Large Ovarian Cysts Research Articles

Protected Laparoscopic Large Ovarian Cyst Aspiration: A 5-Step Alternative to Laparotomy

In this video, we describe a 5-step surgical technique that allows us to safely incise and aspirate the content of large ovarian cysts through a single-port laparoscopic incision. This allows performing laparoscopic oophorectomies instead of large xipho-pubic laparotomies. A stepwise demonstration of the technique with narrated video footage. Ovarian masses, especially cysts, are common gynecologic conditions [1]. However, depending on their size, large adnexal cysts are usually managed with transverse or midline laparotomies [2]. This is to prevent cyst ruptures and abdominal contamination and ensure oncological safety of the procedure [3-5]. Different leak-proof aspiration techniques have been described in the literature allowing for safe large cyst aspiration and adnexectomy through a mini-laparotomy incision or via laparoscopy [2,3,6-10]. We describe a 5-step surgical technique allowing for closed aspiration of ovarian intracystic fluid and adnexectomy while respecting oncological safety. Step 1: Perform diagnostic laparoscopy to rule out peritoneal carcinomatosis contraindicating this procedure and then after cyst exposition, thoroughly dry the cyst wall. Step 1 Bis: Cut the cuff of a sterile glove to prepare a square piece of membrane. Step 2: Place a protective gauze and then apply the surgical glue to the ovarian cyst wall followed by the glove/membrane application. Perform a purse suture through the glove/membrane and the ovarian wall superficially to ensure further adhesion and prevent ovarian fluid spillage. Step 3: Incise the ovarian wall, introduce the aspiration cannula and tighten the purse suture to aspirate the cystic fluid. Step 4: After aspiration is complete, tighten the suture and close the glove to guarantee a closed space and prevent abdominal contamination. Step 5: Perform laparoscopic oophorectomy or cystectomy. Safely remove the specimen in an endoscopic retrieval bag through the trocar incision. This technique allows safe laparoscopic large ovarian cysts resections while respecting oncologic safety and preventing intra-abdominal spillage and contamination.

Ovarian conservation in a patient with a large ovarian cyst and adnexal torsion – a confirmatory video with intravenous indocyanine green

To share our experience of intravenous indocyanine green (ICG) application during conservative ovarian surgery in a young patient with adnexal torsion, a large ovarian cyst, and apparent ovarian necrosis. This confirmatory video of ovarian reperfusion uses footage from the laparoscopic treatment and ICG application in a young patient with adnexal torsion and apparent necrosis. Academic, multisite medical center. A 24-year-old patient with a 12-cm dermoid cyst, adnexal torsion, and apparent tissue necrosis. Five milligrams intravenous ICG, de-torsion, ovarian cystectomy, and ovarian reconstruction. The patient approved the ICG off-label use. Ovarian preservation and perioperative morbidity. This video demonstrates the surgical treatment of a patient with adnexal torsion. The perfusion patterns before and after the surgical treatment, i.e., cyst de-torsion and cyst removal are documented using intravenous ICG. The perfusion patterns guided the surgeon to perform ovarian conservation despite apparent initial ischemia. The patient recovered well, and no postoperative 30-day morbidity occurred. Intraoperative subjective overestimation of the true ovarian ischemia may lead to unnecessary oophorectomy. Per the American College of Obstetrics and Gynecology recommendation, patients with adnexal torsion should be treated surgically with ovarian conservation regardless of the appearance of the ovary. As demonstrated, ovaries reperfuse despite multiple twists along the infundibulopelvic pedicle, apparent necrosis, and large cysts. Unilateral salpingo-oophorectomies are avoidable even in these cases.

