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Rosary ovaries
Images in Gynecology
www. AJOG.org
Rosary ovaries Physicians discovered an unusual anomaly in a 13-year-old girl Xavier Deffieux, MD, PhD; Alessio Carloni, MD; Hervé Fernandez, MD
CASE NOTES
A 13-year-old postpubertal girl presented with a 4-day history of abdominal pain in the right lower quadrant. The patient, at Tanner stage IV with respect to breast and pubic hair development, had been 9 years old at menarche. She had a regular 28-day menstrual cycle. During laparoscopic appendectomy, an unknown ovarian malformation was identified: both ovaries were divided into balls that were arranged in a rosarylike fashion along the ovarian ligament (Figure 1). Six spherical structures were noted on the right side, 5 on the left. These ranged in diameter from 5 to 15 mm. The most inferior mass was a 10 mm left adnexal cyst (Figure 2). No normal ovary was found, but the uterus and the fallopian tubes were normal in appearance.
Deffieux. Rosary ovaries. Am J Obstet Gynecol 2008.
CONCLUSIONS The patient rapidly recovered from the appendectomy, and a pathological examination confirmed acute appendicitis. A genetic evaluation indicated that her karyotype was 46,XX. Basal endocrine testing proved normal. Results were as follows: antimüllerian hormone, 8.43 ng/mL; follicular stimulating hormone,
From the Department of Obstetrics and Gynecology (Drs Deffieux and Fernandez) and Department of Surgery (Dr Carloni), Assistance Publique Hopitaux de Paris, Antoine Beclere Hospital, and University Paris-Sud (Drs Deffieux and Fernandez) and UMR-S0782 (Drs Deffieux and Fernandez), Clamart, France. Cite this article as: Deffieux X, Carloni A, Fernandez H. Rosary ovaries. Am J Obstet Gynecol 2008;199: 93.e1-93.e2. 0002-9378/$34.00 © 2008 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2008.04.026
4.7 IU/L; luteinizing hormone, 3.6 IU/L; estradiol, 16 pg/mL; delta-4-androstenedione, 1.5 ng/mL; and total testosterone, 27 ng/dL). Magnetic resonance imaging confirmed a normal-sized uterus and the absence of normal ovaries. However, a coronal T2-weighted magnetic resonance image demonstrated ovarian follicles with a normal appearance (Figure 3). No teratoma or ovarian tumor was seen. Accessory ovaries, multilocular cyst, or multiple dermoid cysts are essential elements in the differential diagnosis. Because no normal ovary was identified during laparoscopy, accessory ovaries were ruled out. Furthermore, magnetic resonance imaging showed normal-looking ovarian follicles and excluded the possibility of dermoid cysts. At a follow-up visit 1 year later, the patient continued to have typical 28 day menstrual cycles. Results from endocrine testing remained normal.
To our knowledge, this ovarian malformation has never been reported, and its potential significance is unclear. Normal development of the ovary passes through several phases, including migration of the germ cells from the yolk sac to the posterior body wall; differentiation of the germ cells; and descent of the FIGURE 2
Laparoscopic view of the pelvis
Deffieux. Rosary ovaries. Am J Obstet Gynecol 2008.
JULY 2008 American Journal of Obstetrics & Gynecology
93.e1
Images in Gynecology FIGURE 3
Coronal T2-weighted magnetic resonance imaging of the pelvis
ovary to reach the pelvis along the gubernaculum. Perhaps this ovarian malformation is related to an abnormal migration of the germ cells or fetal gonads along the gubernaculum. It might also be related to abnormal organization of the collagenous connective tissue (the tunica albuginea) that covers the ovary just below the surface epithelium. We have chosen not to biopsy the ovarian tissue at this time. The patient currently has no endocrinological, developmental, or gynecological symptoms. However, laparoscopy might be repeated at a later date if an endocrine disorder develops or if an ultrasonographic survey reveals an adnexal abnormality.
Deffieux. Rosary ovaries. Am J Obstet Gynecol 2008.
