What is the normal size of an ovarian cyst in pediatrics?

From the Guidelines

Ovarian cysts in pediatric patients are typically considered clinically significant when they exceed 3 cm in diameter, as cysts less than or equal to 3 cm are often physiologic and may resolve spontaneously. When evaluating ovarian cysts in pediatric patients, it is essential to consider the size and appearance of the cyst, as well as the patient's symptoms and growth pattern. According to the O-RADS US risk stratification and management system, a consensus guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee 1, simple cysts up to 10 cm in diameter on transvaginal ultrasonography performed by experienced ultrasonographers are likely to be benign and may be safely monitored using repeat imaging without surgical intervention, even in postmenopausal patients. However, in pediatric patients, cysts less than or equal to 3 cm are considered physiologic, and no additional management is required.

Some key points to consider when evaluating ovarian cysts in pediatric patients include:

• Cysts measuring less than or equal to 3 cm are often physiologic and may resolve spontaneously
• Cysts greater than 3 cm but less than 10 cm may require follow-up ultrasound in 8-12 weeks to confirm their functional nature or to reassess for cyst wall abnormalities
• Larger cysts exceeding 10 cm generally require surgical evaluation due to increased risk of complications such as torsion, rupture, or hemorrhage
• Simple cysts with thin walls, no solid components, and no internal echoes are more likely benign
• Surgical intervention is typically recommended for cysts that are symptomatic, complex in appearance, rapidly growing, or persistent beyond 3 months despite observation.

It is crucial to note that the management of ovarian cysts in pediatric patients should be individualized, taking into account the patient's age, symptoms, and overall health status, as well as the cyst's size, appearance, and growth pattern, as recommended by the American College of Obstetricians and Gynecologists Committee on Practice Bulletins—Gynecology 1.

From the Research

Size of Ovarian Cyst in Pediatrics

• The size of ovarian cysts in pediatric patients is an important consideration in determining the appropriate treatment approach 2.
• A study published in the Journal of pediatric endocrinology & metabolism found that larger lesions were more common in pre-pubertal patients and were associated with increased symptoms and postoperative complications 2.
• The same study suggested that in adolescents, only cysts larger than 6 cm that do not resolve with estro-progestinic therapy within 6 months should be surgically approached 2.
• In contrast, a consensus statement from the European Paediatric Surgeons' Association recommended that neonates with simple ovarian cysts larger than 4 cm should be offered surgical interventions within 2 weeks of life 3.
• Another study published in the Journal of pediatric and adolescent gynecology found that the mean cyst size in children undergoing laparoscopic cystectomy was 8.4 cm, with a range of 5-13 cm 4.
• The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee systematic review recommended that preoperative estimation of malignant potential is essential to planning an optimal surgical strategy for ovarian masses in pediatric patients, and that tumor markers, ultrasound malignancy indices, and the presence or absence of the ovarian crescent sign on imaging can help estimate malignant potential 5.

Treatment Approaches

• Laparoscopic surgery is a safe and effective treatment approach for ovarian pathologies in children, with a low risk of complications and a good cosmetic appearance 2, 4.
• The European Paediatric Surgeons' Association consensus statement recommended complete laparoscopic cyst aspiration and fenestration with bipolar instruments as the preferred approach for neonates with simple ovarian cysts larger than 4 cm 3.
• The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee systematic review recommended that fertility-sparing techniques may be appropriate depending on the type of tumor, and that both unilateral oophorectomy and cystectomy have been used successfully for germ cell and borderline ovarian tumors 5.