Assessment of ovarian reserve and role of its determining factors in patients with endometriomas combined with pelvic inflammatory disease

Resume. Endometriosis affects from 10% to 50% of women of reproductive age and is one of the most common diseases in gynecology. One of its most common kinds – ovarian endometrial cysts – accounts from 17% to 44% of all patients. The aim of the study was to evaluate the parameters of the ovarian reserve in patients with endometriomas combined with pelvic inflammatory disease. Research materials and methods. Two groups of patients were formed: group I included 45 women with endometriomas combined with pelvic inflammatory disease; group II consisted of 45 patients with isolated endometriomas. Generally accepted criteria were used to assess the ovarian reserve: FSH level, AMH > 1.0 n/ml, number of follicles D, volume of both ovaries. Statistical calculations included the method of calculating the odds ratio (OR) and its 95% confidental interval (95% CI).
 Research results and their discussion. The frequency of the decrease in main parameters of the ovarian reserve showed a deviation in two-thirds of cases in women of group I (68.9%), which is 2.2 times more common (p<0.05). AMH parameters showed a deviation by 3.6 times compared to the control group, and by 1.7 times compared to the parameters of group II (p<0.05). The average level of FSH in blood serum of women in group I was 2.0 times higher than the control indicators, and 1.5 times higher than the indicators of patients in group II. The number of antral follicles < 5 in group II was in 22.2% of observations; and in group 1 – in 91.1% (p<0.05). The endometrioma itself demonstrated a significant influence on the parameters of the ovarian reserve: in the case of a significant share of multiple bilateral endometrial cysts (OR=5.65; 95% CI: (1.71-18.67); p<0.05), their large sizes (OR=7.94; 95% CI: (3.0-21.0); p<0.05), combination with pelvic inflammatory disease, (OR=29.42; 95% CI: (6.33 -146.72); p<0.05) and tubo-ovarian tumours (OR=6.96; 95% CI: (1.44-33.51); p<0.05), as well as aggressive consequences during surgical intervention on both ovaries (OR=8.26; 95% CI: (2.65-25.79); p<0.05). Conclusions. About half of the patients with endometriomas combined with pelvic inflammatory disease note a decrease in the ovarian reserve. Statistically reliable factors are multiple and large ovarian endometrial cysts, a combination with recurrent pelvic inflammatory disease, tubo-ovarian tumours and surgical interventions on the ovaries.

Massive Ovarian Cyst Mimics Constipation

BackgroundAbdominal pain and constipation are common presenting symptoms of pediatric patients presenting to the emergency department. Sometimes these symptoms are related to uncomplicated constipation from stool burden, and other cases may be secondary to more serious pathologies, including obstruction from intra- or extra-intestinal compression. Point-of-care ultrasound (PoCUS) can be helpful in discerning the etiology for this undifferentiated symptomatology. Case ReportA 14-year-old girl presented with 3 days of constipation and abdominal pain. This was similar to previous symptoms that resolved with laxatives. This time, however, her symptoms were associated with one episode of vomiting. PoCUS expanded a narrow differential with the discovery of a large ovarian cyst. This finding helped to expedite her transfer to a pediatric hospital for definitive treatment in the operating room. Why Should an Emergency Physician Be Aware of This?Constipation is one of the leading reasons pediatric patients present to the ED with abdominal pain. PoCUS can detect uncommon causes of constipation, especially pathologies associated with large volumes of fluid, such as a large ovarian cyst, bladder outlet obstruction, or small bowel obstruction.

Laparoscopic management of large ovarian dermoid cyst and the safety of controlled spillage of dermoid content. case report

The safety and efficacy of laparoscopic management of benign cystic teratoma, and tips to improve results of surgery complications that may result from cyst spillage The patient is placed in a trendelenburg position, the bladder was emptied. Clorhexidine was applied to the abdominal area and vagina. Umbilical port 10 mm was inserted by an open technique (Hasson technique), creation of pneumoperitoneum, intra- abdominal pressure 12 mmHg, two 5mm ancillary trocars were placed under direct endoscopic control at both quadrant sites. A 10 mm, 30-degree laparoscope was used and we identified the left adnexal mass, and incision was made on the wall cyst with the bipolar forceps, we developed a plane between the ovarian wall and cyst by traction and countertraction. And inadvertent rupture of the dermoid cyst was presented so we drained all the material to an endobag. We roll out the ovarian capsule and the bleeding from the ovary was controlled with the bipolar forceps. The resected tissue were removed through the 10 mm laparoscopic port. And finally with applied the rule of jet-wash irrigation with copious amounts of fluid, removing up to microscopic particles of cyst contents. We conclude that laparoscopic management of dermoid cysts is a safe and valuable method in selected cases. Review of 15 studies in the literature, revealed only 0.2% incidence of chemical peritonitis following laparoscopic removal of dermoid cysts. The unnecessary fear of dermoid cyst content spillage was championed by the fact that spillage never affects patient morbidity or prognosis in benign cystic teratoma, as shown in the literature. In case of spillage it seems satisfactory to contain all spilled material in the endobag and vigorous jet-wash suction irrigation.

