHODS. In a prospective study, 23 neonates, infants, and young children (age range, 1 day to 36 months) with a lower abdominal cystic mass underwent sonography. We defined the daughter cyst sign as the presence of a small cyst along the wall of a cystic mass. The diagnosis of ovarian cyst was made when this sign was present. Detailed pathologic correlation was available in four ovarian cysts. The size, wall thickness, and contents of the cysts were also evaluated.
RESULTS. The 23 cystic lesions included ovarian cyst (n = 11), lymphangioma (n = 3), enteric duplication cyst (n = 3), enteric cyst (n = 1), meconium pseudocyst (n = 2), hydrometrocolpos (n = 2), and urachal cyst (n = 1). The daughter cyst sign was seen in nine (82%) of 11 ovarian cysts but in none of the other cystic lesions. Sensitivity, specificity, and positive predictive value of the daughter cyst sign for differentiating ovarian cysts from other cystic lesions were 82%, 100%, and 100%, respectively. The daughter cyst corresponded to an ovarian follicle on pathologic examination.
CONCLUSION. The daughter cyst sign is a specific sonographic finding for an ovarian cyst and may be useful in differentiating uncomplicated ovarian cysts from other cystic masses in neonates, infants, and young children.
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It is well known that normal ovaries in neonates and children have small cysts that represent unstimulated follicles [11]. In this prospective study, we tried to show that follicles in neonatal ovarian cysts, namely a "daughter cyst" sign, can be seen on sonography. We also assessed the diagnostic value of this sonographic sign in differentiating ovarian cysts from other cystic masses in neonates, infants, and young children.
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All sonographic examinations were prospectively performed by the primary author. Scans were obtained by using a real-time sonographic unit (model 128; Acuson, Mountain View, CA) with 5-MHz convex and 7-MHz linear transducers. In addition to routine scanning of the abdominopelvic cavity, special attention was paid to the cyst wall to identify the daughter cyst sign, which was defined as a visualization of small cysts along the cyst wall (Fig. 1A,1B).
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Images were independently reviewed by two radiologists who were unaware of the results. The diagnosis of ovarian cyst was made by recognition of the daughter cyst sign. In a cyst with the daughter cyst sign, the size and numbers of the daughter cysts were measured. The size (the largest diameter), wall thickness, and contents of the main cysts were also evaluated. Wall thickness was defined as thin if less than 2 mm and thick if 2 mm or more. The contents were categorized as anechoic, having septations, or having debris.
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Table 1 summarizes the sonographic features of the cystic lesions. The daughter cyst sign was seen in nine (82%) of 11 ovarian cysts (Fig. 2), but in none of the other cystic lesions. The mean size of the daughter cysts was 2.8 mm and ranged from 2 to 8 mm. The mean number of daughter cysts in each ovarian cyst was 1.8 and ranged from one to three. The four ovarian cysts, seen in patients who underwent cystectomy, proved to be simple ovarian cysts on pathology. The daughter cysts on sonography corresponded to follicles on pathologic correlation (Fig. 3A,3B). Sensitivity, specificity, and positive predictive value of the daughter cyst sign for the diagnosis of ovarian cyst were 82%, 100%, and 100%, respectively.
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Table 2 summarizes the sizes of the ovarian cysts and other cystic lesions. All ovarian cysts, one lymphangioma, one enteric duplication cyst, and one enteric cyst were thin-walled cysts. Ten ovarian cysts and two enteric duplication cysts were anechoic.
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The sonographic appearance of an ovarian cyst varies, depending primarily on whether the cyst is uncomplicated or complicated by torsion or hemorrhage. A complicated cyst usually contains a fluid-debris level, retracting clot, or septa or is completely filled with echoes resembling a solid mass. An uncomplicated cyst is anechoic with an imperceptible wall. The following criteria are used to identify ovarian cysts: the presence of a cystic structure that is regular in shape and usually located on one side of the abdomen, the integrity of the urinary and gastrointestinal tract, and female sex of the neonate [10]. Sonography can suggest a diagnosis of ovarian cyst. However, because of the overlapping in imaging features of other cystic masses such as mesenteric cysts, urachal cysts, or enteric duplication cysts, the diagnosis is usually presumptive and surgical exploration is necessary to establish a definitive diagnosis.
Anatomic studies revealed small follicular cysts in 34% of neonates [11]. These small follicular cysts were detected using high-resolution sonography [12, 13]. We obtained images of these follicles in neonatal ovarian cysts and paid particular attention to the morphologic findings concerning the wall of the cystic masses.
Our results suggest that the daughter cyst sign appears to be specific for uncomplicated ovarian cysts because this finding was seen in none of the other cystic lesions. In our series, other sonographic features of ovarian cyst including anechoic, unilocular, and thin-walled structures substantially overlapped with those of unilocular lymphangioma, enteric duplication cyst, and enteric cyst, which are associated with major differential considerations. Although we did not include fetal cysts in this study, we found the daughter cyst sign in a few fetuses with an ovarian cyst seen on prenatal sonography.
Neonatal ovaries are functionally and anatomically similar to pubertal and adult ovaries [11]. They are primarily of germinal or graafian epithelial origin [2, 14] and consist of follicular theca lutein, corpus luteum, or simple cysts in which the cell lining has been destroyed. All four cases proved to be simple cysts and the daughter cyst on sonography corresponded to a follicle on pathology.
All ovarian cysts in this study were uncomplicated and, thus unfortunately, we were not able to apply the daughter cyst sign to complicated ovarian cysts. However, if the daughter cyst sign is observed in a complex cystic mass, the diagnosis of ovarian cyst would be more likely than ovarian tumor. Further investigation is needed.
Small septa traversing a cyst may be confused with the daughter cyst sign. However, a septum is linear rather than round. No disagreement about differentiating a septum and the daughter cyst sign was observed between the two radiologists who reviewed the images.
In summary, the results of the study show that the daughter cyst sign represents a follicle within an ovarian cyst. We believe that when the daughter cyst sign is identified in a cystic mass in neonates, infants, and young children, the diagnosis of ovarian cyst can be suggested with confidence, and conservative management can be recommended without further investigation. In fact, three ovarian cysts larger than 5 cm in diameter, which was an indication for surgical intervention according to the size criterion [15], were successfully managed conservatively in our series.
In conclusion, we believe that the sonographic daughter cyst sign is diagnostic of an ovarian cyst in neonates, infants, and young children.
Acknowledgments
We thank Seung Hyup Kim for his kind review of this manuscript.
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