93.e2
American Journal of Obstetrics & Gynecology JULY 2008
www.AJOG.org
www. AJOG.org
Rosary ovaries Physicians discovered an unusual anomaly in a 13-year-old girl Xavier Deffieux, MD, PhD; Alessio Carloni, MD; Hervé Fernandez, MD
CASE NOTES
A 13-year-old postpubertal girl presented with a 4-day history of abdominal pain in the right lower quadrant. The patient, at Tanner stage IV with respect to breast and pubic hair development, had been 9 years old at menarche. She had a regular 28-day menstrual cycle. During laparoscopic appendectomy, an unknown ovarian malformation was identified: both ovaries were divided into balls that were arranged in a rosarylike fashion along the ovarian ligament (Figure 1). Six spherical structures were noted on the right side, 5 on the left. These ranged in diameter from 5 to 15 mm. The most inferior mass was a 10 mm left adnexal cyst (Figure 2). No normal ovary was found, but the uterus and the fallopian tubes were normal in appearance.
Deffieux. Rosary ovaries. Am J Obstet Gynecol 2008.
CONCLUSIONS The patient rapidly recovered from the appendectomy, and a pathological examination confirmed acute appendicitis. A genetic evaluation indicated that her karyotype was 46,XX. Basal endocrine testing proved normal. Results were as follows: antimüllerian hormone, 8.43 ng/mL; follicular stimulating hormone,
From the Department of Obstetrics and Gynecology (Drs Deffieux and Fernandez) and Department of Surgery (Dr Carloni), Assistance Publique Hopitaux de Paris, Antoine Beclere Hospital, and University Paris-Sud (Drs Deffieux and Fernandez) and UMR-S0782 (Drs Deffieux and Fernandez), Clamart, France. Cite this article as: Deffieux X, Carloni A, Fernandez H. Rosary ovaries. Am J Obstet Gynecol 2008;199: 93.e1-93.e2. 0002-9378/$34.00 © 2008 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2008.04.026
4.7 IU/L; luteinizing hormone, 3.6 IU/L; estradiol, 16 pg/mL; delta-4-androstenedione, 1.5 ng/mL; and total testosterone, 27 ng/dL). Magnetic resonance imaging confirmed a normal-sized uterus and the absence of normal ovaries. However, a coronal T2-weighted magnetic resonance image demonstrated ovarian follicles with a normal appearance (Figure 3). No teratoma or ovarian tumor was seen. Accessory ovaries, multilocular cyst, or multiple dermoid cysts are essential elements in the differential diagnosis. Because no normal ovary was identified during laparoscopy, accessory ovaries were ruled out. Furthermore, magnetic resonance imaging showed normal-looking ovarian follicles and excluded the possibility of dermoid cysts. At a follow-up visit 1 year later, the patient continued to have typical 28 day menstrual cycles. Results from endocrine testing remained normal.
To our knowledge, this ovarian malformation has never been reported, and its potential significance is unclear. Normal development of the ovary passes through several phases, including migration of the germ cells from the yolk sac to the posterior body wall; differentiation of the germ cells; and descent of the FIGURE 2
Laparoscopic view of the pelvis
Deffieux. Rosary ovaries. Am J Obstet Gynecol 2008.
JULY 2008 American Journal of Obstetrics & Gynecology
93.e1
Images in Gynecology FIGURE 3
Coronal T2-weighted magnetic resonance imaging of the pelvis
ovary to reach the pelvis along the gubernaculum. Perhaps this ovarian malformation is related to an abnormal migration of the germ cells or fetal gonads along the gubernaculum. It might also be related to abnormal organization of the collagenous connective tissue (the tunica albuginea) that covers the ovary just below the surface epithelium. We have chosen not to biopsy the ovarian tissue at this time. The patient currently has no endocrinological, developmental, or gynecological symptoms. However, laparoscopy might be repeated at a later date if an endocrine disorder develops or if an ultrasonographic survey reveals an adnexal abnormality.
Deffieux. Rosary ovaries. Am J Obstet Gynecol 2008.
93.e2
American Journal of Obstetrics & Gynecology JULY 2008
www.AJOG.org