A case of successful pregnancy outcome with a large ovarian cyst- a case report.

Background: Ovarian cyst in pregnancy though uncommon but may be associated with adverse maternal and fetal outcome. Case Presentation: A 30 year old multi gravida, presented during pregnancy at 34 weeks with antenatal ultrasonographic diagnosis of huge unilateral ovarian cyst and normal obstetrics findings. Elective lower segment caesarean section (LSCS) with left salpingo-oophorectomy was done at 37 weeks of gestation. Conclusion: Though a rare event but Ovarian cyst in pregnancy must be followed up carefully. Early diagnosis, timely and appropriate intervention is the key to the best of maternal and fetal outcome. With proper planning, management and expertise the pregnant women with ovarian cyst can have a good maternal and fetal outcome.

The Review aim is to Evaluate the Clinical Results of Solitary Laparoscopy for Removing Large Ovarian Cysts (16 CM) to those of Laparotomy and Three-Port Laparoscopy

Aim: Though standard laparoscopy has increasingly gained acceptance as the surgical therapy for ovarian cancer, decreasing laparoscopy sequence number remains a significant issue for bigger ovarian tumors. Thus, the goal of this review is to contrast the clinical results of solitary laparoscopy for eliminating large ovarian cysts (16 cm) to those of laparotomy and 3-port laparoscopy. Methods: Our current research included 96 individuals with large ovarian cysts (>16 cm) which had single-port, 3-port, or else laparotomy. Patients’ health records, perioperative surgical results, postoperatively score, and complications were all evaluated and discussed retrospectively. Our current research was conducted at Services Hospital Lahore from May 2020 to April 2021. Results: 1-port laparoscopy produced improved perioperative results and less postoperative discomfort compared to 3-port laparoscopy and laparotomy. The duration during process and waking up in the morning was significantly shorter in 1-port laparoscopy than in laparotomy and three-port laparoscopy (18.548.17 vs 28.428.58 vs 23.558.77, P0.02). The hospital admission was substantially lower in single-port laparoscopy set than in extra two sets (5.070.6 vs 6.472.64 vs 5.820.84, P0.002). Furthermore, single-port laparoscopy resulted in lower postoperative discomfort notches than laparotomy and 3-port laparoscopy. Conclusion: Single-port laparoscopy is indeed very secure and effective method for large ovarian cysts, only with benefits of the shorter surgery duration, less anticipated blood loss, a shorter hospital stays, a reduced spillage rate, and lesser postoperative discomfort. Keywords: Clinical Results, Solitary Laparoscopy, Ovarian Cysts, Laparotomy, Three-Port Laparoscopy.

Torsion of a Large Ovariancyst during the Postpartum Period: A Case Report from the Niger-Turkey Friendship Hospital in Niamey

Adnexal torsion is defined by the existence of a partial or complete torsion of the ovary and a tubal portion around its vascular pedicle. It is a rare gynecological emergency. We report the case of adnexal torsion on a large postpartum ovarian cyst in a 40-year-old patient. The diagnosis was suspected based on clinical and ultrasound signs and confirmed by exploratory laparotomy. The appearance of the cyst was suggestive of a mucinous cystadenoma of the ovary. The treatment was radical by performing an adnexectomy. The surgical piece weighed 5.2 kg. The postoperative course was simple. Anatomopathological examination had not been carried out; the parents had buried the operating piece.

Laparoscopic Management of a Large Ovarian Cyst Twist in a 14-Year Old Young Girl in Emergency: A Case Report

The diagnosis and the treatment of twisted ovarian tumors are still challenging, especially in adolescent girls. We describe an adolescent girl with a twisted ovarian cyst, in whom emergent laparoscopic surgery was successful. She visited us due to severe abdominal pain. Ultrasound revealed a large cystic mass, indicative of an ovarian cyst. Laparoscopy revealed a large left ovarian cyst twisted on its axis. We punctured the cyst and detorsed it. The lessons learned here are: sudden-onset abdominal pain of adolescent associated with nausea and vomiting is strongly suggestive of a ovarian cyst torsion; ultrasound should be performed immediately, if ovarian cyst torsion is suspected, timely intervention with diagnostic laparoscopy is indicated, a minimally invasive surgical approach is recommended to preserve the adnexal structures and ovarian function.

Undiagnosed hypothyroidism presenting as recurrent bilateral large ovarian cyst in an early adolescent girl. A rare case report.

Hypothyroidism may manifest as large ovarian cyst formation with precocious puberty in young prepubertal girls, which frequently regress upon starting thyroxin suplemntation. We present a case report of 10 year old girl who had undergone unnecessary laparoscopic cystectomy for bilateral large ovarian cyst as the diagnosis of hypothyroidism was missed. She again had recurrence of bilateral ovarian cyst which regressed upon thyroxin supplementation.

Perioperative outcomes of laparoendoscopic single-site extracorporeal versus intracorporeal cystectomy for benign ovarian cysts: a retrospective cohort study based on propensity score matching.

BackgroundOvarian cysts are the most common gynecological disease, and laparo-endoscopic single-site (LESS) cystectomy is a popular surgical procedure. A new laparoscopic technique combining the advantages of LESS surgery and open surgery has been introduced to treat large ovarian cysts. To our knowledge, no previous research has compared LESS-extracorporeal (LESS-E) cystectomy to LESS-intracorporeal (LESS-I) cystectomy. This study compared the perioperative results of LESS-E cystectomy and LESS-I cystectomy in the treatment of benign ovarian cysts.MethodsTwo hundred eighty-eight cases of cystectomy from our institutional database were retrospectively reviewed. 1:1 propensity score matching (PSM) was performed to minimize bias due to any imbalanced baseline features between the 2 groups, which were matched in terms of age, body mass index, and the largest diameter of ovarian cysts. Seventy-nine cases were then selected from each group, and the perioperative outcomes of the 2 cohorts were analyzed.ResultsThe mean (standard deviation) largest diameter of ovarian cysts was 8.30 (3.56) cm in the LESS-I group and 9.14 (3.15) cm in the LESS-E group (P=0.118). No statistically significant difference was found between the 2 groups in terms of estimated blood loss, postoperative hemoglobin decline, postoperative pain in 24 hours, postoperative hospital stay, and total hospital costs (P>0.05). However, the mean operation time of the LESS-E group was shorter than that of the LESS-I group (85.01 vs. 104.25 minutes; P=0.001). Additionally, the spillage rate of the LESS-I group was significantly greater than that of the LESS-E group (46.8% vs. 17.7%; P<0.001). The mean pain scores at 6 postoperative hours as measured by a visual analogue scale were significantly greater in the LESS-I group than the LESS-E group (3.85 vs. 3.37; P=0.016).ConclusionsLESS-E cystectomy is a safe and feasible approach with a shorter operation time and lower spillage rate than LESS-I cystectomy.

Laparoscopic Cystectomy in Pregnancy: Viability in a 9,9 × 7,5 Inches Lesion

Study Objective Voluminous ovarian cysts during pregnancy constitute a rare and challenging situation. Minimally invasive techniques can potentially provide safe and effective removal without compromising the fetus. This video demonstrates a case of a 28 years old and 17-week pregnant patient with a 9.9 inches ovarian cyst with thin septae managed by laparoscopy. Design This video demonstrates a case of a 28 years old and 17-week pregnant patient with a 9.9 inches ovarian cyst with thin septae managed by laparoscopy. The patient had a prior salpingo oophorectomy and a strong fertility desire. We started evacuating the cyst content, without content spillage to the peritoneal cavity. Setting We start with a first entry under direct view in the upper left quadrant with an 11mm trocar millimeters (mm). After retrieving 2.5 gallons of clear fluid liquid, the cyst was kept attached to the abdominal wall until empty, and evaluation of the abdominal cavity was performed. An umbilical 11mm port and 3 other 5mm accessory ports were inserted. Patients or Participants Directly selected after analysis of exams and patient's desire. Interventions An incision was performed with a monopolar hook and scissors, with a careful dissection of the plane between the cyst wall and a normal ovarian parenchyma. The cyst was completely removed, and a significant amount of this single ovarian tissue was preserved. Total time was 183 min, total blood loss was 150 cc, and the patient was discharged next morning. An ultrasound confirmed fetal vitality before and after surgery. Measurements and Main Results Surgery occurred uneventfully with ovarian preservation. The pregnancy was uneventful and a healthy child was born at 38 weeks, weighing 3.6 kilos. The final anatomopathological report consisted of a borderline mucinous tumor, with an intact capsule. Conclusion This video demonstrates that laparoscopic cystectomy is feasible for large ovarian cysts, during pregnancy, if oncologic rules are followed. Voluminous ovarian cysts during pregnancy constitute a rare and challenging situation. Minimally invasive techniques can potentially provide safe and effective removal without compromising the fetus. This video demonstrates a case of a 28 years old and 17-week pregnant patient with a 9.9 inches ovarian cyst with thin septae managed by laparoscopy. This video demonstrates a case of a 28 years old and 17-week pregnant patient with a 9.9 inches ovarian cyst with thin septae managed by laparoscopy. The patient had a prior salpingo oophorectomy and a strong fertility desire. We started evacuating the cyst content, without content spillage to the peritoneal cavity. We start with a first entry under direct view in the upper left quadrant with an 11mm trocar millimeters (mm). After retrieving 2.5 gallons of clear fluid liquid, the cyst was kept attached to the abdominal wall until empty, and evaluation of the abdominal cavity was performed. An umbilical 11mm port and 3 other 5mm accessory ports were inserted. Directly selected after analysis of exams and patient's desire. An incision was performed with a monopolar hook and scissors, with a careful dissection of the plane between the cyst wall and a normal ovarian parenchyma. The cyst was completely removed, and a significant amount of this single ovarian tissue was preserved. Total time was 183 min, total blood loss was 150 cc, and the patient was discharged next morning. An ultrasound confirmed fetal vitality before and after surgery. Surgery occurred uneventfully with ovarian preservation. The pregnancy was uneventful and a healthy child was born at 38 weeks, weighing 3.6 kilos. The final anatomopathological report consisted of a borderline mucinous tumor, with an intact capsule. This video demonstrates that laparoscopic cystectomy is feasible for large ovarian cysts, during pregnancy, if oncologic rules are followed.

A Case of Laparoscopic Excision of a Large Ovarian Cyst with Controlled Drainage

<h3>Study Objective</h3> Video presentation showing laparoscopic excision of a large ovarian cyst with controlled drainage. <h3>Design</h3> Case presentation. <h3>Setting</h3> This case was performed in an academic tertiary medical center. The patient was in dorsal lithotomy position with arms tucked. We used 4 total ports; the umbilical port for the camera, a supra-pubic port and right and left lateral lower abdominal port. A balloon trocar was used for controlled cyst content drainage. Potassium Titanium Phosphate laser was used for fine dissection. <h3>Patients or Participants</h3> 21-year-old Gravida 0 presented with pelvic pressure and palpable mass for months. Ultrasound showed an 11 cm simple ovarian cyst and 5cm adjacent complex cyst with peripheral echogenic foci without internal vascularity consistent with dermoid cyst. She had mildly elevated alpha fetoprotein and otherwise negative tumor markers. <h3>Interventions</h3> Laparoscopic excision of right ovarian cyst. <h3>Measurements and Main Results</h3> The case was completed uncomplicated. The patient showed significant improvement in her symptoms on follow-up with resolution of pelvic pressure. <h3>Conclusion</h3> Maintaining clear planes between the cyst wall and the ovarian cortex as well as excellent hemostasis is key in ovarian cystectomies. Care must be taken to preserve as much ovarian cortex as possible for future fertility.

Ovarian Cysts Management Following Laparoscopic Surgery

Objective: To analyze diagnostic and surgical outcomes in patients with extremely large ovarian cysts treated by laparoscopic surgery.&#x0D; Methods: A total of 120 cases of large adnexal masses and suspected for malignancy were treated laparoscopically at the at general surgery department of Liaquat University of Medical &amp; Health Sciences. Under endotracheal anesthesia, all surgeries were performed using nasogastric tubes in the stomach. An incision of approximately 1.5 centimeter was made at the supraumbilical or umbilical region and peritoneal cavity was approached. The intra-abdominal approach in all cases was cautiously standardized. The resection of the adnexal mass was performed as per routine method.&#x0D; Results: 12 females were premenopausal and 8 were postmenopausal. 12 women presented with the signs of urinary retention, urinary urgency and abdominal pain. Incidental sonography detected cysts in 8 patients which were asymptomatic. The average volume of the resected cystic fluid was 3000ml (range 900 to 9000 ml). The specimens of frozen section were obtained within the surgical procedure in all patients except 2 patients having para-ovarian cysts. The histopathology presented mucinous benign cystadenoma. There was no blood loss and related other complications reported in all operations.&#x0D; Conclusion: Laparoscopic management of large ovarian cyst observed to a effective, feasible and less complicated surgical option. However accurate selection and diagnosis of the patients, the any ovarian cyst size can be treated easily via laparoscopic surgery.

Ovarian cyst mimicking acute appendicitis in pregnancy: A case report

Ovarian cysts, also known as ovarian masses or adnexal masses are fluid filled sacs or pockets in an ovary or on its surface. These are found incidentally in asymptomatic women. Ovarian cysts are considered large in size when they are over 5 cm and giant when they are over 15 cm. Acute appendicitis is the most common surgical problem encountered during pregnancy. Pregnancy is associated with various anatomic and physiologic changes that may disguise and delay the diagnosis of acute appendicitis. Antibiotic treatment does not always improve the outcome and emergency intervention is required. Early diagnosis and surgical intervention is mandatory for the eventful outcome of pregnancy. Here we present a case of a primigravida patient with a large ovarian cyst mimicking acute appendicitis.

Cystic Ovarian Mucinous Carcinoma With Carcinosarcomatous Mural Nodules: An Uncommon Entity.

Mural nodules in ovarian mucinous cystic tumors are uncommon, with only 80 cases reported over the last 30 yr. The literature describes only 5 cases of carcinosarcomatous mural nodules with mucinous ovarian neoplasm. We compared and summarized the literature related to mural nodules in mucinous ovarian tumors to elaborate on the clinical and histomorphologic features. A 21-yr-old woman presented with 2 mo history of abdominal distension. Physical examination showed a palpable pelvic mass. Radiologic investigation showed a 31×18.6×25 cm large right ovarian cyst. Few nodular solid masses were also seen, the largest mass measured 3.5×3.1 cm. On histomorphology and immunohistochemistry, it was a mucinous ovarian carcinoma with carcinosarcomatous mural nodules. Carcinosarcomatous mural nodules with ovarian mucinous neoplasm affects younger females. It presents at an early stage and does not carry an adverse prognosis.

Modelling Benign Ovarian Cyst Risk Factors and Symptoms via Log-Linear Model

Ovarian cancer among women is known as “The Silent Killer”. It is caused by the malignant ovarian cyst, which can spread to other organs if it is not treated at an early stage. Some are benign ovarian cyst which can be treated through medical procedures such as laparoscopic and laparotomy. The type of medical procedure that the patients have to undergo depends on the size of cyst. A few risk factors that can cause benign ovarian cyst are age, pregnancy, menopause and menstrual cycle. Apart from that, there are a few symptoms of benign ovarian cyst which are fever, nausea and abdominal pain, abdominal distension, dysmenorrhea and intermenstrual bleeding. The association between these 12 discrete categorical data variables (factors, symptoms, treatment and size) are measured using the log-linear analysis in this study. According to the analysis, the patients who have large benign ovarian cyst need laparoscopic procedure, while those with smaller cyst need either laparotomy procedure or they do not have to undergo any surgery at all. Among all of the factors, menopause gives the highest risk factor of benign ovarian cyst, followed by age, pregnancy and menstrual cycle. Meanwhile, the interaction between nausea, abdominal pain and intermenstrual bleeding give the highest symptom rate to the benign ovarian cyst.

The Predictive Value of Decisive and Soft Ultrasound Criteria for Ectopic Pregnancy Identification in 321 Preoperative Cases.

To define the predictive value of morphological types (MTs) and further criteria in diagnosing ectopic pregnancy (ECP) by transvaginal sonography (TVS) prior to operative confirmation and treatment. Retrospective cohort analysis of 321 consecutive patients with suspected ECP who were advised to undergo operation. ECP was investigated by TVS in all 321 patients. Application of the five selected MTs (blob sign, bagel sign, yolk sac, embryo, heart action) resulted in 85 % of cases receiving a conclusive diagnosis and 12 % receiving a presumed ECP diagnosis. 3 % remained nondiagnostic due to large or multiple ovarian cysts, large myoma, extended hemoperitoneum, or severe pain. ECP diagnosis was confirmed intraoperatively in 97 % of cases and was otherwise (3 %) immediately followed by curettage (CUR). The assessment of free fluid by TVS was achieved in most cases and correlated significantly with free blood. In the majority of cases, free blood was not bound to transmural ECP rupture. Histology confirmed the ECP diagnosis directly or by exclusion in 99 % of cases. Three cases of tubal ECP were diagnosed by TVS but not confirmed by LSC (1 %) and, finally, histology from CUR proved miscarriage (false-positive rate 1 %). We confirm the high accuracy of TVS diagnosis of ECP relying on five clearly different MTs, independent of its location. The blob and bagel sign emerged as important types (75 % of all ECPs). Histology from CUR was needed when ECP could not be visualized in LSC. Assessment of free fluid was essential and accurate in predicting free blood.

6-Year-Old Girl With a Luteinized Follicular Ovarian Cyst and an Estradiol Level &amp;gt; 1,000 PG/ML

Background: Precocious puberty in girls is defined as onset of secondary sexual characteristics, such as breast development, before 8 years of age. To differentiate between central and peripheral precocious puberty, laboratory and imaging evaluation is helpful. When gonadotropins are low but estradiol is elevated, results may suggest a primary ovarian source of estrogen production. Small ovarian cysts are not uncommon, are benign and self-resolve. However, large ovarian cysts are rare, let alone ones requiring surgical removal. Clinical Case: A 6 year 7 month old girl presented with several days of breast tenderness and palpable bilateral breast tissue noted by her mother. There was no history of vaginal bleeding. There were no reported exposures to estrogen-containing products. Her mother reached menarche at age 14 years. The patient was born full term and was otherwise healthy. On exam, her height was at the 90-95th %ile (mid-parental height at the 95th %ile) and her growth velocity was 10.9 cm/yr. She had Tanner 2 breasts (1 cm breast bud on the left and 1.5 cm on the right), Tanner 1 pubic hair and no axillary hair, body odor, acne or café-au-lait macules. A bone age was read as 6 years at a chronological age of 6 years 7 months. A laboratory evaluation revealed an estradiol of 1,029 pg/mL (<15 pg/mL), LH <0.02 mIU/mL, FSH <0.09 mIU/mL, 17-hydroxyprogesterone (17-OHP) 410 ng/dL (<91 ng/dL), AFP 2.3 ng/mL (<6.1 ng/mL), beta-hCG <2 mIU/mL, TSH 2.41 mIU/L (0.5-3.2 mIU/L), and free T4 0.9 ng/dL (0.9-1.4 ng/dL). Pelvic ultrasound revealed a large unilocular cystic structure measuring 6.5 x 4.1 x 6.1 cm in the left adnexal region with no left ovary visualized. The right ovary appeared prepubertal. The uterus was prepubertal in appearance with endometrial thickness of 2 mm. Abdominal ultrasound showed no evidence of a suprarenal mass. A laparoscopic cyst resection was completed, given the risk of left ovarian torsion. Cytology was negative; pathology revealed a luteinized follicular cyst. Repeat labs in one month showed a prepubertal estradiol level of 6.7 pg/mL with LH 0.02 mIU/mL and FSH 0.38 mIU/mL. 17-OHP normalized to 29 ng/dL. Breast tissue had regressed. Conclusion: This case describes the rare finding of a large luteinized follicular ovarian cyst that required surgical removal in a 6-year-old girl in the setting of a significantly elevated estradiol level. Luteinized follicular cysts have been described in newborns, though rare. To our knowledge, this is the first described case of a luteinized follicular cyst in this patient’s age group. Laboratory and imaging evaluation should be considered in girls presenting with precocious puberty, despite the extent of thelarche, as the clinical examination does not always correlate with degree of estradiol elevation. This is especially important if clinical changes are acute and other features are consistent with puberty, such as rapid linear growth.

A Follicular Stimulating Hormone Secreting Adenoma

A gonadotroph secreting pituitary adenoma, a rare endocrinopathy, is often overlooked due to ambiguous symptoms leading to other diagnoses, such as ovarian hyperstimulation syndrome (OHSS).A 53 year old African American woman presented for evaluation of a 4 month history of right hemianopsia. Her past medical history included a total hysterectomy and bilateral oophorosalpingectomy for recurrent ovarian cysts 11 years prior. Initial MRI:4.1x3.6x3.9 cm pituitary macroadenoma with prechiasmtic optic nerve compression. Initial laboratory studies: follicular stimulating hormone (FSH) level 186.83 mIU/mL (RR:23.0-116.3 mIU/mL) and luteinizing hormone (LH) 14.44 mIU/mL (RR:15.9-54.0 mIU/mL). Other pituitary labs were unremarkable. Debulking surgery was performed to relieve mass effect; pathology showed an FSH immunoreactive adenoma. Postoperatively, FSH was 2.55 mIU/mL and LH was 0.75 mIU/mL.The prevalence of pituitary adenomas is 80-100 per 100,000 persons; 15-30% are non-functional. The majority of gonadotroph adenomas are difficult to identify because they may not produce biologically active hormones. Clinically functioning gonadotroph adenomas are very rare, often macroadenomas when found, most often found in reproductive age women, and preferentially secrete FSH. In reproductive age women, a FSH secreting adenomas may present clinically with OHSS, with multiple large ovarian cysts found on ultrasound for menstrual or pelvic complaints as seen in our patient. While OHSS is a known complication of assisted reproductive procedures, spontaneous OHSS is atypical and suggests need for evaluation of a FSH-secreting adenoma. Men may present with macroorchidism. Children may present with precocious puberty.The treatment of choice is surgical removal of the adenoma, normalizing FSH to an age appropriate level. When OHSS is present, this results in a rapid decline in estradiol level and regression of ovarian cysts. Medical treatment, if surgery is contraindicated, is limited to cabergoline, which can initially decrease FSH and estradiol levels. In patients with normal pituitary function, gonadotropin-releasing hormone agonists acutely stimulate LH and FSH, thereby desensitizing GnRH receptors and decreasing gonadotropin secretion. In patients with FSH-secreting adenomas, they may have a persistent stimulatory effect, and in rare cases, result in pituitary apoplexy. Tumors that cannot be completely surgically removed may be treated by adjuvant radiotherapy or radiosurgery.